Every finding on record at Eastway Health & Rehabilitation

Based on interview, record review, and facility policy review, the facility failed to fully develop and implement the comprehensive person-centered care plan for one of 49 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned for staff to place the Resident in a common area when she became restless. The care plan, however, was not fully developed with interventions to include supervision and monitoring while in the common area. While staff were in the nurses' station, the Resident was left unattended and fell in the common area, fracturing her hip. This caused actual harm to the Resident. The findings include: Review of the facility's policy titled, Care planning – Comprehensive Person – Centered, undated, revealed the comprehensive care plan was to promote patient (resident) safety, and reflect currently recognized standards of practice. Review of R17's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/18/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 12/15, indicating intact cognition. Review of the MDS Assessment, with an ARD of 12/19/2024, revealed the facility assessed R17 to have a BIMS score of 8/15, indicating moderate cognitive impairment. Review of R17's care plan for fall risk revealed an intervention dated 08/28/2024, to place the resident in the common area to address her restlessness. However, further review of the care plan intervention revealed it did not specify staff were to monitor R17 after placing her in the common area. Review of the Nurses' Notes and Change of Condition Notes revealed on 07/29/2025, staff implemented R17's intervention to place her in the common area for anxious behavior. Review further revealed however, staff left R17 unattended after implementing the intervention which resulted in the resident sustaining a fall with hip fracture. In interview on 07/31/2025 at 12:20 PM, State Registered Nurse Aide (SRNA) 4 stated R17 had been restless on 07/25/2025; however, her medications had started to kick in. She reported they took R17 to the common area and sat her there while they all went to the nurses' station to chart. The SRNA said while charting they heard a thump and left the nurses' station and found R17 lying on the floor. She further stated the people present in the nurses' station at the time of R17's fall had been SRNA 5, Licensed Practical Nurse (LPN) 5, and Kentucky Medication Aide (KMA) 1. In interview on 07/31/2025 at 12:40 PM, LPN 5 stated R17 had been restless all night and had gotten up out of bed. She said so staff sat R17 in the common area as she was care planned, so they could keep an eye on her while they were charting. LPN 5 reported while charting at the nurses' station staff heard a thump, and found R17 lying on the floor in front of the elevators in the common area. She further stated she agreed with SRNA 4's statement that everyone had been in the nurse's station charting. In interview on 08/01/2025 at 10:07 AM, LPN 3 stated for R17's care plan intervention to place the resident in the common area, she expected staff would be in close proximity to the resident. She additionally stated it would not have been appropriate for all the staff on the floor to be in the nurse's station while R17 was in the common area alone. In interview on 08/04/2025 at 2:19 PM, the MDS Coordinator stated when implementing R17's care plan intervention of placing the resident in the common area, it was expected staff would be monitoring the resident and the area for the resident's safety.

Based on interview, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision to prevent injury for 1 out of 29 sampled residents, Resident (R)17. Resident 17 had a history of falls and was care planned to place the resident in a common area when she became restless. Staff implemented the resident's care plan by placing the resident in the common area; however, failed to ensure the resident was supervised while in the area. While staff were in the nurses' station, the Resident fell while in the common area unsupervised and sustained a fractured hip, which caused actual harm to the resident. The findings include: During an interview with the Director of Nursing (DON) on 08/05/2025 at 3:57 PM, she stated it was her expectation that staff would provide supervision to the residents. Review of Resident (R)17's medical record revealed the facility admitted the resident on 03/04/2025, with diagnoses that included Congestive Heart Failure, Alzheimer's unspecified, chronic obstructive pulmonary disease, and repeated falls. Review of R17's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/18/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. Review of the MDS Assessment, with an ARD of 12/19/2024, revealed the facility assessed R17 to have a BIMS score of 8/15, indicating moderate cognitive impairment. Review of the medical record for R17 revealed a history of wandering when anxious and the resident had sustained previous unwitnessed falls. Continued review of R17's medical record revealed the facility performed a Falls Assessment on admission, and when the resident sustained a fall on 07/28/2025, an assessment was completed after each fall, with new interventions developed after the falls. Review revealed the Interdisciplinary Team (IDT) met after each fall to conduct a root cause analysis. Record review revealed the facility developed a care plan intervention to place R17 in the common area when experiencing restlessness, in order to address unwitnessed falls. Further record review revealed on 07/29/2025, R17 was placed in the common area where the resident was not monitored, and sustained a fall, which resulted in a fractured hip. During interview with State Registered Nurse Aide (SRNA) 4 on 07/31/2025 at 12:20 PM, she stated R17 had been restless on 07/28/2025, but her medications were beginning to take effect. She said they sat R17 in the common area and everyone working on the unit went to the nurses' station to chart, which included herself, Licensed Practical Nurse (LPN) 5, SRNA 5, and Kentucky Medication Aide (KMA) 1. SRNA 4 reported while they were all in the nurses' station, they heard a thump, and left the nurses' station and found R17 lying on the floor. During interview on 07/31/2025 at 12:40 PM, LPN 5 stated that R17 had been restless all night and had gotten up out of bed. She said they sat R17 in the common area as care planned so they could keep an eye on her while they were charting. The LPN reported they heard a thump, and R17 had fallen in front of the elevators in the common area. She said all staff were in the nurses' station charting at the time of R17's fall. During interview with LPN 3 on 08/01/2025 at 10:07 AM, she stated her expectation was for staff to be in close proximity to a resident placed in the common area for restlessness. She stated it was not appropriate for all staff on the floor to be in the nurses' station while the resident was alone in the common area. During interview on 08/04/2025 at 2:19 PM, the MDS Coordinator stated when staff implemented R17's care plan intervention for placing the resident in the common area it was expected they would monitor the resident in that area for safety. She reported when placing a resident who wandered or was anxious in the common area, that intervention relied on the common area being a heavily trafficked area. During an interview with the Director of Nursing (DON) on 08/05/2025 at 3:57 PM, she stated it was her expectation that staff would provide supervision to the residents.

Based on observation, interview, record review, and review of facility policies, the facility failed to provide a safe, clean, comfortable and homelike environment. This had the potential to affect all residents residing in the facility. The findings include: Review of the facility's undated policy titled, Pests Control, revealed the facility should maintain an effective pests control program to ensure the building was kept free of insects and rodents. Review of the facility's policy titled, Environmental Services Quality Control, dated 10/01/2021, revealed housekeeping and laundry departments had developed a quality control program that measured the level of the quality of services provided by those departments.1) Observation on 07/29/2025 at 10:27 AM, revealed R170's side of the room was cluttered with clothing, books, a couple of boxes, and magazines. Continued observation revealed R170's overbed table was also cluttered with cups. a. Observation on 07/29/2025 at 10:40 AM, revealed R153's and R115's room floor was sticky and dirty looking. Additional observation on 07/30/2025 at 1:35 PM, revealed the floor in the room in which R153 and R115 resided remained sticky and dirty. b. Observation on 07/29/2025 at 10:45 AM, revealed R80's room had dirty linens lying on the floor. c. Observation of the lunch meal service on 07/29/2025 at 12:10 PM in the fifth-floor dining room revealed one table had a red substance that was sticky spilled on it. Residents were observed to sit at the table to eat their lunch and were served their lunch trays without the table being cleaned. Further observation revealed the dining room floor had old food debris observed in several areas. d. Observation on 07/30/2025 at 10:20 AM, during the morning activity in the main dining room on the first floor, revealed the tablecloths were stained with spilled liquids. Further observation revealed the residents attending the activity were asked to sit at the tables with the stained tablecloths. e. In interview on 07/30/2025 at 1:20 PM, R43 stated housekeeping did come in his room every day, though the floor was still dirty and sticky after they were in. When the SSA Surveyor asked R43 how he felt about living at the facility, the resident stated, I have been in a lot of places since I had my amputations, and this is the worst place I have ever been. f. In telephone interview on 08/01/2025 at 8:35 AM, R44's Family member (FM) stated she had sent in pictures and a letter to corroborate how dirty the Resident's room was with linens lying on the floor with feces on them; soiled briefs left in the garbage can; and not taken out, and the floor dirty and sticky. She reported R44's room had a serious roach problem before; however, she had seen a pest control company in the room and the roach problem had been resolved. R44's FM said there was still a big problem with gnats in the Resident's room, though. She stated the floors in the facility were dirty and sticky every time she visited. The FM stated she saw housekeeping on the Resident's unit but never saw them in the Resident's room when she was visiting. She reported R44's room was often without paper towels to dry her hands with, so she had been bringing paper towels in for the Resident to use. R44's FM stated the Resident's room was also frequently out of toilet paper. g. In interview on 07/29/2025 at 10:05 AM, R143 stated, It's awful here. She reported having seen roaches in her room about a month ago and said, we shouldn't have to live like that. In an additional interview on 08/04/2025 at 3:00PM, R143 stated there was often a bad smell in the hallway. She stated, It just smells like shit up here all the time. The resident further stated her linens got changed, not very often, maybe once a month and sometimes her dirty linens just got left lying on the floor. 2. Observation on 07/30/2025 at 1:35 PM, revealed two flies and several gnats were flying about R153's and R115's room. Observation on 07/30/2025 at 1:50 PM, revealed R115's room had two flies and several gnats observed in it. a. In telephone interview on 08/01/2025 at 8:51 AM, R115's FM, stated gnats were a problem, all the time. He reported seeing the gnats all around R115's food and all around him in his bed. R115's FM stated the resident's trash was overflowing any time he came to visit the Resident, and there was even trash lying on the floor of the room. He explained it bothered him that R115's urinal was always sitting on the table right by his meal tray. b. In interview on 07/31/2025 at 9:35 AM, R170 stated he had seen a lot of cockroaches in his room and had reported that information to staff. R170 further stated a contract pest control agency had been in here (referring to his room) spraying a couple of times; however, the resident said he still saw roaches at night. R170 stated housekeeping was supposed to come every day but lately it's been only about every two days. I think that's just because they are short-staffed. The resident further stated his bed linens got changed most every day.In interview on 07/30/2025 at 2:05 PM, Medical Technician (MT) 1 stated she had seen gnats sometimes and had heard residents complain about the gnats. She said she thought the gnats were due to uncovered food and drink she saw in residents' rooms and gnats were drawn to that. MT 1 reported housekeeping was only here in the day shift hours so after night shift she saw a lot of crumbs and food debris and sometimes spilled drink and food. She further stated she thought having housekeeping staying later in the evening might help the gnat situation. In interview on 08/03/2025 at 12:20 PM, Certified Nursing Assistant (CNA) 12 revealed she had heard residents' complaints about pests and had also seen for herself the facility's issues with pests. She reported she had seen roaches and gnats mostly, and that the situation had gotten bad. CNA 12 further stated she had seen a pest control company coming out to the facility a lot. Interview with Licensed Practical Nurse (LPN) 11 on 08/03/2025 at 12:56 PM revealed that she has seen a good bit of gnats and has had some residents complain of gnats. The LPN stated that she had observed the pest control people coming out. In interview on 08/05/2025 at 3:23 PM, the Director of Nursing (DON) stated her expectation was for residents' bed linens to be changed on bath days and any time they needed to be changed. In interview on 08/05/2025 at 4:17 PM, the Administrator, who just started work at the facility the previous week, stated she expected the Guardian Angels to be making note of issues like pests, dirty environment, soiled linens, and odors on their rounds. She further stated if the pests' issues continued, she would have to change vendors from the current pest control company to another company that could get the issue under control.

AMENDEDBased on observation, interview, record review, and review of facility policies, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional needs, taking into consideration the preferences of each resident. Resident (R)44 had a known allergy to watermelon; however, staff continued to serve the Resident watermelon during her meal service. Additionally, R150's dietary order documented the resident should have no pork; however, this was not documented on the Resident's meal ticket and interview with R150 revealed staff continued to serve her pork which made her feel terrible. Further, the facility failed to ensure the Residents with allergies or specialized diets were care planned with appropriate interventions to address their needs. Lastly, interview with the Resident Council and R143 revealed the facility did not provide substitutes or alternatives to their meals or offer enough to eat which caused the Residents emotional distress making statements of being anxious, sad, and hangry. The findings include:Review of the facility policy titled, Specialized Diets, dated 10/01/2021, revealed residents' meals were to be prepared and served according to the prescribed diet. Per review, the menu card or tool that included the diet order, any restrictions, precautions, and resident preferences/dislikes was to be used by staff preparing and delivering food to the resident.1a.) Review of R44's Electronic Medical Record (EMR) revealed the facility admitted R44 on 11/27/2017. Resident's diagnoses included Multiple Sclerosis, Type II Diabetes Mellitus, Vascular Dementia, Essential (Primary) Hypertension, and Major Depressive Disorder. Further review of the clinical record revealed R44's allergies included: nuts, peanuts, and watermelon. Record review revealed that R44 had an allergy to nuts, peanuts, and watermelon documented on her EMR face sheet. These allergies were listed on the Allergies box on page one of her care plan. Her care plan also reflected planning for these allergies with one intervention listed, Monitor dietary card prior to serving for any food allergies. Review of R44's meal tray ticket and observation, on 07/31/2025 at 12:50 PM, revealed the resident had allergies to nuts, peanuts, and watermelon. However, observation revealed R44 was served watermelon on her tray.During interview with R44's Family Member, on 08/01/2025 at 8:35 AM, she stated she had a big concern that R44 was served watermelon as she was allergic to watermelon. Further, she stated she had observed watermelon on the resident's tray on several occasions, despite R44 having a documented allergy to watermelon.b. Review of R150 Electronic Medical Record revealed the facility admitted R150 on 06/21/2023 with diagnoses including cerebral palsy, malnutrition, and schizophrenia. The facility assessed R150 with a BIMS exam score of 14, indicating intact cognition. Additional record review revealed the resident had a dietary order for no pork. Review of the resident's meal tray ticket on 08/01/2025 at 3:00PM revealed no mention of this order. In an in interview with R150 on 08/04/2025 at 3:08 PM, the Resident stated that she was often served pork and stated that it made her feel terrible. Further, she stated that this continued to happen.Additionally, the facility failed to ensure the Residents with allergies or specialized diets were care planned with appropriate interventions. were care planned for their allergies and/or specialized diet. 2 a) Record review revealed the facility admitted R25 on 04/19/2022 with diagnoses including diabetes mellitus, renal insufficiency and a history of cerebral vascular accident (CVA). On 06/17/2025 the facility assessed R25 with a BIMS exam score of 15, indicating intact cognition. Additional review revealed R25 had a lactose intolerance documented on his face sheet. Review of the Resident's meal ticket revealed the resident was documented to be lactose intolerant. Review of his care plan revealed that while his lactose intolerance was listed on the first page of his care plan, there was no focus, goal, and interventions related to his lactose intolerance. b. Review of the clinical record under the face sheet revealed R52 had an allergy to shellfish. Review of the Resident's meal ticket revealed the resident was documented to have an allergy to shellfish. Review of the resident's care plan revealed her care plan had this allergy listed in the Allergies box on page one. However, there was no focus, goal, and interventions related to her shellfish allergy. c. Record review revealed the facility admitted R59 on 06/27/2019, with diagnoses including diabetes mellitus, dementia, and bipolar disorder. On 06/19/2025 the facility assessed R59 with a BIMS exam score of 8, indicating moderately impaired cognition. Continued review revealed a fish allergy was correctly documented on the face sheet in the EMR. Review of the Resident's meal ticket revealed he had an allergy to fish. However, his care plan stated that this resident had no allergies. d. Record review revealed the facility admitted R82 on 03/06/2025 with diagnoses including heart failure, dementia, and malnutrition. Review of the quarterly assessment dated [DATE] revealed the facility assessed R82 with a BIMS exam score of 15 indicating intact cognition. Continued review revealed R82's allergies to bananas and strawberries were correctly listed on her face sheet in the EMR. These allergies were listed on page one of her care plan in the box marked Allergies. However, there was no care planning in place for this resident's allergies. e. Record review for R101 revealed that his shellfish allergy was correctly documented in the EMR on his face sheet. This allergy was appropriately listed on page one of his care plan under the Allergies box. However, there was no focus, goal, or interventions in place for this allergy. In interview with Dietary Aide (DA) 1 on 08/01/2025 at 3:00 PM, he stated the purpose of the meal tray ticket was to ensure every resident receives the right diet meals. He further stated, someone could be allergic to seafood, for example.In interview with DA 2 on 08/01/2025 at 3:25 PM, he stated the meal tray ticket's purpose was to tell you the resident's diet. When the State Survey Agency (SSA) Surveyor asked DA 2 about the section on the tray ticket labeled allergies, he stated, It is the only way we would know what a resident was allergic to.In interview with the Regional Dietary Manager (RDM) on 08/02/2025 at 3:47 PM, she stated the tray ticket was a tool that instructed dietary staff on how to serve the resident meals. She reported it outlined the resident's diet, their consistency needs, dislikes, and allergies. In interview, the RDM emphasized the importance of the tray ticket for meeting residents' needs and to ensure we do not harm them. She stated, in regards to how she was made aware of residents' dietary orders, the dietary management software she used to print tray tickets was synchronized with Point Click Care (PCC, a cloud-based healthcare software provider) so any dietary orders inputted by clinical staff automatically synchs with her system.In interview on 08/05/2025 at 11:40 AM, the Director of Nursing (DON) stated PCC was intended to be integrated with the kitchen's dietary management software. She said when dietary orders were entered into the facility's PCC system, they were sent to the dietary manager. The DON reported her expectation was that residents' tray tickets matched the dietary orders documented in PCC. She stated however, the facility began using its current dietary management system approximately two to three weeks ago and noticed right away it was not integrated. The DON stated as a result, she had been manually entering any changes made to residents' dietary orders, as well as all dietary orders for any new admissions. Per interview, the DON stated she had only recently become aware the integration issue had not been limited to updates. She said she had learned the integration issue also affected pre-existing dietary orders. She further stated the facility was now manually auditing all residents' meal tray tickets; however, the process was currently incomplete.Review of the facility's policy, titled, Resident's Right to Make Personal Dietary, Food, and Meal Choices, dated 10/01/2021 and revised 05/22, revealed that the resident's diet order will be determined by the physician/practitioner with the resident and/or resident representative in accordance with his/her informed choices, goals, beliefs, and preferences, rather than exclusively by diagnosis and recommendations from the interdisciplinary team and the facility will offer alternate food choice, should the primary menus not meet the resident's choice or preference. 3) In an interview with the Resident Council with 10 residents present, on 07/31/2025 at 1:35 PM, revealed R30, R151, R150, R112, R19, R113, R70, R3, R173, and R7 stated they did not know who the dietician was and that they have attempted to get the dietician invited to Resident Council, but they have gotten no response. The residents further agreed in unison, they wanted their diets to be addressed by the dietician. Resident 30 stated that on 07/27/2025 she was served raw hamburger and four pieces of pasta for dinner. She stated that she reported this, and staff called the kitchen, but the kitchen had no food to provide as a substitute. 4) Review of facility record revealed the facility admitted R143 on 08/10/2022 with diagnoses including diabetes mellitus, CVA, and depression. On 06/24/2025 the facility assessed R143 with a BIMS score of 14 indicating intact cognition. In an interview with R143 on 08/04/2025 at 3:00 PM, she stated the food was cold most of the time when it was served. She said the food was not good, and that there was not enough food on the meal trays. R143 stated, a lot of times I go to bed hungry. She stated that this made her feel hangry, but it also makes me sad and anxious. In an interview with CNA12 on 08/03/2025 at 12:20 PM, she stated that she has had residents complain after a meal. Per the interview, she stated many of the residents have stated that they were still hungry after a meal. The CNA stated she has observed the residents' portion sizes to be too small and that, it never matches the slip, referring to the dietary ticket and what the portion size was supposed to be. Further, she stated she has had residents whose trays were not delivered to their units and were, forgotten and did not get a tray at all and when she had called down to the kitchen, she stated she was told all the food had already been thrown away and the resident had to eat a sandwich for that meal. In an interview with CNA13 on 08/03/2025 at 1:06 PM, she stated the residents complained about still being hungry after meals. Further, she stated, their portion sizes are not enough for a toddler. The CNA stated that she has reported this to the kitchen staff and has been ignored. Further, she stated she has witnessed the portions sizes being very small. The CNA stated at times, she would go to the kitchen and bug them until they gave her sandwiches or chips to take to the residents who were hungry. In interview with LPN12 on 08/03/2025 at 1:20 PM, she stated that she does hear complaints about residents still being hungry after meals. She stated that she has seen the portion sizes, and they were not sufficient in her opinion. In an interview with the Director of Nursing (DON) on 08/05/2025 at 11:49 AM, she stated that communication of dietary preferences should interface from information entered into Point Click Care to Dietary Manager. She stated that the dietary tickets should correctly reflect the allergies and food preferences of each resident. Further, she stated that any changes in residents' preferences would have to be manually entered by her. Per the interview, the DON stated that risk that would occur by not following a resident's diet preferences could restrict resident's intake and lead to weight loss. The DON stated that this was being done by the interim Administrator and was started when the previous Dietary Manager left approximately 1 month prior to this survey.

AMENDEDBased on observation, interview, and review of the facility's policy, the facility failed to ensure menus were prepared to meet the nutritional needs of residents in accordance with established national guidelines for 8 of 15 sampled residents of the total sample of 49 residents, (Resident (R)67, R88, R118, R115, R43, R70, R143, and R170). Interviews with the residents revealed they were often hungry and anxious as they were served small portions of food. Additionally, facility staff stated they did not have enough snacks to give to all the residents. The findings include:Review of the facility's policy titled, Kitchen Weights and Measures, dated 10/01/2021 revealed Food Services staff were to be trained in proper use of cooking and serving measurements to maintain portion control. Further review revealed the Food Service Supervisor was to ensure cooks prepared the appropriate amount of food for the number of servings required. 1) Observation of the lunch meal on 07/29/2025 at 12:10 PM revealed residents' portions were small. Per review of R88's meal ticket the resident was supposed to receive double portions. However, observation of R88's portions on the meal tray revealed the resident had received food that amounted to one serving. This lunch tray included a roll, a serving of cooked vegetables that consisted of one large piece of cauliflower, one large size and three small pieces of carrot, and approximately 10 small pieces of broccoli stalks and a cup of chicken and dumplings. When the resident placed his spoon into the chicken and dumplings, the chicken and dumplings did not cover the bowl of the spoon.In interview with R88 on 07/29/2025 at 1:25 PM, the resident stated his food was warm but complained that he felt like his portions were not sufficient. 2) In interview with R43 on 07/29/2025 at 9:45 AM, the resident stated his food was bad and cold and there was not enough food. R43 stated on 07/30/2025, he did not think the food at meals was enough. He stated the facility did not give the residents snacks. On this date, this resident received the same meal of a roll, cooked vegetables, and chicken and dumplings. His portions were consistent with that of R88. During the interview on 08/04/2025 at 3:38 PM, R43 stated, I am hungry most of the time because I don't eat because it is horrible. They do not offer snacks at night; I didn't even know they had them [snacks]. 3) In interview with R143 on 08/04/2025 at 3:00 PM, the resident stated the food was cold most of the time when it gets served. She stated the food was not good, and there was not enough food on the meal trays. R143 stated A lot of times I go to bed hungry. She stated that made her feel hangry, but it also makes me sad and anxious. The resident explained that the facility did not provide snacks in the evenings. She stated, they used to [provide snacks] sometimes but they haven't in a long time. R443 stated, I guess it costs too much for them to give us snack. You have to buy your own stuff if you want a snack here. 4) In interview with R115 on 07/29/2025 at 10:40 AM and on 07/30/2025 at 1:35 PM, the resident stated there was never enough food served at each meal, and he was often hungry after meals. He stated he had snacks in his room that his family/friends brought in to him. R115 stated the facility did not provide snacks to residents without the residents having to ask for them. 5) In interview with R70 on 07/31/2025 at 9:35 AM, the resident stated the portion sizes at meals were not nearly enough. He stated he was supposed to get double portions at meals but that was still not enough. 6) In interview with R170 on 08/04/2025 at 2:35 PM, the resident stated she did not feel like the meal trays contained enough food. She stated, I'm always hungry, that's why I got that refrigerator so I can have my own snacks. R170 stated when she was still hungry after meals, it made her feel anxious. 7) In interview with R67 on 07/29/2025 at 11:35 AM, the resident stated he did not get enough to eat as the serving sizes did not satisfy him and so he was hungry most of the time. He stated when he asked staff for more food, they told him there was no more. R67 stated he was not offered snacks, and when he requested a snack, staff told him they did not have any to give him. 8) In interview with R118 on 07/29/2025 at 3:53 PM, the resident stated he did not feel he got enough food to eat. R118 stated after meals he was still hungry, and staff did not offer him any snacks. Observation of the tray line on 07/31/2025 at 11:15 AM during the lunch service, revealed the Regional Dietary Manager (RDM) had to instruct the Dietary Aide (DA) who was plating meals to fill the scoop completely. Further observation revealed the RDM explained to the DA that the initial portion she (the DA) plated had not met the required serving size. In interview with Certified Nursing Assistant (CNA) 12 on 08/03/2025 at 12:20 PM, she stated she had residents complain after a meal that they were still hungry. She stated she heard residents, especially those who were on a pureed diet, say they were hungry between meals. CNA 12 stated she had observed the portion sizes on residents' meal trays being too small. She stated, It never matches the slip referring to the dietary ticket and what the portion size was supposed to be. CNA 12 explained that dietary did not send up enough snacks for each resident in the evenings. She stated the snacks were usually PB&J (peanut butter and jelly) that were sent up on the dinner tray cart. The CNA stated, It's never enough for everyone. She stated she had residents who had been forgotten and had not received a meal tray at all. CNA 12 stated when she called down to the kitchen, she was told all the food that had been served had already been thrown away, so the resident had to eat a sandwich for that meal. In interview with CNA 13 on 08/03/2025 at 1:06 PM, she stated she had residents complain about still being hungry after meals. She stated, their portion sizes are not enough for a toddler. CNA 13 explained she had reported that information to the kitchen but had been ignored. She stated she had witnessed the portions sizes being very small. The CNA stated, Sometimes we get snacks and sometimes we don't. She stated when snacks were sent up from the kitchen, there was not enough snacks for every resident on the floor. CNA 13 stated she went to the kitchen and would bug them until they gave her sandwiches or chips to take to the residents who were hungry. In interview with Medication Technician (MT) 1 on 07/30/2025 at 2:05 PM, she stated she did hear residents complaining about not having enough food at meals. She stated she had observed that the portions were very small and seemed insufficient to her. MT 1 stated she would take sandwiches and snack items off of the cart when meals were served. She explained she then labeled and dated the sandwiches and snacks and placed them in the fridge so she had something to feed residents if they complained of still being hungry. However, MT 1 stated there was not enough of those sandwiches and snacks for each resident to have some. In interview with Licensed Practical Nurse (LPN) 7 on 07/31/2025 at 4:54 PM, she stated she had heard residents complaining of still being hungry after meals because they did not get enough food at meals. She stated the residents had been complaining of small portion sizes. LPN 7 stated she had visualized portions on residents' meal trays that were too small. In interview with Licensed Practical Nurse (LPN) 11 on 08/03/2025 at 12:56 PM, she stated she had witnessed some of the residents' meal trays and felt the portion sizes were not sufficient. She stated she had reported that to the kitchen and was told that, they would do better. LPN 11 stated dietary did not send up snacks for each resident in the evenings. She further stated dietary sent up a tray of snacks on the dinner cart; however, that was not enough for each of the residents to have a snack. In interview with LPN 12 on 08/03/2025 at 1:20 PM, she stated she did hear complaints about residents still being hungry after meals. She stated she had seen the portion sizes, and they were not sufficient in her opinion. LPN 12 stated the kitchen sent up sandwiches and snacks and she thinks there was enough for all residents. In interview with Dietary Aide (DA) 1 on 08/01/2025 at 3:00 PM, he stated he had gotten a lot of feedback from residents and staff regarding food portions. He stated there was one resident specifically who was supposed to get double portions, and he complained he still did not feel it was enough food. In interview on 08/01/2025 at 3:47 PM, the Regional Dietary Services Manager (RDSM) stated the cook was the person who chose the scoop for serving the residents' food. She stated she was going to get a color-coded chart that listed each scoop and the amount the scoop served and post it in the kitchen for staff to reference. In interview with the Regional Registered Dietician (RRD) on 08/05/2025 at 11:25 AM, she stated prior to switching menu companies a month ago she was aware of portion size concerns. The RRD stated she thought that was an ordering process issue.In interview with the Director of Nursing (DON) on 08/05/2025 at 11:49 AM, she stated she had not seen any issues herself with the residents' portion sizes on meal trays. She stated she had residents complain of that before, but it had been a while. The DON stated she had gone to the Dietary Manager at the time, and he made sure the kitchen staff were using the correct measuring devices. She stated she would be surprised to hear that multiple residents were complaining of being hungry because that was not a complaint she had been hearing. The DON stated the facility had a food council previously, which was a resident council meeting every week to meet and discuss food issues. She stated the interim Administrator had done that and the issue started when the previous Dietary Manager left. The DON stated when they switched over from contracted dietary staff to in-house dietary staff things started to get better.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure each resident was provided a nourishing snack at bedtime. This had the potential to affect all residents receiving snacks from the facility's kitchen. The findings include:Review of the facility's policy titled, Between Meal and Bedtime Snacks, dated 10/01/2021 revealed, the purpose of this procedure is to provide the resident with adequate nutrition. This policy further stated, review the resident's care plan and provide for any special needs of the resident, check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. It also stated, the person performing this procedure should record the following information in the resident's medical record: date and time the snack was served, name and title of the individual who served the snack, amount of snack eaten by the resident (i.e. 50%m 75%, etc.). Finally, this policy stated, notify the licensed nurse if the resident refused the snack and the reason why and the intervention taken.1 a. Interview with Resident Council, in the afternoon of 07/31/2025, revealed the residents stated that they did not get snacks, especially since the new people took over. Per the interview, the residents stated, yesterday they [facility staff] did give out peanut butter and jelly sandwiches, but they [the residents] only received that due to state or corporate being in the building b. R70 stated (during the Resident Council meeting) that when the last company was in charge, he had arranged for snacks to be sent up on lunch and dinner trays but when the new company took over the snacks stopped.c. Observation of the refrigerator on the second floor on 08/01/2025 at 10:40 AM revealed there were four sandwiches contained in plastic wrap. Only one of the sandwiches was dated, and the date was 07/30. On 08/01/2025 at 10:53 AM observation of the residents' refrigerator located on the fourth floor held three sandwiches contained in plastic wrap and none of the sandwiches were labeled or dated. There were also seven packets of Goldfish crackers. Further observation on 08/01/2025 beginning at 12:15 PM revealed there were no longer any snacks in the second-floor residents' refrigerator, there were five peanut butter and jelly sandwiches and seven packet of Goldfish crackers in the fourth-floor residents' refrigerator. There were no snacks in the residents' refrigerators on the fifth, sixth, and seventh floors. d. Interview with R43 on 07/29/2025 at 9:45 AM revealed the facility did not give the residents snacks. During interview with R43 on 08/04/2025 at 3:38 PM he stated, They do not offer snacks at night; I didn't even know they had them. e. During interview with R8 on 07/29/2025 at 10:18 AM, the resident stated the facility did not offer snacks. f. R99 stated on 07/29/2025 at 10:38 AM that the facility did not offer any snacks. He stated that he orders snacks from Amazon, and his family/friends bring him food because otherwise he would be hungry. g. During interviews with R115 on 07/29/2025 at 10:40 AM and on 07/30/2025 at 1:35 PM, he stated that there was never enough food served at each meal, and he was often hungry after meals. R115 stated that he has snacks in his room that his family/friends bring him. He stated the facility did not provide snacks to residents without the resident having to ask. h. During interview with R67 on 07/29/2025 at 11:35 AM, he stated he was not offered snacks. R67 stated that when he requested a snack, staff told him that they did not have any to give. i. During Interview with R118 on 07/29/2025 at 3:53 PM, he stated he did not feel as though he got enough to eat. R118 stated that after meals he was still hungry and that staff did not offer him any snacks. j. During interview with R143 on 08/04/2025 at 3:00 PM, she stated the facility did not provide snacks each evening. The Resident stated, they used to sometimes, but they haven't in a long time. She stated, I guess it costs too much for them to give us snacks and You have to buy your own stuff if you want a snack here. In an interview with CNA 13 on 08/03/2025 at 1:06 PM, she stated that when snacks were sent up from the kitchen, there were not enough snacks for every resident on the floor. She stated that she would go to the kitchen and bug them until they gave her sandwiches or chips to take to the residents who were hungry. During interview with Medical Technician (MT) 1 on 07/30/2025 at 2:05 PM, she stated she has heard the residents complain about not having enough food. Further, she stated the facility did not have enough for each resident to receive a snack. During interview with LPN11 on 08/03/2025 at 12:56 PM, she stated that dietary did not send up snacks for each resident in the evenings. She stated, They do send up on the dinner cart a tray of snacks. However, she stated that this was not enough for each resident. During interview with LPN12 on 08/03/2025 at 1:20 PM she stated that she had heard residents complain about still being hungry after meals. She stated that she had seen the portion sizes, and they were not sufficient in her opinion. LPN12 stated that the kitchen sends up sandwiches and snacks and that she thinks it was not enough for all residents. During the interview with the Regional Registered Dietician on 08/05/2025 at 11:25 AM, she stated that she thought this was an ordering process issue. However, stated she was not intimately involved in the process. During interview with the DON on 08/05/2025 at 11:49 she stated that she expected residents to have a nourishing snack whenever they want. She stated, I want them to have enough but I would have to get with the dietician to find out what constitutes a nourishing snack. The DON stated that her expectation was that there should be enough snacks provided for every resident and that staff should hand out a snack to each resident. She stated that the CNAs should document in the Electronic Medical Record whether or not the resident accepted or refused snacks, how much of the snack they consumed, and that the N/A (low sodium) option would only apply to residents with g-tubes. The DON stated that the facility was required to provide a nutritious snack at bedtime.

Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety which had the potential to affect all residents consuming meals from the kitchen. The findings include:Review of facility policy titled, Dishwashing Machine Use, undated, revealed high temperature sanitation dishwashing machines hot water sanitation rinse temperatures may not be more than 194 degrees ( ) Fahrenheit (F), or less than 165 F for stationary rack, single temperature machines and 180 for all other machines. Review of the instructions provided on the facility's document titled, Dish Machine Log - Low Temp, dated 2019, revealed staff were to, Record wash temperature and sanitizer PPM (Parts Per Million) provide initials, three times per day.Review of the facility's May 2025 dishwashing records revealed staff were documenting on a form titled, Dish Machine Log - Low Temp, dated 2019, which instructed staff to record wash temperature and sanitizer PPM three times per day and to notify supervisor immediately if sanitizer PPM is not within acceptable range of 50-100. Per review, the form was intended for a low-temperature dishwasher utilizing chemical sanitizer.Review of the May 2025 low-temperature log revealed staff had been recording temperatures in both the wash and PPM columns rather than an actual sanitizer concentration. Further review revealed the recordings noted under the PPM column appeared to be temperatures for the rinse cycle.1.Observation of the kitchen on 07/29/2025 at 8:36 AM, during the initial tour, of the dish machine log temperatures revealed the last recorded temperatures noted for all three meals was on 05/31/2025. Per review, there was no record of temperatures recorded for the dish machine in the month of June 2025. The facility never provided a June log as per the request. Continued review of the dish machine logs revealed for the month of July, a Dish Machine Temperature Log, had been initiated and included a space for recording wash temperatures, final rinse temperatures, and utensil surface temperature. Further review revealed the July 2025, Dish Machine Temperature Log had only been completed for days 1 through 10; however, temperatures had only been recorded for the breakfast and lunch time periods. Additional observation on 07/30/2025 at 10:25 AM, and on 07/31/2025 at 11:12 AM, revealed no recorded temperatures for either of those days. Further observation on 08/01/2025 at 2:50 PM, revealed a new log with recordings starting on that day. In interview with Dietary Aide 2 on 08/01/2025 at 3:25 PM, he stated dishwasher temps are recorded by aides. In interview on 07/30/2025 at 10:25 AM, the Dietary Manager stated she became aware the dishwasher had not been reaching the appropriate temperature for sanitization. She stated the facility had switched to chemical sanitization as of that day. However, she stated due to the lack of accurate and complete dish machine temperature logs since 07/10/2025, it could not be determined how long the dishwasher had been operating below the required sanitization temperatures. She stated they did not know whether dishes used for meal service between 07/10/2025 and 07/29/2025, had been properly sanitized in accordance with food safety standards. During initial tour and interview with the Regional Dietary Manager (RDM) on 07/29/2025, which began at 8:36 AM, the Regional Dietary Manager stated the facility had a high-temperature dishwasher, which did not use chemical sanitizer and required documentation of the final rinse temperature. The RDM stated she had been made aware of the incomplete logs for the dish machine. She stated, We are going to start fresh in August. In a follow-up interview on 08/22/2025 at 4:35 PM, the RDM stated dishwasher temperatures should be done after each meal-breakfast, lunch, and dinner-and confirmed this was the responsibility of the dietary aide working in the dishwashing room. Regarding the risks posed by failure to maintain dishwasher temperature logs, she stated, there could be bacteria on the plates and that could cause illness; if the logs aren't done, we won't catch it. It is preventative.In an interview with the Director of Nursing (DON) at 4:22 PM on 08/22/2025, she stated her expectation was that the logs be up-to-date and accurate. Regarding the risks posed by failure to maintain temperature logs, she stated, the logs confirm temps are correct. Incorrect temps could lead to improper sanitation of the dishes, which could result in illness.Per review of the facility's policy titled, Refrigerators and Freezers, dated 10/01/2021, revealed, All food will be properly dated to ensure proper rotation by expiration dates. Per review, received dates (date of delivery) were to be marked on cases and on the individual items removed from the case for storage. Continued review revealed the use by dates might be completed with expiration dates on all prepared food in the refrigerators. Further review revealed expiration dates on unopened food were to be observed and the use by dates indicated once food was opened. In addition, supervisors/designees were responsible for ensuring food items in the pantry, refrigerators, and freezers were not expired or past perish dates.2a). Observation on 07/29/2025 at 8:30 AM, of the walk-in freezer revealed: two boxes of sweet potato fries that expired on 03/06/2025; a box of hashbrowns that expired on 02/14/2025; and a box of fries that expired on 05/2025. Per observation, the spice shelf, located at the back of the kitchen, contained multiple expired and undated items that included: basil leaves expired 08/07/2024; ground cloves expired 03/17/2024; ground allspice expired 07/10/2024; dill weed expired 11/2024; ground cinnamon with no expiration date; another ground cinnamon expired 07/14/2025; ground sage with no expiration date but labeled opened 9/11; and a box of chicken flavor base with no date. Continued observation revealed the following: burgundy kitchen wine expired 09/01/2024; red wine vinegar expired 01/20/2025; and an opened container of soy sauce stored unrefrigerated despite labeling that stated, refrigerate after opening. Additionally, observation on 07/29/2025 at 8:30 AM, of the dry storage room revealed: one box contained six cartons of thickened dairy drink, honey consistency, expired 06/12/2024; another box containing 12 cartons expired 08/24/2024; and a third box with seven cartons expired 06/12/2024. Observation also revealed a separate box containing six cartons of thickened dairy drink, nectar consistency, expired 10/04/2024, and another box contained two cartons expired 10/03/2024; and two boxes of thickened tea packets (one expired 11/08/2024 and the other expired 03/09/2025). Further observation of the dry storage room revealed: a white carton of unidentified liquid with no label or date; a bag of shredded coconut expired 07/10/2025; an unmarked, opened bag of brown sugar; two boxes of rice pilaf with no dates; and a box of 24 cans of diced sweet red peppers with no visible date.In interview with Dietary Aide (DA) 1 on 08/01/2025 at 3:00 PM, he stated, basically everyone is responsible for removing expired items from the kitchen, adding, We all look at dates. He stated, some of my coworkers don't know the process, like how the first items in should be the first used. He stated he was often the one who stocked the delivery of dry goods, and he dated the food upon arrival.In interview with the Dietary Manager (DM) on 08/05/2025 at 3:47 PM, she stated she was training staff to label food with the date it was received. The DM stated that she and the cooks were responsible for ensuring expired food was disposed of as required. She stated, typically the morning cook will do a sweep as she preps, the same with the PM cook. The DM stated her expectation was for the cook to take responsibility for it, but I also do it as I do my weekly inventory checks.In an interview with the DON at 4:22 PM on 08/22/2025, she reported her expectation was that there would be no food present in the kitchen past the expiration date. Regarding the potential risks of residents consuming expired food, she stated, residents could become sick.(b). Observation on 08/01/2025 at 10:40 AM, of the residents' refrigerator on the second floor revealed four sandwiches wrapped in plastic, of which only one was dated (07/30/2025). Per observation, a shopping bag in the refrigerator drawer held an energy drink and peanut M&Ms that were unlabeled and undated. Observation of the freezer section of the residents' refrigerator revealed it held a blue fabric shopping bag tied shut and bound with rubber bands, which was not labeled nor dated. Observation on 08/01/2025 at 10:53 AM, of the fourth-floor resident refrigerator revealed it contained three sandwiches wrapped in plastic, none of which were labeled or dated. Observation on 08/01/2025 at 11:05 AM, of the seventh-floor resident refrigerator revealed it contained two boxes of pizzas that were unlabeled and undated.In interview with Certified Nursing Assistant (CNA) 9 on 08/01/2025 at 11:06 AM, she stated all items in the residents' refrigerators, located on each unit, must have the date the item was put in the fridge, as well as the initials of the resident if it was an item specifically for that resident. She stated, in regard to whose responsibility it was to ensure refrigerators were maintained as required night shift cleaned them out every night.In interview with CNA (Certified Nurse Aide) 10 on 08/01/2025 at 11:33 AM, she stated all items in the residents' refrigerators were required to be marked with the resident's name and dated. CNA 10 stated, CNAs are responsible for them, and they should be checking them daily.3(a). Review of the facility's policy titled, Refrigerators and Freezers, dated 10/01/2021, revealed the acceptable temperature range for freezers was less than zero degrees.Observation on 07/29/2025 at 8:30 AM, of the walk-in freezer revealed a temperature of 7 F. Observation on 07/30/2025 at 10:25 AM, revealed the walk-in freezer remained at 7 F. In interview on 08/05/2025, the Regional Dietary Manager (RDM) stated freezers were to be maintained at two degrees or less. The RDM stated the freezer would have been out of compliance at 7 F. She stated she was unaware the policy required a temperature of less than zero degrees F. In an interview with the DON at 4:22 PM on 08/22/2025, she reported her expectation was for freezer temperatures to be at the required range. Regarding the risks posed by out-of-range freezer temperatures, she stated, food could spoil, which could make residents ill.(b). Further review of the facility's policy titled, Refrigerators and Freezers, dated 10/01/2021, revealed, Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and closing in the evening. Further policy review revealed the Supervisor, or designee was to take immediate action if temperatures were out of range. Observation on 07/29/2025 at 8:30 AM, of the walk-in refrigerator revealed no temperature log in place. Continued observation revealed a temperature log posted on the door; however, the last recorded temperature was on 06/30/2025. Observation on 07/29/2025 at 8:42 AM, revealed reach-in freezer number three had a log posted, with the most recent temperature recorded on 07/22/2025. Additional observation on 07/30/2025 at 10:18 AM and on 07/31/2025 at 11:17 AM, revealed no changes to the temperature logs on the walk-in refrigerator and walk-in freezer. In interview on 08/01/2025 at 3:00 PM, DA 1, who was responsible for maintaining temperature logs for the refrigerators and freezers in the kitchen, stated, I believe it is the cook that does that. In interview on 8/01/2025 at 3:25 PM, DA 2 stated the cooks were responsible for recording the refrigerator and freezer temperatures.In interview on 08/05/2025 at 3:47 PM, the RDM stated logging refrigerator and freezer temperatures was the responsibility of the cooks. She stated she was ultimately responsible for making sure that happens. In an interview with the DON at 4:22 PM on 08/22/2025, she reported her expectation was for refrigerator and freezer temperature logs to be completed according to policy and procedure, and to be up to date and accurate. Regarding the risks posed by temperature logs not being maintained, she stated, food could spoil, and residents could become ill if they consume expired food.Review of the facility's policy titled, Food Preparation and Service, undated, revealed under the section, Specific Procedures/Guidance of the Food Preparation Area, noted food preparation staff were to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Further review revealed under the section titled, Food Service/Distribution, revealed, Gloves are worn when handling food directly and changed between tasks.4. During lunch observation on 07/30/2025 at 12:15 PM, the dietary aide (DA) responsible for plating food was observed to stop serving food, wipe sweat from her forehead and face with a paper towel with her gloves still on, then placed the soiled paper towel on the counter behind her. However, she did not wash her hands before continuing to serve food. The RDM was present overseeing the tray line at the time and observed the DA's action but did not provide redirection. Continued observation at 12:30 PM, revealed the same DA left the tray line, walked to the back of the kitchen, got a replacement dish of peas and carrots, and once again resumed plating food without replacing her gloves. The RDM observed the DA's actions but did not prompt the DA to perform hand hygiene. Further observation at 12:45 PM, revealed another dietary staff member left her workstation, where she had been placing napkins with silverware together, to go assist on the tray line. Additionally, observation revealed that staff member retrieved hamburger buns and patties needed to make hamburgers for the tray line without washing her hands between the tasks. In interview on 08/01/2025 at 3:00 PM, DA 1 stated, Every time you step out of the kitchen; anytime you switch gloves, go to a different workstation, handle trash, or touch your clothes, hand hygiene was to be performed. DA 1 stated if there was a break in task while plating food, you should Wash your hands and put on new gloves. He further stated, You are touching new things when performing the new task, such as retrieving an item from elsewhere in the kitchen, and that could cause cross-contamination.In interview with DA 2 on 08/01/2025 at 3:25 PM, he stated staff should wash their hands and put on new gloves if they needed to take a break from plating food to obtain something elsewhere in the kitchen. DA 2 stated, Switch gloves; you have to do this anytime you touch something different or do something different.In interview with the RDM on 08/05/2025 at 3:47 PM, she stated staff needed to wash their hands and re-glove if they go to grab something or walk off the tray line.In an interview with the DON at 4:22 PM on 08/22/2025, she reported her expectation was for staff to follow hand washing policies. Regarding the risks posed by improper hand hygiene, she stated, bacteria that could cause illness.

Based on interview, policy review and record review, the facility failed to provide a bed hold notification for 2 out of 5 sampled residents (Resident (R)46 and R18) when an emergent transfer to the hospital was necessary.The findings include:Review of the facility's policy titled, Bed Hold undated, revealed that if it is an emergency transfer, a written bed hold notice must be given to patient or patient representative within 24 hours. Per the policy, the each family is provided information on the bed hold policy at the time of admission as well for transfers planned or emergent.1. Review of Resident (R)46 Electronic Medical Record (EMR) revealed the resident was sent to the emergency room on [DATE] and 07/11/2025 and there was no documentation of a bed hold notification given to the resident or her representative in the electronic or paper chart. The facility was unable to produce copies of the bed hold notifications for these hospital visits.During an interview with R46 on 08/01/2025, she stated she does not recall ever being given a bed hold notice. 2. Review of R18's EMR revealed she was sent to the emergency room on [DATE] and there was no documentation of a bed notification given to the resident or her representative in the electronic or paper chart. The facility was unable to produce copies of bed hold notifications for these hospital visits. During an interview on 08/04/2025 at 1:20 PM Licensed Practical Nurse (LPN) 3 the unit seven manager, stated that at one time the nurses on the floor gave the bed hold notices to the residents but that it was the business office that would complete the bed hold notifications now.During an interview with the current Business Office Manager (BoM) on 08/04/2025 at 1:35 PM, she stated that the nurses on the floor were responsible for issuing a bed hold notifications for all emergent hospital visits.During an interview on 08/04/2025 at 2:41 PM with the Human Resources1(HR1), the prior BoM, stated that bed hold notifications were given by the nurses on the unit in the case of emergent situations.During an interview with LPN 13 on 08/04/2025 at 2:49 PM, she stated that when a resident was sent out in an emergency, the nurses on the floor give the bed hold notification to the resident or the resident representative.During an interview with the Director of Nursing (DON) on 08/04/2025 at 3:20 PM, she stated the facility policy and expectation was that each resident would be given a bed hold notification before transfer to the hospital, and that it was the responsibility of the floor nurses to ensure the resident or resident representative was given the form.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs and medical supplies were stored in accordance with professional standards including expired medications and products. This affected 1 of 3 treatment carts.The findings include:Review of the facility's policy titled, Medication Storage, not dated, revealed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologics. All such drugs shall be returned to the dispensing pharmacy or destroyed. In addition, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. As well as Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologics shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During an observation on 07/31/2025 at 9:03 AM of the seventh-floor treatment cart revealed one roll labeled, Unna Rite boot with zinc. This item expired 05/2024. Further observation revealed one Comprilan bandage 10 cm (centimeter) x 5cm; expiration date of 07/14/2025; and one bottle of Sodium Chloride Irrigation which expired 07/19/2024. During an interview on 07/31/2025 at 9:11 AM, with the unit manager/Licensed Practical Nurse (LPN) 3, she stated that there were not any expired items in the treatment cart, she had gone through it herself. She stated the nurses were responsible for ensuring treatment items stored inside the cart were maintained with current dates. She stated she was the unit manager and ultimately it was her responsibility. She stated it was an oversite on her part. During an observation on 07/31/2025 at 9:31 AM of the first-floor employee medication refrigerator located in a room used for new employee orientation revealed the room was without a lock. Further observation revealed one bottle of hot sauce stored with one bottle of flu vaccine and one bottle of Tuberculin testing. During an interview on 08/01/2025 at 1:49 PM with the Director of Nursing (DON), she stated the nurses on each unit were responsible for proper maintenance of the treatment carts. She stated her expectation for expired products was that they would be discarded. She stated that the facility had an orientation class for new hires in the room with the unlocked refrigerator that stored the employees' flu vaccines and Tuberculin testing. The DON stated she believed one of the staff had placed the bottle of hot sauce in the refrigerator. During an interview on 08/05/2025 at 1:49 PM with the Administrator, she stated she was not aware who specifically managed the treatment carts, but it should be a nurse. She stated each shift a nurse should ensure that treatment carts did not have any expired medications or products. The Administrator stated she did not know who oversees the maintenance of the medication refrigerators. She stated someone in nurse management should ensure that items like a bottle of hot sauce were not stored in the medication refrigerators.

Based on observation, interview, record review, and review of the facility's policies and procedures, the facility failed to implement appropriate transmission-based precautions for 3 of 49 sampled residents, Resident (R)183, R184, and R70. This failure had the potential to result in the transmission of a communicable disease to other residents, staff, and visitors.The findings include:Review of the facility's policy titled, Infection Control Program, no revision date listed, revealed the facility was responsible for, Development isolation precaution protocols for when control of an infectious or communicable disease or disease risk is required in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations.Review of the facility's policy titled, Infection Prevention and Control Committee, no revision date listed, revealed duties of the Infection Preventionist and/or committee included, Review, and revise, if necessary, isolation precaution techniques and procedures to help ensure personnel, residents, and visitors follow established procedures/precautions. Further review revealed training, and education should include standard and transmission-based precautions as well as types of personal protective equipment (PPE) that were to be used when performing tasks that may involve exposure to blood/bodily fluids and the procedures to follow when PPE was used. 1.Review of R183's Electronic Medical Record (EMR) under the physician's orders, dated 07/28/2025 at 7:00 PM, revealed, Contact/Droplet Precautions due to Covid +.Observation on 07/29/2025 at 10:34 AM, revealed R183's door had a sign that indicated she was on enhanced barrier precautions. PPE was observed in a cart outside R183's door. Observation on 07/29/2025 at 11:21 AM, revealed the sign on the outside of R183's door had been changed to indicate the resident was on droplet precautions. Interview with Licensed Practical Nurse 1 (LPN1) on 07/29/2025 at 10:34 AM, revealed R183 had a diagnosis of COVID-19. Further interview with LPN1 revealed R183 should be in transmission-based precautions, she was unsure if it should be contact or droplet. During interview with LPN1 on 07/29/2025 at 10:34 AM, she stated if anyone went into R183's room without donning (putting on) the appropriate PPE. She stated they could potentially be infected with COVID-19 and spread it throughout the facility. LPN1 stated having the correct sign on R183's door with the correct transmission-based precautions listed was very important.2. Review of R184's electronic medical record (EMR) under Orders revealed there was an order for R184 to be on enhanced barrier precautions. Observation on 07/31/2025 at 8:17 AM revealed Medication Technician 3 (Med Tech 3) removed the enhanced barrier precautions sign from R184's door. Further observation revealed Med Tech 3 entered the room without donning personal protective equipment (PPE).Observation on 07/31/2025 at 8:23 AM revealed Licensed Practical Nurse (LPN) 3 approached Med Tech 3 and informed Med Tech 3 that R184 was supposed to be on enhanced barrier precautions. LPN 3 stated the signage should still be on R184's door, even though the PPE container was not sitting outside R184's room. During interview with Med Tech 3 on 07/31/2025 at 8:17 AM, she stated R184 should not be on transmission-based precautions. Med Tech 3 stated on 07/31/2025 at 9:52 AM, that the way staff were informed of a resident being on transmission-based precautions or on enhanced barrier precautions was when there was .a bin with PPE gear near the resident's room to alert staff that the resident is on enhanced barrier precautions. Med Tech 3 stated, I should have verified with the nurse, for the safety of the resident and the safety of staff.During interview with LPN 3 on 07/31/2025 at 10:04 AM, she stated she expected staff to keep the enhanced barrier precautions sign posted on R184's door, and Make sure there is a bin in front of the resident's door with enhanced barrier precautions. LPN 3 stated that if there was a PPE container in the vicinity of the resident's room, that was acceptable. 3. Review of R70's Electronic Medical Record (EMR) under Orders revealed a physician's order for transmission-based precautions of Contact Isolation. The order was dated 07/04/2025. Observation on 07/29/2025 at 10:50 AM revealed R70 had an enhanced barrier precautions sign outside the door as well as PPE. Observation on 07/30/2025 at 9:20 AM revealed R70's door still had a sign for enhanced barrier precautions outside R70's door, as well as PPE. Observation on 07/30/2025 at 1:45 PM revealed R70's signage on his door had been changed to transmission-based precautions of Contact Isolation. During an interview with the Infection Preventionist (IP) on 08/01/2025 at 10:07 AM, she stated residents would be in enhanced barrier precautions when they had any organic opening in the body, such as a gastrostomy tube (G-tube/feeding tube), an indwelling catheter, or an intravenous catheter (IV). The IP stated precaution orders were communicated between staff by the CARDEX and in each resident's care plan. She stated the nurse could discern that a resident needed to be in transmission-based precautions, specifically droplet isolation, and was able to implement these precautions prior to the physician entering orders into the EMR. The IP stated the resident required transmission-based precautions of droplet isolation for COVID-19.During an interview with the Director of Nursing (DON) on 08/05/2025 at 3:20 PM, she stated she expected an order to be in the resident's EMR, the precautions placed in the resident's care plan, a sign on the door, and PPE to be outside the room for any resident on transmission-based precautions. The DON stated if a resident was admitted with COVID-19, she expected staff to go ahead and have the resident placed in contact or droplet isolation precautions, prior to the physician giving the order. The DON stated when a resident was in enhanced barrier precaution, staff only needed to don PPE if they provided direct care to the resident. The DON stated when a resident was in transmission-based precautions of contact isolation, staff should don PPE prior to entering the resident's room.

Based on observation, interview, record review, and review of facility policy, it was determined the facility to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation revealed multiple food items in the pantry, refrigerator and freezer that were opened but not dated. Further observation revealed kitchen staff were not properly wearing hair restraints to prevent hair from contacting food. The findings include: The facility did not provide any policies requested by the survey team related to labeling and dating food items, food storage, or hairnets. Observation of the facility kitchen's dry storage pantry, on 07/08/2024 at 11:00 AM, revealed a country style gravy package opened, re-sealed and undated. A package of turkey gravy wrapped in plastic wrap but was not dated. A package of brownie mix wrapped in plastic wrap and sealed but not dated. A package of pasta noodles was sealed but not dated. A bottle of worcestershire sauce was opened, and had an original label, but no date. Continued observations included Refrigerator A, and revealed a sheet pan of gelatin cake stored with wax paper lying on top but not sealed properly. Further observation of the walk-in Refrigerator, revealed a large bag of shredded cheddar cheese, wrapped in plastic wrap but not dated. A package of sliced cheddar cheese was wrapped in plastic wrap but not dated. Additional observation revealed a rolling bread cart with a package of sliced bread, sealed but not dated. Observation of Dishwasher 1, on 07/08/2024 at 11:15 AM, revealed he was wearing a hairnet; however, the hairnet was not worn properly, and his hair hung down outside the hairnet. In an interview with Dishwasher 1, on 07/08/2024 at 11:20 AM, he stated he worked in the facility for about three weeks. He stated he was a dishwasher but worked in the kitchen wherever assigned. He stated he was aware that hairnets were to cover all the hair to prevent hair from falling into resident's food and cause contamination. In an interview with the Dietary Manager, on 07/08/2024 at 11:30 AM, he stated he worked in his position since 03/2024. He stated he was aware food items were to be labeled and dated when stored in the pantry, and/or refrigerators and freezers. Generally, he stated he was responsible for ensuring those food items were sealed, labeled, and dated. He further stated he did not want to serve residents unsafe food products. In an interview with the Director of Nursing (DON), on 07/12/2024 at 6:46 PM, she stated she expected all dietary staff to follow food service safety guidelines and to ensure they were wearing the hairnets properly. During an interview with the Administrator, on 07/12/2024 at 7:07 PM, he stated, regarding hairnets and food storage, that dietary staff should always follow CMS guidelines, state and federal regulation, and the facility policy and procedures regarding food safety and resident safety.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Observations revealed staff entering resident rooms marked with precaution signage without donning (putting on) protective equipment. Additionally, observations of the facility laundry room revealed concerns including incorrect ventilation, lack of defined sorting areas, and no personal protective equipment available for staff use. The findings include: Review of facility policy Guidelines for Infection Prevention Control, revised 04/05/2022, revealed the purpose of the policy included to establish, maintain, and manage an effective infection prevention and control program. Added review revealed the program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Continued review revealed standard and transmission-based precautions were followed to prevent spread of infection. Continued review revealed facility personnel handled/stored/processed and transported linens to prevent spread of infection. Review of facility policy Infection Control/Isolation Guidelines revised 08/01/2023 revealed the objective of the policy was to prevent unprotected exposure of residents, visitors, and staff to potentially infectious microorganisms or diseases and to decrease the spread of in-house acquired infections. Added review revealed droplet precautions were intended to reduce the risk of respiratory droplet transmission of infectious agents. Continued review revealed transmission-based precautions were intended to be used for additional control measures beyond the standard precautions and included contact, droplet, and airborne precautions. Review of Post Public Health Emergency-Standard and Guidelines, reviewed 05/23/2023 revealed facility followed the Centers for Disease Control (CDC) guidelines to prevent unnecessary exposures of COVID-19. Review of facility policy Laundry Policies and Procedures for Laundry Personnel, undated, revealed soiled laundry/bedding was handled in manner that prevented gross microbial contamination of the air and persons handling the linen. Added review revealed anyone who handled soiled linens must wear protective gloves and other protective equipment such as gowns. Further review revealed infected/Bio-Hazard/Covid-19 Linen was placed in a yellow biohazard bag inside an approved bio-hazard transport container for transportation. Continued review revealed employees wore proper personal protective equipment (PPE) for sorting. Review of facility policy C-Diff, Covid-19, MERSA, Noro Virus, Influenza Infectious Area Cleaning Policies and Procedures, undated, revealed the purpose of policy was to provide a clean and safe environment for residents, visitors, and those staff responsible for housekeeping and laundry. Added review revealed staff was to check with nursing staff on requirements for entering the room, ensure signage was posted on door and to wear appropriate personal protective equipment (PPE) such as gown, eye protection, mask, and gloves. Continued review revealed daily cleaning procedures included to clean isolation rooms last and that mop water cannot be used for more than one room. Review of Resident (R) 140's face sheet revealed the facility admitted resident on 09/12/2022 with diagnoses to include morbid obesity, anxiety, and depression. Review of Physician orders dated 07/07/2024 revealed R140 was placed in Transmission-Based/ Droplet precautions. Continued review of R140's medical record revealed the resident tested positive for Covid-19 on 07/07/2024. Observation on 07/09/2024 at 2:15 PM, revealed Housekeeper (HK) 2 entered R140's room which was marked with signage indicating Transmission Based/Droplet Precautions for Covid, without donning an N-95 mask (a respiratory protective device with a very close fit, and very efficient filtration of airborne particles) or a face shield, wearing only a medical blue surgical-type mask and gown. Added observation revealed HK2 removed her gown after exiting room. Continued observation revealed HK2 entered room [ROOM NUMBER] and room [ROOM NUMBER], neither designated as isolation, wearing the same mask worn in R140's room. Added observation revealed mop water was not changed; however, mopheads were changed between rooms and placed in a bag. Observation of the laundry room on 07/09/2024 at 9:24 AM revealed no defined sorting area for sorting dirty linens with a short distance from last washer to clean drying area. Continued observation revealed no Personal Protective Equipment (PPE) for staff to don prior to sorting dirty linens. Further observation of the laundry room revealed a large floor fan sitting at third washer with the exhaust aimed at dryers and table on clean processing side. During attempted interview with HK2, at 2:35 PM on 07/09/2024, she stated she was too busy to talk and refused interview. Interview was not attempted again. Interview at time of the laundry room tour, on 07/09/2024 at 9:24 AM, with the Laundry Supervisor, revealed when asked what PPE was worn by staff when sorting dirty linens, she stated staff wore regular gloves and gown. When asked about face protection for sorting dirty linens she did not reply. When asked about gowns worn for sorting dirty linens, the supervisor was unable to locate a gown immediately; however, she located one in the back of the room after a short time of searching. The Laundry Supervisor and Director of Nursing were unable to locate any face protection, including face shield or goggles. As the laundry room tour continued and when asked how isolation linens were processed the Laundry Supervisor stated there were separate washers in a separate room. Continued interview with Housekeeping/Laundry Supervisor on 07/12/2024 at 11:45 AM revealed she stated as Manager her expectations were for staff to follow signage on isolation room doors, don proper PPE, which included a N-95 mask for Covid rooms. She added upon learning of HK2 entering a Covid room without N-95 mask, training was immediately provided to all of her staff. When asked about changing mop water and mop heads after cleaning a Covid room, she stated mop water is not changed since the microfiber mop heads are changed after each mopping and there is disinfectant in the mop water. She continued and added the Covid rooms are cleaned once daily or as needed and wiped down with a disinfectant with a kill time of three (3) minutes. When asked how linens from a Covid room was processed, she explained those linens were placed in a dissolvable bag which was placed in a red bag then brought to laundry area and the dissolvable bag was put in a washer. She added the trash from isolation rooms was placed in a red biohazard bin in the dirty utility room on each floor. She added her concern for staff not following procedure and guidelines for isolation precautions was that germs and bacteria can be spread to other rooms. Interview with Licensed Practical Nurse (LPN) 11 on 07/12/2024 at 4:05 PM, Certified Nursing Assistant (CNA) 6 at 9:20 AM, LPN2 on 07/10/2024 at 1:50 PM, CNA7 on 07/10/2024 at 1:55 PM, and CNA8 on 07/11/2024 at 2:30 PM, they stated in interviews signage for isolation rooms should be followed and when entering a Covid room a N-95 mask, and face shield should be donned along with the other PPE. During interview with the Infection Preventionist (IP), on 07/12/2024 at 10:33 AM, with Standard precautions/ Universal precautions staff should wear gloves and if a possibility of splashing to face, a face shield and gown should be worn. She added that laundry service staff does not attend her trainings; but, attended monthly in-services which is an overall training for infection control, but not specific to laundry services. The IP nurse stated staff should, when entering a Covid room for cleaning, wear a N-95 mask, gown, gloves, and face shields. The IP nurse stated Isolation rooms should be cleaned more frequently, at least couple times a day especially for high touch surfaces. When asked about any concern for staff not following guidelines and signage for isolation rooms, she stated that germs could spread and added they are trained to don (put on) PPE prior to entering the room and doffing (remove) prior to exiting the room. During an interview with Director of Nursing (DON) on 07/12/2024 at 6:40 PM, revealed staff should follow infection control protocol and guidelines to prevent spread of illnesses, and she expected them to do so, stating guidelines and protocols are important. The DON stated when an infection control issue was identified, immediate education was given to staff. During an interview with the facility Administrator at 6:56 PM on 07/12/2024, revealed as administrator he always had concerns for infection control and as an administrator his expectations were that staff followed trainings, policies, and guidance. He continued and stated retraining was immediate if something was identified or whatever was needed to correct the problem adding following guidelines were important to prevent infection.

Based on observation, interview, record review, and review of the Consulting Dietician Company's policy, it was determined the facility failed to prepare, store, and serve food under sanitary conditions as determined by Temperature logs that were not documented for the dish machine and reach-in refrigerator. The walk-in freezer temperature log was not recorded accurately, which resulted in thawed food. The findings include: Review of the Consulting Dietitian Company's policy titled, Use-By-Guidelines, dated 12/03/2022, revealed the recommended temperature guidelines for storage freezers was negative five (-5) degrees Fahrenheit to zero (0) degrees Fahrenheit. Review of the Consulting Dietitian Company's form, Freezer: Record of Refrigeration Temperatures, dated 06/2022, for the walk-in freezer, revealed from 06/11/2022 to 06/20/2022, the temperature measured three (3) degrees Fahrenheit with a line drawn down the page under time for 06/04/2022 at 7:00 AM to 06/19/2022 to indicate the same time temperature was checked daily. Further review revealed, under initials, there appeared to be a line drawn from 06/04/2022 to 06/11/2022, for the same initials, and from 06/15/2022 through 06/19/2022. This appeared again for 06/15/2022 through 06/19/2022. Review of the PM checks of the freezer revealed, on 06/10/2022, a line was drawn down the page to continue the same temperature of minus four (-4) degrees Fahrenheit. Under the initials, the line was drawn down from 06/09/2022 to 06/12/2022. Maintenance found the freezer opened on 06/20/2022. Observation, on 06/21/2022 at 11:30 AM, during the initial kitchen tour, revealed the walk-in freezer had stopped, and food in it appeared to be thawing. Continued tour of the kitchen revealed no documentation of the reach-in refrigerator temperatures, in the food preparation area, and no documentation of the dish machine temperatures. Interview with the Maintenance Director, on 06/21/2022 at 11:45 AM, revealed it took more than a couple of hours for food to thaw. He stated he needed to reset the compressor on the walk-in freezer. Interview with Cook/Dietary Aide #5, on 06/21/2022 at 12:35 PM, revealed there had been a temperature log on the reach-in refrigerator, but it had not been seen for a while. Interview with Dietary Aide (DA) #4, on 06/23/2022 at 2:48 PM, revealed the DA had not been instructed concerning equipment temperature logs. Interview with DA # 1, on 06/23/2022 at 3:30 PM, revealed there had been a temperature log for the dish machine which was posted near the dish machine on the doors near the dish room. Interview with the Assistant Dietary Manager, on 06/23/2022 at 4:15 PM, revealed it was important to document temperatures for equipment and the dish machine to prevent cross contamination. The Assistant Dietary Manager stated the food in the freezer was checked and some of the food from the freezer was thrown out because the food had thawed. Interview with the Director of Nursing (DON), on 06/23/2022 at 7:30 PM, revealed it was important for Dietary to keep accurate temperatures for equipment, including the dish machine to prevent and protect against bacteria. Interview with the Administrator, on 06/23/2022 at 8:04 PM, revealed it was important to document accurately the equipment temperatures twice daily and to ensure the dish machine was properly sanitizing the dinnerware.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from abuse for three (3) of fifteen (15) sampled residents, Resident #2, #3, and #9. On [DATE], per the facility's investigation, Resident #3 approached Resident #2 for money. Resident #2 said no and Resident #3 spit and hit Resident #2, and Resident #2 returned a punch to Resident #3. On [DATE], per the facility's investigation, Resident #3 called Resident #9 a name, and Resident #9 called Resident #3 a name. The findings include: Review of the facility's document titled, Abuse Prevention Program, not dated, revealed physical abuse was defined as hitting, slapping, pinching, kicking, etc. Per the document, verbal abuse was defined as any use of oral language that willfully included disparaging and derogatory terms to residents or their families. In addition, verbal abuse included, within hearing distance, describing residents, regardless of their age, ability to comprehend, or disability. Review of Resident #3's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS Assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #3's care plan, dated [DATE], revealed Resident #3 exhibited episodes of verbal aggression related to smoking and refusal of care. This aggression included calling staff names, throwing items, and general rudeness to staff. In addition, the care plan stated Resident #3 had a documented history of refusal to take medications and of refusal of any psychiatric evaluation or treatment. Further review revealed the care plan had been updated, on [DATE], for physical aggression toward other residents, with spitting and hitting another resident in the face. 1. Review of the facility's Investigation Report, dated [DATE], revealed staff heard screaming and thought a resident had fallen. They found Resident #3 screaming and blood on his/her mouth in Resident #2's room. They removed Resident #3 from the room to separate him/her from Resident #2. Per the report, Resident #3 wanted a stuffed animal, and Resident #2 said Resident #3 wanted $2.00 dollars to get it. The report stated when Resident #2 told Resident #3, No, Resident #3 spit and hit Resident #2. Per the report, Resident #2 then hit Resident #3. The incident occurred on [DATE]. Review of Resident #2's statement, dated [DATE], revealed Resident #3 entered Resident #2's room and asked for money. Resident #2 said no, and Resident #3 spit to the left side of his/her face. The statement revealed Resident #2 told Resident #3 to leave his/her room. Then, Resident #3 hit Resident #2 with his/her right hand to Resident #2's left eye. Per the statement, Resident #2 responded and hit Resident #3 in the mouth. Also, the statement revealed Resident #3 told Resident #2 to call the police. Resident #2's statement revealed he/she told employees he/she did not want anything to do with Resident #3. Review of Resident #3's statement, dated [DATE], revealed Resident #2 smacked and hit him/her and would not stop, so Resident #3 hit Resident #2. Per the statement, Resident #2 hit Resident #3 in the face and lip. Review of Resident #2's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #2's care plan, dated [DATE], updated [DATE], revealed Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, the care plan stated Resident #2 was in a relationship with a female resident and allowed the female resident to call him/her inappropriate names as part of the relationship. Resident #2's care plan was updated to redirect as needed, dated [DATE] after the [DATE] incident. Review of the facility's form, Close Watch Documentation, for Resident #3, revealed hourly documentation of one-to-one (1:1) supervision with a sitter, from [DATE] at 10:00 PM until [DATE] at 3:00 PM. Review of the facility's form, 15 Minute Checks, for Resident #3, revealed every fifteen (15) minute checks occurred, from [DATE] at 3:00 PM to [DATE] at 11:45 AM. Observations, from [DATE] to [DATE], during the survey, revealed no apparent bruising on the faces of Resident #2 and Resident #3. Interview with Resident #2, on [DATE] at 4:30 PM, revealed Resident #3 had entered his/her room and asked for $2.00 dollars. Resident #2 stated he/she said no, and Resident #3 threw water at him/her and punched him/her in the left eye. Resident #2 stated he/she responded with a hit back at Resident #3 face. Resident #2 stated he/she had talked with the police. Interview with Resident #3, on [DATE] at 9:35 AM, revealed he/she wanted to get a stuffed animal out of Resident #2's room, when the incident began. Resident #3 stated he/she wanted to continue a relationship with Resident #2 and currently had no concerns with seeing Resident #2. Interview with the Social Service Director (SSD), on [DATE] at 10:00 AM, revealed when she checked on Resident #3, shortly after the incident, he/she was sitting in his/her room watching television with the sitter and had a blackened eye. She stated Resident #3 appeared calm and expressed that he/she did not like having a sitter or being watched. Per the interview, when she checked on Resident #2, he/she had a blood blister to the left eye. The SSD stated she sometimes received calls over the weekend concerning Resident #3's behaviors, and a Social Worker would arrive at the facility to assist with calming Resident ##3. She stated Resident #2 was vocal about not wanting Resident #3 to be near him/her. She further stated Resident #3 wanted to continue the relationship with Resident #2; however, Resident #2 had stated he/she did not want to continue the relationship. Per the interview, Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD stated Resident #3 was placed on one-to-one (1:1) supervision with a sitter, and then placed on fifteen (15) minute checks. The SSD stated Resident #3 did not like the increased supervision. Interview with the Director of Nursing (DON), on [DATE] at 6:57 PM, revealed Resident #3's behaviors were monitored by staff. She stated she assisted in talking Resident #3 down during these behaviors. In addition, the DON stated Resident #3 had the potential for an outburst with other residents. She stated, after the incident, Resident #2 and #3 were separated, and the investigation was completed. Interview with the Administrator, on [DATE] at 8:04 PM, revealed the incident between Resident #2 and #3 was abuse. The Administrator stated Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Then, the Administrator explained, Resident #3 should be asked to leave if he/she was showing abusive behaviors. 2. Review of the facility's Investigation Report, dated [DATE] and signed by the Director of Nursing (DON), revealed it was reported by a staff member that on [DATE], Resident #3 and Resident #9 used inappropriate language towards one another. The residents were separated, and an investigation was initiated immediately. Per the report, both residents were interviewed and both admitted to using inappropriate words toward one another. The staff member, at the time of the incident, intervened between residents while speaking loudly, thus causing Resident #9's open hand to brush across Resident #3's right shoulder. The report stated skin and pain assessments on both residents were completed with no issues identified. Also, Resident #9 agreed to go to the hospital for evaluation due to agitation regarding the incident. Per the report, upon return from the hospital emergency department (ED), Resident #9 was placed on one-to-one (1:1) supervision until seen by psychiatric services. Because of this incident, the report stated, staff ensured that both residents smoked at different times, and Social Services followed up with both residents daily for three (3) days to monitor for psychosocial distress, with no issues identified. Per the report, Resident #9 was seen by psychiatric services, and a recommendation was made to discontinue one-to-one (1:1) supervision, with the care plan revised and updated. The report stated although both residents used inappropriate words toward one another, the intention was not to cause mental anguish or humiliation. Per the report, neither resident felt humiliated, and both showed remorse for their choosing to use inappropriate language toward one another. The report stated Resident #9's agitation was not directed to the word choice that Resident #3 used, but that Resident #3 interjected him/herself into a conversation with another resident. Review of Resident #9's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS Assessment, dated [DATE], revealed a BIMS score of nine (9) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #9's care plan, dated [DATE], revealed he/she was care planned for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the care plan, the resident was very sensitive to perceived disrespect from people. The care plan stated Resident #9 made verbal threats toward other residents. Also, the resident exhibited occasional manic behavior, singing loudly with an elevated mood, and had episodes of hitting the wall in his/her room. Interview with Resident #3, on [DATE] at 11:00 AM, revealed he/she went to the smoking area, on [DATE], where he/she saw Resident #9 waiting for his/her turn to go smoke. Resident #3 stated Resident #9 did not have cigarettes, and Resident #3 verbalized this. Per the interview, Resident #9 said to Resident #3, [OBSCENITY] why you are meddling? Resident #3 said he/she verbalized that Resident #9 did not have cigarettes because he/she wanted to give Resident #9 a cigarette. Resident #3 stated both residents called each other names, and then Resident #3 called Resident #9's mother a [OBSCENITY] . Resident #3 stated Resident #9 got very upset and swatted at Resident #3, but the attending nurse, Licensed Practical Nurse (LPN) #1, came between them. Resident #3 stated local law enforcement was called, and law enforcement gave him/her a card and report. Per the interview, Resident #3 stated he/she was okay to be around Resident #9 and was not afraid of Resident #9. Resident #3 stated he/she and Resident #9 did not have the same smoking time anymore. Interview with Resident #9, on [DATE] at 1:00 PM, revealed Resident #3 said something, and Resident #9 called Resident #3 a [OBSCENITY] . Per Resident #9, as a response, Resident #3 called Resident #9's mother a [OBSCENITY] , which made Resident #9 very upset because his/her mother was deceased . Resident #9 stated, as a response to Resident #3 calling his/her mother a name, Resident #9 pushed Resident #3's face. Resident #9 stated after this, both he/she and Resident #3 were okay. Resident #9 stated he/she was on speaking terms with Resident #3, and the residents had not had any other altercations. Interview with LPN #1, on [DATE] at 2:15 PM, revealed she overheard the altercation, on [DATE], between Resident #3 and Resident #9. She stated Resident #9 stood up and was walking toward Resident #3. LPN #1 stated she got between the residents, and Resident #9 attempted to hit Resident #3, but she blocked it. LPN #1 stated she was not hurt. She stated Resident #9 then sat down but was very upset about Resident #3 talking about his/her mother. LPN #1 stated Resident #3 told her Resident #9 did not have any cigarettes, which he/she verbalized, and that made Resident #9 very mad and provoked the resident. According to LPN #1, Resident #3 and #9 had not had any previous altercations. LPN#1 stated she called the DON. She also stated she called the police to redirect Resident #9 because after Resident #9 walked away, the residents continued to verbally attack each other. LPN #1 stated Resident #9 went with the police to have a psychiatric evaluation. After three (3) hours, LPN #1 stated, Resident #9 returned to the facility and was placed on one-to-one (1:1) supervision. Continued interview with the SSD, on [DATE] at 10:00 AM, revealed Resident #3 instigated fights with people. She stated Resident #3 told Resident #9 that Resident #9 had no cigarettes. Then, she stated, they started calling each other names. Resident #3 called Resident #9's mother a [OBSCENITY] . She stated Resident #3 kept provoking Resident #9, and LPN #1 intervened to stop Resident #9 from hitting Resident #3. She stated Resident #3 would never accept any responsibility for the altercation. Further, the SSD stated a Psychologist was seeing Resident #3. After the incident, according to the SSD, Resident #3 was not allowed in the smoking area. The SSD stated both residents were ordered to stay away from each other. Interview with the Unit Manager (UM), on [DATE] at 11:45 AM, revealed if there was an incident on the weekend, social services was notified. The Unit Manager stated she heard about the incident during the morning meeting. She stated Resident #3 was aggressive toward staff, using curse words and yelling; but she stated she had not witnessed such behaviors toward other residents. According to the UM, she did not know what triggered Resident #3's behavior; however, Resident #3 knew what to say to trigger behaviors in other residents. The UM stated staff usually tried to re-direct Resident #3 and used one-to-one (1:1) supervision, different times to smoke, activities to intervene, and playing music on his/her cell phone. The UM also stated Resident #3 had a roommate, and there had been no problems with the roommate. Interview with the Smoke Attendant, on [DATE] at 2:30 PM, revealed Resident #3 and #9 could not come to smoke together after the incident, but they usually were friends. He stated he heard there was an exchange of words but no hitting. He stated Resident #3 never provoked anyone in front of him, and Resident #9 was generally friendly and tried to help people. Interview with the DON, on [DATE] at 4:30 PM, revealed Resident #3 had the potential for being aggressive. She stated staff documented Resident #3's behavior and re-directed the resident. She also stated most staff knew what triggered Resident #3's aggressive behavior. The DON stated Resident #3 had been offered psychological services. In addition, the DON stated she did not consider the incident as abuse; although, she agreed the name calling and foul language had the potential for engendering abuse. Interview with the Administrator, on [DATE] at 6:15 PM, revealed technically the incident could be considered abuse, but he did not believe either of the residents took it as abuse.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide necessary hygienic care for one (1) of fifteen (15) sampled residents, Resident #1. Observations on 06/21/2022 and 06/22/2022, revealed Resident #1 had long fingernails with jagged, chipped edges. In addition, a dark substance was observed under the resident's nails. The facility assessed Resident #1 as requiring total care with Activities of Daily Living (ADL's), to include personal hygiene and bathing. The findings include: Review of the facility's policy titled, Nail Care, not dated, revealed it was the policy of the facility to provide personal hygiene needs to promote health, safety, and the prevention of infection. This included clean, smooth nails at a well-groomed length acceptable to the resident. Review of Resident #1's medical record revealed the facility admitted the resident, on 06/20/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/04/2022, revealed the facility assessed the resident as needing extensive assistance of one (1) person for personal hygiene, and the resident was totally dependent on staff for meeting his/her bathing needs. The resident scored a fifteen (15) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS), which indicated the resident had intact cognition and was interviewable. Review of Resident #1's shower sheets, dated 06/21/2022, 06/14/2022, 06/10/2022, 06/07/2022, 05/27/2022, 05/24/2022, 05/20/2022, 05/17/2022, 05/13/2022, 05/10/2022, 05/06/2022 and 05/03/2022 all signed by CNA #1, revealed a section for Fingernails, and of the three options, yes, no, and filed, the CNA checked no, on all of the forms. Observation, on 06/21/2022 at 11:53 AM, revealed Resident #1 was sitting in a wheel chair in his/her room. The resident's right hand was contracted, but he/she was still able to partially open it. The resident's finger nails on both hands were very long, with broken, chipped edges, particularly on the right hand that he/she tended to bend in toward the palm. In addition, a dark brown/black substance was observed under some of the nails. The resident's speech was difficult to understand. Observation, on 06/22/2022 at 9:40 AM, revealed Resident #1 still had long fingernails with broken, jagged edges. Interview with Certified Nursing Assistant (CNA) #1, on 06/22/2022 at 9:40 AM, revealed she had given Resident #1 a shower yesterday, and CNA's were supposed to document any skin concerns on a shower sheet that would be given to the resident's nurse. She stated she was supposed to document if she provided nail care, or if the nails needed to be clipped or filed. CNA #1 said she could easily see the nails on Resident #1's left hand, but she had not seen the condition of his/her nails on the right hand because the resident held that hand partially closed and very close to his/her body. The CNA stated Resident #1's nails on the right hand were not only long, but were chipped, and there was a dark substance under the nails on the right hand. CNA #1 said she would report the condition of Resident #1's nails to the nurse. Interview with Licensed Practical Nurse (LPN) #1, on 06/22/2022 at 10:30 AM, revealed she just trimmed Resident #1's fingernails and they were long and had jagged edges. She stated the CNA's were supposed to complete a shower sheet with each shower and turn them into the nurses, but sometimes that was hit or miss with the aides, meaning they do not always turn them in. Interview with CNA #3, on 06/22/2022 at 5:00 PM, revealed when the facility was short on staff, direct care staff was not able to check and clean residents' nails. The CNA said staff tried to work on other areas of care such as bathing the residents. Interview with CNA #5, on 06/23/2022 at 10:46 AM, revealed CNA's were to check a resident's nails daily and use an orange stick to clean under the resident's nails. She stated if the resident was not diabetic, the CNA's could trim the nails or file to smooth the nail edges. CNA #5 stated a resident could sustain a skin tear from long and chipped fingernails, or he/she could accidentally scratch someone else with long and broken nails. Interview with the 5th Floor Unit Manager (UM), on 06/23/2022 at 4:00 PM, revealed the Fingernail section of the shower sheet could be interpreted in different ways, but the CNA's could always write a note on the sheet to inform the nurse that the resident's fingernails were long and/or broken, so the nurse could follow up by trimming or filing the nails. She stated she made shower assignments and reviewed shower documentation. She said the nurses assigned to the medication carts for the hallways should conduct weekly skin assessments, which provided another opportunity for staff to observe the condition of a resident's nails and trim or clean them, as needed. The UM stated long, chipped fingernails were not acceptable, and since Resident #1's right hand was contracted, long broken nails could dig into the palm of the resident's hand, cause him/her to develop an open area to the palm, and further, pose a risk for infection. She stated the Fingernails section of the shower sheet form could be clearer, in terms of what was done to address nail care. She said it was hard to understand what yes and no meant in the form's current format. Interview with CNA #6, on 06/23/2022 at 4:45 PM, revealed if the resident was not a diabetic, CNA's should trim long, broken fingernails. He stated if a resident's nails had repeated contact with an area of skin, such as when a resident kept the hand folded with long jagged nail edges near the palm, the resident might sustain a skin tear or other skin irritation. Interview with LPN #6, on 06/23/2022 at 4:50 PM, revealed CNA's trimmed or filed a resident's fingernails during showers, as long as the resident was not diabetic. She stated if the aide was uncomfortable providing nail care, he or she could document that on the shower sheet, and the nurses would then know to follow up and provide the care. She said the nurse's signature on the bottom of the shower sheet meant the nurse had reviewed the shower sheet. Interview with the Director of Nursing (DON), on 06/23/2022 at 6:50 PM, revealed there were many opportunities for CNA's and nurses to inspect a resident's fingernails. She stated those observations could occur during showers, skin assessments, and medication administration. She said she would expect direct care staff to trim or file a resident's nails if they were long or broken. She stated Resident #1 could have potentially sustained a skin injury due to his/her long, broken fingernails. The DON said the Fingernail section of the shower sheet currently in use, was unclear. She offered the example that no could mean no issue; or no, not cleaned or trimmed; or no, the resident refused nail care. She stated it was unacceptable for staff to say nail care was not a priority due to staffing levels. The DON stated staff was hired to ensure the residents' care needs were met. Interview with the Administrator, on 06/23/2022 at 8:30 PM, revealed he expected staff to provide all necessary resident care. He said today he asked staff members if they had a sufficient amount of supplies for performing care such as washing residents' hair, cleaning their nails, removing facial hair, and for providing oral care. He stated when residents felt clean, groomed, and comfortable, he believed it improved their quality of life.

Based on interview, record review and the facility's policy, it was determined the facility failed to protect three (3) of 18 (eighteen) sampled residents from abuse (Resident #69, Resident #410 and Resident #420). 1. The facility failed to protect Resident #69 and Resident #410 from sexual abuse. Staff observed Resident #69 and Resident #410 lying on the floor in Resident #69's room, with their knees touching. Resident #69 was wearing a gown, and Resident #410 had his/her pants and brief pulled down below his/her knees, with his/her genitalia exposed to Resident #69. The facility had assessed the residents as unable to consent to having sexual contact with another person. Both residents had displayed sexually inappropriate behaviors in the recent past. Resident #410 had an incident of sitting in the common area without his/her brief on, and Resident #69 had been verbally sexually inappropriate with a staff member of the opposite sex. On another occasion. Resident #69 was on the couch in the common area with his/her legs splayed apart (spread apart), and saying, Do you want some of this., to no one in particular. 2. The facility failed to protect Resident #420 from abuse. Certified Nursing Assistant (CNA) #94 was observed by Nursing Assistant (NA) #3 to poke Resident #420 on the forehead while the resident was sitting on his/her toilet. Resident #420 became upset, stood up and tried to walk towards CNA #94 and started to stumble. NA #3 then observed CNA #94 place his hands, open palmed, on Resident #420's chest and pushed the resident backwards, causing him/her to fall backwards onto the wall. Resident #420 received an abrasion to his/her back and a knot to his/her hip as a result of the fall. The facility's failure to ensure Resident #69, Resident #410 and Resident #420 were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F609; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.70 Administration; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867, at a Scope and Severity of a J. The Immediate Jeopardy was determined to exist on 10/17/2021 and the facility was notified of the Immediate Jeopardy on 12/04/2021. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and AoC validation Survey were conducted on 12/09/2021 which determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S (scope and severity) of D; F609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F835 Administration at S/S of D; F837 Governing Body at S/S of D; and, 42 CFR 48.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's Abuse Policy, updated 05/02/2017, revealed the facility was to prevent resident abuse, neglect, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review, if a resident mistreated another resident, the resident performing the mistreatment was to be immediately separated from the other resident. Further review revealed an assessment of the resident, doing the mistreatment, was to be performed to determine the most suitable therapy, care approaches and placement, considering his/her safety, as well as the safety of other residents of the facility. Review of the facility's investigation for the alleged sexual abuse incident involving Resident #69 and Resident #410, revealed on 11/29/2021 at approximately 8:30 PM, a staff member observed Resident #69 lying fully clothed on his/her room floor, facing Resident #410. The residents' knees were touching, and the other resident had his/her pants and brief pulled below the knees with his/her genitalia exposed to Resident #69. Continued review revealed the residents were immediately separated by staff and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Comprehensive Care Plan, dated 09/05/2021, revealed the facility had care planned the resident for his/her behaviors with interventions which included removing Resident #69 from situations that might cause anxiety or aggression, and for staff to speak in a calm voice when attempting to deescalate his/her agitated behaviors. Continued review revealed the care plan had Foci (focus points) dated 07/23/2021, 08/24/2021 and 09/23/2021, which noted Resident #69 did not desire to have sexual contact with another person at that time. Further review of the care plan and the intervention revealed the Foci goal was to encourage Resident #69 to notify staff if he/she desired to have sexual contact with another person. Observation, on 12/02/2021 at 10:15 AM, revealed Resident #69 in the 7th floor dining room, sitting at a table in the middle of the room. The resident was with House Supervisor #1, coloring a picture. Observation, on 12/03/2021 at 10:45 AM, revealed Resident #69 was in the dining room decorating the windows with the help of Activity Aide #4. She stated however, she was unaware of why Resident #69 required the 1:1 monitoring. Continued observation, on 12/03/2021 at 10:50 AM, revealed CNA #96 brought Resident #410 to the dining room, where Resident #69 was located, to eat his/her snack. CNA #96 sat down at a table with Resident #410 while he/she consumed the snack. Observation revealed Resident #69 continued to place stickers on the dining room windows, but stopped briefly to walk over to the table where Resident #410 was sitting. Resident #69 was observed to say something to Resident #410; however, the State Survey Agency (SSA) Surveyor was unable to hear the resident's comment. Observation at that time, revealed Resident #410 answered in response to Resident #69's comment, I am old. Additional observation revealed the Activity Aide immediately came to Resident #410's table to redirect Resident #69 back to the decorating activities. 1.(b) Review of Resident #410's clinical record revealed the facility admitted him/her on 11/19/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #410 Comprehensive Care Plan revealed Foci dated 07/28/2021, 08/26/2021 and 09/24/2021. Further review revealed the facility assessed that Resident #410 did not have the capacity to consent to sexual activity. The goal was documented as Resident #410 would express feelings, as needed. The intervention was to allow the resident time to express his/her feelings. Review of Resident #410's Quarterly MDS Assessments dated 01/27/2021, 04/29/2021, and 07/29/2021, and the Annual MDS assessment dated [DATE], revealed the facility had assessed the resident with a BIMS score of six (6) which indicated severe cognitive impairment. Further review revealed the facility had not assessed Resident #410 to display sexually inappropriate behaviors. Observation, on 12/03/2021 at 9:46 AM, revealed Resident #410 was lying on his/her bed, with eyes open covered with a sheet. Continued observation revealed CNA #96 was sitting in a chair beside the resident's bed. Additional observation, on 12/03/2021 at 10:30 AM, revealed Resident #410 sitting in a wheelchair near the nurses' station with CNA #96 sitting nearby monitoring the resident. Interview, on 12/03/2021 at 10:35 AM with CNA #96, who was assigned to monitor Resident #410, revealed she did not know why staff were providing the 1:1 observation of Resident #410. She stated she had just taken over the 1:1 monitoring of Resident #410 that morning at shift change. Further interview revealed she had not asked the staff member she was relieving why Resident #410 required 1:1 observation, and the staff person had not provided the information to her. Unsuccessful attempts were made on 12/02/2021 and 12/03/2021 to interview Resident #69. Interview with Resident #410 on 12/03/2021 at 10:30 AM, revealed the resident was unable to recall the 11/29/2021, incident when he/she had been lying on the floor with Resident #69. Resident #410 stated he/she had a special friend of the opposite sex, but that person did not live at the facility. Interview, on 12/02/2021 at 1:28 PM with Registered Nurse (RN) #11, revealed on 11/29/2021 around 8:15 PM, he started his evening medication pass. RN #11 stated he was looking for Resident #410 and started checking residents' rooms. Per interview, when he opened the door to Resident #69's room, he observed Resident #69 and Resident #410 lying on the floor facing each other. He stated Resident #69 was wearing a gown and brief. RN #11 stated Resident #410 had a shirt on; however, his/her pants and brief were pulled down below the knees, so his/her genitalia was exposed. RN #11 said Resident #410 did not act startled and stated, You caught us early, and nothing happened yet. The RN stated Resident #69 acted upset that he had opened the door and asked him why he entered the room without knocking. Continued interview revealed Resident #69 was so upset he/she tried to hit some of the nurse aides who responded to the room when the nurse called for assistance. RN #11 stated he asked the House Supervisor to assess Resident #69 and he would assess Resident #410. He stated Resident #69 had been evaluated by a psychiatric provider in the past for displaying sexually suggestive gestures and making sexually suggestive comments. Review of Resident #69's Nursing Progress Notes revealed documentation related to RN #11's comments on the resident displaying sexually suggestive gestures and making sexually suggestive comments noted on 10/17/2021 and 10/19/2021. Review of Resident #69's and Resident #410's skin assessments, dated 11/29/2021, revealed no evidence of concerns noted. Per review, the House Supervisor had completed Resident #69's skin assessment and RN #11 conducted the skin assessment for Resident #410. Telephone interview on 12/02/2021 at 1:40 PM with Certified Nursing Assistant (CNA) #92, revealed she worked on the 7th floor, which was a Dementia Unit, the evening of 11/29/2021. She stated when RN #11 called out for assistance, she went immediately to Resident #69's room. RN #11 stated when she looked in the room, Resident #69 was getting up from the floor. She stated Resident #69 was wearing a gown, and she saw a pull-up on Resident #69's bed; however, she was not sure if the resident had a brief or pull-up on or, not when she entered the room. Continued interview revealed Resident #69 acted angry and said he/she was going to hit RN #11 in the mouth because he did not knock on the door before entering the resident's room. CNA #92 stated Resident #410 was lying on the floor with his/her pants and brief below his/her knees. The CNA stated she had not heard him/her say anything to the staff who entered the room. Further interview revealed after the nursing supervisor assessed the situation, CNA #97 took Resident #410 back to his/her room. Interview, on 12/03/2021 at 8:41 AM with CNA #97, revealed she had been assigned to Resident #410 on the evening of 11/29/2021 when the incident occurred. She stated Resident #410 finished eating supper about 7:00 PM, so she changed the resident's brief in his/her room, and took him/her to the dining room to watch television. CNA #97 said the resident was still sitting in the dining room at approximately 7:45 PM, when she took her meal break. According to the CNA, around 8:30 PM, RN #11 asked her the whereabouts of Resident #410, and she told the RN to check in the dining room, where she last saw the resident. Per interview, RN #11 quickly returned from the dining room, stating Resident #410 was not in the dining room. The CNA stated she told the RN to check in Resident #69's room, because sometimes Resident #69 tried to assist Resident #410 by pushing him/her around in the wheelchair. Continued interview revealed she followed RN #11 to Resident #69's room and entered the room just behind the RN. CNA #97 stated RN #11 tried to get into the room, but Resident #410's wheelchair was blocking the door. She stated when RN #11 was finally able to get through the door, she entered the room and observed Resident #410 on the floor with his/her brief and pants down to his/her ankles, and Resident #69 was trying to get up from the floor. Per the CNA, Resident #69 was wearing a gown, but she was unsure if Resident #69 was wearing a brief. She stated she heard Resident #410 say that he/she and Resident #69 had not had a chance to do anything because staff came to the room too quickly. Interview revealed while taking Resident #410 back to his/her room, she asked the resident what he/she and Resident #69 were doing in the room, and his/her reply was that they had been trying to beat it up. Per CNA #97, Resident #410's comment was slang which meant the resident had been trying to have sex with Resident #69. Further interview revealed CNA #97 stated Resident #410 had told her that he/she was embarrassed by the incident. Continued interview with CNA #97 on 12/03/2021 at 8:41 AM, revealed she told RN #11 that Resident #69 was persistent about things, and that she thought Resident #69 would likely pursue a sexual encounter, more so than Resident #410. According to the CNA, when Resident #410 was in his/her wheelchair, Resident #69 tried to push him/her around. Observation, on 12/03/2021 at 9:35 AM, revealed Licensed Practical Nurse (LPN) #75 was at the medication cart near Resident #410's room. Interview with LPN #75, revealed she was an agency nurse, and this was the first day she had worked on the 7th floor. LPN #75 stated she knew Resident #69 and Resident #410 were on 1:1 (one to one) observation; however, she did not know why they were on that type of observation. Further interview revealed the night shift staff had not given her the reason, or explained why staff were providing 1:1 supervision of the residents. Interview, on 12/02/2021 at 1:57 PM with CNA #93, revealed she had been assigned to Resident #69's care on 11/29/2021, on evening shift when the incident occurred. She stated she had assisted Resident #69 in preparing for bed, and the resident's brief was changed and he/she put on a gown. CNA #93 stated the resident had laid down on his/her bed about 8:00 PM, and she covered Resident #69 with a blanket. Continued interview revealed CNA #93 left Resident #69's room to go do some of her charting, which she was doing around 8:30 PM, when she heard RN #11 and CNA #97 say they wondered how Resident #410 had gotten into Resident #69's room. CNA #93 stated she immediately went to Resident #69's room and saw Resident #410 lying on the floor in Resident #69's room, with his/her pants and brief below his/her knees, with his/her genitals exposed. CNA #93 stated she did not hear Resident #410 say anything. Further interview revealed Resident #410 required a wheelchair for mobility, and staff usually moved him/her from one place to another. However, the resident was able to self propel in the wheelchair very slowly. Interview, on 12/03/2021 at 11:03 AM with House Supervisor #1, revealed Resident #69 and Resident #410 were currently under 1:1 observation, because both residents had been found lying together on the floor in Resident #69's room. She stated she thought they had been trying to engage in sex. House Supervisor #1 stated that staff that were assigned to monitor both residents should know why the residents were being monitored 1:1 in order to know how to supervise the residents to keep them, as well as other residents safe. Further interview revealed things or situations with either resident could change in the blink of an eye. She stated the assigned staff providing the monitoring had to be fully aware of why the residents were under an increased level of supervision. Interview with the facility's Interim Administrator on 12/03/2021 at 3:40 PM and again on 12/04/2021 at 4:33 PM, revealed her role was to oversee the operations of the facility. Per the Interim Administrator, no sexual abuse had occurred due to the staff providing enhanced supervision. Interview revealed the enhanced supervision being provided for Resident #69 and other residents was more frequent rounds of residents being performed by nursing staff. The Interim Administrator stated the facility had also assigned a full-time Activities person to the 7th floor (where Resident #69 resided), and more resident activities had been initiated on the 7th floor. The Interim Administrator further revealed she could only say the facility's Interdisciplinary Team (IDT) had discussed Resident #69 and Resident #410 in the IDT meetings held since she had been the Interim Administrator, which had been for three and a half (3 ½) weeks. She additionally revealed the IDT's discussion of Resident #69 had been regarding his/her verbal and aggressive behaviors, and for Resident #410 the IDT had discussed his/her rejection of care. Review of Resident #69's Nursing Progress Notes dated 10/17/2021 through 11/29/2021, revealed the facility had placed the resident on every fifteen (15) minute checks and 1:1 supervision, for his/her verbal and/or physical aggression towards staff. Interview with the Director of Nursing, (DON) on 12/04/2021, at 5:15 PM revealed she expected residents to be care planned for inappropriate sexual behaviors with interventions documented, which would include redirection. The DON stated she was aware of the two (2) documented incidents of Resident #69 displaying inappropriate sexual behavior in October 2021, and that the resident had been placed on [MEDICATION(S)] medication (an antipsychotic medication). Continued interview revealed the DON did not feel there had been a facility system failure or failure in its processes in regards to the incident involving Resident #69 and Resident #410. 2. Review of the facility's policy titled, Abuse Prevention Program, updated 05/02/2017, revealed each resident was to receive care and services in a person-centered environment in which all individuals were treated as human beings. Per review, the facility defined abuse as the willful infliction of injury resulting in physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker. Further review revealed physical abuse was defined as a willful act against a resident by another resident or staff, to include shoving. Review of the facility's policy titled, Dignity, undated, revealed residents were to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what was being said or done by others. Continued review revealed staff was to always be polite and respectful to residents, and not carry on long conversations with each other about their personal issues unrelated to the resident, as that could make the resident feel ignored and hurt his/her feelings. Review of Resident #420's medical record revealed the facility admitted the resident on 09/05/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Pre-Admission Screening and Resident Review (PASRR), dated 09/02/2021, revealed Resident #420 had an unsteady balance related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #420 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed the resident as noncompliant at times. Further review revealed Resident #420's Intelligent Quotient (IQ) was noted to range from forty-two (42) to sixty (60) which indicated a moderate degree of cognitive limitation. Review of Resident #420's Admission Minimum Data Set (MDS) Assessment, dated 09/12/2021, revealed the facility had assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated moderate cognitive impairment. Further review revealed the facility had not assessed Resident #420 to have behaviors. Review of Resident #420's Comprehensive Care Plan (CCP), dated 09/30/2021, revealed the facility had care planned the resident for intellectual impairment and exhibiting temper fits when limits were set with food and drink intake related to his/her dietary restrictions and changes in his/her routine or a planned activity. Continued review revealed Resident #420 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #420's interventions included: for staff to assist the resident with reality orientation when episodes of fantasy/fabrications interfered with his/her well-being. Per review, Resident #420 liked associating with others such as celebrities and characters on television or in movies. The care plan revealed Resident #420 enjoyed conversing with staff in the common area of the unit, or interacting one-on-one with staff. Further review revealed staff were to validate Resident #420's concerns; however, they were to set limits with the resident's negative behavior. Review of the facility's Incident Report, dated 11/26/2021 timed at 12:54 PM, revealed Nurse Aid (NA) #3 reported she witnessed CNA #94 place his finger on Resident #420's forehead and push the resident's head backwards. Continued review revealed in response, Resident #420 stood up and started walking towards CNA #94 and was attempting to hit the CNA. Per review, NA #3 then witnessed CNA #94 place the palms of his hands on Resident #420's chest and push him/her backwards. Resident #420 fell which resulted in a red abrasion to his/her back. Continued review revealed later on a raised area was observed to the resident's hip. Record review revealed witness statements were obtained and all parties involved in the incident were suspended after the incident had been reported to facility management. Per review of the Incident Report, Resident #420 reported injuring his/her back at the time of the fall. Further review revealed when Resident #420 was using the restroom CNA #94 played a prank on him/her and made him/her fall against the wall. Additional review revealed when Resident #420 walked to the shower room after using the restroom, he/she noticed a big thing on his/her right hip. Review of Resident #420's Progress Note, dated 11/25/2021 at 5:51 PM, revealed a Change in Condition had been completed. Continued review of the Progress Note revealed an abrasion and bruising was noted on the resident's mid and left lower back. Further review of the Progress Note revealed staff notified the Nurse Practitioner, and a new order was received for triple antibiotic ointment (TAO) to the abrasion and to continue to monitor the area of bruising. Record review revealed an X-Ray Report, dated 11/25/2021, which was obtained after the incident. Resident #420 received an x-ray to his/her right hip for swelling and pain; however, there was no obvious fracture observed. Continued record review revealed another X-Ray Report dated 11/29/2021, and an Ultrasound (US) report documented a subcutaneous solid lesion which might represent a hematoma. Further review revealed a recommendation for Resident #420 to have a Computed Tomography (CT) scan performed. Review of Resident #420's medical record revealed a CT scan was scheduled for 12/07/2021. Observations of Resident #420 on 12/02/2021 at 1:52 PM and 12/02/2021 at 8:45 AM, revealed the resident sitting up in his/her wheelchair. Observation of Resident #420's back revealed no evidence of an abrasion to the resident's back. When asked if the State Survey Agency (SSA) Surveyor could observe his/her right hip, Resident #420 declined to allow the observation. Interview with Resident #420, at the time of observation, revealed after breakfast on 11/25/2021, CNA #43 and NA #3 assisted him/her to go use the restroom. Continued interview revealed Resident #420 had been sitting on the commode when CNA #94 came into his/her room. The resident stood up and tried to practice karate on CNA #94. Per interview, that was when Resident #420 lost his/her balance and fell against the wall causing an injury to his/her back. Further interview revealed Resident #420 noticed the injury to his/her hip on the way to the shower room and the nurse had been notified. Interview with NA #3, on 12/02/2021 at 3:40 PM, revealed she was in training to start CNA classes and had only worked at the facility for two (2) weeks. Per interview, she was training with CNA #43 and they were assigned to Resident #420 on 11/25/2021. She stated 11/25/2021 was Resident #420's shower day and after the resident's breakfast, she and CNA #43 assisted Resident #420 to the restroom with his/her walker. She stated they assisted the resident to the commode, where he/she sat down. According to NA #3, after the resident used the restroom, she and CNA #43 were going to assist Resident #420 to the shower room. Continued interview revealed while Resident #420 was using the toilet in the restroom, CNA #94 walked into the room and went straight to the resident and poked him/her in the forehead causing his/her head to move backward. NA #3 stated Resident #420 became upset and raised up off the commode and used his/her walker to move forward toward CNA #94. She stated Resident #420 let go of his/her walker and attempted to hit CNA #94 and became unsteady and started to stumble. Per NA #3, CNA #94 then placed his hands, palms opened, on Resident #420's chest near his/her shoulders and pushed the resident backwards. Interview revealed she and CNA #43 observed Resident #420 fall backwards and make contact with the floor. She stated at that time, CNA #43 lifted Resident #420's shirt and noticed red scratches on the resident's back. She stated she told CNA #94 to come and look at what he had done. Further interview revealed CNA #94 immediately left the room. She and CNA #43 got Resident #420 off the floor (without notifying the nurse to come and assess the resident) and continued to take him/her to the shower room. NA #3 stated after entering the shower room with Resident #420, CNA #43 left to get the nurse. She stated LPN #38 entered the shower room and asked Resident #420 what happened, and the resident responded, (CNA #94) pushed me. NA #3 further revealed while completing the resident's shower, she noticed a knot on Resident #420's hip and notified LPN #38. Additionally, she stated LPN #38 stated he would call and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed she was in training and hadn't yet started her CNA classes. She stated she had only worked about 8 shifts in the facility before the incident. She stated she was shaken up after the incident because she had never seen anything like that before. NA #3 stated she did not report it until she went home and spoke to her mother, who was a CNA. An additional interview with NA #3, on 12/04/2021 at 10:09 AM, revealed she had been educated and knew she should report any allegations of abuse immediately; however, she was not sure who she was to report the allegations of abuse to. She further revealed Resident #420 had reported the incident to the nurse, after the incident on 11/25/2021, while he/she was in the shower room. Interview with CNA #94, on 12/02/2021 at 2:52 PM, revealed on the morning of 11/25/2021, he entered Resident #420's room and was speaking to CNA #43 and NA #3 while Resident #420 was using the restroom. Per interview, CNA #43 left the resident's room to prepare for his/her shower. Interview revealed he and Resident #420 had an ongoing joke about Resident #420's twin brother. He stated he was joking with Resident #420 about it when the resident stood up from the commode and started to come toward CNA #94. Continued interview revealed Resident #420 became unsteady and started to stumble. CNA #94 stated he grabbed Resident #420's walker while NA #3 grabbed Resident #420's elbow to help stabilize him/her. An additional interview with CNA #94, on 12/04/2021 at 9:24 AM, revealed he had received abuse training at the facility. Continued interview revealed he was aware of the different types of abuse and he knew that any allegation of abuse needed to be reported immediately to his supervisor. CNA #94 stated he knew he could also report any allegation of abuse to the Director of Nursing (DON). Interview with LPN #38, on 12/04/2021 at 12:05 PM, revealed CNA #43 notified him that Resident #420 had fallen against the wall in his/her room. LPN #38 stated he noticed the abrasion on Resident #420's back and asked what happened, but none of the staff answered. According to LPN #38, he assumed the abrasion was where staff transferred Resident #420 onto the shower chair. Continued interview revealed after the resident's shower, staff brought Resident #420 to the nurse's station as usual to sit there. LPN #38 stated at that time, Resident #420 told him that he/she had been pushed by CNA #94. Interview revealed because of Resident #420's past history of making up stories about people he/she was aggravated with the LPN put the resident's statement in the back of his mind. Further interview revealed LPN #38 ultimately forgot about the incident reported by Resident #420 that he/she was pushed by CNA #94. He further stated Resident #420 stayed at the area near the nurse's station for the duration of his shift and he had not witnessed any other interactions between CNA #94 and Resident #420. Additionally, LPN #38 stated he had recently been educated on abuse and knew that any abuse allegations needed to be reported immediately to his supervisor but, he failed to report this incident regarding Resident #420. Interview with the DON, on 12/04/2021 at 5:20 PM, revealed upon knowledge of the allegation of abuse reported by the resident and staff member, the facility had immediately suspended all parties involved and initiated an investigation. Continued interview revealed she was notified on 11/25/2021 at approximately 4:30 PM of the allegation by NA #3, after the NA had finished her shift for the day; however, the incident had occurred that morning after breakfast per interview. Per interview, after the notification of alleged abuse, the facility implemented the Guardian Angel Rounds which required managers to round on the units at a specific time and gather any resident complaints, concerns and/or grievances and report any resident complaints, concerns or grievances to her. She revealed she called every shift, floor to floor every day, and monitored residents' documentation every day for anything suspicious (i.e., sudden onset of extreme pain) which could potentially identify a concern for the facility. Further interview revealed she expected staff to ensure residents were kept safe and to report any allegations of abuse immediately. Interview with the Administrator, on 12/04/2021 at 4:34 PM, revealed the abuse investigation was initiated immediately o [TRUNCATED]

Based on interview, record review and facility policy review it was determined the facility failed to ensure staff reported alleged violations and potential abuse of one (1) of eighteen (18) sampled residents (Resident #420). Nurse Aid (NA) #3 witnessed Certified Nursing Assistant (CNA) #94 poke Resident #420 in the forehead while the resident was sitting on the toilet. Resident #420 became agitated at CNA #94, and started to walk toward the CNA, becoming unsteady on his/her feet. NA #3 observed CNA #94 place his open hands on Resident #420's chest, pushing the resident backwards. Resident #420 fell and sustained an abrasion to his/her back. NA #3 told CNA #94, See what you did. Even though NA #3 witnessed the incident, she failed to report it until her shift ended and she went home, approximately six (6) hours later. Resident #420 told Licensed Practical Nurse (LPN) #38 that CNA #94 pushed him/her, which resulted in a fall. However, LPN #38 did not report the incident as he did not believe the incident was abuse of Resident #420. The facility's failure to ensure staff reported alleged violations and potential abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F609; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.70 Administration; and, 42 CFR 483.75 Quality Assurance and Performance Improvement, F867, all at a Scope and Severity of a J. The Immediate Jeopardy was determined to exist on 10/17/2021. The facility was notified of the Immediate Jeopardy on 12/04/2021. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and AoC/removal plan validation survey were concluded on 12/09/2021 which determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S (scope and severity) of D; F609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F835 Administration at S/S of D; F837 Governing Body at S/S of D; and, 42 CFR 48.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Program, updated 05/02/2017, revealed nursing staff were responsible for reporting the appearance of bruises, lacerations, or other abnormalities on residents as the injuries occurred. Further review revealed after being notified of the residents' injuries, the Nursing Supervisor was responsible for assessing the resident, reviewing the documentation, and reporting the resident's injuries to the Administrator or designee. Per review, if the injury was related to suspected abuse, staff were to separate the alleged perpetrator from other residents, ensure all other residents' safety, notify their nurse or supervisor immediately, and notify the Administrator or Director of Nursing (DON) or the person in charge of the facility at the time. Continued review revealed staff members suspected of abuse of a resident, or misconduct were to immediately be barred from any further contact with the residents. Record review revealed the staff person suspected of abuse was also to be suspended from duty pending the outcome of the facility's investigation, prosecution, or disciplinary action against the employee. Per policy review, the Administrator or designee was to notify the State Agencies, and Law Enforcement Officials of alleged or suspected resident abuse or neglect incidents immediately after being informed of such incidents. Review of the facility's policy titled, Abuse Reporting, updated 05/02/2017, revealed the facility would not tolerate resident abuse or mistreatment by anyone, including its staff members. The policy stated all personnel were to promptly report any incident or suspected incident of resident abuse and could do so without fear of retaliation or retribution from the facility or other staff. Continued review revealed staff, who observed an incident of resident abuse, were to immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. Per review, the Charge Nurse was to immediately examine the residents(s) involved in the incident, and immediately report the incident to the Administrator or his/her designee. Review of Resident #420's clinical record revealed the facility admitted the resident on 09/05/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Pre-Admission Screening and Resident Review (PASRR), dated 09/02/2021, revealed Resident #420 had adaptive behavior of an eight (8) year, five (5) month old. The resident's unsteady balance was related to his/her weakness. Additional review revealed Resident #420 was noted to have an Intelligent Quotient (IQ) ranging from forty-two (42) to sixty (60) which indicated a moderate degree of cognitive limitation. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #420 with a Brief Interview of Mental Status (BIMS) score of ten (10) out of fifteen (15) which indicated the resident had moderate cognitive impairment. Review of Resident #420's Comprehensive Care Plan (CCP), dated 09/30/2021, revealed the facility had noted the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan interventions included for staff to assist Resident #420 with reality orientation when he/she experienced episodes of fantasy/fabrications that interfered with the resident's well-being. Continued review revealed staff were to validate Resident #420's concerns. However, they were to set limits with the resident's negative behaviors. Resident #420 enjoyed sitting in the common area of the unit and conversing with staff, or having one-to-one (1:1) interactions with staff. Review of the facility's Incident Report, dated 11/26/2021 and timed at 12:54 PM, revealed NA #3 reported on 11/25/2021, that she had witnessed CNA #94 place his finger on Resident #420's forehead and push the resident's head backwards, while the resident was sitting on the toilet. Per review, the incident occurred sometime between breakfast and lunch. Continued review revealed Resident #420 stood up from the toilet, and began to walk towards CNA #94, attempting to hit the CNA for pushing his/her head back. The Incident Report stated NA #3 then observed CNA #94 place the palms of his hands on Resident #420's chest and push the resident backwards causing the resident to fall to the floor. Record review revealed Resident #420 obtained a red abrasion to his/her back; and, was later assessed to have a raised area to his/her hip. Further review revealed witness statements were obtained and later, all parties involved were suspended after the incident had been reported to the facility management. Review of the facility's timeline for the 11/25/2021 incident revealed NA #3 had not reported the incident of alleged abuse of Resident #420 until after her shift was over on that date (which was after 3:00 PM). Continued review revealed facility management was not made aware of the incident on 11/25/2021 until 4:36 PM. Review of the facility's interview with Resident #420, on 11/25/2021 at 6:38 PM, after the incident had been reported, revealed CNA #94 Kinda played a prank or joke on me and made me fall and injure my back. Interview with NA #3, on 12/02/2021 at 3:40 PM, revealed she had observed CNA #94 enter Resident #420's room while the resident was sitting on the toilet in his/her restroom on 11/25/2021, sometime between breakfast and lunch. NA #3 stated she observed CNA #94 poke Resident #420 on the forehead which caused the resident's head to go backwards. She stated Resident #420 became upset and stood up trying to move towards CNA #94 to hit the CNA and the resident started to stumble. Per interview, at that time, CNA #94 placed his opened hands on Resident #420's upper chest area near his/her shoulders and pushed the resident backwards causing him/her to fall down. According to NA #3, after the incident she and CNA #43 took Resident #420 to the shower room and Licensed Practical Nurse (LPN) #38 also entered the shower room. Further interview revealed Resident #420 notified LPN #38 that CNA #94 had pushed him/her down which caused the resident to scratch his/her back. NA #3 stated she ultimately decided to notify the facility of the incident after her shift ended at 3:00 PM, and she had gone home. She stated she had been educated to report incidents; however, she did not known to whom she was to report them to. Record review revealed no documented evidence the facility's management was immediately notified of the alleged abuse after the incident, as per the policy. Interviews with NA #3, LPN #38, and CNA #94 revealed CNA #94, the alleged perpetrator, continued to work on the unit near Resident #420 and provided care for other residents living on that unit. Interview with LPN #38 on 12/04/2021 at 12:05 PM, revealed CNA #43 notified him that Resident #420 had fallen against the wall. He stated when he saw Resident #420, after he had been notified, the resident was already in the shower chair in the shower room. LPN #38 stated he had observed the abrasion on Resident #420's back and asked the resident what had happened. However, the resident did not answer. LPN #38 stated he assumed the resident's abrasion was from the transfer from his/her wheelchair to the shower chair. Continued interview revealed it wasn't until after Resident #420's shower, when the resident was brought to the nurse's station, that Resident #420 reported CNA #94 pushed him/her. Further interview revealed he did not report what Resident #420 told him as potential abuse at that time. The LPN stated he ultimately forgot to report the incident due to the resident's past history of embellishing/fabricating the truth. Interview further revealed in hindsight he should have reported the allegation of abuse immediately. LPN #38 stated he had received the abuse education provided by the facility, and knew he should have reported the incident immediately. However, he had not done so. Interview with the Director of Nursing (DON), on 12/04/2021 at 5:20 PM, revealed she expected all staff to report any allegation of abuse immediately. She stated when the facility became aware of the allegation, all parties were suspended immediately and an investigation was started. The DON stated she did not feel that failure to report had been a failure on the facility's part, as she felt the staff members involved in the incident had not followed their training and the facility's policies and procedures. Continued interview revealed the staff members involved in the incident were no longer employed at the facility. Further interview revealed it was NA #3's perception that CNA 94 pushed Resident #420 down. Interview with the Administrator, on 12/04/2021 at 4:34 PM, revealed an abuse investigation had immediately been initiated once the facility was notified of the abuse allegations. Per interview, she did not believe the incident had been a failure on the part of the facility regarding the late reporting, as the facility had reported the allegation once the management team had been notified. She stated she believed it was a failure on the part of the staff. Interview revealed all the staff involved in the incident had received the abuse education provided, including reporting, on a weekly basis, if not more. The Administrator stated all those staff had been educated; however, they still had not reported the incident immediately as required, and that was the reason the facility ultimately determined they needed to fire those staff. The facility took the following actions to remove the Immediate Jeopardy (IJ): 1. The abuse allegation regarding Resident #420 was reported to the appropriate agencies as soon as the facility became aware of the incident. 2. A skin assessment and pain assessment were completed for Resident #420 on 11/25/2021 with a new treatment order per the physician. 3. Social Services (SS) followed and monitored Resident #420 for three (3) days following the incident. 4. The involved staff were terminated from the facility at the close of the investigation. 5. Event calls were held on 11/25/2021, 11/26/2021, 11/27/2021 and 11/28/2021. The facility held an Ad Hoc QAPI meeting on 11/29/2021 with the IDT to review the allegations and interventions. Follow up calls were held on 11/30/2021, 12/02/2021, and 12/05/2021. 6. The facility began interviews and skin assessments on all residents on 11/25/2021. These were completed on 11/29/2021. 7. The Administrator was responsible to ensure all reportable events were reported. 8. The facility developed a twenty-four (24) hour supervision schedule beginning 12/06/2021 to ensure better reporting of potential allegations of abuse. 9. Abuse education was started on 12/05/2021, and was completed by the Nurse Management Team. 10. The facility reported all nursing notes were being reviewed in the Clinical Quality Indicators (CQI) meetings. 11. The facility placed Resident #69 on one-on-one (1:1) supervision on 11/29/2021. 12. Social Services (SS) monitored Resident #69 for three (3) days. 13. The facility's contracted Provider Services assessed Resident #69 on 11/30/2021 to determine his/her cognitive ability to consent to sexual conduct. 14. Resident #69 was assessed by psychiatric (psych) services on 12/03/2021 with a follow up on 12/06/ . 15. Resident #69's care plan was reviewed and updated by the Interdisciplinary Team (IDT) on 11/24/2021, 11/29/2021, 11/30/2021, and 12/01/2021 with added interventions. 16. Resident #69 was reviewed weekly in the Behavior Meetings. 17. Resident #410 was placed on 1:1 supervision on 11/29/2021. 18. SS monitored Resident #410 for three (3) days. 19. Resident #410 was assessed by psych services on 12/03/2021 with a follow up on 12/06/2021. 20. Resident #410's care plan was reviewed and updated by the IDT on 11/29/2021, 11/23/2021 and 12/03/2021. 21. Resident #410 was being reviewed weekly in the Behavior Meetings. 22. Resident #410 was moved to a different room on 11/30/2021 and to a different unit on 12/03/2021 to decrease the risk of reoccurring events. 23. IDT reviewed Resident #410 on 12/03/2021 and determined it was safe to decrease the 1:1 supervision to every fifteen (15) minute checks. 24. The facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting and event calls on 12/01/2021. Follow up event calls were conducted on 11/30/2021, 12/02/2021 and 12/05/2021 with the RDO, RNC, Governing Body, Administrator and DON regarding Resident #69 and Resident #410. 25. Any new, continuing, or worsening behaviors will be reviewed daily during the Clinical Quality Indicators (CQI) Meeting. 26. On 12/06/2021, all residents with a documented history of sexual behaviors were reviewed by the IDT and care plans were updated to increase safety. 27. The SS Department will assess the resident's desire to have sexual contact upon admission or readmission to the facility. 28. Abuse education was started on 12/05/2021, and was completed by the Nurse Management Team. 29. The SS Director began audits of four (4) resident charts daily beginning 12/05/2021, with residents who had known behaviors. 30. The audits will be reviewed daily by the RDO or RNC. 31. The audits reviewed by the RDO or RNC will be presented to the QAPI committee. 32. The RDO or RNC will attend the QAPI meetings weekly for four (4) weeks, then monthly for three (3) months. The State Survey Agency (SSA) validated the facility took the following actions: 1. Review of the Long-Term Care - Self Reported Incident, dated 12/02/2021, revealed the facility notified the proper State Agencies on 11/25/2021. 2. Review of the Pain Review, dated 11/25/2021 and Skin Check, dated 11/25/2021, revealed a licensed nurse completed assessments with a small abrasion noted to Resident #420's back. Continued review revealed a new order for Triple Antibiotic Ointment was obtained on 11/25/2021, per the provider. Unsuccessful attempts were made on 12/09/2021 at 12:45 PM and 1:30 PM, to contact the Licensed Nurse who obtained the order. 3. Record review revealed the SS Director monitored Resident #420 for three (3) days on 11/26/2021, 11/29/2021 and 11/30/2021 after the incident for any signs or symptoms of distress with no concerns noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM revealed she monitored Resident #420 for three (3) days for concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 4. Personnel record review revealed CNA #94, LPN #38, NA #3, and CNA #43 were terminated on 12/03/2021, following the outcome of the investigation. 5. Review of the facility's QAPI Meeting Minutes, dated 11/29/2021 revealed the IDT held a meeting to discuss the incident and allegation. Continued review revealed event calls were held regarding the incident involving Resident #420 on 11/25/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/30/ , 12/02/2021, and 12/05/2021. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she participated in the Ad Hoc QAPI meeting with follow up event calls regarding Resident #420. They discussed the incident and to keep the team updated on the investigation. They also brainstormed on the type of action plan that was needed. Interview with the RNC, on 12/09/2021 at 3:04 PM, revealed he participated in the Ad Hoc QAPI meeting and the follow up event calls regarding the incident involving Resident #420. Continued interview revealed, we are updated on the investigation and tried to determine the root cause of the incident. Per interview, suggestions had been given to the facility and to determine what else could be completed to ensure the right procedures were being followed. Interview with a representative of the facility's Governing Body, on 12/09/2021 at 3:41 PM, revealed the Governing Body members had been present for the Ad Hoc QAPI meeting and follow up event calls. He stated the event calls were placed regarding identified concerns, any serious reportable events. Per interview, we evaluated all the facts, ensured interviews were completed, discussed resident assessments and interventions. He further revealed during the event calls, there was also discussion of whether there was a need for improvement and if a concern was identified it became part of the QAPI process. Interview with the DON, on 12/09/2021 at 2:05 PM, revealed she had been a part of the Ad Hoc QAPI meetings and event calls. She stated during the meetings and event calls, the event was discussed. She stated they attempted to determine what led up to the incident and what the plan would be after the event occurred. Interview with the Administrator, on 12/09/2021 at 2:43 PM, revealed she had been a part of the Ad Hoc QAPI and event calls. Continued interview revealed the team discussed the allegations regarding Resident #420 and what had been reported to the facility. She stated the facts of the event were discussed, along with ensuring that the necessary reporting occurred and where the facility went from there. 6. Record review revealed the facility completed interviews or skin assessments on all present residents for any concerns of possible abuse. No concerns were identified. 7. Interview with the Administrator, on 12/09/2021 at 2:43 PM, revealed she would report any abuse allegation if the DON did not. Continued interview revealed she would notify the appropriate State Agencies. She stated the DON or ADON would complete the initial incident report and keep her updated on the investigation, she would advise if needed. Per interview, she would ensure the five (5) day report was completed and sent to the reporting agencies timely. 8. Interview with the DON, on 12/09/2021 at 2:50 PM, revealed managers had been delegated to complete rounds during the off-business hours and the rounding sheets were reviewed every morning and evening. 9. Review of the staff list revealed permanent staff, agency, and therapy staff completed education regarding the abuse policy, behaviors, with the opportunity for question and answer along with a posttest that required a 100% pass rate. Continued review revealed staff who had not yet received the education had not worked since 12/08/2021. Those staff had to complete the education prior to being allowed to work. Interview with the Activity Aide, on 12/09/2021 at 1:28 PM, revealed she had received the education on abuse and reporting. The education included to whom to report abuse allegations to, and when to report it. Continued interview revealed she received education regarding behaviors in residents; the importance of reporting new or worsening behaviors; and, to ensure that residents were kept safe. Further interview revealed she had also completed care plan education which stated the importance of updating a resident's care plan if there was a resident change. She stated there was post test that she completed. Interview with Laundry Aide #2, on 12/09/2021 at 1:12 PM, revealed she had been educated on abuse training and the importance of reporting anything suspicious to the nurse or supervisor. Continued interview revealed she received education regarding resident behaviors. If any behaviors were identified she was to report them to a nurse or supervisor. Additionally, she revealed she completed a posttest after receiving the education. Interview with the Dietary Aide, on 12/09/2021 at 1:18 PM, revealed he had received abuse training regarding reporting any abuse allegations immediately. Per interview, he had also received education related to if you observed harm to a resident, or a resident reported something to you to ensure that was reported. Continued interview revealed if behaviors were noted as new, continuing or worsening to report them to a nurse. He further revealed a post test had been completed. Interview with CNA #26, on 12/09/2021 at 1:43 PM, revealed she completed abuse training on the different types of abuse, and the importance of reporting abuse immediately to the supervisor and to ensure residents were safe. Continued interview revealed she received education on resident behaviors regarding the importance of reporting any new or continuing behaviors. Further interview revealed she received care plan education on the importance of using the care plan. Additionally, she revealed she completed a post test. Interview with CNA #51, on 12/09/2021 at 1:33 PM revealed she completed abuse training and the importance of reporting it immediately. Per interview, she had received behavior education regarding using the binders on the units to report any new, worsening, or continuing behaviors and to ensure all behaviors were charted. Further interview revealed if there was a resident change, that change needed to be reflected in the resident's care plan. She stated a post test had been completed. Interview with Certified Medication Technician (CMT) #4, on 12/09/2021 at 1:59 PM, revealed she completed abuse training regarding reporting immediately and the signs of potential abuse (i.e., suspicious bruising). Continued interview revealed she received education on residents' behaviors. She stated there was a binder on each unit with residents who had behaviors that could be used to understand triggers and different interventions to use to address those behaviors. Further interview revealed she received education about residents' care plans and the importance of updating the care plan with any changes to ensure residents were receiving the proper care. She completed a post test. Interview with LPN #42, on 12/09/2021 at 2:02 PM, revealed she received abuse training regarding how to identify abuse and when and whom to report it to and ensure the residents were kept safe. Continued interview revealed regarding behaviors, if staff noticed a change in the resident's behaviors they were to report it to the nurse immediately. Per interview, staff were to ensure any behaviors were care planned and documented. Further interview revealed she received education regarding the use of the resident's care plan, how to use it and the importance of following the care plan. She completed a post test. Interview with LPN #43, on 12/09/2021 at 1:04 PM, revealed she received education regarding reporting abuse immediately, and ensuring that any new or worsening behaviors were reported and documented, along with why the care plans were important to follow. Further interview revealed a post test had been included with the education provided. Interview with LPN #50, on 12/09/2021 at 1:24 PM, revealed she completed abuse training regarding what to do immediately when an allegation was made and whom to report it to. Continued interview revealed any behaviors were to be reported to the supervisor and documented along with updating the care plan with any resident changes. Interview with RN #5, on 12/09/2021 at 1:51 PM, revealed she received education regarding who, when and what to report regarding abuse allegations. Continued interview revealed she received training on residents' behaviors, and the use of the binders on each unit. Per interview, she had received training to notify the nurse if there was any new behaviors or worsening behaviors noted. Further interview revealed she completed care plan education regarding the importance of updating the care plan if there was a change in the resident. She further revealed she had completed a post test. Interview with the Nurse Management Team (Director of Clinical Services, DON, RDO, Staff Development Coordinator, RNC, and ADON), on 12/09/2021 at 2:11 PM, revealed staff education had been completed in small groups, through 1:1 training, or telephonically with staff members who all had completed the post test. Continued interview revealed staff were educated on abuse, Governing Body, care planning, reporting abuse, reporting falls, incidents and abuse allegations timely. Further interview revealed care plans were discussed with the importance of the care plans being resident centered. Interview further revealed the importance of a resident having appropriate care plans in place, and ensuring they were followed was also discussed. 10. Interview with the CQI staff, which included the Administrator, DON, Assistant DON, Unit Managers, Minimum Data Set (MDS) Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director, and the RDO on 12/09/2021 at 2:25 PM, revealed they reviewed all Nurses' Progress Notes every day during the morning clinical meeting for anything abnormal, for any behaviors, and/or potential abuse concerns. 11. Record review revealed the facility placed Resident #69 on 1:1 supervision on 11/29/2021 which continued through 12/08/2021. No concerns were identified. 12. Record review revealed the SS Director completed monitoring for Resident #69 for three (3) days on 11/30/2021, 12/01/2021, and 12/02/202. There were no concerns of psychosocial distress noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM, revealed she had monitored Resident #69 for three (3) days for any concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 13. Record review revealed contracted provider services assessed Resident #69 on 11/30/2021 and determined Resident #69 was not capable of giving informed consent regarding consensual sexual activity. Per review, no new orders had been received at that time. 14. Record review revealed psych services assessed Resident #69 on 12/03/2021 and 12/06/2021 with new orders for a new medication to be started. 15. Review of the Comprehensive Care Plan revealed Resident #69's care plan had been updated on 11/24/2021, 11/29/2021, 11/30/2021, and 12/01/2021 with interventions that included: placing a bright sign on his/her door to assist the resident in identifying his/her correct room; 1:1 observation; residents to be separated; and pain and skin assessments to be completed. Continued review revealed additional interventions included: Social Services to observe for psychosocial distress; evaluations to be completed by the contracted provider services; psych services to follow; and the IDT had determined Resident #69 did not have the cognitive capacity to consent to sexual activity. Interview with the IDT members which included, but were not limited to, the Administrator, DON, ADON, Unit Managers, MDS Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director and the RDO, on 12/09/2021 at 2:25 PM revealed they had reviewed Resident #69's care plan. They reviewed the care plan to ensure proper interventions were in place to help monitor the resident's behaviors and maintain safety for him/her and other residents. 16. Review of the Behavior Meeting Agenda revealed Resident #69 was reviewed in the weekly behavior meetings. The most recent meeting was held on 12/02/2021. Interview was conducted with the Behavior Meeting Members which included, but was not limited to, the Administrator, DON, ADON, Unit Managers, MDS Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director and the RDO on 12/09/2021 at 2:25 PM. Further interview revealed that during the meetings, they reviewed residents for any concerns regarding verbal aggression, physical aggression, refusal of medications, sexual behaviors, any abnormal behaviors and anything which affected the resident or other residents. 17. Record review revealed Resident #410 was placed on 1:1 supervision on 11/29/2021 through 12/03/2021, with no concerns noted. 18. Record review revealed the SS Director observed Resident #410 for three (3) days on 11/30/2021, 12/01/2021 and 12/02/2021 with no concerns of psychosocial distress noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM, revealed she monitored Resident #410 for three (3) days for concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 19. Record review revealed Resident #410 was seen by psych services on 12/03/2021 with a follow up visit on 12/06/2021, and no new orders received. 20. Review of the Comprehensive Care Plan (CCP) revealed the IDT reviewed and updated Resident #410's care plan on 11/29/2021, 11/30/2021 and 12/03/2021 with interventions that included 1:1 staff observation; residents were separated; skin and pain assessments completed; moved the resident's room to a more visible location near the nurse's station. Continued review revealed further interventions which included: SS was to follow for signs [TRUNCATED]

Based on interview, record review, and review of the facility's documents, it was determined the facility failed to develop and implement the Comprehensive Person-Centered Care Plan for one (1) of eighteen (18) sampled residents (Resident #69). Review of Resident #69's Comprehensive Care Plan revealed the resident expressed no desire to have sexual contact with another person, after assessments on 07/27/2021, 08/24/2021 and 09/23/2021. The interventions included: for staff to encourage Resident #69 to notify them if he/she had the desire to have sexual contact with another person. Review of the Progress Notes for Resident #69 dated 10/17/2021 and 10/19/2021 revealed the resident made sexual statements to male staff, and sat with his/her legs spread in a common area encouraging staff to come and get some. However, review of Resident #69's Comprehensive Care Plan revealed these behaviors were not identified and addressed in the care plan. On 11/29/2021, at approximately 8:30 PM, a staff person observed Resident #69 lying on the floor in his/her room facing another resident. The other resident, (Resident #410) had his/her pants and adult brief pulled down below the knees and his/her genitalia was exposed to Resident #69. The facility's failure to ensure Resident #69's Comprehensive Person-Centered Care Plan was developed and implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F609; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.70 Administration; and, 42 CFR 483.75 Quality Assurance and Performance Improvement, F0867, at a Scope and Severity of a J. The Immediate Jeopardy was determined to exist on 10/17/2021. The facility was notified of the Immediate Jeopardy on 12/04/2021. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and Removal Plan Validation Survey were conducted on 12/09/2021 which determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S (scope and severity) of D; F609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F835 Administration at S/S of D; F837 Governing Body at S/S of D; and, 42 CFR 48.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's document titled, 4.7 The RAI{Resident Assessment Instrument} and Care Planning, undated, revealed a good assessment was the starting point for good clinical problem solving and decision making and ultimately for the creation of a sound care plan. Per review, the care plan should be reviewed and revised on an ongoing basis to ensure interventions were effective and to reflect changes in the resident and the care he/she was receiving. Review of Resident #69's clinical record revealed the facility admitted the resident, on 02/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Annual Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed Resident #69 was assessed as having a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was moderately cognitively impaired. Per review, Resident #69 was not assessed as having physical behaviors which included hitting, grabbing or displaying sexually inappropriate behavior. Review of Resident #69's Progress Notes revealed a note dated 10/17/2021 at 2:54 AM, which stated the resident made inappropriate sexual statements to staff. Review of a Progress Note dated 10/19/2021 at 4:12 PM, revealed Resident #69 had been sitting (dressed) in the common area of the unit, with his/her legs spread open, encouraging staff to come and get it. Further review of the 10/19/2021 Progress Note revealed Resident #69 was also telling male employees he/she wanted to grab their junk. Review of Resident #69's Comprehensive Care Plan (CCP), dated 09/05/2021 revealed the facility had care planned the resident for behaviors with interventions which included: removing Resident #69 from situations that might cause anxiety or aggression; staff to speak to the resident in a calm voice when attempting to deescalate agitated behaviors. Continued review of the CCP revealed a Focus on Resident #69's care plans dated 07/23/2021, 08/24/2021 and 09/23/2021, which noted the resident did not desire to have sexual contact with another person at that time. The goal stated Resident #69 would notify staff if he/she desired to have sexual contact with another person. However, there was no evidence the facility developed interventions to address Resident #69's comments and behaviors documented in the 10/17/2021 and 10/19/2021 Progress Notes. Review of the facility's investigation revealed on 11/29/2021 at approximately 8:30 PM, a staff member had observed Resident #69 lying on the floor in his/her room floor, with another resident facing Resident #69. Per review, Resident #69 was fully clothed; however, the other resident had his/her pants and brief pulled below the knees (exposing his/her genitalia to Resident #69). Continued review revealed the staff member observed that the two (2) residents' knees were touching. Staff immediately separated the residents and both residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor attempted to interview Resident #69; however, all attempts were unsuccessful. Review of Resident #410's clinical record revealed the facility had assessed the resident to have a BIMS score of six (6) which was indicative of severe cognitive impairment. Interview on 12/03/2021 at 10:30 AM, with Resident #410 revealed the resident was unable to remember anything about Monday night (11/29/2021, the date of the incident). Interview with RN #11, on 12/02/2021 at 8:37 AM, via phone, revealed he had been performing his medication pass around 8:15 PM. RN #11 stated he had not seen Resident #410 sitting in the common area where he/she had been previously. He stated when he went to look for Resident #410, he noted that Resident #69's room door was closed. Per interview, he knocked on Resident #69's door, and entered his/her room where he observed Resident #410 lying on the floor with his/her brief and pants down to the ankles and his/her genitals exposed to Resident #69. Further interview revealed Resident #69 was wearing a gown and brief. He stated Resident #69 was upset with him (RN #11) for being in his/her room. Interview with the facility's Interim Administrator on 12/03/2021 at 3:40 PM and again on 12/04/2021 at 4:33 PM, revealed overseeing the facility's operations was her role as Administrator. The Interim Administrator stated regarding the care planning issues identified, she had no clinical background and was unable to speak to those issues. She stated she could only say Resident #69 and Resident #410 had been discussed in the facility's Interdisciplinary Team (IDT) meetings ever since she had become the Interim Administrator. She stated they discussed Resident #69 related to his/her verbal and aggressive behaviors and Resident #410 for his/her rejection of care. According to the Interim Administrator, she was aware of Resident #69's previous sexually inappropriate behavior. Interview revealed residents could be placed on every fifteen (15) minute checks or 1:1 supervision by nursing staff using their nursing judgement without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing, (DON) on 12/04/2021, at 5:15 PM, revealed she expected any resident's inappropriate behaviors to be care planned with interventions documented and staff were to implement the interventions. Continued interview revealed the DON felt there had been no failure in the facility's current system or processes, or in the care planning of interventions for Resident #69. Per interview, the DON stated it was not feasible for the facility to keep a constant eye on all residents with behaviors. The DON stated she felt staff had been following Resident #69's care plan interventions at the time of the incident. However, the facility had assessed the residents to be unable to give consent for sexual contact with another person, and had been care planned to have no desire for sexual contact with others. The facility took the following actions to remove the Immediate Jeopardy (IJ): 1. The abuse allegation regarding Resident #420 was reported to the appropriate agencies as soon as the facility became aware of the incident. 2. A skin assessment and pain assessment were completed for Resident #420 on 11/25/2021. A new treatment was ordered. 3. Social Services (SS) followed and monitored Resident #420 for three (3) days following the incident. 4. The involved staff were terminated from the facility at the close of the investigation. 5. Event calls were held on 11/25/2021, 11/26/2021, 11/27/2021 and 11/28/2021. The facility held an Ad Hoc QAPI meeting on 11/29/2021 with the IDT to review the allegations and interventions. Follow up calls were held on 11/30/2021, 12/02/2021, and 12/05/2021. 6. The facility began interviews and skin assessments to determine any potential abuse allegation or suspected abuse. The interview and assessments were started on 11/25/2021 and all were completed on 11/29/2021. 7. The Administrator was responsible to ensure all reportable events were reported. 8. The facility developed a twenty-four (24) hour supervision schedule beginning 12/06/2021 to ensure better reporting of potential allegations of abuse. 9. Education was started on 12/05/2021, and was completed by the Nurse Management Team. 10. The facility reported all nursing notes were being reviewed in the Clinical Quality Indicators (CQI) meetings. 11. The facility placed Resident #69 on one-on-one (1:1) staff supervision on 11/29/2021 for increased supervision. 12. Social Services (SS) monitored Resident #69 for three (3) days. 13. The facility's contracted medical services provider assessed Resident #69 on 11/30/2021 to determine his/her cognitive ability to consent to sexual contact. 14. Resident #69 was assessed by psychiatric (psych) services on 12/03/2021 with a follow up on 12/06/ . 15. Resident #69's care plan was reviewed and updated by the Interdisciplinary Team (IDT) on 11/24/2021, 11/29/2021, 11/30/2021, and 12/01/2021 with added interventions. 16. Resident #69 was being reviewed weekly in the Behavior Meetings. 17. Resident #410 was placed on 1:1 supervision on 11/29/2021. 18. SS monitored Resident #410 for three (3) days. 19. Resident #410 was assessed by psych services on 12/03/2021 with a follow up assessment on 12/06/2021. 20. Resident #410's care plan was reviewed and updated by the IDT on 11/29/2021, 11/23/2021 and 12/03/2021. 21. Resident #410 was being reviewed weekly in the Behavior Meetings. 22. Resident #410 was moved to a different room on 11/30/2021 and to a different unit on 12/03/2021 to decrease the risk of reoccurring events. 23. IDT reviewed Resident #410 on 12/03/2021 and determined it was safe to decrease his/her 1:1 supervision to every fifteen (15) minute checks. 24. The facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting and event calls on 12/01/2021 with follow up event calls on 11/30/2021, 12/02/2021 and 12/05/2021 with the RDO, RNC, Governing Body, Administrator and DON regarding Resident #69 and Resident #410. 25. Any new, continuing, or worsening behaviors will be reviewed daily during the Clinical Quality Indicators (CQI) Meeting. 26. On 12/06/2021, all residents with a documented history of sexual behaviors were reviewed by the IDT. Care plans were updated to increase safety. 27. The SS Department will assess the resident's desire to have sexual contact upon admission or readmission to the facility. 28. Staff education was started on 12/05/2021, and completed by the Nurse Management Team. 29. The SS Director began audits of four (4) residents' charts daily beginning 12/05/2021. Residents with known behaviors were audited. 30. The audits will be reviewed daily by the RDO or RNC. 31. The audits reviewed by the RDO or RNC will be presented to the QAPI committee. 32. The RDO or RNC will attend the QAPI meetings weekly for four (4) weeks, then monthly for three (3) months. The State Survey Agency (SSA) validated the facility took the following actions: 1. Review of the Long-Term Care - Self Reported Incident, dated 12/02/2021, revealed the facility notified the proper State Agencies on 11/25/2021. 2. Review of the Pain Review, dated 11/25/2021 and Skin Check, dated 11/25/2021, revealed a licensed nurse completed assessments with a small abrasion noted to Resident #420's back. Continued review revealed a new order for Triple Antibiotic Ointment was obtained on 11/25/2021, per the provider. Unsuccessful attempts were made to contact the Licensed Nurse, who obtained the order, on 12/09/2021 at 12:45 PM and 1:30 PM. 3. Record review revealed the SS Director monitored Resident #420 for three (3) days on 11/26/2021, 11/29/2021 and 11/30/2021 after the incident for any signs or symptoms of distress with no concerns noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM revealed she monitored Resident #420 for three (3) days for concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 4. Personnel record review revealed CNA #94, LPN #38, NA #3, and CNA #43 were terminated on 12/03/2021, following the outcome of the investigation. 5. Review of the facility's QAPI Meeting Minutes, dated 11/29/2021, revealed the IDT held a meeting to discuss the incident and allegation. Continued review revealed event calls were held regarding the incident involving Resident #420 on 11/25/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/30/ , 12/02/2021, and 12/05/2021. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she participated in the Ad Hoc QAPI meeting with follow up event calls regarding Resident #420, to discuss the incident and to keep the team updated on the investigation, and to brainstorm on the type of action plan needed. Interview with the RNC, on 12/09/2021 at 3:04 PM, revealed he participated in the Ad Hoc QAPI meeting and the follow up event calls regarding the incident involving Resident #420. The RNC stated, We are updated on the investigation and tried to determine the root cause of the incident. Per interview, suggestions had been given to the facility to determine what else could be completed to ensure the right procedures were being followed. Interview with a representative of the facility's Governing Body, on 12/09/2021 at 3:41 PM, revealed the Governing Body members had been present for the Ad Hoc QAPI meeting and follow up event calls. He stated the event calls were placed regarding identified concerns, any serious reportable events. Per interview, we evaluated all the facts, ensured interviews were completed, discussed resident assessments and interventions. He further revealed during the event calls, there was also discussion of whether there was a need for improvement and if a concern was identified it became part of the QAPI process. Interview with the DON, on 12/09/2021 at 2:05 PM, revealed she had been a part of the Ad Hoc QAPI meetings and event calls. She stated during the meetings and event calls the event was discussed; attempted to determine what led up to the incident; and, what the plan would be after the event occurred. Interview with the Administrator, on 12/09/2021 at 2:43 PM, revealed she had been a part of the Ad Hoc QAPI and event calls. Continued interview revealed the team discussed the allegations regarding Resident #420 and what had been reported to the facility. Per interview, the facts of the event were discussed, along with ensuring the necessary reporting occurred and where the facility went from there. 6. Record review revealed the facility completed interviews or skin assessments on all present residents for any concerns of possible abuse. 7. Interview with the Administrator, on 12/09/2021 at 2:43 PM, revealed she would report any abuse allegation if the DON did not. Continued interview revealed she would notify the appropriate State Agencies. She stated the DON or ADON would complete the initial incident report and keep her updated on the investigation, she would advise if needed. Per interview, she would ensure the five (5) days was completed and sent to the reporting agencies timely. 8. Interview with the DON, on 12/09/2021 at 2:50 PM, revealed managers had been delegated to complete rounds during the off-business hours and the rounding sheet were reviewed every morning and evening. 9. Review of the staff list revealed permanent staff, agency, and therapy staff completed education regarding the abuse policy, behaviors, with the opportunity for question and answer along with a posttest that required a 100% pass rate. Continued review revealed staff who had not yet received the education were staff that had not worked since 12/08/2021 and those staff had to complete the education prior to being allowed to work. Interview with the Activity Aide, on 12/09/2021 at 1:28 PM, revealed she had received the education about abuse regarding reporting, whom to report abuse allegations to, and when to report it. Continued interview revealed she received education regarding resident behaviors, and the importance of reporting new or worsening behaviors and to ensure that residents were kept safe. Further interview revealed she had also completed care plan education which stated the importance of updating a resident's care plan if there was a resident change and a post test had been completed. Interview with Laundry Aide #2, on 12/09/2021 at 1:12 PM, revealed she had been educated on abuse training and the importance of reporting anything suspicious to the nurse or supervisor. Continued interview revealed she received education regarding; if resident behaviors were identified to who to report them to, a nurse or supervisor. Additionally, she revealed she completed a posttest after receiving the education. Interview with the Dietary Aide, on 12/09/2021 at 1:18 PM, revealed he had received abuse training regarding reporting any abuse allegations immediately. Per interview, he had also received education related to if you observed harm to a resident, or a resident reported something to you to ensure that was reported. Continued interview revealed if behaviors were noted as new, continuing or worsening to report them to a nurse. He further revealed a post test had been completed. Interview with CNA #26, on 12/09/2021 at 1:43 PM, revealed she completed abuse training on the different types of abuse, and the importance of reporting abuse immediately to the supervisor and ensure residents were safe. Continued interview revealed she received education on resident behaviors regarding the importance of reporting any new or continuing behaviors. Further interview revealed she received care plan education on the importance of using the care plan. Additionally, she revealed she completed a post test. Interview with CNA #51, on 12/09/2021 at 1:33 PM revealed she completed abuse training and the importance of reporting it immediately. Per interview, she had received behavior education regarding using the binders on the units to report any new, worsening, or continuing behaviors and ensure all behaviors were charted. Further interview revealed if there was a resident change, that change needed to be reflected in the resident's care plan. Additionally, she stated a post test had been completed. Interview with Certified Medication Technician (CMT) #4, on 12/09/2021 at 1:59 PM, revealed she completed abuse training regarding reporting it immediately and the signs of potential abuse (i.e., suspicious bruising). Continued interview revealed she received education on residents' behaviors and there was a binder on each unit with residents, who had behaviors that could be used to understand triggers and different interventions to use to address those behaviors. Further interview revealed she received education about residents' care plans and the importance of updating the care plan with any changes to ensure residents were receiving the proper care. She revealed she completed a post test. Interview with LPN #42, on 12/09/2021 at 2:02 PM, revealed she received abuse training regarding how to identify abuse and when and who to report it to and ensure the residents were kept safe. Continued interview revealed regarding behaviors, if staff noticed a change in the resident's behaviors, they were to report it to the nurse immediately. Per interview, staff were to ensure any behaviors were care planned and documented. Further interview revealed she received education regarding the use of the resident's care plan, how to use it and the importance of following the care plan. Additionally, she revealed a post test had been completed. Interview with LPN #43, on 12/09/2021 at 1:04 PM, revealed she received education regarding reporting abuse immediately, and ensuring that any new or worsening behaviors were reported and documented. She also received education along with why the care plans were important to follow. Further interview revealed a post test had been included with the education provided. Interview with LPN #50, on 12/09/2021 at 1:24 PM, revealed she completed abuse training regarding what to do immediately when an allegation was made and to whom to report it to. Continued interview revealed any behaviors were to be reported to the supervisor and documented along with updating the care plan with any resident changes. Interview with RN #5, on 12/09/2021 at 1:51 PM, revealed she received education regarding who, when and what to report regarding abuse allegations. Continued interview revealed she received training on residents' behavior, and the use of the binders on each unit. Per interview, she had received training to notify the nurse if there were any new behaviors or worsening behaviors noted. Further interview revealed she completed care plan education regarding the importance of updating the care plan if there was a change in the resident. She further stated she had completed a post test. Interview with the Nurse Management Team (Director of Clinical Services, DON, RDO, Staff Development Coordinator, RNC and ADON), on 12/09/2021 at 2:11 PM, revealed staff education had been completed in small groups, through 1:1 training, or telephonically with staff members who all had completed the post test. Continued interview revealed staff were educated on abuse, Governing Body, care planning, reporting abuse, reporting falls, incidents and abuse allegations timely. Further interview revealed care plans were discussed with the importance of the care plans being patient/resident centered. Interview further revealed the importance of a resident having appropriate care plans in place, and ensuring they were followed was also discussed. 10. Interview with the CQI staff which included, but not been limited to the Administrator, DON, Assistant DON, Unit Managers, Minimum Data Set (MDS) Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director, and the RDO on 12/09/2021 at 2:25 PM, revealed they reviewed all Nurses' Progress Notes every day during the morning clinical meeting for anything abnormal, for any behaviors, and/or potential abuse concerns. 11. Record review revealed the facility placed Resident #69 on 1:1 supervision on 11/29/2021, which continued through 12/08/2021. No concerns were identified. 12. Record review revealed the SS Director completed monitoring for Resident #69 on 11/30/2021, 12/01/2021, and 12/02/2021. No concerns of psychosocial distress were noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM, revealed she had monitored Resident #69 for three (3) days for any concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 13. Record review revealed the facility's contracted medical services provider assessed Resident #69 on 11/30/2021 and determined Resident #69 was not capable of giving informed consent regarding consensual sexual activity. Per review, no new orders had been received at that time. 14. Record review revealed psych services assessed Resident #69 on 12/03/2021 and 12/06/2021 with new orders for a new medication to be started. 15. Review of the Comprehensive Care Plan revealed Resident #69's care plan had been updated on 11/24/2021, 11/29/2021, 11/30/2021, and 12/01/2021 with interventions that included: placing bright sign on his/her door to assist the resident in identifying his/her correct room:1:1 observation; residents to be separated; and, pain and skin assessments were completed. Continued review revealed additional interventions included: Social Services to observe for psychosocial distress; evaluations to be completed by the facility's contracted medical services provider; psych services to follow; and the IDT had determined Resident #69 did not have the cognitive capacity to consent to sexual activity. Interview with the IDT members which included, but were not limited to, the Administrator, DON, ADON, Unit Managers, MDS Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director and the RDO, on 12/09/2021 at 2:25 PM revealed they had reviewed Resident #69's care plan. The review included to ensure proper interventions were in place to help monitor the resident's behaviors and maintain safety for him/her and other residents. 16. Review of the Behavior Meeting Agenda revealed Resident #69 was being reviewed in the weekly behavior meetings, the most recent being 12/02/2021. Interview with the Behavior Meeting Members which included; but was not limited to the Administrator, DON, ADON, Unit Managers, MDS Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director and the RDO on 12/09/2021 at 2:25 PM, revealed during the meetings they reviewed residents for any concerns regarding verbal aggression, physical aggression, refusal of medications, sexual behaviors, any abnormal behaviors and anything which affected the resident or other residents. 17. Record review revealed Resident #410 was placed on 1:1 supervision on 11/29/2021 through 12/03/2021 with no concerns noted. 18. Record review revealed the SS Director observed Resident #410 for three (3) days on 11/30/2021, 12/01/2021 and 12/02/2021 with no concerns of psychosocial distress noted. Interview with the SS Director, on 12/09/2021 at 12:54 PM, revealed she monitored Resident #410 for three (3) days for concerns of sadness, any changes from baseline, lack of participation in activities, and any change from his/her normal daily activities. Continued interview revealed no concerns had been identified. 19. Record review revealed Resident #410 was seen by psych services on 12/03/2021 with a follow up visit on 12/06/2021, and no new orders received. 20. Review of the Comprehensive Care Plan (CCP) revealed the IDT reviewed and updated Resident #410's care plan on 11/29/2021, 11/30/2021 and 12/03/2021 with interventions that included 1:1 staff observation; residents were separated; skin and pain assessments completed; moved the resident's room to a more visible location near the nurse's station. Continued review revealed further interventions which included: SS was to follow for signs and symptoms of psychosocial distress; gather information on past falls, and attempt to determine the root cause of the fall and to anticipate and intervene to prevent recurrence. Interview with the Behavior Meeting Members which included but was not limited to; the Administrator, DON, ADON, Unit Managers, MDS Coordinator, SS Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director and the RDO on 12/09/2021 at 2:25 PM, revealed they had reviewed Resident #410's care plan. The review included to ensure proper interventions were in place to help monitor the resident's behaviors and maintain safety for him/her and other residents. 21. Review of the Behavior Meeting Agenda revealed Resident #410 was discussed and monitored weekly in the Behavior meetings. The most recent meeting was on 12/02/2021. Interview with the Behavior Meeting Members revealed during the meetings they were reviewing residents for any concerns regarding verbal aggression, physical aggression, refusal of medications, sexual behaviors, any abnormal behaviors and anything which affected the resident or other residents. 22. Review of the facility's Census List revealed Resident #410 had been moved to a different room on 11/30/2021 and to a different unit on 12/03/2021. 23. Record review revealed on 12/03/2021, the IDT determined to relocate Resident #410 to a different unit. 1:1 supervision would be discontinued when the resident was settled into the new room; seen by psych services; and, the resident had not been displaying sexual behaviors over the last five (5) days of 1:1 monitoring. Record review revealed every fifteen (15) minute checks were completed for Resident #410 on 10/08/2021 through 12/04/2021 continuing through the current review. Interview with the IDT members, on 12/09/2021 at 2:25 PM revealed when Resident #410 was moved to another unit, he/she adapted well to the new environment with no concerns identified. The team reviewed the residents prior to determining the 1:1 supervision was no longer needed 24. Review of the QAPI Meeting Minutes, dated 12/01/2021 revealed the members were not limited to, the RDO, RNC, Governing Body members, Administrator and DON. Further review revealed an Ad Hoc QAPI meeting had been held regarding Resident #69 and Resident #410. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she participated in the Ad Hoc QAPI meeting with follow up event calls regarding Resident #410 and Resident #69 to discuss the incident. Per interview, the meeting and event calls had been to keep the team updated on the investigation, and to brainstorm on the type of action plan needed if indicated. Interview with the RNC, on 12/09/2021 at 3:04 PM, revealed he participated in the Ad Hoc QAPI meeting and follow up event calls for the involved residents. Continued interview revealed during the meeting and event calls they were updated on the facility's investigation and tried to determine the root cause of the incident. Further interview revealed the QAPI members gave the facility suggestions, helped determine what else could be completed and to ensure the right [TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoCs) for the 07/03/2021 Recertification Survey and the 12/06/2019 Recertification Survey, it was determined the facility failed to have an effective Administration responsible for establishing and implementing policies regarding management and operation of the facility. The facility was re-cited at F-600, F-609, and F-656. Review of the 12/06/2019 Recertification Survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F-600) at a Scope and Severity of an E; and, at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F-656) at a Scope and Severity of a G. Review of the 07/03/2021, Recertification Survey, revealed the facility was again cited at 42 CFR Freedom from Abuse, Neglect and Exploitation (F-600); and 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F-656) both at a Scope and Severity of a J. As those were repeat deficiencies, the State Survey Agency (SSA) additionally cited 42 CFR 483.70 Administration (F-835 and F-837) and 42 CFR 483.75 Quality Assurance and Performance Improvement (F-867) all at a Scope and Severity of a J, The facility was also cited at 42 CFR Freedom from Abuse, Neglect, and Exploitation (F-609) at a Scope and Severity of a J. Interview and record review revealed the facility failed to ensure residents were free from abuse; residents' behaviors were addressed; and residents' care plans were developed and implemented per the facility's PoCs. In addition, the facility failed to ensure all allegation of abuse were reported timely. 1. Record review revealed Resident #69 exhibited sexual behaviors directed towards staff on 10/17/2021 and 10/19/2021; however, there was no documented evidence the facility developed and implemented a care plan to address the behaviors. Review of the facility's investigation for an alleged sexual abuse incident involving Resident #69 and Resident #410, revealed on 11/29/2021 at approximately 8:30 PM, a staff member observed Resident #69 lying fully clothed on his/her room floor. The residents' knees were touching, and the other resident had his/her pants and brief pulled below the knees with his/her genitalia exposed to Resident #69. Continued review revealed the residents were immediately separated by staff and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Per interview, the facility failed to protect Resident #420 from abuse. Certified Nursing Assistant (CNA) #94 was observed by Nursing Assistant (NA) #3 to poke Resident #420 on the forehead while the resident was sitting on his/her toilet. Resident #420 became upset, stood up and tried to walk towards CNA #94 and started to stumble. NA #3 then observed CNA #94 place his hands, open palmed, on Resident #420's chest and pushed the resident backwards, causing him/her to fall backwards onto the wall. Resident #420 received an abrasion to his/her back and a knot to his/her hip as a result of the fall. NA #3 failed to immediately report the allegation and waited until after her shift (approximately six hours). LPN #38 failed to report the allegation when Resident #420 reported the incident to LPN #38. The facility's failure to have an effective system to ensure the Administrator used it's resources in a manner to ensure responsible for establishing and implementing policies regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F-600 and F-609; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F-656; 42 CFR 483.70 Administration; and, 42 CFR 483.75 Quality Assurance and Performance Improvement, F-867, all at a Scope and Severity of a J. The Immediate Jeopardy was determined to exist on 10/17/2021 and the facility was notified of the Immediate Jeopardy on 12/04/2021. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F-600 and F-609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and Immediate Jeopardy removal survey conducted on 12/09/2021 determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at S/S (Scope and Severity) of D; F-609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F-656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F-835 Administration at S/S of D; F-837 Governing Body at S/S of D; and, 42 CFR 48.75 Quality Assurance and Performance Improvement, F-867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator Job Description, not dated, revealed the Administrator led and directed the overall operation of the facility in accordance with residents' needs, federal and state government regulations, and company policies/procedures to maintain quality of care for all residents. Per review, the Administrator worked with facility management staff and consultants in planning all aspects of the facility's operations. Further review revealed the Administrator monitored each department's activities, evaluated their performance, and monitored the operations of all facility departments. Further review revealed the Administrator ensured the facility appropriately utilized its consultants and other support resources. The Job Description revealed the Administrator was to maintain a working knowledge of all governmental regulations and ensured the facility was compliant with those regulations. In addition, the Administrator was to have an understanding of and ensure compliance of all rules regarding residents' rights. Review of the facility's Director of Nursing (DON) Job Description, not dated, revealed the DON, under the supervision of the Administrator, had authority, responsibility, and accountability for the functions, activities, and training of all nursing services staff. Review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week. Per review, the DON was to conduct periodic reviews of residents' care plans to ensure they were interdisciplinary and were updated daily by the charge nurse as changes occurred. Further review revealed the DON was to review all resident accidents and incidents (A/I) daily and develop an appropriate plan to prevent future accidents and incidents. In addition, the Job Description revealed the DON was to ensure he/she was aware of Resident Abuse Reporting Law, ensure all nursing staff understood the Law, and ensure compliance with it was maintained. Review of the facility's Plan of Correction for the Recertification Survey, dated 07/03/2021, under F-600 revealed all staff were inserviced beginning 06/21/2021 on the facility's abuse policy. Per the PoC, residents with new, continuing, or worsening behaviors would be reviewed in the weekly behavior meeting. Continued review revealed the Behavior Tracking Tool All Staff Usage was initiated on 09/10/2021, to report new, continuing and worsening behaviors to the IDT. Per the PoC all new, continuing and worsening behaviors would be reviewed in the morning CQI meeting and care planned interventions updated as needed. Continued review revealed residents with increased behaviors and/or a history of aggression to staff or other residents, would be reviewed weekly in the Behavior Meeting beginning 09/10/2021. Care plan and treatment regimens would be adjusted as needed. The Social Services Director would report to the QAPI committee weekly a summary of the weekly behavior meeting. If any patterns were identified, an Action Plan would be written and monitored weekly by the Administrator until resolved. Review of the facility's Plan of Correction for Recertification Survey, dated 07/03/2021, under F-609 revealed education was conducted on 09/03/2021 and completed on 09/10/2021 for all staff. Per the PoC, the education included the facility's abuse policy focusing on what abuse was, reporting allegations and suspected abuse/neglect, who to report abuse and what to report. Per the PoC, auditing would be completed and presented to the QAPI Committee weekly for review and recommendations until desired threshold of 100% compliance was met for three (3) consecutive months. If any patterns were identified, an Action Plan would be written and monitored weekly by the Administrator until resolved. Review of the facility's Plan of Correction for the Recertification Survey, dated 07/03/2021, under F-656, revealed residents with increased behaviors were to be reviewed weekly in Behavior Meetings, with care plans adjusted as needed to include nursing interventions. This information was to be reported to the QAPI committee weekly. Review of the facility's Plan of Correction for Recertification Survey dated 12/09/2019, under F-600 revealed an inservice for all staff including agency was held 01/16/2020 through 02/05/2020. Continued review revealed the education presented included the facility's abuse policy, resident rights (to include the right to be free from abuse in any form), Care Planning for residents with behaviors to include redirection and supervision. 1. Clinical record review revealed the facility admitted Resident #69 on 02/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. Continued review revealed the facility assessed Resident #69 as having verbal behaviors exhibited one to three (1-3) days which had significantly impacted his/her care, disrupted the privacy of other residents and impacted the living environment within the facility. Further review revealed Resident #69 had not been assessed as having behaviors that included hitting, grabbing or sexually inappropriate acting out. Review of Resident #69's Comprehensive Care Plan (CCP), dated 09/05/2021 revealed the facility had care planned the resident for behaviors with interventions which included: removing Resident #69 from situations that might cause anxiety or aggression; staff to speak to the resident in a calm voice when attempting to deescalate agitated behaviors. Review of Resident #69's Behavior Note, dated 10/17/2021 at 2:54 AM, revealed the resident had been combative and had inappropriate sexual behaviors. Continued review revealed the resident was sexually aggressive to male employees. However, there was no documented evidence a care plan was developed and implemented for this behavior, per the PoC. Continued review of Resident #69's Behavior Notes, dated 10/19/2021 at 4:12 PM, revealed the resident was sitting on the couch in the common area and stated he/she wanted to grab the employee's junk. Continued review revealed Resident #69's legs were spread open and he/she was telling staff come and get it. Per the note, the resident was mainly making the statements towards male staff and became more agitated with redirection; however, there was no documented evidence a care plan was developed and implemented for this behavior, per the PoC. Continued review of the CCP revealed a Focus on Resident #69's care plan dated 07/23/2021, 08/24/2021 and 09/23/2021, which noted the resident did not desire to have sexual contact with another person at that time. The goal stated Resident #69 would notify staff if he/she desired to have sexual contact with another person. However, there was no documented evidence the facility developed interventions to address Resident #69's comments and behaviors documented in the 10/17/2021 and 10/19/2021 Progress Notes. Interview with Registered Nurse (RN) #11 on 12/02/2021 at 1:28 PM, revealed on 11/29/2021 around 8:15 PM, he was performing the medication pass, and was looking for Resident #410, who had previously been sitting in his/her wheelchair in the dining area. RN #11 started checking for Resident #410 in other residents' rooms. Continued interview revealed when he checked Resident #69's room, he observed Resident #69 lying on the floor facing Resident #410, who had his/her pants and brief pulled down below the knees with his/her genitals exposed to Resident #69. Per RN #11, the residents were separated and assessed after the incident. Further interview revealed Resident #69 had previously displayed sexually suggestive gestures and comments which had been inappropriate, and the resident had been evaluated by a psychiatric provider. 2. Review of Resident #420's medical record revealed the facility admitted the resident on 09/05/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #420's Admission Minimum Data Set (MDS) Assessment, dated 09/12/2021, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated moderate cognitive impairment. Further review revealed the facility had not assessed Resident #420 to have behaviors. Review of the facility's, Pre-Admission Screening and Resident Review (PASRR), dated 09/02/2021, revealed Resident #420 had an unsteady balance related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #420 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed the resident as noncompliant at times. Further review revealed Resident #420's Intelligent Quotient (IQ) was noted to range from forty-two (42) to sixty (60) which indicated a moderate degree of cognitive limitation. Interview with NA #3, on 12/02/21 at 3:40 PM, revealed on 11/25/2021, she had observed CNA #94 enter Resident #420's room while the resident was sitting on the toilet in his/her restroom. NA #3 stated she observed CNA #94 poke Resident #420 on the forehead which caused the resident's head to go backwards. She stated Resident #420 became upset and stood up trying to move towards CNA #94 to hit the CNA and the resident started to stumble. Per interview, at that time, CNA #94 placed his opened hands on Resident #420's upper chest area near his/her shoulders and pushed the resident backwards causing him/her to fall down. Further interview revealed Resident #420 notified LPN #38 that CNA #94 had pushed him/her down which caused the resident to scratch his/her back. NA #3 stated she ultimately decided to notify the facility of the incident after her shift ended at 3:00 PM, and she had gone home, approximately six (6) hours after the incident. She stated she had been educated to report incidents; however, she did not known to whom she was to report them to. Interview with LPN #38, on 12/04/2021 at 12:05 PM, revealed after the resident's shower, Resident #420 reported to him that CNA #94 pushed him/her. Further interview revealed he did not report what Resident #420 told him as potential abuse at that time. The LPN stated he ultimately forgot to report the incident due to the resident's past history of embellishing/fabricating the truth. LPN #38 stated he had received the abuse education provided by the facility, and knew he should have reported the incident immediately. However, he had not done so. Interview with the Director of Nursing (DON) on 12/04/2021 at 5:19 PM, revealed she did not feel there had been a failure in the facility's Administration. Per interview, Resident #69 had no prior sexual behaviors directed toward other residents, so there was no failure in care planning for the residents, prior to the 11/29/2021 facility self-reported sexual abuse allegation. Continued interview revealed the incident involving Resident #420, on 11/25/2021, which staff initially failed to report, revealed the facility terminated the staff involved as they were trained on reporting, which had been part of the facility's previous POC. The DON stated once administration became aware of the allegation, they had responded appropriately. Interview with the facility's Interim Administrator on 12/03/2021 at 3:40 PM, and again on 12/04/2021 at 4:33 PM, revealed her role was to oversee the operations of the facility. She revealed she had assisted in formulating a Plan of Correction for the previous deficient practice cited. Per interview, the Interim Administrator had been performing the auditing from the facility's prior Plan of Correction. Per interview, her job was to conduct some of the audits and ensure other audits were being conducted properly. She revealed she had taken it upon herself to oversee the facility's staff education process, because she felt there was room for improvement, as the staff had been re-educated multiple times. In reference to the 11/29/2021 facility reported sexual abuse allegation involving Resident #69 and Resident #420, she stated she did not believe there had been a failure on the facility's part which resulted in sexual abuse. Continued interview revealed no sexual abuse had occurred due to the enhanced supervision provided by facility staff. Per interview, the enhanced supervision the facility had provided for Resident #69 and other residents was nursing staff making more frequent resident rounds, assigning a full-time Activities staff person to the 7th floor (where Resident #69 resided), and initiation of more activities for the residents on that floor. According to the Interim Administrator, as she had no clinical background, she could not speak to the care planning issues identified. She said she could only say both Resident #69 and Resident #410 had been discussed in the Interdisciplinary Team (IDT) meetings during the three and a half (3 ½) weeks she had been the Interim Administrator. Interview revealed the discussion in the IDT meetings for both residents centered around Resident #69's aggressive and verbal behaviors, and Resident #420's rejection of care. Regarding the facility reported physical abuse allegation involving Resident #420, the Interim Administrator said the facility had followed its plan of correction by terminating staff who failed to report suspected abuse. Interview with the Regional Director of Operations (RDO) on 12/04/2021 at 5:55 PM, revealed the Administrator's job was to make sure the facility's PoC was implemented as written, and audits were conducted per the PoC. The RDO revealed the Administrator was to ensure any patterns identified in the audits were examined, and plans were being put into place, as needed, to address any issues identified. Per interview, a great deal of time was spent by the facility to ensure staff understood abuse reporting, what to report, when to report, and who to report incidents to. She stated per the PoC, staff who failed to report incidents were subject to disciplinary action. Continued interview revealed as there had been a failure on staff's part to report the incident involving Resident #410, the decision was made to terminate that staff person. Further, she stated the person currently in the Administrator role, was managing things in the facility effectively. Interview with the Regional Vice President (RVP) on 12/04/2021 at 6:58 PM, revealed the RDO oversaw the Administrator and his/her job duties. Per interview, he received daily follow-up regarding the facility from the RDO and was a participant in the facility calls on Tuesdays and Thursdays. He stated he took ownership of any decisions, and if the facility fell short, he took responsibility for it and saw that it was corrected. (refer to F-600, F-609 and F-656) The facility took the following actions to remove the Immediate Jeopardy (IJ): 1. The RDO was to review all resources available, and the Administrator and IDT were to ensure resources were available and utilized. The RDO would monitor weekly for four (4) weeks, then monthly for three (3) months. The RDO or the Registered Nurse Consultant (RNC) was to be present in the facility seven (7) days a week until compliance was met. The RDO or RNC was to update the RVP until compliance was achieved. 2. The Administrator and the Interdisciplinary Team Members (IDT) were educated on the resources available for the facility. The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she reviewed all resources available for the facility with the Administrator and IDT. She revealed she was monitoring to ensure all resources were utilized. Per interview, she was present in the facility seven (7) days a week, and had been providing daily updates to the RVP to ensure continuing compliance was being met. 2. Interview with the IDT, on 12/09/2021 at 2:43 PM, verified the completion of an in-service regarding available resources for the facility. Review of the facility's documentation revealed the IDT, which included the Administrator, had received the in-service education on resources available for the facility. Interview with the IDT (which included the Administrator, DON, Assistant DON, Unit Managers, Minimum Data Set (MDS) Coordinator, Social Services (SS) Director, Activity Director, Dietary Manager, Rehabilitation (Rehab) Manager, Medical Director, and the RDO, on 12/09/2021 at 2:25 PM, revealed they had received in-service education on the resources available to the facility to ensure compliance was maintained.

Based on interview, record review, review of the facility's policy and previous Plans of Correction (POCs) for the 12/06/2019 and the 07/03/2021 Recertification Surveys, it was determined the facility failed to have an effective Governing Body responsible for establishing policies and ensuring the implementation of the policies regarding the management and operation of the facility. The facility failed to maintain substantial compliance, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609); and, 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656). Review of the 12/06/2019 Recertification Survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600) at a Scope and Severity of an E; and, at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) at a Scope and Severity of a G. Review of the 07/03/2021, Recertification Survey, revealed the facility was again cited at 42 CFR Freedom from Abuse, Neglect and Exploitation (F600); and 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656) both at a Scope and Severity of a J. As those were repeat deficiencies, the State Survey Agency (SSA) additionally cited 42 CFR 483.70 Administration (F835 and F837) and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) all at a Scope and Severity of a J, The facility was also cited at 42 CFR Freedom from Abuse, Neglect, and Exploitation (F609) at a Scope and Severity of a J. The facility's failure to provide an effective Governing Body responsible for establishing and implementing policies regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was identified on 12/04/2021 and was determined to exist on 10/17/2021, at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600) (F609), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), 42 CFR 483.70 Administration (F835) (F837) and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) all at a Scope and Severity of a J. The facility was notified of the Immediate Jeopardy on 12/04/2021. In addition, Substandard Quality of Care (SQC) was identified in 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and Immediate Jeopardy Removal Validation Survey were concluded on 12/09/2021 which determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S (scope and severity) of D; F609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F835 Administration at S/S of D; F837 Governing Body at S/S of D; and, 42 CFR 48.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Governing Body policy requested - none received Review of the facility's Plan of Correction for the Recertification Survey, dated 07/03/2021, under F-600 revealed all staff were inserviced beginning 06/21/2021 on the facility's abuse policy. Per the PoC, residents with new, continuing, or worsening behaviors would be reviewed in the weekly behavior meeting. Continued review revealed the Behavior Tracking Tool All Staff Usage was initiated on 09/10/2021, to report new, continuing and worsening behaviors to the IDT. Per the PoC all new, continuing and worsening behaviors would be reviewed in the morning CQI meeting and care planned interventions updated as needed. Continued review revealed residents with increased behaviors and/or a history of aggression to staff or other residents, would be reviewed weekly in the Behavior Meeting beginning 09/10/2021. Care plan and treatment regimens would be adjusted as needed. The Social Services Director would report to the QAPI committee weekly a summary of the weekly behavior meeting. If any patterns were identified, an Action Plan would be written and monitored weekly by the Administrator until resolved. Review of the facility's Plan of Correction for Recertification Survey, dated 07/03/2021, under F-609 revealed education was conducted on 09/03/2021 and completed on 09/10/2021 for all staff. Per the PoC, the education included the facility's abuse policy focusing on what abuse was, reporting allegations and suspected abuse/neglect, who to report abuse and what to report. Per the PoC, auditing would be completed and presented to the QAPI Committee weekly for review and recommendations until desired threshold of 100% compliance was met for three (3) consecutive months. If any patterns were identified, an Action Plan would be written and monitored weekly by the Administrator until resolved. Review of the facility's Plan of Correction for the Recertification Survey, dated 07/03/2021, under F-656, revealed residents with increased behaviors were to be reviewed weekly in Behavior Meetings, with care plans adjusted as needed to include nursing interventions. This information was to be reported to the QAPI committee weekly. Review of the facility's Plan of Correction for Recertification Survey dated 12/09/2019, under F-600 revealed an inservice for all staff including agency was held 01/16/2020 through 02/05/2020. Continued review revealed the education presented included the facility's abuse policy, resident rights (to include the right to be free from abuse in any form), Care Planning for residents with behaviors to include redirection and supervision. 1. Review of Resident #69's Behavioral Notes revealed Resident #69 exhibited sexual behaviors directed towards staff on 10/17/2021 and 10/19/2021; however, there was no documented evidence the facility developed and implemented a care plan to address the behaviors, per the facility's PoC. Review of the facility's investigation for an alleged sexual abuse incident involving Resident #69 and Resident #410, revealed on 11/29/2021 at approximately 8:30 PM, a staff member observed Resident #69 lying fully clothed on his/her room floor. Per the report, the residents' knees were touching, and Resident #410 had his/her pants and brief pulled below the knees with his/her genitalia exposed to Resident #69. Continued review revealed the residents were immediately separated by staff and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Per interview, the facility failed to protect Resident #420 from abuse. Certified Nursing Assistant (CNA) #94 was observed by Nursing Assistant (NA) #3 to poke Resident #420 on the forehead while the resident was sitting on his/her toilet. Resident #420 became upset, stood up and tried to walk towards CNA #94 and started to stumble. NA #3 then observed CNA #94 place his hands, open palmed, on Resident #420's chest and pushed the resident backwards, causing him/her to fall backwards onto the wall. Resident #420 received an abrasion to his/her back and a knot to his/her hip as a result of the fall. NA #3 failed to immediately report the allegation and waited until after her shift (approximately six hours). LPN #38 failed to report the allegation when Resident #420 reported the incident to LPN #38. Interview, on 12/02/2021 at 1:34 PM with the facility's Minimum Data Set (MDS) Director, revealed facility management was on phone calls with Corporate staff all the time. She stated any time there was an unusual occurrence, such as a reportable event (defined as any event required to be reported to the SSA), the Governing Body would review the incident information before it was sent to the State Survey Agency. Interview with the DON on 12/02/2021 at 2:58 PM, revealed the RDO had audit tools for the previous PoC and was responsible for ensuring all the audits performed were in compliance. The DON said to ensure the audits were performed as required, she called the facility on shifts when she was not present, and instructed a staff person to go floor to floor, asking staff members the abuse prevention questions, and they were to report the results of the staff interviews to her. The DON said, specific to former citations of F600 and F609, the facility was monitoring the newly admitted and readmitted residents to determine their preference regarding sexual desire, and the capacity to consent. Further interview revealed protecting residents was a part of the facility's abuse policy, and if an event (incident) occurred, the facility immediately initiated an investigation, which was was the case for the currently cited incidents. Interview with the Regional Nurse Consultant (RNC) on 12/04/2021 at 6:38 PM, revealed the Governing Body, and Regional Vice President (RVP), had been to the facility on and off and there were conference calls with the CEO and CNO. He revealed the Governing Body was kept aware of what was going on in the facility. Per interview, the Governing Body had been on several event (reportable incidents per the RNC) calls, as well as, the normal Tuesday and Thursday calls held every week where the progress of the previous POC had been reviewed. The RNC stated the abuse allegation involving Resident #420, and the sexual abuse allegation involving Resident #69 and Resident #410, cases of event calls to discuss the incidents, he and the members of the Governing Body had been on those calls. Further interview revealed the RVP was always on all those phone calls, and the facility's CNO and CEO, who were also a part of the Governing Body, were on some of the phone calls as well. Interview with the facility's Regional Director of Operations (RDO) on 12/02/2021 at 2:24 PM and again on 12/04/2021 at 5:55 PM, revealed Corporate had shifted from weekly reviews with the Administrator to twice weekly phone calls with the Administrator and other facility staff which included the Director of Nursing (DON), Regional Nurse Consultant (RNC) Regional Vice President (RVP), and at times, with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO). Per interview, the RNC was stationed at the facility full time as a resource. She stated during phone calls, the Corporate and facility staff reviewed where the facility was with their PoC, and any new concerns were discussed, along with any need for additional resources. Continued interview revealed the Governing Body was kept informed about what the facility was doing, with event phone calls which were related to incidents that were reportable to the State Survey Agency. The RDO stated the event calls were in addition to the normal phone calls the facility held with the Governing Body on Tuesdays and Thursdays every week. Per interview, education on abuse and reporting was provided on more than one occasion for three (3) of the four (4) staff involved in the physical abuse allegation involving Resident #420. The RDO revealed they were trained to report and failed to do so. Further interview revealed the facility spent a lot of time ensuring staff understood the reporting process, such as, how to report, what to report, and when to report incidents. Continued interview revealed she wasn't sure what the issue with Resident #69's care plan was. She believed appropriate interventions were in place for the 10/17/21 and 10/19/21 incidents involving staff, and stated Resident #69 had no history of sexual behavior in more than a year. She stated Resident #69 had not expressed wanting to have sex, and she did not feel there had been a failure to develop or implement new interventions due to behaviors on 10/17/21 and 10/19/21. Interview with the RVP on 12/04/2021 at 6:58 PM, revealed the Administrator reported directly to the RDO, who was considered part of the Governing Body. Per interview, the RVP followed up with the RDO daily. He revealed he had been kept informed on what was going on at the facility and was responsible for the facility, as well as, other facilities in his region. Per the RVP, he was perplexed as to why the State Survey Agency team was considering the identified concerns at the Immediate Jeopardy (IJ) level, and did not perceive the facility had done anything wrong. Further interview revealed the RVP said he did not feel the concerns were at the IJ level due to the increased vigilance at the facility and improvements in residents' care. The facility took the following actions to remove the Immediate Jeopardy (IJ): 1. The RNC and/or the RDO were to provide seven (7) days a week coverage. 2. Daily updates would be provided to the RVP daily by the RNC or RDP until compliance was achieved. The Governing Body, RDO or RNC were to report back to the Governing Body weekly to ensure progress was being made towards compliance. 3. The facility's Governing Body was to be represented and involved in the QAPI process. 4. Audit results were to be presented to the QAPI Committee weekly until compliance was met. The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the RDO, on 12/09/2021 at 3:13 PM revealed she and/or the RNC would be in the facility, seven (7) days a week until compliance was achieved. 2. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she was notifying the Regional Vice President (RVP) through daily updates at that time and when the facility decided compliance had been maintained they would make the determination to change to twice weekly updates. Interview with the RVP, on 12/09/2021 at 3:41 PM, revealed he had been receiving updates from the RDO or RNC daily at that time. He revealed during the telephone calls they discussed any events of the day; the percentages of the staff education completed; whether any additional resources were needed; the outside firm's focus areas and it's progress; and the general progress of the facility on its Plan of Correction and status. 3. Interview with the Governing Body Representative, on 12/09/2021 at 3:41 PM, revealed he was participating in the facility's QAPI meetings daily. Per interview, prior to the current jeopardy notices, he had been participating twice weekly in the QAPI meetings, and participating in the event calls. He further revealed he would continue to participate as listed now in the facility's Immediate Jeopardy removal plan. 4. Interview on 12/09/2021 at 2:25 PM, with the QAPI Committee members (which included the Administrator, Director of Nursing (DON), Assistant DON, Unit Managers, Minimum Data Set (MDS) Coordinator, Social Services (SS) Director, Activity Director, Dietary Manager, Rehab Manager, Medical Director, and the RDO, revealed the QAPI Committee was reviewing the results of all the facility's audits weekly and had not identified any concerns at the time of the interview. Further interview revealed however, if concerns were identified, the team would discuss the concerns and generate a plan to address them.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective process in place to address system failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. The facility failed to identify quality of care deficiencies and failed to take actions aimed at performance improvement to ensure improvements were realized and sustained. Repeated deficient practice was cited at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609); and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656). The same deficiencies were cited during the 07/03/2021 Recertification Survey. Review of the Plan of Correction for the Abbreviated Survey dated 07/03/2021 revealed data collected in the weekly QAPI meetings would be reviewed, as well as the minutes of the meeting, where areas of concern that required an Action Plan or a PIP (Performance Improvement Plan) were decided upon. Per review any written Action Plan or PIP would be reviewed for appropriateness and accuracy and progress towards the end goal, with any concerns to be addressed. Further review revealed the alleged compliance date was 09/18/2021. However, record review revealed the facility failed to ensure residents were free from abuse; failed to report allegations of abuse to the State Survey Agency (SSA) within two (2) hours of the alleged violation; failed to ensure resident care plans were developed; and, failed to ensure the facility was effectively managed with an quality assurance program to maintain substantial compliance. (Refer to F600, F609, and F656). The facility's failure to provide an effective Quality Assurance Performance Improvement (QAPI) Program responsible for planning, developing, implementing, and maintaining an effective, comprehensive, and data driven program in accordance with Federal Guidelines focused on indications of outcomes in the facility has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F609; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.70 Administration, F835 and F837; and, 42 CFR 483.75 Quality Assurance and Performance Improvement all at a Scope and Severity of a J. The Immediate Jeopardy was determined to exist on 10/17/2021. The facility was notified of the Immediate Jeopardy on 12/04/2021. Additionally, Substandard Quality of Care (SQC) was identified in 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600 and F609). An acceptable removal plan was received on 12/07/2021 alleging removal of the Immediate Jeopardy on 12/08/2021. An Extended Survey and AoC validation Survey were conducted on 12/09/2021 which determined the Immediate Jeopardy had been removed on 12/08/2021, as alleged, prior to exit on 12/09/2021. The remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S (scope and severity) of D; F609 Reporting Alleged Violations at S/S of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan; F656 Develop/Implement Comprehensive Care Plan at S/S of D; 42 CFR 483.70 Administration, F835 Administration at S/S of D; F837 Governing Body at S/S of D; and 42 CFR 48.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and Plan, dated 2017, revealed the mission of the facility's QAPI plan was to develop, implement, and maintain an effective, comprehensive, and data driven QAPI Program in accordance with Federal Guidelines. Per review, the QAPI plan was to be focused on indicators of outcomes of quality of care (QOC) and quality of life (QOL) for residents. Further review revealed the facility's comprehensive and ongoing program was to address the full range of care and services provided by the facility including all systems of care and management practices, clinical care, QOL and resident choices. Continued review revealed the QAPI plan noted the facility was to utilize the best available evidence for defining and measuring quality indicators and have goals reflective of the processes of care and facility operations predictive of the desired outcomes. Continued review revealed the facility's QAPI program was to reflect the complexities, and unique care and services provided by the facility. Further review revealed the plan described the facility's processes, systems, and reports which were to guide its efforts in ensuring its care and services were maintained at acceptable levels of performance and for ongoing improvement. In addition, review of the QAPI plan revealed the Administrator was fully responsible for the facility's QAPI Program. Review of the facility's 2021 Quality Assurance & Performance Improvement (QAPI) Plan, revealed it was signed on 10/29/2021 by the Medical Director, the Regional Director of Operations (RDO), the Director of Nursing (DON), and on 11/01/2021 by the Interim Administrator. Per review, the goals noted included the facility would have no unreported abuse allegations. Continued review revealed the Plan noted the facility would reduce the risk of behaviors and wandering in residents through formalized behavioral meetings weekly, with a goal to have no resident-to-resident substantiated abuse. Review of the Plan revealed under the section on Governance and Leadership, the facility's leadership had the responsibility for planning, designing, implementing, and coordinating care and services and selecting QAPI activities to meet the needs of all residents. Interview with Licensed Practical Nurse (LPN) #41 on 12/02/2021 at 11:05 AM, revealed as a Unit Manager she attended the facility's QAPI meetings. She stated the QAPI Committee met monthly on Thursdays, and the Medical Director was also in attendance. Per interview, LPN #41 assisted with checking crash carts, glucometers, use of mechanical lifts, and making sure wounds were care planned. Further interview revealed the Administrator made sure all the facility's audits were completed and up to date, and the findings of audits were discussed in the QAPI meetings. Interview, on 12/02/2021 at 11:37 AM, with the Assistant Director of Nursing (ADON), who had previously been the Staff Development Coordinator (SDC), revealed she attended the facility's QAPI meetings which were held on Thursdays. Per interview, the QAPI meetings were held to discuss identified deficiencies that were being worked on through the auditing process. In addition, she stated the facility had also implemented weekly behavior meetings with social services and the IDT, during which all residents' behaviors were discussed. Further interview revealed she had assisted with the audits from the previous POC regarding new resident admissions and readmissions of residents. The ADON stated she had audited to ensure residents Brief Interview for Mental Status (BIMS) score had been assessed; the question regarding whether a resident desired sexual contact had been asked; and, that the residents' care plans reflected their response with interventions in place. Interview with the facility's Activities Director on 12/02/2021 at 2:11 PM, revealed she attended the weekly QAPI meetings as a result of the previous POC. She stated there were corporate people on voice call during the meetings. The Activities Director stated resident behaviors were discussed during the meetings, and that helped them to come up with interventions for the residents. Further interview revealed the solutions discussed in the QAPI meetings were pretty much working. However, she was not a part of the facility's auditing process. Interview with the DON on 12/02/2021 at 2:58 PM, revealed she had attended the weekly QAPI meetings as part of the previous POC. Per interview, she participated in discussion of the audits conducted, and if issues were identified she assisted with how to correct them. The DON stated the QAPI meetings were now a lot more in depth than they had been in the past, with much greater information on what had been identified, and what the facility was doing to correct the identified issues. Interview on 12/04/2021 at 5:19 PM, revealed the DON stated that to her knowledge, there had been no indications of previous sexual desire by either Resident #69 or Resident #410. She stated she felt there had been no failure on the facility's part regarding the incident involving those residents. The DON stated she did not think there was a failure regarding reporting the incident in which Resident #420 was allegedly abused by staff. Further interview revealed the facility had provided staff training as per the previous POC. However, four [4] staff failed to follow that education regarding the reporting of incidents; and, three [3] of those staff failed to immediately report potential abuse of a resident. In addition, two [2] residents that the facility assessed as unable to give consent for sexual contact were not provided the supervision necessary to keep them safe. The DON stated the staff involved failed to follow the training they received. As a result, they were terminated from employment. Interview with the facility's Regional Nurse Consultant (RNC) on 12/02/2021 at 3:22 PM, revealed he attended the weekly QAPI meetings. He stated the audits being managed by the Administrator were reviewed to determine if they were being completed as per the previous POC, and anything that needed to be discussed was discussed. According to the RNC, staff in the QAPI meetings had gone through to ensure everyone was educated on abuse as required. He stated there had been extensive abuse education for all staff working in the building. Further interview revealed, any issues which arose during the facility's IDT meetings were often discussed in ad-hoc QAPI meetings, and then reviewed again in the monthly QAPI meetings. Interview on 12/04/2021 at 6:38 PM, revealed the RNC stated he made suggestions and recommendations and encouraged the use of his recommendations regarding the previous POC. He stated he had helped provide some of the staff education on abuse and different things like that. Interview revealed the facility had educated staff on reporting incidents in a timely manner, and immediately if abuse was suspected. Continued interview revealed staff were trained to report incidents to an immediate supervisor, Administrator, and DON. Per the RNC, the immediate supervisor was to report the incident to the DON and Administrator per the education. Further interview revealed if staff felt their immediate supervisor was not doing what needed to be done, they were to follow the facility's chain of command and report the incident to the DON or Administrator. He further revealed the Administrator was to adhere to maintaining the facility's QAPI meetings, and ensuring all pieces and parts of identified concerns/issues were followed up on. Interview with the facility's Interim Administrator on 12/03/2021 at 3:40 PM and again on 12/04/2021 at 4:33 PM, revealed her role was to oversee the operations of the facility. According to the Interim Administrator, she had provided assistance in developing the facility's previous Plan of Correction (POC). Continued interview revealed she had been performing and overseeing the auditing indicated on the facility's previous POC. The Interim Administrator revealed she had taken it upon herself to supervise the staff education process for the facility as there was room for improvement with the staff having been re-educated multiple times. Additional interview revealed she could not answer 100% what the facility's process was regarding care planning. She stated both Resident #69 and Resident #410 had been reviewed weekly in the facility's behavior meeting. Per interview, the facility had been reviewing Resident #69 for his/her aggressive behaviors, and Resident #410 for his/her rejection of care. According to the Interim Administrator, she was aware of Resident #69's previous sexually inappropriate behavior. Interview on 12/04/2021 at 5:55 PM, with the Regional Director of Operations (RDO) revealed there had been no failure in the facility's QA process. She stated ad-hoc QAPI meetings had been occurring for the 11/29/2021 abuse incident involving Resident #69 and Resident #410 and, also for the incident involving Resident #420. She stated the action plans had been put into place for both incidents, and the facility had followed their previous POC as written. Interview with the Regional Vice President (RVP) on 12/04/2021 at 6:58 PM, revealed he had been participating in the facility's QAPI meeting reviews and discussions. He stated he had been ensuring the facility had the necessary resources on site to address any needs. He revealed he had been on follow up calls with the facility on Tuesdays and Thursdays, and was in daily contact with the RDO, who participated in the QAPI reviews with the facility's team. The facility took the following actions to remove the Immediate Jeopardy (IJ): 1. On 12/07/2021, the QAPI Committee and Medical Director reviewed and approved the facility's standardized agenda. 2. The QAPI Committee was in-serviced by the RDO on the revised QAPI plan. 3. The RDO or RNC would provide seven (7) days a week covering in the facility and provide the RVP daily updates. 4. The QAPI tool for monitoring the effectiveness of the QAPI committee will be utilized quarterly. The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the Medical Director, on 12/09/2021 at 3:00 PM, revealed he took part in the facility's QAPI meeting held on 12/07/2021, and reviewed and approved the revised agenda. Interview with the QAPI Committee members, which included; the Administrator, Director of Nursing (DON), Assistant DON, Unit Managers, Minimum Data Set (MDS) Coordinator, Social Services (SS) Director, Activity Director, Dietary Manager, Rehab Manager, and the RDO, on 12/09/2021 at 2:25 PM, revealed the Committee, along with the Medical Director, reviewed the facility's revised QAPI agenda and approved it. 2. Interview with the QAPI Committee members, on 12/09/2021 at 2:25 PM, revealed they had all been in-serviced by the RDO on the facility's revised QAPI plan and agenda. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she had completed the inservice education for the QAPI Committee members regarding the facility's revised QAPI plan and agenda. Continued interview revealed she reviewed the facility's audits and would review the previous audits performed, and resolve them as applicable. 3. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed she was notifying the Regional Vice President (RVP) through daily updates at that time. Per interview, when the facility determined compliance had been maintained they would make the determination to change to twice weekly updates. Interview with the RVP, on 12/09/2021 at 3:41 PM, revealed he received updates from the RDO or RNC daily at that time. The RVP stated during the phone call updates the facility's events of the day were discussed, and the percentages of completed staff education. Per interview, during the calls they also discussed whether any additional resources were needed, the outside firm's focus areas and it's progress; and the facility's general progress on its Plan of Correction and status. 4. Interview with the RDO, on 12/09/2021 at 3:13 PM, revealed to monitor QAPI effectiveness, the Committee would complete the QAPI review and review all the audit results. She revealed they discussed the process and how they were interpreting the data to ensure issues were reviewed correctly.

Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure residents were free from abuse for seven (7) of one hundred-thirteen (113) sampled residents (Residents #161, #47, #74, #344, #345, #90 and 136). Resident #161 and Resident #47 related to resident to resident sexual abuse; Resident #74 related to verbal abuse; and, Resident #344, Resident #345, Resident #90 and Resident 136 related to resident to resident physical abuse. 1. On 03/19/2021, after the dinner meal, around 7:30 PM, Certified Nurse Aide (CNA) #36 left the unit to go on break. The CNA left Resident #161 in the dining room/dayroom unsupervised. CNA #35 was at the nurse's station and watched the camera monitor. However, the CNA left the nurse's station to assist another resident, and was gone from the monitor for about five (5) minutes. Upon CNA #35's return to the nurse's station, she observed on the camera monitor, Resident #47 next to Resident #161 in the dayroom. The lights in the dayroom had been turned off. CNA #35 observed Resident #161 with his/her hand on Resident #47's exposed genitalia, in the fourth floor dining room/dayroom. The facility did not assess Resident #161 and Resident #47 for capacity to consent to sexual contact with others to protect the resident(s) from further abuse. 2. Resident #74's bathroom overflowed, with water and feces all over the floor. Upon discovery of the bathroom, Licensed Practical Nurse (LPN) #11 cursed. Resident #74 and Resident #343 indicated they heard the nurse's comments. 3. On 05/05/2020, Resident #345 hit Resident #344 with a reacher multiple times and caused a skin tear to Resident #344's upper chest. 4. On 05/21/2021, Resident #136 was talking with a nurse when Resident #90 came over and also started talking to the nurse. Resident #136 began to disagree about staff, Resident #136 became upset and made a comment to Resident #90 about his/her mother. Resident #90 became upset and hit Resident #136 in the face with his/her fist. Immediate Jeopardy was identified on 05/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at S/S of J and F607 Develop/Implement Abuse/Neglect, etc. Policies at S/S of J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.40 Behavioral Health, F745 Provision of Medically Related Social Services at S/S of J, and 42 CFR 483.70, Administration, F835 Administration at S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F600 Free from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect, etc. Policies, and 42 CFR 483.40, F745 Provision of Medically Related Social Services. The facility was notified of the Immediate Jeopardy on 05/17/2021. An extended survey was conducted 06/30/2021 through 07/02/2021. The State Survey Agency validated the facility's Allegation of Compliance/Removal Plan and found the facility had removed the immediacy on 06/27/2021, as alleged. The findings include: Review of the facility's policy, Abuse Prevention Program, updated 05/02/2017, revealed it was the policy of the facility to prevent resident abuse. Each resident received care and services in a person-centered environment in which all individuals were treated as human beings. Any incident or allegation that involved abuse or mistreatment resulted in an abuse investigation. Further review revealed the investigation gathered further facts prior to making a determination. If there was reasonable cause to suspect abuse, the Administrator or designee investigated the allegation. The final report included facts determined during the investigation and included a conclusion of the investigation based on known facts. Residents who allegedly mistreated another resident were immediately removed from contact with that resident during the investigation. The accused resident's condition was evaluated to determine the most suitable therapy, care approaches and placement, and considered his/her safety, as well as the safety of other residents of the facility. Continued review of the Abuse Prevention Program policy revealed sexual abuse included, but was not limited to, sexual harassment, sexual coercion, or sexual assault. The Administrator was the facility's Abuse Coordinator. The findings of the investigation were provided to the Administrator who either ruled-out or substantiated the allegation of abuse. Review of the facility's policy, Standard Supervision and Monitoring, dated 11/25/2011, revealed supervision and guidance to the resident was an essential part of nursing care in which standard approaches were successful in meeting the residents' physical and psychosocial needs. When either the staff nurse or psychosocial staff assessed a resident to have stable physical and psychosocial needs, regular rounds would be maintained to ensure the resident's needs were met. The resident would be visualized at a minimum every two (2) hours, as well as the start and end of shift and during meal times. At any time a resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident may require one to one (1:1) supervision. Review of the facility's policy, Resident Behavior and Facility Practices, not dated, revealed residents had the right to be free from sexual abuse. The facility must implement procedures that protect residents from abuse. The facility did not provide a policy related to residents' capacity or incapacity to consent. The facility did not provide a policy related to Power of Attorney. The facility provided the resident's Brief Interview for Mental Status (BIMS) assessment from the Resident Assessment Instrument (RAI) as the reference the facility used to determine a resident's capacity to consent. Review of the Abbreviated Instructions for Conducting the BIMS, revised 10/2011, revealed a BIMS' score range of thirteen (13) to fifteen (15) was cognitively intact, eight (8) to twelve (12) was moderately impaired, and zero (0) to seven (7) was severe impairment. Review of the facility's contract with the Psychology (Psych) Consulting Group, dated 01/20/2020, revealed the psych group provided professional medical and psychological services including, but not limited to: Clinical Psychology, Psychiatry, and Gerontology. The psych group contracted with licensed health professionals and reviewed their professional credentials. Review of the facility's contracted Consultant Group, dated 01/01/2021, revealed the Consultant Group provided assistance, consultation services, and training. Consultants were qualified by education, experience, training, professional licensure and/or certification. Services provided included Social Service Consultation and Social Service Interim. The Consultant Group provided the facility's QA Committee's written reports of activities, recommendations, plans for implementation, and continuing assessment, as appropriate. 1. Review of the clinical record for Resident #161 revealed the facility readmitted the resident on 10/09/2017. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #161's Durable Power of Attorney (POA), dated 10/04/2011 revealed the resident appointed a POA as his/her true and lawful attorney to act in, manage, and conduct all my estate and all my affairs, for me and in my name, in the doing or executing of, all or any of the following acts, deeds, and things. Number thirteen (13) stated, authorized to take charge of my person in case of sickness or disability of any kind; to remove and place me in such hospitals or places as such attorney may deem best for my personal care, comfort, benefit, and safety; and to authorize such medical procedures, care, or attention as I may need. Review of Resident #161's admission documents revealed the resident's POA signed the facility's Admission Agreement, on 07/05/2016, and Advanced Directives, on 10/09/2017, with the designation of POA. Additionally, the POA signed the Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order, on 07/05/2016. Review of Resident #161's care plan revealed, on 04/13/2018, risk of falls included interventions not to leave the resident alone in his/her room when out of bed, keep him/her around the nurse's station. Review of a facility investigation revealed, on 04/05/2019, Resident #161 sat in his/her wheelchair (w/c) next to another resident in the common area in front of the fourth floor nurse's station. Resident #161's hand was on the other resident's exposed genitalia. The facility placed Resident #161 on one to one (1:1) supervision at that time. The facility assessed the resident's BIMS as a three (3), indicating the resident was severly cognitively impaired. Resident #161 could not recall the incident. The other resident reported Resident #161 rolled up to him/her in the w/c and reached out to hold his/her hand as the resident did many times with staff and residents. However, when the other resident reached for a drink on the table next to him/her, Resident #161 moved his/her hand into the other resident's pants. Further review of the comprehensive care plan for Resident #161 revealed the facility initiated a care plan for behavior of reaching out for others, on 04/06/2019. Interventions included to discuss the resident's behavior, explain/reinforce why the behavior was inappropriate and/or unacceptable if there was a concern, and intervene as necessary to protect the rights and safety of others. An additional intervention, related to falls, dated 05/01/2019, included not to leave the resident unattended in the dining room when out of bed. On 05/18/2020, the facility added an intervention for every hour safety checks related to the risk of falls care plan. Further review of the care plan revealed the facility included an intervention for Activities of Daily Living (ADL) Self Care Performance Deficits, on 05/29/2020, that the resident used a geri-chair while out of bed. Review of a Geriatric Visit Note revealed the Nurse Practitioner (NP) saw Resident #161, on 01/20/2021. The Review of Systems included Psychiatric, with reported Disorientation and Memory Loss; and, Neurological, with reported Memory Loss and Chronic Confusion. Additionally, review of the Psychiatric notation revealed the resident was oriented to person, had advanced dementia, and was disoriented to place, time, and situation. Review of a Psychology Progress Note, dated 01/26/2021, revealed the facility referred Resident #161 to the psychology provider for assessment, determination of care needs, and establishment of medically necessary and clinically indicated mental and behavioral health treatment. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was oriented to person and situation, and had difficulty concentrating, with memory deficit immediate, memory deficit recent, and memory deficit remote noted. The resident had expressive communication difficulty during the session, which required additional prompting to accurately assess the resident's input. Additionally, the provider administered, with facility staff assistance, the Dementia Severity Rating Scale (DSRS), which the resident scored thirty-one (31) out of fifty-four (54), indicting moderate severity of symptoms. The resident had impairment to memory and orientation, and rarely made any decisions for himself/herself. Review of Resident #161's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2021 revealed safety checks every hour every shift began 05/18/2020, with documentation three (3) times per day from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. The safety checks were discontinued (d/c) on 01/21/2021. Beginning 01/21/2021, the January, February, and March 2021 MAR and TAR documentation revealed safety checks every hour, with hourly documentation noted, for Safety check. Review of a Psychology Progress Note, dated 03/09/2021, revealed the resident was oriented to person and situation, had difficulty concentrating, and had memory deficits immediate, recent, and remote. The resident's comprehension, executive function, insight, and judgement were all noted as Moderate Impairment. Behavioral and psychological symptoms included impairment in memory, comprehension, executive functioning, insight, and judgement. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #161 with a BIMS' score of eleven (11). The facility assessed that the resident was totally dependent upon staff for transfers with two (2) person physical assist, and total dependence to move about the unit with one (1) person assistance. The resident had impairment on one (1) side for upper and lower extremities. Review of a facility incident report, completed by the Assistant Director of Nursing (ADON) dated 03/19/2021 at 10:10 PM, revealed staff observed Resident #47 standing with his/her genitalia exposed and standing by Resident #161. Resident #161 was unable to verbalize if anything occurred. Review of Resident #161's care plan revealed, on 03/19/2021, an intervention was added that he/she was not to be left alone in the dayroom. Review of the COVID-19 Testing Note revealed the Nurse Practitioner (NP) saw Resident #161, on 03/20/2021. The Note stated the resident had disorientation, memory loss, and chronic confusion. Resident #161 was oriented to person only and had advanced dementia. Review of the Psychology Progress Note, dated 03/23/2021, revealed staff requested the visit due to possible sexually inappropriate behavior. The Assessment noted the resident's cognition as oriented to person and situation, difficulty concentrating, memory deficit immediate, memory deficit recent, and memory deficit remote. The resident's comprehension, executive function, insight, and judgement were all noted as moderate impairment. The Note further revealed the resident was minimally responsive and speech was noted for expressive [CONDITION(S)]. The resident did not endorse memory of the recent behavior in question and redirection/reorientation intervention was administered. Additionally, the note documented due to dementia, the resident did not have the capacity to make major decisions, including consent for relationships with other residents. Ongoing mental and behavioral assessment and treatments were clinically indicated and appropriate. Recommendations included further cognitive assessment, further assessment of mental and emotional status, and both supportive and cognitive-behavioral psychotherapeutic interventions. Current stressors that impacted function included cognitive decline. Further review revealed the resident's confusion and impaired verbal communication required simplified and careful vocabulary, repetition, and clarification. Review of a Psychiatric Progress Note, dated 03/30/2021, revealed Resident #161 was a poor historian due to cognitive/psychiatric impairment. Observation of Resident #161, on 05/06/2021 at 2:23 PM, revealed the resident was in a geri-chair at the fourth floor nurse's station. A pillow was under the resident's head. Staff asked the resident if he/she wanted to lay back more, the resident nodded and staff adjusted the back of the geri-chair. Observations, on 05/12/2021 at 3:26 PM; 05/13/2021 at 2:26 PM and 3:43 PM; 05/14/2021 at 2:27 PM; 05/16/2021 at 9:05 AM; and, on 05/18/2021 at 1:40 PM revealed Resident #161 in the geri-chair at the nurse's station. Further observations on 05/19/2021 at 10:54 AM, 06/02/2021 at 2:44 PM, and 06/03/2021 at 11:19 AM, 06/08/2021 at 1:51 PM, revealed Resident #161 in the geri-chair at the nurse's station. Attempted interview with Resident #161, on 05/06/2021 at 2:23 PM, revealed the resident did not respond. Observation of Resident #161, on 06/10/2021 at 8:27 AM, and on 06/14/2021 at 8:48 AM, revealed the resident was in bed, a meal tray was on the over bed table on the left side of the bed. Staff entered the room, sat the resident up in the bed, and began to feed the resident. Interview, on 04/29/2021 at 1:54 PM, with Certified Nurse Aide (CNA) #35 revealed on 03/19/2021 after dinner, sometime between 7:00 PM and 8:00 PM, CNA #36 left to go on break. CNA #35 stated she sat at the nurse's station and saw Resident #161 on the monitor from the camera in the dayroom, and saw Resident #47 in his/her doorway. CNA #35 stated she left the nurse's station, for about five (5) minutes, to assist another resident. She stated when she returned to the nurse's station, Resident #47 was no longer in his/her doorway. CNA #35 stated after a few minutes, she looked at the monitor and noticed the lights to the dayroom were off. Further interview revealed she saw Resident #47's face on the monitor, to the right of Resident #161, who was in a geri-chair, and his/her body moved back and forth. The aide stated at that time, CNA #36 returned from break and she asked her to check on the residents. CNA #35 also stated another resident, who was also in the dayroom reported to her that Resident #47 turned off the lights in the dayroom. The CNA stated Resident #161 would put his/her hand out and try to grab people, and put things in his/her mouth like a child. She further stated Resident #161 would use signs to communicate, such as put his/her hand to his/her mouth when hungry. Interview with Licensed Practical Nurse (LPN) #30, on 04/29/2021 at 2:54 PM, revealed she was the nurse for Resident #161 and was on break when Resident #161 and Resident #47 had sexual contact with the other, after dinner. The nurse stated she was unaware Resident #161 had a similar incident with another resident until the Power of Attorney (POA) informed her of the previous incident, when she notified the POA of this incident on 03/19/2021. The LPN stated Resident #161 said, It was wonderful, however the resident did not say what it was. LPN #30 stated Resident #161 could say if he/she was hungry or in pain. However, it was hit and miss how oriented the resident was and if he/she could carry on a conversation. On 04/29/2021 at 3:12 PM, interview with CNA #36 revealed when she returned from her thirty (30) minute break, CNA #35 asked her to check on Residents #161 and #47 in the dayroom, as she saw them on the monitor together. CNA #36 stated when she got to the dayroom, Resident #47 was on Resident #161's right side, and the lights were off. She stated Resident #161 had his/her hand on Resident #47's genitalia, and Resident #47 covered himself/herself with the pillow behind Resident #161's head. The CNA stated Resident #161 laughed and said it was wonderful. CNA #36 stated Resident #161 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated Resident #161 could carry on a conversation; however, he/she had confusion. She further stated for Resident #161, staff had to be present when the resident was in the dining room, not just watch on the monitor, due to the resident being at risk for falls. CNA #36 stated Resident #161 could not move about on his/her own in the geri-chair and could not walk. Interview, on 04/29/2021 at 3:55 PM, with House Supervisor (HS) #1 revealed CNA #35 and CNA #36 told her Resident #161 and Resident #47 had sexual contact with each other. The HS stated Resident #161 did not speak a lot and could answer short questions, however the resident had confusion. She stated she was unaware of any increase in supervision for Resident #161 before this incident. On 04/29/2021 at 4:39 PM, interview with CNA #37 revealed she witnessed Resident #161 have previous similar sexual contact with another resident, with his/her hand on the other resident's exposed genitalia, about two (2) years ago. The aide stated Resident #161 was not to be left alone. She further stated when staff went on break, they told the other aides and nurse on the floor. Interview with Registered Nurse (RN) #5, on 06/10/2021 at 10:29 AM, revealed Resident #161 could answer yes/no questions or shake his/her head. She stated the resident would hold his/her hand out, which could be misinterpreted by someone. She further stated she could not recall a time the resident told her no and she had never heard the resident say no. The RN stated she did not think Resident #161 would understand complexities. She further stated she did not think Resident #161 was able to understand what was involved in a sexual relationship. RN #5 stated Resident #161 needed his/her POA to make decisions as the resident was not capable to make decisions for himself/herself. On 04/30/2021 at 6:27 AM, interview with House Supervisor (HS) #2 revealed she was informed of a previous similar sexual contact incident between Resident #161 and another resident about one (1) to two (2) years ago. She stated Resident #161 had his/her hand on another resident's genitalia. HS #2 further stated Resident #161 was not cognitively intact then. She also stated Resident #161 should not be left alone in common areas and was at the nurse's station a lot. HS #2 revealed someone needed to keep an eye on Resident #161. She further stated if Resident #161 was left alone in the common area, inappropriate contact between Resident #161 and another resident could happen again. On 04/30/2021 at 9:09 AM, interview with Social Service Designee #2 revealed she was immediately informed that Resident #161 tried to touch Resident #47's exposed genitalia, while in the dayroom. She stated Resident #161 had previous sexual behaviors of public masturbation and sexual activity in the common area. She stated, however, Resident #161 had not previously touched another resident, and thought this was the first time the resident reached out. The Designee stated she could not recall if Resident #161 had any previous inappropriate contact with another resident. Interview, on 04/30/2021 at 9:27 AM, with the fourth floor UM revealed she was the UM on the fourth floor at the time of the incident between Resident #161 and Resident #47. She stated she was not aware of any prior sexual behaviors from Resident #161. The UM stated the facility already monitored Resident #161 due to being a high fall risk, and the resident was at the nurse's station when out of bed. She further stated Resident #161 was in a geri-chair and should not be left alone in the dayroom. The UM stated no resident should be left alone in the dayroom if he/she could not move back and forth on his/her own. She also stated if Resident #161 was in the dayroom, then staff should also be in the room as the resident was not alert and oriented and there were no call lights in the dayroom. On 04/30/2021 at 1:00 PM, interview with Social Service Designee #1 revealed Resident #161 was not able to self-propel or wheel him/herself around. On 04/30/2021 at 2:06 PM, interview with the Assistant Director of Nursing (ADON) revealed she was the facility's abuse coordinator and responsible for the facility's investigations. She stated she came into the facility and spoke to Resident #161, who smiled and said Resident #47 was tying his/her shoe. The ADON revealed Resident #161 was cognitively impaired. She stated Resident #161 denied anything occurred. Continued interview, on 06/03/2021 at 9:44 AM, with the ADON revealed Resident #161 was not able to turn off the lights in the dayroom unless he/she sat near the light switch as the resident was in a geri-chair at the time of the incident and was not able to move around on his/her own. She stated she was not aware of the previous incident in which Resident #161 touched another resident's genitalia in 2019. The ADON further stated Resident #161 denied the incident with Resident #47 occurred, even when she (the ADON) told the resident staff witnessed the sexual contact. She revealed Resident #161 was welcome to have a relationship with others, as his/her BIMS was higher. She further stated Resident #161's BIMS score was high enough to provide consent. Additionally, the ADON stated she was unsure if the resident's POA gave permission for Resident #161 to have a sexual relationship. She stated Resident #161 had periods of confusion that fluctuated, dependent on the time of day. Additionally, she stated the facility placed Resident #161 on one (1) hour safety checks after the incident with Resident #47, to see what the resident was doing, where he/she was, and if the resident needed anything. Interview with the Physician, on 06/03/2021 at 9:17 AM, revealed Resident #161 had Dementia and was cognitively challenged. He recalled the resident had a POA who was very involved in the resident's care. The Physician stated psychiatric services was involved in Resident #161's care. He further stated Resident #161 was cognitively challenged and was not able to make a decision to engage in sexual behavior with another. On 06/03/2021 at 10:32 AM, interview with the Administrator revealed Resident #161 was not able to turn out the light in the dayroom. She stated she was unaware of the facility's root cause analysis of the incident between Resident #161 and Resident #47. However, she was sure the ADON or the former DON conducted one. She stated Resident #161 denied anything happened, and was capable to make decisions for himself/herself. The Administrator further stated Resident #161 had not been deemed incompetent by a court. She stated a durable POA would make decisions when a resident was not able to make decisions for himself/herself. The Administrator stated Resident #161's POA was notified any time there was a change in condition, change in medication, and when this incident with Resident #47 occurred. She stated Resident #161 was able to make decisions for himself/herself, including when to get up, when to go to doctor appointments, and if he/she wanted to come out of his/her room. The Administrator stated the resident made healthcare decisions, such as if he/she wanted lab draws or diagnostics. She also stated Resident #161 did not speak with her about the incident, and did not speak with those he/she was not comfortable with. She revealed Resident #161 could answer questions based on who conducted the BIMS' score, as he/she might not answer questions, which resulted in a lower score. Interview, on 06/03/2021 at 1:30 PM, with Resident #161's POA revealed she had been the resident's POA since 2011. She stated Resident #161 had advanced Dementia and was not able to make his/her own decisions. The POA stated the resident lived with her for several years before he/she was admitted to the facility. She further stated the resident was not able to say if he/she wanted to be in a relationship. The resident's POA stated Resident #161 could not recall what happened. The POA stated the resident had a habit to reach out to others and if he/she did that, someone else might take advantage of the situation. She stated Resident #161 did not begin conversations, but could answer yes/no questions. She stated the resident would smile or answer questions if he/she knew you. The POA stated she was very upset about what happened and Resident #161 should not have been left alone in the room. She stated the resident should not have been put in that situation. On 06/03/2021 at 1:48 PM, interview with the former DON revealed the ADON reported to her when the incident occurred between Resident #161 and Resident #47. She stated she was informed no one saw anything. The former DON stated she was unaware of a previous similar incident with Resident #161 and another resident. She stated Resident #161's care plan stated not to leave the resident unattended in the dining room may have been a fall's intervention. However, she stated the purpose of the intervention was to keep the resident safe. Interview with the Administrator, on 06/03/2021 at 3:16 PM and 4:02 PM, revealed the facility followed the law related to the POAs. She stated the facility did not have a policy for POAs. She stated the facility followed the MDS and did not have a policy for the BIMS' assessment. The Administrator also stated the facility did not have a policy related to resident capacity to consent and the only consent the facility used was the consent signed on admission. She stated the facility assessed to determine if Resident #161 had the capacity to give consent to sexual contact based on the BIMS' assessment, and they generally used a score of nine (9) and above. However, she further stated some residents had BIMS' scores that fluctuated from assessment to assessment. On 06/03/2021 at 3:46 PM, interview with the ADON revealed it was hard to determine if the sexual contact between Resident #161 and Resident #47 was abuse or consensual. The ADON stated she was unaware the physician indicated Resident #161 did not have capacity to consent to a sexual relationship. She further stated if a resident did not have capacity to consent, the resident was not able to engage in sexual relationships. The ADON stated Resident #161 should not have been left in the backroom unattended. Interview, on 06/04/2021 at 3:19 PM and 4:52 PM, with the Administrator revealed the facility used a BIMS' score of eight (8) and above, not nine (9), to give consent. She stated the facility used a risk management company; however, they company did not provide information related to consent and intimacy. She stated the risk management company was involved in all reportable events. The Administrator stated Resident #161 had capacity to consent. However no one assessed if the resident wanted to be in a sexual relationship or have sexual contact. She stated the facility did not ask residents if they had a need or urge for sex. She further stated a BIMS of eight (8) to twelve (12) was moderately impaired, the resident may not know the month or year, but was still capable to make decisions based on their BIMS' score. On 06/07/2021 at 11:40 AM, interview with the Regional Director of Operations (RDO) revealed although the facility did not have a policy, it was a standard for residents with a BIMS of eight (8) and above, to allow the resident to consent, if the resident was interviewable. She stated Resident #161 had the right to make his/her own decisions, even though he/she had a POA. She further stated the facility did not have a policy for a resident to give consent, although the facility did not condone it. The RDO stated the residents did not have sex, and denied anything happened. She stated Resident #161's BIMS varied because if the resident did not like or know you, he/she would not answer. She further stated what occurred between Resident #161 and Resident #47 was not abuse as there was no psychosocial distress or injury. Interview with the DON, on 06/07/2021 at 12:10 PM, revealed a resident BIMS' score of eight (8) or above determined if a resident was capable to give consent. She stated the purpose of the BIMS score was to determine if the resident had stabilized cognition and a resident with a fluctuated BIMS' score would mean the resident had periods of confusion. She stated she was not the DON at the time of the incident. Interview with the Administrator, on 06/07/2021 at 1:58 PM, revealed the facility ensured a resident was capable of consent based on the BIMS' score. She stated at times Resident #161 would not talk to others and sometimes he/she would answer questions, scoring higher on the BIMS on some days than others. The Administrator revealed the facility was not able to determine if Resident #161 or Resident #47 initiated contact with the other. Interview with the ADON, on 06/08/2021 at 8:54 AM, revealed she spoke to psych, when they saw Resident #161 after the incident with Resident #47, who said he/she was not a threat to himself/herself or others. However, the ADON did not ask if the resident had capacity to consent and had not read the psych note. She stated based on the documentation by psych on 03/23/2021

Based on observation, interview, record review, and facility policy review it was determined the facility failed to develop or implement their policy related to facility abuse and neglect for two (2) of one hundred-thirteen (113) sampled residents (Residents #47 and #161) . The facility failed to develop a policy related to assessment for capacity to consent to sexual contact for Resident #47 and Resident #161. On 03/19/2021, Resident #47 and Resident #161 had sexual contact with each other. The facility assessed the resident Brief Interview for Mental Status (BIMS) scores after the incident, and used the BIMS' score results as a determination of capacity to consent to the contact. However, the facility did not have a policy to reference how to determine resident capacity, or when BIMS scores were used as the sole assessment for resident capacity. Immediate Jeopardy was identified on 06/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at S/S of J and F607 Develop/Implement Abuse/Neglect, etc. Policies at S/S of J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision at S/S of J; 42 CFR 483.40 Behavioral Health, F745 Provision of Medically Related Social Services at S/S of J, and 42 CFR 483.70, Administration, F835 Administration at S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F600 Free from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect, Policies, and 42 CFR 483.40, F745 Provision of Medically Related Social Services. The facility was notified of the Immediate Jeopardy on 05/17/2021. An extended survey was conducted 06/30/2021 through 07/02/2021. The State Survey Agency validated the facility's Allegation of Compliance/Removal Plan and found the facility had removed the immediacy on 06/27/2021, as alleged. The findings include: 1. The facility did not provide a policy related to a resident's capacity to consent, or residents who were not able to give consent to sexual contact with others. The facility did not provide a policy related to resident Durable Power of Attorney (POA). Review of the facility's policy, Abuse Prevention Program, updated 05/02/2017, revealed it was the policy of the facility to prevent resident abuse, neglect, and mistreatment. Each resident received care and services in a person-centered environment. Residents who allegedly mistreated another resident would be immediately removed from contact with that resident during the investigation. The accused resident's condition should be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his/her safety, and safety of other residents. Sexual abuse included, but not limited to, sexual harassment, sexual coercion, or sexual assault. Upon receiving information concerning a report of abuse, social services would monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation. Review of the facility's policy, Assessments, dated 08/2017, revealed assessments would be completed when an event occurred that required an assessment by a qualified medical professional. An assessment would be completed based on the event and included Post-Behavior event. Review of the Accident Incident Reporting Policy, not dated, revealed an immediate assessment of the resident would be completed when a resident was involved in an incident. A written report would be completed in the risk management section of the PCC for any resident involved in an incident while residing in the facility. When possible, a descriptive statement would be obtained from the resident or witness. A more extensive investigation was required for resident to resident altercation and suspected/alleged abuse. Based on the results of the investigation, the resident's care plan was revised as necessary to prevent or minimize further incidents when possible. Review of the facility's policy, Standard Supervision and Monitoring, dated 11/25/2011, revealed a proactive intervention that promoted enhanced physical and psychosocial well-being. The physician/psychiatrist would be notified for further evaluation and treatment to further assess and treat the resident if increased supervision and guidance was required. Review of the facility's policy, Resident Behavior and Facility Practices, not dated, revealed residents had the right to be free from sexual abuse. The facility must implement procedures that protect residents from abuse. Review of the facility's document Abbreviated Instructions for Conducting the BIMS (Brief Interview for Mental Status), revised 10/2011, revealed the intent was to determine the resident's attention, orientation, and ability to register and recall new information. For more in-depth instructions for completing the BIMS, refer to Chapter 3: MDS Items Section C: Cognitive Patterns. Repetition Of Three (3) Words Section determined if the resident was able to actively engage in a verbal interaction. Temporal Orientation (Orientation to Year, Month, and Day) section referred to the ability to place himself/herself in correct time. For the BIMS, it was the ability to indicate the correct date in current surroundings. The Recall section revealed residents with cognitive impairment could be helped to recall if provided clues. The Total Score revealed a BIMS score of thirteen (13) to fifteen (15) was cognitively intact, eight (8) to twelve (12) was moderately impaired, and zero (0) to seven (7) was severe impairment. Review of the clinical record revealed the facility readmitted Resident #161 on 10/09/2017. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #161's care plan (CP) revealed the resident had [CONDITION(S)], Cognitive Communication Deficit, and Cerebral Infarction diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions, dated 04/03/2018, included: use task segmentation to support short-term memory deficits; discuss concerns about confusion, disease process, nursing home placement with the resident and family. Further review of the CP revealed Resident #161 exhibited behaviors of reaching out to others when seated in common areas. This behavior was related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention, dated 04/06/2019, stated to intervene as necessary to protect the rights and safety of others, divert attention, and remove the resident from the situation and take to an alternate location. Continued review of Resident #161's CP revealed an intervention to offer choices daily (e.g. choice of clothing, food/drink, activity) and may need supervision/assistance with all decision making, initiated 10/24/2019. Review of a Geriatric Visit Note for Resident #161 revealed, the Nurse Practitioner (NP) saw the resident on 01/20/2021. The NP noted the resident had disorientation, memory loss, and chronic confusion. The resident was oriented to person, disoriented to place, time, and situation, and had advanced dementia. Review of a Psychology Progress Note, dated 01/26/2021, revealed Resident #161 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had difficulty concentrating and was oriented to person and situation. The resident's memory deficit included immediate, recent, and remote. Review of a Psychology Progress Note, dated 03/09/2021, revealed Resident #161 was moderately impaired in comprehension, executive function, insight, and judgement. The resident also had memory deficits. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #161 with a Brief Interview Mental Status (BIMS) of eleven (11), and moderate cognitively impaired. Review of a facility incident, dated 03/19/2021 at 10:10 PM, revealed staff observed Resident #47 next to Resident #161 with his/her genitalia exposed. Resident #161 was unable to verbalize if anything occurred. The incident report was not complete, with information missing related to Resident #161's mental status and if any predisposing factors were present related to the environment, physiological, or situational factors. Additional review of the CP for Resident #161 related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed on 03/20/2021, revealed the NP saw Resident #161 for fatigue. The NP assessed the resident as disoriented, had memory loss, and chronic confusion. The note revealed the resident was oriented to person only, and had advanced dementia. Review of a Psychology Progress Note, dated 03/23/2021, revealed staff requested the visit due to possible sexually inappropriate behavior for Resident #161. The resident did not endorse any memory of the recent behavior and due to dementia, the resident did not have capacity to make major decisions, including consent for relationships with other residents. Continued review of the CP for Resident #161 revealed the facility added an intervention, on 03/24/2021, for every one (1) hour safety checks. Review of a Psychiatric Progress note, dated 03/30/2021, revealed Resident #161 was a poor historian due to cognitive/psychiatric impairment. Observation, on 05/06/2021 at 2:23 PM, of Resident #161 revealed the resident in a geri-chair at the fourth floor nurse's station, with a pillow under his/her head. Staff asked the resident if he/she wanted to lay back more. The resident nodded yes and staff adjusted the back of the geri-chair. Observation of Resident #161, on 05/12/2021 at 3:26 PM, 05/13/2021 at 2:26 PM, 05/14/2021 at 2:27 PM, 05/16/2021 at 9:05 AM, 05/18/2021 at 1:40 PM, 05/19/2021 at 10:54 AM, 06/02/201 at 2:44 PM, 06/03/2021 at 11:19 AM, and 06/08/2021 at 1:51 PM, revealed the resident in the geri-chair at the nurse's station, with a pillow under his/her head. Attempted interview, on 05/06/2021 at 2:33 PM, with Resident #161 revealed the resident did not respond to the State Survey Agency (SSA) Surveyor. Interview with Certified Nurse Aide (CNA) #35, on 04/29/2021 at 1:54 PM, revealed Resident #161 would hold his/her hand out and tried to grab people. She stated like a kid, the resident grabbed things and tried to put things in his/her mouth. Interview on 04/29/2021 at 2:54 PM, with Licensed Practical Nurse (LPN) #30 revealed she was not aware Resident #161 had a prior incident with another resident until the resident's POA (Power of Attorney) told her. She stated Resident #161 would touch and grab people. LPN #30 revealed the resident would grab and rub others' hands. The nurse stated the resident could say he/she was hungry or hurting, however it was hit or miss how oriented the resident was. Interview, on 04/29/2021 at 3:12 PM, with CNA #36 revealed Resident #161 would reach out and grab people. She stated the resident grabbed her arm and rubbed it. The aide revealed the resident had confusion. Interview with House Supervisor (HS) #1, on 04/29/2021 at 3:55 PM, revealed Resident #161 had confusion and did not speak a lot. She stated the resident could answer short questions. On 04/29/2021 at 4:18 PM, interview with Certified Medication Technician (CMT) #5 revealed Resident #161 would reach out and grab people when they passed by, which was the resident's normal behavior. She stated she was not aware the resident had any prior sexual behaviors. Interview, on 04/29/2021 at 4:39 PM, with CNA #37 revealed she witnessed a similar incident with Resident #161 and another resident about two (2) years ago. She stated the resident was more cognitively intact then, than he/she was now. Interview with the Unit Manager (UM) for the fourth floor, on 04/30/2021 at 9:27 AM, revealed she was unaware Resident #161 had a similar prior incident with another resident. She stated Resident #161 should not be left in the dayroom alone as the resident was in a geri-chair and could not move back and forth on his/her own. The UM revealed Resident #161 was not alert and oriented times three (3), and there was no call light in the dayroom to let staff know if he/she needed something. Interview, on 04/30/2021 at 1:00 PM, with Social Service Designee (SS) #1 revealed she followed up with Resident #161 after the incident with Resident #47. She stated the resident could do better on the BIMS' score on one (1) day, but not as well on another day. The Designee stated the resident could let staff know if he/she was hungry, but used the bathroom on himself/herself and not say anything. She stated Resident #161 had some cognitive impairment. On 04/30/2021 at 2:06 PM, interview with the Assistant Director of Nursing (ADON) revealed she was the Abuse Coordinator for the facility and conducted the facility's investigations. She stated when she spoke with Resident #161 related to the incident, he/she stated that Resident #47 was just tying his/her shoe. The ADON revealed Resident #161 was cognitively impaired. Interview with the Director of Nursing (DON), on 05/14/2021 at 9:20 AM, revealed she had only been with the facility, and as DON, for about six (6) weeks. Interview, on 06/03/2021 at 9:17 AM, with Resident #161's Physician revealed the resident had Dementia, was cognitively challenged, and received psychiatric (psych) services. He revealed the resident did not have the ability to make a decision to engage in sexual behavior with another. Continued interview with the ADON, on 06/03/2021 at 9:44 AM, revealed Resident #161 denied anything occurred with Resident #47. She stated the resident had a higher BIMS and was welcome to have a relationship if it was okay with the responsible party. The ADON revealed the resident's BIMS was high enough to consent to the event. She further revealed the resident had a POA and was unsure if the POA gave permission for a sexual relationship for Resident #161. She stated the resident had periods of confusion that fluctuated depending on the time of day. On 06/03/2021 at 10:32 AM, interview with the Administrator revealed Resident #161 was still able to make decisions for himself/herself and had not been deemed incompetent. She stated a durable POA made decisions when a resident was not able to make decisions for himself/herself. The Administrator revealed Resident #161 decided when to get up, when to attend doctor appointments, and when to come out of his/her room. She further revealed the resident decided whether or not he/she wanted to have labs drawn. She stated Resident #161 did not speak with her and she thought the resident was embarrassed. The Administrator further stated the resident could answer questions based on who asked, as the resident did not talk to people he/she was not comfortable with. Continued interview with the Administrator, on 06/03/2021 at 2:18 PM, revealed the facility did not have a policy for resident BIMS's scores, resident's POA, or resident's capacity to give consent. She stated the only consent the facility had, was obtained when admitted . Additional interview with the ADON, on 06/03/2021 at 3:46 PM, revealed it was difficult to determine if the contact between Resident #161 and Resident #47 was consensual or abuse. She stated Resident #161 denied what occurred and had a BIMS over eight (8). The ADON revealed the resident came up with a good answer. She stated the POA would step in if a resident was not able to speak for himself/herself. She further stated if a resident was determined unable to give consent the resident would not be able to engage in sexual relationships. Interview, on 06/03/2021 at 4:10 PM with the Administrator revealed the facility assessed the resident's capacity to consent based on the resident's BIMS score. She stated a BIMS score of nine (9) and above was generally determined to have capacity to consent. On 06/04/2021 at 2:12 PM, interview with Social Service Designee #2 revealed the facility assessed residents' capacity to consent with the BIMS score. She stated a resident with a BIMS of eight (8) and above was able to make his/her own choices, even if he/she had a POA. The Designee revealed there may be some impairment, but the resident with a BIMS of eight (8) and above was able to make his/her own decisions about his/her care. Interview with the Administrator, on 06/04/2021 at 3:01 PM, revealed if a resident had a BIMS of eight (8) or greater the resident had the right to make his/her own decisions, even when the resident had Dementia. She stated the facility followed the criteria to determine the resident's BIMS score based on how the resident answered the questions correctly. The Administrator stated the facility used a BIMS of nine (9) to determine the resident could make decisions, that it was common practice, although the facility did not have a policy. However, on 06/04/2021 at 3:19 PM, the Administrator stated she wanted to change her answer from a BIMS of nine (9) to a BIMS of eight (8) and above to give consent. Continued interview, on 06/04/2021 at 4:52 PM, revealed the risk management consulting group did not provide any information on consent and intimacy. She stated the facility determined Resident #161 could give consent. She further stated a BIMS of eight (8) to twelve (12) was cognitively moderately impaired, the resident may not know the month or year however, they could still be capable to make decisions. The Administrator revealed she was unaware of any reference or source for what moderate impairment meant. Interview with the Regional Director of Operations (RDO), on 06/07/2021 at 11:40 AM, revealed Resident #161 was assessed to have a BIMS of nine (9) after the incident with Resident #47. The RDO stated a BIMS of eight (8) and above was interviewable and was standard across the board, and the facility did not have a policy. She stated the resident had the right to make his/her own decisions, did not engage in sex, and denied anything happened. The RDO further stated the facility did not have a policy on resident consent. On 06/07/2021 at 12:10 PM, interview with the DON revealed the assessment to determine a resident's BIMS score, with a BIMS of eight (8) and above, determined if a resident was capable to give consent. She stated she was unsure if the facility had a policy stating that a resident with a BIMS of eight (8) and above had capacity to consent. Additional interview with the Administrator, on 06/07/2021 at 1:58 PM, revealed the facility ensured a resident had the capacity to consent based on his/her BIMS score. She stated sometimes Resident #161 would answer the questions and score higher on the BIMS, and other days the resident would not talk. The Administrator revealed the Centers for Medicare and Medicaid Services (CMS) referred to the Resident Assessment Instrument (RAI) for level of cognition. Interview, on 06/11/2021 at 10:21 AM, with the ADON revealed she was unsure who assessed a resident's capacity to consent. She stated for a reportable incident she listened to the resident, and noted if the story changed. She also considered the resident's BIMS score when she made a determination as part of the investigation. The ADON was unsure if the facility had a policy related to consent; however the facility used the CMS guidelines, (specific guideline(s) not indicated), as a resource. On 06/11/2021 at 10:50 AM, interview with the DON revealed she was not familiar with the State Operations Manual (SOM) and did not want to speak to the document. She stated she was unsure if the facility had a policy for resident consent, and was unsure what resource was used to determine what the facility would use to determine capacity to consent. The DON stated the facility used the resident BIMS score to determine capacity to consent. On 06/11/2021 at 11:22 AM, continued interview with the Administrator revealed it was common sense to use the resident's BIMS score to determine capacity to consent. She stated the RAI manual determined a resident's cognition. Interview with the DON, on 06/11/2021 at 11:31 AM, revealed the facility used the CMS guidelines and based on the resident's cognitive level, Resident #161 would know the risks and benefits of sexual contact. Interview with the Administrator, on 06/11/2021 at 11:45 AM, revealed the facility did not have a policy related to resident consent, or a resource for use of the BIMS score of eight (8) and above as consensual. She stated there was no risk or benefit to touching, and Resident #161 was able to make his/her decision through the BIMS score. Continued interview with the ADON, on 06/15/2021 at 3:58 PM, revealed only the resident BIMS score was used to determine capacity to consent. However, she stated as part of her investigation she reviewed the care plan (CP), diagnoses, history, and spoke with the resident. She revealed she used the facility's Abuse policy for the investigation. She revealed she was not aware of any policy for a resident who could not give consent. The ADON stated if a resident did not give consent and did not know what he/she was doing, it would not be abuse as it was unintentional. The facility took the following actions: 1. A physician assessed Resident #47 and Resident #161 to determine their capacity to consent to sexual activity. 2. A policy was written with reference to CMS guidelines, included resident rights, and included resident assessments if residents were able to consent to sexual contact. The regional team and risk management provided input, and approved by the Medical Director. 3. Social services assessed residents, by 06/24/2021, with a BIMS score, with an eight (8) or above and a desire to engage in sexual relationship with another consenting adult, and provided Safe Sex education to the resident. 4. Residents with a BIMS of eight (8) and above who expressed a desire for sexual contact were further assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. New admissions and re-admissions were assessed for capacity to consent and care plans reflected the resident's capacity to consent to sexual contact. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Service Director (SSD) monitored ten (10) medical records five (5) days a week for three (3) months, then weekly for six (6) months. Residents were reviewed on a rotating basis, included new and re-admissions, for capacity to consent defined per assessment, and care plans reflected the resident's capacity. 6. Clinical Quality Indicator (CQI) meetings, held Monday through Friday, revealed new and re-admissions and scheduled assessment for capacity to consent, within fourteen (14) days of admission. Care plan conferences would also review capacity to consent 7. A regional team member monitored facility policy on assessments and care plan for consent to sexual contact weekly for three (3) months. 8. The Regional Director of Operations (RDO) trained the trainers (the DON and ADON), on 06/17/2021. The DON, ADON, or designee trained all staff in all departments, therapy staff, and agency staff, begun 06/21/2021, on the abuse policy, resident rights, consenting adult right to engage in sexual contact with another consenting adult, what was consent, who was assessed for consent, who assessed for consent and when, need for documented ability to consent. Staff completed a post-test, which required a passing score of 100% answers correct. No staff worked prior to receiving the training, after 06/24/2021, included new hire staff and agency staff. 9. The Quality Assurance Performance Improvement (QAPI) reviewed the audits weekly, then monthly, and included new and re-admissions assessments for consent to sexual contact, and a face-to-face interview with a physician for any resident who expressed desire for sexual contact with another consenting adult. 10. A regional team member would attend weekly QAPI meetings, then monthly for three (3) months. The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the Assistant Director of Nursing (ADON), on 07/03/2021 at 4:19 PM, the DON, on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03/2021 at 6:17 PM, revealed the physician attempted to assess Resident #47 for capacity to consent, however the resident walked away from the physician. The ADON stated a physician assessed Resident #161 who determined the resident could not consent to sexual contact due to cognitive impairment. 2. Review of the facility policy Consent for Sexual Contact, not dated, revealed residents with a Brief Interview Mental Status (BIMS) of eight (8) and above, who expressed a desire for sexual contact would be educated on safe sex practices, have a face-to-face session with a physician to determine if the resident had the capacity to consent, and the care plan would reflect the resident's capacity. Additionally, the resident would be asked to sign the Consensual Sexual Relationship Agreement. Interview with the Assistant Director of Nursing (ADON), on 07/03/2021 at 4:19 PM, the Director of Nursing (DON), on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03/2021 at 6:17 PM, revealed the facility policy addressed factors to consider capacity to consent to sexual contact included the BIMS, the resident's diagnosis, and assessment by a physician. The DON stated the policy was implemented on 06/25/2021. The Administrator revealed the RDO and risk management was involved in the creation of the policy, and was approved by the Medical Director. 3. Review of resident BIMS assessments revealed BIMS assessments conducted through 06/25/2021. Review of the Consensual Sexual Relationship Agreement, not dated, revealed the resident and staff signed that the resident was assessed, capable of making decisions, and educated on safe sex practices. On 07/03/2021 at 4:19 PM, interview with the ADON, on 07/03/2021 at 5:35 PM, interview with the DON, and on 07/03/2021 at 6:17 PM, interview with the Administrator revealed social services assessed resident BIMS, and residents with a BIMS of eight (8) and above who indicated a desire for a sexual relationship were educated on safe sex 4. Interview, on 07/03/2021 at 4:19 PM, with the ADON, on 07/03/2021 at 5:35 PM, with the DON, and on 07/03/2021 at 6:17 PM, with the Administrator revealed residents with a BIMS of eight (8) and above who had a desire for sexual contact were assessed by a physician via a telehealth face-to-face for capacity to consent. 5. Review of audits, dated 06/28/2021 through 07/01/2021, revealed ten (10) resident records reviewed daily. Interview with the ADON, on 07/03/2021 at 4:19 PM, and the DON, on 07/03/2021 at 5:35 PM, revealed she participated in monitoring ten (10) medical records five (5) days a week, to continue for three (3) months, and then ten (10) records weekly for six (6) months for completion of the resident assessment for completion of the resident BIMS assessment, desire for sexual contact, if the resident had a Power of Attorney (POA) or responsible party, a physician assessment for capacity to consent completed, and the care plan updated to reflect capacity to consent. Each resident on each floor would be rotated through, and included new and re-admissions. 6. Interview, on 07/03/2021 at 4:19 PM, with the ADON, on 07/03/2021 at 5:35 PM, with the DON, and on 07/03/201 at 6:17 PM, with the Administrator revealed the Clinical Quality Indicator (CQI) meeting met Monday through Friday and reviewed new and re-admissions, and scheduled capacity to consent assessment within eight (8) days. Care plan conferences would also review a resident's capacity to consent. 7. Interview with the ADON, on 07/03/2021 at 4:19 PM, and the DON, on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03/2021 at 6:17 PM, revealed the Regional Director of Operations (RDO) would review the medical record audits of assessments weekly for three (3) three months. 8. Review of post-tests and training materials revealed the facility trained one hundred seventy-one (171) staff in the following departments: housekeeping, laundry, dietary, maintenance, nursing, social services, admissions, central supply, smoke monitors, and reception. Seventeen (17) staff needed to be trained, and were on leave or PRN status. Fifteen (15) therapy staff and forty-four (44) agency staff were trained. Review of a QAPI Committee Meeting Minutes, dated 06/17/2021, revealed the Administrator, DON, ADON, and the RDO by phone, discussed CMS guidelines, policies, and procedures to train staff with a post-test. Interview with Receptionist #2, on 07/02/2021 at 10:48 AM, Unit Manager (UM) #1, on 07/02/2021 at 10:54 AM, the Cook, on 07/02/2021 at 11:13 AM, Laundry Aide #3, on 07/02/2021 at 11:19 AM, Customer Service Representative, on 07/02/2021 at 11:24 AM, Housekeeper #4, on 07/02/2021 at 11:31 AM, Certified Nurse Aide (CNA) #38, on 07/02/2021 at 11:37 AM, Occupational Therapist (OT) #1, on 07/02/2021 at 11:47 AM, the Unit Secretary, on 07/02/2021 at 11:56 AM, House Supervisor #3, on 07/03/2021 at 3:22 PM, Licensed Practical Nurse (LPN) #3, on 07/03/2021 at 3:49 PM, LPN #43, on 07/03/2021 at 3:53 PM, CNA #56, on 07/03/2021 at 4:03 PM, CNA #43, on 07/03/2021 at 4:11 PM, revealed they were trained recently on abuse, resident rights, what was consent and how residents were assessed for consent and by whom, and right of consenting residents. Interview with the ADON, on 07/03/2021 at 4:19 PM, the DON, on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03/2021 at 6:17 PM, revealed they were trained by the RDO on 06/17/2021, and they then trained staff, beginning 06/21/2021, with a post-test requirement of 100% to pass. 9. Review of QAPI discussion notes and sign in sheets, dated 06/24/2021 and 07/01/2021, revealed audits reviewed related to admissions and re-admissions for consent to sexual contact, which included further assessment and face-to-face interviews by a physician with residents. On 07/03/2021 at 4:19 PM, interview with the ADON, on 07/03/2021 at 5:35 PM, interview with the DON, and on 07/03/2021 at 6:17 PM, interview with the Administrator revealed audits for assessments of capacity to consent were reviewed in QAPI weekly, then monthly. She stated the RDO and Medical Director participated in the QAPI meetings. 10. Interview with the DON, on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03.2021 at 6:17 PM, revealed the RDO attended the weekly QAPI meetings, the most recent on 07/01/2021, either in person or by phone. On 07/03/2021 at 6:20 PM, interview with the RDO revealed she attended weekly QAPI meetings, by phone or in person. She stated she would participate for three (3) months.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure resident care plans were revised/updated for seven (7) of one hundred-thirteen (113) sampled residents (Residents 32, 47, 74, 87, 130, 159, 161). 1. On 03/19/2021 around 7:30 PM, staff found Resident #161 with his/her hand on Resident #47's exposed genitalia. The residents were in the dining room/dayroom area, the lights were off, and no staff were in the room. Resident #161 had a similar incident in 2019, with his/her hand on another resident's exposed genitalia while in a common area, however the resident's care plan was not revised to reflect sexual contact with another resident after the 2019 incident occurred. 2. The care plan for Resident #47 revealed the facility revised the resident's care plan for exposure of his her genitalia, after the sexual contact incident with Resident #161 occurred, on 03/19/2021. However, Resident #47's care plan did not reflect that sexual contact with another resident occurred. 3. Resident #130 had four (4) unwitnessed falls between March 2021 and May 2021, with two (2) falls resulted in major injury. Resident #130 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician, on 05/07/2021, ordered Physical Therapy (PT), however therapy services were not initiated until 05/18/2021. On 05/16/2021 at 2:30 AM, Resident #130 had an unwitnessed fall. Resident #130 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The facility identified, on 05/08/2021, a new Stage II pressure ulcer (PU) to the right buttock of Resident #159. During observation of a skin check for Resident #159, on 05/17/2021 at 9:21 AM, revealed an open area on the right upper buttock. The comprehensive care clan for Resident #159 revealed he/she was at risk for developing impaired skin integrity. The most recent update for this focus was initiated on 02/13/2019 to turn and reposition resident every two (2) hours, however the care plan was not revised for an actual wound. 5. The facility assessed Resident #32 at risk for falls with care plan risk of falls, initiated on 03/07/2019, interventions included keep the call light in reach and encourage resident to use it for assistance, gripper tape next to the bed, gather information on past falls and attempt to determine the root cause of the fall, and intervene to prevent reoccurrence. The resident fell again on 02/25/2021, 04/20/2021, 04/21/2021, and on 04/23/2021, After each of these three (3) falls, the care plan was revised based on incomplete incident reports and Root Cause Analysis to prevent future falls. 6. Resident #74's comprehensive care plan, initiated 03/03/2021, included the resident would be able to make basic needs known by speaking/ hand gestures/ process of elimination/ call to family for translation until effective communication could be created. However the resident did not have a communication board, which staff interviews revealed was not used, and was not discontinued until the re-certification survey. 7. Resident #87 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/01/2020, Resident #69 pushed Resident #87 to the floor, as Resident #87 sat in Resident #69's seat. On 02/27/2020, Resident #87 wandered around the unit all night and into other rooms. On 04/18/2020 Resident #87 wandered into another resident room and took the other resident's cookie. However, the CP was not revised until 11/10/2020, with an intervention for psychiatric services as needed. On 03/10/2021 the resident wandered into other resident rooms, and on 04/02/2021 the resident wandered into other resident rooms, got into their beds, and took their belongings. On 04/22/2021, the resident was yelling in another resident's room and removed all the blankets from one (1) of the beds. The CP interventions were not revised after 04/02/2021 for these behaviors. Immediate Jeopardy was identified on 05/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at S/S of J and F607 Develop/Implement Abuse/Neglect, etc. Policies at S/S of J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.40 Behavioral Health, F745 Provision of Medically Related Social Services at S/S of J, and 42 CFR 483.70, Administration, F835 Administration at S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F600 Free from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect, etc. Policies, and 42 CFR 483.40, F745 Provision of Medically Related Social Services. The facility was notified of the Immediate Jeopardy on 05/17/2021. An extended survey was conducted 06/30/2021 through 07/02/2021. The State Survey Agency validated the facility's Allegation of Compliance/Removal Plan and found the facility had removed the immediacy on 06/27/2021, as alleged. The findings include: Review of the facility's policy, Baseline Care Plan Assessment/ Comprehensive Care Plans, revised 03/23/2021, revealed the comprehensive care plan would include measurable objectives and timetables to meet the resident's medical nursing, mental, and psychosocial needs. Additional changes would be made to the comprehensive care plan based on the assessed needs of the resident. The MDS staff would attend the morning CQI meetings where an in-depth review of the twenty-four (24) hour report since the prior morning meeting were reviewed and discussed as well as other pertinent circumstances regarding the residents. They will then see that the care plans for those residents were revised and updated as necessary. 1. Review of Resident #161's clinical record revealed the facility readmitted the resident on 10/09/2017. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #161 revealed he/she was at risk for falls related to history of falls, cognitive impairment, and decreased safety awareness. Interventions included not to leave the resident alone in his/her room when out of bed, to keep him/her around the nurse's station, initiated 04/13/2018. Review of the facility's investigation revealed on 04/05/2019, Resident #161 was in the common area in front of the nurse's station and had his/her hand on another resident's exposed genitalia. Review of the incident report revealed Resident #161 was confused, had impaired memory, and oriented to himself/herself only which was within the resident's normal limits. Further review revealed the care plan also included the resident exhibited behaviors related to reaching out for others when seated in common areas and included an intervention, dated 04/06/2019, to intervene as necessary to protect the rights and safety of others and remove from the situation and take to an alternate location as needed. Additional intervention included if reasonable and appropriate, discuss the resident's behavior, explain/reinforce why behavior was inappropriate and/or unacceptable to the resident if there was a concern, initiated 04/06/2019. Further review of the care plan for Resident #161, initiated 05/01/2019, revealed do not leave unattended in the dining room when out of bed. Further review of the care plan (CP) for Resident #161 revealed the resident was at risk of decline in cognitive function and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention, dated 10/24/2019, included the resident may need supervision/assistance with all decision making, and encourage and praise when decisions were made. The comprehensive CP revealed, on 05/29/2020, the resident used a geri-chair when out of bed. Review of the Quarterly Minimum Data Set (MDS) for Resident #161, dated 03/16/2021, revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) of eleven (11). The MDS noted the resident was totally dependent on staff for transfers, and to move about the unit with one (1) person assistance. The resident had impairment on his/her upper and lower extremities on one (1) side of the body. Further review of the care plan for Resident #161 revealed the resident exhibited episodes of sexual behavior and exposing himsself/herself in common areas. Interventions included remove the resident from public area and provide privacy of his/her own room when sexual behaviors were present and not be left alone in the dayroom, dated 03/19/2021. Additional intervention, dated 03/24/2021, included every one (1) hour safety checks. Observation of Resident #161, on 05/06/2021 at 2:23 PM, revealed the resident in a geri-chair at the fourth floor nurse's station. A pillow was under the resident's head. Staff asked the resident if he/she wanted to lay back more, the resident nodded and staff adjusted the back of the geri-chair. Observations, on 05/12/2021 at 3:26 PM, 05/13/2021 at 2:26 PM and 3:43 PM, 05/14/2021 at 2:27 PM, 05/16/2021 at 9:05 AM, 05/18/2021 at 1:40 PM, 05/19/2021 at 10:54 AM, 06/02/2021 at 2:44 PM, 06/03/2021 at 11:19 AM, 06/08/2021 at 1:51 PM, revealed Resident #161 in the geri-chair at the nurse's station with a pillow under the resident's head. Attempted interview with Resident #161, on 05/06/2021 at 2:23 PM, revealed the resident did not respond to the State Survey Agency (SSA) surveyor. Attempted interview, on 06/02/2021 at 2:44 PM, with Resident #161 revealed he/she nodded his/her head when the SSA surveyor asked how he/she was doing, with no other response from the resident. Interview, on 04/29/2021 at 2:54 PM, with Licensed Practical Nurse (LPN) #30 revealed she was the nurse assigned to Resident #161 when he/she had sexual contact with Resident #47, on 03/19/2021. She stated she worked with Resident #161 in the past, however she was not aware of the incident Resident #161 had with another resident in 2019 until Resident #161's family informed her of the incident. The LPN revealed she worked for the facility about four (4) years on different floors. She stated she did not update the resident's care plan, it was the responsibility of MDS department to update the care plan. Interview with House Supervisor #1, on 04/29/2021 at 3:55 PM, revealed she worked for the facility about one (1) year, and had worked previously through an agency. She revealed she was unaware of sexual behaviors from Resident #161 before, and had worked with the resident in the past. House Supervisor #1 stated she was not aware of any increased monitoring or supervision for Resident #161 in the past. She stated she did not update the resident's care plan, the nurses were responsible to update them. Interview with House Supervisor #2, on 04/30/2021 at 6:27 AM, revealed she worked for the facility about twenty-four (24) years and was aware Resident #161 touched another resident's genitalia about one (1) to two (2) years ago. She stated Resident #161 was monitored after that incident, and was not cognitively intact at the time. House Supervisor #2 revealed Resident #161 was at the nurse's station a lot and should not be left alone in common areas. She stated she did not update Resident #161's care plan, as it was the responsibility of the Unit Manager, ADON, or DON. She revealed staff needed to watch Resident #161 when he/she was in the back common area to keep an eye on the resident after the first incident. The Supervisor stated if the resident was left alone, the incident that occurred of inappropriate contact could happen again. She further stated she was unsure if the nurses were trained to update the care plan, and she had not been trained to update the care plan. Interview, on 04/30/2021 at 2:06 PM, with the ADON revealed everyone who participated in the morning meeting was responsible to update the care plan. She stated care plan updates were discussed and updated as a team. The ADON revealed she, Social Services, or MDS would make the updates. She stated the purpose of the care plan was to identify risk or how to properly care for a resident. She further stated nurses were trained how to update the care plan, however for the situation such as what occurred between Resident #47 and Resident #161, the morning team would update the care plan instead of the nurses. On 05/17/2021 at 3:05 PM, interview with the MDS Director revealed care plans were updated when there were any changes to a resident's status, such as medication changes, by the entire IDT team during the morning Clinical Quality Indicators (CQI) meetings five (5) days a week. She stated they reviewed the twenty-four (24) hour report and new orders, and everyone was responsible to update the care plan in a reasonable time. Continued interview with the ADON, on 06/03/2021 at 9:44 AM, revealed she updated the care plan for Resident #161, although she was unaware of the similar incident in 2019 between Resident #161 and another resident. Interview, on 06/03/2021 at 1:48 PM, with the former Director of Nursing (DON) revealed she thought Resident #161's care plan intervention not to leave him/her unattended in the dining room was related to a risk for falls. She stated the only sexual behaviors she was aware of, from Resident #161, was related to the resident would place his/her hands in his/her pants. The former DON revealed the resident's previous sexual behaviors occurred before she worked at the facility, and did not recall a prior incident of sexual contact with another resident. Interview with ADON, on 06/08/2021 at 8:54 AM, revealed Resident #161's care plan intervention, dated 03/19/2021, stated the resident was not to be left alone in the dayroom so staff could intervene if the resident exhibited episodes of sexual behavior. On 06/08/2021 at 9:36 AM, interview with the Administrator revealed the intervention not to leave Resident #161 alone in the dayroom was no longer relevant as it was no longer an issue. Interview, on 06/08/2021 at 11:02 AM, with Unit Manager (UM) #4 revealed the care plan, for Resident #161, intervention not to leave alone in the dayroom was to keep an eye on the resident so a similar situation that occurred would not happen again. Interview with the DON, on 06/08/2021 at 11:53 AM, revealed Resident #161's care plan intervention, dated 03/19/2021, was out in place for the resident's safety pending the outcome of the facility's investigation. She stated once the investigation was unsubstantiated, the intervention should have been removed from the care plan, and updated with a different intervention. The DON revealed the resident's care plan for sexual activity included an intervention to remove from public areas and provide privacy of his/her own room when sexual behaviors were present, however this did not reflect if the resident was or was not capable to give consent which was based on BIMS' scores. On 06/15/2021 at 1:52 PM, interview with UM #4 revealed she was not aware if Resident #161 had any sexual behaviors prior to the incident with Resident #47. She stated she was unaware of the purpose of the intervention for Resident #161 to remove from public areas when sexual behaviors were present. Interview with House Supervisor #1, on 06/15/2021 at 2:49 PM, revealed she did not work with Resident #161 and was not aware of the resident's capacity to consent to sexual contact. She stated she was unaware of the reason the resident had a care plan intervention to remove and provide privacy for sexual behaviors. The Supervisor revealed she heard the resident messed with him/himself/herself, although she had never seen the resident exhibit any sexual behaviors before. Interview, on 06/15/2021 at 3:04 PM, with Social Service Designee #2 revealed Resident #161's care plan intervention to provide privacy of his/her own room may have been related to the incident two (2) years ago with another resident, however staff reported the resident masturbated. She stated she was told to add to the resident's care plan not to leave him/her alone in the dayroom after the incident with Resident #47, although she could not recall who instructed her to add the intervention. The Designee revealed she added the intervention as Resident #161 should not be left alone in the dayroom to make sure what occurred did not happen again, to keep the resident safe. On 06/15/2021 at 3:30 PM, interview with LPN #30 revealed Resident #161's care plan intervention to provide privacy in his/her own room when he/she had sexual behaviors was related to the resident was seen with his/her hand down his/her brief. She stated she was told the resident was known to masturbate, and was unaware of a similar incident prior to this incident. Interview with the ADON, on 06/15/2021 at 3:58 PM, revealed she was unaware of Resident #161's sexual behaviors that led to the care plan intervention to remove from public areas and provide privacy. She stated during her investigation of the incident between Resident #47 and Resident #161, she discovered Resident #161 had a similar prior incident which would be relevant to the investigation with Resident #47, as she reviewed the resident care plan in her investigation. 2. Record review revealed the facility admitted Resident #47 on 06/11/2020. Resident #47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 08/03/2020, for Resident #47 revealed the resident had episodes of verbal aggression toward another resident with interventions to assess the resident's understanding of the situation and psychiatric consult as indicted. Additional intervention added, on 02/10/2021, included redirect as needed. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #47 as severely cognitively impaired with a Brief Interview Mental Status (BIMS) of seven (7). Review of a Psychiatry Progress note, dated 03/19/2021, revealed the resident had Dementia, was confused, and insight was impaired. The note documented the resident was oriented to person, place, and situation on this day. The resident was severely impaired in executive function, insight, and judgement. Resident #47 had a memory deficit, both recent and remote. Review of a facility incident report, dated 03/19/2021 at 10:03 PM, revealed Resident #47's genitalia was exposed and he/she stood in front of Resident #161. Resident #161 was unable to verbalize what occurred. Resident #47 stated he/she came from the bathroom and forgot to zip his/her pants. The facility immediately placed Resident #47 on one to one (1:1) supervision with staff. Review of the Psychology Report, dated 03/22/2021, revealed Resident #47 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff requested follow up and reported the resident was recently discovered to have his/her private area out in front of another resident in the common room. The resident was moved to another floor. Resident #47 stated nothing occurred in the common room with the other resident. The note further revealed the resident's comprehension, executive function, insight, and judgement were noted Severe Impairment. The note documented the resident had memory deficit, both recent and remote. The resident did not endorse he/she made any advances toward the other resident. Further review of Resident #47's care plan revealed the resident had episodes of exposing him/herself in common areas with an intervention, added on 03/24/2021 and discontinued on 06/11/2021, for the resident to remain on one (1) hour safety checks. The care plan did not reflect the resident was involved in a sexual contact incident with another resident. Observation of Resident #47, on 04/28/2021 at 2:04 PM, revealed the resident sat in a chair with a cell phone in his/her doorway on the third floor. Interview with Resident #47, on 04/28/2021 at 2:04 PM, revealed no other residents had touched him/her inappropriately. On 04/29/2021 at 1:26 PM and 05/06/2021 at 2:32 PM, observation revealed Resident #47 sat in a chair in his/her doorway and listened to music on a cell phone. Observation, on 05/07/2021 at 1:18 PM, of Resident #47 revealed the resident stood in his/her doorway. On 05/14/2021 at 3:37 PM and 05/17/2021 at 1:56 PM, continued observation revealed the resident exited the elevator and ambulated independently. On 05/18/2021 at 9:35 AM, observation revealed Resident #47 ambulated with a cane toward his/her room. Further observation, on 06/08/2021 at 1:53 PM, revealed Resident #47 ambulated independently from the direction of the elevator toward his/her room. Observation of Resident #47, on 06/14/2021 at 8:54 AM, revealed the resident in the therapy room with staff on the fourth floor, which was at the end of hall that Resident #161 resided. The resident utilized an exercise bike that worked both upper and lower extremities. Interview with Registered Nurse (RN) #30, on 04/29/2021 at 2:54 PM, revealed she was the nurse for Resident #47 at the time of the incident. She stated she did not update the resident care plan after the sexual contact with Resident #161. The nurse revealed the MDS Coordinator usually updated the care plan. On 04/29/2021 at 3:55 PM, interview with House Supervisor #1 revealed she did not update Resident #47's care plan after he/she had sexual contact with Resident #161. She stated the nurse was responsible to update the care plan. Interview, on 04/30/2021 at 6:27 AM, with House Supervisor #2 revealed she did not update the care plan for Resident #47. She stated the Unit Manager (UM) or Assistant Director of Nursing (ADON) was responsible to update the care plan. The Supervisor further stated she was unsure of the nurses were trained to update the care plan, and she had not been trained to update the care plan. On 04/30/2021 at 9:09 AM, interview with Social Services Designee #2 revealed she updated Resident #47's care plan after the incident with Resident #161. She stated Resident #47 did not have prior sexual behaviors. Interview with Social Services Designee #1, on 04/30/2021 at 1:00 PM, revealed Social Services Designee #1 was responsible to update the residents' care plans for any behaviors. She stated the MDS department may also update the care plans related to behaviors. Interview, on 04/30/2021 at 1:33 PM, with MDS Coordinator #2 revealed MDS staff was responsible for the resident's care plan when the resident was first admitted to the facility. She stated the nurses were responsible to update the care plan if the MDS Department was not there at the time of day. She revealed she did not update Resident #47's care plan, which should have been completed the night of the incident. MDS Coordinator #2 stated the care plan should be updated to ensure the resident's needs were met, for the resident's safety. She further stated the care plan informed staff how to care for a resident. On 04/30/2021 at 1:46 PM, interview with the MDS Director revealed if a resident had sexual behaviors, the facility would care plan for those behaviors. She stated the nurses were trained how and when to update the care plan. Interview, on 04/30/2021 at 2:06 PM, with the ADON revealed she was initially informed Resident #47 exposed himself/herself to another resident in the common area dining room/dayroom. She stated Resident #47 reported to her that nothing happened and he/she forgot to zip his/her pants after exiting the bathroom. The ADON revealed everyone in the morning meeting was responsible to update the resident care plan. She stated the team discussed the care plan together and updated the care plan as a team. She revealed she (the ADON), MDS, and Social Services could update the care plan. Additionally, the ADON stated the nurses were trained how to update the care plan and would update the care plan when needed. She revealed, however, the nurses would not update the care plan for a reportable incident such as the incident between Resident #47 and Resident #161, that it was reviewed and updated together. She stated the purpose of the care plan was to identify the risk or how to properly care for the resident. Continued interview with the MDS Director, on 05/17/2021 at 3:05 PM, revealed the morning meeting reviewed the twenty-four (24) hour report, nurse's notes, and any new activity/orders and reviewed the resident's care plan for appropriate interventions. She stated they were all responsible to update the care plan in a reasonable time. The MDS Coordinator stated new interventions put into place may not be listed on the care plan. Interview with the ADON, on 06/03/2021 at 9:44 AM, revealed the facility placed Resident #47 on one (1) hour safety checks after the incident with Resident #161 to look at his/her emotional needs, where he/she was, and what he/she was doing. She stated staff checked on the resident for emotional upset and documented on the Medication Administration Record (MAR). Interview with the former Director of Nursing (DON), on 06/03/2021 at 1:48 PM, revealed the ADON informed her staff did not witness any sexual acts occur between Resident #47 and Resident #161, and no one visually saw anything occur. She stated the purpose of the care plan was to keep the resident safe. On 06/03/2021 at 3:46 PM, additional interview with the ADON revealed the root cause analysis determined what and how an incident occurred to prevent it from happening again. She stated she was unable to substantiate or un-substantiate what occurred between Resident #47 and Resident #161, it was undetermined as the residents denied anything occurred although staff witnessed sexual contact between the residents. Continued interview with the ADON, on 06/08/2021 at 2:04 PM, revealed she determined through her investigation there was sexual contact between Resident #47 and Resident #161. Interview, on 06/08/2021 at 2:38 PM, with the Administrator revealed the facility investigation determined Resident #47 and Resident #161 did not have sexual contact with the other. Interview with Unit Manager (UM) #7, on 06/11/2021 at 4:25 PM, revealed he just began to help cover UM duties for part of the third floor, which included Resident #47, around 06/07/2021. He stated Resident #47 was on one (1) hour safety checks to check the resident for verbal aggression or exposing himself/herself. The UM revealed Resident #47's care plan did not identify he/she engaged in sexual contact with another resident. He stated the facility used agency nurses and CNAs, and if an agency staff worked with Resident #47 and did not know Resident #47, the agency staff may not know he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, he stated Resident #47 could move about after the one (1) hour safety check and had the potential to offend again. Continued interview with Social Services Designee #2, on 06/11/2021 at 5:00 PM, revealed she discontinued Resident #47's one (1) hour safety checks on this day as she forgot to remove the intervention after psych saw the resident. She stated the one (1) hour safety checks were to check to make d\sure the resident was safe, where he/she was supposed to be, and doing anything he/she was not supposed to do. The Designee revealed the resident's care plan did not have information that the resident had sexual contact with another resident, and she was not sure how she missed it. She further revealed agency staff would not know Resident #47 had sexual contact with another resident if it was not on the care plan, however she was not sure if anything would come of it. The Designee stated she was unsure if agency staff would know what to look for when they conducted the one (1) hour safety checks. Interview with the ADON, on 06/11/2021 at 5:20 PM, revealed she added to Resident #47's care plan that he/she exposed himself/herself the night of the incident with Resident #161. She stated Social Services Designee #2 did not update the care plan to include sexual contact with another resident as the facility unsubstantiated the incident. On 06/14/2021 at 10:30 AM, interview with MDS Coordinator #1 revealed Social Services was responsible for the care plans related to behaviors and cognition. She stated the entire Interdisciplinary Team (IDT) could update the care plan. She stated she was aware of the incident between Resident #47 and Resident #161. The MDS Coordinator revealed she did not update Resident #47's care plan, however she would expect to see care plans updated with what was going on for a resident. She stated Resident #47's care plan did not reflect sexual contact with another resident, only that he/she exposed himself/herself in a common area. She further stated when staff conducted Resident #47's one (1) hour safety checks, they checked if the resident was okay, if he/she was agitated, and if the resident needed anything. Interview, on 06/14/2021 at 1:14 PM, with the DON revealed the purpose of Resident #47's one (1) hour safety checks was to look for anything that may pose a safety threat to the resident or other residents, such as falling, wandering into other resident rooms, elopement, or go anywhere there was a potential for injury. She stated the facility used agency nurses and CNAs. The DON revealed the one (1) hour safety checks did not specifically have to be related to sexual behaviors, and staff did not look for any one (1) certain thing. She stated Social Services was responsible for the resident's care plan related to behaviors. She further stated the IDT reviewed care plans anytime there was a change in status. Interview with the Administrator, on 06/14/2021 at 1:53 PM, revealed the purpose of Resident #47's one (1) hour safety checks was to ensure he/she did not exhibit any behaviors that might have needed to be reported. On 06/15/2021 at 3:58 PM, interview with the ADON revealed the care plan for Resident #47 should have been updated to include sexual contact with another resident. She stated the purpose was so all staff would be aware to look for signs and symptoms and intervene as necessary. She further stated they were all responsible to update the care plan. The ADON revealed if the care plan was not updated to reflect Resident #47 had sexual contact with another resident, he/she could expose himself/herself to another resident, or touch another resident. 3. Review of the clinical record revealed the facility admitted Resident #32 on 02/22/2019. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed the resident, 02/18/2021, with a Brief Interview Mental Status (BIMS) of fifteen (15). Review of Resident #32's care plan for risk of falls, initiated on 03/07/2019, revealed interventions that included keep the call light in reach and encourage resident to use it for assistance, gripper tape next to the bed, gather information on past falls and attempt to determine the root cause of the fall, and intervene to prevent reoccurrence. The care plan for ADL self-care deficit, dated 03/07/2019, noted the resident ambulated independently and an intervention to provide assistance with mobility as needed. An additional intervention, dated 01/20/2020, included supervision - set-up for transfers, and the resident used bi-lateral ½ bed side rails for positioning related to muscle weakness and chronic pain. Review of a facility incident report, dated 02/25/2021, revealed Resident #32 fell when he/she reached for items on the nightstand and was on the floor next to his/her bed. The resident thought he/she lost his/her balance when he/she reached for the items, and the facility educated the resident on the importance and safety to utilize the call light for

Based on observation, interview, and record review it was determined the facility failed to ensure two (2) of one hundred thirteen (113) residents received medically related social services related to assessment for a resident's capacity to consent to sexual contact with others. On 03/19/2021, Resident #47 and Resident #161 engaged in sexual contact with each other. At the time of the incident, the facility did not have a full time Social Worker to ensure Resident #47 and Resident #161 were assessed to determine his/her capacity to consent. The facility utilized a contracted social worker approximately one (1) day per week. Additionally, the facility failed to inform the contracted social worker of the sexual contact that occurred between Resident #47 and Resident #161. Immediate Jeopardy was identified on 05/17/2021 and determined to exist on 03/19/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free From Abuse and Neglect at S/S of J and F607 Develop/Implement Abuse/Neglect, etc. Policies at S/S of J, 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision at S/S of J, 42 CFR 483.40 Behavioral Health, F745 Provision of Medically Related Social Services at S/S of J, and 42 CFR 483.70, Administration, F835 Administration at S/S of J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12, F600 Free from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect, etc. Policies, and 42 CFR 483.40, F745 Provision of Medically Related Social Services. The facility was notified of the Immediate Jeopardy on 05/17/2021. The facility failed to ensure residents were free from abuse. On 03/19/2021 Resident #47 and Resident #161 were in the dining room/dayroom common area without staff in the room and the lights off. Certified Nurse Aide (CNA) #36 entered the room and found Resident #16'w hand on Resident #47's exposed genitalia. The facility failed to assess the residents for capacity to consent to sexual contact. An Extended Survey and AoC validation Survey were conducted 06/30/2021 through 07/03/2021 and determined the facility implemented the AoC as alleged by 06/27/2021, prior to exit on 07/03/2021, with remaining non-compliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 Free from Abuse and Neglect at S/S of D, F607 Develop/Implement Abuse/ neglect, etc. Policies at S/S of D, 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision at S/S of D, 42 CFR 483.40 Behavioral Health, F745 Provision of Medically Related Social Services, F745 at S/S of D, and 42 CFR 483.70 Administration, F835 Administration at S/S of D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of Social Services Aide job description, not dated, revealed the Aide reported to the Director of Social Services and assisted in planning, developing, organizing, implementing, evaluating, and directing social service programs. The Aide must assure medically related emotional and social needs of the resident were met/maintained on an individual basis. Additionally, the Aide safeguarded the health, safety, and welfare of all residents of the facility. The Aide was delegated responsibility to carry out assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Review of the Consulting Services Agreement, effective 01/01/2021, revealed the contracted group provided assistance, consultation, and training. Consultation services were provided onsite, remotely, via telephone, fax, and email to the facility. Consultants were qualified by education, experience, training, professional licensure and/or certification. Services included Social Service Consultation and Social Service Interim. Review of the Assessments policy, dated 08/2017, revealed assessments were completed when an event occurred that required an assessment by a qualified medical professional. An example of an assessment based on the event included Post Behavior. Nurses and other qualified health professionals would perform appropriate assessments of the resident. The facility did not provide a policy related to resident consent for sexual contact with others. 1. Review of the clinical record for Resident #161 revealed the facility readmitted the resident on 10/09/2017. The resident's diagnoses included [CONDITION(S)] with Behavioral Disturbance, Cognitive Communication Deficit, and Cerebral Infarction. Review of the Durable Power of Attorney (POA), dated 10/04/2021, for Resident #161 revealed the resident authorized his/her POA to take charge of the resident in case of sickness or disability. Review of a facility investigation revealed Resident #161 engaged in sexual contact with another resident, on 04/05/2019, in a common area. Resident #161's Brief Interview Mental Status (BIMS) of three (3), and the resident severely cognitively impaired. Review of Resident #161's care plan revealed the facility initiated a care plan for reaching out for others, on 04/06/2019, with an intervention to intervene as necessary to protect the rights and safety of others, and discuss the resident's behavior. Review of a Geriatric Visit note revealed the Nurse Practitioner saw Resident #161, on 01/20/2021. The NP note revealed the resident had memory loss and chronic confusion, oriented to person only, and had advanced dementia. Review of a Psychology Progress note for Resident #161, dated 01/26/2021, revealed the resident was moderately impaired for comprehension, executive function, insight, and judgement. The resident had impairment to memory, orientation, and rarely made decisions for him/herself. A Psychology Progress note, dated 03/09/2021, revealed Resident #161 had memory deficits immediate, recent, and remote. The resident was moderately impaired in comprehension, executive function, insight, and judgement. Review of a quarterly Minimum Data Set (MDS) for Resident #161, dated 03/16/2021, revealed the facility assessed the resident with a BIMS of eleven (11), and moderately impaired. Review of the facility incident report revealed Resident #47 stood by Resident #16, with his/her genitalia exposed. Resident #161 was unable to verbalize if anything occurred. Review of the care plan for Resident #161 revealed, on 03/19/2021, an intervention added not to leave the resident alone in the dayroom. Review of a Psychology Progress note, dated 03/23/2021, revealed Resident #161 was moderately impaired for comprehension, executive function, insight, and judgement. The resident did not endorse memory of the recent behavior and, due to dementia, the resident did not have capacity to make major decisions, including consent for relationships with other residents. Observation, on 05/06/2021 at 2:23 PM, revealed Resident #161 in a geri-chair at the nurse's station on the fourth floor. Attempted interview, on 05/06/2021 at 2:23 PM, revealed Resident #161 did not respond to the State Survey Agency (SSA) surveyor. 2. Review of the clinical record for Resident #47 revealed the facility admitted the resident on 06/11/2020. The Resident diagnosed with Personal history of [CONDITION(S)] (TIA), Cerebral Infarction without residual effects, and Dementia with Behavioral Disturbance. Review of the care plan, dated 08/03/2020, for Resident #47 revealed the resident had episodes of verbal aggression toward another resident. Interventions, dated 08/03/2020, included assess resident understanding of the situation, and psychiatric consult as indicted. Additional intervention added, on 02/10/2021, included redirect as needed. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #47 with a Brief Interview Mental Status (BIMS) of seven (7), and severely cognitively impaired. The resident required supervision for transfers, and one (1) person assistance for locomotion on the unit. Review of a Psychiatry Progress note, dated 03/19/2021, revealed the resident had Dementia, was confused, and insight was impaired. The note documented the resident was oriented to person, place, and situation this day. The resident was severely impaired in executive function, insight, and judgement. Resident #47 had a memory deficit recent, and memory deficit remote. Review of a facility incident report, dated 03/19/2021 at 10:03 PM, revealed Resident #47 was seen with his/her exposed genitalia, standing in front of Resident #161. Resident #161 was unable to verbalize what occurred. Resident #47 stated he/she came from the bathroom and forgot to zip his/her pants. The facility immediately placed Resident #47 on one to one (1:1) supervision with staff. Review of the Psychology Report, dated 03/22/2021, revealed Resident #47 had a diagnosis of [CONDITION(S)] and recent cognitive impairment. Facility staff requested follow up, and reported the resident was recently discovered to have his/her private area out in front of another resident in the common room. The resident was moved to another floor. Resident #47 stated nothing occurred in the common room with the other resident. The note further revealed the resident's comprehension, executive function, insight, and judgement were noted Severe Impairment. The note documented the resident has memory deficit, both recent and remote. The resident did not endorse he/she made any advances toward the other resident. Further review of Resident #47's care plan revealed an intervention added, on 03/24/2021 and discontinued on 06/11/2021, for the resident to remain on one (1) hour safety checks. Observation of Resident #47, on 04/28/2021 at 2:04 PM, revealed the resident sat in a chair with a cell phone in his/her doorway on the third floor. Interview with Resident #47, on 04/28/2021 at 2:04 PM, revealed no other residents had touched him/her inappropriately. Interview, on 04/30/2021 at 1:00 PM, with Social Service Designee #1 revealed she interviewed other residents as part of the facility investigation of the sexual contact between Resident #47 and Resident #161. She stated she asked residents if they felt safe, if anyone tried to hurt him/her or see anyone get hurt, and if the resident knew who to go to if he/she was hurt by someone. She stated the facility completed three (3) day follow up with residents involved in the reportable incident to see how the resident was doing. She revealed she completed the three (3) day follow up visits with Resident #47, who did not say much to her. Additionally, the Designee stated she completed the three (3) day follow up visits with Resident #161. Designee #1 revealed she was unaware of what happened between Resident #47 and Resident #161. She further revealed Resident #161 could do better on his/her BIMS score on one (1) day but not as well on another day. She stated Resident #161 had some impairment. On 04/30/2021 at 2:06 PM, interview with the Assistant Director of Nursing (ADON) revealed Resident #47 told her nothing happened, and Resident #161 said Resident #47 tied his/her show. The ADON stated both residents were cognitively impaired. She revealed social services department interviewed other residents, and followed up with Resident #47 and Resident #161 daily to determine if the resident had any emotional needs or psychological issues. Interview with the Physician, on 06/03/2021 at 9:17 AM, revealed Resident #47 and Resident #161 were both cognitively challenged. He stated Resident #47 had cognitive impairment, and Resident #161 had Dementia. He revealed neither resident was able to make decisions to engage on sexual behavior with another. Continued interview with the ADON, on 06/03/2021 at 9:44 AM, revealed if a resident's BIMS was high enough or the responsible party was okay with it, a resident could have sexual relations with another person. She stated Resident #47 and Resident #161 both had higher BIMS, and was high enough to consent to sexual contact. The ADON revealed she was unsure if Resident #161's POA gave permission for the resident to engage in a sexual relationship. She stated Resident #161 had fluctuated periods of confusion. Interview, on 06/03/2021 at 1:30 PM, with Resident #161's POA revealed functioned in the capacity of POA since 2011. She stated Resident #161 was not able to say he/she wanted to be in a relationship and was not able to make his/her own decisions. The POA further stated she did not think Resident #161 would remember what happened. On 06/04/2021 at 2:12 PM, interview with Social Service Designee #2 revealed the assessment used to determine if a resident was capable to give consent was the BIMS. She stated she completed the BIMS for Resident #47 and Resident #161 after the incident. Interview with the Administrator, on 06/04/2021 at 4:52 PM, revealed no one assessed if Resident #161 wanted to be in a sexual relationship or have sexual contact. She stated the facility did not ask residents if they had a need or urge for sex. The Administrator revealed A BIMS between eight (8) and twelve (12) was moderately impaired. She further revealed a resident with a BIMS between eight (8) and twelve (12) may not know the month, or year, however the resident was still capable to make decisions. She stated the facility did not have a resource of what moderately impaired meant. She also stated the residents were able to make decisions based off their BIMS scores. Continued interview with Social Service Designee #2, on 06/08/2021 at 9:16 AM, revealed she asked the psych provider to see Resident #47 and Resident #161 after the incident. She stated she could not recall his report to her about the residents. Designee #2 further stated psych emailed her their reports, she printed and read them, and gave them to the Unit Managers to read and file in the chart. She revealed she did not believe the psych report for Resident #161, dated 03/23/2021, that the resident did not have capacity to give consent. Designee #2 stated if Resident #161's BIMS was below eight (8) theny would know he/she was impaired. Interview with the Psychologist, on 06/08/2021 at 3:21 PM, revealed he saw Resident #47 and Resident #161 after the incident. He stated Resident #161 was moderately cognitively impaired and not able to make decisions. He revealed he believed he shared with the facility social services department that Resident #161 was not able to consent in a sexual relationship. Interview, on 06/11/2021 at 8:34 AM, with the Administrator revealed the facility used a consultant company at the time of the incident between Resident #47 and Resident #161 to fulfill the duties of the social services director. She stated the consulting company was unaware of the incident. On 06/11/2021 at 9:13 AM, interview with Social Services Consultant #1 revealed her organization provided consultant services to the facility for social services in the role of the interim Social Services Director. She stated the Social Services Designees with the facility we able to provide all social services duties and there was nothing Designee #2 could not do as long as her agency provided oversight. Consultant #1 revealed her agency assisted the facility when the facility was without a social services director. She further revealed her agency helped with care plan meetings, behavior management meetings, and BIMS assessments. Additional interview with Social Service Designee #2, on 06/11/2021 at 9:55 AM and 10:15 AM, revealed when there was not a social service director, she completed the duties of the office. She stated the social services consultant was in the building once a week and available by phone. Designee #2 revealed she informed the Social Services Consultant #2 about the incident between Resident #47 and Resident #161, however she could not recall when she informed the consultant. She stated the consultant did not provide any direction regarding the two (2) residents, and no one asked her to determine if either resident gave consent. She further stated she did not assess if Resident #161 was aware of or had knowledge of risks and benefits of sexual contact with others. Designee #2 stated she took direction from Consultant #2. Interview with the ADON, on 06/11/2021 at 10:21 AM, revealed she did not ask Resident #161 if he/she was aware of the risks and benefits of sexual contact with others and did not know who would be responsible. On 06/11/2021 at 11:31 AM, interview with the DON revealed she based on Resident #47 and Resident #161 cognitive levels they should know the risks and benefits of sexual contact, and their cognitive levels let them decide if they want to engage or not. She revealed each state may have differences how to assess if a resident was aware of the risks and benefits of sexual activity, and was unsure of Kentucky's requirement. She stated the facility used the CMS guidelines and the court was responsible to determine capacity to consent as his/her rights as a human being were still in full effect. Interview, on 06/11/2021 at 11:45 AM, with the Administrator revealed there was no risk or benefit to sexual touching as Resident #47 and Resident #161 were both able to make his/her own decisions based on their BIMS scores. Interview with Social Services Consultant #2, on 06/15/2021 at 8:48 AM, revealed she was a social service consultant to the facility and was the main contact when the facility needed help. She revealed she usually delegated to the facility designees anything they could do. Consultant #2 stated the facility did not inform her what happened between Resident #47 and Resident #161. She revealed the facility informed her it was investigated and there was nothing to share. Consultant #2 stated a resident was determined for capacity to consent through the BIMS score, then if unsure refer the resident to psych for a third party evaluation of how the resident thought things through, his/her mental status, and if there may have been any medical issues that could have affected the resident's cognition. The facility took the following actions: 1. A licensed social worker reviewed Resident #47 and Resident #161's medical records, on 06/17/2021, and on 06/23/2021 when the social worker also visited with the residents [NAME]-to-face. Review of medical records included assessments for capacity to consent to sexual contact with another consenting adult. 2. Social services reviewed all resident medical records, by 06/24/2021 for all social service related assessments were reviewed and new assessments completed if indicated. Resident care plans and CNA assignment sheets were revised and updated. 3. New admission and re-admissions would have social service related assessments completed within fourteen (14) days, with care plans completed based on results of assessments. CNA assignment sheets would be updated as indicated. If further assessments was needed by another outside provider, the need would be reflected on the care plan and the resident seen. 4. The DON/ADON/Designee monitored ten (10) resident medical records five (5) days a week for three (3) months, then weekly for six (6) months, on a rotating basis and included new admissions and re-admissions to ensure assessments and care plans were completed by social services. 5. At the CQI meeting progress notes reviewed that prompted a social services assessment would be listed. Social services would complete the assessment and care plan and report back to the IDT. 6. Beginning 06/21/2021, all staff were trained by the DON, ADON, or designee on the abuse policy, resident rights, the role of the social services designee, when to refer a resident/family member, or visitor to social services, and how staff could assist the designee to meet resident needs. A post-test required 100% for passing grade. The RDO trained the trainers, on 06/17/2021. 7. A regional team member would review the social services assessments weekly for three (3) months. 8. Monitoring results by the DON, ADON, designee, and RDO related to social services assessments were presented to the QAPI committee weekly, then monthly. A regional team member would attend QAPI meetings weekly, then monthly for three (3) months. The State Survey Agency (SSA) validated the following: 1. Review of a Progress Note for Resident #47 and Resident #161, dated 06/23/2021, revealed the Social Service Director (SSD) reviewed the resident chart on 06/17/2021 and 06/23/2021, with BIMS assessments completed and care plans reviewed. Interview with the Assistant Director of Nursing (ADON), on 07/03/201 at 4:19 PM, revealed social services monitored the medical records for Resident #47 and Resident #161. On 07/03/2021 at 6:17 PM, interview with the Administrator revealed social services reviewed medical records for Resident #47 and Resident #161, and conducted a face-to-face with both residents. 2. Review of resident care plans revealed twenty-two (22) resident care plans were updated on 06/25/2021. On 07/03/2021 at 6:17 PM, interview with the Administrator revealed the Social Services Director (SSD) reviewed resident medical records for social service assessments and new assessments were completed. She stated the SSD updated resident care plans and the CNA information. 3. Interview, on 07/03/2021 at 4:19 PM, with the ADON, on 07/03/2021 at 5:35 PM, with the DON, and on 07/03/2021 at 6:17 PM, with the Administrator revealed new admission and re-admission residents would have social services assessments completed within fourteen (14) days, care plans and CNA information updated, and if needed an outside provider would evaluate the resident. 4. Review of the audit calendar tool, from 06/28/2021 through 07/01/2021, revealed ten (10) resident records reviewed each day. Interview with the ADON, on 07/03/2021 at 4:19 PM, and the DON, on 07/03/2021 at 5:35 PM, revealed she participated in monitoring ten (10) medical records five (5) days a week, to continue for three (3) months, and then ten (10) records weekly for six (6) months for completion of the resident assessment and the care plan updated. 5. Interview, on 07/03/201 at 6:17 PM, with the Administrator revealed the Clinical Quality Indicator (CQI) meeting reviewed residents Monday through Friday for any needed assessments, admissions, and care plan updates. 6. Review of a QAPI Committee Meeting Minutes, dated 06/17/2021, revealed the Administrator, DON, ADON, and the RDO by phone, discussed CMS guidelines, policies, and procedures to train staff with a post-test. Review of post-tests and training materials revealed the facility trained one hundred seventy-one (171) staff in the following departments: housekeeping, laundry, dietary, maintenance, nursing, social services, admissions, central supply, smoke monitors, and reception. Seventeen (17) staff needed to be trained, and were on leave or PRN status. Fifteen (15) therapy staff and forty-four (44) agency staff were trained. Interview with Receptionist #2, on 07/02/2021 at 10:48 AM, Unit Manager (UM) #1, on 07/02/2021 at 10:54 AM, the Cook, on 07/02/2021 at 11:13 AM, Laundry Aide #3, on 07/02/2021 at 11:19 AM, Customer Service Representative, on 07/02/2021 at 11:24 AM, Housekeeper #4, on 07/02/2021 at 11:31 AM, Certified Nurse Aide (CNA) #38, on 07/02/2021 at 11:37 AM, Occupational Therapist (OT) #1, on 07/02/2021 at 11:47 AM, the Unit Secretary, on 07/02/2021 at 11:56 AM, House Supervisor #3, on 07/03/2021 at 3:22 PM, Licensed Practical Nurse (LPN) #3, on 07/03/2021 at 3:49 PM, LPN #43, on 07/03/2021 at 3:53 PM, CNA #56, on 07/03/2021 at 4:03 PM, CNA #43, on 07/03/2021 at 4:11 PM, revealed they were trained recently on abuse, resident rights, the role of social services and designees, when to refer a resident or family, visitor to social services, and how staff could assist social services department to meet resident needs. Interview with the ADON, on 07/03/2021 at 4:19 PM, the DON, on 07/03/2021 at 5:35 PM, and the Administrator, on 07/03/2021 at 6:17 PM, revealed they were trained by the RDO on 06/17/2021, and they then trained staff, beginning 06/21/2021, with a post-test requirement of 100% to pass. 7. Interview with the ADON, on 07/03/2021 at 4:19 PM, with the DON, on 07/03/2021 at 5:35 PM, and with the Administrator, on 07/03/202 at 6:17 PM, revealed the Regional Director of Operations (RDO) reviewed social services assessments weekly for three (3) months. Interview, on 07/03/2021 at 6:20 PM, with the RDO revealed she conducted weekly reviews of assessments either in person or by phone, for three (3) months. 8. Review of QAPI sign in sheets and discussion notes, dated 06/24/2021 and 07/01/2021, revealed audits reviewed related to resident assessments by social services. On 07/03/2021 at 4:19 PM, interview with the ADON and, on 07/03/2021 at 5:35 PM, interview with the DON, and on 07/03/2021 at 6:17 PM, with the Administrator revealed audits for assessments by social services, included capacity to consent, BIMS, questionnaire, were reviewed in QAPI weekly, then monthly. She stated the RDO and Medical Director participated in the QAPI meetings, either in person or by phone. Interview with the RDO, on 07/03/2021 at 6:20 PM, revealed she participated by phone or in person to the weekly meetings, then monthly for three (3) months. Surveyor [NAME] Based on interview, record review and review of the facility's policy it was determined the facility failed to provide medically related social services to attain and maintain the highest practicable well-being for one (1) of one-hundred and nineteen (119) sampled residents, Resident #87. Review of Resident #87's Comprehensive Care Plan last reviewed on 09/01/2021, revealed the care plan had not been updated to incorporate behaviors, increased supervision and monitoring of the resident. Additionally, psychological notes and recommendations were not followed. Review of the facility's policy and procedure, titled Social Service Behavioral Monitoring undated, revealed the Social Service Director (SSD) or Designee would review the twenty-four (24) hour Nursing Report and/or Behavioral Occurrence forms daily. The review of notes would be done prior to the morning Department Head meeting. The team would discuss events with the management team and attempt to identify the root cause and need for reassessment and/or new interventions to address the problem. Facility policy revealed it was the responsibility of the SS team to review residents' notes and determine if any new behaviors were present. Additionally, it was the Social Services (SS) team's responsibility to immediately implement any new interventions when concerns were identified. Continued review of the Social Service Behavioral Monitoring policy, revealed the SS designee would update the care plan with new interventions. When new interventions were documented it was the responsibility of the SS designee to ensure initiated dates were included in the care plan. Review of Resident #87's clinical record revealed the facility admitted the resident on 07/09/2019, with diagnoses of Alzheimer's Disease, Dementia with Behavioral Disturbances, Anxiety, Major depressive disorder, and Cognitive communication deficit. Interviews with LPN #2, LPN #3, LPN #5, LPN #40, LPN #46, Unit Manager (UM) #1, and Social Service Designees #1 and #2 revealed Resident #87 had a history of wandering into other residents' rooms, took items from other residents' rooms, and got in other residents' beds. Review of Resident #87's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), and determined the resident was not interviewable. Resident #87 was assessed for bed mobility, transfers, walk in room, walk in corridor, locomotion on the unit and off unit and to eat as supervision-oversight, encouragement and cueing with the assistance of one (1) staff member. Resident was assessed as two (2) staff physical assist to get dressed and for personal hygiene. Continued review of the Resident #87's MDS assessment, dated 06/13/2021, revealed the resident was not steady on his/her feet but could stabilize without staff assistance to move from a sitting to standing position, to walk, could turn around, move on and off the toilet, and could transfer from surface-to-surface. Resident #87 was not noted to have any upper or lower body extremity impairments. Resident #87 did not require the use of any mobility devices. The resident was noted to be frequently incontinent of bladder and always incontinent of bowels. Review of Resident #87's Comprehensive Care Plan, last reviewed on 09/01/2021, revealed the facility care planned the resident for wandering behaviors on 07/10/2019. Resident was documented to have episodes in which he/she entered other resident's rooms, took other resident's personal property, attempted to undress other residents, sit on other residents if he/she wanted to sit where they sat, and the resident used other resident bathrooms or defecated in their sinks. Additionally, the care plan revealed Resident #87 had a history of getting in female, male and empty beds which was documented on 07/10/2019 without revision. Per Resident #87's care plan, last reviewed on 09/01/2021, the interventions listed for the resident's wandering behavior included: allowing the resident to make choices about treatment; providing a sense of control (Initiated 07/10/2019, no revisions); and giving clear explanation of all care activities (Initiated 07/10/2019, no revisions). If Resident #87 refused Activities of Daily Living (ADLs) staff was to reassure the resident, leave and return in five (5) to ten (10) minutes, and try again (Initiated 07/10/2019, no revisions). Additionally, staff was to check on the resident frequently and meet needs in a timely manner, (with an initiation date 04/02/2021). Resident #87's care plan also revealed staff was to offer immediate education and redirection of possible outcomes for not complying with treatment or care as needed and staff were to the provide the resident with opportunities to make choices during care (Initiated 07/10/2019). On 12/27/2019, another intervention for wandering was added; redirect resident as needed. Interview with Certified Nursing Assistant (CNA) # 1 on 09/29/2021 at 4:00 PM, revealed Resident #87 wandered all of the time and got into bed with other resident's and if the other resident's did not know any better, they did not say anything and do not care. CNA #1 revealed she has told management on several occasions this facility may not be the best fit for this resident. Interview with CNA #58 on 10/03/2021 at 2:53 PM, revealed she had physically witnessed Resident #87 in bed with male and female residents all the time. She revealed she always reported this information to the nurse on duty, but everybody knows he/she gets in everybody's bed. Interview with Certified Medication Technician (CMT) #5 on 10/03/2021 at 9:26 AM, revealed she had physically found Resident #87 in bed with both male and female residents and resident would just be asleep. She also revealed she always let the floor supervisor know about these events. CMT #5 revealed she referred to Resident #87 as a team project. She revealed she told the staff who worked with her, Resident #87 had to be watched at all times, checked and changed frequently. Interview with Licensed Practical Nurse (LPN) #2 on 09/30/2021 at 2:05 PM, revealed she had worked at the facility for three (3) months. She revealed Resident #87 liked to wander and that he/she liked to cuddle with anybody in bed. LPN #2 revealed on this day she had taken Resident #87 to his/her bed and went back fifteen (15) minutes later to give resident medication and resident was not there. LPN #2 went to look for resident and found him/her in room 701, in an unoccupied bed with his/her eyes closed. The resident in room 701 was in his/her bed as[TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of repeated deficient practice citations, it was determined the facility failed to have effective administration responsible for establishing and implementing policies regarding the management and operation of the facility. This was evidenced by the facility being cited on 12/06/2019 for F584, F600, F656, F657, F689, F761, and F880; on 11/08/2020 for F656, and F689; and current citations including F584, F600, F656, F657, F689, F761, and F880. Record review and interview revealed the facility failed to ensure residents were free from abuse and ensure resident behaviors were addressed; failed to ensure residents' care plans were developed, revised and implemented; failed to ensure the facility was safe, comfortable, and supervised for residents, and medications were labeled and stored accordingly. The facility's failure to provide an effective administration responsible for establishing and implementing policies regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F607, at a scope and severity of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657, at a scope and severity of a J; 42 CFR 483.40 Behavioral health Services, F745, at a scope and severity of J; 42 CFR 483.70 Administration, F835, at a scope and severity of a J; and, 42 CFR 483.75 Quality Assurance and Performance Improvement, F867, at a scope and severity of a J. The Immediate Jeopardy was determined to exist on 03/17/2021 and the facility was notified of the Immediate Jeopardy on 06/17/2021. Substandard Quality of Care (SQC) was identified in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.40 Behavioral Health Services, (F745). The facility provided an IJ Removal Plan on 06/27/2021, alleging removal of the Immediate Jeopardy on 06/27/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 06/27/2021, as alleged, prior to exit on 07/03/2021, with remaining non-compliance at a Scope and Severity of a G while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. Additional repeat deficiencies, from the 12/06/2019 recertification survey, were identified in the areas of 42 CFR 483.10 Resident Rights, (F584); 42 CFR 483.45 Pharmacy Services (F761); and 42 CFR 483.80 Infection Control (F880). The findings include: Review of the Administrator Job Description, not dated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations and company policies/procedures to maintain quality care for residents. The Administrator worked with facility management staff and consultants in planning all aspects of facility operations. The Administrator monitored each department's activities, evaluated performance, and monitored operations of all departments, cleanliness and appearance of the facility. He/she ensured the facility appropriately utilized consultants and other support resources, and maintained a working knowledge and ensured compliance with all governmental regulations. The Administrator ensured adequate staffing through appropriate orientation, training, and staff education. Furthermore, the Administrator ensured maintenance of the building and grounds and equipment, and that work areas were clean, safe, and orderly. The Administrator ensured infection control, isolation, and sanitation practices and procedures were followed. Review of the Director of Nursing (DON) Job Description, not dated, revealed under the direction of the Administrator the DON had authority, responsibility, and accountability for the functions, activities, and training of nursing services staff. The DON demonstrated knowledge and skills necessary to care for residents with needs for dementia, infectious disease, and therapeutic needs. The DON conducted periodic review to ensure the environment was clean. He/she conducted periodic reviews of care plans to ensure they were interdisciplinary and updated by the charge nurse daily as changes occurred. He/she ensured all nursing personnel followed established hand-washing procedures and possessed strong knowledge of state, federal, and local regulations as they pertain to long-term care. Interview with Administrator, on 06/17/2021 at 3:32 PM, revealed she reported to the Regional Director of Operations (RDO). She further revealed the RDO interviewed and hired her into the role as the administrator. The RDO was whom she reported to and who provided the Administrator the onboarding process for the facility. She further stated she has been in long-term care; she was responsible for the functioning of the facility. Continued interview with the Administrator, revealed the purpose for the plan of correction (POC) was to correct deficient practice and not continue with repeat allegations of the same deficient practices. She revealed if an identified area of concern occurred, then the facility developed a new plan, or perhaps put an old plan back in place. She further revealed difficulty with staffing to meet the needs of the residents and sure, things have fell through the cracks. She revealed the prior sitting administrator identified all of the deficiencies as cleared; therefore, she stated she did not review the prior plan of correction. Telephonic interview with the Regional Director of Operation, on 07/01/2021 at 3:28 PM, revealed the facility was a Limited Liability Company (LLC) with the administrator responsible for the facility. Interview with the Center Nurse Executive (CNE), on 05/11/2021 at 11:25 PM, revealed she worked at the facility since 10/13/2020. Per interview, she stated she was aware of the repeated deficiencies of F600, F656, F657, and F740. The CNE further stated she did not discuss the outcomes of the audits as per the POC; she was aware staff did not complete the rounds frequently on the Memory care unit and facility staffing was discussed; however, there were no concerns identified. The facility took the following actions: 1. The administrator and Interdisciplinary Team (IDT) would ensure its resources were used, including operating budget, staff, supplies, or other services necessary to provide care to residents. 2. A regional team member would review the available resources with the Administrator, and included outside providers such as the Regional Director of Operations (RDO), Regional Nurse Consultant, and Social Services Consultant. MDS Consultant, and any other ancillary staff who could assist in maintaining services and/or assist that required assessments were completed, care plans completed. 3. The RDO monitored weekly for three (3) months, then at least bi-weekly, to ensure the Administrator had all needed ancillary or support staff available to ensure residents were successfully cared for and needs met. 4. The RDO in-serviced the Administrator and IDT, on 06/17/2021, to the facility's resources, including CMS guidelines, policies and procedures, administrator reference manual, various consultants, and risk management. Also included resident capacity to consent and care plan updates. 5. The RDO's monitoring that the facility had all needed resources would be presented to the COO monthly. 6. An Ad-hoc QAPI meeting was conducted, on 06/18/2021, with the Administrator and IDT to review and implement the AOC. A full QAPI meeting was held on 06/24/2021. Education began 06/18/2021. The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the Administrator and Director of Nursing (DON), on 07/02/2021 at 2:35 PM, revealed the Administrator and Interdisciplinary Team (IDT) would ensure the facility's resources were used. 2. Review of Audit Tool #6 revealed, on 07/01/2021, the RDO educated the Administrator on outside resources available, policies and procedures, all ancillary support available with assigned nurse consultant out and coverage maintained by other RNC, resident needs were met and no issues identified. On 07/02/2021 at 2:35 PM, interview with the Administrator and DON revealed the Administrator and IDT were educated to ensure the facility's resources were used. Interview with the Regional Director of Operations (RDO), on 07/03/2021 at 6:20 PM, revealed she reviewed the budget, the available resources to include the Regional Nurse Consultant, the MDS Consultant, Social Services Consultant, and Risk Management, and agency or contracted support, and the Administrator's Reference Manual. 3. Interview with the Administrator and DON, on 07/02/2021 at 2:35 PM, revealed the RDO completed audits the facility used its resources. Interview, on 07/03/2021 at 6:20 PM, with the RDO revealed she monitored weekly followed by bi-weekly audits to ensure the facility resources were available. 4. Review of a QAPI Committee Meeting Minutes and sign in sheet, dated 06/17/2021, revealed the Regional Director of Operations (RDO) in-serviced by phone the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Administrator regarding resources of the CMS guidelines, consultants, administrator reference manual, risk management, policies and procedures, and care plans. Interview with the Administrator and the Director of Nursing (DON), on 07/02/2021 at 2:35 PM, revealed the RDO reviewed the budget, available consulting services, such as the Regional Nurse Consultant, the MDS Consultant, Social Services Consultant, and Risk Management, and agency or contracted support. On 07/03/2021 at 6:20 PM, interview with the RDO revealed she reviewed with the Administrator, DON, and SSD on the facility's available resources and any staff who failed to comply with the in-service information provided would be further educated or progressively disciplined. 5. Review of Audit #4 revealed on 07/01/2021 the RDO reviewed all audits and noted review of resources, to determine consent, with psych and physicians completed, education completed, and policies, procedures, and audits were updated. Interview, on 07/03/2021 at 6:20 PM, with the RDO revealed she submitted her monitoring data to the COO monthly. 6. Review of a sign in sheet for the combined form for Morning Meeting Stand-Up and Afternoon Meeting Stand Down, revealed an Ad-hoc QAPI at stand down, dated 06/18/2021, noted IJ in-services related to consent, develop practices for sexual consent, and what tools to use. Review of QAPI Committee Meeting Minutes sign in sheet, dated 06/24/2021, revealed noted corrective action audits, education and post-test, sexual consent, resident rights, and resources. The RDO participated by phone, and the Medical Director participated. Interview, on 07/02/2021 at 2:35 PM, with the Administrator and DON, revealed an Ad-hoc QAPI meeting met on 06/18/2021, and QAPI also met on 06/24/2021, to review development and progress, and included the RDO by phone on 06/18/2021. Interview with the RDO, on 07/03/2021 at 6:20 PM, reviewed an Ad-hoc QAPI meeting was conducted on 06/17/2021, and met on 06/24/2021, and discussed abuse, resident rights, and education.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to address systerm failures through regular scheduled Quality Assurance Performance Improvement (QAPI) meetings. The facility failed to identify quality of care deficiencies, and failed to take actions aimed at performance improvement to ensure improvements were realized and sustained. This is evidenced by repeated deficient practice cited at 42 CFR 482.10 Resident Rights (F584); 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 and F657); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.45 Pharmacy Services (F761); and 42 CFR 483.80 Infection Control (F880). These deficiences were cited during the 12/06/2019 recertification survey. Record review revealed the facility failed to ensure residents were free from abuse and failed to ensure residents' behaviors were addressed; failed to ensure residents' care plans were developed, revised and implemented; and, failed to ensure the facility was effectively managed with an effective quality assurance program to maintain substantial compliance. (Refer to F600, F656, F657, F689, F761, and F880). The facility's failure to provide an effective Quality Assurance Performance Improvement (QAPI) Program responsible planning, developing, implementing, amd maintaining an effective, comprehensive, and data driven program in accordance with Federal Guidelines focused on indications of outcomes in the facility has caused or is likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation, F600 and F607, at a scope and severity of a J; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657, at a scope and severity of a J; 42 CFR 483.40 Behavioral health Services, F745, at a scope and severity of J; 42 CFR 483.70 Administration, F835, at a scope and severity of a J; and, 42 CFR 483.75 Quality Assurance and Performance Improvement, F867, at a scope and severity of a J. The Immediate Jeopardy was determined to exist on 03/17/2021 and the facility was notified of the Immediate Jeopardy on 06/17/2021. Substandard Quality of Care (SQC) was identified in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.40 Behavioral Health Services, (F745). The facility provided an IJ Removal Plan on 06/27/2021, alleging removal of the Immediate Jeopardy on 06/27/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 06/27/2021, as alleged, prior to exit on 07/03/2021, with remaining non-compliance at a Scope and Severity of an G while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. Additional repeat deficiencies, from the 12/06/2019 recertification survey, were identified in the areas of 42 CFR 483.10 Resident Rights, F584 at a scope and severity of a E; 42 CFR 483.45 Pharmacy Services (F761) at a s/s of E; and 42 CFR 483.80 Infection Control (F880), at a s/s of E. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and Plan, version dated 2017, revealed the mission of the QAPI plan was to develop, implement, and maintain an effective, comprehensive, and data driven QAPI Program in accordance with Federal Guidelines focused on indicators of outcomes of quality of care (QOC) and quality of life (QOL) for the residents. The comprehensive and ongoing program addresses the full range of care and services provided by the facility including all systems of care and management practices, clinical care, QOL and resident choices. Utilization of the best available evidence defining and measuring indicator of quality and facility goals reflecting the processes of care and facility operations predictive of the desired outcomes. In addition, the program reflects the complexities, the unique care and services provided by the facility. The plan describes the processes, systems and reports guiding the facility's efforts to ensure care and services maintained at acceptable levels of performance and ongoing improvement. Review of the QAPI Committee Meeting, dated 02/25/2021 at 8:30 AM revealed the committee discussion consisted of dietary tray cards and diets, falls, and weight loss listed as POC; however, the follow-up date was not identified. Additionally, no documented evidence the facilty was auditing and/or monitoring previous defeciences cited. Review of the QAPI Committee Meeting, dated 03/25/2021 and not timed revealed the committee discussion were continued food and laundry; however, the follow-up date was identified for the next QAPI meeting, dated 04/29/2021. Additionally, no documented evidence the facilty was auditing and/or monitoring previous defeciences cited. Review of the QAPI Committee Meeting, dated 04/29/2021 and not timed revealed the committee discussion identified QAPI Plan of food and laundry with the follow-up date listed as the next meeting, dated 05/27/2021. Additionally, no documented evidence the facilty was auditing and/or monitoring previous defeciences cited. Interview with Director of Housekeeping and Laundry, on 06/17/2021 at 11:56 AM revealed he attends the Quality Assurance Performance Improvement meeting; however, was not aware this was a committee. He revealed employment began in December 2019 at the end of the survey. He stated the plan of correction was not his plan of correction, but provided to him by a prior administrator. He stated the adminitrator provided him with three of four clip boards for housekeeping and the laundry with the to do audits. Resident interviews with two (2) residents any locations of the facility pertaining to laundry and housekeeping were initiated. Another clipboard for tracking residents personal laundry. He revealed tracking the laundry as idendified when pulled from the floor and again when the laudry was returned. However, if the laundry was late, then the resident was to be notified when the laundry was late and why it was late. Also, a random audit of one room, per floor, per day. He stated the POC audits were stopped in June or July, 2020 as the interim administrator decided audits had occured long enough and had sufficient results to stop. He stated he was not providing any follow up with the residents for any laundry exceeding the time frame identified in the prior POC, nor collecting any data for the QAPI with late laundry not returned. He stated there were not any audits, documentation, or logs kept tracking the resident's laundry or clothing. He stated he makes observation of the clothing in the facility's laundry. He stated the current administertor was focused on the facility's linens earlier in 2021, not the resident's personal laundry. He further stated he did audits identifying the retention and availability of the facility's linens. He stated there was a mountain of unidentified clothing in the laundry. He stated the facility has a Clothes Closet as there were so many unidentified clothing. In addition, in revealed being unsure if the resident's laundry was being processed and returned within the forty-eight (48) hour time frame identified during the plan of correction. Interview with Unit Manager (UM) #1, on 07/02/2021 revealed data was collected for the QAPI meetings. She revealed data collection was related to pressure ulcers, and staging, pain management information. She revealed the information was presented to the Director of Nurses (DON) for QAPI. Interview with Unit Manager (UM) #7, on 07/02/2021 at 11:20 AM revealed ongoing data collection for the QAPI meetings included data on wounds, indwelling catheters, respiratory care, pain management and anticoagulants. Continued interview revealed no memory recall of data collection or discussion of any information related to previous deficiencies. Interview with Administrator, on 06/17/2021 at 3:32 PM revealed the Quality Assurance Performance Improvement (QAPI) process were included in her responsibilities. She stated the purpose for the plan of correction (POC) were to correct deficient practice and not continue with repeat allegations of the same deficient practices. She revealed if an identified area of concerns occurred, then a new plan placed, or an old plan back in place. She further revealed moving residents around in the building, and difficulty with staffing meeting the needs of the residents. Per interview with the Administrator, she revealed things have fallen through the cracks. She revealed the facility has the Guardian Angel Program. The Guardian Angel program does not utilize any tracking tool, nor any data collected on the findings identified. Continued interview revealed she claimed not being a micromanager, and she has a Director of Nursing (DON) to address the clinical concerns. Continued interview revealed the prior sitting administrator identified all of the deficiencies were cleared; therefore, she did not review the prior plan of correction, but should have. Telephonic interview with the Regional Director of Operation (RDO), on 07/01/2021 at 3:28 PM, revealed the purpose of the plan of correction (POC) were to correct actions and deficient practice. The POC goal were to correct and maintain compliance. She stated the Quality Assurance Performance Improvement (QAPI) process for the POC was to ensure compliance; however, once compliance was determined she was not sure how the compliance was maintained. She revealed repeat citations should not occur following a plan of correction. The RDO revealed she does not attend the regular QAPI meeting. She revealed the tours of the facility were completed individually without any of the department directors. Continued interview revealed the facility self reported incident lead to an event call to the facility. The purpose of the event call was to review ideas, solutions, and areas for review when identifying a root cause and analysis of the reportable incident.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure an allegation of abuse was reported for five (5) of one hundred thirteen (113) sampled residents (Residents #51, #54, #74, #92, and #146). Staff failed to report an allegation of staff to resident verbal abuse related to Resident #146. On 04/23/2021, the facility sent CNA (certified nursing assistance) #18 home related to sleeping and displayed behaviors of playing with resident items, going through resident's belongings, and laying across a sink. Staff stated the facility had them write witness statements related to the event. However, the facility had no documented evidence of staff statements and the incident was not reported to the State Survey Agency. On the night of 05/07/2021, Resident #92 reported to staff CNA #18 exhibited the behaviors above, but was allowed to complete the shift. The facility did not report the allegation of abuse/neglect until the morning of 05/08/2021, when additional resident, Resident #54, reported more behaviors from CNA #18, including the CNA showing residents her backside. Resident #51 reported to staff his/her concerns regarding treatment provided by a CNA but staff failed to report the allegation to management. Resident #74 reported to staff his/her concerns regarding language used by Licensed Practical Nurse #11 but the concern was not reported to management. The findings include: Review of the facility's policy, Abuse Prevention, updated 05/02/2017, revealed all personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin. The policy defined verbal abuse as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. The policy revealed any alleged violations involving mistreatment, abuse, neglect, misappropriation of resident property and any injuries of an unknown origin must be reported to the Administrator and Director of Nursing (DON). The policy revealed the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse would immediately report the incident to the Administrator or to the individual in charge of the facility during the Administrator's absence. 1. Review of the clinical record revealed the facility admitted Resident #146 on 03/30/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and determined he/she was interviewable. Observation of Resident #146, on 05/03/2021 at 5:35 PM, revealed the resident seated in bed, dressed and groomed. Interview during the observation, revealed the resident requested a muscle relaxer the evening of 04/30/2021; however, Licensed Practical Nurse (LPN) #39 stated there were none available. The resident stated later in the evening he/she asked LPN #32 for a muscle relaxer; the nurse told the resident he/she had to wait until 2:00 AM for a pain pill. The resident stated he/she explained to the nurse that he/she had already taken pain medication and needed a muscle relaxer for spasms/pain in his/her waist and legs. According to the resident, both nurses were rude, spoke to him/her like a child and caused him/her to cry. Resident #146 stated he/she dealt with the pain and cried himself/herself to sleep. Continued interview revealed Resident #146 reported the incident the next morning to the nurse who said she would report it. Resident #146 stated he/she reported the incident to Social Services Designee #2 the morning of 05/03/2021. According to the resident, the Social Services Designee stated she would look in to it. Review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy Delivery Manifest, dated 04/27/2021 at 3:55 PM, revealed thirty (30) tablets of [MEDICATION(S)] were delivered to the facility for Resident #146, and on 05/01/2021 at 4:58 AM, thirty (30) additional tablets of [MEDICATION(S)] were delivered. Review of Resident #146's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the facility assessed the resident with a pain level of zero (0) out of ten (10) on the 3 PM-11 PM and 11 PM-7 AM shift; however, interview with the resident revealed he/she reported unrelieved pain to LPN #39 and #32. Review of the clinical record for Resident #149 revealed the facility admitted the resident on 04/01/2021. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #149 with a Brief Interview for Mental Status score of fifteen (15) and determined he/she was interviewable. Interview with Resident #149, on 05/10/2021 at 2:10 PM, revealed LPN #32 was disrespectful and hollered at Resident #146. According to the resident, Resident #146 was so upset he/she started crying. Interview with LPN #39 was attempted on 05/27/2021; however, the staffing agency did not provide a contact number. Interview with LPN #32, on 05/27/2021 at 4:11 PM, revealed her interactions with Resident #146 were cordial; however, she had apologized to the resident if she made (him/her) feel any kind of way. She stated she was not aware of any concerns regarding her interactions with the resident. Review of the 2nd floor Staffing Assignment Sheet, dated 05/01/2021, revealed LPN #3 was assigned to Resident #146 on the 7:00 AM - 3:00 PM shift. Interview was attempted with LPN #3, on 05/27/2021 at 3:16 PM; however, the LPN did not return the call. Interview with Social Services Designee #2, on 05/25/2021 at 2:16 PM, revealed Resident #146 reported he/she could not get a muscle relaxer when requested. She stated the resident told her that a nurse was nasty towards him/her. According to the Social Services Designee, the resident stated it did not make them feel good because he/she had muscle spasms and pain. The Social Services Designee stated she reported the allegation to the 2nd floor Unit Manager (UM) and the Assistant Director of Nursing (ADON). She revealed she did not submit a written statement regarding the allegation and was not aware of the outcome of an investigation. Interview with the 2nd Floor Unit Manager (UM), on 05/28/2021 at 9:27 AM, revealed allegations of abuse should be reported to the ADON, DON and Administrator immediately to ensure the resident's well-being. He stated the Social Services Designee mentioned Resident #146's concern a little while back; however, he forgot to address it. Interview with the ADON, on 05/27/2021 at 9:50 AM, revealed staff were responsible for reporting an allegation of abuse immediately to their supervisor, ADON, Director of Nursing (DON), or Administrator to initiate an investigation and ensure resident safety. She revealed the Social Services Designee notified her of Resident #146's allegation on 05/25/2021 (25 days after the alleged incident) and she immediately went to speak with the resident. The ADON stated she questioned the resident regarding his/her stay and staff treatment; however, she did not interview specific to the allegation. She revealed the facility did not investigate the incident because the resident did not mention concerns with staff or indicate abuse occurred. Interview with Resident #146, on 05/27/2021 at 10:54 AM revealed the facility had not interviewed or followed-up with him/her regarding the incident. Interview with the DON, 05/28/2021 at 3:22 PM, revealed she was not aware of Resident #146's concerns with treatment by nursing staff. She revealed the ADON was responsible for notifying her and the Administrator for anything of concern and investigating the issue. The DON revealed the ADON interviewed Resident #146; however, the resident did not have any complaints. The DON revealed she was not aware of any issues with timely reporting of abuse allegations. Interview with the Administrator, on 05/28/2021 at 4:13 PM, revealed the facility investigated all issues that were concerning and could be considered reportable. She stated all issues were first reported to the ADON. The Administrator revealed the ADON initiated the investigation and reported the findings to her. The Administrator revealed the facility had not identified issues with reporting of abuse. 2. Review of the facility's policy, Resident Rights, undated, revealed residents had the right to be free from verbal, sexual, physical or mental abuse. In addition, the facility implemented procedures to protect residents from abuse, neglect or mistreatment. In the event of an alleged violation, the facility is required to report to the appropriate officials and promptly and thoroughly investigated. Through interview, State Survey Agency (SSA) revealed Certified Nurse Assistant (CNA) #18 was sent home on 04/23/2021 due to sleeping and related behaviors in front of residents. However, the facility had no report or documentation related to incident. Record review of time punches on 04/23/2021 revealed CNA #18 clocked in at 7:15 PM and clocked out 9:00 PM. Interview with CNA #18 on 05/27/2021 at 12:42 AM, revealed a Certified Medication Technician (CMT), unknown name, accused her of being on drugs about a month prior to SSA interview. The CMT reported CNA #18 was asleep at the sink and acting weird. Interview with CMT #1, on 05/27/2021 at 10:18 AM, revealed she was familiar with CNA #18. She stated CNA #18 wasn't there and indicated she should not have been working with the residents. She stated she observed CNA #18 acted as if she did not know what she was doing and was not acting how she should. CMT #1 explained she reported the behavior to LPN #10. CMT #1 indicated CNA #18 left early that day and she had not seen her since. CMT #1 additionally stated she was asked to write a statement and gave it to HS #1. Interview with LPN #10, on 05/26/2021 at 1:22 PM, revealed on 04/23/2021 CMT #1 reported weird behavior from CNA #18. LPN #10 explained, she approached CNA #18 and asked if she was okay. CNA #18 replied there was something in her eye and she had to take out her contact. LPN #10 also described CMT #1 had reported CNA #18 was looking for something on the floor and said she dropped an earring. LPN #10 then observed CNA #18 entered room [ROOM NUMBER], took linen and filled up the inside of sink to make it flush with counter, and laid her head down in the sink. LPN #10 told CNA #18, You can't be here and asked her what was wrong? CNA #18 said, Please don't send me home, I'm just tired and exhausted and haven't ate. Upon observation, LPN #10 stated she called HS #1 and she came to the 6th floor and walked her down. Additionally, LPN #10 stated CNA #18's shift started at 7:00 PM and she was sent home within hour or so. LPN #10 stated she wrote statement for the incident on 04/23/2021. Interview with HS #1, on 05/27/2021 at 3:34 PM, revealed on 04/23/2021 CMT #1 and an unnamed nurse on the sixth (6th ) floor called HS #1 to report CNA #18 falling asleep, unknown time, in resident room and not acting quite right. HS #1 stated she went upstairs and interviewed CNA #18. CNA #18 reported she was just tired. HS #1 stated CNA #18 appeared tired upon observation. HS #1 called Assistant Director of Nursing (ADON) to inform her of observations. ADON advised let her go home due to resident safety. HS #1 additionally stated when staff is sleeping on the job, they are no good to the residents and accidents can easily happen. HS #1 said she did not evaluate or interview the residents at the time. However, indicated now in hindsight she should have talked to a few residents. Further stating, CNA #18 could have injured or potentially dropped a resident. HS #1 stated she asked staff to write statements related to their observations on 04/23/2021. HS #1 stated she placed the statements in the ADON box, mailbox behind the reception desk. Interview with the DON and Administrator, on 05/26/2021 at 2:35 PM, revealed the facility had no witness statements from any staff related to CNA #18 being sent home on 04/23/2021. Both staff indicated CNA #18 had no write-up in personnel file. Interview with DON, on 05/28/2021 at 8:49 AM, revealed she was not familiar with CNA #18 behaviors on 04/23/2021; nor was she aware the facility sent CNA #18 home early. However, she stated it should have been reported. The DON indicated witness statements should be obtained from management staff, house supervisor, DON, ADON, and Human Resources (HR). The DON stated if staff was sent home early, she was notified by phone or text. DON stated the House supervisor had the authority to send staff home if resident care was comprised. Further stating HS #1 should have called her make aware of CNA #18's behaviors. She indicated CNA #18 clocked out at 9:00 PM on 04/23/2021. Interview with the Administrator, on 05/28/2021 at 11:57 AM, revealed she was aware CNA #18 was reported asleep the evening of 04/23/2021 and HS #1 made the decision to send CNA #18 home to get rest. She additionally stated HS #1 made rounds to ensure there was no negative impact on resident. Administrator stated if staff was found sleeping on job they would typically be sent home because its against policy. The SSA investigated an additional allegation related to CNA #18 that occurred on 05/07/2021. Observation and interview with Resident #54, on 05/08/2021 at 8:22 AM, revealed facility staff interviewed Resident #54 after he/she asked to speak with a supervisor during morning rounds. He/she described a CNA he/she had seen once before, unknown name, as thin, white, had brown hair in a bun, tall, and not typically on the floor. Facility identified the CNA to be CNA #18. Resident #54 stated her roommate, Resident #58, needed to be changed and CNA #18 was rude. CNA #18 started going through Resident #58's bag and played with his/her dolls. Resident #54 explained, CNA #18 set the dolls on the bed like she (CNA #18) was a little kid and was not playing with Resident #58. CNA #18 looked like she was on drugs and could barely keep her eyes open. Resident #54 recalled CNA #18 said, That's what happens when you go deep in thought. Resident #54 additionally explained CNA #18 started showing Resident #58 her tattoos on her bottom, belly, back, and legs. Resident #54 explained Resident #58 could not express herself verbally and this upset CNA #18. Resident #54 stated CNA #18 started cussing at Resident #58 and he/she started crying. Resident #54 reported no nurse came back into the room after evening medication pass on 05/07/2021. Record review and interview with Resident #92 on 05/26/2021 at 9:20 AM, revealed he/she was admitted to the facility on [DATE]. His/her quarterly MDS dated [DATE] revealed the facility assessed Resident #92 with a BIMS of 15, indicating he/she was cognitively intact. Resident #92 stated CNA #18 appeared higher than a [NAME]. Resident #92 stated he/she was walking down the odd side of the hall when CNA #18 came out of room [ROOM NUMBER] and was unsteady like she was drunk. Resident #92 reported the situation to the nurse, unknown name, on the floor. Record review and interview with Resident #67, on 05/25/2021 at 2:43 PM, revealed he/she was admitted to the facility on [DATE]. His/her annual MDS dated [DATE] revealed the facility assessed Resident #67 with a BIMS score of fourteen (14), indicating he/she was cognitively intact. Resident #67 remembered CNA #18, he/she stated it was strange she kept nodding off, and leaning over the bed. He/she further stated, I had to wake her up a couple times. Record review and interview with Resident #96, on 05/26/2021 at 10:50 AM, revealed he/she was admitted to the facility on [DATE]. The facility assessed Resident #96 on 03/18/2021 with a BIMS score of fifteen (15), indicating he/she was cognitively intact. Resident #96 stated CNA #18 was acting like she was drunk. Resident #96 reported CNA #18 was going one room to another collecting garbage bags, she was swaying like she was on drugs. She came in to collect garbage and almost fell over. Record review revealed the facility admitted Resident #54 on 04/25/2019. The facility assessed Resident #54 on 02/25/2021 with a Brief Interview for Mental Status (BIMS) fifteen (15), indicating he/she was cognitively intact. Interview with LPN #15, on 05/26/2021 at 8:56 AM, revealed on the night of 05/07/2021, she was the nurse for both sides of the unit after 10:30 PM. She recalled complaints from staff and residents related to CNA #18. Resident #92 asked, Is that girl high? LPN #15 explained she reported the concerns related to CNA #18 to House Supervisor #1 around 8:00 PM or 9:00 PM. House Supervisor #1 and UM #1 came to the floor, talked to her, and said she was okay. LPN #15 stated CNA #18 seemed tired. Interview with LPN #14, on 05/25/2021 at 2:30 PM, revealed the morning of 05/08/2021, CNA #18 told LPN #14 she was tired. LPN #14 stated when she started her rounds residents complained of care. Resident #54 and Resident #67 complained about care or stated the CNA was nodding off. SSA attempted to call UM #1 for interview on 05/26/2021 at 2:54 PM, no answer. Review of the facility obtained statement from UM #1 on 05/08/2021 revealed she went to the sixth (6th) floor to meet HS #1 and assess CNA #18, untimed. She observed CNA #18 to be tired. However, no staff on the floor reported anything unsafe. They decided it was okay for CNA #18 to stay in the facility. Interview with House Supervisor (HS) #1, on 05/26/2021 at 3:09 PM and 05/27/2021 at 3:34 PM, revealed on 05/07/2021, LPN #15 called her to the sixth (6th ) floor at 8:20 PM and reported a problem with CNA #18 appearing under the influence and sleepy. HS #1 interviewed LPN #15 who stated she was going off what residents reported to her. Further interview with CNA #18, on 05/27/2021 at 12:42 AM, revealed she worked for the facility full time for about 1.5 months and did not have any additional jobs. She stated on 05/07/2021 UM #1 came to the sixth (6th ) floor to talk to her around 8:00-9:00 PM because someone had complained about her and said she was discombobulated and possibly on drugs. CNA #18 indicated she was informed of the investigation the morning of 05/08/2021 after her shift ended when she was approached by the ADON and spoke with the DON. The DON said they would conduct an investigation and drug test and CNA #18 was suspended for five (5) days. After five (5) days the facility said she could return to work, everything was fine. CNA #18 stated she returned to work on Saturday 05/15/2021. Further interview with DON, on 05/28/2021 at 8:49 AM, revealed the process of reporting staff behavior was dependent on who made the observation and what the behavior was to decide how to take action. The DON stated sleeping on the job would be cause to send staff home as sleeping could lead to residents not being taken care of, frustration with co-workers, and call lights not answered. DON stated she was made aware CNA #18 seemed impaired on 05/08/2021 at approximately 8:45 AM. Interview with Administrator, on 05/28/2021 at 11:57 AM, revealed she was made aware of the events on 05/07/2021 around 8:00 PM or 9:00 PM. She stated UM #1 and HS #1 assessed CNA #18 and reported no unusual behavior. CNA #18 was allowed to continue to work. Administrator further stated she was not aware of any resident interviews that evening after the initial allegations. She additionally stated resident interviews were conducted the next morning. Further interview with the Administrator revealed the process of reporting staff behaviors was to report to next level supervisor. The supervisor would investigate and deem behaviors inappropriate or not. If found to be inappropriate, the supervisor would report to both DON and Administrator. 3. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #11 provided a written statement on 03/30/2021 at 11:32 AM, which revealed LPN #11 admitted to yelling out F-Me after being notified by a CNA of an overflowing toilet, along with poop & water all over the floor. Interview with Registered Nurse (RN) #2, on 05/24/2021 at 2:12 PM, revealed Resident #74 was unable to get anyone to help him/her to empty the bedside commode, so Resident #74 emptied it himself/herself, which resulted in the toilet clogging up due to all of the toilet paper, etc. Further interview revealed an employee came in and said some rude things about the clogged toilet which Resident #74 overheard. Interview with Licensed Practical Nurse (LPN) #11, on 05/25/2021 at 11:51 AM, revealed that on the date of the incident, she was told that there was water on the bathroom floor. Upon entering Resident #74 bathroom, water and feces were found all over the floor. LPN #11 stated that she was completely shocked by the scene and that an expletive came out of her mouth. LPN #11 was escorted out of the building during her shift, when administration was informed of the statements made. LPN #11 stated she signed a statement of admission. Interview with Certified Nursing Assistant (CNA) #7, on 05/26/2021 at 1:49 PM, revealed Resident #74 took all of his/her paper towels off the sink and put them in the toilet and CNA #7 told LPN #11. While in the hallway CNA #7 heard LPN #11 say[OBSCENITY] and [OBSCENITY] I can't believe the toilet is overflowing. Then Resident #343 said something about hearing the comments as well. Interview with the Administrator, on 05/28/2021 at 10:20 AM, revealed after the allegation it was the expectation for the staff receiving that info to report it immediately. 4. Review of Resident #51's Care Plan dated 03/16/2020, indicated the resident was receiving care at the facility for restorative nursing and other services. The Care Plan stated Resident #51 wished to remain at the facility until his health improved and a safe discharge was arranged. Interventions included but were not limited to, meeting with the resident to discuss plans to return to the community with each full assessment. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #51 had a Brief Interview of Mental Status (BIMS) of eleven (11). Review of the Progress Note dated 05/06/2021, revealed that Resident #51 a\was able to voice wants and needs with clear speech. Review of investigation documents and employee statements revealed Resident #51 made a complaint of treatment to Licensed Practical Nurse (LPN) #3 on 05/04/2021 regarding the loud voice of a CNA. Interview with Resident #51, on 05/05/2021 at 1:44 PM, revealed the resident had a bad incident last night. Resident #51 stated Certified Nursing Assistant (CNA) #2, reportedly talked to Resident #51 like a child and kept yelling at him/her. Per Resident #51, CNA #2 told Resident #51 to get up and was real pushy and domineering. Resident #51 stated that he/she was not afraid of the CNA but did not want to be pushed around. Interview with Unit Manager (UM) #1, on 05/05/2021 at 3:24 PM, revealed the staff identified by Resident #51 was on the schedule last night as reported, but stated she had not received any incident reports or grievances from any residents. Interview with Unit Manager (UM) #1 on 05/07/2021 at 10:15 AM revealed the incident was under investigation. Interview with CNA #2, on 05/10/2021 at 10:22 AM, revealed she talked loudly because she was tone deaf. CNA #2 stated she was giving Resident #51 a shower and afterward Resident #51 asked for the CNA's name and the name of her Supervisor. Resident #51 informed CNA #2 that he/she was going to report her to LPN #3. Resident #51 said he/she was going to tell LPN #3 that she was yelling at him/her. Interview with Licensed Practical Nurse (LPN) #3, on 05/17/2021 at 10:17 AM, revealed Resident #51 told her that CNA #2 was talking loud to him/her in the shower room and he/she did not like it. LPN #3 did not feel that it was a reportable incident, so she did not say anything about it to the next nurse during shift report, because she forgot. LPN #3 stated that it slipped her mind. LPN #3 believed Resident #51 took offense because he/she felt like CNA #2 was yelling at him. If there was evidence of abuse or allegations, LPN #3 stated she was supposed to report to the Assistant Director of Nursing (ADON) within a two (2) hour window. Interview, on 05/18/2021 at 1:22 PM, with the Director of Nursing (DON) revealed she currently oversaw the investigation process. Staff were expected to report incidents and allegations immediately and the DON expected a thorough investigation to be completed. The DON stated resident complaints of yelling or harsh treatment by staff should be reported to the supervisor immediately. The supervisor should then report to the DON or ADON. LPN #3 should have reported the resident's complaint immediately. Any kind of distress could cause harm to the resident. The CNA should have been suspended immediately. Interview with the Administrator, on 05/28/2021 at 10:20 AM revealed if a resident informed staff he or she had issues with another resident or staff, it was the expectation for the staff receiving that info to report it immediately. LPN #3's statement that she forgot to follow up on the resident's complaint and failed to report the incident because she did not believe anything happened, was not acceptable and did not follow facility protocol. Based on interview, record review and review of facility policy it was determined the facility failed to report an injury of unknown origin within two hours to state agency for one (1) of one-hundred and nineteen (119) residents, Resident #87. On 09/25/2021 during morning rounds Licensed Practical Nurse (LPN) #2 found Resident #87 with blood on the forehead and a laceration in which she was unable to determine how the resident got it. LPN #2 revealed she contacted the nurse supervisor on duty, LPN #3 and informed her resident had a cut. She then contacted the Nurse Practitioner (NP) and agreed to send resident out to the emergency room (ER). Resident #87 was treated with seven (7) sutures to the forehead and received a splint for a fractured pinky finger. The finding include: Review of the facility's Abuse Prevention Program policy dated 05/02/2017, revealed all personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin. An injury should be classified as an injury of unknown origin when the source of the injury was not observed or known by any person, and the Initial Risk Management Investigation could not determine the cause of the injury. Additionally, any alleged violation involving an injury of unknown origin must be reported to the Administrator and Director of Nursing (DON). The person who witnessed the event must immediately report to the Charge Nurse (CN) and the CN must immediately report tot eh Administrator or designee. The CN must complete an incident report and obtain a written, signed and dated statement from the person who reported the incident. Review of Resident #87's clinical record revealed the facility admitted the resident on 07/09/2019, with multiple diagnosis, which included Alzheimer's Disease, Dementia with Behavioral Disturbances, anxiety, major depressive disorder, and cognitive communication deficit. Staff report Resident historically wandered into other resident's rooms, took items and got in their beds. Review of Resident #87's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), and determined the resident was not interviewable. Resident #87 was assessed for bed mobility, transfers, walk in room, walk in corridor, locomotion on unit and off unit and to eat as supervision-oversight, encouragement and cueing with the assistance of one (1) staff member. Resident was assessed as two (2) staff physical assist to get dressed and for personal hygiene. Review of the facility Risk Management Investigation (RMI) #3221completed on 09/25/2021 at 7:15 AM, by LPN #2, revealed the location of the incident was unknown. The incident itself was documented as an injury of unknown origin. Review of discharge documents for 09/25/2021 revealed the ER doctor noted Resident #87 was seen in the emergency department and a face-to-face diagnostic evaluation was completed of the patient. The patient presented with a laceration above the left eye. The patient was found by staff with blood on his/her bed and a laceration above the eye. The patient did not know specifically what happened or how he/she got injured. The patient was a poor historian. Interview with LPN #2 on 09/30/2021 at 2:05 PM, revealed when she completed her morning rounds, she found Resident #87 in bed and noticed something on his/her head. Resident had blood on his/her face, on their pillow, on their hand and on the floor by the head area and she could not determine what happened. LPN #2 revealed she called the Nurse Practitioner (NP) and was told to use her discretion to determine if the resident needed to be sent to the ER. LPN #2 revealed the laceration to the resident's head was pretty wide open. Resident #87 was sent to the ER for the laceration and concerns about his/her pinky finger. Continued interview with LPN #2 on 09/30/2021 at 3:15 PM, revealed she was instructed by LPN #3 to complete the RMI. She further revealed she documented the incident as an injury of unknown origin not as a fall. LPN #2 revealed she had to return to the facility because she was unaware she was supposed to complete the RMI. She also revealed she did not tell LPN #3 it was a fall. LPN #2 also revealed she and a Certified Nurse Assistant (CNA) changed Resident #87's brief just before Emergency Medical Services (EMS) arrived because resident was wet. LPN #2 revealed she knew this incident was reportable because it was a head injury. Interview with LPN #3 on 10/08/2021 at 10:53 AM, revealed she reported this incident as a fall. She revealed she was contacted by LPN #2 and informed resident had fallen out of bed. She revealed based on her nineteen (19) years of experience and her knowledge about Resident #87, she determined the resident had a fall. LPN #3 revealed she was off the floor when the incident took place. When she went to assess resident, resident was in bed with his/her feet wrapped up in the sheets. She further revealed she texted the DON and told her she believed resident had an unwitnessed fall with an injury and resident was sent out to the ER. LPN #3 revealed she could not think of anything else it could be. She believed the resident fell and got up and back in bed. LPN #3 described a fall is when someone could not get up off the ground and an injury of unknown origin is when you did not know where the injury came from. However, she still believed the resident must had fallen. LPN #3 stated, I assumed it was a fall. Interview with DON on 10/08/2021 at 1:40 PM, revealed Resident #87's head wound was investigated as a fall. The DON revealed she conducted an interview on 09/27/2021 and she revealed there were two parts of a fall investi [TRUNCATED]

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure residents were free from accidents and hazards for five (5) of one hundred thirteen (113) sampled residents (Residents #130, #32,#109, #75 and #). Resident #130 sustained multiple falls including falls with fractures. Resident #32 related to multiple falls. Resident #109 related to smoking, and Resident #75 related to unsupervised wandering behaviors, and risk for falls. The findings include: Review of the facility's policy, Incidents/Accidents/Falls, not dated, revealed in section eleven (11) that all falls had a site investigation by appropriate staff in an effort to define the root cause of the fall. This provided information to enable staff to roll out interventions to prevent another similar occurrence. Each resident fall needed a new intervention rolled out with therapy involvement to some degree. Section twelve (12) of the policy revealed some occurrences required a more extensive investigation process. These included but were not limited to falls with significant injury and any fracture. Review of the facility's policy Baseline Care Plan Assessment/ Comprehensive Care Plans, revised 03/23/2021, revealed in section nine (9), the facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to receive services with reasonable accommodations to individual needs and interests. 1. Review of Resident #130's clinical record revealed the resident had four (4) unwitnessed fall incidents between March 2021 and May 2021. Two (2) of the four (4) falls resulted in major injury. Resident #130 received treatment for a fractured tibia during the hospitalization on [DATE]. Resident #130 received treatment for a fracture of the femur on the right leg during the hospitalization on [DATE]. Review of Resident #130's Care Plan identified the following interventions put in place after the initial fall with significant injury, which included staff to assist with toileting, dated 03/15/2021, and prompt response to calls/call light dated 04/12/2021. Review of Nursing Progress Notes revealed on 05/04/2021 at 2:00 AM, Resident #130 had an unwitnessed fall next to his/her bed. Resident was diagnosed with a Urinary Track Infection ([CONDITION(S)]) and returned to the facility with antibiotics per progress note 05/08/2021. Review of IDT (Inter-Disciplinary Team) Meeting note revealed during 3rd shift hours Resident #130 tried to ambulate to the bathroom from the bed without assist, fell and hit his/her head. Further review of Progress Notes revealed on 05/16/2021 at 2:30 AM, Resident #130 had an unwitnessed fall with baseline confusion noted. Staff assisted the resident off the floor and to the bathroom. On 05/24/2021 at 2:30 AM, Resident #130 had an unwitnessed fall near his/her closet door. Observations noted the closet door was adjacent to the resident's bathroom. Review of admission records dated 09/25/2020 revealed Resident #130 had a diagnosis of Irritable Bowel Syndrome with diarrhea and [CONDITION(S)]. Clinical records revealed the resident was incontinent of bowel and bladder. Interview with Licensed Practical Nurse (LPN) #1, on 05/08/2021 at 6:49 AM, revealed she was present and sought medical attention for the resident following his/her fall on 05/04/2021. LPN #1 stated Resident #130 had a history of falls occurring maybe once every month and a half. Interventions in place included checking on the resident every hour, assist to bathroom, and use of wheelchair. Interview with Resident #130, on 05/08/2021 at 8:06 AM, revealed he/she fell while going towards his/her bathroom door on 05/04/2021. Resident #130 stated he/she fell more than anyone (he/she) knew. Resident #130 stated he/she hit his/her head and received treatment for a [CONDITION(S)] at the hospital. The resident stated he/she knew he/she was supposed to call staff for help when he/she needed to get up or go to the bathroom. The resident stated he/she had a call button that he/she used to call for help. The resident stated he/she had to have someone with him/her when taking a shower and when going to the bathroom. The resident indicated falls generally happened when he/she was attempting to go to the bathroom on his/her own. Interview with Registered Nurse (RN) #1, on 05/10/2021 11:15 AM, revealed Resident #130 had no symptoms of [CONDITION(S)] prior to hospitalization . RN #1 found the resident on the floor near the bathroom on 05/04/2021 and the resident's frequency of falls had increased. RN #1 stated she believed Resident #130 was sent to the 7th floor secured Memory Care unit from the 3rd floor, due to falls, wandering into other rooms, and trying to escape. The resident reportedly fell about three (3) months ago and broke his/her leg. Interview with Licensed Practical Nurse (LPN) #1, on 05/17/2021 at 1:05 PM, revealed Resident #130 had been falling more often. LPN #1 stated, every other week he/she has been falling in the past month. Resident #130 got out of bed in the middle of the night and he/she became disoriented. LPN #1 stated the facility may not have made changes to his/her plan for the recent fall because the Unit Manager was out. LPN #1 was not sure who was responsible for updating the plan in the manager's absence. Interview with Physical Therapist (PT) #6, on 05/18/2021 at 9:36 AM, revealed Resident #130 discharged from therapy services on 04/27/2021. PT staff educated Resident #130 on risks of self-ambulating, but PT #6 understood Resident #130 may not remember the education given. Interview with the Director of Nursing (DON), on 05/18/2021 at 1:22 PM, revealed she was aware of Resident #130 frequent falls and fall with significant injury. Interview with the MDS Director #12, on 05/20/2021 at 2:50 PM, revealed it was the resident's right to get up and go to the bathroom on his/her own, however, the facility was responsible for resident care and safety. Interview with Resident #130 on 05/28/2021 at 1:54 PM revealed the resident fell again around 2:30 AM on Monday 05/24/2021, at which time the resident sustained a broken hip. Resident #130 revealed he/she was trying to get to the bathroom when the fall occurred. Resident #130 revealed staff checked on him/her about three (3) to four (4) times a day, to see if he/she needed to go the bathroom. Resident #130 pushed the call button before getting up to go to the bathroom, but sometimes staff took forever to come. Prior to the fall this week, no one was coming in to check on Resident #130 every thirty (30) minutes or every hour, according to his/her account. MDS INFORMATION Interview with Certified Nurse Assistant (CNA), #1 on 05/28/2021 at 2:04 PM, revealed CNA #1, assigned to Resident #130's hall, was not sure if Resident #130 was supposed to be on frequent hourly checks as noted in the resident's medical chart and care plan. Interview with Licensed Practical Nurse (LPN) #40, on 05/28/2021 at 2:20 PM, revealed Resident #130 was a fall risk. Resident #130 cried out around 2:30 AM, when LPN #40 went in and discovered Resident #130 sitting on the floor by the closet, near his/her bathroom. Interview with the Administrator, on 05/28/2021 at 10:20 AM, revealed it was the facility's responsibility to ensure care plans and physician orders were followed. 2. Review of the clinical record revealed the facility admitted Resident #32 on 02/22/2019. Diagnoses included Dementia without Behavioral Disturbances, Anxiety Disorder, Hypertension, and Overactive Bladder. The facility assessed the resident on 02/18/2021, with a Brief Interview Mental Status (BIMS) of fifteen (15) and determined the resident was interviewable. Review of the facility's care plan for risk of falls, initiated 03/07/2019, revealed the resident had a history of falls in the facility and included interventions for gripper tape to the right side of the bed, ensure call light was in reach and encourage to use it for assistance, anticipate and meet resident needs, and complete the Fall Risk, per the facility's protocol. Additionally, the care plan identified that Resident #32 had Activities of Daily Living (ADL) self care deficits and included interventions to supervise transfers and the resident ambulated independently. Review of the facility's incident report, dated 02/25/2021, revealed Resident #32 was discovered on the floor next to his/her bed. The resident thought he/she lost his/her balance when he/she reached for the items from the nightstand. The facility educated the resident on the importance and safety to utilize the call light for assistance. The report was incomplete, missing information related to the resident's mental status, any predisposing physiological factors. Predisposing Environmental Factors were marked as None. However the report did not reveal the distance from the bed to the nightstand, or the items the resident reached for. The facility's Root Cause Analysis (RCA) of the fall, dated 02/25/2021, revealed the Nursing Progress Note of the fall with the same information as the report. The RCA did not reveal what led to the resident's inability to reach the items on the nightstand, which led to the fall. The care plan for Resident #32 revealed no new interventions implemented for the resident's fall risk after the fall occurred on 02/25/2021. Review of the facility's incident report for Resident #32, dated 04/20/2021, revealed the resident laid on the floor at the third floor smoking patio. The resident stated he/she fell when he/she turned to sit on the concrete bench in the smoking area. The report was incomplete, with Other (Describe) marked as Predisposing Situation Factors, however no other descriptive information was documented. The facility's RCA, dated 04/21/2021, revealed the Nursing Progress Note of the fall documented the fall was witnessed. The Note further revealed Resident #32 stumbled on the smoke patio ramp. The RCA did not document the type of footwear the resident wore, or what may have led the resident to stumble. Review of Resident #32's care plan revealed the facility revised the care plan, on 04/21/2021, with interventions to encourage proper positioning when attempting to sit down and ask for assistance when sitting down. Review of an incident report, dated 04/23/2021, revealed Resident #32 laid on the floor on his/her side at the foot of the bed and his/her pants around the ankles. The resident stated he/she stood up to put on his/her pants and fell . The report noted the resident was clean and dry, and continent of bladder and bowel. The report was incomplete, with information missing related to Predisposing Environmental Factors. There was no information about the resident's footwear or the immediate environment around the resident, such as clutter, wet floor, furniture, or uneven walking surface. The facility's RCA revealed the Nursing Progress Note, dated 04/23/2021, documented the nurse educated the resident. The care plan, revised 04/23/2021, revealed an added intervention included to encourage to use the call light for transfer/ambulation assist. Continued review of Resident #32's care plan revealed an intervention to encourage to use the call light for transfer/ambulation assistance was added, dated 04/23/2021. Review of the facility's incident report, dated 04/29/2021, revealed staff found Resident #32 on the bedroom floor entangled in bed sheets. The resident stated he/she tried to get up. The facility staff educated the resident about wearing nonskid footwear and gave the resident his/her call light. The report was incomplete, with no information marked for Predisposing Situation Factors. The facility's RCA revealed the Nursing Progress Note, dated 04/29/2021, documented the resident was entangled in his/her sheets when staff found the resident on the floor and the resident said he/she tried to get up. The RCA did not indicate if the resident had on any footwear or the type of footwear, or if the call light was in or out of reach at the time of the fall. The care plan, revised 04/30/2021, revealed an added intervention of safety awareness education as needed. On 04/30/2021, further review of the care plan revealed an intervention added for safety awareness education as needed for Resident #32. Observation of Resident #32, on 05/04/2021 at 3:42 PM, revealed the resident in bed, wore eyeglasses, a rollator near the bed, and non-skid strips on the floor on the side of the bed. Observation, on 05/17/2021 at 1:58 AM, revealed Resident #32 ambulated with his/her rollator to the nurse's station. The resident then left the rollator and drug a chair from the nurse's station over to another resident in the common area at the nurse's station, sat down, then moved his/her rollator in front of him/her. Interview with Resident #32, on 05/04/2021 at 3:42 PM, revealed he/she fell out of bed a few nights ago, and was dizzy for a few minutes. The resident revealed he/she got a new rollator, which replaced a wobbly walker from physical therapy. Interview with Certified Nurse Aide (CNA) #26, on 05/14/2021 at 10:00 AM, revealed when she came in to work a couple of weeks ago, Resident #32 fell and had already gotten up off the floor. She stated the resident does pretty good to walk. The aide stated the resident was sometimes mixed up. The CNA stated the resident told her he/she fell and the aide reported to the nurse. The aide further stated the resident did not use the call light a lot of times, as he/she liked to do for himself/herself. On 05/14/2021 at 10:14 AM, interview with Licensed Practical Nurse (LPN) #27 revealed Resident #32 was a little confused at times. She stated the resident was independent walking with episodes of falls. The nurse further stated the resident was noncompliant with using the rollator, and needed reminding to get his/her walker, or staff would bring the walker to the resident. The LPN revealed when a resident fell , the computer system had a risk management incident report that should be completed, and went to the Director of Nursing (DON), and was reviewed with the care plan in the morning meeting. Interview, on 05/14/2021 at 1:38 PM, with LPN #33, revealed she did not recall Resident #32's fall. However, she recalled the resident did not use any assistive devices. She stated the resident would ask for help and did not have any issues with noncompliance by the resident. Interview with LPN #23, on 05/14/2021 at 3:13 PM, revealed she was the nurse on duty when Resident #32 fell at the smoking patio. She stated the resident did not usually go to the smoking patio, but decided to go on that day for fresh air. The nurse revealed the staff at the smoke patio told the resident to sit on the bench and the resident tripped over his/her own feet and fell . LPN #23 stated the resident walked independently at the time and did not have a rolling walker. The nurse stated the fall documentation needed to be completed, as the purpose was to communicate from one (1) shift to the next. She stated leadership updated the care plans when they completed their risk management changes in the computer. On 05/14/2021 at 3:25 PM, interview with Unit Manager (UM) #6 revealed she was the nurse assigned to work with Resident #32 when the resident fell on [DATE]. She stated the fall occurred early in the morning with CNA #26. She stated they found the resident sitting on the floor in his/her room, with his/her feet intertwined in the sheets. The LPN revealed the resident said he/she tried to get up to go to the bathroom. The nurse stated Resident #32 was independent with walking and transfers, and did not use an assistive device at the time of the fall. Interview with the MDS Director, on 05/17/2021 at 3:05 PM, revealed she was familiar with Resident #32 but could not recall the resident's falls. She stated when a resident fell an incident report was completed. The Director revealed she was not aware of any issues with the incident reports not being completed. She stated the incident reports questions included what the resident was doing, if there was something medical going on such as a urinary tract infection ([CONDITION(S)]), and if there were any medicine changes. She stated the facility should determine what the resident tried to do to ensure safety interventions were appropriate. The MDS Director stated they reviewed falls every day and conducted a root cause analysis (RCA) in the morning meeting and determined then what interventions were appropriate. Interview, on 05/19/2021 at 2:56 PM, with the Director of Nursing (DON) revealed she had been with the facility about six (6) weeks. The DON revealed she reviewed the incident reports, risk management investigations, for any type of event that may have occurred. She further revealed the resident's nurse was responsible to complete the incident report. She stated the Interdisciplinary Team (IDT) discussed resident falls to determine the root cause of the event. The DON revealed the IDT decided what interventions were best for the resident to prevent the event from reoccurring. She stated she was unsure if the facility had a falls program. She further stated her expectation when a resident fell , the fall investigation would be thoroughly complete. The DON revealed the incident report did not carry over to the twenty-four (24) hour report. 3. Review of facility policy titled, Smoking Policy, not dated, revealed the facility allowed smoking for residents, staff and visitors in designated areas. Smoking activity must be fifteen (15) feet from any doorway, window or vent system. The facility kept all residents' smoking materials. All staff members received education on the smoking policy and smoking assessments during general orientation. The policy further stated residents were to be assessed for smoking upon admission and educated on smoking practices, and in addition assessed quarterly, annually, or after an unsafe smoking episode, or a change of condition. The Social Service Designee (SSD) conducted the smoking assessment. The care plan and Certified Nursing Assistant (CNA) assignment sheet were reflective of the resident's needs as far as safe smoking. The admitting nurse may complete the smoking assessment if SSD was not available. Review of the facility's policy titled, Standard Supervision and Monitoring not dated revealed, the facility recognized supervision and guidance to the resident was an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychological needs. Review of facility's document titled. 3rd floor smoking privileges and restrictions, dated 05/23/2017, revealed the designated smoking area as the third (3rd) floor patio. Residents were assessed to wear a smoking apron and must have it on prior to lighting a cigarette. Continued review of the document revealed no assigned seating in the smoking area, cigarettes and trash placed in appropriate containers, and residents may not wait in line for the smoking patio to open. The policy continued to state no verbal or physical altercations to occur among residents while on the patio. Review of the position description titled Smoking Monitor not dated, revealed the purpose of the smoking monitor was to provide each resident with a safe smoking environment, and monitor residents during smoking hours. In addition, the smoking monitor ensured supervision of residents at all times while on the smoking patio. Record review for Resident #109, revealed the facility admitted the resident on 04/19/2017 with diagnoses that included [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction, Contractures, [CONDITION(S)], [CONDITION(S)] heart disease, Falls, Peripheral Vascular Disease, Low vision Right Eye Category 1, [CONDITION(S)] Left Eye Category 3. Review of the Minimum Data Set (MDS) revealed the facility assessed the resident with a BIMs score of ten (10) and determined the resident with mild cognitive impairment. Review of Resident #109's Care Plan initiated 05/15/2018 and updated 04/12/2021, revealed Resident #109 was to wear a smoking apron, provided with a copy of the smoking policy, could smoke in a designated area, and undergo a smoking assessment quarterly and as needed. Review of the Smoking Policy and care/safety of smoking residents, revealed Resident #109's signature present. Interview on 05/06/2021 10:15 AM, with Resident #109, revealed the smoking times were 9:00 AM, 1:00 PM, 3:00 PM and 6:00 PM. Resident#109 continued to explain the staff covered him/her with a smoking apron and kept an eye on residents. Resident #109 reported he/she had to wear a smoking apron because of burning a hole in his/ her clothing a while ago. Interview on 05/15/2021 at 8:30 AM, with Resident #109, revealed staff assisted him/her to and from the smoking porch. However, when returning from the porch the smoking monitor positioned his/her wheel chair in front of the elevators and nurses' station. Resident #109 stated he/she must find his/her way back to the room by feeling along the hall way, sometimes staff took the resident back to his/her room. Observation, on 05/12/2021 at 9:30 AM, revealed Resident #109 on the smoking patio wearing a smoking apron, however, the apron was not fully covering the resident's legs. Further observation revealed the Smoking Monitor was seated at the card table inside the building. Observation revealed Resident#109 on the porch out of direct view of the monitor with his/her back facing the window. Observation, on 05/12/2021 at 9:37 AM, revealed a Restorative Assistant (RA) wheeled Resident #109 from the smoking porch to the third (3rd) floor elevators, leaving the smoking porch unattended for approximately thirty (30) seconds. Interview, on 05/14/2021 at 1:27 PM, with Smoking Assistant (SA), revealed groups come in and cigarettes were distributed. Residents can have three (3) cigarettes during the smoke break. Further interview revealed there were three (3) smoke breaks a day. The Scheduler informed the SA, which residents needed special precautions like a smoking apron. SA continued, Resident #109 was blind and she positioned Resident #109 to face toward her and placed a smoking apron on the resident. The SA continued to explain, Resident #109's aid or nurse returned him/her to their room. However, sometimes she had to leave the porch to take Resident#109 back to the nurse's station and it might take around thirty (30) seconds. The SA explained that the purpose of having a smoking aid was to make sure everybody was safe and six (6) feet apart. Observation on 05/14/2021 at 1:27 PM, revealed an SA seated at card table while residents were on the smoking patio out of direct view of the SA. Interview, on 05/14/2021 at 2:25 PM, with the Scheduler revealed nursing informed her if a resident had special needs related to smoking. The Scheduler continued stating the role of the SA was to pass out cigarettes, and in addition, the SA was trained on the smoking apron, fire blanket and observation. Furthermore, the SA needed to stand outside on the patio with the residents and not leave the area while residents were smoking. Observation, on 05/15/2021 at 9:00 AM, revealed the smoking patio was open, with four (4) residents waiting to enter the smoking patio and nine (9) residents on the deck with two (2) smoke attendants. Resident #109 was on the smoking patio with his/her back to window and wearing a smoking apron. Observation, on 05/16/2021 at 10:00 AM, revealed one (1) resident on the smoking patio outside under the awning, lightly raining. Observation revaled a resident in the corner, wearing a smoking apron. The Ssmoking attendant was observed on the porch on the other side of the table texting on a phone. Continued observation revealed a resident was out of her line of vision. Interview, on 05/16/2021 at 10:00 AM, with CNA #33 revealed she usually stood at the door to observe residents but, she was texting a co-worker. Interview, on 05/18/2021 at 9:57 AM, with the Social Service Designee (SSD), revealed the role of the attendant was to ensure safety and assist the residents with smoking. Furthermore, the attendant should be observing all residents on the patio at all times for safety, social distancing, and smoking practices. SSD #2 stated a resident smoking should be positioned on the patio in a way that they that could be seen. The nurse obtained the resident contract and provided education for smoking during the admission process. SSD #2 stated she had not reviewed the smoking policy nor received any training related to residents that smoked in the facility. SSD #2 stated she was not aware of training for the smoking attendants. SSDv#2 stated if the smoking policy was not followed it could affect the resident's safety and if the attendant was distracted it could be a problem for resident safety. Interview on 05/19/2021 at 9:14 AM, with Registered Nurse (RN) #5, revealed she had not been oriented to the smoking apron or smoking safety for residents. However, if she identified [CONDITION(S)] on a resident she assessed the patient, interviewed them, and informed the nurse manager. RN #5 stated that smoking monitor was assigned to the smoking patio to make sure everyone was safe, socially distanted, and distributed cigarettes. Interview, on 05/18/2021 at 3:49 PM, with the Director of Nursing (DON) revealed she was not aware of the process around smoking and supervision on the smoking patio. Furthermore, the DON stated she had not received orientation to the facility's smoking procedure. The DON stated a smoking monitor attended to the residents on the smoking patio to ensure safety while residents smoking. She stated residents not monitored on the smoking patio were at risk for injury. Interview on 05/20/2021at 9:51 AM, Administrator (ADM) revealed all smokers were supervised in the designated smoking area on third floor patio. Further interview with ADM revealed a smoke attendant provided assistance, lit the residents' cigarettes, and ensured residents wore a smoking apron if indicated. The ADM stated the smoking attendant should not be on the phone while observing smoking residents and the smoking monitor needed to have the ability to lay eyes on the resident frequently. 4. Review of the facility policy, Standard Supervision and Monitoring, undated, revealed the facility recognized supervision and guidance to the resident was an essential part of nursing care. At any time the resident was being supervised and required redirection, the direct care staff member may need to redirect the resident through verbal and/or physical guidance and/or care. Review of the facility policy, Incidents /Accidents/Falls, undated, revealed based on the results of the incident/accident/fall the resident's care plan was addressed to ensure appropriate interventions were in place. In addition, the CNA information sheet was updated as indicated to reflect the plan of care. Review of the clinical record revealed, the facility initially admitted Resident #75 on 02/08/2012 and readmitted the resident on 11/26/2020 with diagnoses including Alzheimer's disease, Down Syndrome, moderate intellectual disabilities, Bi-polar Disorder, and Obsessive Compulsive Disorder (OCD). Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #75 with a BIMS score of four (4), indicating the resident was severely cognitively impaired. Review of Resident #75's behavior care plan revealed a focus care plan with a diagnosis of [CONDITION(S)] disorder and Obsessive Compulsive Disorder (OCD) with episodes of hoarding, name calling, episodes of refusing required care such as by mouth meals, snacks, medications, showers, changing clothes, vaccinations, blood pressure checks. Resident exhibited episodes of wandering the halls and trying to get on the elevator. Resident exhibited episodes of clogging up sink and toilet in room causing water to flood the floor. Resident wandered in to other resident's rooms and took items, he/she refused care or refused to allow staff to take vital signs. Interventions included to approach resident warmly and positively, assist him/her in selection of appropriate coping mechanisms; if resident was unwilling to leave an area such as a closed room or come inside the building, offer orange soda or ice cream as an incentive; observe and document his/her behavior and report any changes to physician. Other interventions included observe resident frequently when in room and educate not to place items in the sink related to possible negative outcome; redirect as needed. Review of Resident #75 comprehensive care plan initiated 06/06/2018 revealed a focus, resident was at risk for falls related to cognitive disorder and impaired Activities of Daily Living (ADLs). Interventions, revised 05/07/2021, revealed staff were to ensure the residents pants were rolled up if too long. Review of the CNA information sheet, undated, revealed Resident #75's special instructions included half (½) side rails, living environment clutter free, non skid socks, Q1H (every one hour) safety checks, assist with toileting, encourage resident to lay down in bed when sleepy. Review of Resident #75's Physician's Orders revealed an active order effective 12/04/2020 at 3:00 PM to monitor resident for wandering every shift. Observation of Resident #75, on 05/06/2021 at 3:05 PM, revealed the resident wandered the halls and attempted to open the locked door at the end of the hall. Observation, on 05/12/2021 at 9:44 AM, revealed Resident #75 ambulating to the employee lounge. No staff was present on the hall, Resident #75 opened the lounge door approximately three (3) inches where staff was visible in the gap of the door. Observation of Resident #75, on 05/12/2021 at 9:45 AM, revealed the resident at end of the odd side of the hall. He/she opened the break room door and looked inside of break room beside chapel. Observation of Resident #75, on 05/12/2021 at 9:50 AM, revealed Resident #75 turning the doorknob of the chapel. Observation of Resident #75, on 05/13/2021 at 3:28 PM, revealed the resident in the employee breakroom standing behind the door by the trashcan. Interview with Housekeeper #3 at the time of observation revealed Resident #75 will get into the trash sometimes. Observation of Resident #75, on 05/19/2021 at 10:34 AM, revealed Resident #75 entered room 604, opened the bathroom door, stood at the bathroom vanity, touched and picked up linen on the sink counter. On 05/19/2021 at 10:42 AM, Resident #75 exited room 604. No staff present to redirect Resident #75 at the time of observation. Interview with CNA #13, on 05/14/2021 at 10:56 AM, revealed she tried to redirect Resident #75 when he/she entered resident's room. Interview with LPN #17, on 05/14/2021 at 3:03 PM, revealed in report, she was not told of any interventions for residents that wandered. Interview with LPN #12, on 05/19/2021 at 3:05 PM, revealed she monitored wandering residents closer. She stated occasionally she saw Resident #75 in the staff bathroom or staff break room. Interview with Unit Manager (UM) #3 on 05/19/2021 at 3:16 PM, revealed falls were monitored by adding a care plan intervention anytime someone had a fall. She added each fall was individual and each had a different intervention. UM #3 also addressed wandering behaviors and stated each resident has the right to wander. She further stated it was hard to ensure Resident #75 did not go into other resident rooms. Review of Resident #75's Progress Notes, dated 05/07/2021 at 1:54 PM, revealed the IDT (Interdisciplinary Team) met and discussed residents' previous falls event. On 05/06/2021, Resident #75 ambulated with a staff member behind him/her and witnessed the fall. Further review revealed the resident's pants were too long

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pain management for one (1) of one hundred thirteen (113) sampled residents (Resident #146). Interview with Resident #146 revealed he/she experienced pain and notified staff. Resident #146 stated the pain was so bad he/she cried himself/herself to sleep. However, staff did not administer the resident's ordered pain medication. The findings include: Review of the facility's policy, Management of Pain, undated, revealed as part of a comprehensive approach to pain assessment and management, pain would be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. The policy defined pain as whatever the experiencing person said it was, existing whenever the experiencing person said it did. Further review revealed staff assessed and managed pain in a timely fashion, especially if it was of recent onset. Staff notified the physician of the resident's complaint of pain when not relieved by the medication as ordered by the physician. The policy stated thorough communication with the physician ensured an appropriate pain management plan. Further review of the policy revealed pain monitoring was documented on the back of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Effectiveness was measured one to two (1-2) hours after administration. Review of the clinical record revealed the facility admitted Resident #146 on 03/30/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and determined he/she was interviewable. Observation of Resident #146, on 05/03/2021 at 5:35 PM, revealed the resident seated in bed dressed and groomed. Interview, during the observation, revealed the resident requested a muscle relaxer the evening of 04/30/2021; however, Licensed Practical Nurse (LPN) #39 stated none was available. The resident stated later in the evening he/she asked LPN #32 for a muscle relaxer; the nurse told the resident he/she had to wait until 2:00 AM for a pain pill. The resident stated he/she explained to the nurse that he/she had already taken pain medication and needed a muscle relaxer for spasms/pain in his/her waist and legs. According to the resident, both nurses were rude, spoke to him/her like a child and caused him/her to cry. Resident #146 stated he/she dealt with the pain and cried himself/herself to sleep. Continued interview revealed Resident #146 reported the incident the next morning to the nurse who said she would report it. Review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy Delivery Manifest, dated 04/27/2021 at 3:55 PM, revealed thirty (30) tablets of [MEDICATION(S)] were delivered to the facility for Resident #146. Further review of the pharmacy Delivery Manifest, dated 05/01/2021 at 4:58 AM, revealed thirty (30) additional tablets of [MEDICATION(S)] were delivered. Review of Resident #146's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the facility assessed the resident with a pain level of zero (0) out of ten (10) on the 3 PM-11 PM and 11 PM-7 AM shift; however, interview with the resident revealed he/she reported unrelieved pain to LPN #39 and LPN #32. Interview with Certified Nursing Assistant (CNA/Aide) #48, on 05/10/2021 at 10:01 AM, revealed Resident #146 usually got out of bed right before lunch, stayed up for two (2) or three (3) hours, then went back to bed because of back spasms. The Aide stated he noticed Resident #146 was still up in the wheelchair when he went on break around 8:00 PM. CNA #48 stated the resident had been up in the wheelchair for about twelve (12) hours. He stated the resident was crying and stated he/she needed a muscle relaxer for pain. The CNA stated he reported the resident's pain to LPN #39. Interview with LPN #39 was attempted on 05/27/2021; however, the staffing agency did not provide a contact number. Interview with LPN #32, on 05/27/2021 at 4:11 PM, revealed she administered the resident's muscle relaxer and pain medication in a timely manner; however, she did not document the administration on the MAR. The nurse stated she did not know why she did not document the medication administration. In addition, the LPN stated she was responsible for assessing the resident's pain level, documenting in the MAR, and following up every thirty (30) minutes to determine if the medication was effective. She stated she initially assessed Resident #146 with a pain level of zero (0) out of ten (10) because the resident was not hurting a lot. The LPN stated she reassessed the resident for effectiveness of the medication; however, she did not document the findings. The LPN stated she did not notify the physician about Resident #146's pain because she felt like it was not debilitating. LPN #32 stated she could not recall if the resident cried. Review of the 2nd floor Staffing Assignment Sheet, dated 05/01/2021, revealed LPN #39 was assigned to Resident #146 on 7:00 AM - 3:00 PM shift. Interview was attempted with LPN #39, on 05/27/2021 at 3:16 PM; however, the LPN did not return the call. Interview with the 2nd floor UM, on 05/28/2021 on 9:27 AM, revealed residents should be assessed every shift for pain and medicated accordingly. He stated the physician should be notified and alternative interventions for pain management should be used if medications were not effective. The UM stated interventions for pain management would include repositioning, backrub, or adjusting pain medications. He revealed pain assessment and medication administration should be documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DON, 05/28/2021 at 3:22 PM, revealed she was not aware of issues with management or monitoring of residents' pain. The DON stated it was the nurse's responsibility to assess for pain, administer pain medications, and follow-up to determine the effectiveness of the pain treatment, including documentation of these steps. She stated the facility expected that residents would have an acceptable level of pain. Interview with the Administrator, on 05/28/2021 at 4:13 PM, revealed she was not aware of issues regarding residents and pain management. She stated she could not imagine being in pain and not having those issues addressed.

Based on record review, interview, and review of the facility policy it was determined the facility failed to implement the care plan for one (1) of thirty-five (35) sampled residents. The care plan for Resident #[AGE] revealed the resident was to be transferred with a maxi-lift and the assistance of two (2) persons. The findings included: Review of the facility policy, Baseline Care Plan Assessment/Comprehensive Care Plans, undated, revealed the facility Interdisciplinary team would discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. Observation of Resident #[AGE], on 12/03/19 at 9:04 AM, revealed the resident lying in bed with the head of the bed up about ninety (90) degrees. The resident responded the surveyor. Further observation revealed the resident's right leg was flexed at the knee and the lower part of the leg was on a pillow, outwardly rotated. The resident stated he/she had broken her leg, but did not know how. When asked if he/she fell , the resident stated yeah. Observed right leg flexed at knee lying on a pillow, [MEDICAL CONDITION] noted in foot, color pink. Review of the medical record revealed the facility admitted Resident #[AGE] to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), quarterly assessment, dated 07/11/19, revealed the facility assessed the resident with a Brief Interview Mental Status (BI[CONDITION]) exam score of ninety-nine (99), which indicated the resident was not able to complete to the interview due to being seldom/never understood. The MDS also revealed the resident required extensive assistance of two (2) persons for the task of transfer. Review of the care plan for Resident #[AGE], dated 04/06/18 revealed the resident had deficits in activities of daily living (ADL) tasks and required the use of a Maxi-lift for all transfers. Review of the nurse aide care plan, dated as of 12/03/19, revealed Resident #[AGE] required a Maxi-lift for transfers. Review of the 5th floor certified nurse aide (CNA) guide, undated, revealed Resident #[AGE] required a Maxi-lift with assist of two (2) persons. Review of Nursing Progress noted, dated 08/27/19 at 6:13 PM, authored by Licensed Practical Nurse (LPN) #6, revealed resident was guarding the right leg and was observed to have pain upon movement. The note also stated the right leg was swollen from midway the calf through the right foot. The note further stated the resident was unable to to verbalize what was causing the pain and swelling. The LPN also documented the physician was contacted and received an order for [REDACTED]. Review of the radiology interpretation of the right lower extremity x-ray, performed on 08/27/19, revealed nondisplaced fractures of the distal tibia and fibula. Review of the incident investigation involving Resident #[AGE], initiated on 08/28/19, revealed a statement signed by a Certified Nurse Assistnat (CNA) #17, stating she provided Resident #[AGE] with a shower on 08/27/19. Further review of the statement revealed she was providing the shower without assistance of other staff and used the standup lift and transferred the resident into the wheelchair from the shower chair by herself. The statement then reveaked the resident slid out of the wheelchair onto the floor. Interview with CNA #17 was attempted, on 12/06/19 at 10:50 AM. Interview with CNA #1, on 12/03/19 at 2:47 PM, revealed she assisted CNA #17 to transfer Resident #[AGE] into the wheel chair, from the floor, in the shower room on 08/27/19. Interview with CNA's #12 and #13, on 12/06/19 at 9:06 AM and 9:11AM, revealed the level of assistance required by a resident is listed on the care plan provided to them at the beginning of the shift. Both CNA's referred to the care plans as the pocket sheets which detailed how a resident should be transferred, including any special equipment and how many persons are needed. Interview with Unit Manager #4, on 12/06/19 at 9:18 AM, revealed pocket sheets are given to all the staff at the start of the shift. She further stated if a staff member is not familiar with the residents she prefers to walk them around to the residents. She also stated CNA #17 admitted Resident #[AGE] fell in the shower on 08/27/19 and that she was transferring the resident by herself when it occurred. She stated the aide was immediately removed from the floor upon discovering this information. Interview with the Director of Nursing, on 12/06/19 at 2:48 PM, revealed the careplan is on the nurse aide Kardex. She further stated the pocket sheets are readily available and are a quick reference for the staff. She added every time there is a change the pocket sheets were updated. She stated CNA #17 was not following the care plan.

Based on observation, interview, record review and policy review it was determined the facility faciled to ensure resident's were afforded care and services for a safe environment for one (1) of thirty-five (35) sampled residents, Resident #[AGE]. Review of an investigation of an incident involving Resident #[AGE], dated 08/28/19, revealed a written statement by CNA #17, that she transferred the resident using a Standup Lift without assistance. She also revealed she reported to the nurse the resident was throwing a fit, but did not report the resident suffered a fall. The findings include: Review of the facility policy, Accident/Incident Reporting Policy, undated, revealed any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. Observation of Resident #[AGE], on 12/04/19 at 10:06 AM, revealed the resident lying in bed with a pillow propped behind the back and the resident tilted to the right side. Further observation revealed half side rails were up bilaterally and the bed was in a low position. The resident wore a hospital gown and stated the right leg was not hurting at that time. Review of the medical record revealed the facility admitted Resident #[AGE] on 08/18/15 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), quarterly assessment dated , 07/11/19, revealed the facility assessed the resident with a Brief Interview Mental Status (BI[CONDITION]) score of ninety-nine (99), and determined the resident was not able to complete the interview, as the resident was seldom/never understood. The MDS also revealed the resident required extensive assistance of two (2) persons for the tasks of transfer. Review of the care plan for Resident #[AGE], dated 04/06/18 revealed the resident had deficits in activities of daily living (ADL) tasks and required the use of a Maxi-lift for all transfers. Review of the nurse aide care plan, dated 12/03/19, revealed Resident #[AGE] required a Maxi-lift for transfers. Review of the 5th floor certified nurse aide (CNA) guide, undated, revealed Resident #[AGE] required a Maxi-lift with assist of two (2) persons. Review of Nursing Progress noted, dated 08/27/19 at 6:13 PM, authored by Licensed Practical Nurse (LPN) #6, revealed resident was guarding the right leg and was observed to have pain upon movement. The note also stated the right leg was swollen from midway the calf through the right foot. The note further stated the resident was unable to verbalize what was causing the pain and swelling. The LPN also documented the physician was contacted and received an order for [REDACTED]. Review of the radiology interpretation of the right lower extremity x-ray, performed on 08/27/19, revealed non-displaced fractures of the distal tibia and fibula. Review of the investigation of the incident involving Resident #[AGE], dated 08/28/19, revealed a written statement by CNA #17, that stated she transferred the resident using a Standup Lift by herself. She stated she did this because the resident was trying to have bowel movement. She revealed the resident then slid out of the wheelchair. She also revealed she reported to the nurse the resident was throwing a fit, but did not report the resident suffered a fall. Interview with CNA #17 was attempted, on 12/06/19 at 10:50 AM. The CNA answered and stated she would the call to the surveyor back but never returned the call. Interview with Unit Manager #4, on 12/06/19 at 9:18 AM, revealed CNA #17 admitted Resident #[AGE] had fallen in the shower on 08/27/19 and that she was transferring the resident by herself when it occurred. She stated the aide was immediately removed from the floor upon discovering this information. Interview with the Director of Nursing, on12/06/19 at 2:48 PM, revealed SRNA #17 was not following the care plan and should have reported the fall immediately.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement care plan interventions for seventeen (17) of sixty-four (64) sampled residents, Residents #7, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #25, #27, #37, #55 and #58. Interview and record review revealed the facility failed to implement care plan interventions for Resident #13 related to monitoring for weight loss and [MEDICAL CONDITION] medication use. The resident had a forty-two (42) pound weight loss. The resident was weighed at the facility on [DATE] with no documented evidence the resident was weighed from (MONTH) (YEAR) through (MONTH) 2019. The goal on the care plan was for the resident to maintain adequate nutrition and stable weight. On [DATE], the weight loss was identified when the resident was admitted to the hospital. In addition, the facility failed to assess a change in condition when the resident became lethargic and was taking [MEDICATION NAME] and [MEDICATION NAME]. The resident was transferred to the hospital, on [DATE], and diagnosed with [REDACTED]. Observation, interview, and record review revealed the facility failed to implement care plan interventions for Resident #16 related to supervision during meals, monitoring behaviors and wandering, providing incontinent care, monitoring for weight loss, and falls. Resident #16 had a sixty-five (65) pound weight loss from [DATE] through [DATE] with no evidence the facility requested a Dietitian consult for the significant weight loss. On [DATE], Resident #16 sustained a fall, which resulted in a right [MEDICAL CONDITION]. The fracture required a surgical repair and the resident expired from complications post surgery. Observations, interview, and record review revealed the facility failed to implement care plan interventions for Resident #55 related to monitoring the use of side rails and to observe for entrapment. On [DATE], the resident was observed to be entrapped, with arms and hands between the bed and the rail and head between the mattress and the rails. In addition, care plan interventions were not implemented for Resident #7 related to access to the call light; for Residents #12, #14, #15, #17, #18, #19, #20 and #25 related to assistance with meals and monitoring for choking; for Resident #21 related to pain management; for Resident #22 related to assistance with toileting; and Residents #27, #37 and #58 related to restorative services. The facility's failure to have an effective system in place to ensure care plans were implemented, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Record review of the facility's policy, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed the Comprehensive Care Plan would be a person-centered plan of care approach for each resident that included measureable objectives and timetables, which would be implemented to meet the resident's nursing, physical functioning, mental, and psychosocial needs. 1. Review of the closed clinical record revealed the facility admitted Resident #13 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #13's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15) and determined the resident was not interviewable. Review of Resident #13's Care Plan for [MEDICAL CONDITION] Medication use related to Behavior Management, initiated [DATE], revealed a goal for the resident to remain free from drug related complications, which included cognitive/behavioral impairment, through the next review date. The plan of care directed staff to administer medications as ordered, and monitor and document for side effects and effectiveness. In addition, staff should monitor and record target behaviors, per the facility protocol. The plan continued to direct staff to record and report to the physician medication side effects and adverse reactions such as refusal to eat, loss of appetite, fatigue, weight loss, and behavior symptoms not usual for the resident. Review of Resident #13's Psychiatric Periodic Evaluation (PPE), dated [DATE], revealed the resident received [MEDICATION NAME] 0.5 milligrams (mg) three (3) times a day for anxiety. Continued reviewed of the PPE revealed Resident #13 received a dose of [MEDICATION NAME] M-tab 0.5 mg every morning and 1 mg at 2:00 PM daily for Alzheimer's with Behaviors. Review of Nursing Documentation, dated [DATE], revealed Resident #13 kept falling asleep and the nurse attempted to feed the resident but he/she refused all attempts. The resident was unable to propel himself/herself in the wheelchair. All medications were given as ordered. However, nursing did not report these signs and symptoms to the physician per the plan of care. Continued review of nursing documentation and clinical record revealed no assessments detailing whether Resident #13 exhibited, or not, the identified target behaviors, per the plan of care, in order to track and manage his/her behaviors. Further review of Nursing Documentation, dated [DATE] and timed at 2:39 PM, revealed the resident was lethargic and would open eyes at times. The nurse felt uncomfortable giving the resident his/her afternoon medications, so she held the medications. The nurse continued to check on the resident every hour and the resident responded the same, each time. However, nursing did not report these signs and symptoms to the physician per the plan of care, nor was there evidence documented the resident exhibited target or disruptive behaviors. Nursing Documentation, on [DATE] at 2:38 PM, revealed the resident did not eat much breakfast, could not propel self, and fell asleep in the wheelchair. However, nursing staff did not report these signs and symptoms to the physician, or document the resident exhibited target behaviors per the plan of care. Continued review of Nursing Documentation revealed staff did not document notes on [DATE] through [DATE], regarding Resident #13's mental, behavioral, or physical health status nor whether the resident exhibited potential side effects of the [MEDICAL CONDITION] medication administered, as directed by the plan of care. Nursing staff made a note on [DATE], that Resident #13 received all morning medications, continued to sleep, and only ate a little breakfast. Further review revealed Resident #13 ate a small amount of lunch, kept falling asleep, and staff administered afternoon medications as ordered. However, nursing did not report these signs and symptoms to the physician per the plan of care. Nursing staff noted on [DATE] at 12:30 PM, Resident #13 received morning medications as ordered and continued to sleep. Staff did not make narrative notations from [DATE] through [DATE] on Resident #13's health or mental status per the plan of care. On [DATE], staff noted Resident #13 was lethargic and the nurse held the resident's morning dose of [MEDICATION NAME]. However, did not report these signs, symptoms, or nursing actions to the physician, per the plan of care. There was no documentation whether the resident experienced signs or symptoms from [MEDICAL CONDITION] medication administration per the plan of care until [DATE] at 9:34 AM, when staff noted Resident #13 received his/her morning medications then went back to sleep and did not eat his/her breakfast or lunch. Staff noted the resident experienced lethargy at lunch and held afternoon medications. Staff continued to note the resident was lethargic through the second shift and held nighttime medications. However, staff did not report these signs, symptoms, or nursing actions to the physician, per the plan of care. On [DATE] at 9:49 AM, nursing staff noted the resident experienced lethargy all night. The next morning nursing staff withheld morning medications due to the resident's lethargy and noted the resident did not eat breakfast. Staff noted at 2:17 PM, afternoon medications were held related to lethargy and notified the Nurse Practitioner (NP) of the resident's condition and received orders for laboratory blood tests. At 7:39 PM, staff notified the NP of Resident #13's abnormal laboratory results and received an order to transfer the resident to the hospital due to a change in mental status and for evaluation of possible [MEDICAL CONDITION]. Review of an Emergency Department (ED) Encounter Report, dated [DATE], revealed the resident's oxygen saturation during transport to the hospital was 83% (normal range 95% to 100%) on a 15-liter non-rebreather mask without improvement. The resident was diagnosed with [REDACTED]. In addition, Resident #13 received [DIAGNOSES REDACTED]. Due to Resident #13's poor prognosis, the hospital contacted the State Guardian regarding the need for Hospice/Palliative care. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 6:45 AM, revealed she did not know Resident #13's specific care plan interventions related to [MEDICAL CONDITION] medication use and behavior management. She did not know how to view the care plan in the electronic medical record to be aware of care plan interventions. LPN #10 stated if Resident #13's care plan interventions directed staff to monitor, document, and report findings to the physician related to [MEDICAL CONDITION] medication use, then staff should implement those interventions. However, the facility had not provided her with a form to use in order to document/track behavior occurrences, nor had she received recent training on the facility's policy related resident behavior monitoring. Per interview, on [DATE], Resident #13 exhibited lethargy and she held the resident's morning and evening medications. Resident #13 remained lethargic on [DATE], and she withheld the medications again. She stated she should have notified the physician per the plan of care regarding the change in condition on [DATE], but instead waited until around 2:00 PM on [DATE]. She received orders for laboratory testing, the results came back abnormal, and the next shift transferred the resident to the hospital. She stated she learned later from the Director of Nursing (DON) the resident experienced respiratory distress requiring a breathing machine once he/she reached the hospital. LPN #10 stated staff should follow the care plan to prevent resident decline. Interview with LPN #18, on [DATE] at 4:00 PM, revealed Resident #13's care plan directed staff with interventions for resident care; however, she had not reviewed Resident #13's care plan related to [MEDICAL CONDITION] medication use and behavior management to ensure she implemented the individualized interventions. She stated nursing staff should have assessed and reassessed the resident, per the plan of care, documented findings, and reported to the physician. She stated if staff did not implement the plan of care, resident harm could occur. Interview with Resident #13's Physician, on [DATE] at 11:00 AM, revealed he expected staff to monitor/track resident behaviors for him to better assess and [DIAGNOSES REDACTED]. He stated he expected nursing staff to follow the plan of care and he depended on nursing staff to provide information related to the resident's condition so he could provide orders to improve the resident's health status. Interview with the DON, on [DATE] at 8:30 AM, revealed Resident #13 had advanced Dementia with Behaviors and staff should have documented the resident's behaviors in the medical record, per the plan of care. The DON revealed nursing staff should have monitored the resident closely, documented the findings, and notified the physician, as directed by the plan of care. She stated if nursing did not follow the care plan, residents could experience a decline. Review of Resident #13's Nutrition Care Plan, initiated [DATE], revealed the resident had an issue related to obesity and the goal was for the resident to maintain adequate nutrition and stable weight and no signs or symptoms of malnutrition through the next review date. The interventions directed staff to monitor, document, and report to the physician signs or symptoms of dysphagia. Nursing staff should monitor medication side effects and effectiveness. In addition, staff was to obtain resident weight as ordered. Continued review of Resident #13's clinical record revealed the facility obtained a weight of 196 pounds on [DATE], and did not obtain or document another weight after [DATE]. Further review of the Hospital emergency room record, dated [DATE], revealed Resident #13 weighed 154 pounds upon admission, which was a 42 pound weight loss from [DATE]. Interview with Certified Nursing Assistant (CNA) #15, at 9:38 AM on [DATE], revealed the care plan and nurses reminded her which residents needed a weight obtained. She stated due to staffing issues she was not always able to obtain resident weights and she would have to pass it on to the next shift to do. She stated it was important to follow the care plan because if staff did not get the resident's weight, the resident could have a weight loss and staff would not know. Interview with LPN #10, on [DATE] at 6:45 AM, revealed the Assistant Director of Nursing (ADON) provided the unit with a list of required resident weights and she would direct the CNAs to weigh the residents on the list. She stated the unit did not always get all the residents on the list weighed timely and the next shift would have to obtain the weights. LPN #10 stated if the resident had a care plan directing staff to obtain weight, then the staff should follow the plan of care in order to assess for weight loss or gain. She stated residents could experience a weight loss and staff would not know, which could be harmful to the resident. Interview with ADON #1, on [DATE] at 7:31 AM, revealed she provided the unit with a list of residents that needed to be weighed. The unit did not always obtain the resident's weight the day it was scheduled and she would forget to follow-up and remind staff to obtain the weight. In addition, she stated the unit was under staffed, which prevented them from completing all required care planned tasks. The ADON stated she was not aware staff had not weighed Resident #13 since (MONTH) (YEAR), and she had not assessed the resident to determine if weight loss had occurred either. She revealed staff should follow care plan interventions requiring staff to obtain weights to monitor for weight loss or gain, and if not followed the resident could experience a decline. Interview with the DON, on [DATE] at 8:30 AM, revealed she was not aware staff had not weighed Resident #13 since (MONTH) of (YEAR). She stated the ADONs were to supervise staff and ensure they followed the plan of care. She stated if staff did not follow the plan of care regarding obtaining weights, a resident could experience a weight loss and decline. 2. Review of Resident #16's clinical record revealed the facility admitted the resident with the [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to need extensive assistance of one (1) person with meals. The resident weighed 183 pounds, which was based on the most recent measure in the last thirty (30) days. The facility determined the resident was not interviewable with a BIMS score of three (3) of fifteen (15). Review of Resident #16's CNA Care Plan, not dated, revealed the plan directed staff to provide meal supervision while eating and to offer the resident an opportunity to lay down for a nap after meals. Review of the Nutrition Plan of Care for Resident #16, initiated [DATE], revealed the resident had a nutritional problem related to obesity with a weight of 183.3 pounds. The goal stated the resident would maintain adequate nutritional status as evidence by maintaining a stable weight, with no signs or symptoms of malnutrition, and would consume at least 50% of most meals. The care plan directed staff to honor food preferences, monitor, document, and report to the physician any swallowing, choking, pocketing of food, drooling, or refusing to eat. In addition, staff was to weigh the resident per policy, weekly, and record. Review of the Memory Care Unit Meal Schedule, not dated, revealed the document listed Resident #16 under the Feeder Group for the CNAs to feed the resident during meals. Review of Resident #16's Medication Administration Record [REDACTED]. However, continued review of the MAR indicated [REDACTED]. Review of Resident #16's weights revealed on [DATE], the resident weighed 183.3 pounds, and on [DATE], the resident weighed 130 pounds. Review of Resident #16's MAR, dated (MONTH) 2019, revealed the facility recorded the resident's weight on [DATE] as 118 pounds, a difference of 65 pounds (from [DATE]). Observation, on [DATE] at 8:12 AM, revealed Resident #16 seated in his/her wheelchair in the Sunroom and he/she had a thin physique. CNA #13 served the resident his/her tray, fed the resident two (2) bites of food, cued the resident to drink his/her milk and juice, and then left the sunroom area to retrieve additional resident meal trays. When CNA #13 returned to the sunroom area, she passed by Resident #16 and asked him/her if he/she was still hungry and the resident replied yes. However, CNA #13 did not offer to assist the resident with eating the rest of his/her meal, per the resident's care plan, and continued delivering other residents' meal trays. At 8:47 AM, staff removed Resident #16's tray from him/her without asking if he/she was still hungry, if he/she wanted an alternative, or if he/she wanted to lay down after his/meal, per the plan of care. Interview with CNA #13 and #10, on [DATE] at 10:36 AM, revealed the plan of care directed staff in how to care for each resident. However, they had many tasks to complete and due to short staffing, they were not always able to implement residents' care plan interventions. They stated Resident #16 needed assistance with eating but they had to deliver other resident trays, answer call lights, and get others up for breakfast. Both CNAs stated they did not know which residents on the unit were at risk for choking or required monitoring during meals for choking hazards. In addition, they were not sure if Resident #16 had lost weight or not. Each stated nurses would notify them regarding which residents needed a weight obtained, per the plan of care. However, due to short staffing they did not always have time to weigh the residents. They both stated residents could have weight loss or choke if not assisted/monitored during meal service as directed per the plan of care. Interview with LPN #1, on [DATE] at 11:00 AM, revealed she did not receive a report regarding Resident #16's recent weight loss when she began her shift. Interview with LPN #27, on [DATE] at 8:15 AM, revealed Resident #16 had a recent weight loss but she did not know if it was a significant weight loss. She had noticed the resident would not eat very much of his/her meal; however, had not noticed if staff was consistently providing assistance with meals to ensure the resident consumed at least 50% of most meals per the plan of care or monitored for trouble swallowing. LPN #27 stated the resident's plan of care directed staff in the care of the resident and if staff did not implement the plan the resident could decline or lose weight. Interview with ADON #1, on [DATE] at 7:31 AM, revealed the plan of care directed staff in the care of the resident. She stated she was not aware Resident #16 had a significant weight loss. ADON #1 stated if the facility assessed the resident to need the assistance of one (1) with meals then staff should provide the assistance. Interview with the DON, on [DATE] at 8:30 AM, revealed the facility developed Resident #16's care plan using the resident's diagnoses, needs, strengths, and weakness. She stated the ADONs had not reported to her staff was not monitoring Resident #16 for choking risk or to ensure he/she ate at least 50 % of most meals. The DON stated she was ultimately responsible for ensuring Resident #16's care needs were met and if not met the resident could experience a decline. Further review of Resident #16's Quarterly MDS, dated [DATE], revealed the facility assessed the resident for the presence and frequency of Behavioral Symptoms and determined the resident had behaviors of public sexual acts, rummaging, and verbal/vocal symptoms like screaming or disruptive sounds one (1) to three (3) times during the assessment period. Review of Resident #16's CNA Care Plan, not dated, revealed the plan directed staff to monitor and record the resident's behavior and mood for occurrence of target behaviors of wandering and violence/aggression towards staff/others per the facility protocol. Continued review of Resident #16's Plan of Care, initiated on [DATE], revealed the resident had a Potential for Alteration in Mood/Behavior related to Anxiety, [MEDICAL CONDITION] with delusions, and Mood Affective Disorder. The desired outcome for the resident was for the resident to display less than two (2) signs or symptoms of mood/behavior decline weekly. The plan of care directed staff to approach the resident in a calm manner and explain care before beginning; provide an opportunity for the resident to vent feelings in a non-judgmental manner; and provide a structured care routine with a quiet environment when signs and symptoms of identified behaviors were present. Observation of the Memory Care Unit, on [DATE] at 7:49 AM, revealed nursing staff was in the nurses' station area while others delivered residents breakfast trays. Resident #16 was seated in his/her wheelchair with a white sheet wrapped around his/her shoulders in the area between the nurses' station and elevators. The resident yelled, Help me, three (3) times and then yelled, I am cold. However, staff did not address the resident's pleas for help. The resident continued to yell loudly, Please help me, I am cold, help, help, help, with no staff intervention until staff transported Resident #16 to the sunroom area for breakfast. Continued observation, on [DATE] from 7:19 AM to 10:36 AM, revealed Resident #16 yelled for help with little staff assistance to address his/her distress. Interview with CNA #20, on [DATE] at 9:30 AM, revealed Resident #16 hollered all the time. She stated the resident was always cold and they would give him/her blankets but he/she continued to yell. She stated the Memory Care unit had just recently opened; however, she had very little training on interventions for dementia care. CNA #20 stated staff should implement the plan of care to meet the residents' physical and emotional needs. Interview with LPN #14, on [DATE] at 2:00 PM, revealed the care plan directed staff in the care of the resident. She stated she was not sure of Resident #16's care plan interventions for behaviors, but she had heard Resident #16 hollering while she passed medications. The LPN stated Resident #16 yelled out quite a bit and she provided him/her the white sheet early in the morning after the resident hollered he/she was cold. She stated the unit was shorted staff and it was difficult to meet resident needs when staff had to complete medication pass, dressing changes, and answer lights and such. LPN #14 stated it was important for staff to implement resident care plan interventions in order to address resident needs and/or prevent decline. She stated staff did the best they could. Further review of Resident #16's Quarterly MDS, dated [DATE], revealed the facility assessed the resident did not display wandering behavior. However, review of the Care Plan noted Resident #16 had a behavior of Wandering the unit and going in and out of other residents' rooms. The care plan directed staff to redirect and educate the resident when trying to enter female residents' rooms. In addition, staff was to redirect the resident when found in areas that he/she should not be and should check on the resident frequently to make sure he/she stayed in common areas and not in other resident rooms. Further observation at 7:54 AM on [DATE], revealed Resident #16 rolled himself/herself into room [ROOM NUMBER] while he/she continued to yell, Help me. Two (2) residents were in their beds with eyes closed as Resident #16 stopped at the end of bed 2 and continued to yell, Oh no, oh I am cold. However, staff did not respond to redirect the resident per the plan of care. At 8:06 AM the resident hollered, Hey, hey, help me, it is cold, wow I am cold, as he/she wheeled himself/herself out of room [ROOM NUMBER] and into room [ROOM NUMBER]. The resident continued to yell help while in the room. At 8:10 AM, staff was close by and walked past room [ROOM NUMBER] without addressing Resident #16's pleas or attempt to redirect the resident per the plan of care. Interview with CNA #13 and #10, on [DATE] at 10:36 AM, revealed each had numerous duties and the unit was short staff, which prevented them from implementing all resident care plan interventions, such as monitoring the resident wandering and yelling behaviors. Per the Quarterly MDS, dated [DATE], revealed the facility assessed the resident was always incontinent of bowel and bladder and required extensive assistance of two (2) staff for toileting. Resident #16 also had a Care Plan related to Skin Breakdown due to incontinence and UTIs, initiated [DATE]. The care plan directed staff to check the resident every two (2) to three (3) hours and as required for incontinence, monitor/document for signs or symptoms of UTIs, altered mental status, and change in behavior or eating behaviors. Review of Resident #16's CNA Care Plan, not dated, revealed the plan directed staff to check and change the resident every two (2) to three (3) hours and as required for incontinence. Continued observation on [DATE] at 9:29 AM, revealed Resident #16 yelling, Stomach killing me, somebody help me, as CNA #32 passed by with another resident's breakfast tray. At 9:46 AM on [DATE], the resident left the Activity Room and went into room [ROOM NUMBER], stopped by the end of the second bed and yelled, Oh my stomach hurts, help me, without staff intervention. Again, the resident yelled his/her stomach hurt awful bad and it was killing him/her and the resident had to poop. However, staff did not transport the resident to the toilet until 10:36 AM and observation revealed the resident's brief was wet with urine and had feces in it. Interview with CNA #32, on [DATE] at 9:23 AM, revealed she heard Resident #16 yell; however, she was on light duty and could not toilet residents because of a back injury. She stated if staff did not assist residents per the plan of care, the resident could experience a decline. Interview with CNA #13 and #10, on [DATE] at 10:36 AM, revealed Resident #16's plan of care directed them to check/change/toilet the resident every two (2) to three (3) hours. They stated the third shift staff had gotten the resident up before 6:00 AM and they had not toileted the resident since they had arrived on duty. They stated each had numerous duties and the unit was short staff, which prevented them from implementing all resident care plan interventions. They stated residents could experience decline, skin breakdown, weight loss, and distress if needs were not met per the plan of care. Interview with LPN #7, at 10:45 AM on [DATE], revealed the plan of care directed staff in how to meet the residents' care needs and if not implemented, residents could experience decline or harm. She stated staff should toilet residents every two (2) to three (3) hours or as needed. LPN #7 stated she was not aware Resident #16 had not been toileted since he/she had gotten out of bed. LPN #7 revealed residents could experience skin breakdown if staff did not provide incontinent care per the plan of care. She stated Resident #16 wandered the unit every day and it was hard to implement care plan interventions for that behavior when they were short staffed. Interview with LPN #1, on [DATE] at 11:00 AM, revealed she had heard the resident hollering but had many tasks to complete and was not aware staff had not toileted the resident since they had arrived for work. She stated staff should implement the plan of care to meet the resident's needs or he/she could experience a decline. Further review of Resident #16's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required the extensive assistance of two (2) with transferring from a seated to a standing position. Review of Resident #16's Falls Plan of Care, initiated on [DATE], revealed the resident was at risk for falls due to a history of falls, cognitive impairment, and decreased safety awareness. In addition, the resident had impulsiveness and attempted to stand or self-transfer without assistance from staff. The plan of care directed staff to reposition the resident every two (2) to three (3) hours for comfort, to anticipate and meet the individual needs of the resident, and for staff to respond promptly to all requests for assistance. Observation, on [DATE] at 7:49 AM, revealed Resident #16 leaned forward then back, scooted his/her bottom close to the edge of the seat, and straightened his/her legs out in front of him/her. However, staff did not reposition the resident to prevent a fall, per the plan of care. Observation, on [DATE] at 7:46 AM, revealed Resident #16 leaned forward, scooted his/her bottom to the edge of the wheelchair, and yelled, Help me, with no staff intervention. At 8:01 AM and 8:27 AM, Resident #16 continued to holler and lean forward in the wheelchair. However, staff did not reposition the resident to prevent a fall, per the plan of care. Review of Nursing Documentation, dated [DATE] and timed at 9:11 AM, revealed LPN #13 witnessed the resident slide out of his/her wheelchair onto the floor in the Sunroom and no injuries were noted at that time. At 2:45 PM, nursing staff noted resident complained of pain. A physician order [REDACTED]. The facility transferred the resident to the hospital for treatment at 9:04 PM. Review of Hospital Discharge Documentation for Resident #16, dated [DATE], revealed on [DATE], Resident #16 had a surgical repair of the right femur fracture and passed from complications after the surgery. Interview with the Administrator, on [DATE] at 10:27 AM, revealed nursing leaders had not brought it to his attention that staff

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents at risk for choking were monitored during meals to prevent accidents for nine (9) of sixty-four (64) sampled residents, Resident #12, #14, #15, #16, #17, #18, #19, #20, and #25. Review of Resident #16's Falls Care Plan, initiated on [DATE], revealed the resident was at risk for falls due to a history of falls, cognitive impairment, and decreased safety awareness. In addition, the resident had impulsiveness and attempted to stand or self-transfer without assistance from staff. The plan directed staff to anticipate and meet the individual needs of the resident, and for staff to respond promptly to all requests for assistance. Observation on [DATE] at 7:46 AM, revealed Resident #16 leaned forward, scooted his/her bottom to the edge of the wheelchair; however, staff failed to react to reposition the resident to prevent a fall. Review of Nursing Documentation, dated [DATE] and timed at 9:11 AM, revealed Licensed Practical Nurse (LPN) #13 witnessed the resident slide out of his/her wheelchair onto the floor in the Sunroom and no injuries were noted at that time. At 2:45 PM, nursing staff noted resident complained of pain. A physician order [REDACTED]. The facility transferred the resident to the hospital for treatment at 9:04 PM. Review of Hospital Discharge Documentation for Resident #16, dated [DATE], revealed the hospital determined upon admission, on [DATE], the resident was septic, most likely from a Urinary Tract Infection [MEDICAL CONDITION]. On [DATE], Resident #16 had a surgical repair of the right femur fracture. However, after surgery the resident'[MEDICAL CONDITION] led to acute [MEDICAL CONDITION], which required a breathing tube and machine. After placement on the breathing machine, the resident lost his/her pulse. The documentation revealed hospital staff attempted to resuscitate the resident multiple times, but resuscitation ceased after state guardianship notification of the resident's poor opportunity for a meaningful recovery occurred and the resident passed. Record review revealed Resident #12, #14, #15, #16, #17, #18, #19, #20, and #25 were assessed needing supervision when eating to monitor for choking; however, observations revealed staff served the residents their meals and left the residents unsupervised while they ate. Resident #20 coughed while eating his/her breakfast and no staff was supervising the resident while he/she ate in case the resident began to choke. The facility's failure to have an effective system in place to ensure resident safety has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Incident/Accidents/Falls, not dated, revealed if a resident was found to be at risk for falls the resident's care plan would be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place to prevent falls. Review of the facility's policy, Aspiration Precautions, not dated, revealed aspiration was a common problem among the resident who had difficulty swallowing or diagnosed with [REDACTED]. When such material went into the lungs it could cause Aspiration Pneumonia, which could worsen quickly if not identify and treated. Residents identified at risk would be monitored on a regular basis. Review of the facility's policy, Meal Service, not dated, revealed all residents would be provided adequate supervision to meet each resident's nursing and meal service needs. Residents would be monitored for appropriate positioning, diet consumed, food preferences, and feeding assistance. 1. Review of the clinical record revealed the facility admitted Resident #16 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was not interviewable with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15). The facility determined the resident required extensive assistance of two (2) staff with transferring from a seated to a standing position. Per the MDS, the resident had no falls since the last assessment. Review of Resident #16's Falls Care Plan, initiated on [DATE], revealed the resident was at risk for falls due to a history of falls, cognitive impairment, and decreased safety awareness. In addition, the resident had impulsiveness and attempted to stand or self-transfer without assistance from staff. The plan directed staff to reposition and check for incontinence every two (2) to three (3) hours for comfort, to anticipate and meet the individual needs of the resident, and for staff to respond promptly to all requests for assistance. Review of Nursing Documentation for Resident #16, dated [DATE], revealed the nurse heard Resident #16 yelling out for help. Nursing staff found the resident in his/her room sitting on the floor in front of his/her wheelchair. Nursing noted no injuries and the resident reported he/she was hurting all over. Observation, on [DATE] at 7:49 AM, revealed Resident #16 leaned forward then back, scooted his/her bottom close to the edge of the seat, and straightened his/her legs out in front of him/her without staff intervention to prevent a fall. Observation on [DATE] at 7:46 AM, revealed Resident #16 leaned forward, scooted his /her bottom to the edge of the wheelchair, and yelled, Help me, with no staff intervention. At 8:01 AM, Resident #16 hollered, Please hey, help me, oooh I am pooping, hey, hey. Resident #16 then grunted, leaned forward in the wheelchair, and again hollered, Help me, help me, help me, please hey, help me, without staff intervention to prevent a fall. Observation of Resident #16, at 8:27 AM on [DATE], revealed he/she leaned over in his/her wheelchair without staff intervention to prevent a fall. Review of Nursing Documentation, dated [DATE] and timed at 9:11 AM, revealed LPN #13 witnessed the resident slide out of his/her wheelchair onto the floor in the Sunroom and no injuries were noted at that time. At 2:45 PM, nursing staff noted resident complained of pain. A physician order [REDACTED]. The facility transferred the resident to the hospital for treatment at 9:04 PM. Review of Hospital Discharge Documentation for Resident #16, dated [DATE], revealed the hospital determined upon admission, on [DATE], the resident was septic, most likely from a UTI. On [DATE], Resident #16 had a surgical repair of the right femur fracture. However, after surgery the resident'[MEDICAL CONDITION] led to acute [MEDICAL CONDITION], which required a breathing tube and machine. After placement on the breathing machine, the resident lost his/her pulse. The Documentation revealed hospital staff attempted to resuscitate the resident multiple times, but resuscitation ceased after state guardianship notification of the resident's poor opportunity for a meaningful recovery occurred and the resident passed. Interview with LPN #13, on [DATE] at 2:36 PM, revealed she was in the sunroom when Resident #16 fell from his/her wheelchair. LPN #13 stated she was in the room area tending to another resident when she noticed Resident #16 lean forward in his/her wheelchair. She stated Resident #16 does this frequently but this time the resident leaned forward too far and toppled out of the wheelchair. LPN #13 stated she observed Resident #16 leaning forward and realized the resident was going to fall out from the wheelchair be she was not able to get to Resident #16 to prevent the fall. LPN #13 stated she helped with an assessment of Resident #16 after the fall. The resident moved all extremities and made no complaints of any pain or discomfort. LPN #13 stated the resident began complaining of leg pain later in the evening. Additionally, LPN #13 stated she completed and submitted an incident report but was unable to verbalize what happened with the incident report or where the facility was regarding an investigation into the fall. Interview with Director of Nursing (DON), on [DATE] at 8:30 AM, revealed Resident #16 was at risk for falls and staff were aware the resident would abruptly stand without assistance. However, it was important for staff to anticipate resident needs. She stated at the time of Resident #16's fall the nurse was across the room and could not get to him/her to prevent the fall from the wheelchair. Interview with the Administrator, on [DATE] at 10:27 AM, revealed the residents on the seventh floor needed more supervision due to the [DIAGNOSES REDACTED].#16 and could not get to him/her in time to prevent the fall from the wheelchair. He stated it was his expectation staff provide the required supervision for resident safety. Continued review Resident #16's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) staff during meals. Review of Resident #16's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff was to monitor for a concerned appearance while eating. Observation, on [DATE] at 8:12 AM, revealed Resident #16 seated in his/her wheelchair in the Sunroom and Certified Nursing Assistant (CNA) #13 served the resident his/her tray and fed the resident two (2) bites of food. CNA #13 cued the resident to drink his/her milk and juice and then left the sunroom area to retrieve additional resident meal trays. No other staff was present in the Sunroom to monitor the resident while he/she drank and attempted to pick at his/her food to monitor for coughing, pocketing, or choking risk. Interview with CNA #10, on [DATE] at 10:36 AM, revealed if Resident #16 was at risk for choking and if staff did not monitor the resident, he/she could aspirate food/liquid. Interview with CNA #13, on [DATE] at 10:36 AM, revealed she did not know she had to monitor the resident for choking risk. She stated if the resident was at risk for choking, staff should remain in the dining area to monitor for choking. 2. Review of the clinical record revealed the facility admitted Resident #12 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #12's Admission MDS, dated [DATE], revealed the facility assessed the resident required limited assistance with one (1) staff for eating. Review of Resident #12's Physician Orders, for (MONTH) 2019, revealed staff was to encourage the resident to perform a double swallow with each bite of solid food. Review of Resident #12's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff should watch the resident for multiple swallowing attempts when eating his/her meal. Observation, on [DATE] at 8:10 AM, of Resident #12 revealed staff served the resident his/her breakfast in his/her room and left. The resident began to consume food without staff present to encourage the resident to perform a double swallow. Interview, on [DATE] at 8:15 AM, with Certified Medication Technician (CMT) #3 revealed she did not know which residents on the unit were at risk for choking or if it was ok for residents at risk for choking to remain in their room without staff supervision. She stated if staff did not supervise residents at risk for choking, the resident could choke, and staff would not be there to provide assistance. Interview, on [DATE] at 10:05 AM, with LPN #1 revealed Resident #12 had a recent stroke and was at risk for choking. The nurse stated staff should monitor residents at risk for choking during meals. However, she did not know staff had not supervised Resident #12 during his/her breakfast meal. She stated the resident could experience harm if not supervised while eating their meals. 3. Review of the clinical record revealed the facility admitted Resident #14 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required supervision and setup during meals. Review of Resident #14's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff should watch to see if the resident appeared concerned during meals. Observation of Resident #14, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast tray and left the room. The resident consumed his/her breakfast meal without staff supervision to monitor for pocketing, choking, or coughing. Interview, on [DATE] at 10:36 AM, with CNA #13 and #10 revealed if residents were at risk for choking and were not monitored they could aspirate food/liquid without staff knowledge. Both CNAs stated they could not remain in the Sunroom, deliver trays, and get residents up for breakfast at the same time. Each stated it was important to prevent accidental choking by monitoring residents while they ate. Interview with Assistant Director of Nursing (ADON) #1, on [DATE] at 07:31 AM and the Director of Nursing (DON) at 8:30 AM, revealed both were not aware staff had not provided supervision while Resident #14 ate his/her meal. Each stated the resident could experience harm if not monitored since he/she was at risk for choking. 4. Review of the clinical record revealed the facility admitted Resident #15 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #15's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) staff during meals. Review of Resident #15's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. Observation of Resident #15, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast and left the room instead of providing supervision to monitor for pocketing, choking, or coughing. Interview, on [DATE] at 9:23 AM, with CNA #32 revealed she did not know which residents required supervision while eating until the Administrator informed the staff. She stated if Resident #15 was at risk for choking and staff did not remain in the Sunroom while the resident ate, he/she could choke, and no one would know. Interview, on [DATE] at 11:00 AM, with LPN #1 revealed she was not aware Resident #15 required monitoring for choking risk. She stated if the resident was at risk for choking, staff should definitely supervise the resident while he/she ate his/her meal for safety reasons. 5. Review of the clinical record revealed the facility admitted Resident #17 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #17's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required supervision and meal tray set-up during meals. Review of Resident #17's Physician Orders, dated (MONTH) 2019, revealed staff was directed to cut the resident's food into small pieces and monitor to remind him/her to eat slowly. Review of Resident #17's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff was to monitor for a concerned appearance while eating. Observation of Resident #17, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast and did not stay to supervise for pocketing, choking, or coughing while the resident ate his/her breakfast. Interview with CNA #32, on [DATE] at 9:23 AM, revealed she did not know she had to monitor the resident while eating until the Administrator informed her of the resident's care need. She stated if Resident #17 required supervision due to the risk of choking while eating staff should remain in the Sunroom until the resident had finished his/her meal. Interview with LPN #1, on [DATE] at 11:00 AM, revealed she did not know Resident #17 required supervision in the Sunroom while he/she ate, until the Administrator informed the staff they needed to remain the Sunroom until the resident finished the meal. She stated if a resident was at risk for choking, and staff left the Sunroom, a resident could choke and no one would know. 6. Review of the clinical record revealed the facility admitted Resident #18 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #18's Admission MDS, dated [DATE], revealed the facility assessed the resident required supervision and one (1) staff to assist during meals. Review of Resident #18's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff was to monitor for a concerned appearance while eating. Observation of Resident #18 in the Sunroom, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast and did not remain in the Sunroom to monitor the resident for choking risk while he/she ate breakfast. Interview, on [DATE] at 11:00 AM, with LPN #1 revealed it was the first time she had worked the Dementia Care unit and she did not know if Resident #18 was at risk for choking. She stated if the resident was at risk and staff did not monitor the resident while eating, he/she could choke and staff would not know. 7. Review of the clinical record revealed the facility admitted Resident #19 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #19's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required limited assistance of one (1) staff to eat during meals. Review of Resident #19's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff was to monitor for a concerned appearance while eating. Observation of Resident #19 in the Sunroom, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast and left the Sunroom to serve other resident meals. Continued observation revealed no staff was present to monitor for choking risk. Interview with CNA #32, on [DATE] at 9:23 AM, revealed she was not aware she had to stay and supervise residents while they ate. CNA #32 stated if Resident #19 was at risk for choking and staff left the Sunroom while the resident ate, the resident could choke and no one would know. 8. Review of the clinical record revealed the facility admitted Resident #20 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #20's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required the limited assistance of one (1) staff during meals. Review of Resident #20's Nutritional Care Plan, last reviewed [DATE], revealed staff was directed to monitor the resident during meals for signs and symptoms of Dysphagia such as pocketing, choking, coughing, and drooling. In addition, staff was to monitor for a concerned appearance while eating. Observation of Resident #20, on [DATE] at 8:12 AM, revealed staff served the resident his/her breakfast and did not remain to monitor for choking risk. A visitor came and sat with Resident #20 who coughed while eating and the visitor told Resident #20 to not choke eating his/her toast. No staff was present in the Sunroom while Resident #20 ate his/her breakfast. Interview, on [DATE] at 10:36 AM, with CNA #10 revealed she was busy delivering other resident trays and could not stay in the Sunroom to monitor residents. She stated she did not know which residents were at risk for choking and required supervision while eating. However, if a resident was at risk for choking, staff should supervise while eating to provide assistance. Interview, on [DATE] at 11:00 AM, with LPN #1 revealed she did not know if Resident #20 had a risk for choking. She stated if the resident was at risk, staff should monitor for choking while the resident ate his/her meal to ensure the resident's safety. 9. Review of Resident #25's clinical record revealed the facility admitted the resident on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #25's Quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) staff with eating. Review of Resident #25's Nutritional Care Plan, last reviewed [DATE], revealed staff was to monitor for pocketing, choking, coughing, or drooling, several attempts to swallow, or refusal to eat. Observation, on [DATE] at 8:34 AM, revealed staff delivered and set up Resident #25's breakfast tray in his/her room and left the room with the table at arm's length from the resident. At 9:22 AM, the resident was eating and staff was not in the room to monitor for choking. Interview with ADON #1, on [DATE] at 7:31 AM and the DON at 8:30 AM, revealed they had not made staffing assignments to ensure staff monitored residents at risk for choking while eating. Each stated residents at risk could choke while eating and staff would not be present to tend to the residents' needs. Further interview, on [DATE] at 8:30 AM, with the DON revealed when a resident was at risk for choking, staff should provide supervision during meals. She stated nursing leaders were responsible for monitoring and ensuring this occurred. However, she was not aware staff had not monitored residents while eating and she was ultimately responsible for ensuring staff supervised residents at risk for choking were monitored during meals. Interview with the Administrator, on [DATE] at 10:27 AM, revealed he identified staff had not provided supervision to the residents while eating on [DATE], and directed staff to remain in the Sunroom until the residents finished their meals. He stated residents could choke and experience harm if not supervised. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was

Based on observation, interview, record review, and review of the facility's assessment, it was determined the facility failed to ensure adequate staffing was provided to meet the needs of thirteen (13) of sixty-four (64) sampled residents, Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #25, #27, #37, and #58. Observation, interview, and record review revealed staff was unable to provide assistance at meals and monitoring residents assessed at choking risk, weigh residents per the facility's policy and/or physician order, and provide restorative services due to insufficient staff. Resident #13 was to be monitored for weight loss. However, the only weight documented on the resident was 196 pounds recorded on [DATE]. The resident was weighed on [DATE], when admitted to the hospital with [REDACTED]. Resident #16 sustained a significant weight loss of sixty-five (65) pounds from (MONTH) (YEAR) through [DATE]. However, continued review of the medical record revealed the facility did not reweigh the resident to confirm the significant weight loss per policy. Residents #12, #14, #15, #17, #18, #19, #20, and #25 were to be assisted with meals and monitored for choking; however, observations throughout the survey revealed this was not provided. Residents #27, #37, and #58 did not receive restorative nursing per their plan of care. The facility's failure to have an effective system to provide adequate nursing staff has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to an E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Resident Census and Conditions of Residents, dated [DATE], revealed the facility had a census of 216 residents. Of these residents, 177 required the assistance of at least one (1) or two (2) staff to total dependence for bathing; 182 resident required the assistance of at least one (1) or two (2) staff to total dependence for dressing; and 184 residents required the assistance of at least one (1) or two (2) staff to total dependence for transferring. In addition, 175 resident required the assistance of at least one (1) or two (2) staff to total dependence for toilet use; and 63 residents required the assistance of at least one (1) or two (2) staff to total dependence to eat. Interview with the Director of Nursing, on [DATE] at 1:38 PM, revealed the facility did not have a policy specific to staffing. 1. Review of the facility's Facility Assessment Tool revealed the facility determined a staffing level for each resident floor to include five (5) registered nurses (RN) and/or licensed practical nurses (LPN) each day, and nine (9) direct care staff (Certified Nursing Assistants (CNA) and/or Certified Medication Technicians (CMT)) each day for each resident floor. This staffing level required thirty (30) RNs and/or LPNs daily, and fifty-four (54) CNAs and/or CMTs daily. The facility assessment indicated the facility needed two (2) nurses for each floor for first and second shifts, and one (1) nurse during third shift. In addition, the assessment indicated a staffing level included four (4) CNAs for each floor on first shift, three (3) CNAs on each floor during second shift, and two (2) CNAs on each floor for third shift. Additional review of the facility assessment revealed staffing guidelines included two (2) nurses scheduled on each of the six (6) resident floors for the first and second shifts, for a total of twelve (12) nurses for each shift. Review of the (MONTH) staffing sheets reveled twenty-one (21) days ([DATE], 3, 4, 6, 7, 8, 10, 12, 13, 15, 16, 17, 18, 20, 21, 22, 26, 27, 28, and 29), in which twelve (12) nurses were not staffed for the first shift. Multiple days the nurse staffing numbers included CMT's. Review of second shift staffing revealed zero (0) days in (MONTH) in which twelve (12) nurses were staffed. Review of the staffing sheets, dated [DATE] - [DATE], revealed fourteen (14) days in which the number of nurses staffed for the first shift was below twelve (12), (February 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 16, 17, 18,and 21). Review of the second shift staffing sheets revealed no days during this time period in which twelve (12) nurses were scheduled as per the facility assessment. Interview with CNA #1, on [DATE] at 1:50 PM, revealed there was supposed to be four (4) CNAs on the floor at all times. She stated some residents needed a two (2) person assist and if two (2) CNAs were with a resident there was only one (1) or no other CNA for the rest of the residents. At this time, there were only two (2) CNAs on the floor. Interview with CNA #6, on [DATE] at 3:00 PM, revealed there were supposed to be four (4) CNAs on the unit on all shifts; however, most of the time there were only two (2). CNA #6 revealed when only two (2) CNAs, it was hard to attend to every residents' needs. Interview with CNA #8, on [DATE] at 1:35 PM, revealed it was the CNAs' responsibility to pass out food trays and complete care for the resident such as feeding, changing, showering, and all other Activities of Daily Living (ADL) even when short staffed. CNA # 8 stated some nurses did assist but they do not have to help. She revealed yesterday was the first time the nurses helped pass out meal trays. Interview with CNA #13 and #10, on [DATE] at 10:36 AM, revealed the memory care unit was short staff on several shifts and this prevented them from providing the needed care and supervision for residents that wandered or were at risk for falls, as they stated they could only be in one place at a time. CNA #10 and #13 stated at times they would be assigned to go to other floors to check and change other residents when the other floor was short staffed, which left the nurse on the floor to monitor all the residents and provide care with one other CNA. Both believed this was an unsafe practice. They stated if both were in a room providing care to a resident that required two (2) person assist, that left no staff on the floor monitoring call lights or other residents. Both stated residents could experience harm or a decline if sufficient staff were not available to meet their care needs. Interview with LPN #1, on [DATE] at 1:52 PM, revealed at this time there was only two (2) CNAs on the floor. She stated sometimes there were only a nurse and a CMT on the floor. Interview with LPN #2, on [DATE] at 1:55 PM, revealed there were numerous call-ins from the CNAs, three (3) to four (4) per shift. She stated the CNAs would call out for any reason. Interview with LPN #34, on [DATE] at 3:35 PM, revealed the residents on this floor required more staff than what was on the schedule as this was a high acuity floor, and there were two (2) CNAs and two (2) nurses on the floor. LPN #34 stated this was too much for four (4) people to handle. 2. Observation, interview, and record review revealed the facility failed to provide care and services to Resident #16 related to supervision during meals and monitoring for weight loss. Resident #16 had a 65 pound weight loss from [DATE] through [DATE]. Interview and record review revealed the facility failed to provide care and services to Resident #13 related to monitoring for weight loss. The resident had a 42 pound weight loss. The resident weighed 196 pounds on [DATE] with no documented evidence the resident was weighed from (MONTH) (YEAR) through (MONTH) 2019. On [DATE], the resident was admitted to the hospital and had an admission weight of 154 pounds. On [DATE] at 10:36 AM, interview with CNA #13 and #10 revealed they had many tasks to complete and the unit was short staffed on several shifts, which prevented them from always meeting the resident's needs. They stated Resident #16 needed assistance with eating; however, they had to deliver other resident trays, answer call lights, and get others up for breakfast. Each stated the nurses would notify them regarding which residents needed a weight obtained but due to short staffing, they did not always have time to weigh the residents. Interview with CNA #15, at 9:38 AM on [DATE], revealed the care plan and nurses reminded her which residents needed a weight obtained. She stated due to staffing issues she was not always able to obtain resident weights and she would have to pass it on to the next shift to do. Interview with Assistant Director of Nursing (ADON) #1, on [DATE] at 7:31 AM, revealed she provided the unit with a list of residents that needed to be weighed. The unit did not always obtain the resident's weight the day it was scheduled and she would forget to follow-up and remind staff to obtain the weight. In addition, she stated the unit was under staffed, which prevented them from completing all required care planned tasks. 3. Interview and record review revealed the facility failed to provide care and services to Residents #12, #14, #15, #16, #17, #18, #19, #20, and #25 related to supervision when eating to monitor for choking. Observations revealed staff served the residents their meals and left the residents unsupervised while they ate. Resident #20 coughed while eating his/her breakfast and no staff was supervising the resident while he/she ate in case the resident began to choke. On [DATE] at 10:36 AM, interview with CNA #13 and #10 revealed since they were short staffed frequently, staff could not remain in the Sunroom to monitor and help residents with meals because they were too busy delivering trays and getting residents out of bed. 4. Interview and record review revealed the facility failed to provide restorative services consistently to Residents #27, #37, and #58. Interview with CNA #11, on [DATE] at 8:45 AM, revealed the floor CNAs were responsible for completing the residents' restorative therapy; however, she stated there was not enough time for the floor CNAs to do the therapy. She stated if they did all the restorative therapy they were supposed to, the CNAs would get nothing else done. Interview with CNA #1, on [DATE] at 10:50 AM, revealed the floor CNAs were responsible for doing restorative therapy with residents but the therapy was not being done because there was not enough time. Interview with LPN #2, on [DATE] at 11:07 AM, revealed the facility did not have restorative aides and the floor CNAs were supposed to do the therapy. However, per interview, the first shift CNAs did not have time to complete restorative therapy. Interview with ADON #1, on [DATE] at 7:31 AM, revealed units were short staffed routinely due to staff calling in sick or just not showing up to work. She stated the staff on duty did the best they could to meet resident needs, but could only do so much working short. The ADON stated she did not know staff was not weighing residents routinely and this was due to the facility not having enough staff to complete all tasks every day. She stated residents could experience weight loss, falls, or distress if the facility did not provide adequate staffing to meet resident care needs. Interview with the Director of Nursing (DON), on [DATE] at 8:30 AM, revealed the facility assessment helped them determined the staffing numbers for each unit in order to meet the needs of the residents. However, the facility could not meet those staff numbers consistently. She stated the facility had a lot of employees call in for various reasons, which resulted in the units not having the desired number of staff. She stated nursing leaders had gotten creative with staffing assignments to try to meet resident needs. She stated there were nights when units did not have enough CNAs, and CNAs on floors with enough staff were assigned to leave their floor at certain times to go to another floor to care for the residents that did not have a CNA to care for them. The DON believed this was a good solution, even though it left the other floor short staffed. She stated she was not aware staff could not perform incontinent care rounds every two (2) hours, or that staff did not obtain residents weights as ordered due to being short staffed. She stated she depended on the ADONs to supervise and report care not provided. She stated the office nursing staff had worked some four (4) hour shifts to help but she had not mandated they work when not all shifts were covered to ensure resident care needs were met. The DON stated she had requested to hire agency staff to help ensure resident needs were met; however, the request was declined. She stated sufficient staff should be provided to meet the residents care needs; however, the facility was having difficulty doing so. Interview with the Administrator, on [DATE] at 10:27 AM, revealed nursing leaders had not brought it to his attention resident needs were not met. He stated the facility had experienced issues with staffing since [DATE], and at times did not have adequate staffing numbers according to the facility's assessed staffing needs to ensure resident care needs were met. He stated the facility had seven (7) floors, six (6) of which had residents residing. The Administrator stated each floor should have two (2) licensed nurses and four (4) CNAs when there was a full census on day shift, which averaged thirty-eight (38) to forty (40) residents, except the Dementia unit that had twenty (20) or more residents. On second shift the CNA number dropped to three (3) on each floor with two (2) nurses and the night shift had two (2) CNAs and one (1) nurse. Per interview, on nights when CNAs called in, a staffing decision was made to have a CNA from another floor go make rounds on the short floor to provide incontinent care. He stated he had not mandated the office nursing staff to work the floors when the units were short staff. In addition, he had not approved the DON's request for agency staff until [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed an assessment of Resident #55 regarding the use of side rails and determined the resident would benefit from a scoop mattress. Additionally, the DON revealed all residents were assessed for side rail use as indicated, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The DON stated she or the ADONs had monitored ten (10) residents three (3) days weekly on a rotating basis as indicated. Interview with the ADON #1 and #3, on [DATE] at 5:55 PM, revealed all residents were assessed for side rail usage, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The ADONs stated they or the DON had monitored ten (10) residents for side rail usage three (3) days weekly on a rotating basis as indicated. Review of facility records revealed ten (10) residents were monitored for side rails as indicated. 2. Interview with the DON, on [DATE] at 6:35 PM, revealed she, the Administrator, and the Staff Scheduler assessed facility staffing levels and prepared a sufficient staffing schedule. She stated she and/or the Administrator and the Staff Scheduler reviewed schedules daily, prior to the actual date to allow for adjustments. In addition, the DON, the Administrator, and/or the Regional Director of Operations (RDO) met at least weekly to discuss staffing concerns. The DON stated she, the ADONs, or the SSD interviewed at least fifteen (15) interviewable residents, and fifteen (15) staff members weekly to ensure resident needs were met and staffing assignments completed. Interview with the Administrator, on [DATE] at 7:05 PM, revealed he, the DON, and the Staff Scheduler met on [DATE], to assess staffing levels and they prepared a staffing schedule, in addition to discussing staff concerns daily with the Staff Scheduler. The Administrator stated he or the RDO authorized supplemental staff, extra shift bonuses, and/or agency staff as necessary. The Administrator stated he and the DON met with the RDO at least weekly to discuss staffing concerns. Interview with the RDO, on [DATE] at 5:45 PM, revealed he met with the Administrator and the DON at least weekly to discuss staffing concerns. In addition, the RDO stated he authorized the use of supplemental staff, shift bonuses, or agency staff as necessary. Interview with the Staff Scheduler revealed she met with the Administrator and DON on [DATE], and developed a staffing schedule sufficient to meet the needs of residents. Interview with the SSD, on [DATE] at 1:38 PM, revealed she assisted with conducting resident interviews to ensure needs were met as indicated. Interview with the ADONs, on [DATE] 5:55 PM, revealed they interviewed residents and staff regarding meeting care needs and completion of tasks. Review of staff schedules, dated [DATE] through [DATE], and time sheet records, revealed the facility scheduled the amount of staff needed to meet resident needs, per their assessment. In addition, fifteen (15) residents and fifteen (15) staff were interviewed to ensure care needs were met and staff assignments completed. 3. Interviews on [DATE], with the DON at 6:35 PM, the SSD at 1:38 PM, and the SSD Consultant at 10:24 AM, revealed they completed the audits of residents receiving psychoactive medications. In addition, they compiled a listing of these residents and reviewed resident records to monitor for indications of weakness or lethargy. The DON and SSD monitored at least twenty (20) residents with known behaviors. Interview with the ADONs, on [DATE] at 5:55 PM, revealed they assisted with monitoring resident records as indicated. Review of facility records revealed records of audits and monitoring of twenty (20) residents as indicated. 4. Interview with the Dietary Manger (DM), on [DATE] at 2:20 PM, revealed she completed the baseline weight audit of all resident records as indicated from [DATE] through [DATE]. In addition, the DM worked jointly with the Corporate Dietician and created a plan to ensure resident weights were obtained timely. Interview with the Corporate Dietician, on [DATE] at 10:30 AM, confirmed this allegation. Interview with the ADONs, on [DATE] at 5:55 PM, the DM, and the Registered Dietician (RD), on [DATE] at 10:40 AM, revealed weekly and monthly weights respectively. Interview with the DON, on [DATE] at 5:55 PM, and the DM revealed they monitored resident records to ensure weights were obtained timely and accurately. Record review revealed weights were obtained and monitored. 5. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Director at 4:25 PM, the RD at 2:20 PM, the SSD at 1:38 PM, the SSD Consultant at 10:24 AM, and the ST at 10:46 AM, revealed they reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58. They reviewed the resident records for appropriate diagnoses, care plan interventions and related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for those residents with Dysphagia, behaviors, risk for falls, or side rails. Record review revealed the resident records were audited. 6. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:25 PM, the RD at 10:40 AM, and the ST at 10:46 AM, revealed they conducted a review of the medical records for residents at the facility with a [DIAGNOSES REDACTED]. In addition, they developed a process to screen resident admissions, re-admissions, or new [DIAGNOSES REDACTED]. Continued interview with the DON and ADONs revealed two (2) resident meals were monitored at least three (3) days weekly to ensure staff monitored residents with dysphagia if care planned for supervision with dining. Record review revealed two (2) meals were monitored three (3) days a week. 7. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:35 PM, and Therapy staff at 9:57 AM, revealed they audited records of those residents with no falls assessment completed in the last quarter. In addition, they audited for related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. Additionally, the DON, ADONs, and/or the House Supervisor monitored daily progress notes for resident falls notations and added these residents to the Falls Quality Assurance (QA) Audit Tool. The DON or ADONs monitored any resident fall through this Falls QA Audit Tool and discussed these falls weekly during a CQI meeting. Continued interview with the DON, and interview with the Administrator, on [DATE] at 7:05 PM, revealed either monitored the Falls QA Audit Tool weekly. Review of facility records revealed documented/completed review of Falls QA Audit Tools. 8. Interviews, on [DATE], with the Administrator at 7:05 PM, the DON at 6:35 PM, the RDO at 5:45 PM, the SDC at 2:24 PM, the MDS Nurse at 4:25 PM, the Rehabilitation Manager at 9:57 AM, the SSD at 1:38 PM, and the Medical Director at 3:05 PM, revealed they held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for the removal of immediate jeopardy. Additionally, the Administrator and the DON reported regularly to the RDO regarding progress towards compliance. Record review revealed QAPI meetings were held at stated in the A[NAME]. 9. Interviews, on [DATE], with the ST at 10:46 AM and the DON at 6:35 PM, revealed all nursing staff were educated on [DATE], regarding Dysphagia, resident behaviors, resident falls, and side rail usage. This education included care plan interventions, CNA assignment sheets, diet orders, supervision of residents with choking risks, staff response to resident falls, side rail assessments, and monitoring of residents with side rails. Interview with the SSD at 4:35 PM and the DON at 6:35 PM, revealed they educated nursing staff regarding medication administration, and the signs of psychoactive medications, such as lethargy, dose reductions, and behavior monitoring. They stated staff took post-test they were required to pass, if the failed, they were not allowed to work until they passed the test. Interview with LPN #2, on [DATE] at 9:34 AM, revealed she received training regarding care planning, side rail usage, resident choking hazards, falls, falls risk assessment. Interview with the Cook Supervisor, on [DATE] at 9:55 AM, revealed he was in-serviced on resident safety including bed rails, entrapment, and resident falls. Interview with LPN #14, on [DATE] at 10:32 AM, revealed she received training regarding resident care plans, side rail usage, falls, resident assessments, and residents at risk for choking. Interview with LPN # 24, on [DATE] at 11:14 AM, revealed she received education recently regarding resident medication monitoring, behaviors, and resident bed rail usage Interview with Housekeeping #2,

Based on interview, record review, review of facility Job Descriptions, and review of the facility's policy, it was determined the facility failed to be administered in a manner to use its resources effectively and efficiently to ensure residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being for thirteen (13) of sixty-four (64) sampled residents, Residents #12, #13, #14, #15, #16, #17, #18, #19, #20, #25, #27, #37, and #58. (Refer to F656, F689, F692, and F725) Observation, interview, and record review revealed staff was unable to provide assistance at meals and monitoring residents assessed at choking risk, weigh residents per the facility's policy and/or physician order, and provide restorative services due to insufficient staff. The facility's failure to have an effective system in place to ensure the facility was administered effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to an E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Job Description for the Administrator, not dated, revealed the Administrator led and directed the overall operations of the facility in accordance with the resident needs, federal and state government regulations and company policies to maintain quality care for the resident while achieving the facility's business objectives. The Administrator's essential job duties included conducting regular rounds to ensure staff addressed resident needs and to monitor operations of all departments. The Administrator managed turnover and ensured adequate staffing through the development of recruitment sources, and through appropriate selection, orientation, training and staff education. Additional roles and responsibilities included recognizing potential hazards and monitoring personnel to ensure safety procedures were followed. The Administrator would ensure the understanding of and compliance with, all rules regarding residents' rights. The Administrator would work with the facility management staff and consultants in planning all aspects of facility's operations, including setting priorities and job assignments. Review of the facility's policy, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed the Comprehensive Care Plan would be a person-centered plan of care approach, for each resident, that included measureable objectives and timetables, which would be implemented to meet the resident's nursing, physical functioning, mental, and psychosocial needs. Review of the facility's policy, Meal Service, not dated, revealed all residents would be provided adequate supervision to meet each resident's nursing and meal service needs. Residents would be monitored for appropriate positioning, diet consumed, food preferences, and feeding assistance. Review of the facility's policy, Weight Assessment and Intervention, not dated, revealed nursing staff would record the resident's weight the day they moved in, the next day, and once a week for four (4) weeks thereafter. If no weight concerns were noted, the resident weight would be recorded monthly thereafter. Any weight change of five percent or more since the previous weight assessment would be retaken the next day to confirm. If the weight was verified, nursing staff would notify Dining Services. The Registered Dietitian would review the weight record each month to follow individual weight trends. Negative trends would be evaluated by the treatment team to determine whether or not significant weight change occurred. Interview with the Administrator (ADM), on [DATE] at 10:27 AM, revealed he made routine rounds to check on residents and to ensure care needs were met. He stated the facility had staffing concerns due to staff calling in sick or not showing up. The facility determined its staffing needs through a Facility Assessment (FA) and each floor needed four (4) Certified Nursing Assistants (CNA) to provide care and two (2) licensed nursing staff for first shift. However, on [DATE] the seventh floor had only two (2) CNAs to meet resident care needs on first shift. He stated two (2) CNAs were not sufficient to meet resident needs. However, he had not directed the Director of Nursing, Assistant Director of Nursing, nor the office nursing staff to work the floor when staff called in to ensure resident care needs were met. The ADM stated he was aware that over the weekend of [DATE] and [DATE], there were significant staff call outs and the units were not staffed according to the FA; however, he did not provide direction to nursing. Per interview, he had faith in his Director of Nursing to handle the situation. In addition, the ADM stated he had not approved the Director of Nursing's request for agency staff, in order to meet facility's staffing needs, until [DATE]. Further interview with the ADM revealed he identified, on [DATE], during the breakfast meal that staff was not supervising residents for choking risk. The ADM stated a resident could choke or lose weight and staff would not know. He stated when he identified staff not supervising residents; he directed staff on the unit to remain in the Sunroom while residents ate their meals. However, no corrective action was put in place to ensure ongoing supervision after he identified the deficient practice. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed an assessment of Resident #55 regarding the use of side rails and determined the resident would benefit from a scoop mattress. Additionally, the DON revealed all residents were assessed for side rail use as indicated, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The DON stated she or the ADONs had monitored ten (10) residents three (3) days weekly on a rotating basis as indicated. Interview with the ADON #1 and #3, on [DATE] at 5:55 PM, revealed all residents were assessed for side rail usage, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The ADONs stated they or the DON had monitored ten (10) residents for side rail usage three (3) days weekly on a rotating basis as indicated. Review of facility records revealed ten (10) residents were monitored for side rails as indicated. 2. Interview with the DON, on [DATE] at 6:35 PM, revealed she, the Administrator, and the Staff Scheduler assessed facility staffing levels and prepared a sufficient staffing schedule. She stated she and/or the Administrator and the Staff Scheduler reviewed schedules daily, prior to the actual date to allow for adjustments. In addition, the DON, the Administrator, and/or the Regional Director of Operations (RDO) met at least weekly to discuss staffing concerns. The DON stated she, the ADONs, or the SSD interviewed at least fifteen (15) interviewable residents, and fifteen (15) staff members weekly to ensure resident needs were met and staffing assignments completed. Interview with the Administrator, on [DATE] at 7:05 PM, revealed he, the DON, and the Staff Scheduler met on [DATE], to assess staffing levels and they prepared a staffing schedule, in addition to discussing staff concerns daily with the Staff Scheduler. The Administrator stated he or the RDO authorized supplemental staff, extra shift bonuses, and/or agency staff as necessary. The Administrator stated he and the DON met with the RDO at least weekly to discuss staffing concerns. Interview with the RDO, on [DATE] at 5:45 PM, revealed he met with the Administrator and the DON at least weekly to discuss staffing concerns. In addition, the RDO stated he authorized the use of supplemental staff, shift bonuses, or agency staff as necessary. Interview with the Staff Scheduler revealed she met with the Administrator and DON on [DATE], and developed a staffing schedule sufficient to meet the needs of residents. Interview with the SSD, on [DATE] at 1:38 PM, revealed she assisted with conducting resident interviews to ensure needs were met as indicated. Interview with the ADONs, on [DATE] 5:55 PM, revealed they interviewed residents and staff regarding meeting care needs and completion of tasks. Review of staff schedules, dated [DATE] through [DATE], and time sheet records, revealed the facility scheduled the amount of staff needed to meet resident needs, per their assessment. In addition, fifteen (15) residents and fifteen (15) staff were interviewed to ensure care needs were met and staff assignments completed. 3. Interviews on [DATE], with the DON at 6:35 PM, the SSD at 1:38 PM, and the SSD Consultant at 10:24 AM, revealed they completed the audits of residents receiving psychoactive medications. In addition, they compiled a listing of these residents and reviewed resident records to monitor for indications of weakness or lethargy. The DON and SSD monitored at least twenty (20) residents with known behaviors. Interview with the ADONs, on [DATE] at 5:55 PM, revealed they assisted with monitoring resident records as indicated. Review of facility records revealed records of audits and monitoring of twenty (20) residents as indicated. 4. Interview with the Dietary Manger (DM), on [DATE] at 2:20 PM, revealed she completed the baseline weight audit of all resident records as indicated from [DATE] through [DATE]. In addition, the DM worked jointly with the Corporate Dietician and created a plan to ensure resident weights were obtained timely. Interview with the Corporate Dietician, on [DATE] at 10:30 AM, confirmed this allegation. Interview with the ADONs, on [DATE] at 5:55 PM, the DM, and the Registered Dietician (RD), on [DATE] at 10:40 AM, revealed weekly and monthly weights respectively. Interview with the DON, on [DATE] at 5:55 PM, and the DM revealed they monitored resident records to ensure weights were obtained timely and accurately. Record review revealed weights were obtained and monitored. 5. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Director at 4:25 PM, the RD at 2:20 PM, the SSD at 1:38 PM, the SSD Consultant at 10:24 AM, and the ST at 10:46 AM, revealed they reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58. They reviewed the resident records for appropriate diagnoses, care plan interventions and related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for those residents with Dysphagia, behaviors, risk for falls, or side rails. Record review revealed the resident records were audited. 6. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:25 PM, the RD at 10:40 AM, and the ST at 10:46 AM, revealed they conducted a review of the medical records for residents at the facility with a [DIAGNOSES REDACTED]. In addition, they developed a process to screen resident admissions, re-admissions, or new [DIAGNOSES REDACTED]. Continued interview with the DON and ADONs revealed two (2) resident meals were monitored at least three (3) days weekly to ensure staff monitored residents with dysphagia if care planned for supervision with dining. Record review revealed two (2) meals were monitored three (3) days a week. 7. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:35 PM, and Therapy staff at 9:57 AM, revealed they audited records of those residents with no falls assessment completed in the last quarter. In addition, they audited for related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. Additionally, the DON, ADONs, and/or the House Supervisor monitored daily progress notes for resident falls notations and added these residents to the Falls Quality Assurance (QA) Audit Tool. The DON or ADONs monitored any resident fall through this Falls QA Audit Tool and discussed these falls weekly during a CQI meeting. Continued interview with the DON, and interview with the Administrator, on [DATE] at 7:05 PM, revealed either monitored the Falls QA Audit Tool weekly. Review of facility records revealed documented/completed review of Falls QA Audit Tools. 8. Interviews, on [DATE], with the Administrator at 7:05 PM, the DON at 6:35 PM, the RDO at 5:45 PM, the SDC at 2:24 PM, the MDS Nurse at 4:25 PM, the Rehabilitation Manager at 9:57 AM, the SSD at 1:38 PM, and the Medical Director at 3:05 PM, revealed they held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for the removal of immediate jeopardy. Additionally, the Administrator and the DON reported regularly to the RDO regarding progress towards compliance. Record review revealed QAPI meetings were held at stated in the A[NAME]. 9. Interviews, on [DATE], with the ST at 10:46 AM and the DON at 6:35 PM, revealed all nursing staff were educated on [DATE], regarding Dysphagia, resident behaviors, resident falls, and side rail usage. This education included care plan interventions, CNA assignment sheets, diet orders, supervision of residents with choking risks, staff response to resident falls, side rail assessments, and monitoring of residents with side rails. Interview with the SSD at 4:35 PM and the DON at 6:35 PM, revealed they educated nursing staff regarding medication administration, and the signs of psychoactive medications, such as lethargy, dose reductions, and behavior monitoring. They stated staff took post-test they were required to pass, if the failed, they were not allowed to work until they passed the test. Interview with LPN #2, on [DATE] at 9:34 AM, revealed she received training regarding care planning, side rail usage, resident choking hazards, falls, falls risk assessment. Interview with the Cook Supervisor, on [DATE] at 9:55 AM, revealed he was in-serviced on resident safety including bed rails, entrapment, and resident falls. Interview with LPN #14, on [DATE] at 10:32 AM, revealed she received training regarding resident care plans, side rail usage, falls, resident assessments, and residents at risk for choking. Interview with LPN # 24, on [DATE] at 11:14 AM, revealed she received education recently regarding resident medication monitoring, behaviors, and resident bed rail usage Interview with Housekeeping #2, on [DATE] at 1:24 PM, revealed she attended in-services regarding resident falls, bed rails, and entrapment. Interview with CNA #35, on [DATE] at 1:39 PM, revealed she received education about a week ago regarding resident choking hazards, falls, bed rails, and entrapment. Interview with Housekeeping #1, on [DATE] at 1:56 PM, revealed she attended training regarding resident falls and bed rails. Interview with PTA #2, on [DATE] at 2:01 PM, revealed she attended in-services regarding resident falls, bed rails, dining supervision, and plans of treatment. Record review revealed staff education was completed along with post-tests. 10. Interview, on [DATE] with the RDO at 5:45 PM and the RNC at 5:35 PM, revealed they provided an in-service to the Administrator and the IDT regarding the facility QAPI program on [DATE]. The RDO and the RNC stated one or both of them had been at the facility at least two (2) days weekly to provide oversight. Record review revealed the RDO and RNC in-serviced the Administrator and the IDT, and completed weekly oversight. 11. Interviews, on [DATE] with the RNC at 5:35 PM and the RDO at 5:45 PM, revealed they re-educated the Administrator and the DON regarding facility policies and procedures as indicated in the A[NAME]. Record review revealed the Administrator and DON were reeducated regarding facility polices and procedures. 12. Interviews, on [DATE] with the DM at 2:20 PM, the MDS Nurse at 4:25 PM, the SSD at 4:35 PM, the RDO at 5:45 PM, the ADONs on [DATE] at 5:55 PM, the DON at 6:35 PM, the Administrator at 7:05 PM, revealed they participated in a QAPI meeting on [DATE] and discussed audit results.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement their Quality Assurance Process Improvement (QAPI) program to ensure the identification of opportunities for improvement in the care and services provided to residents. The facility's QAPI process did not identify issues with care and services related to supervision during meals of residents who were at risk for choking; monitoring residents' weights to identify weight loss; assessing and monitoring the use of side rails; and, monitoring resident behaviors and the use of antipsychotic medications. (Refer to F689, F692, F700, F725, and F757) Resident #13 was to be monitored for weight loss and [MEDICAL CONDITION] medication use. However, the only weight documented on the resident was 196 pounds recorded on [DATE]. The resident was weighed on [DATE], when admitted to the hospital with [REDACTED]. In addition, Resident #13 had a documented change in condition on [DATE]; however, the resident was not assessed for signs and symptoms of potential side effects of [MEDICAL CONDITION] medication use until [DATE]. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED]. Resident #16 had a 65 pound weight loss from [DATE] through [DATE] with no evidence the facility requested a Dietitian consult for the significant weight loss. In addition, observations revealed the resident's impulsive behavior making the resident at risk for falls was not monitored. On [DATE], Resident #16 sustained a fall, which resulted in a right [MEDICAL CONDITION]. The fracture required a surgical repair and the resident expired from complications post surgery. Resident #55 was to be monitored for the use of side rails and entrapment. On [DATE], the resident was observed to be entrapped, with arms and hands between the bed and the rail, and head between the mattress and the rails. Residents #12, #14, #15, #17, #18, #19, #20, and 25 were to be assisted with meals and monitored for choking; however, observations throughout the survey revealed this was not provided. Interviews with staff revealed they could not meet the needs of the residents due to being short staffed. The facility's failure to ensure the implementation of the QAPI process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes The findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI), not dated, revealed the mission of the facility was to create a culture of ongoing performance improvement and to improve the lives of others by standardizing work to ensure best practices. The facility's guiding principles guided the facility in what they did, why they did it, and how they conducted the QAPI process. The QAPI process meant to improve resident safety, quality of life, and restorative services. The QAPI goal was to improve process and used Lean-Six Sigma techniques in regards to data collection, analyzing, and measurement of facility progress towards the goal and revision of the goal, when necessary. In addition, the facility QAPI goals were based on the facility's vision, mission, and purpose which guided them to develop goals, how they would measure progress, and how they would choose a timeline to attain the goal. The progress towards set goals would be determined by measurement of monthly indicators, compared to baseline indicators, and ongoing process of continuous observation and measurement. The facility's baseline and continuous collection of data was specific to the resident population and enabled the facility to determine success in the care delivery or need for improvement in services. The facility would use data from the current clinical practice guidelines, or state/and or national data, to establish and attain realistic goals for all services. The goal would be relevant to the care delivered to the residents and the voice of the customer, which were the resident, family, and staff's choices and preferences. Interview with Assistant Director of Nursing (ADON) #1, on [DATE] at 7:31 AM, revealed she attended the daily Interdisciplinary Team (IDT) Meeting where they discussed QAPI issues; however, the facility had not identified obtaining resident weights as an issue or that Resident #13 or #16 had significant weight loss requiring intervention or action plan. She stated she did not know of a corrective action plan in place for residents that had a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on [DATE] at 8:30 AM, revealed she attended the QAPI committee monthly meetings and the daily IDT meetings; however, no formal or informal action plans to improve care and services were developed to meet resident needs related to supervision not provided for residents at risk for choking, significant weight loss or obtaining weights, or staff not monitoring residents with behaviors or on antipsychotic medications. In addition, she stated she was unable to address the use of side rails in the facility as she was working on other issues. She stated she was ultimately responsible for ensuring residents received quality care. Interview with the Administrator, on [DATE] at 10:27 AM, revealed the facility discussed quality issues in the daily meeting with the IDT and monthly in the QAPI committee. However, the Administrator stated the facility had not determined through discussions or the QAPI process, issues regarding care and services provided to residents related to residents at risk for choking not provided supervision, or resident's not weighed per policy nor had they identified residents not weighed had experienced significant weight loss. In addition, the facility had not identified quality issues with residents that had a [DIAGNOSES REDACTED]. He was also not aware of any issues with the side rails until Resident #55's entrapment. He stated staffing in general was discussed in the QAPI meeting; however, the plan developed addressed recruiting, orientation, retention, and pruning. He stated the QAPI committee did not discuss or develop a plan to address how to ensure resident care needs were met when the units were short staffed. The Administrator stated he was ultimately responsible for ensuring resident care needs were met. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed an assessment of Resident #55 regarding the use of side rails and determined the resident would benefit from a scoop mattress. Additionally, the DON revealed all residents were assessed for side rail use as indicated, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The DON stated she or the ADONs had monitored ten (10) residents three (3) days weekly on a rotating basis as indicated. Interview with the ADON #1 and #3, on [DATE] at 5:55 PM, revealed all residents were assessed for side rail usage, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The ADONs stated they or the DON had monitored ten (10) residents for side rail usage three (3) days weekly on a rotating basis as indicated. Review of facility records revealed ten (10) residents were monitored for side rails as indicated. 2. Interview with the DON, on [DATE] at 6:35 PM, revealed she, the Administrator, and the Staff Scheduler assessed facility staffing levels and prepared a sufficient staffing schedule. She stated she and/or the Administrator and the Staff Scheduler reviewed schedules daily, prior to the actual date to allow for adjustments. In addition, the DON, the Administrator, and/or the Regional Director of Operations (RDO) met at least weekly to discuss staffing concerns. The DON stated she, the ADONs, or the SSD interviewed at least fifteen (15) interviewable residents, and fifteen (15) staff members weekly to ensure resident needs were met and staffing assignments completed. Interview with the Administrator, on [DATE] at 7:05 PM, revealed he, the DON, and the Staff Scheduler met on [DATE], to assess staffing levels and they prepared a staffing schedule, in addition to discussing staff concerns daily with the Staff Scheduler. The Administrator stated he or the RDO authorized supplemental staff, extra shift bonuses, and/or agency staff as necessary. The Administrator stated he and the DON met with the RDO at least weekly to discuss staffing concerns. Interview with the RDO, on [DATE] at 5:45 PM, revealed he met with the Administrator and the DON at least weekly to discuss staffing concerns. In addition, the RDO stated he authorized the use of supplemental staff, shift bonuses, or agency staff as necessary. Interview with the Staff Scheduler revealed she met with the Administrator and DON on [DATE], and developed a staffing schedule sufficient to meet the needs of residents. Interview with the SSD, on [DATE] at 1:38 PM, revealed she assisted with conducting resident interviews to ensure needs were met as indicated. Interview with the ADONs, on [DATE] 5:55 PM, revealed they interviewed residents and staff regarding meeting care needs and completion of tasks. Review of staff schedules, dated [DATE] through [DATE], and time sheet records, revealed the facility scheduled the amount of staff needed to meet resident needs, per their assessment. In addition, fifteen (15) residents and fifteen (15) staff were interviewed to ensure care needs were met and staff assignments completed. 3. Interviews on [DATE], with the DON at 6:35 PM, the SSD at 1:38 PM, and the SSD Consultant at 10:24 AM, revealed they completed the audits of residents receiving psychoactive medications. In addition, they compiled a listing of these residents and reviewed resident records to monitor for indications of weakness or lethargy. The DON and SSD monitored at least twenty (20) residents with known behaviors. Interview with the ADONs, on [DATE] at 5:55 PM, revealed they assisted with monitoring resident records as indicated. Review of facility records revealed records of audits and monitoring of twenty (20) residents as indicated. 4. Interview with the Dietary Manger (DM), on [DATE] at 2:20 PM, revealed she completed the baseline weight audit of all resident records as indicated from [DATE] through [DATE]. In addition, the DM worked jointly with the Corporate Dietician and created a plan to ensure resident weights were obtained timely. Interview with the Corporate Dietician, on [DATE] at 10:30 AM, confirmed this allegation. Interview with the ADONs, on [DATE] at 5:55 PM, the DM, and the Registered Dietician (RD), on [DATE] at 10:40 AM, revealed weekly and monthly weights respectively. Interview with the DON, on [DATE] at 5:55 PM, and the DM revealed they monitored resident records to ensure weights were obtained timely and accurately. Record review revealed weights were obtained and monitored. 5. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Director at 4:25 PM, the RD at 2:20 PM, the SSD at 1:38 PM, the SSD Consultant at 10:24 AM, and the ST at 10:46 AM, revealed they reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58. They reviewed the resident records for appropriate diagnoses, care plan interventions and related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for those residents with Dysphagia, behaviors, risk for falls, or side rails. Record review revealed the resident records were audited. 6. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:25 PM, the RD at 10:40 AM, and the ST at 10:46 AM, revealed they conducted a review of the medical records for residents at the facility with a [DIAGNOSES REDACTED]. In addition, they developed a process to screen resident admissions, re-admissions, or new [DIAGNOSES REDACTED]. Continued interview with the DON and ADONs revealed two (2) resident meals were monitored at least three (3) days weekly to ensure staff monitored residents with dysphagia if care planned for supervision with dining. Record review revealed two (2) meals were monitored three (3) days a week. 7. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:35 PM, and Therapy staff at 9:57 AM, revealed they audited records of those residents with no falls assessment completed in the last quarter. In addition, they audited for related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. Additionally, the DON, ADONs, and/or the House Supervisor monitored daily progress notes for resident falls notations and added these residents to the Falls Quality Assurance (QA) Audit Tool. The DON or ADONs monitored any resident fall through this Falls QA Audit Tool and discussed these falls weekly during a CQI meeting. Continued interview with the DON, and interview with the Administrator, on [DATE] at 7:05 PM, revealed either monitored the Falls QA Audit Tool weekly. Review of facility records revealed documented/completed review of Falls QA Audit Tools. 8. Interviews, on [DATE], with the Administrator at 7:05 PM, the DON at 6:35 PM, the RDO at 5:45 PM, the SDC at 2:24 PM, the MDS Nurse at 4:25 PM, the Rehabilitation Manager at 9:57 AM, the SSD at 1:38 PM, and the Medical Director at 3:05 PM, revealed they held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for the removal of immediate jeopardy. Additionally, the Administrator and the DON reported regularly to the RDO regarding progress towards compliance. Record review revealed QAPI meetings were held at stated in the A[NAME]. 9. Interviews, on [DATE], with the ST at 10:46 AM and the DON at 6:35 PM, revealed all nursing staff were educated on [DATE], regarding Dysphagia, resident behaviors, resident falls, and side rail usage. This education included care plan interventions, CNA assignment sheets, diet orders, supervision of residents with choking risks, staff response to resident falls, side rail assessments, and monitoring of residents with side rails. Interview with the SSD at 4:35 PM and the DON at 6:35 PM, revealed they educated nursing staff regarding medication administration, and the signs of psychoactive medications, such as lethargy, dose reductions, and behavior monitoring. They stated staff took post-test they were required to pass, if the failed, they were not allowed to work until they passed the test. Interview with LPN #2, on [DATE] at 9:34 AM, revealed she received training regarding care planning, side rail usage, resident choking hazards, falls, falls risk assessment. Interview with the Cook Supervisor, on [DATE] at 9:55 AM, revealed he was in-serviced on resident safety including bed rails, entrapment, and resident falls. Interview with LPN #14, on [DATE] at 10:32 AM, revealed she received training regarding resident care plans, side rail usage, falls, resident assessments, and residents at risk for choking. Interview with LPN # 24, on [DATE] at 11:14 AM, revealed she received education recently regarding resident medication monitoring, behaviors, and resident bed rail usage Interview with Housekeeping #2, on [DATE] at 1:24 PM, revealed she attended in-services regarding resident falls, bed rails, and entrapment. Interview with CNA #35, on [DATE] at 1:39 PM, revealed she received education about a week ago regarding resident choking hazards, falls, bed rails, and entrapment. Interview with Housekeeping #1, on [DATE] at 1:56 PM, revealed she attended training regarding resident falls and bed rails. Interview with PTA #2, on [DATE] at 2:01 PM, revealed she attended in-services regarding resident falls, bed rails, dining supervision, and plans of treatment. Record review revealed staff education was completed along with post-tests. 10. Interview, on [DATE] with the RDO at 5:45 PM and the RNC at 5:35 PM, revealed they provided an in-service to the Administrator and the IDT regarding the facility QAPI program on [DATE]. The RDO and the RNC stated one or both of them had been at the facility at least two (2) days weekly to provide oversight. Record review revealed the RDO and RNC in-serviced the Administrator and the IDT, and completed weekly oversight. 11. Interviews, on [DATE] with the RNC at 5:35 PM and the RDO at 5:45 PM, revealed they re-educated the Administrator and the DON regarding facility policies and procedures as indicated in the A[NAME]. Record review revealed the Administrator and DON were reeducated regarding facility polices and procedures. 12. Interviews, on [DATE] with the DM at 2:20 PM, the MDS Nurse at 4:25 PM, the SSD at 4:35 PM, the RDO at 5:45 PM, the ADONs on [DATE] at 5:55 PM, the DON at 6:35 PM, the Administrator at 7:05 PM, revealed they participated in a QAPI meeting on [DATE] and discussed audit results. Record review revealed QAPI meetings were held as alleged in the A[NAME].

Based on observation, interview, and record review, it was determined the facility failed to have an effective system to ensure physician notification after a resident experienced a change in condition for two (2) of sixty-four (64) sampled residents, Resident #13 and #55. Interview and record review revealed Resident #13 had a change in condition starting on [DATE], sleeping more, not eating well, and less mobile in the wheelchair. Record review revealed the resident continued to experience these symptoms through the month of (MONTH) 2019. However, there was no evidence the resident's physician was notified. On [DATE], Resident #13 was lethargic and the nurse held the resident's [MEDICATION NAME] and [MEDICATION NAME] medication to prevent further drowsiness. The next morning, [DATE], the resident remained lethargic and the nurse again held the resident's medications. However, it was not until 2:00 PM when she notified the Nurse Practitioner of the resident's condition. The Practitioner ordered labs, which resulted out of normal ranges and the resident was transferred to the hospital where he/she experienced respiratory distress requiring a breathing machine once he/she reached the hospital. On [DATE], observation revealed Resident #55 in bed with side rails on each side of the bed. The resident's head and neck laid on the top to the rail and then settled between the mattress and the side rail, entrapping the resident. Interview and record review revealed staff did not notify the power of attorney, the physician, or upper management about the incident. The facility's failure to have an effective system in place to ensure the physician was notified of a change of condition, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: The facility was unable to provide a policy regarding physician notification. 1. Review of the clinical record revealed the facility admitted Resident #13 on [DATE], with [DIAGNOSES REDACTED]. Review of the Emergency Department (ED) Encounter Report, dated [DATE], revealed the nursing staff reported to the Emergency Medical Services (EMS) personnel that Resident #13 became non-verbal and non-responsive three (3) days ago. EMS reported the resident's oxygen saturation during transport to the hospital was 83% (normal range 95% to 100%) on a 15-liter non-rebreather mask without improvement. Review of the ED History and Physical report, dated [DATE] and time 10:17 PM, revealed Resident #13 experienced worsening mental status over several days in the nursing facility, requiring transfer to ED for treatment. EMS noted the resident was hypoxic during transport. Once in the ED, Resident #13's oxygen levels failed to improve. Physicians diagnosed the resident with Acute [MEDICAL CONDITION] and Hypoxemia, which required emergent placement of a breathing tube and machine. In addition, Resident #13 received [DIAGNOSES REDACTED]. Due to Resident #13's poor prognosis, the hospital contacted the State Guardian regarding the need for Hospice/Palliative care. Review of the clinical record revealed on [DATE], nursing documented the resident kept falling asleep and refused to eat. On [DATE], nursing documented the resident was lethargic and held the resident's medications. There was no documentation on the resident's status from [DATE] through [DATE]. On [DATE], nursing staff documented the resident continued to sleep and ate small amounts at meals. On [DATE], nursing documented the resident continued to sleep. There was no documentation on the resident's status from [DATE] through [DATE]. On [DATE], nursing staff documented the resident was lethargic and held the morning dose of [MEDICATION NAME]. However, there was no documented evidence in (MONTH) the physician was notified of the resident's change in condition. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 6:45 AM, revealed Resident #13 had a change in condition on [DATE]. She stated the resident was lethargic and she held the resident's [MEDICATION NAME] and [MEDICATION NAME] medication to prevent further drowsiness. She informed the oncoming nurse of the resident's change in condition and told her to monitor the resident. When she returned to work the next morning, she stated the resident remained lethargic and she again held the resident's medications. However, it was not until 2:00 PM when she notified the Nurse Practitioner (NP) of the resident's condition and the NP ordered labs. The lab results returned out of normal ranges and the NP ordered the resident to be transferred to the hospital. According to LPN #10, she did not think to notify the physician after the resident had a change in condition, but should have. The LPN revealed she learned later from the Director of Nursing (DON) the resident experienced respiratory distress requiring a breathing machine once he/she reached the hospital. Interview with LPN #18, on [DATE] at 4:00 PM, revealed Resident #13 would become lethargic after the administration of [MEDICATION NAME] and [MEDICATION NAME], which was a side effect of the medication. She stated she reviewed [MEDICATION NAME] and [MEDICATION NAME] mediation side effects after the transfer of Resident #13 and found [MEDICATION NAME] had a Black Box warning related to its use in elderly with Dementia. She stated nursing staff should have assessed and reassessed the resident for its known side effects, documented the findings, and reported to the physician. She stated if staff did not notify physicians of a change in condition, resident harm could occur. Interview, on [DATE] at 9:26 AM, with the Psychiatric Mental Health Nurse Practitioner revealed if nursing staff had notified her Resident #13's [MEDICAL CONDITION] medications were withheld on several occasions, due to the resident experiencing lethargy, she would have reduced the dosages. She stated the medications could potentially cause more harm than good. On [DATE] at 11:00 AM, interview with Resident #13's Physician revealed if nursing staff withheld resident medications due to the side effects, he expected notification in order for medication review to occur. He stated he depended on nursing staff to provide him information related to the resident's condition so he could provide orders to improve the resident's health status. On [DATE] at 8:30 AM, interview with the Director of Nursing (DON) revealed Adult Protective Services (APS) entered the building after the transfer of Resident #13 to hospital to investigate the care provided. She stated APS reported to her that EMS personnel reported to the hospital that facility staff reported to them the resident had been non-responsive for several days prior to transfer. She stated she was not aware of this information, so she interviewed the nurse regarding the resident's status prior to transfer and did not find any issue with care provided; even though nursing staff had documented the resident had a change in condition and had withheld medication due to lethargy. She stated nursing staff should have monitored the resident closely, documented the findings, and notified the physician, as directed by the plan of care. She stated physician notification after a change in condition was facility policy and staff should follow policy or residents could experience a decline. Interview with the Administrator, on [DATE] at 10:27 AM, revealed he was aware APS had investigated a complaint regarding care and services for Resident #13. He stated the DON handled the situation and he thought everything was under control. The Administrator stated the DON had not made him aware of any issues that needed his attention or direction, and he felt like the situation was resolved. 2. Review of the facility's policy, Incidents/Accidents/Falls, undated, revealed when there was an incident/accident, the nurses were to notify the physician, DON, Administrator, and the resident's responsible party. Observation, on [DATE] at 9:59 AM, revealed Resident #55 was in bed moaning. The head of the bed was in an upright position and the resident was tilted to the left, with his/her head and neck on top of the rail and then settled between the mattress and side rail. Resident #55 continued to moan as his/her arms and hands fell between the rails of the bed. At 10:06 AM, Licensed Practical Nurse (LPN) #10 walked past Resident #55's room, peered into the room, and walked past onto the nurses' station. At 10:08 AM, Certified Nursing Assistant (CNA) #25 entered Resident #55's room and repositioned the resident. Review of Resident #55's clinical record revealed the facility originally admitted the resident on [DATE], and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #55's electronic medical record with Assistant Director of Nursing (ADON) #1, on [DATE] at 10:25 AM, revealed no progress note regarding notification of the physician or resident's representative regarding the entrapment of Resident #55 as observed by CNA #25. Interview with ADON #1, on [DATE] at 10:55 AM, revealed she was notified by ADON #3 of Resident #55 becoming entrapped on [DATE] at 2:00 PM. She stated she did not inquire if the nurse had made the required notifications per policy. However, interview with ADON #3, on [DATE] at 11:16 AM, revealed ADON #1 notified her of Resident #55 entrapment. Interview with LPN #17, on [DATE] at 4:20 PM, revealed CNA #25 reported Resident #55's incident after she went to the CNA and questioned her about the incident. LPN #17 stated she did not report the side rail entrapment to the resident's physician and family as required by the facility's policy. She revealed she would be very upset if she were not notified her family member had an accident. Interview with LPN #27, on [DATE] at 8:15 AM, revealed families were to be notified of all changes of condition as well as the physician. She further stated if the families and physician were not notified, they could be very upset, and it could affect the resident's care. Interview with LPN #14, on [DATE] at 9:15 AM, revealed any change of condition was to be reported to the residents' families, physician, and supervisors. She further stated she would be irate if she were not notified of an accident. Interview with Family #5, on [DATE] at 9:49 AM, revealed the she was not aware of Resident #55's entrapment on [DATE]. She further stated she was very upset, became emotional, and was audibly crying when she discovered during the phone interview of the incident. Interview with the Staff Educator, on [DATE] at 9:15 AM, revealed staff was to notify residents' families, physician, and supervisors of changes in condition. She stated this was covered in orientation and routinely in staff meetings. Interview with the DON, on [DATE] at 11:25 AM, revealed the facility did not document entrapments on an incident report and she was unaware if the family or physician was made aware. Interview with the Physician, on [DATE] at 4:30 PM, revealed staff did not notify him of Resident #55's entrapment. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed an assessment of Resident #55 regarding the use of side rails and determined the resident would benefit from a scoop mattress. Additionally, the DON revealed all residents were assessed for side rail use as indicated, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The DON stated she or the ADONs had monitored ten (10) residents three (3) days weekly on a rotating basis as indicated. Interview with the ADON #1 and #3, on [DATE] at 5:55 PM, revealed all residents were assessed for side rail usage, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The ADONs stated they or the DON had monitored ten (10) residents for side rail usage three (3) days weekly on a rotating basis as indicated. Review of facility records revealed ten (10) residents were monitored for side rails as indicated. 2. Interview with the DON, on [DATE] at 6:35 PM, revealed she, the Administrator, and the Staff Scheduler assessed facility staffing levels and prepared a sufficient staffing schedule. She stated she and/or the Administrator and the Staff Scheduler reviewed schedules daily, prior to the actual date to allow for adjustments. In addition, the DON, the Administrator, and/or the Regional Director of Operations (RDO) met at least weekly to discuss staffing concerns. The DON stated she, the ADONs, or the SSD interviewed at least fifteen (15) interviewable residents, and fifteen (15) staff members weekly to ensure resident needs were met and staffing assignments completed. Interview with the Administrator, on [DATE] at 7:05 PM, revealed he, the DON, and the Staff Scheduler met on [DATE], to assess staffing levels and they prepared a staffing schedule, in addition to discussing staff concerns daily with the Staff Scheduler. The Administrator stated he or the RDO authorized supplemental staff, extra shift bonuses, and/or agency staff as necessary. The Administrator stated he and the DON met with the RDO at least weekly to discuss staffing concerns. Interview with the RDO, on [DATE] at 5:45 PM, revealed he met with the Administrator and the DON at least weekly to discuss staffing concerns. In addition, the RDO stated he authorized the use of supplemental staff, shift bonuses, or agency staff as necessary. Interview with the Staff Scheduler revealed she met with the Administrator and DON on [DATE], and developed a staffing schedule sufficient to meet the needs of residents. Interview with the SSD, on [DATE] at 1:38 PM, revealed she assisted with conducting resident interviews to ensure needs were met as indicated. Interview with the ADONs, on [DATE] 5:55 PM, revealed they interviewed residents and staff regarding meeting care needs and completion of tasks. Review of staff schedules, dated [DATE] through [DATE], and time sheet records, revealed the facility scheduled the amount of staff needed to meet resident needs, per their assessment. In addition, fifteen (15) residents and fifteen (15) staff were interviewed to ensure care needs were met and staff assignments completed. 3. Interviews on [DATE], with the DON at 6:35 PM, the SSD at 1:38 PM, and the SSD Consultant at 10:24 AM, revealed they completed the audits of residents receiving psychoactive medications. In addition, they compiled a listing of these residents and reviewed resident records to monitor for indications of weakness or lethargy. The DON and SSD monitored at least twenty (20) residents with known behaviors. Interview with the ADONs, on [DATE] at 5:55 PM, revealed they assisted with monitoring resident records as indicated. Review of facility records revealed records of audits and monitoring of twenty (20) residents as indicated. 4. Interview with the Dietary Manger (DM), on [DATE] at 2:20 PM, revealed she completed the baseline weight audit of all resident records as indicated from [DATE] through [DATE]. In addition, the DM worked jointly with the Corporate Dietician and created a plan to ensure resident weights were obtained timely. Interview with the Corporate Dietician, on [DATE] at 10:30 AM, confirmed this allegation. Interview with the ADONs, on [DATE] at 5:55 PM, the DM, and the Registered Dietician (RD), on [DATE] at 10:40 AM, revealed weekly and monthly weights respectively. Interview with the DON, on [DATE] at 5:55 PM, and the DM revealed they monitored resident records to ensure weights were obtained timely and accurately. Record review revealed weights were obtained and monitored. 5. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Director at 4:25 PM, the RD at 2:20 PM, the SSD at 1:38 PM, the SSD Consultant at 10:24 AM, and the ST at 10:46 AM, revealed they reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58. They reviewed the resident records for appropriate diagnoses, care plan interventions and related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for those residents with Dysphagia, behaviors, risk for falls, or side rails. Record review revealed the resident records were audited. 6. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:25 PM, the RD at 10:40 AM, and the ST at 10:46 AM, revealed they conducted a review of the medical records for residents at the facility with a [DIAGNOSES REDACTED]. In addition, they developed a process to screen resident admissions, re-admissions, or new [DIAGNOSES REDACTED]. Continued interview with the DON and ADONs revealed two (2) resident meals were monitored at least three (3) days weekly to ensure staff monitored residents with dysphagia if care planned for supervision with dining. Record review revealed two (2) meals were monitored three (3) days a week. 7. Interviews, on [DATE] with the DON at 6:35 PM, the ADONs at 5:55 PM, the MDS Nurse at 4:35 PM, and Therapy staff at 9:57 AM, revealed they audited records of those residents with no falls assessment completed in the last quarter. In addition, they audited for related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. Additionally, the DON, ADONs, and/or the House Supervisor monitored daily progress notes for resident falls notations and added these residents to the Falls Quality Assurance (QA) Audit Tool. The DON or ADONs monitored any resident fall through this Falls QA Audit Tool and discussed these falls weekly during a CQI meeting. Continued interview with the DON, and interview with the Administrator, on [DATE] at 7:05 PM, revealed either monitored the Falls QA Audit Tool weekly. Review of facility records revealed documented/completed review of Falls QA Audit Tools. 8. Interviews, on [DATE], with the Administrator at 7:05 PM, the DON at 6:35 PM, the RDO at 5:45 PM, the SDC at 2:24 PM, the MDS Nurse at 4:25 PM, the Rehabilitation Manager at 9:57 AM, the SSD at 1:38 PM, and the Medical Director at 3:05 PM, revealed they held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for the removal of immediate jeopardy. Additionally, the Administrator and the DON reported regularly to the RDO regarding progress towards compliance. Record review revealed QAPI meetings were held at stated in the A[NAME]. 9. Interviews, on [DATE], with the ST at 10:46 AM and the DON at 6:35 PM, revealed all nursing staff were educated on [DATE], regarding Dysphagia, resident behaviors, resident falls, and side rail usage. This education included care plan interventions, CNA assignment sheets, diet orders, supervision of residents with choking risks, staff response to resident falls, side rail assessments, and monitoring of residents with side rails. Interview with the SSD at 4:35 PM and the DON at 6:35 PM, revealed they educated nursing staff regarding medication administration, and the signs of psychoactive medications, such as lethargy, dose reductions, and behavior monitoring. They stated staff took post-test they were required to pass, if the failed, they were not allowed to work until they passed the test. Interview with LPN #2, on [DATE] at 9:34 AM, revealed she received training regarding care planning, side rail usage, resident choking hazards, falls, falls risk assessment. Interview with the Cook Supervisor, on [DATE] at 9:55 AM, revealed he was in-serviced on resident safety including bed rails, entrapment, and resident falls. Interview with LPN #14, on [DATE] at 10:32 AM, revealed she received training regarding resident care plans, side rail usage, falls, resident assessments, and residents at risk for choking. Interview with LPN # 24, on [DATE] at 11:14 AM, revealed she received education recently regarding resident medication monitoring, behaviors, and resident bed rail usage Interview with Housekeeping #2, on [DATE] at 1:24 PM, revealed she attended in-services regarding resident falls, bed rails, and entrapment. Interview with CNA #35, on [DATE] at 1:39 PM, revealed she received education about a week ago regarding resident choking hazards, falls, bed rails, and entrapment. Interview with Housekeeping #1, on [DATE] at 1:56 PM, revealed she attended training regarding resident falls and bed rails. Interview with PTA #2, on [DATE] at 2:01 PM, revealed she attended in-services regarding resident falls, bed rails, dining supervision, and plans of treatment. Record review revealed staff education was completed along with post-tests. 10. Interview, on [DATE] with the RDO at 5:45 PM and the RNC at 5:35 PM, revealed they provided an in-service to the Administrator and the IDT regarding the facility QAPI program on [DATE]. The RDO and the RNC stated one or both of them had been at the facility at least two (2) days weekly to provide oversight. Record review revealed the RDO and RNC in-serviced the Administrator and the IDT, and completed weekly oversight. 11. Interviews, on [DATE] with the RNC at 5:35 PM and the RDO at 5:45 PM, revealed they re-educated the Administrator and the DON regarding facility policies and procedures as indicated in the A[NAME]. Record review revealed the Administrator and DON were reeducated regarding facility polices and procedures. 12. Interviews, on [DATE] with the DM at 2:20 PM, the MDS Nurse at 4:25 PM, the SSD at 4:35 PM, the RDO at 5:45 PM, the ADONs on [DATE] at 5:55 PM, the DON at 6:35 PM, the Administrator at 7:05 PM, revealed they participated in a QAPI meeting on [DATE] and discussed audit results. Record review revealed QAPI meetings were held as alleged in the A[NAME].

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents at risk for weight loss did not lose weight for three (3) of sixty-four (64) sampled residents, Resident #13, #16, and #25. Review of the facility's Weight Assessment and Intervention Policy revealed nursing staff would record the resident's weight the day they moved in, the next day, and once a week for four (4) weeks thereafter. If no weight concerns were noted, the resident weight would be recorded monthly thereafter. Any weight change of 5% or more since the previous weight assessment would be retaken the next day to confirm. Record review revealed Resident #13 weighed 196 pounds on [DATE], and there was not another weight obtained by the facility after [DATE], per policy. Review of a Hospital emergency room record, dated [DATE], revealed Resident #13 weighed 154 pounds upon admission; which was a forty-two (42) pound weight loss difference from [DATE]. Interview with Certified Nursing Assistant (CNA) #15 revealed the nurses reminded her which residents needed a weight obtained but due to staffing issues she was not always able to obtain resident weights and she would pass it on for the next shift to obtain. Record review revealed Resident #16 sustained a significant weight loss of sixty-five (65) pounds from (MONTH) (YEAR) through [DATE]. However, continued review of the medical record revealed the facility did not reweigh the resident to confirm the significant weight loss per policy, nor did they request a Dietitian consult for the significant weight loss. Record review revealed Resident #25 lost eleven (11) pounds in thirty (30) days and staff failed to follow the facility's policy related to reporting the weight loss, reweighing the resident, and ensure the Skin and Weight Assessment Team (SWAT) followed the resident weekly for weight loss. Interviews revealed Resident #25 was not followed by SWAT due to being a Hospice resident. Observations revealed Resident #25 was not assisted with meals as care planned and lacked accessibility to fluids. The facility's failure to ensure residents did not have an avoidable significant weight loss, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Weight Assessment and Intervention, not dated, revealed nursing staff would record the resident's weight the day they moved in, the next day, and once a week for four (4) weeks thereafter. If no weight concerns were noted, the resident weight would be recorded monthly thereafter. Any weight change of five percent or more since the previous weight assessment would be retaken the next day to confirm. If the weight was verified, nursing staff would notify Dining Services. The Registered Dietitian would review the weight record each month to follow individual weight trends. Negative trends would be evaluated by the treatment team to determine whether or not significant weight change occurred. 1. Review of Resident #16's clinical record revealed the facility admitted the resident with the [DIAGNOSES REDACTED]. Review of the Nutrition Plan of Care for Resident #16, initiated [DATE], revealed the resident had a nutritional problem related to obesity with a weight of 183.3 pounds. The goal was for the resident to maintain adequate nutritional status by maintaining a stable weight, with no signs or symptoms of malnutrition, and would consume at least 50% of most meals. The care plan directed staff to honor food preferences, monitor, document, and report to the physician any swallowing, choking, pocketing of food, drooling, or refusing to eat. In addition, staff was to weigh the resident per policy, and record. Observation, on [DATE] at 8:12 AM, of Resident #16 revealed the resident had a thin physique and was in his/her wheelchair in the Sunroom. CNA #13 served the resident his/her tray, fed the resident a couple bites of food, cued the resident to drink his/her milk and juice, and then left the Sunroom area to retrieve additional resident meal trays. When CNA #13 returned, she passed by Resident #16 and asked him/her if he/she was still hungry and the resident said yes, but CNA #13 did not offer to assist the resident with eating the rest of his/her meal and continued delivering other residents' meal trays. At 8:47 AM, staff removed Resident #16's tray without asking if he/she was still hungry or wanted an alternative. Review of a Nutrition Dietary Note, dated [DATE], revealed Resident #16's weight of 183.3 pounds, obtained on [DATE], was reviewed at this time and the Registered Dietitian was consulted due to the resident's poor appetite. The Dietitian estimated the resident's daily nutritional needs required the resident to consume 2,190 calories and 2190 milliliters of fluid per day, along with 73 grams of protein. The Dietitian recommended staff to obtain a new weight for her to better assess Resident #16's nutritional status. Review of Resident #16's MAR, dated (MONTH) 2019, revealed staff weighed the resident weekly on Friday, which began on [DATE]. Continued review of the MAR revealed staff did not weigh the resident on [DATE]. Review Resident #16's weights revealed on [DATE], the resident weighed 183.3 pounds, and on [DATE], the resident weighed 130 pounds. Review of Resident #16's MAR, dated (MONTH) 2019, revealed the resident's weight was 118 pounds on [DATE], which was a difference of 65 pounds. However, continued review of the medical record revealed the facility did not reweigh the resident to confirm the significant weight loss per policy. Nor did the facility notify the Dietitian and physician. On [DATE] at 10:36 AM, interview with CNA #13 and #10 revealed they had many tasks to complete and the unit was short staffed on several shifts, which prevented them from always meeting the residents' needs. They stated Resident #16 needed assistance with eating; however, they had to deliver other resident trays, answer call lights, and get others up for breakfast. In addition, they were not sure if Resident #16 had lost weight or not. Each stated nursing would notify them regarding which residents needed a weight obtained but due to short staffing, they did not always have time to weigh or reweigh residents. They both revealed residents could have weight loss if not assisted during meal service. Interview with Licensed Practical Nurse (LPN) #27, on [DATE] at 8:15 AM, revealed Resident #16 had a recent weight loss but did not know if it was a significant weight loss. She reviewed Resident #16's clinical record and MAR with this surveyor to determine the resident's weight history. She stated the resident had a weight documented on [DATE] of 183.3 pounds, and on [DATE] of 130 pounds, and the last weight recorded on [DATE], revealed the resident weighed 118 pounds, which she stated was a significant weight loss. According to LPN #27, she had noticed the resident would not eat very much of his/her meal; however, had not noticed if staff were consistently providing assistance with meals to ensure the resident consumed at least 50% of most meals per the plan of care, or monitored for trouble swallowing. Interview with the Dietitian, on [DATE] at 1:00 PM, revealed at her last assessment, the facility had not weighed Resident #16 so she could not have determined if the resident had a significant weight loss at that time. However, if the resident's current weight were what was documented on the MAR, then it would be a significant weight loss. She stated she would have asked staff to reweigh the resident to confirm since it was such a drastic drop in weight. According to the Dietitian, if staff was not assisting with meals and the resident was only eating 25% of his/her meals, a significant weight loss could occur. Interview with Assistant Director of Nursing ADON #1, on [DATE] at 7:31 AM, revealed she was not aware of Resident #16's significant weight loss. In addition, she had not supervised staff to determine if Resident #16 had received the necessary assistance with meals to ensure a significant weight loss did not occur. She stated the facility was short staffed making it difficult for staff to meet resident needs. Interview with the Director of Nursing (DON), on [DATE] at 8:30 AM, revealed she had not identified Resident #16 had a significant weight loss or that staff had not routinely obtained the resident's weight for the Dietitian to assess for weight loss. She stated if staff did not provide assistance with meals, or weigh residents as ordered, residents could experience a significant weight loss without staff knowledge, and decline. Interview with the Administrator, on [DATE] at 10:27 AM, revealed he did not recall the team discussing Resident #16 having a weight loss. 2. Review of the clinical record revealed the facility admitted Resident #13 on [DATE], with [DIAGNOSES REDACTED]. The facility obtained a weight of 196 pounds on [DATE], and did not obtain or document another weight after [DATE]. Review of Resident #13's Nutrition Dietary Note, dated [DATE], revealed staff obtained the resident's weight of 196 pounds on [DATE]. The estimated daily nutritional needs for the resident were 1,740 Kilocalorie's per day, 58 grams of protein per day, and 1,740 milliliters of fluid per day. Continued review of the clinical record revealed no notations by the Dietitian regarding the resident's dietary needs, or if a decline had occurred requiring an additional assessment. Interview with the Dietitian, on [DATE] at 1:00 PM, revealed if a resident had identified weight loss, then the facility would weigh the resident weekly until the weight stabilized. She stated when she reviewed Resident #13's record on [DATE], the only weight in the record was from [DATE]. The facility had not routinely obtained the resident's weight for her to evaluate for nutritional needs. The Dietitian stated if a current weight was not in the record, she would ask staff to obtain one and if the resident had a significant weight loss to call her so she could re-evaluate the resident's dietary needs. She stated she did not receive a consultant to re-evaluate Resident #13 for a weight loss. The Dietitian stated if a resident lost weight she would add supplements, vitamins, protein supplements, and if the resident needed assistance with eating, order the resident to be assisted with meals. Review of a Hospital emergency room record, dated [DATE], revealed Resident #13 weighed 154 pounds upon admission; which was a 42 pound weight loss difference from [DATE], when the resident weighed 196 pounds. Review of Nursing Documentation, dated [DATE], revealed Resident #13 kept falling asleep and the nurse attempted to feed the resident but he/she refused all attempts. On [DATE] at 12:27 PM, nursing staff noted Resident #13 received all morning medications, continued to sleep, and only ate a little breakfast. Further review revealed nursing noted Resident #13 ate a small amount of lunch, kept falling asleep, and staff administered afternoon medications as ordered. Interview with CNA #15, at 9:38 AM on [DATE], revealed the care plan and the nurses reminded her which residents needed a weight obtained. She stated due to staffing issues she was not always able to obtain resident weights and she would have to pass it on to the next shift to do. The CNA revealed if staff did not get the resident's weight, as ordered, they could have a weight loss, and staff would not know. Interview, on [DATE] at 6:45 AM, with LPN #10 revealed the ADON provided the unit with a list of required resident weights. She would then direct the CNAs to weigh the residents on the list but the unit did not always get every resident on the list weighed timely. She stated if staff did not get the weights done, the next shift would have to weigh the residents. If weights were not obtained, staff could not assess for weight loss or weight gain to evaluate care. She revealed residents could experience a weight loss and staff would not know, which could be harmful to the resident. Interview with ADON #1, on [DATE] at 7:31 AM, revealed she provided the unit with a list of residents that needed a weight, as a reminder; however, she stated the unit did not always obtain the residents' weight the day it was scheduled. The ADON stated she would forget to follow-up and remind staff to obtain the weight. In addition, she stated the unit was under staffed preventing them from completing all required care planned tasks. She was not aware staff had not weighed Resident #13 since (MONTH) (YEAR), and stated the resident could experience a decline if the facility did not identify a significant weight loss. Interview, on [DATE] at 8:30 AM, with the DON revealed she had not identified Resident #13 had a significant weight loss and could not recall discussing the resident's weight in the morning meeting with the team either. She stated if staff did not follow the facility's policy for weighing, residents could experience a significant weight loss without staff knowledge, and decline. Interview, on [DATE] at 10:27 AM, with the Administrator revealed he did not recall the team discussing Resident #13 having a weight loss. 3. Review of the facility's policy, SWAT (Skin and Weight Assessment Team), undated, revealed residents who experience significant weight change were to be monitored on a weekly basis. The team was to review findings, review interventions, and make suggestions in regard to weight stabilization. The team was to document the residents' weight, findings, interventions, and implement of new orders or interventions. The team was to monitor the resident weekly until the resident was four (4) weeks without general concerns, the weight loss was stable for eight (8) weeks unless the medical condition dictated otherwise, wounds were healed, change of condition was stable, and tube feeds were ongoing without reported issues. In addition, the policy did not exclude Hospice residents for ongoing review and assessments for excessive weight loss. Review of the facility's policy, Hydration Management, undated, revealed the facility was to ensure residents received sufficient fluid intake to maintain proper hydration. To facilitate hydration, fluids were to be offered mid-morning, afternoon, and at bedtime in addition to meals and medication pass. Furthermore, if the resident was not on a restriction, fluids were to be at the bedside for consumption at the residents' discretion. Review of Resident #25's clinical record revealed the facility admitted the resident on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed facility assessed the resident required extensive assistance of one (1) staff for eating. The resident had a 5% or more weight loss in the last month or 10 % or more in the last six (6) months, not physician prescribed. Per the MDS, Resident #25 had limited range of motion (ROM) and was impaired one side of the upper extremity, and the resident received Hospice care. Review of Resident #25's Dietitian Note, dated [DATE], revealed the resident was a full assist with food intake. Review of Resident #25's Care Plan, last reviewed [DATE], revealed the resident was at risk for nutritional problems related to a pureed diet, diet restrictions, and obesity. The facility noted a desired outcome for Resident #25 to maintain his/her nutritional status with a stable weight. An intervention included was for staff to set up the resident's meal; however, Resident #25 was a full assist for meal intake. Continued review revealed the resident was to be weighed monthly per facility policy. Resident #25 had constipation with an intervention to encourage the resident to drink fluids. Review of Resident #25's Weight Summary, dated [DATE], revealed on [DATE] the resident weighed 176.6 pounds and on [DATE], the resident weighed 164.7 pounds, a loss of 11.9 pounds in one (1) month. The facility obtained a weight on [DATE] per Surveyor request, as the weight had not been obtained, which resulted 163.6 pounds. Review of the Weight Book revealed the instruction if a resident had a four (4) pound weight loss or gain, the nurse on the unit was to be notified to check the scale. Interview with CNA #34, on [DATE] at 1:39 PM, revealed nurses instructed the CNAs as to whom needed to be weighed and there were several types of scales to be used. She stated if residents lost weight, they could get sick and their health could decline, which could cause them to be transferred to the hospital. Interview with CNA #35, on [DATE] at 2:07 PM, revealed required weights were located in the weight book located on each unit. Residents were color coded for daily, weekly, and monthly weights. She stated the sheets were turned into the nurse but the nurses lose the paper or documented an incorrect weight. The CNA stated communication was lacking between staff as to who had lost a significant amount of weight and who needed higher monitor needs. She further stated each floor completed weights differently and if the facility completed tasks consistently on each floor, the residents would receive better care. Furthermore, she stated residents with significant weight loss could end up in the hospital. Interview with LPN #10, on [DATE] 3:16 PM, revealed nurses determined which residents needed weighed and gave the information to the CNAs. She stated she would find the sheet with no weights documented and was unable to record the weights. The LPN stated residents who lost weight that remained unknown or tracked could cause serious injury to the residents. She stated weights were not on the medication or treatment records to record and track. She further stated weight loss could occur with dehydration. Interview with ADON #1, on [DATE] at 1:25 PM, revealed weights were to be obtained every month by the CNAs and the CNAs were to report a three (3) to five (5) pound weight difference to the nurse. She stated she made sure weights were obtained, placed the results into the computer, printed a monthly report, and reviewed it for weight loss. She stated an eleven (11) pound weight loss would have triggered a reweigh by staff; however, Resident #25's weight loss was not reported or addressed. Per interview, Hospice residents were not followed by SWAT; however, weights were still to be obtained. Further interview at 3:54 PM, revealed she was wrong concerning the SWAT guidelines, as Hospice residents were to be followed by SWAT. Interview with the Hospice Registered Nurse, on [DATE] at 1:56 PM, revealed the Hospice program monitored for weight loss; however, she stated the facility was the driving force for residential care and this included monitoring for significant weight loss with the nutritional monitoring program. She stated she inquired if the facility reweighed the resident and failed to receive an answer from staff. She further stated a significant weight loss could cause skin breakdown for a resident. Interview with the Staff Educator, on [DATE] at 9:15 AM, revealed all residents were to be weighed once a month and the restorative CNAs were assigned to this task. However, the facility's restorative service team was no longer a program in the facility. Therefore, due to this, weights had been sporadic. She stated staff used to turn the weights in to her and she would place them in the computer and review; however, this had stopped and she was unaware who was responsible to review the weights. Per interview, any resident with significant weight loss was to be reevaluated and steps were to be put in place to address the weight loss, and the resident was to be monitored on SWAT. Continue interview with the Staff Educator, on [DATE] at 9:15 AM, revealed residents assessed as full assistance with meals were to be physically fed and supervised at all times during the meal. Observation, on [DATE] at 8:34 AM, revealed staff placed Resident #25's breakfast tray on the bedside table at the right side of the bed and poured liquids into open containers, removed the plate cover, called the resident by name, and left the room with the table at arm's length from the resident. The resident was at a thirty (30) degree angle on his/her back. Staff left the room and did not assist the resident with the meal. Observation, on [DATE] at 8:43 AM, revealed the resident's water containers were positioned on the left side of the bed and unreachable for the resident, as the resident was unable to use his/her left hand/arm and could not reach the containers with his/her right. Observation, on [DATE] at 8:50 AM, revealed Resident #25 with eyes closed in bed at a thirty (30) degree angle with the breakfast tray presented at arm's length. Observation, on [DATE] at 9:22 AM, revealed Resident #25 was awake, remained at a thirty (30) degree angle on his/her back. He/she attempted to eat with the fork stretched as far he/she could to reach the tray and picked up small amounts of foods on the plate and ate what food he/she could get to stay on the fork. There was no staff supervision to assist with the meal. Interview with Resident #25, on [DATE] at 9:22 AM, revealed the food was cold, he/she was unable to adequately reach the food, and he/she had difficulty transferring the food picked up by the fork. Interview with CNA # 1, on [DATE] at 10:30 AM, revealed Resident #25 was to have the meal set up and she was unaware the resident was unable to use his/her left side. She stated LPN #10 told her to keep all items close to the resident. However, she did not receive this information in morning report. Interview with CNA #25, on [DATE] at 10:37 AM, revealed she received very little report during morning shift report and she was unaware Resident #25 needed full feeding assistance. She stated she guessed she would have figured it out eventually. She had been employed at the facility for five (5) days. Observation, on [DATE] at 9:57 AM, revealed Resident #25 was in bed with bilateral side rails in an upright position. The bedside table was pushed away from the bed, was unreachable for the resident, and had the resident's water containers on it. However, the resident was unable to reach the containers. Interview with Resident #25's Family, on [DATE] at 10:17 AM, revealed Resident #25's over the bed table was frequently out of his/her reach and was positioned on the wrong side. She stated the CNAs were to feed the resident or be with the resident for supervision due to the resident's high risk of choking. The Family further stated she and other family members came to the facility at least four (4) days a week to ensure the resident ate a full meal. She revealed she asked the facility to place the resident on a pureed meal because she knew Resident #25 was not supervised with meals and she was afraid he/she would choke. According to the Family, family members fed the resident regular foods because they supervised the intake and did not leave him/her. She stated she was very concerned with the eleven (11) pound weight loss because it meant the resident was not assisted with his/her meal. Per interview, Resident #25 was able to drink from closed lid containers, but the containers were to be on the table on the right side and reachable, which was the key. She further stated she often arrived in the room to find the water containers on the table away from the resident. Interview with LPN #17, on [DATE] at 1:46 PM, revealed Resident #25 was a full assist to feed and she had found Resident #25's fluids and food not in reach of the resident, mostly because staff was new or did not know the resident's needs. The LPN revealed she re-educated staff when items were found not in his/her reach. Continued interview with ADON #1, on [DATE] at 1:25 PM, revealed staff was to set up Resident #25's meal, allow him/her to eat, and then follow-up to assist with the meal if intake was inadequate. ADON #1 stated fluids were to be within the resident's reach at all times. She stated Resident #25's family reported issues of fluid accessibility to her and she re-educated the staff who were on the floor. Interview, on [DATE] at 10:27 AM, with the Administrator revealed the facility had not identified issues with staff not weighing residents per the facility policy. However, staff was to obtain resident weights and assist residents with meals to ensure resident needs were met. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff respon

Based on observation, interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to have an effective system to ensure residents were assessed for use of side rails per facility policy to prevent entrapment for three (3) of sixty-four (64) sampled residents, Resident #55, #59, and #60. Record review revealed the facility did not attempt to try alternative interventions prior to side rail use; the risks and benefits of side rails were not discussed with the resident/representative; and a signed consent was not obtained prior to placement of the side rails. In addition, the facility failed to have current physician orders for side rails with the residents' [DIAGNOSES REDACTED]. On [DATE], observation revealed Resident #55 was in bed with side rails on each side of the bed. The resident's head and neck laid on the top of the bed rail and then the resident's head settled with his/her face between the mattress and the side rail. Resident #55 was moaning and continued to moan as his/her arms and hands slid in between the rail and the bed. Licensed Practical Nurse (LPN) #10 walked past the resident's room, peered into the room, and continued to walk to the nurses' station. Certified Nursing Assistant (CNA) #25 entered Resident #55's room and repositioned the resident. Record review revealed no physician order for [REDACTED]. In addition, Resident #59 and #60 utilized side rails; however, record revealed the residents did not have current physician orders for the side rails; no current SRAs; no documentation of previous attempted interventions; and Resident #59 did not have a consent for use. The facility's failure to ensure residents were appropriately assessed for side rail use has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Side Rails/Enabler Bars, undated, revealed side rails were to be considered only after all other interventions were attempted, failed, listed, and documentation of why the alternative interventions failed or were inappropriate. A specific medical order was required for the use of the side rail, to include the specific type, length, on one (1) or two (2) sides of the bed, and the medical symptoms or [DIAGNOSES REDACTED]. Education with the resident/representative was to be completed; a signed consent was to be obtained and was to be a part of the medical record; and, quarterly re-evaluations were to be completed and documented. Lastly, the goal of the facility was to use the least restrictive intervention for safety. Review of the facility's Immediate Plan of Care Side Rail Implementation Guide, undated, revealed the plan of care identified risks for side rail implementation, which included cognition impairment, assist with bed mobility, medical diagnoses, medications, communication, and the risk of falls. The guide included sections to address previous attempted interventions. Review of the facility's policy, Nursing-Monthly Inspections, dated [DATE], revealed all resident beds were to be inspected monthly for the proper operation of resident side rails. Review of the CMS RAI User's Manual, dated [DATE], Chapter 3, Section P: Restraints and Alarms, revealed bed rail was listed as a physical restraint, and if the resident was restrained at any time during the day or night, the assessor was to evaluate whether the device met the definition of a restraint and code appropriately. If the bed rails were used as a positioning device and the device met the definition of a physical restraint, even if it assisted the mobility of the resident, the facility was to code the bed rail as a restraint. Use of the bed rail with an immobile resident did not meet the definition of a restraint. However, the bed rail might deter physical contact and clinical evaluation of alternative measures was to be considered. Further, the residents' quality of life and the possibility of a creation of an accident hazard situation were to be evaluated. Review of the facility's Bed Rail Consent Form, undated, revealed the facility identified benefits, risks for side rails, and whether the obtained signature revealed the person understood the risk factors of the use and nonuse of the side rail. Review of the facility's Maintenance/Environmental Monthly Task Sheet revealed side rails were listed to be monitored. 1. Observation of Resident #55, on [DATE] at 9:59 AM, revealed the resident was in bed with the head of the bed in full upright position and three quarter side rails, which extended from the head of the bed to the mid-calf of the bed, on each side of the bed. The resident was tilted to the left at the waist, with his/her head and neck on the top of the bed rail, then the resident's head settled with his/her face between the mattress and the side rail. Resident #55 was moaning and continued to moan as his/her arms and hands slid in between the rail and the bed. At 10:06 AM, LPN #10 walked past Resident #55's room while the resident moaned, she peered into the room, and continued on to the nurses' station. At 10:08 AM, CNA #25 entered the resident's room and repositioned the resident. Interview with LPN #10, on [DATE] at 10:31 AM, revealed when she went past Resident #55's room, she did not notice his/her position in the bed or hear the resident moan, as she did not even remember she peered into the resident's room. She stated if this was the case, it was a very bad issue. Interview with CNA #25, on [DATE] at 10:37 AM, revealed when she entered Resident #55's room, his/her head was wedged in the bed and rail, and the resident was moaning and she felt the resident was in distress. She stated she immediately repositioned the resident to the middle of the bed after she lowered the head of the bed. The CNA further stated harm or death could have occurred due to the position in which she found the resident. Per interview, the CNA was new and received very limited report on the resident at shift change and she was unaware the resident was able to move. Review of Resident #55's clinical record revealed the facility originally admitted the resident on [DATE], and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #55's Re-Admission Assessment, dated [DATE], revealed nursing staff was unable to determine Resident #55's orientation to the use of side rails. The resident was identified with poor trunk control and side rails were to be utilized on both sides of the bed for safety. Review of Resident #55's Fall Risk Assessment, dated [DATE], revealed the resident had not had a fall in the past three (3) months. The resident had no [MEDICAL CONDITION] since original admission to the facility in 2012. The facility did not provide a quarterly fall assessment after [DATE]. Review of Resident #55's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely impaired for decision-making. The facility was unable to conduct an interview for mental status. The facility assessed the resident was totally dependent on two (2) staff for bed mobility. Further review revealed the facility did not code side rails as a physical restraint used in bed. Review of Resident #55's Care Plan, last reviewed [DATE], revealed the resident was dependent for Activities of Daily Living (ADL) with interventions for side rails to be used per physician orders for safety with provisions of care and to assist with bed mobility, and staff was to observe for bed entrapment. However, review of Resident #55's Physician Order Sheet, dated [DATE], revealed no order for side rails. Review of Resident #55's Side Rail Assessment (SRA), dated [DATE], revealed the facility assessed the resident was severely impaired with cognitive skills, was periodically restless, and was dependent with all bed mobility. The resident was unable to turn side to side in the bed, had alterations in safety awareness, and bilateral quarter side rails were initiated. There was no documented evidence the facility completed a quarterly SRA after [DATE], per the facility's policy. Further record review revealed no documented evidence a Consent for Use of Side Rails was obtained for Resident #55 per the facility's policy. In addition, there was no documented evidence the facility attempted other interventions prior to the use of side rails for Resident #55 per the facility's policy. Interview with LPN #17, on [DATE] at 1:46 PM, revealed Resident #55 was dependent on staff for all care and position needs and the head of the bed was to be at a thirty (30) degree angle when not being fed and when staff was not in the room. She stated Resident #55 frequently became anxious, wiggled in bed, and she was concerned the resident could roll out of the bed. The LPN stated the rails on the bed were for safety and she did not know why they were not padded since he/she had a [MEDICAL CONDITION] diagnosis. She stated she checked on the resident several times in an eight (8) hour shift and was unaware of the entrapment and stated Resident #55 could not get himself/herself out of a rail. She stated the facility did not provide in-services on side rails routinely, but residents with side rails were to be monitored, any entrapment was to be reported, and entrapment could cause an injury. She stated all staff was responsible for the safety of the residents. She further stated Resident #55 could break an arm if it was caught in the side rails or even fall as the resident was fairly small in size. Interview with Family #5, on [DATE] at 9:49 AM, revealed Resident #55 was unable to use side rails for bed mobility. She stated the resident's [MEDICAL CONDITION] were well controlled and he/she had not had a [MEDICAL CONDITION] for the last five (5) years while at the facility. She stated the resident was able to move his/her arms and legs, and wiggle in the bed. The family member stated the facility placed the side rails on the bed and other least restrictive alternatives were not attempted. She stated she was not educated on the risks of the use of side rails and did not sign a consent. She stated discussion about side rail use were not included in the initial or subsequent care plan meetings. She further stated Resident #55 spent most of his/her time in the bed and was not monitored. Family #5 stated she was not informed of any incidents within the past twenty-four (24) hours regarding a side rail incident. She continued to state when Resident #55 moaned, it meant he/she was in pain, fearful, and his/her [MEDICAL CONDITION] made the fear worse because he/she could not see what caused the pain. Further review of Resident #55's clinical record, with Assistant Director of Nursing (ADON) #1, on [DATE] at 10:25 AM, revealed staff did not document the physician and the resident's representative were notified of the entrapment. There was no documentation a skin or physical assessment was completed, nor an incident report. Interview with ADON #1, on [DATE] at 10:55 AM, revealed ADON #3 informed her of Resident #55 entrapment in the bed and stated CNA #25 was re-educated to not have the resident's head of the bed at a ninety (90) degree angle. However, interview with ADON #3, on [DATE] at 11:16 AM, revealed ADON #1 notified her of Resident #55's entrapment. Per interview, LPN #17 told ADON #1 a skin assessment was completed and injury was not identified. She stated LPN #17 re-educated CNA #25 on proper positioning for Resident #55, which was LPN #17's determination of the reason it occurred. Further interview with LPN #17, on [DATE] at 4:20 PM, revealed when she asked CNA #25 about the incident with Resident #55 and the side rail, she stated CNA #25 said the resident was not in distress or impinged into the side rail when she entered the room, only that the resident's bed was at a ninety (90) degree angle. She stated she reeducated the CNA on proper positions for Resident #55. LPN #17 did not report the side rail entrapment to the resident's physician and family, and did not complete an incident report Interview with the Staff Educator, on [DATE] at 9:15 AM, revealed any issues with side rails were to be reported to the nurse, house supervisor, the Director of Nursing (DON), and an investigation was to be started immediately for the safety of the resident. Interview with the DON, on [DATE] at 11:25 AM, revealed she was notified about Resident #55's incident and was told the resident's arms were in the rails. She stated CNA #25 was re-educated by LPN #17, but she was unsure if an incident report was completed but it needed to be documented. In addition, there was no documented evidence management addressed the issue with CNA #25. Per interview, the DON stated she was unable to address the use of side rails in the facility as she was working on other issues. Interview with the Administrator, on [DATE] at 7:38 PM, revealed he was not notified of Resident #55's entrapment in the bed rail until [DATE]. 2. Observation of Resident #59, on [DATE] at 8:20 AM, revealed the resident in bed with full side rails present to the left and right side of the bed. Resident #59 was unable to answer questions and was not aroused verbally for interview. Review of Resident #59's clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 59's Quarterly MDS, dated [DATE], revealed the facility was unable to complete an interview for mental status. The facility assessed the resident was totally dependent on two (2) staff for bed mobility. Further review revealed the facility did not code side rails as a physical restraint used in bed. Review of Resident #59's Physician Order Sheet, dated [DATE], revealed side rails were ordered for safety and security related to [MEDICAL CONDITION]. The facility did not provide the Physician Order Sheets for (MONTH) 2019 and (MONTH) 2019. Review of Resident #59's Care Plan, last reviewed [DATE], revealed the resident was at risk for falls with an intervention for three quarter padded side rails, initiated [DATE]. Review of Resident #59's SRA, dated [DATE], revealed the resident utilized side rails, was noted to have severe impaired cognitive skills, and was total dependence for bed mobility and transfers. The facility assessed the resident as unable to turn side to side with the use of the side rail and full side rails were utilized. However, there was no documented evidence of a quarterly SRA per the facility's policy. Further review of the clinical record revealed no documented evidence the facility attempted other interventions prior to the use of side rails for Resident #59, per the facility's policy. In addition, there was no documented evidence the facility obtained a Consent for Use of Side Rails for Resident #59, per the facility's policy. 3. Observation of Resident #60, on [DATE] at 8:25 AM, revealed the resident in bed with quarter side rails present to both sides of the bed. The resident was asleep and an attempt to wake the resident verbally was unsuccessful. Review of Resident #60's clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #60's Quarterly MDS, dated [DATE], revealed the facility was unable to complete an interview for mental status. The facility assessed the resident was totally dependent on two (2) staff for bed mobility. Further review revealed the facility did not code side rails as a physical restraint used in bed. Review of Resident #60's Physician Order Sheet, dated [DATE] to [DATE], revealed an order for [REDACTED]. Review of Resident #60's Care Plan, dated [DATE], revealed a resident focus was ADL care for impaired mobility with interventions for quarter side rails to assist with bed mobility. Review of Resident #60's Consent for Use of Side Rails, dated [DATE], revealed the purposes listed were safety, security, and mobility per resident request. Further review revealed the last notation of review of the consent with the resident was [DATE]. Further review of the clinical record revealed no documented evidence the facility attempted other interventions prior to the installment of side rails for Resident #60 and no documented evidence a SRA was completed on Resident #60, per the facility's policy. Interview with CNA #36, on [DATE] at 2:09 PM, revealed CNAs did not monitor side rails. He further stated a resident could become entrapped in the rails or the rails could be a restrictive barrier for residents with Dementia. Interview with CNA #27, on [DATE] at 3:26 PM, revealed entrapment meant when someone was stuck in a bed rail and it could cause harm or death to a resident, and residents with side rails were to be supervised to prevent entrapment. Interview with CNA #26, on [DATE] at 8:34 AM, revealed she was trained on side rails use years ago and it was not required for annual training. She was unaware of the meaning of entrapment, but stated side rails were to be checked for proper use and function to prevent a resident from harm. Interview with CNA #32, on [DATE] at 9:31 AM, revealed residents with side rails were to be supervised by staff; however, she stated she was unable to adequately supervise residents at a higher risk of entrapment because she was assigned up to fourteen (14) residents. Interview with LPN #25, on [DATE] at 8:15 AM, revealed side rails could cause entrapment of a resident and heightened supervision of residents with side rails was required. She further stated side rails were used to prevent residents from falling out of the bed. The LPN revealed the ADONs completed all side rail assessments, which were a tool in the computer to determine if the resident needed the side rails. Interview with LPN #14, on [DATE] at 9:15 AM, revealed residents were to have a SRAs to determine if side rails were needed. She stated side rails could cause entrapment, which meant the resident could not get out of the bed. Further interview with the Staff Educator, on [DATE] at 9:15 AM, revealed side rail use and safety was discussed in general orientation but in-services have not been conducted on the subject of side rails. She stated side rails were not to be used until other measures were used and failed, and she was concerned over the high use of side rails in the facility. She stated she had observed residents with cognition impairment leaning on the rails and had told Administration small residents were going to get stuck in the rails. The Educator further stated she was aware side rails were not to be utilized as a safety feature and risks included entrapment. Further interview with LPN #17, on [DATE] at 4:20 PM, revealed the SRAs were to be done on admission and on a quarterly basis, and a physician order was required as well as a consent from either the resident or representative. Orders were to be placed on the physician order sheet. She stated Social Services determined whether a resident needed side rails. However, interview with the Social Services Director, on [DATE] at 9:00 AM, revealed she was not involved with SRAs or the determination of side rail use. Interview with ADON #1, on [DATE] at 10:55 AM, revealed the assessments were put on the nurses' assignment sheets to complete. However, staff interviews revealed the ADONs completed these assessments. Further interview with LPN #17, on [DATE] at 4:20 PM, revealed nursing staff reported to maintenance when the side rails needed repair; however, nursing staff was not responsible to routinely evaluate all side rails for proper operation, as it was to be done by maintenance. However, interview with the Maintenance Assistant, [DATE] at 3:15 PM and [DATE] at 10:28 AM, revealed he was not trained and was not knowledgeable about side rails. He stated the maintenance department only placed and fixed side rails on resident beds when requested by staff, and did not do routine monitoring of the side rails. He further stated once the rails were placed on the beds, nursing staff was responsible to ensure the side rails were monitored. However, review of the facility's Maintenance/Environmental Monthly Task Sheet revealed side rails were listed to be monitored. Further review revealed documentation side rails were last monitored on [DATE]. There was no documented evidence the side rails were monitored in (MONTH) and (MONTH) 2019. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed an assessment of Resident #55 regarding the use of side rails and determined the resident would benefit from a scoop mattress. Additionally, the DON revealed all residents were assessed for side rail use as indicated, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The DON stated she or the ADONs had monitored ten (10) residents three (3) days weekly on a rotating basis as indicated. Interview with the ADON #1 and #3, on [DATE] at 5:55 PM, revealed all residents were assessed for side rail usage, including review of orders, care plans, entrapment education, consents, and CNA assignment review. The ADONs stated they or the DON had monitored ten (10) residents for side rail usage three (3) days weekly on a rotating basis as indicated. Review of facility records revealed ten (10) residents were monitored for side rails as indicated. 2. Interview with the DON, on [DATE] at 6:35 PM, revealed she, the Administrator, and the Staff Scheduler assessed facility staffing levels and prepared a sufficient staffing schedule. She stated she and/or the Administrator and the Staff Scheduler reviewed schedules daily, prior to the actual date to allow for adjustments. In addition, the DON, the Administrator, and/or the Regional Director of Operations (RDO) met at least weekly to discuss staffing concerns. The DON stated she, the ADONs, or the SSD interviewed at least fifteen (15) interviewable residents, and fifteen (15) staff members weekly to ensure resident needs were met and staffing assignments completed. <b

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents that received [MEDICAL CONDITION] medications had adequate monitoring for the responses to or effects of the medications, and that staff responded timely when a resident experienced clinical significant adverse consequences after receiving [MEDICAL CONDITION] medications. In addition, the facility did not assess residents identified with distressed behaviors prior to the initiation of antipsychotic medications without considering a possible underlying medical cause such as a Urinary Tract Infection [MEDICAL CONDITION] for one (1) of sixty-four (64) sampled residents, Resident #13. On [DATE] at 6:45 AM, interview with Licensed Practical Nurse (LPN) #10, revealed Resident #13 had Dementia and acted out at times, by wandering the unit and pulling items off the walls. Nursing staff noted on [DATE], Resident #13 exhibited aggressive behavior of hitting a visitor and received an order to transfer the resident to the hospital for an evaluation. The hospital returned the resident to the facility with a [DIAGNOSES REDACTED]. LPN #10 stated the facility did not provide her with a behavioral tracking form to use to document behavioral occurrences, nor had she received training on the facility's policy related to resident behavior monitoring. Record review revealed Resident #13 had a change in condition on [DATE], sleeping more, not eating well, and less mobile in the wheelchair. Record review revealed the resident continued to experience these symptoms through the month of (MONTH) 2019. However, there was no documented evidence the physician was notified. Per interview, LPN #10 revealed on [DATE], Resident #13 exhibited lethargy and she held the resident's morning and evening medications. She stated Resident #13 remained lethargic on [DATE], and she withheld the medications again. LPN #10 stated she waited until the afternoon of [DATE] to call the physician regarding the resident's condition and received orders for laboratory testing, which were abnormal, indicating possible [MEDICAL CONDITION], and the next shift transferred the resident to the hospital. She stated she learned later the resident experienced respiratory distress requiring a breathing machine once he/she reached the hospital. The facility's failure to have an effective system in place to ensure monitoring of residents who receive [MEDICAL CONDITION] medication, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. However, the State Survey Agency (SSA) determined substantial compliance was achieved on [DATE], not on [DATE] as alleged, based on resident assessments and medical record reviews were not completed until [DATE]. The SSA verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policies, Behavioral Monitoring and Social Service Behavioral Monitoring, not dated, revealed the staff was to document in the clinical record facts, including time, antecedents, actual behavior and consequences or outcome of residents' behaviors. When resident behaviors occurred, the staff nurse or psychosocial staff would document in the resident's episodic notes regarding the behavior and then communicate via the twenty-four (24) hour report regarding the target behaviors and/or absence of target behaviors. Social Service staff would review the twenty-four (24) hour report or unit Behavioral Occurrence forms daily to discuss with the management team to attempt to determine the root cause, need for reassessment, and or new interventions to address the problems identified. Staff would communicate noted changes in the resident behavior to the resident's physician or psychiatrist for follow up evaluation and treatment. In addition, the team would review the resident's documented target behaviors and current interventions to ensure the implementation of effective behavior management interventions. Review of the clinical record revealed the facility admitted Resident #13 on [DATE], with [DIAGNOSES REDACTED]. Review Resident #13's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of seven (7) of fifteen (15) and determined the resident was not interviewable. In addition, the resident received routine scheduled antipsychotics. Review of the Certified Nursing Assistant (CNA) Care Plan for Resident #13, not dated, revealed staff was to monitor for the target behavior symptoms of violence and aggression towards staff/others and document per policy. However, review of the clinical record revealed the CNAs had not monitored for targeted behaviors and documented in Resident #13's record. Review of Resident #13's Care Plan for [MEDICAL CONDITION] Medication use related to Behavior Management, initiated on [DATE], revealed the goal stated the resident would remain free from drug related complications, which included cognitive/behavioral impairment through the next review date. The care plan directed nursing staff to administer medications as ordered, monitor and document for side effects and effectiveness. In addition, staff should monitor and record target behaviors, per the facility protocol. The plan continued to direct staff to record and report to the physician medication side effects and adverse reactions such as refusal to eat, loss of appetite, fatigue, weight loss, and behavior symptoms not usual for the resident. Further review of the clinical record revealed Resident #13 had [DIAGNOSES REDACTED]. Review of the Nursing Notes revealed on [DATE], Resident #13 exhibited aggressive behaviors towards a visitor and the facility received an order to transfer the resident to the hospital for an evaluation. The hospital returned the resident to the facility with a [DIAGNOSES REDACTED]. Review of a Psychiatric Periodic Evaluation (PPE), dated [DATE], for Resident #13, revealed the nature of the presenting problem was [MEDICAL CONDITION], physical aggression, disruptive behaviors, and recent medication change follow-up. The PPE stated the resident had a history of [REDACTED]. The PPE stated nursing staff reported Resident #13 exhibited no physical aggression, agitation, or refusal of care and further stated two (2) days prior the resident began experiencing over sedation and looked snowed, so much so that nursing staff chose to hold the afternoon doses of [MEDICATION NAME] and [MEDICATION NAME]. Continued review of the PPE, dated [DATE], revealed the resident showed no overt [MEDICAL CONDITION]. The Recommendations portion of the PPE stated it was hard to determine if Resident #13's current response to the medications was due to an underlying medical condition or overmedication. Further notation stated it was possible Resident #13's responses to the antipsychotic medication could be skewed [MEDICAL CONDITION] and antibiotic treatment. The note stated the clinician would attempt to decrease the [MEDICATION NAME] and continue [MEDICATION NAME] unchanged. Further review of the Recommendations revealed the clinician did not provide a clinical rationale for continuing the [MEDICATION NAME] after identifying the resident had not exhibited violence or aggression, nursing staff reported the resident experienced the adverse consequence of over sedation, or after determining an underlying medical condition of a UTI, which was diagnosed around [DATE]. Review of Nursing Documentation, dated [DATE], revealed nursing stated they observed Resident #13 with signs and symptoms of UTI, and the resident appeared disoriented and was crying. Review of Resident #13's Psychiatric Periodic Evaluation (PPE), dated [DATE], revealed the resident received [MEDICATION NAME] 0.5 milligrams three (3) times a day for anxiety. (A medication indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety, with known side effects of drowsiness. Elderly or debilitated patients may be more susceptible to the sedative effects of [MEDICATION NAME]; therefore, should be monitored frequently). Continued reviewed of the PPE revealed Resident #13 received a dose of [MEDICATION NAME] M-tab, 0.5 milligrams, every morning and 1 milligram at 2:00 PM daily for Alzheimer's with behaviors. (A medication used to treat [MEDICAL CONDITIONS] Disorder, or irritability associated with Autistic Disorder. Review of the Boxed Warning revealed this medication should not be used to treat behavioral problems in older adults who have Dementia. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs were at an increased risk of death. [MEDICATION NAME] was not approved for the treatment of [REDACTED]. Further review of the PPE, dated [DATE], revealed the resident's Chief Complaint and Nature of Presenting Problems were [MEDICAL CONDITION], Dementia, Disruptive Behavior, and Medication follow-up. The PPE noted staff reported to the practitioner the resident had no recent aggression or refusal of care and was at his/her baseline. The documented examination revealed the resident was cooperative, confused, and tearful. In addition, the resident had disorganized thought processes, no hallucinations, and short-term memory was grossly impaired. The PPE Diagnoses, Assessment and Plan stated the resident had [MEDICAL CONDITION] with behavioral disturbance, Anxiety, and Dementia. The Plan of Care recommendation directed staff to continue medication as prescribed and monitor for changes in mood or behaviors. Review of Nursing Documentation, dated [DATE], revealed nursing staff administered all medications, which included Resident #13's [MEDICATION NAME] and [MEDICATION NAME] per the physician's orders [REDACTED].#13 kept falling asleep and staff attempted to feed the resident but he/she refused all attempts. In addition, Resident #13 could not propel himself/herself in the wheelchair; however, staff did not identify these symptoms as clinically significant or report the signs and symptoms Resident #13 exhibited to the physician. Continued review of the clinical record revealed nursing staff did not provide an assessment regarding whether Resident #13 exhibited or not, the identified target behaviors of violence or aggression in order to track, evaluate, and manage his/her behaviors and [MEDICAL CONDITION] medication use. Further review of Nursing Documentation, dated [DATE] and timed at 2:39 PM, revealed the resident was lethargic (periods of lack of energy, tiredness, fatigue or drowsiness) and would open his/her eyes at times. The nurse documented she felt uncomfortable giving the resident his/her afternoon medications, so the nurse held Resident #13's medications. In addition, the nurse documented she checked on the resident every hour and the resident responded the same each time. However, nursing staff did not identify Resident #13's symptoms as clinically significant nor did the nurse report the signs and symptoms to the physician. In addition, the record did not provide evidence the nurse assessed Resident #13 for the targeted behaviors of violence or aggression. On [DATE] at 2:38 PM, nursing staff documented Resident #13 did not eat much breakfast, could not propel self, and fell asleep in the wheelchair. Continued review of the clinical record and nursing documentation revealed no evidence Resident #13 had an assessment for targeted behaviors in order for staff to track and trend behaviors, for the evaluation of care and continued use of [MEDICAL CONDITION] medication. Continued review of the clinical record revealed nursing staff did not document notes on [DATE] through [DATE], regarding Resident #13's mental, behavioral, or physical health status nor whether the resident exhibited violence or aggressive behaviors or side effects of the [MEDICAL CONDITION] medication. On [DATE] at 12:27 PM, nursing staff noted Resident #13 received all morning medications, continued to sleep, and only ate a little breakfast and a small amount of lunch. In addition, notations stated the resident kept falling asleep and staff administered afternoon medications as ordered. Further review of the clinical record determined nursing did not provide an assessment of Resident #13 related to whether he/she exhibited the targeted behaviors of violence or aggression in order for the facility to evaluate care and medication administration. Nursing staff noted, on [DATE] at 12:30 PM, Resident #13 received morning medications as ordered and continued to sleep. There was no documented evidence, from [DATE] through [DATE], regarding Resident #13's health or mental status related to [MEDICAL CONDITION] medication administration, nor targeted behaviors exhibited. On [DATE], nursing staff noted Resident #13 was lethargic and the nurse held the resident's morning dose of [MEDICATION NAME]. However, nursing staff did not provide an assessment regarding target behaviors that contributed to the use of the [MEDICAL CONDITION] medications administered. Further review revealed nursing staff did not document in the progress notes whether the resident experienced side effects from [MEDICAL CONDITION] medication administration or targeted behaviors until [DATE] at 9:34 AM, when nursing staff noted Resident #13 received his/her morning medications then went back to sleep and did not his/her breakfast or lunch. The resident experienced lethargy at lunch and staff held afternoon medications. The resident was lethargic through the second shift and staff held nighttime medications. However, nursing staff did not report these symptoms as potential side effects of the [MEDICAL CONDITION] medications to the physician for further direction. On [DATE] at 9:49 AM, nursing staff noted the resident experienced lethargy all night. The next morning nursing staff withheld morning medications due to the resident's condition of lethargy. Again, nursing staff noted the resident did not eat breakfast and at 2:17 PM, afternoon medications were held related to lethargy. Nursing staff notified the Nurse Practitioner (NP) of the resident's condition and received orders for laboratory blood tests. Review of laboratory test collected [DATE] at 4:13 PM and received 5:12 PM, revealed the resident's Blood Urea Nitrogen (BUN) level was 63 (normal ,[DATE]) and Creatinine was 2.4 (normal 0XXX,[DATE].3. At 7:39 PM, nursing staff notified the NP of Resident #13's abnormal laboratory results and received an order to transfer the resident to the hospital due to a change in mental status and for evaluation of possible [MEDICAL CONDITION]. Review of the Emergency Department (ED) Encounter Report, dated [DATE], revealed the nursing staff reported to Emergency Medical Services (EMS) personnel that Resident #13 became non-verbal and non-responsive three (3) days ago. EMS reported the resident's oxygen saturation during transport to the hospital was 83% (normal range 95% to 100%) on a 15 liter non-rebreather mask without improvement. Review of the ED History and Physical report, dated [DATE] and time 10:17 PM, revealed Resident #13 experienced worsening mental status over several days in the nursing facility, requiring transfer to ED for treatment. EMS noted the resident was hypoxic during transport. Once in the ED, Resident #13's oxygen levels failed to improve. Resident #13 had a hospital [DIAGNOSES REDACTED]. In addition, Resident #13 received [DIAGNOSES REDACTED]. Due to Resident #13's poor prognosis, the hospital contacted the State Guardian regarding the need for Hospice/Palliative care. Interview with the Psychiatric Mental Health Nurse Practitioner, on [DATE] at 9:26 AM, revealed Resident #13 had disruptive behavior and aggression towards the end of (MONTH) (YEAR). She stated around [DATE], she recalled the resident had a [DIAGNOSES REDACTED]. She stated she expected nursing staff to assess and track behaviors; however, she had no documentation to review and could only go by verbal nursing reports regarding behaviors when she was in to assess the resident for the continued use of the [MEDICAL CONDITION] medications. She stated if she had known nursing staff had withheld the medications on several occasions due to the resident experiencing lethargy, she would have reduced dosages. She stated the medications could potentially cause more harm than good. Interview with Resident #13's Physician, on [DATE] at 11:00 AM, revealed he expected staff to monitor/track resident behaviors for him to better assess and [DIAGNOSES REDACTED]. He stated a resident with a history of UTIs that exhibited increased confusion and new onset behaviors of aggression could indicate the presence of another UTI, which would trigger an order for [REDACTED]. He stated he expected nursing staff to follow the plan of care and he depended on nursing staff to provide information related to the resident's condition so he could provide orders to improve the resident's health status. Interview, on [DATE] at 7:00 AM, with CNA #43 revealed nursing staff had not directed her to document Resident #13's behaviors. She stated Resident #13 would talk mean to staff; however, she had never witnessed the resident hitting anyone. She stated the resident was always sleepy on her shifts, which she thought was normal for the resident. Interview with LPN #10, on [DATE] at 6:45 AM, revealed Resident #13 had Dementia and acted out at times by wandering the unit and pulling items off the walls. She stated nursing staff had requested a psychiatric consult after the resident hit a visitor on the knee and the facility received orders for the administration of [MEDICATION NAME] and [MEDICATION NAME]. LPN #10 stated the facility had not provided her with a form to use in order to document/track behavior occurrence, nor had she received recent training on the facility's policy related to resident behavior monitoring. On [DATE], Resident #13 exhibited lethargy and she held the resident's morning and evening medications, and the resident remained lethargic on [DATE], and she withheld the medications again. LPN #10 stated she waited until the afternoon of [DATE] to call the physician regarding the resident's condition and received orders for laboratory testing, and the results came back abnormal and the next shift transferred the resident to the hospital. Per interview, she learned later from the Director of Nursing (DON) the resident experienced respiratory distress requiring a breathing machine once he/she reached the hospital. She had not correlated the resident's decline with a UTI or Pneumonia, and she thought the decline was due to the [MEDICAL CONDITION] medications. Interview with LPN #18, on [DATE] at 4:00 PM, revealed Resident #13 would become lethargic after the administration of [MEDICATION NAME] and [MEDICATION NAME], which was a side effect of the medication. She reviewed [MEDICATION NAME] and [MEDICATION NAME] mediation side effects after the transfer of Resident #13 and found [MEDICATION NAME] had a Black Box warning related to its use in elderly with Dementia. LPN #18 stated nursing staff should have assessed and reassessed the resident for its known side effects, documented the findings, and reported to the physician. She stated Resident #13 also had a history of [REDACTED]. However, nursing staff did not evaluate to determine if the hitting behavior might be due to signs and symptoms of a UTI. LPN #18 stated the facility had not provided her with direction on behavior protocols for residents receiving [MEDICAL CONDITION] medications. She stated the facility used to have a form but no longer used it and stated tracking and trending of behaviors helped with determining care. Interview, on [DATE] at 8:30 AM, with DON revealed the facility at one point in the past had a Behavioral Monitoring protocol, with a form, for nursing staff to use; however, that was no longer in place. She stated nursing staff was to make a narrative note in the chart regarding assessed behaviors; however, she was not aware of any recent training provided to nursing staff to ensure they were aware of that expectation. The DON stated Resident #13 had advanced Dementia with behaviors and staff was to document the resident's behaviors in narrative form in the clinical record. She stated the resident had periods where he/she would be quiet and at other times would be stirred up. The DON revealed nursing staff requested a psychiatric consult around (MONTH) (YEAR) when the resident had increased aggressive behaviors and the nurse practitioner ordered [MEDICATION NAME] and [MEDICATION NAME] for the behaviors. According to the DON, the nursing team did not correlate the increased behaviors to a possible reoccurrence of a UTI. The DON stated Adult Protective Services entered the building after the transfer of Resident #13 to investigate the care provided because EMS personnel reported to the hospital that facility staff reported the resident had been non-responsive for several days prior to transfer. She was not aware of this information, so she interviewed the nurse regarding the resident's status prior to transfer and did not find any issue with care provided. Even though, nursing staff had documented the resident had a change in condition and had withheld medication due to lethargy. Per interview, nursing staff should have monitored the resident closely, documented the findings, and notified the physician. She stated if a resident had a change in condition, nursing staff noted it on the twenty-four (24) hour report, and the Interdisciplinary Team discussed the findings the next morning. However, she could not remember a discussion or an evaluation regarding Resident #13's behaviors to determine if behaviors were due to a potential underlying medical condition, such as a UTI. Interview with the Administrator, on [DATE] at 10:27 AM, revealed Adult Protection Services came into investigate care and services provided to Resident #13 after the resident transferred to the hospital. He stated the DON investigated the allegation care was not provided accordingly, and found no deficient practice and the issue was resolved. The Administrator stated the DON did not share any opportunities for improvement regarding the care and services provided, and since he believed the issue was resolved, he did not direct the DON to do anything differently. The Administrator stated he trusted the DON and nursing staff, and believed they provided the necessary care and services to each resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Director of Nursing (DON) assessed Resident #55 for the use of side rails and determined the resident would benefit from a scoop mattress and staff care planned and installed the scoop mattress. On [DATE] to [DATE], the DON or Assistant Director of Nursing (ADON) and Therapy staff assessed all residents using side rails for safety. On [DATE] to [DATE], the DON, ADONs, Minimum Data Set (MDS), and Therapy staff completed new side rail assessments for all residents using side rails. Staff reviewed orders and care plans for side rails, entrapment education, side rail consents, and Certified Nursing Assistant (CNA) assignment review. The DON or ADONs would monitor ten (10) residents for side rails three (3) days weekly on a rotating basis to ensure all orders and interventions were in place. 2. On [DATE], the Administrator, DON, and Staff Scheduler assessed the staffing levels and prepared a staffing schedule sufficient to meet the needs of residents on a daily basis. The staffing schedule would be reviewed daily prior to the actual date to allow for necessary adjustments. The Administrator or Regional Director of Operations (RDO) would authorize supplemental staff, extra shift bonuses, and/or use of agency staff. The Administrator, DON, or RDO would meet at least weekly to review staffing concerns. The facility would document efforts to recruit and retain staff until adequate staffing was reached. The DON, ADONs, or Social Services Director (SSD) would interview fifteen (15) interviewable residents and fifteen (15) staff members weekly to ensure resident needs were met and staff was able to complete assignments. 3. On [DATE] to [DATE], the DON, SSD, and SSD Consultant completed an audit of residents in the facility who received psychoactive medications. The DON, SSD, and SSD Consultant compiled a list of those residents and reviewed the resident records to ensure there were no concerns of lethargy. The DON, ADONs, and Nurse Supervisor would review resident progress notes daily to monitor for indications of weakness or lethargy and would investigate to determine the root cause and make appropriate notifications. Appropriate orders would be obtained and would be noted as a Change in Condition. The DON or Administrator would review resident records weekly of those who had a Change of Condition noted to ensure the process was followed. The MDS would update the resident's assessment as indicated. The DON, ADONs, or SSD would monitor twenty (20) residents with known behaviors weekly on a rotating basis for a period of four (4) weeks. 4. On [DATE] to [DATE], the Dietary Manager (DM) completed an audit of all residents and established a baseline weight for all residents. The Corporate Dietician assisted the DM to create a plan to obtain timely and accurate weights. Staff checked orders and care plans and ensured the presence of a current weight, and staff placed residents on the agenda for weekly review at the Skin, Weight Assessment Team (SWAT) as indicated. Staff would review weights daily at the Clinical Quality Indicator (CQI) meeting. The ADONs monitored for weekly weights and the DM and Registered Dietitian (RD) would monitor resident weights monthly to ensure completion. The DON and DM would review weights weekly to ensure they were obtained timely and accurately for four (4) weeks, then every other week for six (6) months. 5. On [DATE] to [DATE], the DON, ADON, MDS Nurse, RD, SSD, SSD Consultant, and Speech Therapy (ST) reviewed the medical records for Resident #4, #12, #14, #15, #17, #18, #19, #20, #21, #25, #27, #37, #55, and #58, for appropriate diagnoses, care plan interventions, related orders, medications, equipment/devices, appropriate assessments, entrapment education, and CNA assignment sheets for residents with dysphagia, behaviors, risk for falls, or side rails. Resident #13 no longer resided at the facility and Resident #16 had expired. 6. On [DATE] to [DATE], the DON, ADONs, MDS, RD, and ST reviewed the medical records of residents at the facility with [DIAGNOSES REDACTED]. The DON, ADONs, MDS, and RD developed a process to screen admissions, re-admissions, or new [DIAGNOSES REDACTED]. The DON, ADONs, or Charge Nurses would monitor two (2) meals, three (3) days weekly to ensure staff was monitoring residents with dysphagia who were care planned for supervision when dining. 7. On [DATE] to [DATE], the DON, ADONs, MDS, and Therapy staff audited residents who had not had a falls risk assessment performed within the last quarter. Staff reviewed related orders, care plan interventions, medications, equipment and devices, and CNA assignment sheets. The DON, ADONs, or Nurse Supervisor would monitor progress notes daily for any resident falls and add these residents to the Falls Quality Assurance (QA) Audit Tool. Staff would perform fall assessments after a fall, in addition to a pain assessment. Staff would make notifications, and obtain orders and update care plans appropriately. The DON or ADONs would monitor any falls via the Falls QA Audit Tool and would discuss falls weekly at a CQI meeting. The Administrator and DON would monitor the tool weekly for six (6) months to ensure ongoing compliance. 8. On [DATE], the facility held a Quality Assurance Performance Improvement (QAPI) meeting and developed a plan for removal of the Immediate Jeopardy. The Administrator, DON, RDO, SDC, MDS, Rehabilitation Manger, SSD, Activities, and the Medical Director were involved in the process. The Administrator and DON participated in daily meetings, weekly QAPI meetings, and regular reporting to the RDO regarding achievement and maintenance towards compliance. 9. On [DATE], the ST and the DON educated all nursing staff on dysphagia, care plan interventions, CNA assignment sheets, diet orders, and supervision of residents with choking risks. The SSD and Therapy staff educated all staff members on resident behaviors, care plan interventions for resident behaviors, and potential harm from resident behaviors, falls, care plan interventions for falls, expected staff response to a resident fall, side rails and their use, side rail assessment, care plan interventions for side rails, and monitoring of residents with side rails on their beds. The DON and the SSD educated all nursing staff on medication administration, side effects of psychoactive medications, signs of lethargy, gradual dose reductions, and behavior monitoring. Educators measured staff knowledge retention of all topics with a post-test, which required a passing score of 100%. Staff who failed to achieve a passing score were re-educated and re-tested before they could work. Those not in attendance, new hires, and agency staff were educated prior to working their next scheduled shift. Human Resources (HR) would continue to monitor for successful completion of education. 10. On [DATE], the RDO and RNC in-serviced the Administrator and the Interdisciplinary Team (IDT) regarding the QAPI program. The RDO and RNC would be at the facility one (1) to two (2) days weekly to provide oversight until the Immediate Jeopardy was resolved and compliance achieved. 11. On [DATE], the RDO and RNC re-educated the Administrator and DON regarding facility policies and procedures in the Administrator Reference Guide and the Director of Nursing Reference Guide. 12. On [DATE], the QAPI Committee met to discuss the audit results and follow-up as needed. The QAPI Committee would meet weekly thereafter for eight (8) weeks and monthly thereafter. A Regional Staff member would attend the weekly QAPI meetings. The SSA validated the facility implemented the following actions: 1. Observation of Resident #55, on [DATE] at 11:25 AM, revealed the resident lying in bed, eyes closed. The resident was lying on a scoop mattress and no bed rails present. Interview with the DON, on [DATE] at 6:35 PM, revealed she performed a

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide pain management for one (1) of sixty-four (64) sampled residents, Resident #21. Interview with Resident #21 on 02/13/19, revealed the resident was in pain due to the facility did not have his/her medication available for administration. Documentation revealed staff did not administer prescribed pain medication on 02/12/19 or 02/13/19, in addition to three (3) other days, 02/05/19, 02/07/19, and 02/08/19. Record review also revealed staff failed to assess the resident's pain characteristics such as intensity, location, and precipitating factors prior to administering pain medication and failed to assess for relief after administration according to the facility's Pain Flow Sheet. The findings include: Review of the facility's policy, Management of Pain, not dated, revealed the facility would achieve goals through promptly and accurately assessing and diagnosing pain, increasing comfort, and reducing depression and anxiety in residents. The facility would continue to achieve goals through optimizing the residents' ability to perform activities of daily living; monitoring treatment efficacy and side effects; preventing and minimizing anticipated pain when possible; and using pain medication judiciously to the resident's desired level of pain relief with avoidance of unacceptable adverse consequences. Further review revealed nursing staff involvement would include pain assessment completed upon admission, readmission, each Minimum Data Set (MDS) assessment, and change of resident condition. The Comprehensive Pain Assessment measured the impact of pain on the resident's function, assessing the resident's physical condition, history, mental status, and Activities of Daily Living (ADL). The assessment would cover the following areas: intensity, location, onset, type, frequency, description, change, treatment, and effect. The nursing staff would document on the back of the Medication Administration Record (MAR)/Pain Flow Sheet the effectiveness of the pain medication. Effectiveness should be measures one (1) to two (2) hours after administration. Interview with Resident #21, on 02/13/19 at 1:35 PM, revealed he/she was in a lot of pain because the facility ran out of his/her pain medication two (2) days ago. Resident #21 stated on a pain scale of one (1) to ten (10) and ten (10) being the worst pain experienced, his/her pain level was an eight (8). The resident stated a nurse informed him/her the pain medication was ordered but the facility had not received it as of yet. Resident #21 stated not having the pain medication was very upsetting and caused him/her a great deal of pain and he/she lost sleep last night due to the pain. Review of Resident #21's clinical record revealed the facility admitted resident on 04/30/14, with [DIAGNOSES REDACTED]. Review of Resident #21's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Per the MDS, the resident was on a scheduled pain medication regimen. Continued record review revealed no Pain Flow Sheets for Resident #21, per the facility's policy. Review of Resident #21's Care Plan, dated 06/20/18, revealed the resident was at increased risk for alteration in pain/discomfort with interventions to administer pain medication as ordered and observe the resident for effectiveness of pain relief. Review of Resident #21's Physician Orders, dated 12/13/18, revealed [MEDICATION NAME] 10 milligram (mg) twice a day for pain, and [MEDICATION NAME] 10 mg every four (4) hours as needed for pain. Review of Resident #21's MAR, dated 02/01/19 to 02/28/19, revealed [MEDICATION NAME] 10 mg twice daily at 8:00 AM and 8:00 PM. Documentation revealed the resident did not receive the 8:00 AM dose of medication on 02/05/19, 02/07/19, and 02/08/19, as the areas for documentation were blank. In addition, the medication was not administered on 02/12/19 at 8:00 AM or 8:00 PM, nor on 02/13/19 at 8:00 AM, as the initials of staff were circled, which review of the MAR instructions revealed the resident refused the medication. However, review of notes on the back of the MAR revealed on 02/12/19, the 8:00 AM dose was not administered due to the resident was out of [MEDICATION NAME] and there was none in the Emergency Drug Kit (EDK). On 02/13/19, the note revealed the 8:00 AM dose was not administered due to no prescription. Continued review of the MAR revealed the as needed dose of [MEDICATION NAME] had not been administered to the resident 02/01/19 to 02/13/19. Review of Resident #21's Progress Notes, dated 02/05/19 to 02/13/19, revealed no documentation related to the resident not receiving his/her [MEDICATION NAME]. Continued interview with and observation of Resident #21, on 02/14/19 at 3:15 PM, revealed he/she had a pain level of six (6) of ten (10). The resident was leaning to the right side of the wheelchair and stated he/she was at the Valentine's Day party but could not stay and was ready to lay down due to his/her back hurting. Continued review of the resident's MAR, dated 02/01/19 to 02/28/19, revealed no documentation the resident was administered an as needed dose of [MEDICATION NAME] on 02/14/19. Interview with Certified Medical Technician (CMT) #2, on 02/14/19 at 3:25 PM, revealed Resident #21 did not have [MEDICATION NAME] available for the 8:00 PM dose last night (02/13/19) and she spoke with pharmacy to acquire permission to obtain pain medication from the EDK. CMT #2 revealed on 02/14/19, the resident received his/her regular scheduled pain medication via STAT (immediate) delivery. Interview with Licensed Practical Nurse (LPN) #1, on 02/15/19 at 9:11 AM after she reviewed Resident #21's MAR, revealed no initials in the blank spaces meant the medication was not administered. Per interview, staff might have forgotten to sign the MAR but would have signed the narcotic sheet; however, Resident #21's narcotic sheet could not be located for the month of (MONTH) 2019 at the time of this interview. Interview with LPN #25, on 02/15/19 at 9:46 AM after he reviewed Resident #21's MAR, revealed if the [MEDICATION NAME] was not initialed, it was not given. LPN #25 stated not giving medication correctly could cause mediation errors, overdoses, illness, or even death. According to the LPN, Resident #21 was able to express his/her pain level but he was unsure if documentation of the resident's pain was completed on the pain flow sheet. Further interview with LPN #1, on 02/15/19 at 9:11 AM, revealed she usually used a pain flow sheet to assess the resident's pain; however, per interview, the sheet was not located in resident's chart and it should have been. Interview with LPN #14, on 02/20/19 at 12:56 PM, revealed if medication was not documented in the resident's chart, that indicated the medication was not given. LPN #14 stated when medications were running low; nursing staff was to re-order the medication, which usually was not an issue. Interview with Assistant Director of Nursing (ADON) #1 and #3, on 03/08/19 at 5:55 PM, revealed for emergencies, the medication was available in the EDK. If medication was not in the EDK, nursing staff notified one of the ADONs to call the pharmacy for a STAT medication order, or call the pharmacy in town as a backup. The ADON, DON, and pharmacy staff had weekly meetings to discuss concerns. The ADONs understood the consequences of a resident missing pain medication could lead to not addressing the resident's pain and could affect their quality of life. Interview with the Administrator, on 02/22/19 at 10:27 AM, revealed he expected staff to follow policy and procedures regarding pain management. He stated if staff had issues meeting resident needs, they should inform nursing leaders and then him so they could be resolved. He stated he did not have knowledge of issues or complaints regarding residents not having their pain managed.

Based on observation, interview, record review, and review of the facility's Dementia Unit packet, it was determined the facility failed to ensure residents individualized dementia care needs were met for one (1) of sixty-four (64) sampled residents, Resident #16. Resident #16 resided on the Dementia Care Unit and observations from 7:19 AM to 10:36 AM, on 02/14/19, revealed Resident #16 yelled for help, stated he/she was cold, made statements regarding pooping and his/her pants were soaked, with minimal staff assistance to address his/her distress. In addition, the resident wandered into several resident rooms while continuing to holler in distress without staff intervention. The findings include: Review of the Hope Springs Dedicated Dementia Care Unit packet revealed all residents, regardless of any cognitive limitations, were entitled to be treated with utmost dignity and respect. Additional review revealed the Unit was free from unnecessary medications and the staff was specifically trained. Review of Resident #16's clinical record revealed the facility admitted the resident with the [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident had behaviors of public sexual acts, rummaging, and verbal/vocal symptoms like screaming or disruptive sounds one (1) to three (3) times during the assessment period. The resident required extensive assistance of two (2) with transferring from a seated to a standing position and toileting, and was always incontinent of bladder and bowel. The facility determined the resident was not interviewable with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15). Review of Resident #16's Certified Nursing Assistant (CNA) Care Plan, not dated, revealed the plan directed staff to provide meal supervision while eating, to offer the resident an opportunity to lay down for a nap after meals, and to check and change the resident every two (2) to three (3) hours and as required for incontinence. In addition, staff was to monitor and record the resident's behavior and mood for occurrence of target behaviors of wandering, and violence/aggression towards staff/others per the facility protocol. Observations of the Memory Care Unit, on 02/13/19 at 7:49 AM, revealed Resident #16 seated in his/her wheelchair with a white sheet wrapped around his/her shoulders, between the nurses' station and the elevators. The resident yelled, Help me, three (3) times and then yelled, I am cold. Neither Licensed Practical Nurse (LPN) #1, who was nearby, nor any other staff address the resident's pleas for help. CNA #20 went by Resident #16 and stated to the resident, Are you hungry? You will be eating soon, then continued on doing other tasks. The resident continued to yell loudly, Please help me, I am cold, help, help, help, with no staff intervention. Continued observations, on 02/14/19 at 7:19 AM to 10:36 AM, revealed the resident yelled for help while staff completed other tasks and did not address his/her pleas. At 7:19 AM, Resident #13 yelled, help me, while seated in his/her wheelchair near the nurses' station. At 7:28 AM, the resident yelled, help me, help me, so cold, help me, please help me, oh I am so cold. At 7:32 AM the resident yelled, I am so cold, help me, oh I am co cold. LPN #1 stood at a medication cart in the hallway not far from Resident #16; however, did not offer to help Resident #16. At 7:43 AM, Resident #16 hollered, Oh that is cold. At 7:46 AM, Resident #16 leaned forward, scooted his /her bottom to the edge of the wheelchair and yelled, Help me. with no staff intervention. The resident again yelled, Oh am I cold, help, help me, help me. Further observation on 02/14/19 at 7:54 AM, revealed Resident #16 rolled himself/herself into room [ROOM NUMBER] while he/she continued to yell, Help me. Two (2) residents were in their beds. As Resident #16 stopped at the end of bed 2, he/she continued to yell, Oh no, oh I am cold. At 7:59 AM, staff nearby completing tasks did not address Resident #16's wandering behaviors and pleas for help. At 8:01 AM, Resident #16 hollered, Please hey, help me, oooh I am pooping. Hey, hey. Resident #16 grunted, leaned forward in the wheelchair, and again hollered, Help me, help me, help me, please hey, help me. The resident hollered again at 8:06 AM, hey, hey, help me, it is cold, wow I am cold, as he/she wheeled himself/herself out of room [ROOM NUMBER] and into room [ROOM NUMBER]. The resident continued to yell for help. Observation at 8:10 AM, revealed staff walked past room [ROOM NUMBER] without addressing Resident #16's pleas. A different voice yelled from room [ROOM NUMBER], Help me, as Resident #16 sat in his/her wheelchair at the foot of bed 1 in room [ROOM NUMBER]. Continued observation revealed staff obtained a breakfast tray, walked into room [ROOM NUMBER] and delivered the tray, and staff removed Resident #16 from the room and into the hallway. On 02/14/19 at 8:11 AM, interview with Resident's #63 and #64, revealed while Resident #16 was in their room (room [ROOM NUMBER]), he/she told them he/she was hungry and wanted coffee. Resident #63 stated Resident #16 entered their room often and he/she had to alert staff to remove Resident #16. Resident #63 stated he/she felt sorry for Resident #16 because he/she was always lost. Continued observation of Resident #16, on 02/14/19 at 8:12 AM, revealed staff transported the resident to the Sunroom, positioned him/her at the table, and brought him/her a breakfast tray. When the Surveyor walked around Resident #16 to review his/her meal ticket, feces could be smelled. Continued observation revealed the CNA left the Sunroom to obtain and deliver other resident trays. Resident #16 continued to holler for help with no staff intervention. Further observation revealed a visitor entered the Sunroom at 8:27 AM, and sat at the table with Resident #16 and #20. Resident #16 continued to yell, Help me, oh I am cold, and the visitor got up and went to staff down the hall to inform them Resident #16 needed help and told the Surveyor after returning that help was coming. Resident #16 leaned over in his/her wheelchair and grunted. At 8:40 AM, CNA #10 entered the Sunroom with another resident's tray told Resident #16 he/she was wrapped up as much as they could wrap him/her up, then asked the resident if he/she was still hungry and cued the resident to eat his/her breakfast. At 8:49 AM, Resident #16 yelled, Oh, I am cold, wow, oh take me home, and then placed his/her head on the table. At 8:52 AM, the Administrator walked into the Sunroom at the same time Resident #16 yelled, Oh help me, help, help, help, help me. At 8:57 AM, Resident #16 again stated he/she wanted to go home and CNA #32 told the resident he/she was home and walked away. At 9:02 AM, the resident again yelled he/she was cold and requested help; however, staff did not address the resident's pleas. At 9:16 AM, Resident #16 left the Sunroom by propelling himself/herself and entered room [ROOM NUMBER] at 9:20 AM, without staff intervention. At 9:22 AM, the resident remained in room [ROOM NUMBER] and yelled, Help me, oh I am soaked, they are killing me, I want to go to bed. Resident #16 remained in room [ROOM NUMBER] and continued to yell for help. At 9:29 AM, Resident #16 yelled, Stomach killing me, somebody help me, as CNA #32 passed by with another resident's breakfast tray. On 02/14/19 at 9:23 AM, interview with CNA #32 revealed she heard Resident #16 yell; however, she was on light duty and could not toilet residents because of a back injury. She stated if staff did not assist residents when they called out for help a resident could experience a decline. On 02/14/19 at 9:30 AM, interview with CNA #20 revealed Resident #16 hollered all the time. She stated the resident was always cold and they would give him/her blankets but he/she continued to yell. She stated the Memory Care unit had just recently opened; however, she had very little training on interventions for Dementia care. CNA #20 stated staff should meet the residents' physical and emotional needs. On 02/14/19 at 10:45 AM, interview with LPN #7 revealed staff should meet the resident's Dementia care needs. However, Resident #16 wandered the unit every day and it was hard to implement care plan interventions for that behavior because they were short staffed. LPN #7 stated the resident yelled all the time and they tried to cover him/her up but it did not help. She stated she had very little training since the Dementia care unit opened and she did not know what else to do. Interview with LPN #1, on 02/14/19 at 11:00 AM, revealed she had heard the resident hollering but had many tasks to complete. She stated she was not aware staff had not toileted the resident and she stated staff should meet the resident's Dementia care needs or he/she could experience a decline. On 02/22/19 at 7:31 AM, interview with Assistant Director of Nursing (ADON) #1 revealed nursing staff supervised the CNAs to ensure interventions for residents with Dementia were implemented. She stated the Dementia Care unit just opened and not all aspects of care were in place yet. She stated the unit was scheduled for renovation so there would be areas to keep residents involved in activities. However, until then not much was in place to address residents that had Dementia with behaviors needing more attention. Interview with the Director of Nursing (DON), on 02/22/19 at 8:30 AM, revealed the Dementia Care unit was not fully operational because they just secured the unit so the wandering residents could be in a safe environment. She stated a few trainings had been completed but more was needed to ensure staff was able to meet resident needs. She stated she believed Resident #16 was terminally restless and not much would help his/her behaviors of yelling and wandering the unit.

Based on interview, record review, facility policy review, and review of the Resident Handbook, it was determined the facility failed to ensure medications were available and administered to meet resident needs for one (1) of sixty-four (64) sampled residents, Resident #21. Resident #21 was to receive pain medication twice a day, and every four (4) hours as needed. However, interview with the resident revealed he/she had not received pain medication when the resident was experiencing pain because the facility ran out. Interviews with staff revealed it could take a couple of days to get medication because the facility was located in Chicago. The findings include: Review of the facility's policy, Ordering Medications, dated (MONTH) (YEAR), revealed medications and related products were ordered from the pharmacy on a timely basis. The new medication order request could be faxed to the pharmacy's main fax number, sent via electronic health records (EHR) system, electronically prescribed by the prescriber, and/or called in by the appropriate personnel according to state laws and regulations. The refill request could be faxed to the pharmacy's main fax number, EHR system, reordered via Framework Link, and/or left on the pharmacy refill voicemail. Refill requests should be sent in seventy-two (72) hours prior to the last dose. Review of the facility's Resident Handbook, Pharmacy Services, undated, revealed the facility had a contract with a pharmacy (Chicago) to provide medications to all residents. The resident had the right to choose another pharmacy to fulfill medication needs if the resident so desire. All medications must have a physician's orders [REDACTED]. Record review revealed Resident #21 had a physician order, dated 12/13/18, for [MEDICATION NAME] 10 milligram (mg) twice a day for pain, and [MEDICATION NAME] 10 mg every four (4) hours as needed for pain. Review of Resident #21's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Per the MDS, the resident was on a scheduled pain medication regimen. Interview, on 02/13/19 at 1:35 PM, with Resident #21 revealed the facility ran out of his/her pain medication two (2) days ago and he/she was in a lot of pain. The resident stated a nurse told him/her the pain medication was ordered but had not gotten to the facility yet. Resident #21 stated not having the pain caused him/her a great deal of pain and he/she lost sleep last night (02/12/19) due to the pain. Review of Resident #21's Medication Administration Record (MAR), dated 02/01/19 to 02/28/19, revealed the order for [MEDICATION NAME] was on the MAR and was to be given at 8:00 AM and 8:00 PM. On 02/05/19, 02/07/19, 02/08/19, and 02/13/19, there was no documented evidence the 8:00 AM dose was administered. In addition, there was no documented evidence the medication was administered on 02/12/19 at 8:00 AM or 8:00 PM. Review of notes on the back of the MAR revealed on 02/12/19, the 8:00 AM dose was not administered due to the resident was out of [MEDICATION NAME] and there was none in the Emergency Drug Kit (EDK). Interview with Licensed Practical Nurse (LPN) #1, on 02/15/19 at 9:11 AM, revealed the pharmacy, located in Chicago, usually required a prescription for controlled medication because the reordering process was not automatic at this facility. She would call to confirm a resident need a prescription, and then would call the physician and/or nurse practitioner for the order. LPN#1 stated when staff called the physician and/or nurse practitioner for the prescription, it might take time due to lack of communication between the physician, the facility, and pharmacy. She stated she called the pharmacy several times for Resident #21's [MEDICATION NAME] and revealed Resident #21 would need a new order since the last prescription was STAT (immediate) and only twenty (20) pills were sent to the facility. LPN stated the nurse practitioner would be in the facility tonight to e-script to pharmacy for Resident #21's regular amount of pain medication, thirty (30) pills. Interview with LPN #26, on 02/15/19 at 2:18 PM, revealed nursing staff was trained to reorder medication, even narcotic medication, when a resident got down to five (5) days' worth of medication. She stated because the pharmacy was located in Chicago, it took up to two (2) to three (3) days before medication was received at the facility but for emergencies, the EDK box was available. There was no way to know if the pharmacy received the fax unless the nurse called to confirm, and sometimes a confirmation fax was received. According to the LPN, the next shift staff would not know if narcotic medications were re-ordered unless indicated on the MAR, documented in nursing notes, or if staff called the pharmacy. LPN #26 stated there was no formal audit system; however, during shift change staff usually discussed resident medication, counted the controlled medications, and pulled labels off medications that needed reordering. Continued interview with LPN #1, on 02/19/19 at 9:32 AM, revealed Resident #21's [MEDICATION NAME] prescription was written and faxed to pharmacy on 02/13/19; however, when she called the pharmacy they had not received the prescription. The LPN stated she would re-fax the prescription today and follow-up with a phone call. LPN #1 revealed the same company operated the facility and pharmacy, and it would be better if the pharmacy were located closer to the facility. Interview with Assistant Director of Nursing (ADON) #1 and #3, on 03/08/19 at 5:55 PM, revealed when ordering or reordering pain medication, a new prescription was needed each time. The written prescription was faxed to the pharmacy, transcribed onto the MAR, and details reported to the next shift. Medication should arrive at the facility within forty-eight (48) hours. In the meantime, if the medication was an emergency, it was available in the EDK. If medication was not in the EDK, the nursing staff notified one of the ADONs to call pharmacy for a STAT medication order or call the pharmacy in town for a back-up supply. Interview with the Administrator, on 02/22/19 at 10:27 AM, revealed he expected staff to follow policy and procedures for ordering pain medication. He stated if staff had issues meeting resident needs they should inform nursing leaders and then him so they could be resolved. He stated he did not have knowledge of issues or complaints regarding residents not receiving pain medication.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure staff provided care in accordance with the Comprehensive Care Plan for one (1) of four (4) sampled residents, Resident #4. Certified Nursing Assistant (CNA) #7 failed to follow Resident #4's Comprehensive Care Plan and CNA Care Plan, which stated staff would use the Maxi-lift with two (2) staff when assisting Resident #4 with transfers. CNA #7 failed to obtain additional staff to assist her with the Maxi-lift when she transferred Resident #4 from the bed to the wheelchair. The resident complained of pain in his/her hip and x-ray results revealed a left [MEDICAL CONDITION]. The findings include: Review of the facility's policy, Interdisciplinary Team Care Plan Guidelines, dated February 2014, revealed an individualized Comprehensive Care Plan included measurable objectives and timetables to meet resident's medical, nursing, mental, and psychological needs was developed for each resident. The Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans at least quarterly and as needed. Review of the facility's policy, CNA Card, dated September 2014, revealed each resident had a card summarizing pertinent information to assist the CNA in delivering care. The CNA Card covered the basics of care and the CNA gave care as outlined on the CNA Card. The CNA Cards were on the inside of each resident's door. If the CNA failed to follow the CNA Card, the facility would perform a root cause analysis. Review of the facility's medical record for Resident #4, revealed the facility admitted the resident on 02/05/10, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment, dated 06/15/16, revealed Resident #4 was totally dependent upon two (2) staff for assistance with bed mobility and transfers between the bed, chair, wheelchair, bath, and toilet. Resident #4 was assessed by the facility with the Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which the facility determined the resident was interviewable. Review of the facility's CNA Care Card, dated 09/22/16, revealed Resident #4 could not stand, pivot, or walk, and required a Maxi-lift for transfers with the assistance of two (2) staff. Review of the facility's Comprehensive Care Plan, dated 06/28/16, revealed Resident #4 was at risk for falls related to [MEDICAL CONDITION] and all transfers were done by two (2) staff with a Maxi-lift. Review of Resident #4's Nurse's Note, dated 09/02/16, revealed Licensed Practical Nurse (LPN) #2 documented Resident #4 was transferred to the wheelchair via the Maxi-lift and he/she complained of pain to the left hip after the transfer. LPN #2 notified Resident #4's family and physician, who ordered an x-ray of his/her left hip. Review of Resident #4's Physician Order, dated 09/02/16, revealed an order for [REDACTED]. Review of Resident #4's x-ray report, dated 09/02/16, revealed Resident #4 had an acute left femoral fracture with mild displacement and Osteopenia. Further review of Resident #4's Physician Order, dated 09/02/16, revealed the physician requested Resident #4 be admitted to the hospital related to a left [MEDICAL CONDITION]. Review of the hospital's Discharge Summary, dated 09/09/16, revealed Resident #4 was hospitalized from [DATE] to 09/09/16, and then he/she returned to the facility. Resident #4 had received a resection of his/her left femoral head and neck (surgical left hip repair) and Thoracentesis (removal of fluid between the lung and chest wall). Resident #4 was also treated for [REDACTED]. Interview with CNA #7, on 11/09/16 at 10:01 AM, revealed she was employed by a staffing agency and had received classroom instruction and clinical orientation from the facility prior to working independently. CNA #7 stated she had learned that the facility's policy was to use two (2) staff when using the Maxi-lift. She stated she was oriented for two (2) hours with another CNA to her specific resident team and understood the CNA Care Card would instruct her about resident care. The CNA Care Cards were located on the back of each resident's door. CNA #7 stated she had been a CNA for twelve (12) years and had a considerable amount of experience with mechanical lifts. Continued interview revealed CNA #7 stated she cared for Resident #4 on 09/02/16. CNA #7 revealed she knew Resident #4 required two (2) staff and a Maxi-lift for transfers, as staff had told her and she had seen it on the CNA Care Card. She stated on 09/02/16, she dressed Resident #4, took her lunch break, and upon returning, looked for additional staff to assist with the lift. She denied the unit being short of staff and saw staff in the break room on the unit but did not ask them for help. She retrieved the Maxi-lift and transferred Resident #4 from his/her bed to the wheelchair. She described she rolled Resident #4 slowly into the sling and kept a hand on him/her at all times during the lift to control his/her movements. She denied Resident #4 bumping anything during the transfer. She reported Resident #4 had no complaints during or immediately after the transfer and Resident #4's roommate (Resident #1) was present during the transfer. Further interview with CNA #7 revealed she checked on Resident #4 sometime later, after she returned the Maxi-lift to the closet, and the resident complained of pain in his/her hip. CNA #7 explained she immediately told LPN #2 of the complaint. CNA #7 stated she thought Resident #4 was care planned for two (2) person assist because he/she was completely dependent. CNA #7 also stated the facility had the two (2) person lift policy in place because some CNAs might not employ common sense and use the lift incorrectly and hurt a resident. CNA #7 stated she did not follow the care plan and used the Maxi-lift alone because Resident #4 was persistent about getting up. CNA #7 stated she knew it was her mistake that she used the Maxi-lift alone. Interview with LPN #2, on 10/26/16 at 11:40 AM, revealed she was the nurse that cared for Resident #4 on 09/02/16. She stated CNA #7 reported to her that Resident #4 complained of hearing a pop and hip pain while being transferred from the bed to the wheelchair. She assessed and interviewed Resident #4 following the complaint of pain and did not find any redness or signs of acute injury. LPN #2 further stated when she interviewed Resident #4 on 09/02/16, the resident described he/she had felt crooked in the sling and had hip pain. Interview with the Unit Manager, on 11/10/16 at 3:00 PM, revealed Resident #4 was care planned as a falls risk and transferred by a Maxi-lift with two (2) staff. She also stated she did random spot checks on CNAs for appropriate lift use, two (2) to three (3) times a week to ensure resident safety. She did not have any memory of having monitored CNA #7 using the lift. Interview with the Assistant Director of Nursing (ADON), on 11/14/16 at 4:20 PM, revealed she had conducted the investigation into Resident #4's [MEDICAL CONDITION] on 09/02/16. She concluded Resident #4's injury was of unknown origin. She further stated agency CNAs received facility education in the classroom and oriented to the floor for four (4) hours. She stated agency CNAs were shown proper lift technique, received a checkoff list, and received a brochure that contained care information for agency personnel. The ADON further stated she had interviewed CNA #7 after the incident and CNA #7 told her she knew the facility had a two (2)person lift policy but she was rushing with Resident #4 and did not follow the policy or the CNA Care Card. The ADON stated the two (2) person lift was a standard of care in the Medicaid CNA classes. She concluded the 09/02/16 incident was an isolated break from facility policy and care plan, by CNA #7. Interview with the Clinical Director of Nursing, on 11/14/16 at 4:50 PM, revealed she was involved in the discussions of Resident #4's incident on 09/02/16. She stated the team had not determined the root cause of the fracture. She stated the interviews with the involved CNA and other staff revealed CNA #7 admitted ly did not follow protocol or the CNA Care Card when CNA #7 did not get staff assistance to transfer Resident #4. Interview with the Administrative Director of Nursing, on 11/14/16 at 4:35 PM, stated she had not conducted the investigation of Resident #4's [MEDICAL CONDITION] but all Administrative staff had collaborated. Following the investigation, the team determined CNA #7 had not followed the facility's policy regarding transfers or Resident #4's CNA Care Card on 09/02/16. Review of the facility's medical record for Resident #1, revealed the facility assessed the resident on 09/05/16, with a BIMS score of fourteen (14) out of fifteen (15) and determined the resident was interviewable. Interview with Resident #1, on 10/26/16 at 8:45 AM, revealed he/she had resided in the bed closest to the door in Resident #4's room for over five (5) years. Resident #1 stated the privacy curtain was drawn on 09/02/16, when the CNA #7 transferred Resident #4 with the Maxi-lift. He/She stated CNA #7 was the only staff in the room during the transfer. Resident #1 heard Resident #4 complain of pain and stated Resident #4 did not cry out and Resident #1 denied hearing a thump. Resident #1 stated Resident #4 had required a lift for years and he/she had never seen a CNA transfer Resident #4 without assistance, prior to this incident. Interview with the Administrator, on 11/14/16 at 5:00 PM, revealed Nursing and Education Administration, tracked data, and observed and audited care to ensure staff implemented comprehensive care plan interventions. He further explained he did spot checks and observed care when he rounded daily, sometimes random and sometimes not. He stated he did not formally document his rounds. He reported he and his staff continually trained on issues as opportunities presented themselves. He stated the facility trained CNA #7 to use the Maxi-lift with two (2) staff. He further stated using the Maxi-lift with two (2) staff was the right thing to do, as it was proper care.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide adequate supervision to prevent accidents for one (1) of four (4) sampled residents, Resident #4, during a transfer with a mechanical lift. Certified Nursing Assistant (CNA) #7 failed to obtain an additional staff person when she transferred Resident #4, using a Maxi-lift, from the bed to the wheelchair. The resident complained of pain in his/her hip and x-ray results revealed a left hip fracture. The findings include: Review of the facility's policy, Lift Transfers, revised March 2016, revealed residents were protected from potential injury by use of the mechanical lift. The Maxi-lift required two (2) CNAs at all times. Review of the facility's policy, Unusual Occurrence Form Procedure, revised November 2014, revealed the facility tracked and trended, identified root causes, examined facility practices, identified the need for change and improved systems to reduce risk of reoccurrences of any situation that required a follow up, including suspected resident abuse/neglect and/or resident related negative outcomes. Review of the facility's medical record for Resident #4, revealed the facility admitted the resident on 02/05/10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment, dated 06/15/16, revealed the facility assessed Resident #4 was totally dependent upon two (2) staff for assistance with bed mobility and transfers between the bed, chair, wheelchair, bath, and toilet. Resident #4 was assessed with [REDACTED]. Review of the facility's CNA Care Plan Card, dated 09/22/16, revealed Resident #4 required a Maxi-lift for transfers with assistance of two (2) staff. Review of the facility's Comprehensive Care Plan, dated 06/28/16, revealed Resident #4 was at risk for falls related to [DIAGNOSES REDACTED] and transferred with a Maxi-lift with assistance of two (2) staff. Review of Resident #4's Nurses Note, dated 09/02/16, revealed Licensed Practical Nurse (LPN) #2 documented Resident #4 was transferred to the wheelchair via Maxi-lift and he/she complained of pain to the left hip after the transfer. LPN #2 notified Resident #4's family and physician, who ordered an x-ray of his/her left hip. Review of Resident #4's Physician Order, dated 09/02/16, revealed an order for [REDACTED].#4's complaints of pain. Review of Resident #4's x-ray report, dated 09/02/16, revealed Resident #4 sustained an acute left femoral fracture with mild displacement and Osteopenia. Further review of Resident #4's Physician Order, dated 09/02/16, revealed the physician requested Resident #4 be admitted to the hospital related to a left hip fracture. Review of the hospital's Discharge Summary, dated 09/09/16, revealed Resident #4 was hospitalized from [DATE] until 09/09/16, at which time he/she returned to the facility. Resident #4 underwent a resection of his/her left femoral head and neck (surgical left hip repair). The resident developed moderate to large right pleural effusion and underwent a Thoracentesis (removal of excess fluid between the lung and chest wall). Resident #4 was also treated for [REDACTED]. Interview with CNA # 7, on 11/09/16 at 10:01 AM, revealed she was a staffing agency employee. She reported the facility educated and oriented her to their policies and systems of care. She reported she was educated on the facility's lift policy, which required two (2) staff for all Maxi-lift transfers. She stated she was oriented to the CNA Care Card, she knew it directed resident care and was located on the back of all the residents' doors. CNA #7 stated she had been a CNA for twelve (12) years and knew how to use the lifts for a long time. CNA #7 revealed she was assigned to care for Resident #4 on 09/02/16. According to CNA #7, she knew Resident #4 required two (2) staff and a Maxi-lift for transfers, as staff had told her and she had seen it on the CNA Care Card. She stated on 09/02/16, she dressed Resident #4, took her lunch break, and upon returning, looked for additional staff for assistance with the lift. She denied being short of staff and saw staff in the break room on the unit but did not ask them for help. She reported she transferred Resident #4 from his/her bed to the wheelchair with the Maxi-lift, without another staff member. She reported Resident #4 had no complaints during or immediately after the transfer and Resident #4's roommate (Resident #1) was present during the transfer. CNA #7 stated she checked on Resident #4 after she returned the Maxi-lift to the closet and Resident #4 complained of hip pain. CNA #7 explained she immediately told LPN #2 that Resident #4 complained of pain. CNA #7 stated the Assistant Director of Nursing (ADON) sent her home for not following the facility's policy. CNA #7 further stated she thought Resident #4 was a two (2) person assist because he/she was completely dependent. CNA #7 also stated the facility has the two (2) person policy in place for all residents because some CNAs might not use common sense, use the lift incorrectly, and hurt a resident. CNA #4 stated she used the lift alone because Resident #4 was persistent about getting up and CNA #7 knew she had made a mistake by doing so. Interview with LPN #2, on 10/26/16 at 11:40 AM, revealed she cared for Resident #4 on 09/02/16. LPN #2 stated CNA#7 reported to her that she had transferred Resident #4 with the Maxi-lift without assistance and Resident #4 complained of hip pain. LPN #2 stated she assessed and interviewed Resident #4 following the complaint of pain and did not find any signs of joint malformation, redness, or acute injury. LPN #2 stated when she interviewed Resident #4, the resident said he/she felt crooked in the sling and had hip pain. Interview with the Unit Manager, on 11/10/16 at 3:00 PM, revealed staff should not have transferred Resident #4 with a Max-lift unless two (2) staff was present. She also stated she did random spot checks on CNAs for appropriate lift use two (2) to three (3) times a week to ensure resident safety. She did not have any memory of monitoring CNA #7 using the lift. Review of the facility's investigation and final report, submitted by the ADON, on 09/08/16, revealed Resident #4 reported to LPN #7 that he/she felt crooked in the lift and felt pain in his/her hip but had not reported any bodily harm or injury had occurred during the transfer. The facility did not substantiate abuse or willful intent. Interview with the ADON, on 11/14/16 at 4:20 PM, revealed she had conducted the investigation into Resident #4's hip fracture on 09/02/16. She concluded Resident #4's injury was of unknown origin. She further stated all agency CNAs received facility education in the classroom and were oriented to the floor for four (4) hours. She stated agency CNAs were shown proper lift techniques, received a checkoff list and a brochure that contained care information for agency personnel. The ADON further stated she had interviewed CNA #7 after the incident and CNA #7 told her she knew the facility had a two (2) person lift policy but she was rushing with Resident #4 and had not followed the policy or Resident #4's care plan. The ADON stated the two (2) person lift was a standard of care in the Medicaid CNA classes. She concluded the 09/02/16 incident was an isolated break in policy and the care plan, by CNA #7. Interview with the Clinical Director of Nursing, on 11/14/16 at 4:50 PM, revealed she was involved in the discussions of the incident on 09/02/16. She stated the team had not determined the root cause of Resident #4's fracture. She stated the interviews with CNA #7 and other staff revealed CNA #7 admitted ly had not followed protocol or the care plan when she transferred Resident #4 without assistance. Interview with the Administrative Director of Nursing, on 11/14/16 at 4:35 PM, revealed she collaborated on the investigation. She stated the team determined CNA #7 had not followed facility policy regarding transfers or Resident #4's care plan on 09/02/16. Review of the facility's medical record for Resident #1, revealed the facility assessed the resident on 09/05/16, with a BIMS score of fourteen (14) out of fifteen (15) and determined the resident was interviewable. Interview with Resident #1, on 10/26/16 at 8:45 AM, revealed he/she had resided in the bed closest to the door in Resident #4's room for over five (5) years. Resident #1 stated the privacy curtain was drawn on 09/02/16, when CNA #7 transferred Resident #4 with the mechanical lift. He/She stated CNA # 7 was the only staff in the room during the transfer. Resident #1 heard Resident #4 complain of pain and stated Resident #4 had not cried out and he/she denied hearing a thump. Resident #1 stated Resident #4 had required a mechanical lift for years and he/she had never seen a CNA transfer Resident #4 without assistance, prior to this incident. Interview with the Administrator, on 11/14/16 at 5:00 PM, revealed Nursing and Education Administration tracked data, observed, and audited care. He further explained he did spot checks and observed care when he rounded daily, sometimes random and sometimes not. He stated he did not formally document his rounds. He reported he and his staff continually trained on issues as opportunities presented themselves. He stated the facility trained CNA #7 to use the lift with two (2) staff. He further stated using the lift with two (2) staff was the right thing to do, as it was proper care.

Based on interview, record review, Emergency Department records, and review of the facility's guidelines, it was determined the facility failed to ensure nursing staff developed a plan of care for one (1) of three (3) sampled residents (Resident #1) to address the resident's level of supervision. On 08/17/15 at 1:30 PM, Resident #1 exited the elevator on the first floor in his/her wheelchair and went out the front entrance to the patio area at 7:07 PM. There was no staff member on the front patio. The resident stayed on the patio until 7:18 PM when he/she opened the patio gate and wheeled himself/herself out of the patio area, without staff knowledge. Resident #1 was found at the bottom of a hill after falling out of the wheelchair near the nursing facility. The Emergency Medical Services (EMS) was called by a bystander. Staff was not aware the resident had left the facility until the resident was found inside the ambulance. The resident was transferred to the hospital. Resident #1 sustained a closed non-displaced [MEDICAL CONDITION] right radius (wrist fracture). The findings include: Review of the facility's Interdisciplinary Team Care Plan Guidelines, dated February 2014, revealed the facility developed and maintained a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The resident's care plan would be developed within seven (7) days of the completion of the resident's Comprehensive Minimum Data Set (MDS) Assessment, Quarterly, and as needed. Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 10/21/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set assessment, dated 06/12/15, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) with a score of 99, which indicated the resident was unable to complete the interview. Review of the Safety Schedule, dated 08/16/15 through 08/22/15, revealed the staff was to check the resident every hour. Review of the Emergency Department Resuscitation Notes, dated 08/17/15, revealed Resident #1 was found at the bottom of a hill after falling out of a wheelchair near a nursing facility. The Emergency Medical Services (EMS) was called by a bystander. The resident sustained [REDACTED]. Review of the facility's video surveillance, on 08/20/15 at 1:30 PM, revealed Resident #1 exited the elevator on the first floor in his/her wheel chair and went out the front entrance to the patio area at 7:07 PM on 08/17/15. There was no staff member on the front patio. The resident stayed on the patio until 7:18 PM when he/she opened the patio gate and wheeled himself/herself out of the patio area. Review of Resident #1's Safety Schedule flow sheet revealed, on 08/17/15 at 6:00 PM, the safety check was completed as evidenced by a check mark and staff initials. The 7:00 PM and 8:00 PM safety checks were not documented as completed. Review of Resident #1's Comprehensive Care Plan, dated 06/16/15, revealed prior to 08/18/15, the resident had interventions in place to have direct supervision by staff while smoking and this was accomplished by a staff person stationed on the 3rd floor patio during smoking. However, there was no supervision scheduled on the patio on the first floor as this was not a smoking area and there were no other smoking areas. Further review of the care plan revealed there was no care plan in place for supervision for the resident on an hourly basis as indicated on the Safety Check form. Interview with the Activity Assistant, on 08/20/15 at 9:35 AM, revealed the resident was allowed to come and go during smoking times on the third floor patio as long as staff was present. Review of Resident #1's Certified Nursing Assistant (CNA) Care Plan revealed there were no interventions related to supervision. The safety schedule checks were not part of the CNA care plan; however, under the daily routine it was noted for the 3-11 shift, that the resident was to go to bed after the last smoke session. Interview with CNA #3, on 08/20/15 at 2:00 PM, revealed every resident in the facility had a flow sheet in their room where they documented their repositioning and safety checks. Interview with CNA #1, on 08/20/15 at 2:25 PM, revealed there was a flow sheet on the resident's door for the week that had hourly checks. She stated the check mark on the flow sheet meant the resident was seen at that time. CNA #1 stated she was never told she had to visualize or call staff in the smoking area to check on the residents who were allowed to leave the unit by themselves. She stated Resident #1 was able to go smoke by himself/herself and go to other parts of the facility unescorted. Interview with the Unit Manager (UM), on 08/24/15 at 2:00 PM, revealed she reviewed the CNA care plans quarterly and it was her understanding that hourly safety checks were on the CNA care plans. However, the UM could not provide any evidence the CNA care plans were reviewed. Interview with the Staff Development Coordinator, on 08/24/15 at 2:15 PM, revealed the Safety Schedule Flow Sheets were reviewed during new hire orientation. She stated all residents get an hourly safety check. Further interview revealed staff was to go and visualize the residents if they were off the unit for such things as smoking, activities, or therapy. She stated if they could not visualize the resident, staff was to call the responsible staff member, such as the activity staff, smoking staff, or therapist, to check on the resident. The Staff Development Coordinator stated safety checks should be on the residents' care plans. Interview the Clinical Director of Nursing, on 08/21/15 at 2:50 PM, revealed CNAs were trained to either find the resident or call the designated areas off the unit to complete safety checks on the residents. Further interview with the Clinical Director of Nursing on 08/24/15 at 2:45 PM, revealed the resident safety schedule was not on the Comprehensive Care Plan or the CNA Care Plan because the Safety Schedule Flow Sheet hung under the CNA care plan in the resident's room.

Based on observation, interview, record review, review of video surveillance, and review of the Emergency Department records, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 08/17/15, facility staff was unaware Resident #1 had exited the facility grounds while out on the patio on the first floor. The assigned staff checked the resident at 6:00 PM; however, staff failed to check the resident at 7:00 PM. Staff did not miss the resident until 8:00 PM. The resident was found approximately 200 feet from the facility. A bystander found the resident and called an ambulance. The resident was transported to the hospital. Resident #1 had sustained a fractured wrist when he/she fell out of the wheelchair. The findings include: Review of Resident #1's clinical record revealed the facility admitted the resident on 10/21/09 with [DIAGNOSES REDACTED]. Observation of Resident #1, on 08/20/15 at 9:25 AM, revealed the resident was in his/her room laying in bed. The resident had a plaster splint on his/her right forearm and hand with limited movement of the arm. There was a roam alert bracelet to the resident's right ankle. The resident had a communication board laying on the over the bed table beside his/her bed. Resident #1 was only able to say yeah to questions. Review of the Emergency Department Resusitation Record, dated 08/17/15, revealed Resident #1, after leaving a nearby nursing facility, was found at the bottom of a hill after falling out of a wheelchair. The Emergency Medical Services (EMS) was called by a bystander. The resident sustained [REDACTED]. Review of the facility's video surveillance, on 08/20/15 at 1:30 PM, revealed on 08/17/15, Resident #1 exited the elevator on the first floor in his/her wheel chair and went out the front entrance to the patio area at 7:07 PM. The resident was propelling himself/herself using his/her left leg. The only other person on the patio was a resident sitting in a chair next to the entrance door. Resident #1 stayed on the patio until 7:18 PM when he/she opened the patio gate and wheeled himself/herself out of the patio area, without staff knowledge. The video did not show any area of the facility grounds beyond the patio gate. Review of Resident #1's Safety Schedule Flow Sheet revealed, on 08/17/15 at 6:00 PM, the safety check was completed as evidenced by a check mark and staff initials. The 7:00 PM and 8:00 PM safety checks were not documented as completed. Interview with the Activities Assistant, on 08/20/15 at 8:30 AM, revealed the smoking patio, which was located on the third floor, was opened for smoking every day from 8:00 AM-9:30 AM; 12:00-2:00 PM; and, 6:00-7:30 PM. She stated there was always a staff member with the residents while they smoked. The Activities Assistant stated the residents did not have to stay during the entire smoke break. Further interview revealed staff assisted the residents, who needed help back to their units; and, the residents who did not need assistance left the smoke area on their own. Interview with the Rehabilitation Technician, on 08/20/15 at 10:09 AM, revealed she had monitored the smokers on the smoking patio on 08/17/15 during the 6:00-7:30 PM smoke break. She stated Resident #1 left the smoking patio at 7:00 PM on his/her own. Further interview revealed Resident #1's normal routine was to go back to his/her unit (fifth floor) after he/she finished smoking. She stated the resident was allowed to go to the front patio, as he/she usually went back to his/her unit. Interview with the Clinical Support Person, on 08/20/15 at 11:40 AM, revealed she had worked on the sixth floor on 08/17/15 when two (2) Certified Nursing Assistants (CNA) came to the floor and reported Resident #1 was missing. She stated she went outside and looked around the front parking area and saw an EMS vehicle parked on the street near the corner of the intersection. Clinical Support Staff stated the EMS personnel told her they had the resident in the vehicle. She stated EMS was able to identify the resident by the facility's arm band the resident was wearing. Further interview revealed the resident was not an elopement risk and was able to have access to the front patio. Interview with CNA #3, on 08/20/15 at 2:00 PM, revealed she worked on the fifth floor on 08/17/15 when Resident #1 could not be found. She stated she assisted in searching the floors for the resident along with going outside to search the facility grounds. She stated she was with the Clinical Support Person when they saw the EMS vehicle; they ran up to the EMS personnel who informed them they had the resident in the vehicle. CNA #3 further stated every resident in the facility had a flow sheet in their room where repositioning and safety checks were documented. However, there was no area to document the location or visual checks of the resident. Interview with CNA #1, on 08/20/15 at 2:25 PM, revealed she worked the fifth floor on 08/17/15 and was assigned to Resident #1. She stated at approximately 8:00 PM, the nurse went to see the resident and he/she was not in his/her room. She stated she went with CNA #3 to look for the resident. CNA #1 stated they looked on all the floors and then went outside to search the facility's grounds. She stated CNA #3 and the Clinical Support Staff informed her at approximately 8:20-8:30 PM, the resident was in the EMS vehicle. Further interview with CNA #1 revealed there was a flow sheet on the resident's door for the week that had hourly checks. She stated the check mark on the flow sheet meant the resident was seen at that time. She stated she was never told she had to visualize or call staff in the smoking area to check on the residents who were allowed to leave the unit by themselves. Further interview revealed Resident #1 was able to go smoke by himself/herself and go to other parts of the facility unescorted. Interview with Licensed Practical Nurse (LPN) #2, on 08/20/15 at 3:05 PM, revealed on 08/17/15, she went to look for Resident #1 between 8:00 and 8:15 PM and could not find the resident. She stated she had the CNAs on the floor begin to look for the resident. Further interview revealed she stated she notified the Nursing Supervisor and a code yellow (per the Wandering/Elopement Risk Policy a code yellow was to be initiated in the event of a noted wander/elopement resident) was called. LPN #2 stated she was notified at approximately 8:40 PM that the resident was found and on his/her way to the hospital. She further stated Resident #1's usual routine was to go to the smoking patio and return to the unit between 7:00-7:30 PM. Interview with the Nursing Supervisor, on 08/20/15 at 3:55 PM, revealed he was first alerted Resident #1 was missing at approximately 8:15 PM on 08/17/15. He stated he sent the CNAs to search the floors and he called a code yellow and staff went outside to search the facility grounds. The Nursing Supervisor stated the Clinical Support Staff reported to him that the resident was on his/her way to the hospital via EMS. Interview with the Staff Development Coordinator, on 08/24/15 at 2:15 PM, revealed the Safety Schedule flow sheets were reviewed during new hire orientation. She stated all residents received an hourly safety check. Further interview revealed staff was to go and visualize the residents if they were off the unit for such things as smoking, activities, or therapy. She stated if staff was not able to leave the unit to visualize the resident, they were to call the responsible staff member, such as the activity staff, smoking staff, or therapist, to check on the resident. Interview with the Clinical Director of Nursing (DON), on 08/21/15 at 2:50 PM, revealed the every one (1) hour checks are completed on all residents. The form is also for turning and repositioning. The CNAs go in and make sure the resident doesn't need anything, turns and repositions them, or either finds the resident or calls the smoke patio, therapy, dining room, lobby or beauty shop, where ever the resident might be/suppose to be. An elopement risk was completed on Resident #26 in February and he/she did not meet the criteria for elopement. Post Survey Interview with the Clinical DON and Administrator, on 09/09/15 at 10:00 AM, revealed every one hour checks was a facility process; however, not a required process. The facility placed every resident on one hour checks whether they needed it or not, it was just an automatic action by the facility. For new residents the staff would search out the resident until a routine was established by the resident. Then staff would call to check on the residents. The staff did not check on Resident #26 at 7:00 PM because they knew the resident was on the smoking patio with staff. However, the resident changed the routine and went outside instead of back to the floor where he/she lived.

Based on interview, record review, review of the facility's policy and the facility's investigations, it was determined the facility failed to have an effective system to protect residents from potential abuse after allegations of abuse were reported to staff for three (3) of forty-three (43) sampled residents (Resident #21, Resident #36 and Resident #37). On 04/01/15, the facility received an allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #21. The allegation stated the CNA was harsh in speaking to the resident and when the resident requested to be repositioned the CNA stated she had just repositioned the resident fifteen (15) minutes ago; she would not do it again; and, left the room. The resident stated although he/she was hurting badly; he/she did not want to call the CNA again. The resident further alleged if the call light was turned on and the CNA answered, he/she would tell her it was an accident because he/she was afraid of the CNA. The resident was unable to provide staff with the CNA's name; however, the resident provided a description of the alleged perpetrator to the facility. The facility identified the CNA based on the description; however, the facility allowed the alleged perpetrator to continue to work with Resident #21 on 04/01/15 during the night shift. Immediate Jeopardy was identified on 04/03/15 and determined to exist on 04/01/15 related to Resident #21. The facility provided an acceptable Allegation of Compliance (AOC) on 04/09/15, which alleged removal of the Immediate Jeopardy on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 it was determined the IJ had not been removed as alleged, on 04/09/15. Per the facility's AOC, dated 04/09/15, when an allegation of abuse was reported the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. The AOC stated all staff would be trained by 04/08/15 on the facility's Abuse policy and the Clinical and Administrative Director of Nursing (DONs) were trained on the policy by the Administrator on 04/03/15. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit the revised abuse allegation logs and new abuse allegation checklist weekly and the results of the audits would be brought to the QA committee. It was determined the facility failed to implement these components of the AOC after the facility self reported two more (2) abuse allegations. On 04/19/15, at approximately 9:30 AM, the facility received a second allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #36. The allegation stated the CNA was mean and rude and threw the bed covers over the resident's head. The resident identified the alleged perpetrator by name. License Practical Nurse (LPN) #9 pulled the CNA from the resident's care, interviewed her, and then allowed the CNA to return to work caring for other residents on that unit. The alleged perpetrator cared for other residents until 11:00 AM, when the House Supervisor suspended her. On 04/26/15, the facility received a third allegation of abuse involving Outreach Technician (ORT) Restorative Aide #1 that alleged ORT Restorative Aide #1 kissed Resident #37 on the lips. CNA #24 stated he had witnessed this incident at 1:00 PM; however, he did not report what he had witnessed to the nurse. The ORT Restorative Aide continued to provide care for at least forty (40) other residents after the incident with Resident #37. The incident was not reported to the House Supervisor until 4:50 PM by LPN #10; at which time ORT Restorative Aide #1 had already left for the day. In addition, the facility failed to report the alleged sexual abuse to the State Survey Agency until 04/28/15 at 3:10 PM, approximately two (2) days after the incident. The facility's failure to protect residents from potential abuse after an allegation of abuse was reported to staff has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable AOC on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The SSA verified Immediate Jeopardy was removed on 05/06/15 as alleged, prior to exit on 05/13/15 with the Scope and Severity lowered to a "D" while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place them on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to Adult Protective Services (APS) and the Office of Inspector General (OIG). However, the policy did not state who was delegated the authority to place an employee on administrative leave. 1. Review of the clinical record for Resident #21 revealed the facility admitted the resident on 03/10/15, with [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) on 03/14/15, and assessed the resident using the Brief Interview for Mental Status (BIMS) assessment with a score of fifteen (15) out of fifteen (15), which meant the resident was interviewable. Additionally, the facility assessed Resident #21 as requiring extensive assistance with bed mobility and transfer, which both tasks required two (2) person physical assistance; and, the resident utilized a wheelchair (w/c). Further review revealed the facility completed a Comprehensive Care Plan for Resident #21, on 03/18/15, that stated the goal was to alleviate the resident's distress, and it directed staff to always assess and incorporate non-pharmacological interventions to alleviate bed discomfort and to answer the call light in a timely manner. The Care Plan further instructed staff to reposition the resident every two (2) hours, or per the current turning schedule. In addition, the staff was to maintain the resident's comfort level. Review of Resident #21's clinical record revealed a Nurse's Note, dated 03/11/15 at 10:27 PM, that stated Resident #21 was alert and oriented times three and had left sided paralysis; was assisted with positioning; had an unequal hand grasp ability; and, was able to move the fingers of his/her left hand. However, he/she was unable to reposition the total extremity. Further review revealed a Nurse's Note, dated 03/18/15 at 1:45 PM, which stated the resident continued to receive the maximum assistance with his/her activities of daily living (ADLs) and transfers. Review of Nurse's Notes, dated 03/23/15 at 1:45 AM, revealed Resident #21 was frequently awake on the 11:00 PM to 7:00 AM shift. The resident was beginning to have sensation in his/her left lower extremity. Interview with Licensed Practical Nurse (LPN) #6, Resident #21's routine nurse, on 04/08/15 at 8:36 AM, revealed Resident #21 was awake some nights and was able to use his/her right side more than the left side of his/her body. The nurse stated the resident would moan and say he/she was stiff. Review of the facility's investigation, dated 04/01/15, revealed Unit Manager (UM) #1 spoke with Resident #21 and received an allegation that the resident asked a night shift CNA to reposition him/her. The resident stated the aide refused and he/she was afraid of the aide because she was rough with him/her. At approximately 12:50 PM on 04/01/15, the Clinical Director of Nursing (DON) was made aware of the allegation made by Resident #21 that he/she expressed fear and that the CNA spoke harshly to him/her. Further review of the investigation revealed the resident stated the incident occurred "late last week", but he/she could not be specific regarding the date or time. Additionally, the facility's investigation revealed the alleged CNA in question was allowed to continue to work with Resident #21 after the allegation was made to the facility. The investigation further stated at approximately 1:05 PM on 04/01/15, the Clinical DON spoke with Resident #21, who reported that late last week he/she had leg pain and put on his/her call light to request someone to reposition him/her. The resident stated the CNA, who responded to the call light, was harsh in speaking to him/her and said she had just repositioned the resident fifteen (15) minutes ago and left the room. Additionally, the resident stated he/she was hurting badly; however, he/she did not want to call the staff member again as he/she did not know how the CNA would react. Resident #21 stated he/she was afraid of the CNA. Approximately ten (10) minutes later, the Clinical DON and the Assistant Director of Nursing (ADON) spoke with Resident #21 and received a physical description of the CNA that spoke harshly to him/her. UM #1 identified CNA #5 as the alleged perpetrator based on the description given by Resident #21. The Assistant Director of Nursing (ADON) unsuccessfully attempted to call CNA #5 on 04/01/15, at 3:15 PM. There was no documented evidence the facility removed CNA #5 from direct resident care. Further review of the facility's investigation, initiated on 04/01/15, revealed the ADON did not obtain CNA #5's statement until the end of her shift on 04/02/15 at 7:30 AM. Interview with the Clinical DON on 04/02/15 at 11:57 AM, revealed the facility unsubstantiated the allegation of abuse, on 04/06/15 because the resident could not determine when the alleged abuse occurred and with no positive identification, the alleged perpetrator denied the allegation. Per the Clinical DON, additional interviews with the resident revealed the resident was not afraid of the CNA and the CNA had taken care of the resident many times before without any problems. Review of the facility's staffing worksheets and CNA #5's time card, from 03/23/15 through 04/01/15, revealed CNA #5 worked the 11:00 PM to 7:00 AM schedule on the same unit that Resident #21 resided. She worked on 03/23/15, 03/24/15, 03/25/15, 03/26/15, 03/28/15, 03/29/15, 03/30/15, and on 04/01/15. Review of the Daily Assignment Sheets revealed CNA #5 was assigned to care for Resident #21 on 03/24/15, 03/25/15, 03/26/15, and on 04/01/15. Review of the facility's call light log revealed Resident #21's call light was activated between the hours of 11:00 PM and 7:00 AM on 03/24/15, 03/26/15, and on 04/01/15 while CNA #5 was assigned to care for the resident. Interview with Resident #21, on 04/01/15 at 2:45 PM, revealed he/she reported an incident "today" (04/01/15) that had occurred in the last week with a CNA. The resident stated he/she used the call light due to pain in his/her leg and he/she needed to be repositioned. Resident #21 also stated he/she was unable to get his/her leg comfortable and could not turn himself/herself. The resident stated a CNA came to the room, and stated harshly that she had just repositioned him/her fifteen (15) minutes ago and left the room. The resident further stated he/she felt intimidated and scared of the CNA and would not use the call light the rest of the night. Additionally, the resident stated he/she had seen the CNA since the night of the allegation, and if this particular CNA responded to his/her call light, the resident would say it was an accident. Resident #21 stated he/she was scared to report the incident; however, he/she was concerned the CNA may be treating other residents in the same way. The resident stated he/she reported the incident, on 04/01/15, to the Assistant Unit Manager (UM). Continued interview with Resident #21, on 04/02/15 at 9:02 AM, revealed the CNA had provided care to the resident after the incident was reported to staff the same night, on 04/01/15. The resident stated although he/she had not seen the CNA's badge, he/she knew the CNA's name began with the letter "R". The resident then gave a description of the CNA that matched the description reported to UM #1 on 04/01/15. Interview, on 04/02/15 at 9:26 AM, with the Assistant UM revealed he received an allegation from Resident #21 on 04/01/15. He stated the resident reported he/she was in pain last week, used the call light and asked to be repositioned. The Assistant UM stated the resident also reported that the CNA who responded to his/her call light, told him/her that she had just repositioned him/her and she would not do it again. He further stated the resident told him, he/she used the call light again and when the same CNA responded, he/she told the CNA the call light was an accident. He stated Resident #21 gave a description of the CNA. The Assistant UM stated CNA #5 was the only person he was aware of that matched the resident's description of the CNA. The Assistant UM stated CNA #5 worked the night shift on 04/01/15. He further stated he reported Resident #21's allegation to the UM #1 immediately. Interview, on 04/02/15 at 12:20 PM, with Unit Manager (UM) #1 revealed she received a report, on 04/01/15 around 12:50 PM to 1:00 PM from the Assistant UM of the allegation regarding Resident #21. She stated she spoke with Resident #21 at that time and the resident reported that in the last week he/she could not get his/her leg comfortable and asked to be turned. UM #1 stated the resident reported he/she was told by the CNA that she had just turned him/her about fifteen (15) minutes ago and was not going to turn him/her again. The resident stated that he/she felt intimidated and gave a description of the CNA. The UM stated CNA #5 was the only CNA she was aware of who matched the description given by Resident #21. She further stated after she spoke to Resident #21, she reported the allegation to the Clinical DON and provided the Clinical DON the name of CNA #5 as the person she (the UM) was aware of that matched the description provided by Resident #21. UM #1 stated CNA #5 worked the night of 04/01/15, which began at 11:00 PM. Further interview with the UM, on 04/03/15 at 9:08 AM, revealed she did not have the authority to place staff on administrative leave; however, continued interview revealed the DONs, ADON, ADM, and House Supervisor had the authority to place staff on administrative leave. The resident reported the allegation of abuse during the dayshift when the DONs were present in the building. Per interview, the allegation was reported to them appropriately, but the Clinical DON delayed in suspending the CNA because the resident could not determine when the allegation occurred and could not give a name. Review of the Abuse Policy revealed it did not state who had the authority to place an employee on administrative leave. Interview, on 04/01/15 at 2:07 PM, with the Clinical DON, regarding the allegation, revealed the facility received an allegation from Resident #21. She stated the resident reported, on 04/01/15, that he/she had leg pain during the last week and had been using the call light for pain medication and assistance with positioning. The Clinical DON further stated the resident reported the CNA spoke harshly, and told him/her that she had repositioned the resident fifteen (15) minutes ago and walked out of the resident's room. She stated the resident gave a description of the CNA and stated he/she was afraid of that CNA. Continued interview on 04/02/15, at 12:37 PM revealed the Clinical DON and the ADON spoke to the resident again, about ten (10) minutes later for a description of the CNA. She stated CNA #5 matched the description given by the resident, and was the only CNA she was aware of that met that description. However, even with this knowledge, the Clinical DON failed to remove CNA #5 from direct resident care. Continued interview with the Clinical DON on 04/02/15 at 12:37 PM, revealed CNA #5 worked the night of 04/01/15 and was scheduled to work again on 04/02/15. She stated when there was an allegation against a staff member the alleged perpetrator would be placed on administrative leave. However, interview and record review revealed CNA #5 was allowed to continue to work the shift and worked the next scheduled shift before being suspended on 04/02/15. Interview with the Clinical DON, on 04/02/15 at 1:27 PM, revealed the purpose of protecting a resident during an investigation was to keep the incident from happening again. She stated Resident #21 had been protected as the facility was extra "vigilant" to make sure the resident was okay; however, she would not give an explanation of what "vigilant" meant. The Clinical DON further stated she did not suspect any staff member had done anything to Resident #21. She stated a staff member would be placed on administrative leave immediately if the facility suspected the individual of abuse. During this interview, she stated that she, the Administrative DON, ADON, Administrator, or Human Resources (HR) could decide if an employee would be placed on administrative leave. The Clinical DON stated CNA #5 had not been placed on administrative leave as the facility did not suspect she had done any harm to Resident #21. She stated the CNA had worked with the resident before the allegation and after the allegation was made and the resident had not voiced any additional complaints about the CNA since the allegation was made on 04/01/15. The Clinical DON further stated Resident #21 had a psychiatric history, and she did not believe the CNA did what Resident #21 alleged. Interview, on 04/02/15 at 2:58 PM, with the Clinical DON revealed CNA #5 was not suspected of abuse. She stated she spoke with the Assistant UM and UM #1 on 04/01/15. She stated when she received the allegation from UM #1, the UM did not say if any staff matched the description the resident had provided and she (the Clinical DON) did not ask. The Clinical DON stated Resident #21 gave a description of the CNA; however, she did not follow-up with the Assistant UM or UM #1 to determine if anyone matched that description. Interview, on 04/02/15 at 12:54 PM, with the ADON revealed she was aware on 04/01/15, during the afternoon, of the allegation related to Resident #21. The ADON further stated she spoke with Resident #21 on 04/01/15, who reported the CNA seemed irritated when he/she used the call light to be repositioned. She stated the ADON gave a description of the CNA and she was aware of only one (1) CNA that worked on that unit that matched the description given by Resident #21; that was CNA #5. However, even with this knowledge, the ADON failed to remove CNA #5 from direct resident care, as per policy, to protect the residents. Continued interview with the ADON on 04/02/15 at 12:54 PM, revealed she spoke with CNA #5, on 04/02/15 at 7:30 AM, after she (CNA #5) worked the night shift on 04/01/15. The ADON further stated when the facility received an allegation of abuse against a staff member, the staff would be placed on administrative leave until the investigation was completed to protect the residents. She stated the purpose of the investigation was to determine if staff should be working in the facility. She stated CNA #5 had not been placed on administrative leave at that time. The ADON stated the Clinical DON was responsible to determine if a staff member should be placed on administrative leave. She further stated the Clinical DON was responsible to conduct the investigation; however, she (the ADON) would assist. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed she worked the night shift, at 11:00 PM, and always worked with Resident #21. She stated the resident would voice complaints of his/her leg hurting, because the resident's left leg was paralyzed. The CNA stated the resident would say he/she had laid on that side too long. She further stated Resident #21 was turned and repositioned every two (2) hours, and the resident would often ask to be repositioned again. CNA #5 stated she could not recall an incident with Resident #21. She further stated the ADON was at the facility and had waited for her to come to work on the 11:00 PM shift. The ADON did not talk with her until 7:30 AM after the shift was over on 04/02/15. However, she was not placed on administrative leave until around 10:53 PM "last night" (04/02/15) before the shift started. Review of the staffing sheets revealed CNA #5 was assigned to care for Resident #21 on 04/02/15. Interview, on 04/02/15 at 2:20 PM, with the Administrative DON revealed the Clinical DON was responsible for the investigation, with the ADON's assistance. She stated residents were protected during an investigation as the staff member would not be allowed back to work with the residents and would be placed on administrative leave, pending the outcome of the investigation. Further interview revealed the Administrative DON was not aware CNA #5 was identified as the alleged perpetrator at the time the allegation was reported. She stated the facility could not place everyone on leave when an alleged perpetrator was not identified. She further stated she was not involved in the investigation, and had not spoken to the Assistant UM or UM #1, but she knew they were aware of the allegation. Further interview revealed CNA #5 had worked "last night" (04/01/15) after the allegation was reported. The Administrative DON stated she was unsure of the reason why CNA #5 had not been placed on administrative leave if staff knew she was the alleged perpetrator. She further stated if a staff member was not placed on administrative leave, the resident would feel intimidation if the same staff member worked with him/her. Interview with the Administrator, on 04/02/15 at 3:35 PM, revealed he knew about the allegation on 04/01/15, but was unaware that the staff knew the name of the alleged perpetrator. Per interview, until the facility determined who the perpetrator was, it was not possible to suspend the entire staff; however, if there was a positive identification of a staff member, that person would be removed immediately. The Administrator stated he assumed the Clinical DON spoke to the Assistant UM and UM #1 on 04/01/15. He further stated he was not aware only one staff member matched the description given by Resident #21 and he was not aware at the time the allegation was made that the Assistant Unit Manager knew the alleged perpetrator was CNA #5. The Administrator stated the purpose of the investigation was to prevent abuse from occurring and prevent a staff member, who had an allegation voiced against them from working with the resident or working in general. He stated if a staff member was not placed on administrative leave, at a minimum, the staff member might be intimidating to a resident. Continued interview with the Administrator, on 04/02/15 at 3:35 PM, revealed he spoke with Resident #21 "today" (04/02/15) and the resident told him he/she was uncomfortable and in pain and had used the call light several times to be repositioned (referring to the date of the incident). The Administrator stated the resident told him that the CNA said she had just been there fifteen (15) minutes ago. He stated the resident also told him he/she felt "afraid" and "intimidated". He/She did not use the call light any more that night. He also stated the resident told him the aide worked "last night" (04/01/15). Further interview with the Administrator, on 04/03/15 at 9:30 AM, revealed he had determined the night before on 04/02/15, that the Clinical DON had been informed of a staff member that matched the description given by Resident #21 on 04/01/15. He stated CNA #5 had been suspended the evening of 04/02/15 by the Clinical DON. 2. Review of the clinical record revealed the facility admitted Resident #36 on 06/02/13. The resident's [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set (MDS) assessment, (a quarterly) dated 02/23/15, revealed the facility assessed the resident using the Brief Interview for Mental Status (BIMS) to have a score of ten (10) out of fifteen (15), which meant the resident had some cognition impairment but was still considered to be interviewable. Additionally, the facility assessed Resident #36 as requiring extensive assistance with bed mobility and transfer, requiring two (2) person physical assistance; the resident was non-ambulatory utilizing a wheelchair. Further review revealed the facility assessed the resident to be occasionally incontinent of bladder and required the extensive assist from staff with toileting needs. Review of the Comprehensive Care Plan dated 06/14/13, revealed the resident had short/long term memory problems and the goal was for the resident to continue to interact with others and participate in care daily. The care plan instructed staff to approach the resident warmly and positively and in a calm manner. Review of the facility's investigation, initiated on 04/20/15, revealed the Certified Medication Technician (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over his/her head and the aide was mean and rude to the resident. The investigation did not specify the definition of "mean" and "rude". The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22. The documented interview with LPN #9 stated CNA #22 switched residents with another aide and was allowed to work with other residents after the abuse allegation was received. The investigation revealed the Clinical DON was notified of the abuse allegation, on 04/19/15 at approximately 10:00 AM. Further review of the abuse investigation revealed Resident #36 was interviewed by the Clinical DON, on 04/20/15 at 3:00 PM. At this time, the resident again reported to staff that the aide threw the bed covers over his/her head and said something the resident didn't like. The Clinical DON interviewed CNA #22 at 3:13 PM via telephone, where she denied the allegation. However, the Clinical DON failed to interview the House Supervisor to determine when the aide was suspended and did not interview further to determine that CNA #22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment of [REDACTED]. The report indicated the aide had been placed on administrative leave at the time of the allegation. However, review of the facility's time card report revealed CNA #22 continued to work after the allegation was reported. Review of the facility's staffing worksheets and CNA #22's time card, for 04/19/15, revealed CNA #22 worked 7:00 AM to 11:00 AM on the unit where Resident #36 resided. Resident #36 reported the allegation of abuse at approximately 9:30 AM. Interview with Resident #36, on 04/28/15 at 12:46 PM, revealed he/she could not recall any incident where a facility staff was rough or mean. The resident stated he/she did not recall any incident where staff had pulled the bed covers over his/her head. A family member was present during the interview and stated the resident's memory was not always good but the resident had reported to the family someone had pulled a sheet over his/her head. The resident had told the family member he/she had not seen that aide again. The family member stated the facility had not interviewed her regarding any knowledge of the incident. Further interview with the family member revealed the resident appeared to be more upset since the incident, whereas the resident was calm before; however, she did not think the resident was afraid of anyone. Interview, on 04/28/15 at 3:29 PM, with CMT #2 who received the allegation of abuse from Resident #36, revealed she was passing medications on 04/19/15 sometime between 9:00 AM-10:00 AM. When she took Resident #36's medications into the room, the resident told her CNA #22 was mean and rude and had pulled the bed covers over the resident's head. The resident told her the aide appeared to be angry. The CMT reported the allegation to LPN #9. She returned to the resident's room with LPN #9 and the resident told her the same story; the aide was mean and rude and had pulled the covers over his/her head. Interview with CMT #3, on 04/28/15 at 3:20 PM, revealed she was working the other side of the unit when CMT #2 came to her and reported there was a problem. She stated it was a few hours into the day shift (7 AM-3 PM). She said CMT #2 reported Resident #36 told her CNA #22 had been rude and mean to him/her and threw the covers over the resident's head. CMT #3 did not specify what the resident meant by rude and mean. CMT #2 told her the aides would have to switch teams, but before they could do that, LPN #9 came onto the floor. She went with CMT#2 and LPN #9 to interview Resident #36. When LPN #9 asked the resident what happened, the resident told them CNA #22 had been rude and threw the covers over his/her head. She stated the House Supervisor was notified then came to the floor and told CNA #22 she had to leave. This was before lunch. She thought the House Supervisor started the investigation. A telephone interview with LPN #9, on 04/29/15 at 9:42 AM, revealed she had worked on 04/19/15 as the LPN Supervisor for the sixth and seventh floors. She stated when she came to the seventh floor, CMT #2 reported what the resident had told her during the medication pass. She then went into Resident #36's room with CMT#2 and CMT #3 to interview the resident. The resident told them the same story that CNA #22 was mean and rude and pulled the covers over his/her head. In addition, the resident told them the aide refused to get him/her a tissue. She stated she then went and found CNA #22 in another resident's room providing care. That was between 9:00 AM-10:00 AM. She took the aide to the nurse's station and interviewed her. She obtained a written statement then she told the aide not to go back into Resident #36's room. She said she reassigned Resident #36's care to CNA #23; however, CNA #22 continued to care for all the other residents that were assigned to her that day. She stated she notified the House Supervisor of the incident and when she came onto the floor, she told CNA #22 she had to clock out and go home. She said the aide provided care to other residents until then because she did not have the authority to suspend any staff. Review of the Abuse Policy revealed it did not state who had authority to suspend an employee during an investigation. Telephone interview with CNA #23, on 04/29/15 at 10:58 AM, revealed around 10:00 AM on 04/19/15, she was told by LPN #9 she had to take over the care of Resident #36. She stated LPN #9 told her there had been an allegation against CNA #22 and she could no longer care for that resident. She stated the aide (CNA #22) provided care to other residents assigned to her until the House Supervisor came onto the floor and told her to go home. She stated it was about an hour from when she was told to care for Resident #36 and when the aide was sent home. Telephone interview with the House Supervisor, on 04/29/15 at 11:12 AM, revealed she received a report from LPN #9 that Resident #36 alleged CNA #22 was rude and unprofessional and threw the covers over the resident's head. She said LPN #9 reported the aide denied the allegation. She text the Clinical DON and informed her of the allegation. She said she went to the unit and told the aide she had to go home. She did not watch the aide clock out. She stated LPN #9 had interviewed the aide and obtained a written statement. Therefore, she did not interview the aide again and did not interview the resident. She stated she had not interviewed any staff. She stated she was not aware of any change in assignments and was not aware the aide had cared for other residents after the abuse allegation was received. She stated it was sometime before lunch when she came onto the floor and sent the aide home. She completed the Unusual Occurrence Report and stated it was her responsibility to start the investigation

Based on interview, record review, and review of the facility's policy, investigations, and the acceptable Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to have an effective system in place to ensure staff followed its policy for the protection of residents during abuse investigations for three (3) of forty-three (43) sampled residents (Resident #21, Resident #36, and Resident #37). (Refer to F225) On 04/01/15, the facility received an allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #21. The allegation stated the CNA was harsh in speaking to the resident and when the resident requested to be repositioned the CNA stated she had just repositioned the resident fifteen (15) minutes ago; she would not do it again; and, left the room. The resident stated although he/she was hurting badly; he/she did not want to call the CNA again. The resident further alleged if the call light was turned on and the CNA answered, he/she would tell her it was an accident because he/she was afraid of the CNA. The resident was unable to provide staff with the CNA's name; however, the resident provided a description of the alleged perpetrator to the facility. The facility identified the CNA based on the description; however, the facility allowed the alleged perpetrator to continue to work with Resident #21 on 04/01/15 during the night shift. Immediate Jeopardy was identified on 04/03/15 and determined to exist on 04/01/15 related to Resident #21. The facility provided an acceptable Allegation of Compliance (AOC) on 04/09/15, which alleged removal of the Immediate Jeopardy on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 it was determined the IJ had not been removed as alleged, on 04/09/15. Per the facility's AOC, dated 04/09/15, when an allegation of abuse was reported the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. The AOC stated all staff would be trained by 04/08/15 on the facility's Abuse policy and the Clinical and Administrative Director of Nursing (DONs) were trained on the policy by the Administrator on 04/03/15. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit the revised abuse allegation logs and new abuse allegation checklist weekly and the results of the audits would be brought to the QA committee. It was determined the facility failed to implement these components of the AOC after the facility self reported two more (2) abuse allegations. On 04/19/15, at approximately 9:30 AM, the facility received a second allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #36. The allegation stated the CNA was mean and rude and threw the bed covers over the resident's head. The resident identified the alleged perpetrator by name. License Practical Nurse (LPN) #9 pulled the CNA from the resident's care, interviewed her, and then allowed the CNA to return to work caring for other residents on that unit. The alleged perpetrator cared for other residents until 11:00 AM, when the House Supervisor suspended her. On 04/26/15, the facility received a third allegation of abuse involving Outreach Technician (ORT) Restorative Aide #1 that alleged ORT Restorative Aide #1 kissed Resident #37 on the lips. CNA #24 stated he had witnessed this incident at 1:00 PM; however, he did not report what he had witnessed to the nurse. The ORT Restorative Aide continued to provide care for at least forty (40) other residents after the incident with Resident #37. The incident was not reported to the House Supervisor until 4:50 PM by LPN #10; at which time ORT Restorative Aide #1 had already left for the day. In addition, the facility failed to report the alleged sexual abuse to the State Survey Agency until 04/28/15 at 3:10 PM, approximately two (2) days after the incident. The facility's failure to protect residents from potential abuse after an allegation of abuse was reported to staff has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable AOC on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The SSA verified Immediate Jeopardy was removed on 05/06/15 as alleged, prior to exit on 05/13/15 with the Scope and Severity lowered to a "D" while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to Adult Protective Services (APS) and the Office of Inspector General (OIG). However, the policy did not state who was designated with the authority to suspend an employee during an investigation. 1. Review of the facility's investigation, dated 04/01/15, revealed Unit Manager (UM) #1 spoke with Resident #21 and received an allegation that the resident asked a night shift CNA to reposition him/her. The resident stated the aide refused and he/she was afraid of the aide because she was rough with him/her. At approximately 12:50 PM on 04/01/15, the Clinical Director of Nursing (DON) was made aware of the allegation made by Resident #21 (the resident expressed fear of the CNA and that the CNA spoke harshly). The resident stated the incident occurred "late last week", but he/she could not be specific regarding the date or time. Additionally, the facility's investigation revealed the alleged CNA in question was allowed to continue to work with Resident #21 after the allegation was made. The investigation further stated at approximately 1:05 PM on 04/01/15, the Clinical DON spoke with Resident #21, who reported that late last week he/she had leg pain and put on his/her call light to request someone to reposition him/her. The resident stated the CNA who responded to the call light was harsh in speaking to him/her and told him/her that she had just repositioned the resident fifteen (15) minutes ago and left the room. Additionally, the resident stated he/she was hurting badly; however, he/she did not want to call the staff member again as he/she did not know how the CNA would react. Resident #21 stated he/she was afraid of the CNA. Approximately ten (10) minutes later, the Clinical DON and the Assistant Director of Nursing (ADON) spoke with Resident #21 and received a physical description of the CNA. UM #1 identified CNA #5, as the alleged perpetrator based on the description given by Resident #21. The Assistant Director of Nursing (ADON) attempted to call CNA #5 on 04/01/15, at 3:15 PM; however, the ADON was not able to speak to CNA #5 to obtain her statement. Review of the investigation revealed no documented evidence the facility removed CNA #5 from direct resident care. Review of the time card report revealed CNA #5 continued to work the shift and worked the next scheduled shift. Although the Abuse policy stated the employee would be suspended immediately. Further review of the facility's investigation, initiated on 04/01/15, revealed the ADON didn't obtain CNA 5's statement until the end of her shift on 04/02/15 at 7:30 AM. Interview with CNA #5, on 04/04/15, revealed Resident #21 apologized when he/she used his/her call light. However, review of the facility's investigation revealed a statement was not obtained from the Assistant UM, who initially received the allegation and there were no other statements obtained from the UM when the allegation was initially reported. The facility unsubstantiated the allegation of abuse, on 04/06/15. Interview with Resident #21, on 04/01/15 at 2:45 PM, revealed he/she reported an incident today (04/01/15) that had occurred in the last week with a CNA. The resident stated the call light was turned on due to pain in his/her leg and the need to be repositioned. The resident stated a CNA came to the room, and stated harshly that she had just repositioned him/her fifteen (15) minutes ago and left the room. The resident further stated he/she felt intimidated and scared of that CNA and would not use the call light the rest of the night. Additionally, the resident stated he/she had seen the CNA since the night of the incident, and if this particular CNA would respond to the call light, he/she (the resident) would say it was an accident. Resident #21 stated he/she was scared to report the incident; however, he/she was concerned the CNA may be treating other residents the same way. The resident reported the allegation on 04/01/15 to the Assistant Unit Manager (UM). Continued interview with Resident #21, on 04/02/15 at 9:02 AM, revealed he/she saw the CNA the previous night, on 04/01/15. Review of CNA #5's time card revealed the CNA worked the 11:00 PM to 7:00 AM shift on 04/01/15. Review of the staffing worksheets and the Daily Assignment Sheets, revealed CNA #5 worked on the same unit Resident #21 resided and was also assigned to care for Resident #21 on 04/01/15 (after the allegation was made). In addition, review of the facility's call light log revealed Resident #21's call light was activated between the hours of 11:00 PM and 7:00 AM on 04/01/15. Interview, on 04/02/15 at 9:26 AM, with the Assistant UM revealed he received a complaint from Resident #21 on 04/01/15 that a CNA would not reposition him/her when he /she was in pain. He stated Resident #21 gave a description of the CNA. Per interview, CNA #5 was the only person he was aware of that matched the description given by Resident #21. The Assistant UM stated he reported Resident #21's allegation to UM #1 immediately. The Assistant UM stated CNA #5 continued to work the night shift on 04/01/15, after the resident had reported the allegation. On 04/02/15 at 12:20 PM, interview with UM #1 revealed she received a report from the Assistant UM, on 04/01/15 around 12:50 PM to 1:00 PM, of an allegation regarding Resident #21. She stated she spoke with Resident #21 and the resident reported the allegation to her. UM #1 stated he/she felt intimidated and gave a description of the CNA. The UM stated CNA #5 was the only CNA she was aware of who matched the description given by Resident #21. She further stated after she spoke to Resident #21, she reported the allegation to the Clinical DON on 04/01/15, and gave the Clinical DON the name of CNA #5 as the person she (the UM) was aware of that matched the description provided by the resident. Per interview, CNA #5 was not placed on administrative leave, per the facility's policy, and worked the night of 04/01/15, which began at 11:00 PM. Interview, on 04/01/15 at 2:07 PM; and, on 04/02/15 at 12:37 PM, with the Clinical DON revealed the facility received an allegation from Resident #21. She spoke to Resident #21 on 04/01/15 around 1:00 PM and the resident reported a CNA was rude and spoke harshly to him/her during the night and felt the CNA did not want to reposition him/her. The Clinical DON stated Resident #21 reported he/she was afraid of the CNA. Further interview with the Clinical DON revealed she and the ADON spoke to the resident again, about ten (10) minutes later for a description of the CNA. She stated CNA #5 matched the description given by the resident, and was the only staff member she was aware of that met that description. She stated when there was an allegation against a staff member the alleged perpetrator would be placed on administrative leave, as per policy. However, per interview and record review, CNA #5 was not removed from resident care per the facility's policy. Further interview with the Clinical DON revealed CNA #5 worked the night of 04/01/15 (11 PM-7 AM) and was also scheduled to work the night of 04/02/15. Interview, on 04/01/15 at 12:54 PM, with the ADON revealed she was made aware on 04/01/15, during the afternoon, of the allegation related to Resident #21. She stated the Clinical DON was responsible to conduct the investigation; however, she (the ADON) was assisting her in the investigation. The ADON further stated she spoke with Resident #21 on 04/01/15, who reported the CNA seemed irritated when she used the call light to be repositioned, and gave a description of the CNA. She stated she was aware of only one (1) CNA that worked on that unit and matched the description given by Resident #21. The ADON further stated when the facility received an allegation of abuse against a staff member, that staff member would be placed on administrative leave until the investigation was completed to protect the resident. The ADON stated the Clinical DON was responsible to determine if a staff member should be placed on administrative leave. She further stated CNA #5 had not been placed on administrative, even though the facility's policy stated the facility would protect residents and/or anyone reporting abuse by placing any employee who was investigated for abuse on administrative leave or be reassigned during the investigation. Continued interview with the Clinical DON, on 04/02/15 at 1:27 PM, revealed she, the Administrative DON, ADON, Administrator, or Human Resources (HR) could decide if an employee would be placed on administrative leave. The Clinical DON stated CNA #5 had not be placed on administrative leave after the allegation was reported because she did not suspect the CNA had done any harm to Resident #21. Per interview, Resident #21 had a psychiatric history, and she did not believe the CNA did what Resident #21 alleged. She further stated if a staff member had abused a resident and was not placed on administrative leave, the resident could be further harmed, or other residents could experience the same abuse. On 04/02/15 at 2:20 PM, interview with the Administrative DON revealed the Administrative team was not made aware the Clinical DON had knowledge of the CNA's name at the time the allegation was reported and she was unsure of the reason the Clinical DON had not been placed CNA #5 on administrative leave, per the facility's policy. Continued interview, on 04/02/15 at 2:58 PM, with the Clinical DON stated she did not suspect CNA #5 of abuse and therefore the CNA was not placed on administrative leave. The Clinical DON stated the facility did not follow its policy to place any employee who was investigated for abuse on administrative leave. The Clinical DON stated if a staff member was not placed on administrative leave, the resident could be harmed. Interview with the Administrator, on 04/02/15 at 3:35 PM, revealed at the time the allegation was reported to him, the facility was not sure who the alleged perpetrator was, and until that was determined it was not possible to suspend the entire staff; however, if there was a positive identification of a staff member, that person would be removed immediately. The Administrator stated he was not aware only one staff member matched the description given by Resident #21 until the day of 04/02/15. The Administrator stated if the alleged perpetrator was identified and not placed on administrative leave, then the facility did not follow it's policy to protect residents during an investigation. Continued interview with the Administrator, on 04/03/15 at 9:30 AM, revealed in the evening hours of 04/02/15, the facility determined the Clinical DON had been informed of the name of a CNA that matched the description given by Resident #21, and CNA #5 had been suspended on 04/02/15. 2. Review of the facility's investigation, initiated on 04/20/15, revealed Certified Medication Tech (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over the resident's head and the aide was mean and rude to the resident. The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22. The documented interview with LPN #9 stated CNA #22 was switched where she did not care for Resident #36, but was allowed to work with other residents after the abuse allegation was received. The investigation revealed the Clinical DON was notified of the abuse allegation on 04/19/15 at approximately 10:00 AM. Further review of the abuse investigation revealed Resident #36 was interviewed by the Clinical DON, on 04/20/15 at 3:00 PM, where the resident again reported the aide threw the bed covers over his/her head and said something the resident didn't like. The Clinical DON interviewed CNA #22 at 3:13 PM via telephone where she denied the allegation. However, the Clinical DON failed to interview the House Supervisor to determine when the aide was suspended and did not interview further to determine that CNA#22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment to be substantiated. The report stated the aide had been placed on administrative leave at the time of the allegation. Review of the facility's staffing worksheets and CNA #22's time card, for 04/19/15, revealed CNA #22 worked 7:00 AM to 11:00 AM on the unit where Resident #36 resided. Interview with Resident #36, on 04/28/15 at 12:46 PM, revealed she could not recall any incident where a facility staff was rough or mean or an incident where staff had pulled the bed covers over his/her head. A family member was present during the interview and stated the resident's memory was not always good, but the resident had reported to the family that someone had pulled a sheet over his/her head. The resident had told the family member he/she had not seen that aide again. Further interview with the family member revealed the facility had not interviewed her regarding any knowledge of the incident. According to the family member, the resident appeared to be more upset since the incident, whereas the resident was calm before, but she did not think the resident was afraid of anyone. Interview, on 04/28/15 at 3:29 PM, with CMT #2 who received the allegation of abuse from Resident #36, revealed she was passing medications on 04/19/15 sometime between 9:00 AM-10:00 AM. When she took Resident #36's medications into the room, the resident told her CNA#22 was mean and rude and pulled the bed covers over the resident's head. The resident told her the aide appeared to be angry. The CMT reported the allegation to LPN #9. She returned to the resident's room with LPN#9 and the resident told them the same story. Interview with CMT #3, on 04/28/15 at 3:20 PM, revealed she was working the other side of the unit when CMT #2 came to her and reported there was a problem. She stated it was a few hours into the day shift (7 AM-3 PM). She said CMT #2 reported Resident #36 told her CNA #22 had been rude and mean to him/her and threw the covers over the resident's head. CMT #2 told her the aides would have to switch teams, but before they could do that, LPN #9 came onto the floor. She went with CMT #2 and LPN #9 to interview Resident #36. When LPN #9 asked the resident what happened, the resident told them CNA #22 had been rude and threw the covers over his/her head. She stated the House Supervisor was notified and came to the floor and told CNA #22 she had to leave. This was before lunch. She thought the House Supervisor started the investigation. Telephone interview with LPN #9, on 04/29/15 at 9:42 AM, revealed she had worked on 04/19/15 as the LPN Supervisor for the sixth and seventh floors. She stated when she came to the seventh floor, CMT #2 reported what the resident had told her during the medication pass. She then went into Resident #36's room with CMT#2 and CMT #3 to interview the resident. The resident told them the same story related to CNA #22. In addition, the resident told them the aide refused to get him/her a tissue. She stated she then went and found CNA #22 in another resident's room providing care. That was between 9:00 AM-10:00 AM. She took the aide to the nurse's station and interviewed her. She obtained a written statement then she told the aide not to go back into Resident #36's room. She said she reassigned Resident #36's care to CNA #23; however, CNA #22 continued to care for all the other residents that were assigned to her that day. She stated she notified the House Supervisor of the incident and when she came onto the floor, she told CNA #22 she had to clock out and go home. She said the aide provided care to other residents until then, because she did not have the authority to suspend any staff. Telephone interview with CNA #23, on 04/29/15 at 10:58 AM, revealed around 10:00 AM on 04/19/15, she was told by LPN #9 she had to take over the care for Resident #36. She stated LPN #9 told her there had been an allegation against CNA #22 and she could no longer care for that resident. She stated the CNA had provided care to the other residents assigned to her until the House Supervisor came onto the floor and told her to go home. She stated it was about an hour from when she was told to care for Resident #36 and when the aide was sent home. Interview with the House Supervisor, via telephone, on 04/29/15 at 11:12 AM, revealed she received a report from LPN #9 that Resident #36 alleged CNA #22 was rude and unprofessional and threw the covers over the resident's head. She said LPN #9 said the aide denied the allegation. She texted the Clinical DON and informed her of the allegation. She stated she went to the unit and told the aide she had to go home. She did not watch the aide clock out. She stated LPN #9 had interviewed the aide and obtained a written statement. Therefore, she did not interview the aide again and did not interview the resident. She revealed she had not interviewed any staff. She stated she was not aware of any change in assignments and was not aware the aide had cared for other residents after the abuse allegation was received. She stated it was sometime before lunch when she came onto the floor and sent the aide home. She completed the Unusual Occurrence Report. Telephone interview with CNA #22, on 04/28/15 at 5:25 PM, revealed she had been assigned to Resident #36 on 04/19/15. She stated around 9:00 AM, she went in to dress the resident. She was putting the resident's support stockings and shoes on when the resident said he/she had to use the toilet. She told the resident he/she would have to wait until she got someone to help her because the resident was a two-person assist with transfers. She stated the resident starting cursing her, calling her a "[***] ", and telling her how to do her job. She stated she removed the resident's support stockings and placed them in the resident's wheelchair. She laid the resident back down (the resident was sitting on the side of the bed) and placed the bed covers over the resident up to the neck. She stated she wanted to let the resident calm down and then she was going to return with help. CNA #22 stated at approximately 9:30 AM, LPN #9 came and informed her of the allegation and requested her to provide a written statement, which she did. After she had written the statement, she continued to care for her other assigned residents. She said she went back into Resident #36's room and took the roommate to the bathroom; this occurred after she had been informed of the allegation. She states she did not provide care for Resident #36, but she did provide care for his/her roommate. She stated LPN #9 assisted her with taking the roommate to the bathroom; however, LPN #9 denied this allegation. She stated around 11:00 AM the House Supervisor came onto the floor and told her to clock out and go home. Interview with the Clinical DON, on 04/29/15 at 4:05 PM, revealed the allegation was reported to her via text from the House Supervisor at 10:11 AM on 04/19/15. She stated she told the House Supervisor to suspend the aide immediately. She stated it was the facility's practice to suspend staff during an abuse investigation. She stated the House Supervisor was the only staff that had the authority to suspend someone during the weekends and they had to call the DONs. She stated supervisors and staff nurses could not suspend staff. Further interview with the Clinical DON revealed she conducted the abuse investigation. She stated she did know that CNA #22 had not been removed from patient care immediately and that she had been allowed to care for other residents after the abuse allegation was reported. She reviewed her text messages and stated that she had texted the House Supervisor at 10:16 AM to suspend the aide. She stated her expectations would be the aide should have been held at the nurse's station until the House Supervisor came onto the floor. However, she stated she had not asked about this during her investigation and she had no reason to review CNA #22's time card. Review of the Activity of Daily Living (ADL) care tracker information for 04/19/15 revealed CNA #22 documented cared for other residents until 10:52 AM, several hours after the allegation was reported. 3. Review of the clinical record for Resident #37 revealed the resident had resided at the facility since January 2011. Review of the most current [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 03/17/15, revealed the facility assessed the resident to have a BIMS score of eleven (11) out of possible fifteen (15) which meant the resident was interviewable. No behaviors were noted and the facility assessed the resident to need limited assist of one-person for transfers and ambulation. Interview with Resident #37, on 04/29/15 at 12:38 PM, revealed when the resident was asked if any staff had been inappropriate with him/her, the resident replied, "Yes", and named the ORT by name. The resident said the ORT had kissed him/her on the mouth and pointed to the lips. The resident stated the kiss occurred in the resident's room when the resident was getting ready to walk with the ORT. The resident said a nurse had seen the ORT kissing him/her. Further interview with the resident revealed the ORT had not kissed him/her before and the resident was surprised. Interview with ORT Restorative Aide #1, on 04/29/15 at 1:00 PM, revealed he denied the allegation. He stated he went to walk the resident and found the resident sitting on the side of the bed. He placed the gait belt around the resident and noticed the resident's pants were loose around the resident's waist. He assisted the resident to a standing position and pulled the resident's pants up at the same time. He walked the resident from the room, to the elevator, and to the end of the hallway. After he ambulated the resident, they returned to the resident's room and he sat the resident on the side of the bed to perform active range of motion exercises. He stated the resident did not say anything during the session. Further interview with the ORT revealed after completion of the range of motion exercises, he told the resident he would see him/her tomorrow and left the room. He could not recall if the resident said anything. He stated the resident didn't appear to be any different from other days. He stated he recalled seeing CNA #24 in the hallway with a blue linen bag. The ORT said he was close to the resident's face, but denied he kissed or touched the resident's face. He said he had never kissed any resident. He stated he did not go back into Resident #37's room, but cared for other residents to the end of his work shift. Review of ORT Restorative Aide #1's time card for 04/26/15 revealed the ORT worked from 7:00 AM to 3:15 PM. Telephone interview with CNA #24, on 04/29/15 at 3:07 PM, revealed he witnessed ORT Restorative Aide #1 kiss Resident #37 on the lips. He said he was passing by the resident's room to take dirty linen to the dirty utility room, which was directly across from the resident's room. He stated the resident had a gait belt around his/her waist and the ORT was assisting the resident from a sitting position from the bed. He stated the resident was rising and the ORT gently kissed the resident on the lips. He stated he couldn't believe what he saw. He thought it could be a culture thing or the kiss could have been a reward. He stated he witnessed the kiss around 1:00-1:30 PM, but he did not report it at this time. He stated he thought about it then reported what he saw to the nurse, but by that time, the ORT had already left for the day. He stated he was trained to report abuse immediately, but he was shocked and didn't want to get the ORT in trouble. Telephone interview with LPN #10, on 04/30/15 at 2:23 PM, revealed CNA #24 had reported what he witnessed to CNA #25 and #26 then they reported to her at approximately 4:15 PM on 04/26/15. She stated she went to look for CNA #24 to ask him about the allegation, but he was off the floor. When he came back on the floor, she interviewed the aide and he told her he had witnessed the ORT kissing the resident on the lips. She asked the aide why he didn't report what he witnessed at that time and he told her he was afraid the ORT aide would know who had reported it. She said she told the aide he should have reported what he saw right away and the aide told her he was afraid of losing his job. She said she then went to find the House Supervisor on the first floor. She reported what was told to her. She said she had interviewed the resident before reporting to the House Supervisor and the resident told her the ORT had kissed him/her on the lips. She asked the resident if the kiss made him/her uncomfortable and the resident said, "Yes." Telephone interview with CNA #26, on 04/30/15 at 3:17 PM, revealed she did not witness the incident, but was told by CNA #24. She stated the aide pulled her and CNA #25 aside and told them he was walking past Resident #37's room and saw the ORT kiss Resident #37 on the lips. She stated CNA #24 told them he didn't know what to do. She told him he should have told the nurse. She stated she and CNA #25 went into Resident #37's room and asked the resident if anyone had kissed him/her on the lips and the resident said, "Yes". After that she reported what the resident had told her to LPN #10. Interview with CNA #25, on 04/30/15 at 3:28 PM, revealed CNA #24 told him he had witnessed ORT Restorative Aide #1 kiss Resident #37. He said CNA #24 told him the ORT had leaned in and kissed the resident on the mouth. He said he told CNA #24 he needed to tell somebody. He stated CNA #26 requested for him to go with her to question the resident. They went into Resident #37's room and asked the resident if it was true, if someone had kissed him/her. The resident looked at him and shook his/her head, "Yes." He asked the resident if that made him/her feel uncomfortable, and the resident shook his/her head, "Yes". He stated the resident's eyes got really big, but he/she didn't say a name. He said he had worked with this resident for years and found his/her answers to be appropriate and correct. He stated he reported what the resident said to LPN #10. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed she had not concluded the investigation. She stated she had identified CNA #24 had delayed in reporting the abuse allegation. She stated the ORT had already left for the day when the allegation was reported and had not worked since and was on administrative leave pending the investigation. She stated CNA #24 was also suspended for not reporting according to the facility's abuse policy. She stated the incident occurred on Sunday, April 26, 2015 around 1:00 PM and the House Supervisor was not notified until 4:50 PM. Review of the facility's investigation revealed, the facility did not follow its policy, as they did not report the alleged sexual abuse to the Office of Inspector General (OIG) until 04/28/15 at 3:10 PM. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revea

Based on observation, interview, record review, review of the facility's policy, and the facility's investigation, it was determined the facility failed to provide care and services according to the care plans for five (5) of forty-three (43) sampled residents (Residents #1, #2, #5, #11 and #21). Certified Nursing Assistant (CNA) #5 failed to reposition Resident #21 when the resident requested to be turned for comfort reasons. CNA #5 stated she would not turn the resident and left the room even though the care plan directed staff to maintain the resident's comfort level and to alleviate distress by providing non-pharmacological resident interventions. Resident #21 activated the call light for assistance with repositioning his/her leg because of pain on 04/01/15. A Certified Nursing Assistant came to the room, and spoke harshly to the resident, telling the resident that she had just repositioned him/her fifteen (15) minutes ago and left the room without assisting the resident. The resident stated he/she felt intimidated and scared of that CNA and would not use the call light the rest of the night. After the facility was made aware of the allegation, they allowed the CNA to continue to work and provide resident care. (Refer to F225) Immediate Jeopardy (IJ) was identified on 04/03/15 and was determined to exist on 04/01/15. However, during an abbreviated survey initiated on 04/28/15 (investigating complaints KY and KY ) it was determined the IJ had not been removed as alleged, on 04/09/15, due to the facility's failure to ensure all components of the AOC were implemented. Additionally, staff failed to administer a tube feeding at the correct rate as care planned for Resident #2 on 03/31/15; and staff failed to provide activities according to the resident's interests noted on their plans of care for Residents #1, #5, and #11. The facility's failure to follow the care plan for the residents has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable AOC on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The SSA verified Immediate Jeopardy was removed on 05/06/15 as alleged, prior to exit on 05/13/15 with the Scope and Severity lowered to a "D" while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Interview with the Administrative Director of Nurses, on 04/07/15 at 1:52 PM, revealed the facility did not have a policy on implementing care plans; however, they used the Center for Medicare/Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual as their policy. Review of the facility's CMS RAI Version 3.0 Manual for Care Planning, dated May 2013, revealed the comprehensive care plan must describe the services that were needed for the resident to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. A resident's care plan would provide information on how issues could be addressed to provide for the resident's highest practicable level of well-being. In addition, the manual stated the facility must provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes and with accepted professional standards and principles that apply to professionals providing services in such a facility. 1. Review of the clinical record for Resident #21 revealed the facility admitted the resident on 03/10/15 with [DIAGNOSES REDACTED]. Review of a Nurse's Note, dated 03/11/15 at 10:27 PM, revealed Resident #21 was alert and oriented times three and had left sided paralysis; was assisted with positioning; had an unequal hand grasp ability; and, was able to move his/her fingers of the left hand; however, he/she was unable to reposition the total extremity. Record review revealed the facility completed an Initial Minimum Data Set (MDS) on 03/14/15, and assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was interviewable. Additionally, the facility assessed Resident #21 as requiring extensive assistance with bed mobility and transfer, requiring two (2) person physical assistance; and, utilized a wheelchair (w/c). Review of Resident #21's Comprehensive Care Plan, completed on 03/18/15, revealed the facility initiated a care plan related to the use of [MEDICAL CONDITION] medications. The care plan included an intervention to always assess and incorporate non-pharmacological interventions to alleviate chair or bed discomfort and to answer the resident's call light in a timely manner. Further review revealed the care plan further instructed staff to reposition the resident every two (2) hours, or per the current turning schedule. In addition, the staff was to maintain the resident's comfort level. Review of the clinical record revealed a Nurse's Note, dated 03/18/15 at 1:45 PM, which stated the resident continued to receive the maximum assistance with his/her activities of daily living (ADLs) and transfers. Review of a Nurse's Note, dated 03/23/15 at 1:45 AM, revealed Resident #21 was frequently awake on the 11:00 PM to 7:00 AM shift; and, the resident was beginning to have sensation in his/her left lower extremity. Interview with Resident #21, on 04/01/15 at 2:45 PM, revealed he/she used the call light due to pain in his/her leg and the need to be repositioned. Resident #21 stated he/she was unable to get his/her leg comfortable and could not turn himself/herself. Continued interview revealed the resident stated CNA #5 came to the room, and "harshly" stated that she had repositioned the resident fifteen (15) minutes ago, and would not turn him/her again and left the room. The resident further stated he/she felt intimidated and scared of CNA #5 and would not use the call light the rest of the night. Additionally, the resident stated he/she had seen CNA #5 since the night of the incident, and if CNA #5 responded to his/her call light, he/she (the resident) would say it was an accident. Interview with the Clinical Director of Nursing (DON), on 04/01/15 at 2:07 PM, revealed the resident reported, that he/she had leg pain within the last week and had put on the call light for assistance. The resident reported CNA #5 answered the call light. When CNA #5 came into the room, she spoke harshly to the resident and told him/her that she (CNA #5) had repositioned him/her fifteen (15) minutes ago and walked out of the resident's room. The DON stated the resident was afraid of CNA #5. Review of the facility's investigation, dated 04/01/15, revealed Resident #21 reported to the Assistant Unit Manager, Unit Manager (UM) #1, the Clinical Director of Nursing (DON), and the Assistant Director of Nursing (ADON), that he/she had asked a night shift CNA (CNA #5) to reposition him/her. The resident stated CNA #5 refused to assist him/her and he/she was afraid of CNA #5 because she was rough with him/her. The resident continued to express fear of CNA #5 because she spoke harshly. Resident #21 reported that late last week he/she had leg pain and put on his/her call light to request someone to reposition him/her. The resident stated CNA #5 who responded to the call light was harsh when speaking to him/her and the aide told him/her that she had just repositioned the resident fifteen (15) minutes ago and left the room. Additionally, the resident reported he/she was hurting badly; however, he/she did not want to call CNA #5 again as he/she did not know how CNA #5 would react. Interview, on 04/02/15 at 9:26 AM, with the Assistant UM revealed the resident reported he/she was in pain last week, used the call light, and asked to be repositioned. The Assistant UM stated the resident also reported CNA #5, who responded, said she had just repositioned the resident and would not do it again. He further stated the resident told him they had used the call light again and when the same staff responded (CNA #5), the resident would tell the aide he/she accidentally activated the call light by mistake and did not request assistance. Interview with the UM, on 04/02/15 at 12:20 PM, revealed the resident reported that in the last week he/she was uncomfortable and asked to be turned. The resident stated he/she was told by CNA #5 that she had just turned him/her about fifteen (15) minutes ago and was not going to turn him/her again. The resident stated he/she felt intimidated by CNA #5. Interview with the Clinical DON, on 04/02/15 at 12:37 PM, revealed the resident felt CNA #5 did not want to reposition him/her. Resident #21 reported he/she was afraid of the CNA. Interview, on 04/01/15 at 12:54 PM, with the ADON revealed Resident #21 reported CNA #5 seemed irritated when he/she used the call light to be repositioned. Interview with the Administrator, on 04/02/15 at 3:35 PM, revealed the resident said he/she was uncomfortable and in pain and had used the call light several times to be repositioned. The resident reported CNA #5 said she was just there fifteen (15) minutes ago. The resident reported he/she felt afraid and intimidated, and did not use the call light any more that night. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed she worked the night shift, starting at 11:00 PM, and always worked with Resident #21. She stated the resident would voice complaints of his/her leg hurting, stating he/she had been on that side to long. CNA #5 stated the resident's left leg was paralyzed and he/she could not turn him/herself. She further stated Resident #21 was turned and repositioned every two (2) hours, and the resident would often ask to be repositioned again. Interview, on 04/07/15 at 12:41 PM, with CNA #7 revealed she had worked with Resident #21 and was his/her CNA that day. The CNA stated she had been in the resident's room more frequently than every two (2) hours that day and had repositioned the resident every time she entered the resident's room as the resident would state his/her left side was hurting. Interview with Licensed Practical Nurse (LPN) #5, on 04/07/15 at 12:50 PM, revealed she worked with Resident #21 and if the resident was in pain, she could give the resident medication, or turn and reposition him/her. The Nurse stated Resident #21 was scheduled for repositioning every two (2) hours; however, he/she should also be repositioned when he/she requested to be repositioned. She further stated repositioning the resident could alleviate the resident's discomfort. Interview with the Assistant UM, on 04/07/15 at 1:09 PM, revealed Resident #21 should be turned and repositioned every two (2) hours, and when he/she voiced pain. He further stated Resident #21 reported to him that he/she had a lot of pain the night of the incident. The Assistant UM stated if the resident was not repositioned when in pain, then the resident's pain would not be alleviated. Interview with the Staff Development Nurse, on 04/07/15 at 2:30 PM, revealed if a resident was in pain and requested to be repositioned, staff was aware they could immediately reposition the resident to make the resident more comfortable. She stated if a resident wanted to be in a different position, then he/she had that right. The Staff Development Nurse further stated if staff did not reposition a resident when he/she requested, then it could be abuse or neglect. Interview, on 04/07/15 at 3:41 PM, with Night Supervisor #2 revealed if a resident requested to be repositioned for comfort staff should turn the resident and try to make the resident comfortable, per the resident's plan of care. Interview with Night Shift Supervisor #1, on 04/07/15 at 4:12 PM, revealed if a resident requested to be repositioned staff was expected to reposition the resident. The Supervisor stated if a resident was not repositioned when he/she asked, the resident could have an increase in discomfort. Interview with the Clinical DON, on 04/08/15 at 12:38 PM, revealed the purpose of the resident care plan was a guide on how to provide that resident's care. She stated she expected staff to follow the interventions on the resident's care plans. She further stated staff could reposition a resident to alleviate discomfort and that was basic nursing. The Clinical DON stated the resident's statement that the CNA refused to reposition him/her would imply the CNA did not follow the care plan. Additionally, she stated when the CNA refused to reposition the resident when requested also did not follow the RAI manual for care planning and did not meet the resident's highest practicable well being. The Clinical DON stated if the resident's care plan was not followed, the resident could have a negative outcome. She stated if a resident was not repositioned and was in pain, the resident would continue to be in pain. She further stated the resident determined what his/her level of pain was and should be treated accordingly. The Clinical DON stated if a resident requested to be repositioned, the staff member would be expected to reposition the resident. She further stated she monitored resident care through the daily team huddle with the Unit Managers. Interview with the Administrator, on 04/08/15 at 1:51 PM, revealed he monitored that resident care met resident needs through speaking with the DONs daily, Quality Assurance (QA) meetings, and morning huddles. He stated the Clinical DON or Administrative DON was responsible to oversee that resident care plan interventions were followed and implemented. He stated Resident #21's care plan was not followed when the resident stated he/she was not repositioned by the aide when asked to be repositioned. The Administrator further stated the resident's allegation would not have met the RAI care plan policy and therefore, would not meet the resident's highest practicable well being. He stated if the resident was not repositioned as requested, and was in pain, the resident would remain in pain. 2. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 11/03/09 with [DIAGNOSES REDACTED]. The facility completed a Significant Change Minimum Data Set (MDS) assessment, on 12/23/14, and stated the resident was comatose and had a Gastrostomy tube ([DEVICE]) in place for nutrition. Review of the Comprehensive Care Plan, dated 12/24/14, revealed a Diet Plan of Care that stated the resident was to receive nothing by mouth, supplements and flushes were in place; and, the resident was at risk for dehydration, weight loss, and aspiration. The care plan interventions stated for staff to provide tube feeding supplements as ordered. Review of a care plan for Skin Failure, dated 12/26/14, revealed the resident was at further risk for skin breakdown secondary to his/her Gastrostomy status and the staff was to provide nutrition and fluids via the [DEVICE] per current orders. Review of the physician's orders [REDACTED]. Additionally, the order stated the tube feeding should be held one (1) hour before and one hour after the administration of [MEDICATION NAME]. The physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Enteral Feeding Progress Note NAR review, dated 03/16/15 at 10:34 AM, revealed Glucerna was to run at 60cc per hour for 20 hours due to the order to hold tube feeding for [MEDICATION NAME], one hour before and one hour after. Review of a Dietary Note, dated 02/17/15, revealed the resident had a weight loss in February of 5.6 pounds from 146 to 140.4 and 4.6 pounds for the last three (3) months. The resident had a Stage IV (4) sacral wound that had improved and the tube feeding should be increased from Glucerna at 55 cc per hour to 60 cc per hour. Review of a Dietary Note, dated 03/16/15, revealed the resident's Glucerna was increased last month due to weight loss of one (1) pound. The 03/25/15 Note, stated the resident had lost five (5) pounds since January from 146 to 141 pounds and the Dietary Note, dated 03/31/15, stated the resident had lost six (6) pounds in the last three (3) months from 147.2 to 141 pounds and his/her tube feeding had been increased. Review of the Treatment Administration Record (TAR), dated March 2015, revealed on 03/31/15, the total amount of tube feeding administered to Resident #2 was 333 cc on the 7:00 AM to 3:00 PM shift. However, the resident's order was for Glucerna at 60 cc per hour for six hours, which would total 480 cc. Observation of Resident #2, on 03/31/15 at 8:34 AM, 10:40 AM, 11:30 AM, 11:56 AM, 12:10 PM, and 3:22 PM, of Resident #2 revealed the tube feeding rate was infusing at 50 cc per hour, not at the 60 cc per hour rate. Interview, on 04/02/15 at 2:22 PM, with Licensed Practical Nurse (LPN) #4 revealed she had provided care for Resident #2 on 03/31/15 during the day shift. She stated when she came on duty the pump (tube feeding) had been held, from 6:00 AM to 7:00 AM due to the [MEDICATION NAME] medication. The nurse stated she started the tube feeding at 7:00 AM at the rate that was already programmed in the pump. The LPN further stated she could not remember if she checked the pump for the correct rate. She stated she was unaware if the tube feeding was held during the shift and there were no problems with the tube feeding infusion that day. The nurse stated she checked how much tube feeding the resident had received around 2:00 PM, and the resident had received 333 cc on her shift. Post survey interview via telephone with LPN #11, on 04/15/15 at 3:56 PM, revealed nurses should check a resident's tube feeding when it was changed; at the beginning of the shift; during medication administration; and, at the end of the shift. She stated the nurse would sign the MAR that the tube feeding was given, including the type of tube feeding and the rate. The nurse further stated Resident #2's tube feeding was turned off for certain medications and would then be re-started after the medication had been given. She stated the tube feeding would be discussed during nursing report only if there was a change in the type or the rate. The nurse stated the resident's care plan included an approach for tube feeding per the current orders and the resident was NPO. The LPN further stated the purpose of the care plan was to ensure a resident received proper care that met the needs of the resident. The LPN stated the resident did have a pressure ulcer area on his/her bottom and the rate of the tube feeding may have been increased due to the weight loss. She stated if the care plan was not implemented or followed, the resident was at risk for developing any problems listed in the care plan the facility was trying to address. Post survey interview via telephone, on 04/15/15 at 4:04 PM, with UM #8 revealed nurses should check the resident's tube feeding at the beginning of the shift; when connecting a new bottle; when giving medications; and, at the end of the shift. She stated the tube feeding would be turned off for a while when the resident received [MEDICATION NAME] and the nurse should check the tube feeding when she turned it back on after the medication was given. The UM stated the tube feeding rate was also on the MAR. She further stated she was unsure how or when it was discovered the tube feeding was at the wrong rate as she had been off from work for several days since 03/30/15. The UM stated the purpose of the care plan was to identify the resident's problems and needs, potential risks, and how to care for the resident. She further stated she monitored that the care plan interventions were followed by reviewing records and talking with the staff. She stated her concern regarding Resident #2 was his/her chronic wound on his/her bottom. The UM further stated if the resident's care plan was not followed, the resident could have weight loss, slow wound healing, or not get the nutrition the resident needed. 3. Review of Resident #1's clinical record revealed the facility readmitted the resident on 06/19/14 after an acute hospital stay, with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, completed on 03/20/15, revealed the facility assessed the resident as needing extensive assistance with dressing, eating, bathing and hygiene. During the MDS assessment a Brief Interview for Mental Status (BIMS) was not conducted due to Resident #1 was rarely/never understood. Review of the Activities' Assessment for Resident #1, dated 12/22/14, revealed the resident was alert and oriented with periods of confusion. The resident was up when tolerated in a cardiac chair. The family visited almost daily and was supportive. Activities visited the resident for one on one visits to provide socialization and stimulation such as playing music, reading a book, conversing, applying lotion, or watching television. Review of the Comprehensive Care Plan for Resident #1 revealed the facility developed an Activity care plan, on 04/17/14, with a goal that did not have a target date, and stated the resident would allow one on one visits from activity staff. The Approaches on the care plan stated the Activity staff was to introduce themselves to the resident before each interaction; schedule activities to allow for limited energy; respect the resident's desire to be alone on occasion; invite resident's family/friends to attend selected activities with resident and respect the resident's choice in regard to limited or no activities. At the end of the pre-printed list of approaches was a hand written notation that family visited. Hand written notations were made to the right side of the document that stated staff reviewed the care plan and no changes were made during reviews conducted in April 2014, July 2014, October 2014 and December 2014. Observation of Resident #1, on 04/01/15 from 10:02 AM until 10:45 AM, revealed the resident was in bed receiving a bed bath, during the time the Wacky Wednesday activity occurred in the common area of the unit. The staff did not invite or provide a choice to attend the activity. Interview with Certified Medication Technician #1, on 04/01/15 at 3:20 PM, revealed she was not sure what activities were scheduled each day. She stated bathing and getting residents up was based on their therapy schedule and not on the activity schedule. She stated the residents that were able to do most of their own activities of daily living and attended activities off the unit did not need the staffs' help. She stated she would ask those that needed help getting out of bed when they wanted to get up. Review of the Certified Nursing Assistant Care Plan for Resident #1, dated 03/19/15, revealed the plan did not contain information that informed nursing assistants of resident's activity preferences. Review of the Activity Calendar (utilized to document a resident's participation in a scheduled activity) for Resident #1 and dated February 2015, revealed the calendar did not indicate the facility assisted the resident to attend, passively attend, or that the resident refused to attend the group activities listed in his/her care plan. Review of Resident #1's Activity Calendar for March 2015, revealed the calendar did not indicate the facility assisted the resident to attend, passively attend, or that the resident refused to attend the group activities listed such as: Music Listening, Bible Study, Special Event of Movie Day Party, Music with Earl, On Unit Activity, Eastern Parkway Church, Birthday Party, Wacky Wednesday events, St. Patrick's Day Party, Sunday Worship each Sunday, On Unit Video or Sit and Fit. Review of Resident #1's activity calendar for April 2015, revealed the calendar did not indicate the facility assisted the resident to attend, passively attend, or that the resident refused to attend the group activities listed such as: Wacky Wednesday, Bible Study, or Bingo Music. One on one activity by facility staff did not occur during the following observations of Resident #1: on 3/30/15 at 5:30 PM, a family member was pushing Resident #1 in their wheelchair in to the resident's room from the hallway; on 03/31/15 at 8:15 AM, the resident was in bed on their back with eyes closed; at 9:30 AM the resident was in bed with their eyes open and positioned on the left side; at 11:20 AM the resident was in bed with their eyes open and positioned on the right side; at 2:05 PM the resident was in bed on their back with eyes closed; on 04/01/15 at 7:46 AM, the resident was in bed on their right side with eyes closed. Continued review of the Comprehensive Care Plan for Resident #1, dated 07/01/14, revealed a problem area of multiple Stage II and Stage III pressure ulcers. The resident was at risk for worsening of these areas and additional skin failure; with goals of open areas will remain clean and discomfort will be managed until next review. Interventions revealed the staff was to provide treatments as ordered; low air loss mattress; reposition every two (2) hours; and provide incontinent care as needed. The care plan did not address the resident's heel boots to be worn at all times or the Kerlix to the skin tear. Review of the CNA care plan, dated 03/19/15, revealed the staff was to place bilateral heel Medix to the resident's feet and notify the nurse if the dressing needed to be changed, as well as, mesh panties to be applied daily and when soiled to hold dressing in place. Observation of Resident #1, on 03/31/15 at 9:30 AM, revealed the resident was lying on the left side on the bed. Resident #1 was raising the bed sheet and revealed the resident did not have a brief on and no abdominal pads were in place to the buttock/sacral area. Observation of Resident #1's skin assessment performed by the 300 Assistant Unit Manager, on 03/31/15 at 11:25 AM, revealed no abdominal pads were in place to the buttock/sacral area. Observation of Resident #1, on 04/01/15 at 10:02 AM, during the bed bath, revealed no abdominal pads were in place to the buttock/sacral area. Interview with Licensed Practical Nurse (LPN) #1, on 04/01/15 at 3:30 PM, revealed she expected the nursing assistants to inform her when the dressing became soiled or needed replacement. Interview with the 300 Assistant Unit Manager, on 04/01/15 at 3:30 PM, revealed he did not know how to keep Resident #1's dressing in place without tape as ordered by the physician and he would have to refer to the wound care nurse for direction. He stated he expected the nursing assistants to notify the nurse assigned to the resident if the dressing needed to be re-applied due to not being in place or soiled. Interview with Clinical Director of Nursing, on 04/01/15 at 3:30 PM, revealed she expected the nursing assistants to notify the nurse assigned to the resident if the dressing needed to be re-applied due to not being in place or soiled. Observation of Resident #1, on 03/31/15 at 11:20 AM, revealed the resident had a bleeding area on the left forearm. The resident used the sheet to blot the bleeding area on the forearm. Observation of Resident #1's skin assessment performed by the 300 Assistant Unit Manager, on 03/31/15 at 11:25 AM, revealed the Assistant Manager noted the new skin tear to Resident #1's left forearm. Review of Resident #1's Physician Verbal Telephone Order, dated 03/31/15 and timed at 11:45 AM, revealed the physician's orders [REDACTED]. Observation of Resident #1, on 03/31/15 at 2:05 PM, revealed the resident did not have a Kerlix on the left arm as ordered by the physician. Observation of Resident #1, on 04/01/15 at 7:46 AM, revealed the resident did not have a Kerlix on the left arm as ordered by the physician. Interview with the 300 Assistant Unit Manager, on 04/01/15 at 3:30 PM, revealed the physician's orders [REDACTED].#1's left arm should have been implemented within one hour after receiving the order. Continued review of the physician's orders [REDACTED].#1 also had an order for [REDACTED]. Observations of Resident #1, on 03/31/15 at 11:20 AM, 11:25 AM and 11:35 AM revealed Resident #1 was lying down on the bed without the ordered bilateral heel Medix boots in place. Interview with Certified Nursing Assistant (CNA) #9, on 03/31/15 at 11:35 AM, revealed she had not been in Resident #1's room since her shift started at 7:00 AM and she had not removed the bilateral heel boots. She stated the facility had a CNA care plan for each resident in their rooms for the CNAs to reference and she would have to reference that form to determine if the resident needed the boots on at all times while in bed. Interview with the 300 Assistant Unit Manager, on 03/31/15 at 11:25 AM, revealed Resident #1 had an order for [REDACTED]. He stated nursing staff were responsible for ensuring boots remained on while in bed. Post survey interview via telephone with CNA #10, on 04/23/15 at 2:40 PM, revealed the resident was to wear bilateral boots at all times while in bed. She stated although the CNA care plan did not state at all times, the staff knew this. However, the resident would kick them off and the CNAs would have to go back and check and replace the boots. Post survey interview via telephone with the 300 Unit UM, on 04/23/15 at 3:10 PM, revealed she ensured the resident's care plan was being followed by checking to see if the nurses had signed the treatment records for completion and she checked the residents against the CNA care plan to ensure the care plan was being followed. However, she stated this was done daily. She further stated the CNAs received report from the nurses and made rounds with oncoming shift for resident needs. 4. Review of Resident #5's clinical record revealed the facility admitted the resident on 10/17/14 with [DIAGNOSES REDACTED]. Review of Resident #5's Initial Activities Assessment, dated 02/09/15, revealed several areas on the form were not completed. A hand written note in the comment section stated the resident was unable to provide information for this assessment. The family provided the information, as the resident was end of life care. Further review of the assessment revealed check marks were placed next to music and spiritual events indicating these were Resident #5's likes. Review of Resident #5's Significant Change Minimum Data Set (MDS) assessment, completed on 02/09/15, revealed the facility assessed the resident as needing extensive assistance with dressing, eating, bathing and hygiene. A Brief Interview for Mental Status (BIMS) was conducted during the assessment and the resident scored a seven (7) out of fifteen (15) indicating severe cognitive impairment and not interviewable. Review of the Comprehensive Care Plan for Resident #5 revealed the facility developed an Activity Care Plan on 01/28/15 with a goal that did not have a target date that stated the resident would receive in room visit stimulation and would respond to the visits by opening his/her eyes and verbally respond to yes or no questions. The approaches on the care plan stated the activity staff would offer a schedule of activities for the resident to select choice(s), and would polish the resident's nails as needed. The resident would receive visits from a Deacon or Priest and would receive communion if able. Activity staff would hold the resident's hand during visits for comforting. Resident #5's care plan approaches stated the family was supportive and came to visit

Based on interview, record review, and review of the facility's policies, Administrator's job description, and the facility's Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to have an effective system in place to ensure the Administrator provided oversight of the corrective actions in the AOC and to ensure all aspects of the AOC and Abuse Policy were implemented and followed by staff to ensure residents were free from abuse for two (2) of forty-three (43) sampled residents (Residents #36 and #37). (Refer to F225, F226 and F520) Immediate Jeopardy (IJ) was identified on 04/03/15 and was determined to exist on 04/01/15 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) at a Scope and Severity of a "J"; and, at 42 CFR 483.20 Resident Assessment (F282) at a Scope and Severity of a "J". The facility's AOC, dated 04/09/15, alleged the IJ was removed on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 (investigating complaints KY and KY ) it was determined the IJ at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) had not been removed as alleged, on 04/09/15. Per the facility's AOC, when an allegation of abuse was reported, the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit weekly the revised abuse allegation logs and new abuse allegation checklist (tools developed to assist with the facility's investigations) and the results of the audits would be brought to the QA committee. Interview and record review determined the facility failed to implement these components of the AOC after the facility self-reported two (2) abuse allegations. On 04/19/15, ten (10) days after the facility had alleged the removal of IJ, Resident #36 alleged Certified Nurse Aide (CNA) #22 was mean and rude and threw the bed covers over the resident's head. CNA #22 was allowed to care for other residents after the abuse allegation was received. The facility did not reported the allegation to the SSA until 4:09 PM on 04/20/15, greater than twenty-four (24) hours after the incident occurred. On 04/26/15, seventeen (17) days after the facility had alleged the removal of IJ, CNA #24 failed to follow the facility's abuse policy for reporting incidents of abuse immediately to the nurse. CNA #24 alleged he saw Outreach Technician (ORT) Restorative Aide #1 kiss Resident #37 on the lips. However, he did not report what he had witnessed until hours later after the alleged perpetrator had left for the day. The ORT Restorative Aide #1 had provided care to approximately forty (40) other residents before the end of his shift. In addition, the facility failed to report the abuse allegation to the State Survey Agency until two (2) days after the alleged abuse occurred. The facility's failure to ensure the Administrator administered in a manner to ensure corrective actions of the AOC were implemented and monitored to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable (AOC) on 05/07/15, which alleged removal of the Immediate Jeopardy on 05/06/15. The State Survey Agency verified Immediate Jeopardy was removed as alleged prior to exit on 05/13/15. The Scope and Severity was lowered to a "D" while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor will immediately report the concern to the State Agencies. Review of the Administrator's job description, dated 10/03/2005, revealed the Administrator's primary function was to manage operations in accordance with current applicable federal, state, and local standards, guidelines, and regulations to assure that the organization is operating effectively and efficiently. The individual would strive to provide to all those entrusted to his/her care the highest quality of appropriate services possible in light of resources or other constraints. Practice administration in accordance with capabilities and proficiencies and strive, in all matters relating to their professional functions, to maintain a professional posture that places paramount the interests of the facility and its residents. Interview with the Administrator, on 04/30/15 at 3:45 PM, revealed he provided oversight over the DONs who conducted the abuse investigations. He stated the abuse investigations were discussed with him. He stated he was not aware CNA #22 was allowed to work after the abuse allegation was received from Resident #36 because the Clinical DON did not know. He was told the aide had been placed on administrative leave. He said he thought the checklist were working. When he saw the checks he assumed the two DONs had reviewed it. Both have to sign off on the abuse log indicating that the investigation was complete. They were to look at each area checked. The Administrator stated the Compliance Auditor's responsibility was to ensure each step was done on the checklist, not just check for marks. He stated he assumed that all steps had been done. He was unaware residents were not protected during an abuse investigation and allegations were not reported according to facility policy. The Administrator stated monitoring and audits were tools used to ensure the AOC was implemented. He revealed he had questioned the Compliance Auditor about the audits, but only spoke of ensuring they were done, not of content. No issues with the audits had been reported to him. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. However, interview with the Compliance Auditor, on 04/30/15 at 1:15 PM revealed this was not done. Continued interview with the Administrator, on 04/30/15 at 3:45 PM, revealed the QA conducted on 04/27/15 was a quarterly QA where the committee discussed issues from January, February, and March 2015. He said they did not talk about the AOC and did not bring the AOC to review during that QA meeting. He added the DONs did not discuss any abuse investigations. He stated the results of the audits conducted by the Compliance Auditor were not discussed and there was limited talk about deficiencies and corrective actions. He said it was his responsibility and there needed to be closer monitoring. The Administrator stated the AOC had not been implemented and he could not say that enough oversight had been provided. He stated he was not sure where the breakdown occurred; however, a lot of assumptions were made. He further stated he did not ask the Medical Director for input. 1. Review of the facility's investigation, initiated on 04/20/15, revealed the Certified Medication Technician (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over the resident's head and the aide was mean and rude to the resident. The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22; however the aide was allowed to work with other residents after the abuse allegation was received. Further review of the abuse investigation revealed the Clinical DON failed to determine when the aide was suspended and did not know CNA#22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment to be substantiated. Interview with CNA #22, on 04/28/15 at 5:25 PM, LPN #9, on 04/29/15 at 9:42 AM, and CNA #23, on 04/29/15 at 10:58 AM, revealed CNA #22 was allowed to care for other residents after the abuse allegation was received. Review of CNA #22's time card, for 04/19/15, revealed CNA #22 worked until 11:00 AM, several hours after the abuse allegation was received at 9:30 AM. Interview with the Clinical DON, on 04/29/15 at 4:05 PM, revealed the investigation had not identified CNA #22 had not been removed from patient care immediately and had been allowed to care for other residents after the abuse allegation was reported. She She had not asked during her investigation and stated she had no reason to review CNA #22's time card 2. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed she had not concluded the investigation of alleged abuse for Resident #37. She stated her investigation had identified CNA #24 did not report the alleged abuse right away on 04/26/15. She stated the ORT Restorative Aide had already left for the day when the allegation was reported and had not worked since. He was placed on administrative leave pending the investigation. She stated the incident occurred on Sunday, April 26, 2015 around 1:00 PM and the House Supervisor was not notified until 4:50 PM. In addition, the Administrative DON revealed she had not reported the alleged abuse to the State Survey Agency until two days after the alleged abuse was reported (04/28/15 at 3:10 PM). She stated the facility's fax machine was not working on 04/27/15 and she did not call and report the abuse allegation. Telephone interview with CNA #24, on 04/29/15 at 3:07 PM, CNA #25, on 04/30/15 at 3:28 PM, and CNA #26, on 04/30/15 at 3:17 PM, revealed they failed to report the alleged abuse according to the facility's abuse policy. Review of the House Supervisor's written statement revealed on 04/26/15 at approximately 4:45 PM, LPN #10 reported ORT Restorative Aide #1 was observed by CNA #24 kissing Resident #37 on the lips. She texted the Administrative DON at 4:51 PM notifying her of the event. Review of ORT Restorative Aide #1's time card for 04/26/15 revealed the ORT worked from 7:00 AM to 3:15 PM. Review of the Restorative Care Participation documentation for 04/26/15 revealed the ORT Restorative Aide documented at 1:27 PM he had worked with Resident #37 for thirty (30) minutes. In addition, the aide documented he provided restorative care to forty (40) residents after Resident #37's session. The State Survey Agency validated the removal of Immediate Jeopardy on 04/09/15 prior to exit as follows: 1. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON revealed she notified Resident #21's physician and family, DCBS and OIG the day the allegation was made, on 04/01/15. Review of the facility's investigation revealed the notifications were made on 04/01/15. 2. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she interviewed and assessed Resident #21 on 04/01/15 for behavioral and psychosocial concerns. The resident was not tearful and did not express any anxiety. Review of the facility's investigation revealed the Clinical DON interviewed the resident on 04/01/15. 3. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed Resident #21 on 04/02/15. 4. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the alleged CNA was placed on administrative leave on 04/02/15. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed the facility suspended her on 04/02/15. 5. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed the Administrator trained the Clinical DON and Administrative DON, on 04/03/15, on the abuse policy and collecting statements jointly, with verbalized understanding. Review of the training records revealed, on 04/03/15, the Administrator trained the Clinical DON and Administrative DON on the abuse policy and collecting statements jointly. 6. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she developed the investigation checklist, on 04/03/15, to ensure every step had been taken during an investigation. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she had been trained by the Administrative DON on the use of the investigation checklist and completed by either DON. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed he approved the new Investigation Checklist. Review of the Investigation Checklist revealed an effective date of April 2015. 7. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON and, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the Administrative DON revised the Allegation Log to include two (2) sets of signatures for review by nursing administration. The Administrative DON trained the Clinical DON how to use the log. Interview, on 04/09/15 at 5:14 PM, with the Administrator revealed he approved the revised Allegation Log which required both DONs to initial they had reviewed the allegations. Review of the Allegation Log revealed it contained Nursing Administration review and was revised April 2015, and was reviewed by the Clinical DON, Administrative DON, the Clinical Support Services, and Administrative Nursing Assistant. Review of the revised allegation log revealed a place for two (2) signatures were added on 04/03/15. 8. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed other interviewable residents regarding possible issues with care and abuse. Review of the Resident Interviews for Resident #21's investigation, dated 04/08/15, revealed, on 04/07/15, the Administrative DON interviewed fourteen (14) interviewable residents if there were any issues or concerns with staff. No concerns were noted. Interview, on 04/09/15 at 4:25 PM, with the Treatment Nurse revealed she completed skin assessments of eight (8) non-interviewable residents, on 04/08/15, on the 3rd floor. She stated she completed one side of the unit and the Outreach Technician (ORT) nurse completed the other side of the unit with no concerns noted. Review of six (6) skin assessments and two (2) wound assessments revealed skin assessments were completed on 04/08/15. Interview with Resident #4, on 04/01/15 at 10:25 AM; Resident #12, on 03/31/15 at 8:46 AM; Resident #13, on 03/31/15 at 7:47 AM; Resident #15, on 04/01/15 at 10:20 AM; and, Resident #16, on 03/31/15 at 9:30 AM, revealed no concerns with staff interactions with the residents. 9. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed she reviewed facility allegations for the last year, for a total of twenty-five (25) investigations with no concerns noted. Review of a statement by the Administrative DON, dated 04/07/15, revealed twenty-five (25) investigations were reviewed in the last twelve (12) months by the Administrative DON, with no concerns noted. Review of four (4) investigations revealed no regulatory violations for Residents #31, #32, #33 and #34. 10. Interviews on 04/09/15 with a total of fifty (50) employees revealed: seventeen (17) CNAs (CNA #13 at 1:56 PM, CNA #3 at 1:57 PM, CNA #22 at 2:00 PM, CNA #21 at 2:06 PM, CNA #8 at 2:12 PM, CNA #9 at 2:20 PM, CNA #17 at 2:21 PM, CNA #15 at 2:52 PM, CNA #14 at 2:46 PM, CNA #16 at 3:05 PM, CNA #19 at 3:05 PM, CNA #10 at 3:09 PM, CNA #18 at 3:12 PM, CNA #20 at 3:15 PM, CNA #11 at 3:17 PM, CNA #23 at 3:20 PM, CNA #12 at 3:31 PM), six (6) LPNs (LPN #1 at 3:07 PM, LPN #5 at 2:47 PM, LPN #3 at 2:45 PM, LPN #9 at 3:07 PM, LPN #10 at 3:30 PM, LPN #8 at 2:18 PM, RN #4 at 2:09 PM, five (5) Unit Managers (UM/RN #2 at 2:00 PM, UM/RN #3 at 2:27 PM, UM/RN #6 at 3:00 PM, UM #1 at 3:00 PM, UM/RN #7 at 3:35 PM), three (3) housekeepers (Housekeeper #2 at 2:09 PM, Housekeeper #3 at 2:15 PM, Housekeeper #4 at 2:15 PM), a CSR at 2:27 PM, a Dietary Aide at 2:31 PM, Central Supply at 2:51 PM, Rehabilitation Secretary at 2:40 PM, Rehabilitation Director at 2:42 PM, the Nutrition Services Director at 1:58 PM, the Social Services Director at 2:11 PM, the Activities Director at 2:24 PM, RAI Coordinator at 2:34 PM, HR Director at 2:43 PM, Receptionist at 3:02 PM, Compliance Auditor at 3:31 PM, QA Director at 3:45 PM, Rehab Manager at 3:55 PM, Treatment Nurse at 4:25 PM, House Supervisor at 4:33 PM, Clinical DON at 4:48 PM, and the Administrative DON at 5:03 PM revealed they had all received abuse training within the last week; they were aware of the types of abuse; when to report abuse; and, to who to report alleged abuse. Review of the training records revealed three hundred and eleven (311) staff had completed post tests between 04/02/15 and 04/08/15. Interview with the HR Director, on 04/09/15 at 2:43 PM, revealed all staff had been trained on abuse except those staff on vacation or leave. The HR Director stated a sign was posted at the time clock and a letter was mailed to those staff not yet trained, that they must receive training prior to working. Observation, on 04/09/15 at 4:04 PM, of the time clock revealed a sign posted with thirteen (13) staff names to obtain abuse training prior to going to their unit. Review of the letter sent to staff revealed it was dated 04/08/15 from the HR Director that stated staff must receive the abuse training and answer the questionnaire before they started work. Review of the facility's staff roster revealed the letter was mailed to ten (10) employees, who were either sick, on vacation, or leave of absence. 11. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, and the QA Director, on 04/09/15 at 3:45 PM, revealed they would review the Allegation Log for completion and signatures weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. They stated the audits would go to the QA meetings for review. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would conduct audits of the Allegation Log and report the findings to the QA Committee. 12. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor and, on 04/09/15 at 3:45 PM, with the QA Director revealed either would audit the Investigation Checklist weekly for four (4) weeks, monthly for three (3) months, then quarterly for a year with results to QA the Committee. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would audit the Investigation Checklist and report to the QA Committee. Review of the Investigation Checklist revealed an inception date of 04/03/15. 13. Review of the third floor care plan updates revealed, on 04/03/15, the care plan for Resident #21 was updated by the RAI Coordinator. 14. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she reviewed resident behavior and antipsychotic care plans on 04/08/15, and then all residents, checking if the care plan had been updated, initiated, and implemented, with no concerns noted. Review of care plan audits for all six (6) floors, dated 04/07/15 revealed all care plans were reviewed for residents on each floor of the facility with 119 care plans revised. 15. Interview with the Social Services Director, on 04/09/15 at 2:11 PM, the RAI Coordinator, on 04/09/15 at 2:43 PM, with the UM on the 2nd floor (RN #2 on 04/09/15 at 2:00 PM and RN #3 on 04/09/15 at 2:27 PM), the UM on the 3rd floor, on 04/09/15 at 3:00 PM, and the Administrative DON, on 04/09/15 at 5:03 PM, revealed they received care plan training this week and was conducted by the Administrative DON, that included who initiated and updated the care plan, and how to implement the care plan, with verbal competency. Review of the care plan training records revealed care plan training included who initiated and updated the care plan, when the care plan should be revised, and who was responsible to implement the care plan. 16. Interview, on 04/09/15 at 2:00 PM, with UM/RN #2; on 04/09/15 at 2:27 PM, with UM/RN #3; and, on 04/09/15 at 3:00 PM, with UM #1 revealed walking rounds were conducted throughout the shift, but they did not document those rounds. The UMs stated they were observing direct staff to ensure care was provided according to the resident's care plan. Review of care plans revealed Resident #4's care plan was revised on 04/07/15, based on the UM rounds, to reflect the current placement in isolation. 17. Interview with the RAI Coordinator, on 04/09/15 at 2:34 PM, revealed she held a Program of Care meeting on 04/08/15 to review and ensure resident care plans were appropriate. Meetings would be held weekly, with discussion of certain residents each week, with all residents discussed quarterly. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM; the Social Services Director, on 04/09/15 at 2:11 PM; the Activities Director, on 04/09/15 at 2:24 PM, revealed their assistants would attend the Program of Care meetings; however, the Directors would attend in the assistants place when needed, and would discuss resident care plan interventions. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Program of Care meetings would review that resident care plans were up to date, make any needed changes, and interventions were implemented. 18. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor revealed she would audit the Program of Care meetings three (3) times a week for four (4) weeks, three (3) times a month for one (1) quarter, then quarterly and give the results to the DON for the QA Committee. 19. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, revealed she would conduct ten (10) chart audits each month for three (3) months, then quarterly to ensure care plans were updated and interventions performed, with discrepancies corrected by the UM. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Compliance Auditor would complete ten (10) chart audits and ensure the residents' care plans interventions were implemented; the UM would correct any issues immediately. She stated results would be taken to the QA Committee. Review of the Care Plan Monitoring Tool, dated April 2015, revealed it included review of the resident care plan, if the care plan had been updated, observations, concerns, if the care plan was followed, and Assistant UM or UM aware of result. 20. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM, the Social Services Director, on 04/09/15 at 2:11 PM, the Activities Director, on 04/09/15 at 2:24 PM, the HR Director, on 04/09/15 at 2:43 PM, the Compliance Auditor, on 04/09/15 at 3:31 PM, the QA Director, on 04/09/15 at 3:45 PM, the Rehab Manager, on 04/09/15 at 3:55 PM, the Medical Director, on 04/09/15 at 4:07 PM, the Treatment Nurse, on 04/09/15 at 4:25 PM, the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed they attended QA meetings, with three (3) held, and discussed the Immediate Jeopardy (IJ), corrective actions, care plans, new checklists, and training. Review of sign in sheets that included review of the IJ and corrective actions revealed QA meetings were held on 04/03/15, 04/06/15, and 04/08/15. An abbreviated survey conducted 04/28/15 investigating KY and KY determined the facility failed to implement the corrective actions of the AOC dated 04/09/15. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. Review of the newly developed checklist to be utilized by the facility to ensure abuse investigations were completed, (which was an intervention on the AOC) revealed no date when it was completed and only checks on the forms without any additional information provided. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed when she reviewed the newly developed checklist she only looked for the check marks and did not review the content of the investigation. In addition, she stated the audits of the abuse investigation checklist were not taken to the Quality Assurance (QA) meeting on 04/27/15. Interview with the Administrator, on 04/30/15 at 3:45 PM, validated the audits of the checklist and the abuse logs were not discussed at the 04/27/15 QA meeting. Immediate Jeopardy was determined not to be removed on 04/09/15 as alleged. The facility was notified of this finding on 04/30/15. The facility took the following actions to remove the Immediate Jeopardy on 05/06/15 as follows: 1. The Clinical DON made notification on 04/20/15 of the allegation (KY ) to Resident #36's family, physician, OIG and DCBS. The Administrative DON made notification of the allegation of abuse (KY ) to Resident #37's family and Physician on 04/27/15. Notification to the OIG and DCBS was made on 04/28/15. 2. On 04/21/15, a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor with no injuries consistent with abuse noted. Fifty-six (56) skin assessments were completed on non-interviewable residents by Unit Managers, Assistant Managers, and Staff Development Nurse as of 05/04/15. No issues were found. 3. 05/04/15, one hundred thirty (130) residents were interviewed by Social Services, and the RAI Coordinators to ensure there were no unresolved or uninvestigated allegations of abuse. No issues were identified. 4. The abuse allegation checklist was revised on 04/28/15 by the Clinical DON to reflect name, date, and time of actions, with a space for narrative documentation to record all actions taken during the abuse investigation. 5. On 05/01/15, the facility obtained the services of a consultant company to provide assistance with training, policy revision, QA and ongoing oversight and consultation. These consultant employees included Nurses, therapists, and Administrators. The facility's Administrative DONs, Human Resources Director, and Assistant Director of Nurses met with the consultants and revised the abuse policy to reflect procedures for immediate protection of residents by removal of the alleged perpetrator from patient care and reporting immediately allegations of any abuse to the state agencies. All staff would receive training on the new Abuse policy revisions and no staff would work past 05/05/15 without receiving the training. This would include agency staff. 6. On 05/05/15, education was provided by the contracted consultant on requirements for abuse allegation reporting and investigation with competency. No staff would be allowed to work past 05/05/15 without receiving the training. This would include agency staff. As of 05/05/15, two hundred ninety-seven (297) employees had been trained. 7. On 05/04/15, the facility implemented a new Nurses' Abuse Allegation Investigation Protocol. The protocol was a step by step reference for nurses and House Supervisors to be used when a resident alleged abuse. The protocol was posted in visible locations on all nursing units and included in all staff education. (Attachment B) 8. On 05/04/15, a QA meeting was held to review the alleged deficient practice and plans of actions established to correct the practices. The consultant observed the QA meeting. Members present included the Administrator, Consultant, Social Services, Medical Director, DONs and other Department Directors. The Administrator established a weekly QA meeting that included review of the deficiencies cited. 9. On 05/04/15, the Elder Justice Act reporting notification requirements was added to the admission packet. The revised Abuse policy and Elder Justice Act information was placed in a binder at the receptionist desk. 10. On 05/05/15, five (5) random staff and resident interviews would be conducted weekly by Social Services and Nursing Administration to ensure there were no unresolved/investigated abuse allegations and staff understanding of reporting requirements. 11. On 05/04/15, the contracted consultant educated the Administrator and made observations at the facility to ensure the Administrator was administering the facility in accordance with professional standards and per his job description included ensuring a system was in place to protect residents from abuse and neglect. 12. Beginning 05/01/15, a consultant would conduct weekly visits for four weeks then monthly visits to ensure the Administrator followed professional standards and job description ensuring systems remained in place for reporting and investigation of allegations of abuse and neglect per established plan of correction. The Administrator established weekly administrative consultative visits with the consultants. 13. The contract consultant re-educated the Administrator, on 05/04/15, on the requirements of a functional QA process to include delegation of action items for identified concerns including oversight of entire AOC and implementation of systems and follow-up to ensure corrections were made and reviewed with the Interdisciplinary Team (IDT). 14. Beginning 05/04/15 the Human Resources Director would update the Administrator daily of the status of staff training on abuse. 15. On 05/05/15, the Administrator amended the agenda for the daily quality meeting with the IDT, to address deficiencies cited. This included reviewing audits, education, and ongoing monitoring to determined effectiveness of current actions. 16. Weekly QA meetings that began on 05/04/15, was held to review identified concerns regarding any issues with the Plan of Correction and follow-up to ensure corrections were sustained. The meeting would consist of at a minimum the Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and other Department Directors. The contract consultant would observe the QA process monthly, including audit tools (attachment E) for at least three (3) months to ensure Quality Assurance Performance Improvement Committee was functional and meeting the identified needs of the facility. The QA committee would consist of the Administrator, DONs, ADON, Social Services, and the Medical Director attending at least quarterly. When the Medical Director was present, they would review a sample of residents' abuse allegations for effectiveness in the revised processes. The QA meeting would review audits (and take action if needed) related to the deficiencies. Theses audits would include resident interviews and skin audits conducted on 05/04/15 and abuse audits which began on 04/08/15 and are ongoing. The reports would be presented by the Compliance Auditor. The State Survey Agency validated the removal of Immediate Jeopardy on 05/13/15 prior to exit as follows: 1. Review of the clinical record and facility investigation validated the Clinical DON notified Resident #36's family, physician, OIG, and DCBS on 04/20/15. Review of the fax verification revealed the OIG was notified on 04/20/15 at 4:09 PM. Review of the clinical record and facility investigation revealed the Administrative DON notified Resident #37's family and physician on 04/27/15. Review of the faxed verification sheet revealed notification to the OIG on 04/28/15 at 3:11 PM. Review of the Department of Community Based Services (DCBS) intake summary revealed the notification was received on 04/29/15. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed the facility's fax machine was broken on Monday, April 27, 2015 and she failed to provide notification via telephone. 2. Review of facility's investigation revealed a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor on 04/21/15, with no injuries consistent with abuse. Review of the skin assessments conducted by the Unit Managers, Assistant Managers, and Staff Development Nurse through 05/04/15, revealed fifty-three (53) skin assessments were conducted for residents with a BIMS score less than eight (8). 3. Review of the resident interview forms revealed Social Services, and the RAI Coordinators conducted one hundred t

Based on interview and review of the facility's policy and Acceptable Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to maintain a Quality Assurance (QA) program implemented and monitored the plans of actions as stated the Allegation of Compliance to correct quality deficiencies as evidenced by the facility's failure to ensure the Abuse Policy was implemented to protect residents from abuse for two (2) of forty-three (43) sampled residents (Resident #36 and #37). (Refer to F225, F226 and F490) Immediate Jeopardy (IJ) was identified on 04/03/15 and was determined to exist on 04/01/15 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) at a Scope and Severity of a "J"; and, at 42 CFR 483.20 Resident Assessment (F282) at a Scope and Severity of a "J". The facility's AOC, dated 04/09/15, alleged the IJ was removed on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 (investigating complaints KY and KY ) it was determined the IJ at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) had not been removed as alleged, on 04/09/15. Per the facility's AOC, when an allegation of abuse was reported, the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. Further review of the revealed the Compliance Auditor or the Quality Assurance (QA) Director would audit weekly the revised abuse allegation logs and new abuse allegation checklist (tools developed to assist with the facility's investigations) and the results of the audits would be brought to the QA committee. However, interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed she only audited the checklist forms to ensure the check marks were made. She did not review any abuse investigation to ensure they were completed, or that they followed the facility's abuse policy. The audits conducted were not taken to the 04/27/15 QA meeting as stated in the AOC. Interview and record review determined the facility failed to implement these components of the AOC after the facility self-reported two (2) abuse allegations. On 04/19/15, ten (10) days after the facility had alleged the removal of IJ, Resident #36 alleged Certified Nurse Aide (CNA) #22 was mean and rude and threw the bed covers over the resident's head. CNA #22 was allowed to care for other residents after the abuse allegation was received. The facility did not reported the allegation to the SSA until 4:09 PM on 04/20/15, greater than twenty-four (24) hours after the incident occurred. On 04/26/15, seventeen (17) days after the facility had alleged the removal of IJ, CNA #24 failed to follow the facility's abuse policy for reporting incidents of abuse immediately to the nurse. CNA #24 alleged he saw Outreach Technician (ORT) Restorative Aide #1 kiss Resident #37 on the lips. However, he did not report what he had witnessed until hours later after the alleged perpetrator had left for the day. The ORT Restorative Aide #1 had provided care to approximately forty (40) other residents before the end of his shift. In addition, the facility failed to report the abuse allegation to the State Survey Agency until two (2) days after the alleged abuse occurred. The facility's failure to have an effective system in place to ensure the QA committee functioned to identify quality deficiencies, develop plans of action, and implement the plans of action has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on 04/01/15. The facility provided a new acceptable (AOC) on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The State Survey Agency verified Immediate Jeopardy was removed as alleged prior to exit on 05/13/15. The Scope and Severity was lowered to a "D" while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: The facility did not provide a policy regarding a Quality Assurance Program. Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse by removing any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to the State Agencies. The Compliance Auditor audited the checklist forms to ensure only the check marks were made. She did not review any abuse investigation to ensure they were completed, or that they followed the facility's abuse policy. The audits conducted were not taken to the 04/27/15 QA meeting as stated in the AOC. Review of the AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor or Quality Assurance Director weekly times four (4) weeks, then monthly, then quarterly. Results of the audits would be brought to the QA Committee. Review of the QA Sign-in Sheets revealed a QA meeting was held on 04/27/15. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed she only audited to ensure the checklist was completed. She stated she only looked to ensure each area was checked; however, she did not go back and see if the investigation had been completed. She stated she was just checking for the "check" marks. Further interview revealed she conducted the audits on the abuse investigation log in the same manner. She was only looking to see if there were two (2) signatures present on the abuse log . She did not check for content. She stated she took the audits to the Quality Assurance (QA) meeting conducted on 04/27/15, but they were not discussed, per the AOC the audits were to be discussed in QA. She revealed this was a quarterly QA meeting and only issues from January, February, and March were discussed. The QA Committee decided to review the audits in the July QA meeting. Further interview revealed she had not identified an problems, as she was only looking for the check marks. Interview with the Administrator, on 04/30/15 at 3:45 PM, revealed he provided oversight over the Director of Nurses (DONs), who conducted the abuse investigations. He stated the abuse investigations were discussed and it was an ongoing process. He said he thought the checklists were working. When he saw the checks he assumed the two (2) DONs had reviewed it, as the both have to sign off on the abuse log that the investigation was complete. He stated the Compliance Auditor's responsibility was to ensure each step was done on the checklist, not just check for marks. He stated he assumed that all steps had been completed. He was unaware residents were not protected during an abuse investigation and allegations were not reported according to facility policy. The Administrator stated monitoring and audits were tools used to ensure the AOC was implemented. He stated he had questioned the Compliance Auditor about the audits, but they only spoke of ensuring they were done, not of their content. No issues with the audits had been reported to him and he was told they were being implemented. Continued interview with the Administrator revealed the QA conducted on 04/27/15 was a quarterly QA where the committee discussed issues from January, February, and March 2015. Per interview, the committee did not talk about or review the AOC and the DONs did not discuss any abuse investigations during this meeting. In addition, he stated the Compliance Auditor did not discuss the results of the audits conducted and there was limited talk about deficiencies and corrective actions. He said there needed to be closer monitoring. The State Survey Agency validated the removal of Immediate Jeopardy on 04/09/15 prior to exit as follows: 1. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON revealed she notified Resident #21's physician and family, DCBS and OIG the day the allegation was made, on 04/01/15. Review of the facility's investigation revealed the notifications were made on 04/01/15. 2. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she interviewed and assessed Resident #21 on 04/01/15 for behavioral and psychosocial concerns. The resident was not tearful and did not express any anxiety. Review of the facility's investigation revealed the Clinical DON interviewed the resident on 04/01/15. 3. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed Resident #21 on 04/02/15. 4. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the alleged CNA was placed on administrative leave on 04/02/15. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed the facility suspended her on 04/02/15. 5. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed the Administrator trained the Clinical DON and Administrative DON, on 04/03/15, on the abuse policy and collecting statements jointly, with verbalized understanding. Review of the training records revealed, on 04/03/15, the Administrator trained the Clinical DON and Administrative DON on the abuse policy and collecting statements jointly. 6. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she developed the investigation checklist, on 04/03/15, to ensure every step had been taken during an investigation. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she had been trained by the Administrative DON on the use of the investigation checklist and completed by either DON. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed he approved the new Investigation Checklist. Review of the Investigation Checklist revealed an effective date of April 2015. 7. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON and, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the Administrative DON revised the Allegation Log to include two (2) sets of signatures for review by nursing administration. The Administrative DON trained the Clinical DON how to use the log. Interview, on 04/09/15 at 5:14 PM, with the Administrator revealed he approved the revised Allegation Log which required both DONs to initial they had reviewed the allegations. Review of the Allegation Log revealed it contained Nursing Administration review and was revised April 2015, and was reviewed by the Clinical DON, Administrative DON, the Clinical Support Services, and Administrative Nursing Assistant. Review of the revised allegation log revealed a place for two (2) signatures were added on 04/03/15. 8. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed other interviewable residents regarding possible issues with care and abuse. Review of the Resident Interviews for Resident #21's investigation, dated 04/08/15, revealed, on 04/07/15, the Administrative DON interviewed fourteen (14) interviewable residents if there were any issues or concerns with staff. No concerns were noted. Interview, on 04/09/15 at 4:25 PM, with the Treatment Nurse revealed she completed skin assessments of eight (8) non-interviewable residents, on 04/08/15, on the 3rd floor. She stated she completed one side of the unit and the Outreach Technician (ORT) nurse completed the other side of the unit with no concerns noted. Review of six (6) skin assessments and two (2) wound assessments revealed skin assessments were completed on 04/08/15. Interview with Resident #4, on 04/01/15 at 10:25 AM; Resident #12, on 03/31/15 at 8:46 AM; Resident #13, on 03/31/15 at 7:47 AM; Resident #15, on 04/01/15 at 10:20 AM; and, Resident #16, on 03/31/15 at 9:30 AM, revealed no concerns with staff interactions with the residents. 9. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed she reviewed facility allegations for the last year, for a total of twenty-five (25) investigations with no concerns noted. Review of a statement by the Administrative DON, dated 04/07/15, revealed twenty-five (25) investigations were reviewed in the last twelve (12) months by the Administrative DON, with no concerns noted. Review of four (4) investigations revealed no regulatory violations for Residents #31, #32, #33 and #34. 10. Interviews on 04/09/15 with a total of fifty (50) employees revealed: seventeen (17) CNAs (CNA #13 at 1:56 PM, CNA #3 at 1:57 PM, CNA #22 at 2:00 PM, CNA #21 at 2:06 PM, CNA #8 at 2:12 PM, CNA #9 at 2:20 PM, CNA #17 at 2:21 PM, CNA #15 at 2:52 PM, CNA #14 at 2:46 PM, CNA #16 at 3:05 PM, CNA #19 at 3:05 PM, CNA #10 at 3:09 PM, CNA #18 at 3:12 PM, CNA #20 at 3:15 PM, CNA #11 at 3:17 PM, CNA #23 at 3:20 PM, CNA #12 at 3:31 PM), six (6) LPNs (LPN #1 at 3:07 PM, LPN #5 at 2:47 PM, LPN #3 at 2:45 PM, LPN #9 at 3:07 PM, LPN #10 at 3:30 PM, LPN #8 at 2:18 PM, RN #4 at 2:09 PM, five (5) Unit Managers (UM/RN #2 at 2:00 PM, UM/RN #3 at 2:27 PM, UM/RN #6 at 3:00 PM, UM #1 at 3:00 PM, UM/RN #7 at 3:35 PM), three (3) housekeepers (Housekeeper #2 at 2:09 PM, Housekeeper #3 at 2:15 PM, Housekeeper #4 at 2:15 PM), a CSR at 2:27 PM, a Dietary Aide at 2:31 PM, Central Supply at 2:51 PM, Rehabilitation Secretary at 2:40 PM, Rehabilitation Director at 2:42 PM, the Nutrition Services Director at 1:58 PM, the Social Services Director at 2:11 PM, the Activities Director at 2:24 PM, RAI Coordinator at 2:34 PM, HR Director at 2:43 PM, Receptionist at 3:02 PM, Compliance Auditor at 3:31 PM, QA Director at 3:45 PM, Rehab Manager at 3:55 PM, Treatment Nurse at 4:25 PM, House Supervisor at 4:33 PM, Clinical DON at 4:48 PM, and the Administrative DON at 5:03 PM revealed they had all received abuse training within the last week; they were aware of the types of abuse; when to report abuse; and, to who to report alleged abuse. Review of the training records revealed three hundred and eleven (311) staff had completed post tests between 04/02/15 and 04/08/15. Interview with the HR Director, on 04/09/15 at 2:43 PM, revealed all staff had been trained on abuse except those staff on vacation or leave. The HR Director stated a sign was posted at the time clock and a letter was mailed to those staff not yet trained, that they must receive training prior to working. Observation, on 04/09/15 at 4:04 PM, of the time clock revealed a sign posted with thirteen (13) staff names to obtain abuse training prior to going to their unit. Review of the letter sent to staff revealed it was dated 04/08/15 from the HR Director that stated staff must receive the abuse training and answer the questionnaire before they started work. Review of the facility's staff roster revealed the letter was mailed to ten (10) employees, who were either sick, on vacation, or leave of absence. 11. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, and the QA Director, on 04/09/15 at 3:45 PM, revealed they would review the Allegation Log for completion and signatures weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. They stated the audits would go to the QA meetings for review. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would conduct audits of the Allegation Log and report the findings to the QA Committee. 12. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor and, on 04/09/15 at 3:45 PM, with the QA Director revealed either would audit the Investigation Checklist weekly for four (4) weeks, monthly for three (3) months, then quarterly for a year with results to QA the Committee. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would audit the Investigation Checklist and report to the QA Committee. Review of the Investigation Checklist revealed an inception date of 04/03/15. 13. Review of the third floor care plan updates revealed, on 04/03/15, the care plan for Resident #21 was updated by the RAI Coordinator. 14. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she reviewed resident behavior and antipsychotic care plans on 04/08/15, and then all residents, checking if the care plan had been updated, initiated, and implemented, with no concerns noted. Review of care plan audits for all six (6) floors, dated 04/07/15 revealed all care plans were reviewed for residents on each floor of the facility with 119 care plans revised. 15. Interview with the Social Services Director, on 04/09/15 at 2:11 PM, the RAI Coordinator, on 04/09/15 at 2:43 PM, with the UM on the 2nd floor (RN #2 on 04/09/15 at 2:00 PM and RN #3 on 04/09/15 at 2:27 PM), the UM on the 3rd floor, on 04/09/15 at 3:00 PM, and the Administrative DON, on 04/09/15 at 5:03 PM, revealed they received care plan training this week and was conducted by the Administrative DON, that included who initiated and updated the care plan, and how to implement the care plan, with verbal competency. Review of the care plan training records revealed care plan training included who initiated and updated the care plan, when the care plan should be revised, and who was responsible to implement the care plan. 16. Interview, on 04/09/15 at 2:00 PM, with UM/RN #2; on 04/09/15 at 2:27 PM, with UM/RN #3; and, on 04/09/15 at 3:00 PM, with UM #1 revealed walking rounds were conducted throughout the shift, but they did not document those rounds. The UMs stated they were observing direct staff to ensure care was provided according to the resident's care plan. Review of care plans revealed Resident #4's care plan was revised on 04/07/15, based on the UM rounds, to reflect the current placement in isolation. 17. Interview with the RAI Coordinator, on 04/09/15 at 2:34 PM, revealed she held a Program of Care meeting on 04/08/15 to review and ensure resident care plans were appropriate. Meetings would be held weekly, with discussion of certain residents each week, with all residents discussed quarterly. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM; the Social Services Director, on 04/09/15 at 2:11 PM; the Activities Director, on 04/09/15 at 2:24 PM, revealed their assistants would attend the Program of Care meetings; however, the Directors would attend in the assistants place when needed, and would discuss resident care plan interventions. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Program of Care meetings would review that resident care plans were up to date, make any needed changes, and interventions were implemented. 18. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor revealed she would audit the Program of Care meetings three (3) times a week for four (4) weeks, three (3) times a month for one (1) quarter, then quarterly and give the results to the DON for the QA Committee. 19. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, revealed she would conduct ten (10) chart audits each month for three (3) months, then quarterly to ensure care plans were updated and interventions performed, with discrepancies corrected by the UM. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Compliance Auditor would complete ten (10) chart audits and ensure the residents' care plans interventions were implemented; the UM would correct any issues immediately. She stated results would be taken to the QA Committee. Review of the Care Plan Monitoring Tool, dated April 2015, revealed it included review of the resident care plan, if the care plan had been updated, observations, concerns, if the care plan was followed, and Assistant UM or UM aware of result. 20. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM, the Social Services Director, on 04/09/15 at 2:11 PM, the Activities Director, on 04/09/15 at 2:24 PM, the HR Director, on 04/09/15 at 2:43 PM, the Compliance Auditor, on 04/09/15 at 3:31 PM, the QA Director, on 04/09/15 at 3:45 PM, the Rehab Manager, on 04/09/15 at 3:55 PM, the Medical Director, on 04/09/15 at 4:07 PM, the Treatment Nurse, on 04/09/15 at 4:25 PM, the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed they attended QA meetings, with three (3) held, and discussed the Immediate Jeopardy (IJ), corrective actions, care plans, new checklists, and training. Review of sign in sheets that included review of the IJ and corrective actions revealed QA meetings were held on 04/03/15, 04/06/15, and 04/08/15. An abbreviated survey conducted 04/28/15 investigating KY and KY determined the facility failed to implement the corrective actions of the AOC dated 04/09/15. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. Review of the newly developed checklist to be utilized by the facility to ensure abuse investigations were completed, (which was an intervention on the AOC) revealed no date when it was completed and only checks on the forms without any additional information provided. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed when she reviewed the newly developed checklist she only looked for the check marks and did not review the content of the investigation. In addition, she stated the audits of the abuse investigation checklist were not taken to the Quality Assurance (QA) meeting on 04/27/15. Interview with the Administrator, on 04/30/15 at 3:45 PM, validated the audits of the checklist and the abuse logs were not discussed at the 04/27/15 QA meeting. Immediate Jeopardy was determined not to be removed on 04/09/15 as alleged. The facility was notified of this finding on 04/30/15. The facility took the following actions to remove the Immediate Jeopardy on 05/06/15 as follows: 1. The Clinical DON made notification on 04/20/15 of the allegation (KY ) to Resident #36's family, physician, OIG and DCBS. The Administrative DON made notification of the allegation of abuse (KY ) to Resident #37's family and Physician on 04/27/15. Notification to the OIG and DCBS was made on 04/28/15. 2. On 04/21/15, a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor with no injuries consistent with abuse noted. Fifty-six (56) skin assessments were completed on non-interviewable residents by Unit Managers, Assistant Managers, and Staff Development Nurse as of 05/04/15. No issues were found. 3. 05/04/15, one hundred thirty (130) residents were interviewed by Social Services, and the RAI Coordinators to ensure there were no unresolved or uninvestigated allegations of abuse. No issues were identified. 4. The abuse allegation checklist was revised on 04/28/15 by the Clinical DON to reflect name, date, and time of actions, with a space for narrative documentation to record all actions taken during the abuse investigation. 5. On 05/01/15, the facility obtained the services of a consultant company to provide assistance with training, policy revision, QA and ongoing oversight and consultation. These consultant employees included Nurses, therapists, and Administrators. The facility's Administrative DONs, Human Resources Director, and Assistant Director of Nurses met with the consultants and revised the abuse policy to reflect procedures for immediate protection of residents by removal of the alleged perpetrator from patient care and reporting immediately allegations of any abuse to the state agencies. All staff would receive training on the new Abuse policy revisions and no staff would work past 05/05/15 without receiving the training. This would include agency staff. 6. On 05/05/15, education was provided by the contracted consultant on requirements for abuse allegation reporting and investigation with competency. No staff would be allowed to work past 05/05/15 without receiving the training. This would include agency staff. As of 05/05/15, two hundred ninety-seven (297) employees had been trained. 7. On 05/04/15, the facility implemented a new Nurses' Abuse Allegation Investigation Protocol. The protocol was a step by step reference for nurses and House Supervisors to be used when a resident alleged abuse. The protocol was posted in visible locations on all nursing units and included in all staff education. (Attachment B) 8. On 05/04/15, a QA meeting was held to review the alleged deficient practice and plans of actions established to correct the practices. The consultant observed the QA meeting. Members present included the Administrator, Consultant, Social Services, Medical Director, DONs and other Department Directors. The Administrator established a weekly QA meeting that included review of the deficiencies cited. 9. On 05/04/15, the Elder Justice Act reporting notification requirements was added to the admission packet. The revised Abuse policy and Elder Justice Act information was placed in a binder at the receptionist desk. 10. On 05/05/15, five (5) random staff and resident interviews would be conducted weekly by Social Services and Nursing Administration to ensure there were no unresolved/investigated abuse allegations and staff understanding of reporting requirements. 11. On 05/04/15, the contracted consultant educated the Administrator and made observations at the facility to ensure the Administrator was administering the facility in accordance with professional standards and per his job description included ensuring a system was in place to protect residents from abuse and neglect. 12. Beginning 05/01/15, a consultant would conduct weekly visits for four weeks then monthly visits to ensure the Administrator followed professional standards and job description ensuring systems remained in place for reporting and investigation of allegations of abuse and neglect per established plan of correction. The Administrator established weekly administrative consultative visits with the consultants. 13. The contract consultant re-educated the Administrator, on 05/04/15, on the requirements of a functional QA process to include delegation of action items for identified concerns including oversight of entire AOC and implementation of systems and follow-up to ensure corrections were made and reviewed with the Interdisciplinary Team (IDT). 14. Beginning 05/04/15 the Human Resources Director would update the Administrator daily of the status of staff training on abuse. 15. On 05/05/15, the Administrator amended the agenda for the daily quality meeting with the IDT, to address deficiencies cited. This included reviewing audits, education, and ongoing monitoring to determined effectiveness of current actions. 16. Weekly QA meetings that began on 05/04/15, was held to review identified concerns regarding any issues with the Plan of Correction and follow-up to ensure corrections were sustained. The meeting would consist of at a minimum the Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and other Department Directors. The contract consultant would observe the QA process monthly, including audit tools (attachment E) for at least three (3) months to ensure Quality Assurance Performance Improvement Committee was functional and meeting the identified needs of the facility. The QA committee would consist of the Administrator, DONs, ADON, Social Services, and the Medical Director attending at least quarterly. When the Medical Director was present, they would review a sample of residents' abuse allegations for effectiveness in the revised processes. The QA meeting would review audits (and take action if needed) related to the deficiencies. Theses audits would include resident interviews and skin audits conducted on 05/04/15 and abuse audits which began on 04/08/15 and are ongoing. The reports would be presented by the Compliance Auditor. The State Survey Agency validated the removal of Immediate Jeopardy on 05/13/15 prior to exit as follows: 1. Review of the clinical record and facility investigation validated the Clinical DON notified Resident #36's family, physician, OIG, and DCBS on 04/20/15. Review of the fax verification revealed the OIG was notified on 04/20/15 at 4:09 PM. Review of the clinical record and facility investigation revealed the Administrative DON notified Resident #37's family and physician on 04/27/15. Review of the faxed verification sheet revealed notification to the OIG on 04/28/15 at 3:11 PM. Review of the Department of Community Based Services (DCBS) intake summary revealed the notification was received on 04/29/15. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed the facility's fax machine was broken on Monday, April 27, 2015 and she failed to provide notification via telephone. 2. Review of facility's investigation revealed a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor on 04/21/15, with no injuries consistent with abuse. Review of the skin assessments conducted by the Unit Managers, Assistant Managers, and Staff Development Nurse through 05/04/15, revealed fifty-three (53) skin assessments were conducted for residents with a BIMS score less than eight (8). 3. Review of the resident interview forms revealed Social Services, and the RAI Coordinators conducted one hundred thirty-three (133) resident interviews by 05/04/15. No resident alleged abuse. The interview form included a questionnaire for staff to determine if the resident had any mood or behavioral changes. None was noted. 4. Interview with the Clinical DON, on 05/13/15 at 4:20 PM, revealed the abuse checklist was revised to give more details to ensure the investigation was conducted and timely. In addition, the Compliance Auditor would be able to determine if the investigation was completed timely and according to the facility's Abuse policy. Review of the checklist for the abuse investigation for Residents #37, 38, 39, 40, 41, 42, and #43 revealed the abuse checklist was completed with details of notification (including the state agencies), protection of the resident, resident and staff interviews, meeting with DONs and Administrator, and when copy of the checklist was sent to the QA committee. Residents #38, 39, 40, 41, 42, and 43 was completed after the facility was notified of the Immediate Jeopardy. 5. Interview with the Administrator, on 05/13/15 at 6:20 PM, revealed a consultant services was obtained on 05/01/15. The consultants had been at the facility providing abuse education to staff and assistance with development of the AOC, and QA guidance. The consultants were at the facility on 05/01/15, 05/04/15, 05/12/15 and 05/13/15. They are scheduled to be at the facility on 05/21/15 and 05/26/15. He stated the Abuse policy was revised on 05/04/15 with input from the consultant services. Review on 05/13/15, of the revised Abuse policy, revealed language changes in how the residents would be protected included the employee suspected of abuse would be removed from the unit and patient care immediately. The House Supervisor or Nursing Administration would assure the employee clocked out and left the facility. Employees who witnessed potential abuse are instructed to immediately intervene to protect the resident, the alleged perpetrator should not be left alone with the resident. All employees were required to immediately report any observations, suspicion, or information of suspected or actual abuse, neglect, or misappropriation of property to the House Supervisor. House Supervisor or Nursing Administration would report all allegations of abuse or neglect to DCBS, Police, and OIG immediately. Four (4) abuse investigations were reviewed on 05/13/15 for Residents #40, 41, 42 and #43 and validated the facility used the abuse investigation checklist and the QA investigation tool. Based on residents' interviews, record review, and review of the facility's investigation, no problems were found with these abuse investigations. Review of the training records revealed all working staff had been trained on the new abuse policy. Observations on 05/13/15 of the second, third, fourth, fi

2 Based on interview, record review, review of the facility's policy and the facility's investigations, it was determined the facility failed to have an effective system to protect residents from potential abuse after allegations of abuse were reported to staff for three (3) of forty-three (43) sampled residents (Resident #21, Resident #36 and Resident #37). On 04/01/15, the facility received an allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #21. The allegation stated the CNA was harsh in speaking to the resident and when the resident requested to be repositioned the CNA stated she had just repositioned the resident fifteen (15) minutes ago; she would not do it again; and, left the room. The resident stated although he/she was hurting badly; he/she did not want to call the CNA again. The resident further alleged if the call light was turned on and the CNA answered, he/she would tell her it was an accident because he/she was afraid of the CNA. The resident was unable to provide staff with the CNA's name; however, the resident provided a description of the alleged perpetrator to the facility. The facility identified the CNA based on the description; however, the facility allowed the alleged perpetrator to continue to work with Resident #21 on 04/01/15 during the night shift. Immediate Jeopardy was identified on 04/03/15 and determined to exist on 04/01/15 related to Resident #21. The facility provided an acceptable Allegation of Compliance (AOC) on 04/09/15, which alleged removal of the Immediate Jeopardy on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 it was determined the IJ had not been removed as alleged, on 04/09/15. Per the facility's AOC, dated 04/09/15, when an allegation of abuse was reported the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. The AOC stated all staff would be trained by 04/08/15 on the facility's Abuse policy and the Clinical and Administrative Director of Nursing (DONs) were trained on the policy by the Administrator on 04/03/15. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit the revised abuse allegation logs and new abuse allegation checklist weekly and the results of the audits would be brought to the QA committee. It was determined the facility failed to implement these components of the AOC after the facility self reported two more (2) abuse allegations. On 04/19/15, at approximately 9:30 AM, the facility received a second allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #36. The allegation stated the CNA was mean and rude and threw the bed covers over the resident's head. The resident identified the alleged perpetrator by name. License Practical Nurse (LPN) #9 pulled the CNA from the resident's care, interviewed her, and then allowed the CNA to return to work caring for other residents on that unit. The alleged perpetrator cared for other residents until 11:00 AM, when the House Supervisor suspended her. On 04/26/15, the facility received a third allegation of abuse involving Outreach Technician (ORT) Restorative Aide #1 that alleged ORT Restorative Aide #1 kissed Resident #37 on the lips. CNA #24 stated he had witnessed this incident at 1:00 PM; however, he did not report what he had witnessed to the nurse. The ORT Restorative Aide continued to provide care for at least forty (40) other residents after the incident with Resident #37. The incident was not reported to the House Supervisor until 4:50 PM by LPN #10; at which time ORT Restorative Aide #1 had already left for the day. In addition, the facility failed to report the alleged sexual abuse to the State Survey Agency until 04/28/15 at 3:10 PM, approximately two (2) days after the incident. The facility's failure to protect residents from potential abuse after an allegation of abuse was reported to staff has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable AOC on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The SSA verified Immediate Jeopardy was removed on 05/06/15 as alleged, prior to exit on 05/13/15 with the Scope and Severity lowered to a D while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place them on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to Adult Protective Services (APS) and the Office of Inspector General (OIG). However, the policy did not state who was delegated the authority to place an employee on administrative leave. 1. Review of the clinical record for Resident #21 revealed the facility admitted the resident on 03/10/15, with [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) on 03/14/15, and assessed the resident using the Brief Interview for Mental Status (BIMS) assessment with a score of fifteen (15) out of fifteen (15), which meant the resident was interviewable. Additionally, the facility assessed Resident #21 as requiring extensive assistance with bed mobility and transfer, which both tasks required two (2) person physical assistance; and, the resident utilized a wheelchair (w/c). Further review revealed the facility completed a Comprehensive Care Plan for Resident #21, on 03/18/15, that stated the goal was to alleviate the resident's distress, and it directed staff to always assess and incorporate non-pharmacological interventions to alleviate bed discomfort and to answer the call light in a timely manner. The Care Plan further instructed staff to reposition the resident every two (2) hours, or per the current turning schedule. In addition, the staff was to maintain the resident's comfort level. Review of Resident #21's clinical record revealed a Nurse's Note, dated 03/11/15 at 10:27 PM, that stated Resident #21 was alert and oriented times three and had left sided paralysis; was assisted with positioning; had an unequal hand grasp ability; and, was able to move the fingers of his/her left hand. However, he/she was unable to reposition the total extremity. Further review revealed a Nurse's Note, dated 03/18/15 at 1:45 PM, which stated the resident continued to receive the maximum assistance with his/her activities of daily living (ADLs) and transfers. Review of Nurse's Notes, dated 03/23/15 at 1:45 AM, revealed Resident #21 was frequently awake on the 11:00 PM to 7:00 AM shift. The resident was beginning to have sensation in his/her left lower extremity. Interview with Licensed Practical Nurse (LPN) #6, Resident #21's routine nurse, on 04/08/15 at 8:36 AM, revealed Resident #21 was awake some nights and was able to use his/her right side more than the left side of his/her body. The nurse stated the resident would moan and say he/she was stiff. Review of the facility's investigation, dated 04/01/15, revealed Unit Manager (UM) #1 spoke with Resident #21 and received an allegation that the resident asked a night shift CNA to reposition him/her. The resident stated the aide refused and he/she was afraid of the aide because she was rough with him/her. At approximately 12:50 PM on 04/01/15, the Clinical Director of Nursing (DON) was made aware of the allegation made by Resident #21 that he/she expressed fear and that the CNA spoke harshly to him/her. Further review of the investigation revealed the resident stated the incident occurred late last week, but he/she could not be specific regarding the date or time. Additionally, the facility's investigation revealed the alleged CNA in question was allowed to continue to work with Resident #21 after the allegation was made to the facility. The investigation further stated at approximately 1:05 PM on 04/01/15, the Clinical DON spoke with Resident #21, who reported that late last week he/she had leg pain and put on his/her call light to request someone to reposition him/her. The resident stated the CNA, who responded to the call light, was harsh in speaking to him/her and said she had just repositioned the resident fifteen (15) minutes ago and left the room. Additionally, the resident stated he/she was hurting badly; however, he/she did not want to call the staff member again as he/she did not know how the CNA would react. Resident #21 stated he/she was afraid of the CNA. Approximately ten (10) minutes later, the Clinical DON and the Assistant Director of Nursing (ADON) spoke with Resident #21 and received a physical description of the CNA that spoke harshly to him/her. UM #1 identified CNA #5 as the alleged perpetrator based on the description given by Resident #21. The Assistant Director of Nursing (ADON) unsuccessfully attempted to call CNA #5 on 04/01/15, at 3:15 PM. There was no documented evidence the facility removed CNA #5 from direct resident care. Further review of the facility's investigation, initiated on 04/01/15, revealed the ADON did not obtain CNA #5's statement until the end of her shift on 04/02/15 at 7:30 AM. Interview with the Clinical DON on 04/02/15 at 11:57 AM, revealed the facility unsubstantiated the allegation of abuse, on 04/06/15 because the resident could not determine when the alleged abuse occurred and with no positive identification, the alleged perpetrator denied the allegation. Per the Clinical DON, additional interviews with the resident revealed the resident was not afraid of the CNA and the CNA had taken care of the resident many times before without any problems. Review of the facility's staffing worksheets and CNA #5's time card, from 03/23/15 through 04/01/15, revealed CNA #5 worked the 11:00 PM to 7:00 AM schedule on the same unit that Resident #21 resided. She worked on 03/23/15, 03/24/15, 03/25/15, 03/26/15, 03/28/15, 03/29/15, 03/30/15, and on 04/01/15. Review of the Daily Assignment Sheets revealed CNA #5 was assigned to care for Resident #21 on 03/24/15, 03/25/15, 03/26/15, and on 04/01/15. Review of the facility's call light log revealed Resident #21's call light was activated between the hours of 11:00 PM and 7:00 AM on 03/24/15, 03/26/15, and on 04/01/15 while CNA #5 was assigned to care for the resident. Interview with Resident #21, on 04/01/15 at 2:45 PM, revealed he/she reported an incident today (04/01/15) that had occurred in the last week with a CNA. The resident stated he/she used the call light due to pain in his/her leg and he/she needed to be repositioned. Resident #21 also stated he/she was unable to get his/her leg comfortable and could not turn himself/herself. The resident stated a CNA came to the room, and stated harshly that she had just repositioned him/her fifteen (15) minutes ago and left the room. The resident further stated he/she felt intimidated and scared of the CNA and would not use the call light the rest of the night. Additionally, the resident stated he/she had seen the CNA since the night of the allegation, and if this particular CNA responded to his/her call light, the resident would say it was an accident. Resident #21 stated he/she was scared to report the incident; however, he/she was concerned the CNA may be treating other residents in the same way. The resident stated he/she reported the incident, on 04/01/15, to the Assistant Unit Manager (UM). Continued interview with Resident #21, on 04/02/15 at 9:02 AM, revealed the CNA had provided care to the resident after the incident was reported to staff the same night, on 04/01/15. The resident stated although he/she had not seen the CNA's badge, he/she knew the CNA's name began with the letter R. The resident then gave a description of the CNA that matched the description reported to UM #1 on 04/01/15. Interview, on 04/02/15 at 9:26 AM, with the Assistant UM revealed he received an allegation from Resident #21 on 04/01/15. He stated the resident reported he/she was in pain last week, used the call light and asked to be repositioned. The Assistant UM stated the resident also reported that the CNA who responded to his/her call light, told him/her that she had just repositioned him/her and she would not do it again. He further stated the resident told him, he/she used the call light again and when the same CNA responded, he/she told the CNA the call light was an accident. He stated Resident #21 gave a description of the CNA. The Assistant UM stated CNA #5 was the only person he was aware of that matched the resident's description of the CNA. The Assistant UM stated CNA #5 worked the night shift on 04/01/15. He further stated he reported Resident #21's allegation to the UM #1 immediately. Interview, on 04/02/15 at 12:20 PM, with Unit Manager (UM) #1 revealed she received a report, on 04/01/15 around 12:50 PM to 1:00 PM from the Assistant UM of the allegation regarding Resident #21. She stated she spoke with Resident #21 at that time and the resident reported that in the last week he/she could not get his/her leg comfortable and asked to be turned. UM #1 stated the resident reported he/she was told by the CNA that she had just turned him/her about fifteen (15) minutes ago and was not going to turn him/her again. The resident stated that he/she felt intimidated and gave a description of the CNA. The UM stated CNA #5 was the only CNA she was aware of who matched the description given by Resident #21. She further stated after she spoke to Resident #21, she reported the allegation to the Clinical DON and provided the Clinical DON the name of CNA #5 as the person she (the UM) was aware of that matched the description provided by Resident #21. UM #1 stated CNA #5 worked the night of 04/01/15, which began at 11:00 PM. Further interview with the UM, on 04/03/15 at 9:08 AM, revealed she did not have the authority to place staff on administrative leave; however, continued interview revealed the DONs, ADON, ADM, and House Supervisor had the authority to place staff on administrative leave. The resident reported the allegation of abuse during the dayshift when the DONs were present in the building. Per interview, the allegation was reported to them appropriately, but the Clinical DON delayed in suspending the CNA because the resident could not determine when the allegation occurred and could not give a name. Review of the Abuse Policy revealed it did not state who had the authority to place an employee on administrative leave. Interview, on 04/01/15 at 2:07 PM, with the Clinical DON, regarding the allegation, revealed the facility received an allegation from Resident #21. She stated the resident reported, on 04/01/15, that he/she had leg pain during the last week and had been using the call light for pain medication and assistance with positioning. The Clinical DON further stated the resident reported the CNA spoke harshly, and told him/her that she had repositioned the resident fifteen (15) minutes ago and walked out of the resident's room. She stated the resident gave a description of the CNA and stated he/she was afraid of that CNA. Continued interview on 04/02/15, at 12:37 PM revealed the Clinical DON and the ADON spoke to the resident again, about ten (10) minutes later for a description of the CNA. She stated CNA #5 matched the description given by the resident, and was the only CNA she was aware of that met that description. However, even with this knowledge, the Clinical DON failed to remove CNA #5 from direct resident care. Continued interview with the Clinical DON on 04/02/15 at 12:37 PM, revealed CNA #5 worked the night of 04/01/15 and was scheduled to work again on 04/02/15. She stated when there was an allegation against a staff member the alleged perpetrator would be placed on administrative leave. However, interview and record review revealed CNA #5 was allowed to continue to work the shift and worked the next scheduled shift before being suspended on 04/02/15. Interview with the Clinical DON, on 04/02/15 at 1:27 PM, revealed the purpose of protecting a resident during an investigation was to keep the incident from happening again. She stated Resident #21 had been protected as the facility was extra vigilant to make sure the resident was okay; however, she would not give an explanation of what vigilant meant. The Clinical DON further stated she did not suspect any staff member had done anything to Resident #21. She stated a staff member would be placed on administrative leave immediately if the facility suspected the individual of abuse. During this interview, she stated that she, the Administrative DON, ADON, Administrator, or Human Resources (HR) could decide if an employee would be placed on administrative leave. The Clinical DON stated CNA #5 had not been placed on administrative leave as the facility did not suspect she had done any harm to Resident #21. She stated the CNA had worked with the resident before the allegation and after the allegation was made and the resident had not voiced any additional complaints about the CNA since the allegation was made on 04/01/15. The Clinical DON further stated Resident #21 had a psychiatric history, and she did not believe the CNA did what Resident #21 alleged. Interview, on 04/02/15 at 2:58 PM, with the Clinical DON revealed CNA #5 was not suspected of abuse. She stated she spoke with the Assistant UM and UM #1 on 04/01/15. She stated when she received the allegation from UM #1, the UM did not say if any staff matched the description the resident had provided and she (the Clinical DON) did not ask. The Clinical DON stated Resident #21 gave a description of the CNA; however, she did not follow-up with the Assistant UM or UM #1 to determine if anyone matched that description. Interview, on 04/02/15 at 12:54 PM, with the ADON revealed she was aware on 04/01/15, during the afternoon, of the allegation related to Resident #21. The ADON further stated she spoke with Resident #21 on 04/01/15, who reported the CNA seemed irritated when he/she used the call light to be repositioned. She stated the ADON gave a description of the CNA and she was aware of only one (1) CNA that worked on that unit that matched the description given by Resident #21; that was CNA #5. However, even with this knowledge, the ADON failed to remove CNA #5 from direct resident care, as per policy, to protect the residents. Continued interview with the ADON on 04/02/15 at 12:54 PM, revealed she spoke with CNA #5, on 04/02/15 at 7:30 AM, after she (CNA #5) worked the night shift on 04/01/15. The ADON further stated when the facility received an allegation of abuse against a staff member, the staff would be placed on administrative leave until the investigation was completed to protect the residents. She stated the purpose of the investigation was to determine if staff should be working in the facility. She stated CNA #5 had not been placed on administrative leave at that time. The ADON stated the Clinical DON was responsible to determine if a staff member should be placed on administrative leave. She further stated the Clinical DON was responsible to conduct the investigation; however, she (the ADON) would assist. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed she worked the night shift, at 11:00 PM, and always worked with Resident #21. She stated the resident would voice complaints of his/her leg hurting, because the resident's left leg was paralyzed. The CNA stated the resident would say he/she had laid on that side too long. She further stated Resident #21 was turned and repositioned every two (2) hours, and the resident would often ask to be repositioned again. CNA #5 stated she could not recall an incident with Resident #21. She further stated the ADON was at the facility and had waited for her to come to work on the 11:00 PM shift. The ADON did not talk with her until 7:30 AM after the shift was over on 04/02/15. However, she was not placed on administrative leave until around 10:53 PM last night (04/02/15) before the shift started. Review of the staffing sheets revealed CNA #5 was assigned to care for Resident #21 on 04/02/15. Interview, on 04/02/15 at 2:20 PM, with the Administrative DON revealed the Clinical DON was responsible for the investigation, with the ADON's assistance. She stated residents were protected during an investigation as the staff member would not be allowed back to work with the residents and would be placed on administrative leave, pending the outcome of the investigation. Further interview revealed the Administrative DON was not aware CNA #5 was identified as the alleged perpetrator at the time the allegation was reported. She stated the facility could not place everyone on leave when an alleged perpetrator was not identified. She further stated she was not involved in the investigation, and had not spoken to the Assistant UM or UM #1, but she knew they were aware of the allegation. Further interview revealed CNA #5 had worked last night (04/01/15) after the allegation was reported. The Administrative DON stated she was unsure of the reason why CNA #5 had not been placed on administrative leave if staff knew she was the alleged perpetrator. She further stated if a staff member was not placed on administrative leave, the resident would feel intimidation if the same staff member worked with him/her. Interview with the Administrator, on 04/02/15 at 3:35 PM, revealed he knew about the allegation on 04/01/15, but was unaware that the staff knew the name of the alleged perpetrator. Per interview, until the facility determined who the perpetrator was, it was not possible to suspend the entire staff; however, if there was a positive identification of a staff member, that person would be removed immediately. The Administrator stated he assumed the Clinical DON spoke to the Assistant UM and UM #1 on 04/01/15. He further stated he was not aware only one staff member matched the description given by Resident #21 and he was not aware at the time the allegation was made that the Assistant Unit Manager knew the alleged perpetrator was CNA #5. The Administrator stated the purpose of the investigation was to prevent abuse from occurring and prevent a staff member, who had an allegation voiced against them from working with the resident or working in general. He stated if a staff member was not placed on administrative leave, at a minimum, the staff member might be intimidating to a resident. Continued interview with the Administrator, on 04/02/15 at 3:35 PM, revealed he spoke with Resident #21 today (04/02/15) and the resident told him he/she was uncomfortable and in pain and had used the call light several times to be repositioned (referring to the date of the incident). The Administrator stated the resident told him that the CNA said she had just been there fifteen (15) minutes ago. He stated the resident also told him he/she felt afraid and intimidated. He/She did not use the call light any more that night. He also stated the resident told him the aide worked last night (04/01/15). Further interview with the Administrator, on 04/03/15 at 9:30 AM, revealed he had determined the night before on 04/02/15, that the Clinical DON had been informed of a staff member that matched the description given by Resident #21 on 04/01/15. He stated CNA #5 had been suspended the evening of 04/02/15 by the Clinical DON. 2. Review of the clinical record revealed the facility admitted Resident #36 on 06/02/13. The resident's [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set (MDS) assessment, (a quarterly) dated 02/23/15, revealed the facility assessed the resident using the Brief Interview for Mental Status (BIMS) to have a score of ten (10) out of fifteen (15), which meant the resident had some cognition impairment but was still considered to be interviewable. Additionally, the facility assessed Resident #36 as requiring extensive assistance with bed mobility and transfer, requiring two (2) person physical assistance; the resident was non-ambulatory utilizing a wheelchair. Further review revealed the facility assessed the resident to be occasionally incontinent of bladder and required the extensive assist from staff with toileting needs. Review of the Comprehensive Care Plan dated 06/14/13, revealed the resident had short/long term memory problems and the goal was for the resident to continue to interact with others and participate in care daily. The care plan instructed staff to approach the resident warmly and positively and in a calm manner. Review of the facility's investigation, initiated on 04/20/15, revealed the Certified Medication Technician (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over his/her head and the aide was mean and rude to the resident. The investigation did not specify the definition of mean and rude. The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22. The documented interview with LPN #9 stated CNA #22 switched residents with another aide and was allowed to work with other residents after the abuse allegation was received. The investigation revealed the Clinical DON was notified of the abuse allegation, on 04/19/15 at approximately 10:00 AM. Further review of the abuse investigation revealed Resident #36 was interviewed by the Clinical DON, on 04/20/15 at 3:00 PM. At this time, the resident again reported to staff that the aide threw the bed covers over his/her head and said something the resident didn't like. The Clinical DON interviewed CNA #22 at 3:13 PM via telephone, where she denied the allegation. However, the Clinical DON failed to interview the House Supervisor to determine when the aide was suspended and did not interview further to determine that CNA #22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment of [REDACTED]. The report indicated the aide had been placed on administrative leave at the time of the allegation. However, review of the facility's time card report revealed CNA #22 continued to work after the allegation was reported. Review of the facility's staffing worksheets and CNA #22's time card, for 04/19/15, revealed CNA #22 worked 7:00 AM to 11:00 AM on the unit where Resident #36 resided. Resident #36 reported the allegation of abuse at approximately 9:30 AM. Interview with Resident #36, on 04/28/15 at 12:46 PM, revealed he/she could not recall any incident where a facility staff was rough or mean. The resident stated he/she did not recall any incident where staff had pulled the bed covers over his/her head. A family member was present during the interview and stated the resident's memory was not always good but the resident had reported to the family someone had pulled a sheet over his/her head. The resident had told the family member he/she had not seen that aide again. The family member stated the facility had not interviewed her regarding any knowledge of the incident. Further interview with the family member revealed the resident appeared to be more upset since the incident, whereas the resident was calm before; however, she did not think the resident was afraid of anyone. Interview, on 04/28/15 at 3:29 PM, with CMT #2 who received the allegation of abuse from Resident #36, revealed she was passing medications on 04/19/15 sometime between 9:00 AM-10:00 AM. When she took Resident #36's medications into the room, the resident told her CNA #22 was mean and rude and had pulled the bed covers over the resident's head. The resident told her the aide appeared to be angry. The CMT reported the allegation to LPN #9. She returned to the resident's room with LPN #9 and the resident told her the same story; the aide was mean and rude and had pulled the covers over his/her head. Interview with CMT #3, on 04/28/15 at 3:20 PM, revealed she was working the other side of the unit when CMT #2 came to her and reported there was a problem. She stated it was a few hours into the day shift (7 AM-3 PM). She said CMT #2 reported Resident #36 told her CNA #22 had been rude and mean to him/her and threw the covers over the resident's head. CMT #3 did not specify what the resident meant by rude and mean. CMT #2 told her the aides would have to switch teams, but before they could do that, LPN #9 came onto the floor. She went with CMT#2 and LPN #9 to interview Resident #36. When LPN #9 asked the resident what happened, the resident told them CNA #22 had been rude and threw the covers over his/her head. She stated the House Supervisor was notified then came to the floor and told CNA #22 she had to leave. This was before lunch. She thought the House Supervisor started the investigation. A telephone interview with LPN #9, on 04/29/15 at 9:42 AM, revealed she had worked on 04/19/15 as the LPN Supervisor for the sixth and seventh floors. She stated when she came to the seventh floor, CMT #2 reported what the resident had told her during the medication pass. She then went into Resident #36's room with CMT#2 and CMT #3 to interview the resident. The resident told them the same story that CNA #22 was mean and rude and pulled the covers over his/her head. In addition, the resident told them the aide refused to get him/her a tissue. She stated she then went and found CNA #22 in another resident's room providing care. That was between 9:00 AM-10:00 AM. She took the aide to the nurse's station and interviewed her. She obtained a written statement then she told the aide not to go back into Resident #36's room. She said she reassigned Resident #36's care to CNA #23; however, CNA #22 continued to care for all the other residents that were assigned to her that day. She stated she notified the House Supervisor of the incident and when she came onto the floor, she told CNA #22 she had to clock out and go home. She said the aide provided care to other residents until then because she did not have the authority to suspend any staff. Review of the Abuse Policy revealed it did not state who had authority to suspend an employee during an investigation. Telephone interview with CNA #23, on 04/29/15 at 10:58 AM, revealed around 10:00 AM on 04/19/15, she was told by LPN #9 she had to take over the care of Resident #36. She stated LPN #9 told her there had been an allegation against CNA #22 and she could no longer care for that resident. She stated the aide (CNA #22) provided care to other residents assigned to her until the House Supervisor came onto the floor and told her to go home. She stated it was about an hour from when she was told to care for Resident #36 and when the aide was sent home. Telephone interview with the House Supervisor, on 04/29/15 at 11:12 AM, revealed she received a report from LPN #9 that Resident #36 alleged CNA #22 was rude and unprofessional and threw the covers over the resident's head. She said LPN #9 reported the aide denied the allegation. She text the Clinical DON and informed her of the allegation. She said she went to the unit and told the aide she had to go home. She did not watch the aide clock out. She stated LPN #9 had interviewed the aide and obtained a written statement. Therefore, she did not interview the aide again and did not interview the resident. She stated she had not interviewed any staff. She stated she was not aware of any change in assignments and was not aware the aide had cared for other residents after the abu

2 Based on interview, record review, and review of the facility's policy, investigations, and the acceptable Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to have an effective system in place to ensure staff followed its policy for the protection of residents during abuse investigations for three (3) of forty-three (43) sampled residents (Resident #21, Resident #36, and Resident #37). (Refer to F225) On 04/01/15, the facility received an allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #21. The allegation stated the CNA was harsh in speaking to the resident and when the resident requested to be repositioned the CNA stated she had just repositioned the resident fifteen (15) minutes ago; she would not do it again; and, left the room. The resident stated although he/she was hurting badly; he/she did not want to call the CNA again. The resident further alleged if the call light was turned on and the CNA answered, he/she would tell her it was an accident because he/she was afraid of the CNA. The resident was unable to provide staff with the CNA's name; however, the resident provided a description of the alleged perpetrator to the facility. The facility identified the CNA based on the description; however, the facility allowed the alleged perpetrator to continue to work with Resident #21 on 04/01/15 during the night shift. Immediate Jeopardy was identified on 04/03/15 and determined to exist on 04/01/15 related to Resident #21. The facility provided an acceptable Allegation of Compliance (AOC) on 04/09/15, which alleged removal of the Immediate Jeopardy on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 it was determined the IJ had not been removed as alleged, on 04/09/15. Per the facility's AOC, dated 04/09/15, when an allegation of abuse was reported the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. The AOC stated all staff would be trained by 04/08/15 on the facility's Abuse policy and the Clinical and Administrative Director of Nursing (DONs) were trained on the policy by the Administrator on 04/03/15. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit the revised abuse allegation logs and new abuse allegation checklist weekly and the results of the audits would be brought to the QA committee. It was determined the facility failed to implement these components of the AOC after the facility self reported two more (2) abuse allegations. On 04/19/15, at approximately 9:30 AM, the facility received a second allegation of abuse involving a Certified Nursing Assistant (CNA) towards Resident #36. The allegation stated the CNA was mean and rude and threw the bed covers over the resident's head. The resident identified the alleged perpetrator by name. License Practical Nurse (LPN) #9 pulled the CNA from the resident's care, interviewed her, and then allowed the CNA to return to work caring for other residents on that unit. The alleged perpetrator cared for other residents until 11:00 AM, when the House Supervisor suspended her. On 04/26/15, the facility received a third allegation of abuse involving Outreach Technician (ORT) Restorative Aide #1 that alleged ORT Restorative Aide #1 kissed Resident #37 on the lips. CNA #24 stated he had witnessed this incident at 1:00 PM; however, he did not report what he had witnessed to the nurse. The ORT Restorative Aide continued to provide care for at least forty (40) other residents after the incident with Resident #37. The incident was not reported to the House Supervisor until 4:50 PM by LPN #10; at which time ORT Restorative Aide #1 had already left for the day. In addition, the facility failed to report the alleged sexual abuse to the State Survey Agency until 04/28/15 at 3:10 PM, approximately two (2) days after the incident. The facility's failure to protect residents from potential abuse after an allegation of abuse was reported to staff has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable AOC on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The SSA verified Immediate Jeopardy was removed on 05/06/15 as alleged, prior to exit on 05/13/15 with the Scope and Severity lowered to a D while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to Adult Protective Services (APS) and the Office of Inspector General (OIG). However, the policy did not state who was designated with the authority to suspend an employee during an investigation. 1. Review of the facility's investigation, dated 04/01/15, revealed Unit Manager (UM) #1 spoke with Resident #21 and received an allegation that the resident asked a night shift CNA to reposition him/her. The resident stated the aide refused and he/she was afraid of the aide because she was rough with him/her. At approximately 12:50 PM on 04/01/15, the Clinical Director of Nursing (DON) was made aware of the allegation made by Resident #21 (the resident expressed fear of the CNA and that the CNA spoke harshly). The resident stated the incident occurred late last week, but he/she could not be specific regarding the date or time. Additionally, the facility's investigation revealed the alleged CNA in question was allowed to continue to work with Resident #21 after the allegation was made. The investigation further stated at approximately 1:05 PM on 04/01/15, the Clinical DON spoke with Resident #21, who reported that late last week he/she had leg pain and put on his/her call light to request someone to reposition him/her. The resident stated the CNA who responded to the call light was harsh in speaking to him/her and told him/her that she had just repositioned the resident fifteen (15) minutes ago and left the room. Additionally, the resident stated he/she was hurting badly; however, he/she did not want to call the staff member again as he/she did not know how the CNA would react. Resident #21 stated he/she was afraid of the CNA. Approximately ten (10) minutes later, the Clinical DON and the Assistant Director of Nursing (ADON) spoke with Resident #21 and received a physical description of the CNA. UM #1 identified CNA #5, as the alleged perpetrator based on the description given by Resident #21. The Assistant Director of Nursing (ADON) attempted to call CNA #5 on 04/01/15, at 3:15 PM; however, the ADON was not able to speak to CNA #5 to obtain her statement. Review of the investigation revealed no documented evidence the facility removed CNA #5 from direct resident care. Review of the time card report revealed CNA #5 continued to work the shift and worked the next scheduled shift. Although the Abuse policy stated the employee would be suspended immediately. Further review of the facility's investigation, initiated on 04/01/15, revealed the ADON didn't obtain CNA 5's statement until the end of her shift on 04/02/15 at 7:30 AM. Interview with CNA #5, on 04/04/15, revealed Resident #21 apologized when he/she used his/her call light. However, review of the facility's investigation revealed a statement was not obtained from the Assistant UM, who initially received the allegation and there were no other statements obtained from the UM when the allegation was initially reported. The facility unsubstantiated the allegation of abuse, on 04/06/15. Interview with Resident #21, on 04/01/15 at 2:45 PM, revealed he/she reported an incident today (04/01/15) that had occurred in the last week with a CNA. The resident stated the call light was turned on due to pain in his/her leg and the need to be repositioned. The resident stated a CNA came to the room, and stated harshly that she had just repositioned him/her fifteen (15) minutes ago and left the room. The resident further stated he/she felt intimidated and scared of that CNA and would not use the call light the rest of the night. Additionally, the resident stated he/she had seen the CNA since the night of the incident, and if this particular CNA would respond to the call light, he/she (the resident) would say it was an accident. Resident #21 stated he/she was scared to report the incident; however, he/she was concerned the CNA may be treating other residents the same way. The resident reported the allegation on 04/01/15 to the Assistant Unit Manager (UM). Continued interview with Resident #21, on 04/02/15 at 9:02 AM, revealed he/she saw the CNA the previous night, on 04/01/15. Review of CNA #5's time card revealed the CNA worked the 11:00 PM to 7:00 AM shift on 04/01/15. Review of the staffing worksheets and the Daily Assignment Sheets, revealed CNA #5 worked on the same unit Resident #21 resided and was also assigned to care for Resident #21 on 04/01/15 (after the allegation was made). In addition, review of the facility's call light log revealed Resident #21's call light was activated between the hours of 11:00 PM and 7:00 AM on 04/01/15. Interview, on 04/02/15 at 9:26 AM, with the Assistant UM revealed he received a complaint from Resident #21 on 04/01/15 that a CNA would not reposition him/her when he /she was in pain. He stated Resident #21 gave a description of the CNA. Per interview, CNA #5 was the only person he was aware of that matched the description given by Resident #21. The Assistant UM stated he reported Resident #21's allegation to UM #1 immediately. The Assistant UM stated CNA #5 continued to work the night shift on 04/01/15, after the resident had reported the allegation. On 04/02/15 at 12:20 PM, interview with UM #1 revealed she received a report from the Assistant UM, on 04/01/15 around 12:50 PM to 1:00 PM, of an allegation regarding Resident #21. She stated she spoke with Resident #21 and the resident reported the allegation to her. UM #1 stated he/she felt intimidated and gave a description of the CNA. The UM stated CNA #5 was the only CNA she was aware of who matched the description given by Resident #21. She further stated after she spoke to Resident #21, she reported the allegation to the Clinical DON on 04/01/15, and gave the Clinical DON the name of CNA #5 as the person she (the UM) was aware of that matched the description provided by the resident. Per interview, CNA #5 was not placed on administrative leave, per the facility's policy, and worked the night of 04/01/15, which began at 11:00 PM. Interview, on 04/01/15 at 2:07 PM; and, on 04/02/15 at 12:37 PM, with the Clinical DON revealed the facility received an allegation from Resident #21. She spoke to Resident #21 on 04/01/15 around 1:00 PM and the resident reported a CNA was rude and spoke harshly to him/her during the night and felt the CNA did not want to reposition him/her. The Clinical DON stated Resident #21 reported he/she was afraid of the CNA. Further interview with the Clinical DON revealed she and the ADON spoke to the resident again, about ten (10) minutes later for a description of the CNA. She stated CNA #5 matched the description given by the resident, and was the only staff member she was aware of that met that description. She stated when there was an allegation against a staff member the alleged perpetrator would be placed on administrative leave, as per policy. However, per interview and record review, CNA #5 was not removed from resident care per the facility's policy. Further interview with the Clinical DON revealed CNA #5 worked the night of 04/01/15 (11 PM-7 AM) and was also scheduled to work the night of 04/02/15. Interview, on 04/01/15 at 12:54 PM, with the ADON revealed she was made aware on 04/01/15, during the afternoon, of the allegation related to Resident #21. She stated the Clinical DON was responsible to conduct the investigation; however, she (the ADON) was assisting her in the investigation. The ADON further stated she spoke with Resident #21 on 04/01/15, who reported the CNA seemed irritated when she used the call light to be repositioned, and gave a description of the CNA. She stated she was aware of only one (1) CNA that worked on that unit and matched the description given by Resident #21. The ADON further stated when the facility received an allegation of abuse against a staff member, that staff member would be placed on administrative leave until the investigation was completed to protect the resident. The ADON stated the Clinical DON was responsible to determine if a staff member should be placed on administrative leave. She further stated CNA #5 had not been placed on administrative, even though the facility's policy stated the facility would protect residents and/or anyone reporting abuse by placing any employee who was investigated for abuse on administrative leave or be reassigned during the investigation. Continued interview with the Clinical DON, on 04/02/15 at 1:27 PM, revealed she, the Administrative DON, ADON, Administrator, or Human Resources (HR) could decide if an employee would be placed on administrative leave. The Clinical DON stated CNA #5 had not be placed on administrative leave after the allegation was reported because she did not suspect the CNA had done any harm to Resident #21. Per interview, Resident #21 had a psychiatric history, and she did not believe the CNA did what Resident #21 alleged. She further stated if a staff member had abused a resident and was not placed on administrative leave, the resident could be further harmed, or other residents could experience the same abuse. On 04/02/15 at 2:20 PM, interview with the Administrative DON revealed the Administrative team was not made aware the Clinical DON had knowledge of the CNA's name at the time the allegation was reported and she was unsure of the reason the Clinical DON had not been placed CNA #5 on administrative leave, per the facility's policy. Continued interview, on 04/02/15 at 2:58 PM, with the Clinical DON stated she did not suspect CNA #5 of abuse and therefore the CNA was not placed on administrative leave. The Clinical DON stated the facility did not follow its policy to place any employee who was investigated for abuse on administrative leave. The Clinical DON stated if a staff member was not placed on administrative leave, the resident could be harmed. Interview with the Administrator, on 04/02/15 at 3:35 PM, revealed at the time the allegation was reported to him, the facility was not sure who the alleged perpetrator was, and until that was determined it was not possible to suspend the entire staff; however, if there was a positive identification of a staff member, that person would be removed immediately. The Administrator stated he was not aware only one staff member matched the description given by Resident #21 until the day of 04/02/15. The Administrator stated if the alleged perpetrator was identified and not placed on administrative leave, then the facility did not follow it's policy to protect residents during an investigation. Continued interview with the Administrator, on 04/03/15 at 9:30 AM, revealed in the evening hours of 04/02/15, the facility determined the Clinical DON had been informed of the name of a CNA that matched the description given by Resident #21, and CNA #5 had been suspended on 04/02/15. 2. Review of the facility's investigation, initiated on 04/20/15, revealed Certified Medication Tech (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over the resident's head and the aide was mean and rude to the resident. The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22. The documented interview with LPN #9 stated CNA #22 was switched where she did not care for Resident #36, but was allowed to work with other residents after the abuse allegation was received. The investigation revealed the Clinical DON was notified of the abuse allegation on 04/19/15 at approximately 10:00 AM. Further review of the abuse investigation revealed Resident #36 was interviewed by the Clinical DON, on 04/20/15 at 3:00 PM, where the resident again reported the aide threw the bed covers over his/her head and said something the resident didn't like. The Clinical DON interviewed CNA #22 at 3:13 PM via telephone where she denied the allegation. However, the Clinical DON failed to interview the House Supervisor to determine when the aide was suspended and did not interview further to determine that CNA#22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment to be substantiated. The report stated the aide had been placed on administrative leave at the time of the allegation. Review of the facility's staffing worksheets and CNA #22's time card, for 04/19/15, revealed CNA #22 worked 7:00 AM to 11:00 AM on the unit where Resident #36 resided. Interview with Resident #36, on 04/28/15 at 12:46 PM, revealed she could not recall any incident where a facility staff was rough or mean or an incident where staff had pulled the bed covers over his/her head. A family member was present during the interview and stated the resident's memory was not always good, but the resident had reported to the family that someone had pulled a sheet over his/her head. The resident had told the family member he/she had not seen that aide again. Further interview with the family member revealed the facility had not interviewed her regarding any knowledge of the incident. According to the family member, the resident appeared to be more upset since the incident, whereas the resident was calm before, but she did not think the resident was afraid of anyone. Interview, on 04/28/15 at 3:29 PM, with CMT #2 who received the allegation of abuse from Resident #36, revealed she was passing medications on 04/19/15 sometime between 9:00 AM-10:00 AM. When she took Resident #36's medications into the room, the resident told her CNA#22 was mean and rude and pulled the bed covers over the resident's head. The resident told her the aide appeared to be angry. The CMT reported the allegation to LPN #9. She returned to the resident's room with LPN#9 and the resident told them the same story. Interview with CMT #3, on 04/28/15 at 3:20 PM, revealed she was working the other side of the unit when CMT #2 came to her and reported there was a problem. She stated it was a few hours into the day shift (7 AM-3 PM). She said CMT #2 reported Resident #36 told her CNA #22 had been rude and mean to him/her and threw the covers over the resident's head. CMT #2 told her the aides would have to switch teams, but before they could do that, LPN #9 came onto the floor. She went with CMT #2 and LPN #9 to interview Resident #36. When LPN #9 asked the resident what happened, the resident told them CNA #22 had been rude and threw the covers over his/her head. She stated the House Supervisor was notified and came to the floor and told CNA #22 she had to leave. This was before lunch. She thought the House Supervisor started the investigation. Telephone interview with LPN #9, on 04/29/15 at 9:42 AM, revealed she had worked on 04/19/15 as the LPN Supervisor for the sixth and seventh floors. She stated when she came to the seventh floor, CMT #2 reported what the resident had told her during the medication pass. She then went into Resident #36's room with CMT#2 and CMT #3 to interview the resident. The resident told them the same story related to CNA #22. In addition, the resident told them the aide refused to get him/her a tissue. She stated she then went and found CNA #22 in another resident's room providing care. That was between 9:00 AM-10:00 AM. She took the aide to the nurse's station and interviewed her. She obtained a written statement then she told the aide not to go back into Resident #36's room. She said she reassigned Resident #36's care to CNA #23; however, CNA #22 continued to care for all the other residents that were assigned to her that day. She stated she notified the House Supervisor of the incident and when she came onto the floor, she told CNA #22 she had to clock out and go home. She said the aide provided care to other residents until then, because she did not have the authority to suspend any staff. Telephone interview with CNA #23, on 04/29/15 at 10:58 AM, revealed around 10:00 AM on 04/19/15, she was told by LPN #9 she had to take over the care for Resident #36. She stated LPN #9 told her there had been an allegation against CNA #22 and she could no longer care for that resident. She stated the CNA had provided care to the other residents assigned to her until the House Supervisor came onto the floor and told her to go home. She stated it was about an hour from when she was told to care for Resident #36 and when the aide was sent home. Interview with the House Supervisor, via telephone, on 04/29/15 at 11:12 AM, revealed she received a report from LPN #9 that Resident #36 alleged CNA #22 was rude and unprofessional and threw the covers over the resident's head. She said LPN #9 said the aide denied the allegation. She texted the Clinical DON and informed her of the allegation. She stated she went to the unit and told the aide she had to go home. She did not watch the aide clock out. She stated LPN #9 had interviewed the aide and obtained a written statement. Therefore, she did not interview the aide again and did not interview the resident. She revealed she had not interviewed any staff. She stated she was not aware of any change in assignments and was not aware the aide had cared for other residents after the abuse allegation was received. She stated it was sometime before lunch when she came onto the floor and sent the aide home. She completed the Unusual Occurrence Report. Telephone interview with CNA #22, on 04/28/15 at 5:25 PM, revealed she had been assigned to Resident #36 on 04/19/15. She stated around 9:00 AM, she went in to dress the resident. She was putting the resident's support stockings and shoes on when the resident said he/she had to use the toilet. She told the resident he/she would have to wait until she got someone to help her because the resident was a two-person assist with transfers. She stated the resident starting cursing her, calling her a [***] , and telling her how to do her job. She stated she removed the resident's support stockings and placed them in the resident's wheelchair. She laid the resident back down (the resident was sitting on the side of the bed) and placed the bed covers over the resident up to the neck. She stated she wanted to let the resident calm down and then she was going to return with help. CNA #22 stated at approximately 9:30 AM, LPN #9 came and informed her of the allegation and requested her to provide a written statement, which she did. After she had written the statement, she continued to care for her other assigned residents. She said she went back into Resident #36's room and took the roommate to the bathroom; this occurred after she had been informed of the allegation. She states she did not provide care for Resident #36, but she did provide care for his/her roommate. She stated LPN #9 assisted her with taking the roommate to the bathroom; however, LPN #9 denied this allegation. She stated around 11:00 AM the House Supervisor came onto the floor and told her to clock out and go home. Interview with the Clinical DON, on 04/29/15 at 4:05 PM, revealed the allegation was reported to her via text from the House Supervisor at 10:11 AM on 04/19/15. She stated she told the House Supervisor to suspend the aide immediately. She stated it was the facility's practice to suspend staff during an abuse investigation. She stated the House Supervisor was the only staff that had the authority to suspend someone during the weekends and they had to call the DONs. She stated supervisors and staff nurses could not suspend staff. Further interview with the Clinical DON revealed she conducted the abuse investigation. She stated she did know that CNA #22 had not been removed from patient care immediately and that she had been allowed to care for other residents after the abuse allegation was reported. She reviewed her text messages and stated that she had texted the House Supervisor at 10:16 AM to suspend the aide. She stated her expectations would be the aide should have been held at the nurse's station until the House Supervisor came onto the floor. However, she stated she had not asked about this during her investigation and she had no reason to review CNA #22's time card. Review of the Activity of Daily Living (ADL) care tracker information for 04/19/15 revealed CNA #22 documented cared for other residents until 10:52 AM, several hours after the allegation was reported. 3. Review of the clinical record for Resident #37 revealed the resident had resided at the facility since January 2011. Review of the most current [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 03/17/15, revealed the facility assessed the resident to have a BIMS score of eleven (11) out of possible fifteen (15) which meant the resident was interviewable. No behaviors were noted and the facility assessed the resident to need limited assist of one-person for transfers and ambulation. Interview with Resident #37, on 04/29/15 at 12:38 PM, revealed when the resident was asked if any staff had been inappropriate with him/her, the resident replied, Yes, and named the ORT by name. The resident said the ORT had kissed him/her on the mouth and pointed to the lips. The resident stated the kiss occurred in the resident's room when the resident was getting ready to walk with the ORT. The resident said a nurse had seen the ORT kissing him/her. Further interview with the resident revealed the ORT had not kissed him/her before and the resident was surprised. Interview with ORT Restorative Aide #1, on 04/29/15 at 1:00 PM, revealed he denied the allegation. He stated he went to walk the resident and found the resident sitting on the side of the bed. He placed the gait belt around the resident and noticed the resident's pants were loose around the resident's waist. He assisted the resident to a standing position and pulled the resident's pants up at the same time. He walked the resident from the room, to the elevator, and to the end of the hallway. After he ambulated the resident, they returned to the resident's room and he sat the resident on the side of the bed to perform active range of motion exercises. He stated the resident did not say anything during the session. Further interview with the ORT revealed after completion of the range of motion exercises, he told the resident he would see him/her tomorrow and left the room. He could not recall if the resident said anything. He stated the resident didn't appear to be any different from other days. He stated he recalled seeing CNA #24 in the hallway with a blue linen bag. The ORT said he was close to the resident's face, but denied he kissed or touched the resident's face. He said he had never kissed any resident. He stated he did not go back into Resident #37's room, but cared for other residents to the end of his work shift. Review of ORT Restorative Aide #1's time card for 04/26/15 revealed the ORT worked from 7:00 AM to 3:15 PM. Telephone interview with CNA #24, on 04/29/15 at 3:07 PM, revealed he witnessed ORT Restorative Aide #1 kiss Resident #37 on the lips. He said he was passing by the resident's room to take dirty linen to the dirty utility room, which was directly across from the resident's room. He stated the resident had a gait belt around his/her waist and the ORT was assisting the resident from a sitting position from the bed. He stated the resident was rising and the ORT gently kissed the resident on the lips. He stated he couldn't believe what he saw. He thought it could be a culture thing or the kiss could have been a reward. He stated he witnessed the kiss around 1:00-1:30 PM, but he did not report it at this time. He stated he thought about it then reported what he saw to the nurse, but by that time, the ORT had already left for the day. He stated he was trained to report abuse immediately, but he was shocked and didn't want to get the ORT in trouble. Telephone interview with LPN #10, on 04/30/15 at 2:23 PM, revealed CNA #24 had reported what he witnessed to CNA #25 and #26 then they reported to her at approximately 4:15 PM on 04/26/15. She stated she went to look for CNA #24 to ask him about the allegation, but he was off the floor. When he came back on the floor, she interviewed the aide and he told her he had witnessed the ORT kissing the resident on the lips. She asked the aide why he didn't report what he witnessed at that time and he told her he was afraid the ORT aide would know who had reported it. She said she told the aide he should have reported what he saw right away and the aide told her he was afraid of losing his job. She said she then went to find the House Supervisor on the first floor. She reported what was told to her. She said she had interviewed the resident before reporting to the House Supervisor and the resident told her the ORT had kissed him/her on the lips. She asked the resident if the kiss made him/her uncomfortable and the resident said, Yes. Telephone interview with CNA #26, on 04/30/15 at 3:17 PM, revealed she did not witness the incident, but was told by CNA #24. She stated the aide pulled her and CNA #25 aside and told them he was walking past Resident #37's room and saw the ORT kiss Resident #37 on the lips. She stated CNA #24 told them he didn't know what to do. She told him he should have told the nurse. She stated she and CNA #25 went into Resident #37's room and asked the resident if anyone had kissed him/her on the lips and the resident said, Yes. After that she reported what the resident had told her to LPN #10. Interview with CNA #25, on 04/30/15 at 3:28 PM, revealed CNA #24 told him he had witnessed ORT Restorative Aide #1 kiss Resident #37. He said CNA #24 told him the ORT had leaned in and kissed the resident on the mouth. He said he told CNA #24 he needed to tell somebody. He stated CNA #26 requested for him to go with her to question the resident. They went into Resident #37's room and asked the resident if it was true, if someone had kissed him/her. The resident looked at him and shook his/her head, Yes. He asked the resident if that made him/her feel uncomfortable, and the resident shook his/her head, Yes. He stated the resident's eyes got really big, but he/she didn't say a name. He said he had worked with this resident for years and found his/her answers to be appropriate and correct. He stated he reported what the resident said to LPN #10. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed she had not concluded the investigation. She stated she had identified CNA #24 had delayed in reporting the abuse allegation. She stated the ORT had already left for the day when the allegation was reported and had not worked since and was on administrative leave pending the investigation. She stated CNA #24 was also suspended for not reporting according to the facility's abuse policy. She stated the incident occurred on Sunday, April 26, 2015 around 1:00 PM and the House Supervisor was not notified until 4:50

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure care plans were followed to prevent a resident from leaving the facility without staff knowledge for one (1) of ten (10) sampled residents. (Resident #1) The findings include: Review of the facility's policy titled, Interdisciplinary Team Care Plan Guidelines, dated February 2014, stated the Nursing Center's Planning/Interdisciplinary Team in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but not limited to, the Minimum Data Set with reviews quarterly and a change of status. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. All disciplines are an integral part to the process. Review of the facility's policy and procedure for Wander/Elopement Risk, dated February 2014, revealed Wandering and Elopement education was provided to all staff members so that they are prepared to provide appropriate care for these residents. The procedure was to complete the Wandering/Elopement Risk Assessment and Care Plan upon admission to determine if the resident was at risk. If the resident was at risk then reassess annually, quarterly, with a change in status and re-admissions. Care plan the resident if the criteria are met for appropriate interventions. Place a Roam Alert and yellow identification band on the resident. If the resident is unable to tolerate the Roam Alert and/or yellow band an alternative placement is decided. The Care Plan and Certified Nursing Assistant Kardex must be updated. Obtain a resident picture and key information to place in the Wander/Elopement Risk binder located at the receptionist desk in the lobby. Observation of the facility's surveillance video footage (containing no audio), on 02/10/15 at 3:20 PM, with the Director of Nursing, revealed Resident #1 walked out the front door of the facility, on 02/02/15 at 3:50 PM, wearing a blue jacket, a light colored shirt, dark colored pair of sweat pants and slip on shoes with no socks. Review of the video footage also revealed an unidentified male visitor who immediately walked out behind the resident. Continued review of the video revealed the Administrator of the facility walked across the lobby floor, and in front of the same door and at the same time Resident #1 was exiting. The video shows the Administrator looking at the front door as the resident and visitor were exiting the building. Interview with Resident #1, on 02/09/15 at 1:45 PM, revealed the resident stated he/she did not belong in the facility and wanted to go home. The resident stated he/she felt restricted in the facility because he/she was only allowed to smoke at designated times. The resident stated he/she enjoyed playing bingo; however the bingo at the facility did not pay money like his/her bingo hall. Resident #1 stated he/she frequented the church and the local bingo hall not far from his/her apartment. The resident stated he/she had asked the staff to take him/her to bingo and they declined. The resident stated he/she had a nephew that would come and take him/her to play bingo, but he had a family and work responsibility and could not always take him/her to bingo. The resident stated he/she snuck out of the facility last week to go to bingo and thought it was on a Sunday. The resident stated he/she walked out and no one paid any attention to him/her and staff probably thought he/she was at the facility visiting someone. The resident stated he/she walked all the way to the bingo hall and it was very cold outside. The resident stated he/she thought it was bingo night at the bingo hall when he/she snuck out, but found out once he/she got to the bingo hall, that bingo was actually on Tuesday night. Review of Resident #1's clinical record revealed the facility admitted the resident on 12/17/14 with [DIAGNOSES REDACTED]. Review of the fourteen (14) day scheduled Minimum Data Set (MDS) Assessment, dated 01/01/15, revealed the facility assessed the resident as requiring limited assistance with walking, and balance was not steady, but was able to stabilize without staff support. The facility assessed the resident with a Brief Interview for Mental Status and determined the resident scored a twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #1's Nursing Care Plan for elopement, dated 01/12/15, revealed approaches for staff to implement once the Roam Alert was placed on the resident, was for the staff to take a photograph of the resident to maintain on file for identification purposes at the receptionist desk. The staff was to observe and report risk factors such as wandering, and making repeated requests to leave the facility. And staff was to check the Roam Alert for proper functioning. Interview with the 6th Floor Unit Manager, on 02/11/15 at 1:55 PM, revealed she assessed Resident #1 at risk for leaving the building without staff knowledge, on the morning of 01/12/15, after the resident exhibited exit seeking behavior; had verbalized the desire to go home; and, expressed the desire to go play bingo at the bingo hall he/she used to frequent. She stated the resident experienced confusion at times and she was concerned the resident would leave the facility without staff knowledge so the decision was made to apply the Roam Alert bracelet on the resident. She stated sometime later during the morning hours and after applying the bracelet she saw the Compliance Officer (CO) in the hallway, and it was at that time, she verbally notified the CO regarding the placement of the Roam Alert bracelet. Review of the Nursing Notes, dated 01/12/15 at 11:00 AM, revealed nursing initiated the Roam Alert secondary to Resident #1 ambulating and talking about going home. The Nursing notes continued to state the resident said he/she had an old hound dog to tend to at home and the resident felt like he/she could take care of his/her self at home. Review of Nursing Notes, dated 01/23/15 and timed at 11:43 AM, revealed the resident was alert and oriented, but experienced memory loss and confusion at times. The nursing note continued to state Resident #1 was independent with toileting, bed mobility and transfers. Interview with Licensed Practice Nurse (LPN) #1, on 02/09/15 at 3:20 PM, revealed her shift began at 2:50 PM on 02/02/15. LPN #1 stated CNA #2 notified her at 5:45 PM that Resident #1 was missing. LPN #1 stated she had not seen Resident #1 prior to 5:45 PM. She stated she went down to the first lobby area and spoke with the receptionist to determine if she had seen the resident and the receptionist told her, she had not seen the resident. Interview with Receptionist #2, on 02/11/15 at 7:45 AM, revealed the Roam Alert binder was kept at the receptionist desk in the lobby on the first floor. She stated the binder was a reference for her to be able to recognize the exit seeking residents when they came down to the first floor. She said she would look at the pictures in the binder and use the identification information to call the floor to let the staff know a resident was exit seeking. She stated then staff would come and get them. Interview with Receptionist #1, on 02/09/15 at 5:10 PM, revealed she was on duty the evening Resident #1 exited the building without staff knowledge. She stated it was determined after reviewing the surveillance video, on 02/02/15, that Resident #1 exited the building through the front door at 3:50 PM. She stated at that time she was seated at the receptionist desk but did not recognize the resident and the Roam Alert alarm did not sound to notify her that a resident was walking out the front door. She stated it was also determined the next day, on 02/03/15, that Resident #1's picture was not in the Roam Alert binder and the alarm system was malfunctioning. Receptionist #1 stated she had worked at the facility for nineteen years and had not received training on the Roam Alert binder. She stated she thought the binder was for the Corporate Compliance Officer's use. She stated she had not received additional training on the Roam Alert binder since Resident #1exited the building. Interview with the Compliance Officer (CO), on 02/10/15 at 10:05 AM, revealed she was responsible for completing chart audits for those residents with a Roam Alert bracelet. She stated once the nurse on the unit placed a bracelet on a resident she would be notified by the nurse. The CO stated she would then take a picture of the resident and put the picture in the Roam Alert binder that was located at the receptionist desk on the first floor. She stated the binder was used to help the receptionist and security guards at the desk recognize residents at risk for elopement. However, she stated Resident #1, was the one fell that through the cracks. The CO stated after Resident #1 left the building, it was determined his/her picture was not in the book. Interview with the Assistant Director of Nursing, on 02/11/15 at 8:30 AM, revealed care plans should be individualized and followed by staff in order to meet the needs of the residents. She stated it was not until the resident returned to the facility that they determined the resident's picture was not in the Roam Alert binder at the receptionist desk. She stated there was a breakdown in communication between the Compliance Officer and the Unit Manager on the 6th floor.

Based on interview, record review, and review of the facility's policies, Administrator's job description, and the facility's Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to have an effective system in place to ensure the Administrator provided oversight of the corrective actions in the AOC and to ensure all aspects of the AOC and Abuse Policy were implemented and followed by staff to ensure residents were free from abuse for two (2) of forty-three (43) sampled residents (Residents #36 and #37). (Refer to F225, F226 and F520) Immediate Jeopardy (IJ) was identified on 04/03/15 and was determined to exist on 04/01/15 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) at a Scope and Severity of a J; and, at 42 CFR 483.20 Resident Assessment (F282) at a Scope and Severity of a J. The facility's AOC, dated 04/09/15, alleged the IJ was removed on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 (investigating complaints KY and KY ) it was determined the IJ at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) had not been removed as alleged, on 04/09/15. Per the facility's AOC, when an allegation of abuse was reported, the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. Per the AOC, the Compliance Auditor or the Quality Assurance (QA) Director would audit weekly the revised abuse allegation logs and new abuse allegation checklist (tools developed to assist with the facility's investigations) and the results of the audits would be brought to the QA committee. Interview and record review determined the facility failed to implement these components of the AOC after the facility self-reported two (2) abuse allegations. On 04/19/15, ten (10) days after the facility had alleged the removal of IJ, Resident #36 alleged Certified Nurse Aide (CNA) #22 was mean and rude and threw the bed covers over the resident's head. CNA #22 was allowed to care for other residents after the abuse allegation was received. The facility did not reported the allegation to the SSA until 4:09 PM on 04/20/15, greater than twenty-four (24) hours after the incident occurred. On 04/26/15, seventeen (17) days after the facility had alleged the removal of IJ, CNA #24 failed to follow the facility's abuse policy for reporting incidents of abuse immediately to the nurse. CNA #24 alleged he saw Outreach Technician (ORT) Restorative Aide #1 kiss Resident #37 on the lips. However, he did not report what he had witnessed until hours later after the alleged perpetrator had left for the day. The ORT Restorative Aide #1 had provided care to approximately forty (40) other residents before the end of his shift. In addition, the facility failed to report the abuse allegation to the State Survey Agency until two (2) days after the alleged abuse occurred. The facility's failure to ensure the Administrator administered in a manner to ensure corrective actions of the AOC were implemented and monitored to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was determined to exist on 04/01/15. The facility provided an acceptable (AOC) on 05/07/15, which alleged removal of the Immediate Jeopardy on 05/06/15. The State Survey Agency verified Immediate Jeopardy was removed as alleged prior to exit on 05/13/15. The Scope and Severity was lowered to a D while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse. The facility would remove any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor will immediately report the concern to the State Agencies. Review of the Administrator's job description, dated 10/03/2005, revealed the Administrator's primary function was to manage operations in accordance with current applicable federal, state, and local standards, guidelines, and regulations to assure that the organization is operating effectively and efficiently. The individual would strive to provide to all those entrusted to his/her care the highest quality of appropriate services possible in light of resources or other constraints. Practice administration in accordance with capabilities and proficiencies and strive, in all matters relating to their professional functions, to maintain a professional posture that places paramount the interests of the facility and its residents. Interview with the Administrator, on 04/30/15 at 3:45 PM, revealed he provided oversight over the DONs who conducted the abuse investigations. He stated the abuse investigations were discussed with him. He stated he was not aware CNA #22 was allowed to work after the abuse allegation was received from Resident #36 because the Clinical DON did not know. He was told the aide had been placed on administrative leave. He said he thought the checklist were working. When he saw the checks he assumed the two DONs had reviewed it. Both have to sign off on the abuse log indicating that the investigation was complete. They were to look at each area checked. The Administrator stated the Compliance Auditor's responsibility was to ensure each step was done on the checklist, not just check for marks. He stated he assumed that all steps had been done. He was unaware residents were not protected during an abuse investigation and allegations were not reported according to facility policy. The Administrator stated monitoring and audits were tools used to ensure the AOC was implemented. He revealed he had questioned the Compliance Auditor about the audits, but only spoke of ensuring they were done, not of content. No issues with the audits had been reported to him. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. However, interview with the Compliance Auditor, on 04/30/15 at 1:15 PM revealed this was not done. Continued interview with the Administrator, on 04/30/15 at 3:45 PM, revealed the QA conducted on 04/27/15 was a quarterly QA where the committee discussed issues from January, February, and March 2015. He said they did not talk about the AOC and did not bring the AOC to review during that QA meeting. He added the DONs did not discuss any abuse investigations. He stated the results of the audits conducted by the Compliance Auditor were not discussed and there was limited talk about deficiencies and corrective actions. He said it was his responsibility and there needed to be closer monitoring. The Administrator stated the AOC had not been implemented and he could not say that enough oversight had been provided. He stated he was not sure where the breakdown occurred; however, a lot of assumptions were made. He further stated he did not ask the Medical Director for input. 1. Review of the facility's investigation, initiated on 04/20/15, revealed the Certified Medication Technician (CMT) #2 received an allegation of physical abuse from Resident #36 on 04/19/15. The resident alleged CNA #22 had thrown the bed covers over the resident's head and the aide was mean and rude to the resident. The investigation revealed the CMT reported the allegation to LPN #9 and she obtained a written statement from CNA #22; however the aide was allowed to work with other residents after the abuse allegation was received. Further review of the abuse investigation revealed the Clinical DON failed to determine when the aide was suspended and did not know CNA#22 was allowed to care for other residents. The five (5) day follow up report, dated 04/27/15, revealed the facility found the allegation of mistreatment to be substantiated. Interview with CNA #22, on 04/28/15 at 5:25 PM, LPN #9, on 04/29/15 at 9:42 AM, and CNA #23, on 04/29/15 at 10:58 AM, revealed CNA #22 was allowed to care for other residents after the abuse allegation was received. Review of CNA #22's time card, for 04/19/15, revealed CNA #22 worked until 11:00 AM, several hours after the abuse allegation was received at 9:30 AM. Interview with the Clinical DON, on 04/29/15 at 4:05 PM, revealed the investigation had not identified CNA #22 had not been removed from patient care immediately and had been allowed to care for other residents after the abuse allegation was reported. She She had not asked during her investigation and stated she had no reason to review CNA #22's time card 2. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed she had not concluded the investigation of alleged abuse for Resident #37. She stated her investigation had identified CNA #24 did not report the alleged abuse right away on 04/26/15. She stated the ORT Restorative Aide had already left for the day when the allegation was reported and had not worked since. He was placed on administrative leave pending the investigation. She stated the incident occurred on Sunday, April 26, 2015 around 1:00 PM and the House Supervisor was not notified until 4:50 PM. In addition, the Administrative DON revealed she had not reported the alleged abuse to the State Survey Agency until two days after the alleged abuse was reported (04/28/15 at 3:10 PM). She stated the facility's fax machine was not working on 04/27/15 and she did not call and report the abuse allegation. Telephone interview with CNA #24, on 04/29/15 at 3:07 PM, CNA #25, on 04/30/15 at 3:28 PM, and CNA #26, on 04/30/15 at 3:17 PM, revealed they failed to report the alleged abuse according to the facility's abuse policy. Review of the House Supervisor's written statement revealed on 04/26/15 at approximately 4:45 PM, LPN #10 reported ORT Restorative Aide #1 was observed by CNA #24 kissing Resident #37 on the lips. She texted the Administrative DON at 4:51 PM notifying her of the event. Review of ORT Restorative Aide #1's time card for 04/26/15 revealed the ORT worked from 7:00 AM to 3:15 PM. Review of the Restorative Care Participation documentation for 04/26/15 revealed the ORT Restorative Aide documented at 1:27 PM he had worked with Resident #37 for thirty (30) minutes. In addition, the aide documented he provided restorative care to forty (40) residents after Resident #37's session. The State Survey Agency validated the removal of Immediate Jeopardy on 04/09/15 prior to exit as follows: 1. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON revealed she notified Resident #21's physician and family, DCBS and OIG the day the allegation was made, on 04/01/15. Review of the facility's investigation revealed the notifications were made on 04/01/15. 2. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she interviewed and assessed Resident #21 on 04/01/15 for behavioral and psychosocial concerns. The resident was not tearful and did not express any anxiety. Review of the facility's investigation revealed the Clinical DON interviewed the resident on 04/01/15. 3. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed Resident #21 on 04/02/15. 4. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the alleged CNA was placed on administrative leave on 04/02/15. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed the facility suspended her on 04/02/15. 5. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed the Administrator trained the Clinical DON and Administrative DON, on 04/03/15, on the abuse policy and collecting statements jointly, with verbalized understanding. Review of the training records revealed, on 04/03/15, the Administrator trained the Clinical DON and Administrative DON on the abuse policy and collecting statements jointly. 6. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she developed the investigation checklist, on 04/03/15, to ensure every step had been taken during an investigation. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she had been trained by the Administrative DON on the use of the investigation checklist and completed by either DON. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed he approved the new Investigation Checklist. Review of the Investigation Checklist revealed an effective date of April 2015. 7. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON and, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the Administrative DON revised the Allegation Log to include two (2) sets of signatures for review by nursing administration. The Administrative DON trained the Clinical DON how to use the log. Interview, on 04/09/15 at 5:14 PM, with the Administrator revealed he approved the revised Allegation Log which required both DONs to initial they had reviewed the allegations. Review of the Allegation Log revealed it contained Nursing Administration review and was revised April 2015, and was reviewed by the Clinical DON, Administrative DON, the Clinical Support Services, and Administrative Nursing Assistant. Review of the revised allegation log revealed a place for two (2) signatures were added on 04/03/15. 8. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed other interviewable residents regarding possible issues with care and abuse. Review of the Resident Interviews for Resident #21's investigation, dated 04/08/15, revealed, on 04/07/15, the Administrative DON interviewed fourteen (14) interviewable residents if there were any issues or concerns with staff. No concerns were noted. Interview, on 04/09/15 at 4:25 PM, with the Treatment Nurse revealed she completed skin assessments of eight (8) non-interviewable residents, on 04/08/15, on the 3rd floor. She stated she completed one side of the unit and the Outreach Technician (ORT) nurse completed the other side of the unit with no concerns noted. Review of six (6) skin assessments and two (2) wound assessments revealed skin assessments were completed on 04/08/15. Interview with Resident #4, on 04/01/15 at 10:25 AM; Resident #12, on 03/31/15 at 8:46 AM; Resident #13, on 03/31/15 at 7:47 AM; Resident #15, on 04/01/15 at 10:20 AM; and, Resident #16, on 03/31/15 at 9:30 AM, revealed no concerns with staff interactions with the residents. 9. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed she reviewed facility allegations for the last year, for a total of twenty-five (25) investigations with no concerns noted. Review of a statement by the Administrative DON, dated 04/07/15, revealed twenty-five (25) investigations were reviewed in the last twelve (12) months by the Administrative DON, with no concerns noted. Review of four (4) investigations revealed no regulatory violations for Residents #31, #32, #33 and #34. 10. Interviews on 04/09/15 with a total of fifty (50) employees revealed: seventeen (17) CNAs (CNA #13 at 1:56 PM, CNA #3 at 1:57 PM, CNA #22 at 2:00 PM, CNA #21 at 2:06 PM, CNA #8 at 2:12 PM, CNA #9 at 2:20 PM, CNA #17 at 2:21 PM, CNA #15 at 2:52 PM, CNA #14 at 2:46 PM, CNA #16 at 3:05 PM, CNA #19 at 3:05 PM, CNA #10 at 3:09 PM, CNA #18 at 3:12 PM, CNA #20 at 3:15 PM, CNA #11 at 3:17 PM, CNA #23 at 3:20 PM, CNA #12 at 3:31 PM), six (6) LPNs (LPN #1 at 3:07 PM, LPN #5 at 2:47 PM, LPN #3 at 2:45 PM, LPN #9 at 3:07 PM, LPN #10 at 3:30 PM, LPN #8 at 2:18 PM, RN #4 at 2:09 PM, five (5) Unit Managers (UM/RN #2 at 2:00 PM, UM/RN #3 at 2:27 PM, UM/RN #6 at 3:00 PM, UM #1 at 3:00 PM, UM/RN #7 at 3:35 PM), three (3) housekeepers (Housekeeper #2 at 2:09 PM, Housekeeper #3 at 2:15 PM, Housekeeper #4 at 2:15 PM), a CSR at 2:27 PM, a Dietary Aide at 2:31 PM, Central Supply at 2:51 PM, Rehabilitation Secretary at 2:40 PM, Rehabilitation Director at 2:42 PM, the Nutrition Services Director at 1:58 PM, the Social Services Director at 2:11 PM, the Activities Director at 2:24 PM, RAI Coordinator at 2:34 PM, HR Director at 2:43 PM, Receptionist at 3:02 PM, Compliance Auditor at 3:31 PM, QA Director at 3:45 PM, Rehab Manager at 3:55 PM, Treatment Nurse at 4:25 PM, House Supervisor at 4:33 PM, Clinical DON at 4:48 PM, and the Administrative DON at 5:03 PM revealed they had all received abuse training within the last week; they were aware of the types of abuse; when to report abuse; and, to who to report alleged abuse. Review of the training records revealed three hundred and eleven (311) staff had completed post tests between 04/02/15 and 04/08/15. Interview with the HR Director, on 04/09/15 at 2:43 PM, revealed all staff had been trained on abuse except those staff on vacation or leave. The HR Director stated a sign was posted at the time clock and a letter was mailed to those staff not yet trained, that they must receive training prior to working. Observation, on 04/09/15 at 4:04 PM, of the time clock revealed a sign posted with thirteen (13) staff names to obtain abuse training prior to going to their unit. Review of the letter sent to staff revealed it was dated 04/08/15 from the HR Director that stated staff must receive the abuse training and answer the questionnaire before they started work. Review of the facility's staff roster revealed the letter was mailed to ten (10) employees, who were either sick, on vacation, or leave of absence. 11. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, and the QA Director, on 04/09/15 at 3:45 PM, revealed they would review the Allegation Log for completion and signatures weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. They stated the audits would go to the QA meetings for review. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would conduct audits of the Allegation Log and report the findings to the QA Committee. 12. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor and, on 04/09/15 at 3:45 PM, with the QA Director revealed either would audit the Investigation Checklist weekly for four (4) weeks, monthly for three (3) months, then quarterly for a year with results to QA the Committee. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would audit the Investigation Checklist and report to the QA Committee. Review of the Investigation Checklist revealed an inception date of 04/03/15. 13. Review of the third floor care plan updates revealed, on 04/03/15, the care plan for Resident #21 was updated by the RAI Coordinator. 14. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she reviewed resident behavior and antipsychotic care plans on 04/08/15, and then all residents, checking if the care plan had been updated, initiated, and implemented, with no concerns noted. Review of care plan audits for all six (6) floors, dated 04/07/15 revealed all care plans were reviewed for residents on each floor of the facility with 119 care plans revised. 15. Interview with the Social Services Director, on 04/09/15 at 2:11 PM, the RAI Coordinator, on 04/09/15 at 2:43 PM, with the UM on the 2nd floor (RN #2 on 04/09/15 at 2:00 PM and RN #3 on 04/09/15 at 2:27 PM), the UM on the 3rd floor, on 04/09/15 at 3:00 PM, and the Administrative DON, on 04/09/15 at 5:03 PM, revealed they received care plan training this week and was conducted by the Administrative DON, that included who initiated and updated the care plan, and how to implement the care plan, with verbal competency. Review of the care plan training records revealed care plan training included who initiated and updated the care plan, when the care plan should be revised, and who was responsible to implement the care plan. 16. Interview, on 04/09/15 at 2:00 PM, with UM/RN #2; on 04/09/15 at 2:27 PM, with UM/RN #3; and, on 04/09/15 at 3:00 PM, with UM #1 revealed walking rounds were conducted throughout the shift, but they did not document those rounds. The UMs stated they were observing direct staff to ensure care was provided according to the resident's care plan. Review of care plans revealed Resident #4's care plan was revised on 04/07/15, based on the UM rounds, to reflect the current placement in isolation. 17. Interview with the RAI Coordinator, on 04/09/15 at 2:34 PM, revealed she held a Program of Care meeting on 04/08/15 to review and ensure resident care plans were appropriate. Meetings would be held weekly, with discussion of certain residents each week, with all residents discussed quarterly. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM; the Social Services Director, on 04/09/15 at 2:11 PM; the Activities Director, on 04/09/15 at 2:24 PM, revealed their assistants would attend the Program of Care meetings; however, the Directors would attend in the assistants place when needed, and would discuss resident care plan interventions. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Program of Care meetings would review that resident care plans were up to date, make any needed changes, and interventions were implemented. 18. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor revealed she would audit the Program of Care meetings three (3) times a week for four (4) weeks, three (3) times a month for one (1) quarter, then quarterly and give the results to the DON for the QA Committee. 19. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, revealed she would conduct ten (10) chart audits each month for three (3) months, then quarterly to ensure care plans were updated and interventions performed, with discrepancies corrected by the UM. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Compliance Auditor would complete ten (10) chart audits and ensure the residents' care plans interventions were implemented; the UM would correct any issues immediately. She stated results would be taken to the QA Committee. Review of the Care Plan Monitoring Tool, dated April 2015, revealed it included review of the resident care plan, if the care plan had been updated, observations, concerns, if the care plan was followed, and Assistant UM or UM aware of result. 20. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM, the Social Services Director, on 04/09/15 at 2:11 PM, the Activities Director, on 04/09/15 at 2:24 PM, the HR Director, on 04/09/15 at 2:43 PM, the Compliance Auditor, on 04/09/15 at 3:31 PM, the QA Director, on 04/09/15 at 3:45 PM, the Rehab Manager, on 04/09/15 at 3:55 PM, the Medical Director, on 04/09/15 at 4:07 PM, the Treatment Nurse, on 04/09/15 at 4:25 PM, the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed they attended QA meetings, with three (3) held, and discussed the Immediate Jeopardy (IJ), corrective actions, care plans, new checklists, and training. Review of sign in sheets that included review of the IJ and corrective actions revealed QA meetings were held on 04/03/15, 04/06/15, and 04/08/15. An abbreviated survey conducted 04/28/15 investigating KY and KY determined the facility failed to implement the corrective actions of the AOC dated 04/09/15. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. Review of the newly developed checklist to be utilized by the facility to ensure abuse investigations were completed, (which was an intervention on the AOC) revealed no date when it was completed and only checks on the forms without any additional information provided. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed when she reviewed the newly developed checklist she only looked for the check marks and did not review the content of the investigation. In addition, she stated the audits of the abuse investigation checklist were not taken to the Quality Assurance (QA) meeting on 04/27/15. Interview with the Administrator, on 04/30/15 at 3:45 PM, validated the audits of the checklist and the abuse logs were not discussed at the 04/27/15 QA meeting. Immediate Jeopardy was determined not to be removed on 04/09/15 as alleged. The facility was notified of this finding on 04/30/15. The facility took the following actions to remove the Immediate Jeopardy on 05/06/15 as follows: 1. The Clinical DON made notification on 04/20/15 of the allegation (KY ) to Resident #36's family, physician, OIG and DCBS. The Administrative DON made notification of the allegation of abuse (KY ) to Resident #37's family and Physician on 04/27/15. Notification to the OIG and DCBS was made on 04/28/15. 2. On 04/21/15, a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor with no injuries consistent with abuse noted. Fifty-six (56) skin assessments were completed on non-interviewable residents by Unit Managers, Assistant Managers, and Staff Development Nurse as of 05/04/15. No issues were found. 3. 05/04/15, one hundred thirty (130) residents were interviewed by Social Services, and the RAI Coordinators to ensure there were no unresolved or uninvestigated allegations of abuse. No issues were identified. 4. The abuse allegation checklist was revised on 04/28/15 by the Clinical DON to reflect name, date, and time of actions, with a space for narrative documentation to record all actions taken during the abuse investigation. 5. On 05/01/15, the facility obtained the services of a consultant company to provide assistance with training, policy revision, QA and ongoing oversight and consultation. These consultant employees included Nurses, therapists, and Administrators. The facility's Administrative DONs, Human Resources Director, and Assistant Director of Nurses met with the consultants and revised the abuse policy to reflect procedures for immediate protection of residents by removal of the alleged perpetrator from patient care and reporting immediately allegations of any abuse to the state agencies. All staff would receive training on the new Abuse policy revisions and no staff would work past 05/05/15 without receiving the training. This would include agency staff. 6. On 05/05/15, education was provided by the contracted consultant on requirements for abuse allegation reporting and investigation with competency. No staff would be allowed to work past 05/05/15 without receiving the training. This would include agency staff. As of 05/05/15, two hundred ninety-seven (297) employees had been trained. 7. On 05/04/15, the facility implemented a new Nurses' Abuse Allegation Investigation Protocol. The protocol was a step by step reference for nurses and House Supervisors to be used when a resident alleged abuse. The protocol was posted in visible locations on all nursing units and included in all staff education. (Attachment B) 8. On 05/04/15, a QA meeting was held to review the alleged deficient practice and plans of actions established to correct the practices. The consultant observed the QA meeting. Members present included the Administrator, Consultant, Social Services, Medical Director, DONs and other Department Directors. The Administrator established a weekly QA meeting that included review of the deficiencies cited. 9. On 05/04/15, the Elder Justice Act reporting notification requirements was added to the admission packet. The revised Abuse policy and Elder Justice Act information was placed in a binder at the receptionist desk. 10. On 05/05/15, five (5) random staff and resident interviews would be conducted weekly by Social Services and Nursing Administration to ensure there were no unresolved/investigated abuse allegations and staff understanding of reporting requirements. 11. On 05/04/15, the contracted consultant educated the Administrator and made observations at the facility to ensure the Administrator was administering the facility in accordance with professional standards and per his job description included ensuring a system was in place to protect residents from abuse and neglect. 12. Beginning 05/01/15, a consultant would conduct weekly visits for four weeks then monthly visits to ensure the Administrator followed professional standards and job description ensuring systems remained in place for reporting and investigation of allegations of abuse and neglect per established plan of correction. The Administrator established weekly administrative consultative visits with the consultants. 13. The contract consultant re-educated the Administrator, on 05/04/15, on the requirements of a functional QA process to include delegation of action items for identified concerns including oversight of entire AOC and implementation of systems and follow-up to ensure corrections were made and reviewed with the Interdisciplinary Team (IDT). 14. Beginning 05/04/15 the Human Resources Director would update the Administrator daily of the status of staff training on abuse. 15. On 05/05/15, the Administrator amended the agenda for the daily quality meeting with the IDT, to address deficiencies cited. This included reviewing audits, education, and ongoing monitoring to determined effectiveness of current actions. 16. Weekly QA meetings that began on 05/04/15, was held to review identified concerns regarding any issues with the Plan of Correction and follow-up to ensure corrections were sustained. The meeting would consist of at a minimum the Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and other Department Directors. The contract consultant would observe the QA process monthly, including audit tools (attachment E) for at least three (3) months to ensure Quality Assurance Performance Improvement Committee was functional and meeting the identified needs of the facility. The QA committee would consist of the Administrator, DONs, ADON, Social Services, and the Medical Director attending at least quarterly. When the Medical Director was present, they would review a sample of residents' abuse allegations for effectiveness in the revised processes. The QA meeting would review audits (and take action if needed) related to the deficiencies. Theses audits would include resident interviews and skin audits conducted on 05/04/15 and abuse audits which began on 04/08/15 and are ongoing. The reports would be presented by the Compliance Auditor. The State Survey Agency validated the removal of Immediate Jeopardy on 05/13/15 prior to exit as follows: 1. Review of the clinical record and facility investigation validated the Clinical DON notified Resident #36's family, physician, OIG, and DCBS on 04/20/15. Review of the fax verification revealed the OIG was notified on 04/20/15 at 4:09 PM. Review of the clinical record and facility investigation revealed the Administrative DON notified Resident #37's family and physician on 04/27/15. Review of the faxed verification sheet revealed notification to the OIG on 04/28/15 at 3:11 PM. Review of the Department of Community Based Services (DCBS) intake summary revealed the notification was received on 04/29/15. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed the facility's fax machine was broken on Monday, April 27, 2015 and she failed to provide notification via telephone. 2. Review of facility's investigation revealed a skin assessment was performed on Resident #36,

Based on interview and review of the facility's policy and Acceptable Allegation of Compliance (AOC) dated 04/09/15, it was determined the facility failed to maintain a Quality Assurance (QA) program implemented and monitored the plans of actions as stated the Allegation of Compliance to correct quality deficiencies as evidenced by the facility's failure to ensure the Abuse Policy was implemented to protect residents from abuse for two (2) of forty-three (43) sampled residents (Resident #36 and #37). (Refer to F225, F226 and F490) Immediate Jeopardy (IJ) was identified on 04/03/15 and was determined to exist on 04/01/15 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) at a Scope and Severity of a J; and, at 42 CFR 483.20 Resident Assessment (F282) at a Scope and Severity of a J. The facility's AOC, dated 04/09/15, alleged the IJ was removed on 04/09/15. However, during an abbreviated survey initiated on 04/28/15 (investigating complaints KY and KY ) it was determined the IJ at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) had not been removed as alleged, on 04/09/15. Per the facility's AOC, when an allegation of abuse was reported, the Administrator/Nursing Administrator would be notified; the alleged perpetrator would be placed on Administrative leave; and, the State Agencies would be notified not to exceed twenty-four (24) hours if no injury occurred. Further review of the revealed the Compliance Auditor or the Quality Assurance (QA) Director would audit weekly the revised abuse allegation logs and new abuse allegation checklist (tools developed to assist with the facility's investigations) and the results of the audits would be brought to the QA committee. However, interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed she only audited the checklist forms to ensure the check marks were made. She did not review any abuse investigation to ensure they were completed, or that they followed the facility's abuse policy. The audits conducted were not taken to the 04/27/15 QA meeting as stated in the AOC. Interview and record review determined the facility failed to implement these components of the AOC after the facility self-reported two (2) abuse allegations. On 04/19/15, ten (10) days after the facility had alleged the removal of IJ, Resident #36 alleged Certified Nurse Aide (CNA) #22 was mean and rude and threw the bed covers over the resident's head. CNA #22 was allowed to care for other residents after the abuse allegation was received. The facility did not reported the allegation to the SSA until 4:09 PM on 04/20/15, greater than twenty-four (24) hours after the incident occurred. On 04/26/15, seventeen (17) days after the facility had alleged the removal of IJ, CNA #24 failed to follow the facility's abuse policy for reporting incidents of abuse immediately to the nurse. CNA #24 alleged he saw Outreach Technician (ORT) Restorative Aide #1 kiss Resident #37 on the lips. However, he did not report what he had witnessed until hours later after the alleged perpetrator had left for the day. The ORT Restorative Aide #1 had provided care to approximately forty (40) other residents before the end of his shift. In addition, the facility failed to report the abuse allegation to the State Survey Agency until two (2) days after the alleged abuse occurred. The facility's failure to have an effective system in place to ensure the QA committee functioned to identify quality deficiencies, develop plans of action, and implement the plans of action has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was determined to exist on 04/01/15. The facility provided a new acceptable (AOC) on 05/07/15 which alleged removal of the Immediate Jeopardy on 05/06/15. The State Survey Agency verified Immediate Jeopardy was removed as alleged prior to exit on 05/13/15. The Scope and Severity was lowered to a D while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: The facility did not provide a policy regarding a Quality Assurance Program. Review of the facility's policy regarding Abuse Prevention, Intervention and Data Collection, revised April 2015, revealed the facility would protect residents from abuse by removing any employee who was suspected of abuse immediately and place on administrative leave during the investigation. The policy stated all employees were required to report immediately any observations, suspicions or information of suspected abuse to the nursing supervisor. After consulting with the Administrator, the supervisor would immediately report the concern to the State Agencies. The Compliance Auditor audited the checklist forms to ensure only the check marks were made. She did not review any abuse investigation to ensure they were completed, or that they followed the facility's abuse policy. The audits conducted were not taken to the 04/27/15 QA meeting as stated in the AOC. Review of the AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor or Quality Assurance Director weekly times four (4) weeks, then monthly, then quarterly. Results of the audits would be brought to the QA Committee. Review of the QA Sign-in Sheets revealed a QA meeting was held on 04/27/15. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed she only audited to ensure the checklist was completed. She stated she only looked to ensure each area was checked; however, she did not go back and see if the investigation had been completed. She stated she was just checking for the check marks. Further interview revealed she conducted the audits on the abuse investigation log in the same manner. She was only looking to see if there were two (2) signatures present on the abuse log . She did not check for content. She stated she took the audits to the Quality Assurance (QA) meeting conducted on 04/27/15, but they were not discussed, per the AOC the audits were to be discussed in QA. She revealed this was a quarterly QA meeting and only issues from January, February, and March were discussed. The QA Committee decided to review the audits in the July QA meeting. Further interview revealed she had not identified an problems, as she was only looking for the check marks. Interview with the Administrator, on 04/30/15 at 3:45 PM, revealed he provided oversight over the Director of Nurses (DONs), who conducted the abuse investigations. He stated the abuse investigations were discussed and it was an ongoing process. He said he thought the checklists were working. When he saw the checks he assumed the two (2) DONs had reviewed it, as the both have to sign off on the abuse log that the investigation was complete. He stated the Compliance Auditor's responsibility was to ensure each step was done on the checklist, not just check for marks. He stated he assumed that all steps had been completed. He was unaware residents were not protected during an abuse investigation and allegations were not reported according to facility policy. The Administrator stated monitoring and audits were tools used to ensure the AOC was implemented. He stated he had questioned the Compliance Auditor about the audits, but they only spoke of ensuring they were done, not of their content. No issues with the audits had been reported to him and he was told they were being implemented. Continued interview with the Administrator revealed the QA conducted on 04/27/15 was a quarterly QA where the committee discussed issues from January, February, and March 2015. Per interview, the committee did not talk about or review the AOC and the DONs did not discuss any abuse investigations during this meeting. In addition, he stated the Compliance Auditor did not discuss the results of the audits conducted and there was limited talk about deficiencies and corrective actions. He said there needed to be closer monitoring. The State Survey Agency validated the removal of Immediate Jeopardy on 04/09/15 prior to exit as follows: 1. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON revealed she notified Resident #21's physician and family, DCBS and OIG the day the allegation was made, on 04/01/15. Review of the facility's investigation revealed the notifications were made on 04/01/15. 2. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she interviewed and assessed Resident #21 on 04/01/15 for behavioral and psychosocial concerns. The resident was not tearful and did not express any anxiety. Review of the facility's investigation revealed the Clinical DON interviewed the resident on 04/01/15. 3. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed Resident #21 on 04/02/15. 4. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the alleged CNA was placed on administrative leave on 04/02/15. Interview with CNA #5, on 04/03/15 at 8:40 AM, revealed the facility suspended her on 04/02/15. 5. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed the Administrator trained the Clinical DON and Administrative DON, on 04/03/15, on the abuse policy and collecting statements jointly, with verbalized understanding. Review of the training records revealed, on 04/03/15, the Administrator trained the Clinical DON and Administrative DON on the abuse policy and collecting statements jointly. 6. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she developed the investigation checklist, on 04/03/15, to ensure every step had been taken during an investigation. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she had been trained by the Administrative DON on the use of the investigation checklist and completed by either DON. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed he approved the new Investigation Checklist. Review of the Investigation Checklist revealed an effective date of April 2015. 7. Interview, on 04/09/15 at 4:48 PM, with the Clinical DON and, on 04/09/15 at 5:03 PM, with the Administrative DON revealed the Administrative DON revised the Allegation Log to include two (2) sets of signatures for review by nursing administration. The Administrative DON trained the Clinical DON how to use the log. Interview, on 04/09/15 at 5:14 PM, with the Administrator revealed he approved the revised Allegation Log which required both DONs to initial they had reviewed the allegations. Review of the Allegation Log revealed it contained Nursing Administration review and was revised April 2015, and was reviewed by the Clinical DON, Administrative DON, the Clinical Support Services, and Administrative Nursing Assistant. Review of the revised allegation log revealed a place for two (2) signatures were added on 04/03/15. 8. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed she interviewed other interviewable residents regarding possible issues with care and abuse. Review of the Resident Interviews for Resident #21's investigation, dated 04/08/15, revealed, on 04/07/15, the Administrative DON interviewed fourteen (14) interviewable residents if there were any issues or concerns with staff. No concerns were noted. Interview, on 04/09/15 at 4:25 PM, with the Treatment Nurse revealed she completed skin assessments of eight (8) non-interviewable residents, on 04/08/15, on the 3rd floor. She stated she completed one side of the unit and the Outreach Technician (ORT) nurse completed the other side of the unit with no concerns noted. Review of six (6) skin assessments and two (2) wound assessments revealed skin assessments were completed on 04/08/15. Interview with Resident #4, on 04/01/15 at 10:25 AM; Resident #12, on 03/31/15 at 8:46 AM; Resident #13, on 03/31/15 at 7:47 AM; Resident #15, on 04/01/15 at 10:20 AM; and, Resident #16, on 03/31/15 at 9:30 AM, revealed no concerns with staff interactions with the residents. 9. Interview, on 04/09/15 at 5:03 PM, with the Administrative DON revealed she reviewed facility allegations for the last year, for a total of twenty-five (25) investigations with no concerns noted. Review of a statement by the Administrative DON, dated 04/07/15, revealed twenty-five (25) investigations were reviewed in the last twelve (12) months by the Administrative DON, with no concerns noted. Review of four (4) investigations revealed no regulatory violations for Residents #31, #32, #33 and #34. 10. Interviews on 04/09/15 with a total of fifty (50) employees revealed: seventeen (17) CNAs (CNA #13 at 1:56 PM, CNA #3 at 1:57 PM, CNA #22 at 2:00 PM, CNA #21 at 2:06 PM, CNA #8 at 2:12 PM, CNA #9 at 2:20 PM, CNA #17 at 2:21 PM, CNA #15 at 2:52 PM, CNA #14 at 2:46 PM, CNA #16 at 3:05 PM, CNA #19 at 3:05 PM, CNA #10 at 3:09 PM, CNA #18 at 3:12 PM, CNA #20 at 3:15 PM, CNA #11 at 3:17 PM, CNA #23 at 3:20 PM, CNA #12 at 3:31 PM), six (6) LPNs (LPN #1 at 3:07 PM, LPN #5 at 2:47 PM, LPN #3 at 2:45 PM, LPN #9 at 3:07 PM, LPN #10 at 3:30 PM, LPN #8 at 2:18 PM, RN #4 at 2:09 PM, five (5) Unit Managers (UM/RN #2 at 2:00 PM, UM/RN #3 at 2:27 PM, UM/RN #6 at 3:00 PM, UM #1 at 3:00 PM, UM/RN #7 at 3:35 PM), three (3) housekeepers (Housekeeper #2 at 2:09 PM, Housekeeper #3 at 2:15 PM, Housekeeper #4 at 2:15 PM), a CSR at 2:27 PM, a Dietary Aide at 2:31 PM, Central Supply at 2:51 PM, Rehabilitation Secretary at 2:40 PM, Rehabilitation Director at 2:42 PM, the Nutrition Services Director at 1:58 PM, the Social Services Director at 2:11 PM, the Activities Director at 2:24 PM, RAI Coordinator at 2:34 PM, HR Director at 2:43 PM, Receptionist at 3:02 PM, Compliance Auditor at 3:31 PM, QA Director at 3:45 PM, Rehab Manager at 3:55 PM, Treatment Nurse at 4:25 PM, House Supervisor at 4:33 PM, Clinical DON at 4:48 PM, and the Administrative DON at 5:03 PM revealed they had all received abuse training within the last week; they were aware of the types of abuse; when to report abuse; and, to who to report alleged abuse. Review of the training records revealed three hundred and eleven (311) staff had completed post tests between 04/02/15 and 04/08/15. Interview with the HR Director, on 04/09/15 at 2:43 PM, revealed all staff had been trained on abuse except those staff on vacation or leave. The HR Director stated a sign was posted at the time clock and a letter was mailed to those staff not yet trained, that they must receive training prior to working. Observation, on 04/09/15 at 4:04 PM, of the time clock revealed a sign posted with thirteen (13) staff names to obtain abuse training prior to going to their unit. Review of the letter sent to staff revealed it was dated 04/08/15 from the HR Director that stated staff must receive the abuse training and answer the questionnaire before they started work. Review of the facility's staff roster revealed the letter was mailed to ten (10) employees, who were either sick, on vacation, or leave of absence. 11. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, and the QA Director, on 04/09/15 at 3:45 PM, revealed they would review the Allegation Log for completion and signatures weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. They stated the audits would go to the QA meetings for review. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would conduct audits of the Allegation Log and report the findings to the QA Committee. 12. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor and, on 04/09/15 at 3:45 PM, with the QA Director revealed either would audit the Investigation Checklist weekly for four (4) weeks, monthly for three (3) months, then quarterly for a year with results to QA the Committee. Interview with the Administrator, on 04/09/15 at 5:14 PM, revealed the Compliance Auditor would audit the Investigation Checklist and report to the QA Committee. Review of the Investigation Checklist revealed an inception date of 04/03/15. 13. Review of the third floor care plan updates revealed, on 04/03/15, the care plan for Resident #21 was updated by the RAI Coordinator. 14. Interview with the Clinical DON, on 04/09/15 at 4:48 PM, revealed she reviewed resident behavior and antipsychotic care plans on 04/08/15, and then all residents, checking if the care plan had been updated, initiated, and implemented, with no concerns noted. Review of care plan audits for all six (6) floors, dated 04/07/15 revealed all care plans were reviewed for residents on each floor of the facility with 119 care plans revised. 15. Interview with the Social Services Director, on 04/09/15 at 2:11 PM, the RAI Coordinator, on 04/09/15 at 2:43 PM, with the UM on the 2nd floor (RN #2 on 04/09/15 at 2:00 PM and RN #3 on 04/09/15 at 2:27 PM), the UM on the 3rd floor, on 04/09/15 at 3:00 PM, and the Administrative DON, on 04/09/15 at 5:03 PM, revealed they received care plan training this week and was conducted by the Administrative DON, that included who initiated and updated the care plan, and how to implement the care plan, with verbal competency. Review of the care plan training records revealed care plan training included who initiated and updated the care plan, when the care plan should be revised, and who was responsible to implement the care plan. 16. Interview, on 04/09/15 at 2:00 PM, with UM/RN #2; on 04/09/15 at 2:27 PM, with UM/RN #3; and, on 04/09/15 at 3:00 PM, with UM #1 revealed walking rounds were conducted throughout the shift, but they did not document those rounds. The UMs stated they were observing direct staff to ensure care was provided according to the resident's care plan. Review of care plans revealed Resident #4's care plan was revised on 04/07/15, based on the UM rounds, to reflect the current placement in isolation. 17. Interview with the RAI Coordinator, on 04/09/15 at 2:34 PM, revealed she held a Program of Care meeting on 04/08/15 to review and ensure resident care plans were appropriate. Meetings would be held weekly, with discussion of certain residents each week, with all residents discussed quarterly. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM; the Social Services Director, on 04/09/15 at 2:11 PM; the Activities Director, on 04/09/15 at 2:24 PM, revealed their assistants would attend the Program of Care meetings; however, the Directors would attend in the assistants place when needed, and would discuss resident care plan interventions. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Program of Care meetings would review that resident care plans were up to date, make any needed changes, and interventions were implemented. 18. Interview, on 04/09/15 at 3:31 PM, with the Compliance Auditor revealed she would audit the Program of Care meetings three (3) times a week for four (4) weeks, three (3) times a month for one (1) quarter, then quarterly and give the results to the DON for the QA Committee. 19. Interview with the Compliance Auditor, on 04/09/15 at 3:31 PM, revealed she would conduct ten (10) chart audits each month for three (3) months, then quarterly to ensure care plans were updated and interventions performed, with discrepancies corrected by the UM. Interview with the Administrative DON, on 04/09/15 at 5:03 PM, revealed the Compliance Auditor would complete ten (10) chart audits and ensure the residents' care plans interventions were implemented; the UM would correct any issues immediately. She stated results would be taken to the QA Committee. Review of the Care Plan Monitoring Tool, dated April 2015, revealed it included review of the resident care plan, if the care plan had been updated, observations, concerns, if the care plan was followed, and Assistant UM or UM aware of result. 20. Interview with the Nutrition Services Director, on 04/09/15 at 1:58 PM, the Social Services Director, on 04/09/15 at 2:11 PM, the Activities Director, on 04/09/15 at 2:24 PM, the HR Director, on 04/09/15 at 2:43 PM, the Compliance Auditor, on 04/09/15 at 3:31 PM, the QA Director, on 04/09/15 at 3:45 PM, the Rehab Manager, on 04/09/15 at 3:55 PM, the Medical Director, on 04/09/15 at 4:07 PM, the Treatment Nurse, on 04/09/15 at 4:25 PM, the Clinical DON, on 04/09/15 at 4:48 PM, the Administrative DON, on 04/09/15 at 5:03 PM, and the Administrator, on 04/09/15 at 5:14 PM, revealed they attended QA meetings, with three (3) held, and discussed the Immediate Jeopardy (IJ), corrective actions, care plans, new checklists, and training. Review of sign in sheets that included review of the IJ and corrective actions revealed QA meetings were held on 04/03/15, 04/06/15, and 04/08/15. An abbreviated survey conducted 04/28/15 investigating KY and KY determined the facility failed to implement the corrective actions of the AOC dated 04/09/15. Review of the acceptable AOC, dated 04/09/15, revealed the abuse allegation checklist and abuse allegation log would be audited by the Compliance Auditor and the results would be brought to the QA committee. Review of the newly developed checklist to be utilized by the facility to ensure abuse investigations were completed, (which was an intervention on the AOC) revealed no date when it was completed and only checks on the forms without any additional information provided. Interview with the Compliance Auditor, on 04/30/15 at 1:15 PM, revealed when she reviewed the newly developed checklist she only looked for the check marks and did not review the content of the investigation. In addition, she stated the audits of the abuse investigation checklist were not taken to the Quality Assurance (QA) meeting on 04/27/15. Interview with the Administrator, on 04/30/15 at 3:45 PM, validated the audits of the checklist and the abuse logs were not discussed at the 04/27/15 QA meeting. Immediate Jeopardy was determined not to be removed on 04/09/15 as alleged. The facility was notified of this finding on 04/30/15. The facility took the following actions to remove the Immediate Jeopardy on 05/06/15 as follows: 1. The Clinical DON made notification on 04/20/15 of the allegation (KY ) to Resident #36's family, physician, OIG and DCBS. The Administrative DON made notification of the allegation of abuse (KY ) to Resident #37's family and Physician on 04/27/15. Notification to the OIG and DCBS was made on 04/28/15. 2. On 04/21/15, a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor with no injuries consistent with abuse noted. Fifty-six (56) skin assessments were completed on non-interviewable residents by Unit Managers, Assistant Managers, and Staff Development Nurse as of 05/04/15. No issues were found. 3. 05/04/15, one hundred thirty (130) residents were interviewed by Social Services, and the RAI Coordinators to ensure there were no unresolved or uninvestigated allegations of abuse. No issues were identified. 4. The abuse allegation checklist was revised on 04/28/15 by the Clinical DON to reflect name, date, and time of actions, with a space for narrative documentation to record all actions taken during the abuse investigation. 5. On 05/01/15, the facility obtained the services of a consultant company to provide assistance with training, policy revision, QA and ongoing oversight and consultation. These consultant employees included Nurses, therapists, and Administrators. The facility's Administrative DONs, Human Resources Director, and Assistant Director of Nurses met with the consultants and revised the abuse policy to reflect procedures for immediate protection of residents by removal of the alleged perpetrator from patient care and reporting immediately allegations of any abuse to the state agencies. All staff would receive training on the new Abuse policy revisions and no staff would work past 05/05/15 without receiving the training. This would include agency staff. 6. On 05/05/15, education was provided by the contracted consultant on requirements for abuse allegation reporting and investigation with competency. No staff would be allowed to work past 05/05/15 without receiving the training. This would include agency staff. As of 05/05/15, two hundred ninety-seven (297) employees had been trained. 7. On 05/04/15, the facility implemented a new Nurses' Abuse Allegation Investigation Protocol. The protocol was a step by step reference for nurses and House Supervisors to be used when a resident alleged abuse. The protocol was posted in visible locations on all nursing units and included in all staff education. (Attachment B) 8. On 05/04/15, a QA meeting was held to review the alleged deficient practice and plans of actions established to correct the practices. The consultant observed the QA meeting. Members present included the Administrator, Consultant, Social Services, Medical Director, DONs and other Department Directors. The Administrator established a weekly QA meeting that included review of the deficiencies cited. 9. On 05/04/15, the Elder Justice Act reporting notification requirements was added to the admission packet. The revised Abuse policy and Elder Justice Act information was placed in a binder at the receptionist desk. 10. On 05/05/15, five (5) random staff and resident interviews would be conducted weekly by Social Services and Nursing Administration to ensure there were no unresolved/investigated abuse allegations and staff understanding of reporting requirements. 11. On 05/04/15, the contracted consultant educated the Administrator and made observations at the facility to ensure the Administrator was administering the facility in accordance with professional standards and per his job description included ensuring a system was in place to protect residents from abuse and neglect. 12. Beginning 05/01/15, a consultant would conduct weekly visits for four weeks then monthly visits to ensure the Administrator followed professional standards and job description ensuring systems remained in place for reporting and investigation of allegations of abuse and neglect per established plan of correction. The Administrator established weekly administrative consultative visits with the consultants. 13. The contract consultant re-educated the Administrator, on 05/04/15, on the requirements of a functional QA process to include delegation of action items for identified concerns including oversight of entire AOC and implementation of systems and follow-up to ensure corrections were made and reviewed with the Interdisciplinary Team (IDT). 14. Beginning 05/04/15 the Human Resources Director would update the Administrator daily of the status of staff training on abuse. 15. On 05/05/15, the Administrator amended the agenda for the daily quality meeting with the IDT, to address deficiencies cited. This included reviewing audits, education, and ongoing monitoring to determined effectiveness of current actions. 16. Weekly QA meetings that began on 05/04/15, was held to review identified concerns regarding any issues with the Plan of Correction and follow-up to ensure corrections were sustained. The meeting would consist of at a minimum the Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and other Department Directors. The contract consultant would observe the QA process monthly, including audit tools (attachment E) for at least three (3) months to ensure Quality Assurance Performance Improvement Committee was functional and meeting the identified needs of the facility. The QA committee would consist of the Administrator, DONs, ADON, Social Services, and the Medical Director attending at least quarterly. When the Medical Director was present, they would review a sample of residents' abuse allegations for effectiveness in the revised processes. The QA meeting would review audits (and take action if needed) related to the deficiencies. Theses audits would include resident interviews and skin audits conducted on 05/04/15 and abuse audits which began on 04/08/15 and are ongoing. The reports would be presented by the Compliance Auditor. The State Survey Agency validated the removal of Immediate Jeopardy on 05/13/15 prior to exit as follows: 1. Review of the clinical record and facility investigation validated the Clinical DON notified Resident #36's family, physician, OIG, and DCBS on 04/20/15. Review of the fax verification revealed the OIG was notified on 04/20/15 at 4:09 PM. Review of the clinical record and facility investigation revealed the Administrative DON notified Resident #37's family and physician on 04/27/15. Review of the faxed verification sheet revealed notification to the OIG on 04/28/15 at 3:11 PM. Review of the Department of Community Based Services (DCBS) intake summary revealed the notification was received on 04/29/15. Interview with the Administrative DON, on 04/29/15 at 2:24 PM, revealed the facility's fax machine was broken on Monday, April 27, 2015 and she failed to provide notification via telephone. 2. Review of facility's investigation revealed a skin assessment was performed on Resident #36, by the Unit Manager of the Seventh Floor on 04/21/15, with no injuries consistent with abuse. Review of the skin assessments conducted by the Unit Managers, Assistant Managers, and Staff Development Nurse through 05/04/15, revealed fifty-three (53) skin assessments were conducted for residents with a BIMS score less than eight (8). 3. Review of the resident interview forms revealed Social Services, and the RAI Coordinators conducted one hundred thirty-three (133) resident interviews by 05/04/15. No resident alleged abuse. The interview form included a questionnaire for staff to determine if the resident had any mood or behavioral changes. None was noted. 4. Interview with the Clinical DON, on 05/13/15 at 4:20 PM, revealed the abuse checklist was revised to give more details to ensure the investigation was conducted and timely. In addition, the Compliance Auditor would be able to determine if the investigation was completed timely and according to the facility's Abuse policy. Review of the checklist for the abuse investigation for Residents #37, 38, 39, 40, 41, 42, and #43 revealed the abuse checklist was completed with details of notification (including the state agencies), protection of the resident, resident and staff interviews, meeting with DONs and Administrator, and when copy of the checklist was sent to the QA committee. Residents #38, 39, 40, 41, 42, and 43 was completed after the facility was notified of the Immediate Jeopardy. 5. Interview with the Administrator, on 05/13/15 at 6:20 PM, revealed a consultant services was obtained on 05/01/15. The consultants had been at the facility providing abuse education to staff and assistance with development of the AOC, and QA guidance. The consultants were at the facility on 05/01/15, 05/04/15, 05/12/15 and 05/13/15. They are scheduled to be at the facility on 05/21/15 and 05/26/15. He stated the Abuse policy was revised on 05/04/15 with input from the consultant services. Review on 05/13/15, of the revised Abuse policy, revealed language changes in how the residents would be protected included the employee suspected of abuse would be removed from the unit and patient care immediately. The House Supervisor or Nursing Administration would assure the employee clocked out and left the facility. Employees who witnessed potential abuse are instructed to immediately intervene to protect the resident, the alleged perpetrator should not be left alone with the resident. All employees were required to immediately report any observations, suspicion, or information of suspected or actual abuse, neglect, or misappropriation of property to the House Supervisor. House Supervisor or Nursing Administration would report all allegations of abuse or neglect to DCBS, Police, and OIG immediately. Four (4) abuse investigations were reviewed