Every finding on record at Edgemont Healthcare

Based on observation, interview, review of a Centers for Disease Control and Prevention (CDC) article, and review of the facility's document and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 17 sampled residents, Resident (R) 4. In addition, the facility failed to have a water management program to prevent and limit growth and spread of opportunistic pathogens which could potentially affect all 64 residents.The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 05/18/2026, revealed, [Facility's Name] maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies. The infection prevention program is designed to incorporate recommendations, guidelines and regulations from multiple agencies including Centers for Disease Control (CDC).Review of the facility's policy titled, Edgemont Healthcare Sanitation, revised 01/31/2018, revealed the facility must procure food from approved sources and store, prepare, distribute, and serve food under sanitary conditions. Review of the CDC's article titled, About Water Management Programs, dated 05/15/2024, revealed, Healthcare facilities usually serve the populations at highest risk for Legionnaires' disease. Also, healthcare facilities can have large complex water systems that promote Legionella growth if not properly maintained. Healthcare facilities include hospitals, critical-access hospitals, and long-term care facilities. For the above reasons, the Centers for Medicare & Medicaid Services requires, and CDC recommends certain healthcare facilities have a water management program. The water management program should effectively limit growth and spread of opportunistic pathogens of premises plumbing, including Legionella. 1. Observations of the kitchen on 07/28/2026 at 9:03 AM, 07/28/2026 at 11:32 AM, and 07/29/2026 at 8:28 AM revealed two plastic bag connectors for the drink box dispenser were lying on the kitchen floor. No staff member handled or removed the connectors during the observation.During an interview with the Assistant Dietary Director on 07/28/2026 at 9:32 AM, she stated she assumed the position on 06/23/2026 and was working through a backlog of tasks left by the previous Dietary Director. She stated storing drink connectors on the floor was unsanitary and further validated the connectors should be covered during periods of non-use to mitigate the risk of contamination.During an interview with the Dietary Director on 07/29/2026 at 3:30 PM, he stated he assumed the position on 06/15/2026, and he was continuing to assess equipment, storage areas, and dry goods due to conditions inherited from the previous Dietary Director. He stated he was unaware the plastic drink connectors were stored on the floor. The Dietary Director stated the connectors should have been stored on the designated cart when not in use to prevent contamination.During an interview with the Assistant Director of Nursing (ADON) on 07/30/2026 at 2:45 PM, she stated she expected staff to follow the facility's policies and procedures related to food storage and infection prevention. She stated kitchen equipment and utensils should be stored appropriately when not in use to prevent contamination.During an interview with the Administrator on 07/30/2026 at 3:22 PM, she stated she expected staff to follow the facility's policies and procedures related to equipment storage and infection prevention. She stated it was unacceptable for staff to fail to properly store kitchen equipment and supplies. The Administrator further stated improper storage of kitchen items could result in contamination.2. Observation on 07/29/2026 at 11:36 AM revealed Registered Nurse (RN) 1 removed a glucometer from the top drawer of a cart in front of R4's room. She went into R4's room and correctly performed the fingerstick. However, when cleaning/disinfecting the glucometer, she took the Sani-Wipe and wiped the glucometer from 11:40:07 AM to 11:41:05 AM, approximately one minute. She then placed the glucometer on the tray on top of the medication cart.During an interview with RN1 at on 07/29/26 at 11:40 AM, she stated she was supposed to keep the glucometer wet for two minutes. She stated she did not leave the wipe on the glucometer because she was concerned the moisture would have contaminated the glucometer. During an interview with the Infection Preventionist (IP) on 07/29/2026 at 11:53 AM, she stated staff was supposed to clean the glucometer before use and after use. She stated the glucometer was to be cleaned with the wipes on the cart (Sani-Wipes). She stated per the Sani-Wipe instructions, the glucometer should be cleaned and remain wet for two minutes. The IP stated if the instructions were not followed it could cause an infection for another resident. She stated the residents did not have their own glucometers because there was not enough room in the cart to hold them.During an interview with the Administrator on 07/30/2026 at 3:12 PM, she stated she expected staff to clean the glucometers according to the directions on the wipes.3. Review of the facility's document Water Management Program, dated 02/13/2023, revealed the facility's domestic water mapping would be reviewed annually. The document stated the water would be tested annually for legionella and other bacteria. However, review of the water testing revealed the date of the last test was 01/31/2023.During an interview with the Maintenance Director on 07/29/2026 at 3:08 PM, he stated he did not have a diagram of the water system, and he did not have a water management program. The Maintenance Director stated he did not have a system for mitigating the growth of bacteria in the facility. He stated he relied on the city water system to prevent bacteria in the water system. The Maintenance Director further stated he did not test the facility's water for bacteria such as Legionella. He stated the Administrator might have a diagram of the water system. The Maintenance Director stated the only log he kept was the temperature of the water.Observation on 07/29/2026 at 3:12 PM of the Water Temperature Log, revealed there were no temperatures above 110 degrees Fahrenheit except for the water going to the laundry.During an interview with the Infection Preventionist (IP) on 07/30/2026 at 8:11 AM, she stated the facility had a suspected case of Legionella in 2023 or 2024. She stated the health department came to the facility and tested the water for Legionella. The IP stated they determined the cause of the Legionella did not come from the facility. She stated she did not have anything to do with the water management system. During an interview with the Administrator on 07/29/2026 at 3:16 PM, she stated she did not have a water diagram for the facility but she might have a blueprint. The Administrator brought the blueprints of the facility to her desk and opened the first one. She then gave the State Survey Agency (SSA) Surveyor a floor plan of the facility that showed where the water entered the facility.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the residents' environment remained free of accident hazards for 1 of 17 sampled residents, Resident (R) 54, but had the potential to affect all 64 residents in the facility. The findings include:Review of the facility's policy titled, Resident Room Safety, revised 05/27/2023, revealed, It is the policy of [the facility's name] to ensure resident room safety focusing on fall prevention, environmental hazard identification, and infection control. Core protocols require keeping the room free of clutter, ensuring proper lighting, and maintaining functional assistive devices. 1. Observation on 07/28/2026 at 9:00 AM revealed there was a can of disinfectant spray sitting on the table at the entrance of the facility.During an interview with Housekeeper 1 on 07/28/2026 at 9:43 AM, she stated she did not leave the disinfectant on the table. Housekeeper 1 stated it must have been someone on night shift. She stated housekeeping did not work on nightshift. Housekeeper 1 stated she never left sprays or any chemicals out where residents could have access to them. During an interview with the Administrator on 07/30/2026 at 3:12 PM, she stated there should never be a disinfectant container in the reach of a resident. She stated if a resident had used the disinfectant it could have harmed them. Review of R54's Face Sheet revealed the facility admitted the resident on 04/05/2021. Diagnoses included Parkinson's disease with dyskinesia, epilepsy, and Alzheimer's disease.Review of R54's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/26/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15. The score indicated the resident was cognitively intact. Review of R54's Care Plan, dated 05/28/2026, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit and was at risk of falls related to self-performance with his ADL's and ability to balance. Documented interventions included to recognize that complications related to having secondary parkinsonism which might include light-headedness/dizziness. Further review revealed a focus for impaired visual function related to macular degeneration and dry eyes. Documented interventions included to recognize the signs and symptoms of acute eye problems that might change his ability to perform ADLs and cause a decline in mobility, such as sudden visual loss, double vision, tunnel vision, or blurred or hazy vision.2. Observation on 07/28/2026 at 9:57 AM revealed the marble windowsill, which was adjacent to R54's bed, was broken with a substantial section missing leaving sharp, irregular edges.Further observation on 07/29/2026 at 11:16 AM revealed the marble windowsill was still broken, and no repairs had been completed. During an interview with the Maintenance Director on 07/29/2026 at 3:45 PM, he stated the facility had a process for staff to report maintenance concerns. He stated staff was expected to complete a work order and place it in his mailbox for review. He stated he generally completed repairs within one week of receiving a work order, and often by the following day, depending on the nature of the repair. Once the repair was completed, he stated he signed the work order and forwarded it to the Administrator. He further stated he had not received a work order regarding the damaged windowsill. He stated the Administrator verbally notified him of the issue, and she would obtain the materials needed for the repair. He stated once the materials were available, he could complete the repair. The Maintenance Director stated he had repaired similar windowsills elsewhere in the facility.During an interview with the Administrator on 07/29/2026 at 3:02 PM, she stated the facility expected any staff member that identified an item needing repair to complete a written work order request. She stated the original work order was submitted to the Maintenance Department, and a copy was provided to the Administrator for tracking and follow-up. The Administrator stated the windowsill in R54's room had recently broken, and a work order had not been submitted by staff. She stated she was aware of the damage and planned to obtain the materials needed for the repair. She stated, due to the windowsill being constructed of marble, specialized materials were required to complete the repair. The Administrator stated the necessary materials had not yet been obtained, and the damaged windowsill remained unrepaired.

Based on observation, interview, and review of the facility's policies, the facility failed to store food items in accordance with professional standards to prevent the use of outdated products and reduce the risk of foodborne illness. This deficient practice had the potential to affect all residents receiving food from the kitchen.The findings include:Review of the facility's policy titled, Food Storage, revised 06/26/2024, revealed, It is the policy of [facility's name] to maintain proper food storage. Further review revealed, All food must be stored per standard guidelines including proper refrigeration temperatures, strict date labeling, and systematic off-the-floor placement. Dating of all opened or outside items, and label ready-to-eat, opened, or prepared foods with the preparation or opening date. Review of the facility's policy titled, Expired Foods, revised 04/12/2024, revealed, It is the policy of [the facility] to dispose of expired foods promptly. Any food or products must be disposed of on their expiration date.Review of the facility's policy titled, [Facility Name] Sanitation, revised 01/31/2018, revealed the facility must procure food from approved sources and store, prepare, distribute, and serve food under sanitary conditions. Further review revealed the physical environment, including floors, walls, ceilings, and vent hoods were cleaned. Per the policy, a pest control program was in place, and the kitchen door was not to be propped open.Observation of the facility's kitchen on 07/28/2026 at 9:02 AM revealed the kitchen door was propped open. Further observation of the kitchen refrigerator revealed multiple drink pitchers containing various beverages; a tray of drinking cups containing unidentifiable liquids; and four trays of pudding cups without preparation dates labeled on the containers. Further observation of the refrigerator revealed an opened, in-use carton of potato salad that was not labeled with the date it was opened. Observation of the freezer at 9:06 AM revealed two opened boxes of cookie dough and one opened box of French toast that were not labeled with an opened date.Observation of the kitchen's dry storage area on 07/28/2026 at 9:10 AM revealed expired food items. Those items were ground thyme with an expiration date of 05/22/2025; dillweed with an expiration date of 05/08/2026; ground ginger with an expiration date of 02/07/2026; and leaf tarragon with an expiration date of 06/13/2026.During an interview with the Assistant Dietary Director on 07/28/2026 at 9:32 AM, she stated she assumed the position on 06/23/2026. She stated it was important to date pre-prepared food items so staff could verify that items were recently prepared prior to serving them to residents. She further stated staff should check expiration dates on food items to ensure expired products were not used or served to residents, as the use of expired food items could increase the risk of foodborne illness. She stated food items should be labeled with the date opened to assist staff in determining whether items remained appropriate for use or required disposal.During an interview with the Dietary Director on 07/29/2026 at 3:30 PM, he stated he assumed the position on 06/15/2026, and he was continuing to assess equipment, storage areas, and the dry goods area. He further stated that neither he nor the dietary staff had completed an inventory of the dry goods storage area to verify whether expired food items were present. The Dietary Director stated he was unaware of unlabeled items stored in the refrigerator and freezer. He stated food items should be properly labeled and dated to ensure staff could verify items were appropriate for use and recently prepared prior to serving. He further stated expiration dates should be checked prior to use to prevent outdated food items from being served to residents and to reduce the risk of foodborne illness.During an interview with the Administrator on 07/30/2026 at 3:22 PM, she stated staff was expected to follow the facility's policies related to food safety practices. She stated it was unacceptable for staff not to check expiration dates on food items or fail to label food items with the appropriate preparation dates. The Administrator further stated serving expired or improperly labeled food items could place residents at risk for foodborne illness.

Based on observation, interview, and review of the facility's document and policies, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and insects. This deficient practice was evidenced by a gnat infestation observed in the kitchen dry goods storage area and had the potential to affect all residents receiving food from the kitchen.The findings include:Review of the facility's policy titled, Homelike Environment, revised 07/08/2023, revealed the facility would provide a home-like environment for residents. The policy further stated the facility would create a warm atmosphere that felt inviting and comfortable for residents. Review of the facility's policy titled, Pest Control, no date provided, revealed the facility would maintain an effective pest control program. Per the policy, the facility maintained an ongoing pest control program to ensure the building was kept free of insects and rodents.Review of the facility's document Pest Control Service Agreement, dated 08/17/2023, revealed pests covered under the current contract included ants, spiders, roaches, rodents, silverfish, and beetles. Further review revealed pests excluded from the service agreement were termites, bed bugs, brown recluse spiders, fleas, mosquitoes, flying insects, hornets, pharaoh ants, and fire ants. Observation on 07/28/2026 at 9:10 AM of the dry goods storage area in the kitchen revealed a large gnat infestation. Multiple gnats were observed flying around the room and landing on multiple food items in the storage area.Observation on 07/30/2026 at 3:32 PM of the dry goods storage area in the kitchen revealed gnats were still present and were landing on multiple food items. During a telephone interview with the Customer Service Representative for the pest control company on 07/29/2026 at 1:52 PM, she stated the standard contract did not cover flying insects such as gnats, but the company would treat them for an additional fee. She stated her records from January 2026 to 07/28/2026 revealed no phone calls for additional pest control had been received. She stated the technician who services the facility monthly had made multiple notes in the chart regarding food and drinks constantly being left out. She further stated, in most cases, the company would make it to the facility to provide the services requested within three to four business days. During an interview with the Assistant Dietary Director on 07/28/2026 at 9:32 AM, she stated she assumed the position on 06/23/2026. She stated gnats had been an ongoing issue in the dry goods storage area since she began working in the department, and she was unsure of the source of the infestation. She stated the presence of gnats in the dry goods storage area posed a concern because the insects could come into contact with food products and contaminate them, creating a potential food safety risk.During an interview with the Dietary Director on 07/29/2026 at 3:30 PM, he stated he assumed the position on 06/15/2026. He stated gnats had been an ongoing issue in the dry goods storage area. He stated, other than fresh fruits and vegetables being stored in the area, he was unsure of the cause of the infestation. The Dietary Director stated the presence of gnats in the dry goods storage area was a concern because they could come into contact with and contaminate food products.During an interview with the Corporate Financial Director on 07/29/2026 at 2:10 PM, she stated binders were maintained at each nurses' station for staff to document additional pest concerns. She stated when the pest control company performed scheduled services, company personnel reviewed the binders for any reported concerns requiring attention. She further stated she expected staff to report any pest issues outside of the routine service schedule directly to her so she could arrange for the pest control company to come to the facility to provide additional treatment.During an interview with the Housekeeping and Laundry Supervisor on 07/30/2026 at 10:22 AM, she stated she expected staff to follow the facility's pest reporting protocol by documenting in the designated binder any observed pests and their location. She further stated staff had not reported any pests in resident rooms to her. However, pests had been observed in the dry goods storage area on several occasions.During an interview with the Assistant Director of Nursing (ADON) on 07/30/2026 at 2:45 PM, she stated the facility maintained a pest log binder at each nurses' station for staff to document any observed pest or rodent activity. She further stated staff was expected to notify the maintenance department of any pest or rodent concerns so the exterminator could be contacted. The ADON stated the pest control company was responsive and typically came to the facility when contacted.During an interview with the Administrator on 07/30/2026 at 3:22 PM, she stated the facility had a process that staff was to report concerns to administrative staff. She stated there was also a book/binder located at each nurses' station where staff could document concerns/observations. The Administrator stated when the pest control company came to perform the monthly treatment, they would check the book for any special areas of concern. She further stated the facility could contact the pest control company with any issue between the monthly scheduled treatments, and they would come to address the issue. The Administrator stated she was not aware there was a gnat issue until staff informed her after the State Survey Agency (SSA) Surveyor addressed the issue with staff.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to treat each resident with respect, dignity, and provide care to promote, maintain, or enhance his or her quality of life recognizing each resident's individuality for 2 of 17 sampled residents, Resident (R) 55 and R57. Observations on 07/28/2026 revealed both residents were assisted with their meals by staff who stood over them and did not sit beside them.The findings include:Review of the facility's policy titled, Resident Rights Policy, revised 04/12/2024, revealed the facility would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Review of the facility's policy titled, Meal Assistance Policy, effective 06/27/2025, revealed the facility would ensure proper nutrition, safety, and dignity through structured mealtime periods. It stated certified nursing staff would provide supervision or assistance to residents to consume their meals while adhering to residents' care plans. Further review revealed nursing staff must complete the following when supervising or assisting a resident consume their meal: sit at eye level, offer small and manageable bite sizes, allow ample time for chewing and swallowing, and alternate solids with liquids.Review of the facility's policy titled, Dignity Policy, revised 03/272024, revealed the facility would protect individual autonomy, personal privacy, and self-worth. It stated staff would focus on personalized daily routines, respectful communication, and customized resident choices. Further review revealed staff must sit rather than stand over residents while helping with meals and actively converse with the resident rather than coworkers.Review of the facility's policy titled, Dining Policy, revised 04/27/2025, revealed the facility would ensure proper nutrition, safety, and dignity through structured mealtimes, individualized diet plans, and sanitary food handling. Key components included daily meal schedules, therapeutic diet compliance, and staff assisted feeding protocols. Further review revealed staff must sit at the resident's level when feeding a resident, communicate respectfully, and pace each bite safely to prevent choking.Review of R55's Face Sheet revealed the facility admitted the resident on 08/09/2023. Diagnoses included neuroleptic induced parkinsonism, dementia with behavioral disturbance, and dysphagia (difficulty with swallowing). Review of R55's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/08/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 99, which indicated the resident had been rarely/never understood. Further review revealed the facility had assessed the resident to have loss of liquids/solids from mouth when eating or drinking. It also assessed the resident as dependent with the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. Review of R55's Care Plan, dated 06/10/2026, revealed he had a nutritional problem due to his weight and receiving a mechanically altered diet and a therapeutic diet. Documented interventions included recognizing that signs and symptoms of dysphagia might include pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals.Review of R55's Physician Orders, dated 10/09/2025, revealed his diet was ordered as regular with puree texture and regular consistency. Review of R55's Speech Language Patholgist Orders, dated 06/27/2026, revealed the consistency of liquids was nectar thick.1. Observation of the lunch meal service on 07/28/2026 at 12:31 PM revealed Certified Nursing Assistant (CNA) 5 was assisting R55 with his meal. CNA5 stood on the right side of R55's wheelchair while doing that.During an interview with CNA5 on 07/28/2026 at 12:36 PM, she stated she should be seated while feeding the resident to maintain eye contact. However, she stated she could not find a chair at the time. Review of R57 Face Sheet revealed the facility admitted the resident on 07/10/2024. Diagnoses included stroke affecting her left dominant side, dysphagia, and aphasia. Review of R57's annual MDS, with an ARD of 07/14/2026, revealed the facility assessed the resident to have a BIMS score of nine out of 15. This score indicated R57 had moderate cognitive impairment. Review of R57's Care Plan revealed R57 had a focus of activities of daily living (ADL) self-care performance deficit, dated 07/19/2024. The intervention, dated 07/22/2025, was for staff to supervise/touch the resident when assisting her.2. Observation on 07/28/2026 at 1:08 PM revealed CNA6 was assisting R57 with eating her lunch. CNA6 stood beside the resident while feeding her. During an interview on 07/28/2026 at 1:08 PM with CNA6, she stated she knew she should be sitting while feeding residents. However, she stated it was hard to find a chair, and she did not feel like looking for one. During an interview on 07/30/2026 at 2:45 PM with the Assistant Director of Nursing (ADON), she stated staff was expected to follow the facility's policy and sit beside the residents when feeding them. She stated the residents would eat better if staff was looking at them and interacting with them. During an interview on 07/30/2026 at 10:44 AM with the interim Director of Nursing (DON), she stated it was her expectation for staff to sit while feeding residents. She stated if there were a lot of residents and staff in the dining room there might not be any seats available. However, she stated the facility had extra chairs throughout the facility which staff could get. She stated it was important for staff members to be at eye level so they could talk and interact with residents. She stated standing could draw unwanted attention.During an interview on 07/30/2026 at 10:23 AM with the Administrator, she stated her expectations were for staff to follow policy, sit with the resident and interact, and not to rush the resident during assisted feedings. She stated it was important not to make the resident uncomfortable. She stated if staff members stood while they were assisting the resident with the meal, the resident might be less apt to eat. She also stated it was a dignity issue because other people could see what was going on. She stated residents should not have staff standing over them because it made them uncomfortable.

Based on interview, record review, and review of the facility's policies, the facility failed to notify the resident and the resident's representative of the bed hold and the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 out of 3 residents reviewed for discharge, Resident (R) 4.Record review revealed R4 was sent to the hospital on [DATE] and 04/06/2026. However, the facility did not provide written notification to the resident and the resident's representative.The findings include:Review of the facility's policy titled, Bed Hold, last revised 03/31/2023, revealed, It is the policy to inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed hold policy.Review of the facility's undated policy titled, Notice of a Transfer and/or Discharge, revealed, It is the policy to provide resident, and/or the resident's representatives (sponsors), with a written notice of an impending transfer or discharge. The resident and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. the name, address, and telephone number of the state long term care ombudsmen; e. the names, addresses, and telephone numbers of individuals or agencies responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); f. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.Review of R4's Face Sheet revealed the facility admitted the resident on 06/08/2016. Diagnoses included hemiplegia affecting left dominant side following a stroke, need for assistance with personal care, and above the knee amputation of the left leg.Review of R4's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/20/2026, revealed the facility assessed the resident to have a Brief Interview Mental Status [BIMS] score of 15 out of 15. The score indicated R4 was cognitively intact. Review of R4's Census revealed R4 was transferred to the hospital on [DATE]. Further review revealed another hospital transfer on 04/16/2026.1. Review of R4's Nursing Facility to Hospital Transfer, dated 02/16/2026, revealed R4 was transferred to the hospital for projectile vomiting and severe diarrhea. However, the document did not include the location to which the resident was being transferred or discharged ; the name, address, and telephone number of the state long term care ombudsmen; the names, addresses, and telephone numbers of individuals or agencies responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and the name, address, and telephone number of the state health department agency that had been designated to handle appeals of transfers and discharge notices.Review of R4's Bed-Hold Notice, dated 02/16/2026, revealed R4 had signed the notice. However, there was no indication that R4's representative was made aware. Review of R4's Nurses Notes revealed an undated written note, timed at 8:54 PM, that stated, Resident has been projectile vomiting and having profuse watery diarrhea for the past 90 minutes continuously. MD notified new order may send to ER.Called report to ER nurse.resident left facility via ambulance at 9:08 PM sitter notified by phone at 9:13 PM.2. Review of R4's Nursing Facility to Hospital Transfer, dated 04/06/2026, revealed R4 was transferred to the hospital for change in condition, vomiting, and body aches. However, the document did not include the location to which the resident was being transferred or discharged ; the name, address, and telephone number of the state long term care ombudsmen; the names, addresses, and telephone numbers of individuals or agencies responsible for the protection and advocacy of mentally ill or developmental disabled individuals (as applies); and the name, address, and telephone number of the state health department agency that had been designated to handle appeals of transfers and discharge notices.Review of R4's Bed-Hold Notice, dated 04/06/2026, revealed verbal consent was obtained from the resident. However, there was no indication that R4's representative was made aware. Review of R4's Nurses Notes, dated 04/06/2026, revealed, 10:40 AM- resident noted with large amount of emesis.resident shivering, requesting heavy blankets and fan to be turned off, states body aches. Doctor notified. Order received to send resident to ER [emergency room] for evaluation. 10:55 AM-dispatch contacted, reported called to ER. 11:10 AM - resident transferred from facility by EMS. 2:52 PM - call received from ER, resident admitted for sepsis. During an interview on 07/29/2026 at 3:45 PM with R4, she stated the facility did not notify her sister, who was listed in her chart as her emergency contact, when she was sent to the hospital. She stated she wished they would because recently when she was at the hospital, her sister showed up at the facility to visit because her sister did not know she was not there. During an interview on 07/30/2026 at 1:18 PM with R4's representative, she stated the facility sometimes would call her to let her know R4 had been sent to the hospital. However, she stated it was not consistent, and staff did not always make her aware. She stated it would be nice to know when R4 was not at the facility, so she did not waste a trip to visit at the facility. During an interview on 07/29/2026 at 3:30 PM with the Business Office Manager (BOM) and Corporate Financial Director, they stated they did not send a reason for transfer or bed hold notice to the resident's representative if the resident was their own person. They stated they might call the family to make them aware if the resident could not make their own decisions. They stated the nurses on the floor were the ones responsible for completing the transfer form and sending it with the resident to the hospital. During an interview on 07/30/2026 at 10:46 AM with the Director of Nursing (DON), she stated the facility always got a bed hold signed by the resident. However, she stated if the resident was not able to sign, staff contacted whoever was listed and made them aware verbally over the phone. She stated she did not know if any notice or document was sent to the resident's representative because it was usually explained over the phone. The DON stated she did not know what the facility policy or what the regulations stated. She stated it would be important for families to know their rights.During an interview on 07/30/2026 at 10:23 AM with the Administrator, she stated the facility usually called whoever was listed as the next of kin for the reason of transfer. She stated the bed holds were done with the residents if they were their own responsible party. She stated it was important for the residents to know what was offered to them and whether they could return to the facility. She stated the resident had to agree for the facility to notify their representative.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and include measurable objectives for 1 out of 17 residents reviewed for care plans, Resident (R) 4.Observation on 07/28/2026 at 4:00 PM revealed R4 did not have bilateral rails on her bed to assist with bed mobility. However, R4 was care planned to have them.The findings include:Review of the facility's policy titled, Comprehensive Care Plans, revised date 04/26/2017, revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights. They shall include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in a comprehensive assessment.Review of R4's Face Sheet revealed the facility admitted the resident on 06/08/2016. Diagnoses included hemiplegia affecting left dominant side following a stroke, need for assistance with personal care, and above the knee amputation of the left leg.Review of R4's annual Minimum Data Set [MDS], with an Assessment Reference Date of 07/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15. The score indicated R4 was cognitively intact. Review of R4's Care Plan revealed R4 had an activities of daily living (ADL) self-care performance deficit related to hemiplegia to the left side, dated 03/21/2025. An intervention included 1/4 rails up to assist with bed mobility, dated 07/24/2025.Review of R4's Bed Rail Assessment, dated 04/10/2026, revealed bilateral side rail placement was recommended to serve as an enabler to promote independence, and the resident had expressed a desire to have side rails/assist bar.Review of R4's Order Details, dated 04/10/2026, revealed an order for bilateral 1/4 side rails up to aide in bed mobility.Observation on 07/28/2026 at 4:00 PM revealed R4 did not have bilateral rails on the bed to assist with bed mobility. The right side bedrail was missing.During an immediate interview with R4, she stated she was supposed to have handrails to assist with turning in bed, she stated the right one had been missing for approximately six months and had not been replaced. R4 stated since she did not have the rail to help herself turn in bed, she now had to rely solely on staff to assist her, and she did not like to ask them to help her turn all the time. During an interview on 07/30/2026 at 10:49 AM with the Director of Nursing (DON), she stated it was her expectation that staff followed care plans for each resident. She stated it was important because it directed staff on how to care for the residents. During an interview on 07/30/2026 at 10:34 AM with the Administrator, she stated care plans should be followed 100 percent of the time because it instructed staff on what actions were required to take care of the resident.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) did not diminish for 1 out of 12 residents reviewed for ADLs, Resident (R) 4.Record review revealed an order for R4 to have bilateral 1/4 side rails to aide the resident in bed mobility. The order was written on 04/10/2026. However, on 07/28/2026, R4 stated the right one had been missing for approximately six months and had not been replaced. The findings include:Review of the facility's policy titled, Activities of Daily Living, dated 08/25/2025, revealed, It is the policy of the facility that activities of daily living are provided for each resident for basic self-care activities that must be performed on a day-to-day basis for one to live independently. the following assistance will be provided to all residents as needed: Mobility-The ability to move about both inside and outside of one's home. This includes walking, going up and down stairs, getting out of bed and into a wheelchair, and standing from a seated position to use a walker.Review of R4's Face Sheet revealed the facility admitted R4 on 06/08/2016. Diagnoses included hemiplegia affecting left dominant side following a stroke, need for assistance with personal care, and above the knee amputation of the left leg.Review of R4's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15. The score indicated R4 was cognitively intact. Review of R4's Care Plan revealed an ADL self-care performance deficit related to hemiplegia to the left side, dated 03/21/2025. An intervention included 1/4 rails up to assist with bed mobility, dated 07/24/2025.Review of R4's Bed Rail Assessment, dated 04/10/2026, revealed bilateral side rail placement was recommended to serve as an enabler to promote independence. It also stated the resident had expressed a desire to have side rails/assist bar.Review of R4's Order Details, dated 04/10/2026, revealed an order for bilateral 1/4 side rails up to aide in bed mobility.Observation on 07/28/2026 revealed the bedrail was not on the right side of the bed for R4 to use.During an immediate interview with R4, she stated she was supposed to have handrails to assist with turning in bed, she stated the right one had been missing for approximately six months and had not been replaced. R4 stated since she did not have the rail to help herself turn in bed, she now had to rely solely on staff to assist her. She stated she did not like to have to ask staff to help her turn all the time. During an interview on 07/30/2026 at 10:50 AM with the Director of Nursing (DON), she stated it was important for residents who were assessed for bed rails, had orders for bedrails, and were care planned for bedrails to have them in place to prevent a decline in ADLs and prevent skin issues. She stated the bedrails helped R4 with bed mobility.During an interview on 07/30/2026 at 10:35 AM with the Administrator, she stated R4 should have the rail in place. She stated it should have been fixed and/or replaced as soon as it was broken. She stated maintenance should have been made aware. The Administrator stated it also was a safety concern.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain grooming and personal hygiene for 1 out of 12 residents reviewed for ADLs, Resident (R) 17.The findings include:Review of the facility's policy titled, Activities of Daily Living, dated 08/25/2025, revealed, It is the policy of [facility name] that activities of daily living are provided for each resident for basic self-care activities that must be performed on a day-to-day basis for one to live independently. Further review revealed, The following assistance will be provided to all residents as needed: personal hygiene - safely getting in and out of the bathtub or shower or cleaning oneself. Also includes other grooming activities such as shaving, nail care, and brushing teeth.Review of the facility's policy titled, Resident Rights Policy, revised 04/12/2024, revealed the facility would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Per the policy, the facility must protect and promote the rights of the resident. Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised 03/27/2024, revealed residents had the right to be treated with dignity and respect, as well as make their own schedule and participate in the activities of choice.Review of the facility's policy titled, Homelike Environment Policy, revised 07/08/2023, revealed resident independence and identity would be respected by all staff, allowing them to make choices about their daily lives.Review of [The facility] Staff and Agency Staff Nurse Aide Expectations, no date listed, revealed all assigned resident showers were to be completed daily. Review of the facility's Shower Schedule, dated 02/13/2026, revealed R17 was to receive a shower on Wednesdays and Saturdays. Review of the facility's Staffing, dated 07/29/2026 (Wednesday) for both day and night shift, revealed R17 did not receive a shower during either shift. The State Survey Agency (SSA) Surveyor requested from the Administrator, on 07/30/2026 at 1:17 PM and 3:37 PM, documentation of showers received or refused by R17. However, this documentation was not provided.Review of R17's Face Sheet revealed the facility admitted the resident on 04/19/2024. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, bilateral primary osteoarthritis of the hip, other intervertebral disc degeneration, and need for assistance with personal care. Review of R17's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/14/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating moderate cognitive impairment. Further review revealed the resident required partial/moderate assistance with bathing self, including washing, rinsing, and drying self (excluding washing of back and hair). Review of R17's Care Plan, dated 02/04/2026, revealed the resident had a self-care performance deficit and was at risk of falls related to self-performance with her activities of daily living (ADL) and her ability to balance. Documented interventions included supervision or touching with upper and lower body dressing and personal hygiene. Further review revealed R17 was substantial to maximal assistance with putting on and taking off footwear, shower/bathe self, tub/shower transfer, sit to stand, chair/bed-to-chair transfer. During an interview on 07/29/2026 at 11:33 AM with R17, she stated on multiple occasions she requested staff assist her with a shower. The resident stated staff members indicated they would return to do the shower but did not return. She stated she could not remember the staff members' names who did that. The SSA Surveyor was present at R17's bedside on 07/29/2026 at 11:33 AM when she requested a shower from CNA9 who had responded to the resident's call light. Observation and interview on 07/30/2026 at 8:15 AM revealed R17 had not had a shower since her request for one on 07/29/2026. R17 stated she had not received a shower since Saturday, 07/25/2026, and felt embarrassed to go out of the room. She stated showers made her feel so much better, not just physically but mentally as well. The State Survey Agency (SSA) Surveyor attempted to interview CNA9 on 07/29/2026 and 07/30/2026 but was unsuccessful. During a telephone interview with CNA10 on 07/30/2026 at 1:55 PM, she stated she worked the night shift on 07/29/2026 and received report from CNA9. CNA10 stated CNA9 reported that everything was fine and did not report that R17 had refused care or her scheduled shower. CNA10 stated, prior to leaving after her shift on the morning of 07/29/2026, she documented the residents due for showers on the shower schedule sheet provided to CNA9. She stated R6 and R17, who were roommates, were both listed on the shower sheet as due for showers.During the continued telephone interview with CNA10 on 07/30/2026 at 1:55 PM, CNA10 stated residents should not miss their scheduled shower days. She further stated if a resident refused a shower during her shift, she would provide alternate care, such as a bed bath, and document the refusal according to the facility's procedure. CNA10 stated R17 typically looked forward to receiving showers, and she could not recall R17 refusing care, especially a shower. She stated if she had been informed that R17 did not receive her scheduled shower, she would have attempted to provide the shower during her shift. CNA10 stated when a shower was completed or a resident refused, staff completed the shower documentation form, obtained the nurse's signature, and submitted the form according to the facility's process.During an interview with CNA11 on 07/30/2026 at 10:03 AM, she stated it was her first day of employment with the facility. She stated nursing staff provided CNAs with a shower schedule at the beginning of each shift. CNA11 stated she planned to begin scheduled showers at the start of her shift to ensure residents received their showers as scheduled. She stated residents looked forward to their showers, and it was important for residents to receive their scheduled care. CNA11 further stated if a resident requested a shower on a day that was not their assigned shower day, she would make every effort to provide the shower. She stated residents should receive their showers on their assigned shower days unless they refused. CNA11 stated if a resident initially refused a shower, staff should attempt to provide the shower again later in the day to determine if the resident had changed their mind prior to documenting the shower as refused.During an interview with the Assistant Director of Nursing (ADON) on 07/30/2026 at 2:45 PM, she stated she expected staff to follow the facility's policies and perform the duties associated with their assigned responsibilities. She stated on a resident's scheduled shower day, staff should ask the resident if they wanted to receive their shower. She further stated if the resident agreed, the shower should be completed; and if the resident refused, the refusal should be documented according to the facility's procedure. The ADON stated staff was expected to provide residents with scheduled showers and to provide showers when requested by residents outside of their scheduled shower days.During an interview with the Administrator on 07/30/2026 at 3:22 PM, she stated her expectation of staff was for all residents to receive their scheduled showers as assigned and in a timely manner. She stated it was unacceptable for residents not to receive a scheduled shower or an alternate form of hygiene care, such as a bed bath, when requested or when a shower could not be completed. The Administrator further stated all residents should receive their showers on their assigned shower days and additionally when they requested a shower outside of their scheduled day.

Based on observation, interview, and review of the facility's policy, the facility failed to store all drugs and biologicals per the facility's policy and under proper temperature controls for 1 out of 2 medication refrigerators, Medication Refrigerator 1. The findings include:Review of the facility's policy titled, Medication Storage, dated 12/28/2025, revealed, It is the policy of the facility that medication be stored in accordance with pharmacy recommendations. The pharmacy will provide guidelines for storage of medications per federal, state, and local regulations. External use drugs in liquid, tablet, capsule or powder form are to be stored separately from drugs for internal use. All medications requiring refrigeration must be kept refrigerated at proper temperatures. medications must be stored under appropriate temperatures: refrigeration 36 [degrees Fahrenheit] to 46 [degrees Fahrenheit].Observation on 07/29/2026 at 10:15 AM of the medication refrigerator in the medication room behind nurses' station 1 (Medication Refrigerator 1) revealed its temperature was 30 degrees Fahrenheit (F). There was ice buildup on the back, inside of the refrigerator. Suppositories were being stored in the door along with an insulin pen. Medications in the refrigerator consisted of bisacodyl suppositories, Ozempic Pens, Prolia injection for osteoporosis, Dupixent injection to treat asthma, Tresiba insulin injection, Novolog injection, insulin glargine injection, Novolog 70/30 injection, Trulicity injection, and Tuberculin Purified Protein Derivative (PPD) vials. During an interview on 07/29/2026 at 10:20 AM with Registered Nurse (RN) 1, she stated the temperature of the refrigerators were checked by the night shift nurses. She stated all medications in the refrigerator were new and unopened medications. She stated she was unsure what the temperature range of the refrigerators was supposed to be.During an interview on 07/30/2026 at 10:51 AM with the Director of Nursing (DON), she stated it was her expectation that the medications were stored under the correct temperature. She stated that would ensure the potency of the medication.During an interview on 07/29/2026 at 10:30 AM with the Administrator, she stated she was unaware of the refrigerator being so full of medications. She also stated she was unaware of the ice buildup on the back of the refrigerator. During an additional interview on 07/30/2026 at 10:38 AM with the Administrator, she stated the refrigerator temperatures were checked every day. She also stated it was important to ensure the refrigerator temperature was within range to ensure the medications were safe to give.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement policies and procedures that established a protocol for the determination of capacity to consent to sexual contact for 2 of 4 sampled residents, Resident (R) 4 and R13. Observations by staff on 07/27/2025 and 07/28/2025 revealed R4 and R13 were engaged in sexual behavior with one another. However, the facility's policy did not address the requirement to assess residents' capacity to consent to a sexual relationship and there was no evidence the facility assessed the residents for their capacity to consent to a sexual relationship.Additionally, the facility's policy failed to contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. The findings include:Review of the facility's policy titled, Abuse Investigation Policy Statement, dated 11/14/2016, revealed one of the seven components of the policy included prevention. Prevention was defined by identification, correction, and intervention of a situation in which abuse was more likely to occur. Further review revealed the policy did not address the identification of when, how, and by whom determinations of capacity to consent to a sexual contact would be made and where this documentation would be recorded. Continued review of the policy revealed the policy did not contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. 1. Review of R4's admission Record revealed the facility admitted the resident on 07/28/2021 with diagnoses which included vascular dementia, delusion disorder, bipolar disorder, Alzheimer's disease, and Lewy Body dementia.Review of R4's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/23/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 of 15, indicating moderately impaired cognition. Review of R4's Care Plan, undated, revealed the resident was care planned for male visitor(s), and staff should allow for privacy. She was also cared planned for a history of delusions, dementia, psychotropic medication, and antibiotics related to an acute urinary tract infection (UTI) and cellulitis of her right lower extremity. Review of R4's medical record revealed no documented evidence the facility had assessed the resident for the ability to consent to a sexual relationship prior to the State Survey Agency (SSA) September 2025 survey.Further review of R4's medical record revealed a Judicial Order, dated 07/21/2021, appointing the state as guardian and conservator of the resident.Review of R4's Psychiatric Progress Notes, dated 09/03/2025, revealed the Psychiatric Nurse Practitioner (PNP), performed an evaluation for capacity to sexually consent.During an interview on 09/03/2025 at 8:25 AM with R4's current State Guardian (SG), he stated he first met R4 during the first week of August 2025. He stated the previous SG told him they were waiting for the court to decide R4's capacity to consent.During an interview on 09/03/2025 at 8:33 AM with R4's previous SG, she stated, to her knowledge, they were not waiting on court proceedings but for the Psychiatric Nurse Practitioner (PNP), who had already been working with the resident, or the physician, to do a capacity to consent evaluation. She stated, unless there was a capacity to consent, the residents were not to have sexual relations of any kind. She stated she was under the impression sexual relations only happened one time. However, she stated when she went to the facility, it appeared it was continuing. She stated she did not know if the capacity to consent assessment was ever done because she was no longer R4's SG.2. Review of R13's admission Record revealed the facility admitted the resident on 09/05/2023, with diagnoses which included anxiety, major depression, and multiple physical co-morbidities.Review of R13's MDS, with an ARD of 06/06/2025, revealed the facility assessed the resident to have a BIMS score of 12 of 15, indicating moderately impaired cognition.Review of R13's medical record revealed no documented evidence the facility had assessed the resident for the ability to consent to a sexual relationship prior to the State Survey Agency (SSA) September 2025 survey.Review of R13's Nurses' Notes dated 07/27/2025 at 7:50 PM and written by Registered Nurse (RN) 3, revealed a State Registered Nurse Aide (SRNA) reported to RN3 that R4 was in R13's room, lying on the bed with no clothes on, and R13 was lying on top of her. The note stated R4 and R13 told RN3 the residents wanted to have sex, and they understood the potential consequences. Per the note, privacy was provided, and the Director of Nursing (DON) and the Administrator were advised of that by phone.Review of R13's Nurses' Notes, dated 07/28/2025 at 2:55 PM and written by RN1, revealed R4 was in R13's room, and R13 was sitting on his bed with his pants down, exposing himself. Per the note, R13's door was closed for privacy, and the Assistant Director of Nursing (ADON), DON, Social Services Director (SSD), and the Administrator were notified. During a telephone interview with State Registered Nurse Aide (SRNA)5 on 09/04/2025 at 3:04 PM, she stated she was passing ice. She stated she knocked on R13's door on the evening of 07/27/2025 and announced she was bringing ice. She stated she saw R13, with his pants down. She stated she saw R4 on the bed, but SRNA5 did not notice what R4 was wearing. She stated she told the nurse, RN3, what she saw.During an interview on 09/03/2025 at 8:39 AM with RN1, she stated R4 and R13 had been alone together on more than one occasion. She stated she was personally aware of three occasions, and the aides had reported it to her twice. She stated she was not sure what was done behind closed doors, and staff attempted to provide privacy. During an interview on 09/03/2025 at 8:47 AM with the Social Services Director (SSD), she stated R4 reported to her that she had been crazy about R13 for a long time. She stated she was made aware of the incident that occurred on 07/27/2025 the following day, on 07/28/2025. She stated she made R4's previous SG aware. She stated the previous SG told her R4 and R13 had the right to engage in sexual activities, so long as they were able to make that decision. She stated, at the time, both R4 and R13 had a BIMS score of 11 (moderate cognitive impairment). The SSD stated the previous SG requested a capacity to consent evaluation from the PNP who had been seeing R4 at the facility. She stated when she asked the PNP to do that, the PNP told her she would look into it. However, she stated R4 was in and out of the hospital around that time for a UTI. She stated, as far as she knew, R4 and R13 were allowed to engage in sexual activity. She stated the PNP came weekly, and it had not come up as an issue. During an interview with the PNP on 09/04/2025 at 12:30 PM, she stated her process to evaluate if a resident had the capacity to consent for sexual activity was to look at the context of the situation. She stated she had not done any assessment or evaluation of R4 or R13 prior to the residents being in a sexual relationship. She stated the facility informed her that R4 was having a relationship with a man, so she evaluated R4 on 09/03/2025.During an interview on 09/04/2025 at 10:13 AM with the Director of Nursing (DON), she stated R4 was highly flirtatious before the UTI, so for her to engage with this resident didn't surprise me. She stated she had not been aware of any sexual activity before these incidents. She stated she knew R4 would flirt with different men, and if the men did not respond, she would move on to someone else. During an interview on 09/04/2025 at 3:55 PM with the Medical Director, who was also R4's and R13's primary care physician, he stated he was aware of an intimate relationship on the first occasion. However, he stated he was not aware of much more than that. He stated he was not aware of a capacity to consent used at the facility, and it would be his preference to have that on file. He stated that, while the physical relationship was not his preference, he did feel that R4 was able to make those types of decisions, and to make her not be able to spend time with R13 seemed to not be in the best interest of either resident.During an interview on 09/04/2025 at 4:53 PM with the Administrator, she stated she was unaware the facility's abuse policy needed to include procedures to assess residents for the capacity to consent to sexual relationships and she was unaware the policy required the eighth component, in which the facility must coordinate situations of abuse with the QAPI program. She stated she felt R4 and R13's relationship was acceptable as she viewed them both to be consenting adults.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide 2 (Resident (R) 54 and R10) of 21 sampled residents the right to reside and receive services with reasonable accommodation of the resident's needs and preferences except when to do so would endanger the health or safety of the resident or others. The facility moved or removed personal items, furnishings, and/or equipment without consideration of resident preferences and accommodation of each resident's individual needs. This failure caused R54 emotional distress over a sustained period of time and the resident was tearful as she related that the facility moved and mounted her television on the wall in a place where she had difficulty seeing it due to her physical limitations, as well as removed shelving that housed her personal collectibles. The findings include: Review of the facility's Homelike Environment Policy, revised 07/08/2023, revealed that it was the policy of the facility to provide a homelike environment for the residents. Further review of the policy revealed that it was the procedure of the facility to encourage residents to decorate their space using their personal belongings to reflect their identity and preferences.Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed that it was the policy of the facility to promote the rights of the residents residing in the facility. Review of this policy stated that it was the procedure of the facility to provide the resident with a dignified existence, self-determination, and communication with and access to persons and services both in and outside of the facility. Further review of the policy revealed that the facility would make every effort possible to assist the resident in exercising his/her rights and to assure that he/she was always treated with respect, kindness, and dignity. The facility would ensure that the resident could exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility.Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised 03/27/2024, revealed that it was the policy of the facility to promote and protect the rights of all residents residing in the facility. Further review of the policy revealed that residents have the right to keep and use their own personal belongings and property if it did not interfere with the rights, safety, or health of others.1. Review of Resident (R)54's Face Sheet revealed that she was admitted to the facility on [DATE], with diagnoses of [NAME] Disease (a rare, chronic, progressive cerebrovascular disorder), multiple sclerosis, muscle contractures (where joints become permanently fixed in a bent or shortened position, limiting movement), stiffness of unspecified joint, and cerebrovascular disease. Review of R54's current Physician Orders revealed an order dated 09/08/2021 that stated, May have convoluted foam mattress [also known as an egg crate mattress] on bed.Review of R54's quarterly Minimum Data Set (MDS), dated [DATE], revealed that she was assessed as participating in assessments and goal setting. Review of R54's Assessments tab revealed a Brief Interview for Mental Status Evaluation (BIMS) score of 15/15, dated 07/02/2025, indicating that the resident was cognitively intact. Review of R54's Comprehensive Care Plan, with the initiation date of 10/28/2024 and a target date of 10/08/2025, revealed that R54 was care planned for being at risk for little or no participation at times in activities per her wishes. The goal for this focus was that R54 would be encouraged to attend or participate in activities of her choice and would socialize with staff and others to improve the quality of her life. One intervention for this focus was that during leisure times in her room, she liked to watch television (TV). Observation on 07/22/2025 at 2:50 PM of R54's room revealed R54 was sitting to the left of the TV, partially in the doorway so that she could view the TV by rolling her eyes to the left to view the TV out of the corner of her eyes. Further observation revealed that the resident had two shelves hanging over her bed. Both of these shelves were greater than 18 inches from the height of any sprinkler heads in the room. The shelves contained stuffed animals and a few Coca-Cola items, messily and tightly stuffed on them. R54's TV was mounted on the wall beside the door. R54's bed was unmade at the time of the observation and there was no foam mattress/mattress topper upon the bed.In an interview with R54 on 07/22/2025 at 2:50 PM, she said that the TV once sat on her bedside table, which was observed to be approximately 2 - 3 feet below where the TV was currently mounted on the wall. R54 tearfully stated that the Administrator told her that her television had to be mounted on the wall and that it was to be placed where the Administrator chose. R54 stated that she was not allowed to have the television placed where she (R54) could see it easily, explaining that due to her neck contracture, she had to sit beside the television and look out of the corner of her eyes to watch the TV. R54 also noted that the facility also took down one of her shelves and was planning on removing her other shelves. R54 stated she had no other place to display her Coca-Cola memorabilia and was told that she would have to box up her things and place them in her closet or send them home with her daughter because the facility would be removing her remaining shelves. R54 stated she was never told why the TV had to be mounted in that specific location or why the facility was removing her shelves. R54 stated she told the Administrator that she did not want her TV moved, or her shelves removed from the wall; however, the Administrator responded that the room belonged to her (the Administrator and the facility) and not to the resident. R54 stated that the Administrator also took away her mattress topper pad, making her bed uncomfortable to sleep upon. R54 asked repeatedly for a new one, but did not receive one, and her requests for moving her television and replacing her shelves and mattress pad were also denied. R54 stated she felt like this treatment was an infringement of her rights and negatively impacted her dignity by making her feel that her needs or opinions did not matter. R54 was unable to give the exact date when her shelf was removed, and her television mounted in a place which did not accommodate the resident's physical needs or preferences, but said it happened at the end of 06/2025. In an interview with State Registered Nursing Aide (SRNA) 2 on 07/23/2025 at 8:33 AM, SRNA2 stated R54 was very upset and screamed and cried when they removed her shelf from her wall and moved her TV to where she could not see it. SRNA2 stated the incident with the shelf being removed and the television being mounted on the wall in R54's room occurred at the same time. SRNA2 was unable to pinpoint an exact date that the incident occurred but knew that it was less than a month ago. In an interview with Registered Nurse (RN) 3 on 07/23/2025 at 9:05 AM, RN3 stated that R54 cried the first day they moved her television and screamed and cried for two days after the TV was mounted on the wall and the shelf removed from her room. R54 told the Administrator that she could not see the TV where it was mounted on the wall and was told by the Administrator that it had to be there. Per RN3, the Administrator told R54 that having shelves on the walls in residents' rooms was a code violation. In an interview with Ombudsman1 on 07/23/2025 at 9:32 AM, Ombudsman1 stated R54 could not understand why her television had to be mounted on the wall and why the facility removed her shelf that had her belongings on it. Ombudsman1 stated she was told the shelves needed to come down because the residents had too much stuff on their shelves, and it was a hazard. Ombudsman1 stated R54 was very upset about this. She stated that they never asked R54 where or if they could move her TV. Ombudsman1 stated R54 did not cry when telling her about the incident, but was very frustrated about it, instead.In an interview with Contract Staff (CS) 2 on 07/23/2025 at 10:49 AM, CS2 stated that R54 was distraught about her TV being placed on the wall where she did not want it and her shelf being taken down. CS2 stated residents' televisions were being mounted on the wall because they looked better there, per the Administrator. CS2 stated she felt the way R54 was treated infringed on her resident rights and diminished her dignity. Although multiple interviews with staff revealed they were aware of the resident screaming, crying, upset, and being distraught, review of R54's clinical record revealed no notes or evidence documenting this distress.2. Review of R10's Face Sheet, revealed that she was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, and anxiety. Review of R10's quarterly MDS, dated [DATE], revealed that R10 was assessed as having a BIMS score of 15/15, indicating that the resident was cognitively intact.Review of R10's Physician Orders, revealed an order dated 09/11/2023 that stated, May have convoluted foam mattress on bed.Observation of R10's room on 07/23/2025 at 1:08 PM revealed that she had two shelves on her wall. The resident's TV was sitting unmounted on a bedside chest. No mattress topper was apparent on R10's bed, which felt hard.In an interview with R10 on 07/23/2025 at 1:08 PM, R10 stated she was told the facility was going to mount her TV to the wall and were going to remove all her shelves. The resident stated no reason was given why this was occurring. She stated that she would like to keep her shelves. R10 added that it was OK if they mounted her TV to the wall; however, she wanted to be the one to decide where it was put. Further interview with R10 revealed that in the past, she had a personal mattress topper like R54; however, the facility came and took it away, stating that she was no longer able to have a mattress topper.In an interview with the Director of Maintenance (DM) on 07/23/2025 at 3:16 PM, the DM stated that the Administrator decided where to mount residents' televisions and he just did what the Administrator told him. He stated that residents do not have a choice in the matter. The DM stated that the Administrator instructed him to mount the televisions on the wall where residents could see the television while lying in bed. He stated he was not sure if the Administrator had asked any resident where to put their televisions or not. He added that shelves were also being taken down because of the televisions being mounted on the walls. The DM stated he did not try and move the shelves to another location in the resident rooms because it was difficult to do so because of the limited space and the shelves had to be eighteen inches from the sprinklers. He noted that the Administrator did not want the shelves moved, only taken down. The DM stated he did not remember when he mounted R54's TV on the wall or took her shelf down. He stated that he did what the Administrator instructed him to and did not receive written work orders or keep logs of maintenance items he performed at the facility,In an interview with the Director of Nursing (DON) on 07/24/2025 at 7:58AM, she stated R54's TV was initially placed in a manner that R54 could not see it; however, it was moved a few days later and R54 was happy with where the TV was now mounted. (However, interview and observation on 07/22/2025 at 2:50 PM with the cognitively intact resident revealed that R54 displayed tearful distress/unhappiness and physical limitation in viewing her TV in the location where it was currently mounted.) Further interview revealed the DON was unaware of the removal of a shelf in R54's room and did not think the other shelves were going to be removed. The DON stated that the mattress toppers were removed prior to her becoming the DON on 04/12/2025, indicating a belief that this was done for infection control, as well as the physician-ordered mattress toppers being a fire hazard. In an interview with the Administrator on 07/24/2025 at 9:24 AM, she stated that she wanted the TVs mounted to the wall, so they were not knocked off and broken. The Administrator stated that R54 wanted her television mounted on the wall where the divider curtain was halfway over the TV. Instead, it was placed on the same location on the wall above where it previously sat on R54's bedside table. The Administrator went on to explain that because some residents in the facility had shelves that were too close to the sprinklers, all resident shelves were being removed, adding that if there were items on the shelves touching the sprinklers, this was against regulations. Further interview with the Administrator revealed the mattress toppers were uncovered egg crate/foam mattress toppers which she considered an infection control issue for incontinent residents. She stated that the mattress toppers also interfered with the mattresses on the beds in preventing pressure ulcers or shearing injuries, adding that nothing else can go on top of the mattress or it does not work correctly. In the interview, the Administrator contradicted herself by first stating that she had told residents they could not have mattress toppers, and then later in the interview, stated that if their family provided a mattress topper, she would allow a resident to have one. When interviewed about honoring the residents' personal preferences/accommodating individual needs (such as TV placement for R54, whose contractures, MS, and muscle stiffness affected her ability to move her head to watch television), the Administrator repeatedly stated, We know what's best for them, indicating that the facility was making decisions for its cognitively intact residents, regardless of their input. Although the Administrator stated that the TVs had to be on the wall to keep the resident safe from injury, and then indicated that mattress toppers could not be used due to risk of fire, the Administrator provided no evidence to indicate that either R54 or R10 had sustained these type of consequences and therefore, could not have input into accommodations to their physical environment, based on safety concerns.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and/or mental and psychosocial needs identified in the comprehensive assessment for three (Resident (R)4, R46, and R36) of 21 sampled residents. The findings include:Review of the facility policy, Comprehensive Care Plans, dated 04/26/2017, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights. Further review revealed the care plan was to include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs.1.a. Review of Resident (R)4's admission Record revealed the facility admitted the resident on 05/18/2019. At this time, the resident had no pressure ulcers. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/2024 revealed the resident was still free from pressure ulcers. The facility identified that the resident was, however, at risk for pressure ulcers. Per the MDS, the resident required moderate to maximal assistance with mobility but was not on a turning and repositioning program. Review of R4's Comprehensive Care Plan (CCP), dated 04/18/2024, revealed the facility assessed the resident as being at risk for pressure ulcer development and included the intervention for staff to assist R4 to reposition according to facility protocol. These protocols were requested; however, the facility failed to provide any such protocols prior to exit on 07/25/2025. Review of the care plan revealed that it did not include resident-specific interventions related to turning and repositioning prior to the resident developing a facility-acquired Stage III pressure ulcer on 01/14/2025. (Refer to F686.)Review of the facility document Initial Wound Evaluation and Management Summary, dated 01/14/2025, revealed the wound doctor assessed R4 to have a new Stage III pressure ulcer on her right buttock. Review of R4's Comprehensive Care Plan, dated 04/18/2024 revealed no evidence that it reflected the new facility-acquired pressure ulcer until 06/17/2025, 155 days after the Stage III pressure ulcer was first identified. At this time, R4s CCP, dated 06/17/2025, documented that R4 had a Stage III pressure ulcer on her right buttock. The care plan continued to list the intervention to follow facility protocols for the prevention and treatment of skin breakdown although the facility was unable to provide any such protocols prior to exit on 07/25/2025. The care plan continued to not include resident-specific interventions related to turning and repositioning for this resident who required moderate-maximal assistance with mobility.Review of the facility document, Wound Evaluation and Management Summary, dated 07/07/2025, revealed R4's wound measured 2cm by 0.5 cm, and the depth was not measurable due to nonviable tissue. Further review revealed the wound doctor documented the wound had worsened due to prolonged sitting. Continued review revealed the wound doctor listed close monitoring and offloading as recommended approaches to wound healing. Review of R4's care plan revealed no evidence that the facility responded to the wound doctor's recommendations, developed a care plan to reflect the recommended approaches, or re-enforced with staff the importance of the previous care plan approaches to promote healing of the facility-acquired pressure ulcer which the wound doctor documented had now been present for greater than 175 days.Continuous observation on 07/23/2025 from 8:56 AM to 11:28 AM revealed R4 was seated in her wheelchair and no staff members came to encourage or assist the resident to change positions for pressure offloading. Interviews on 07/23/2025 at 1:16 PM with Contract Staff (CS)1, on 07/24/2025 at 4:16 PM, R46 (R4's roommate), 07/24/2025 at 3:46 PM, with SRNA5, 07/24/2025 at 2:20 PM with SRNA4, and 07/24/2025 at 4:29 PM with Registered Nurse (RN)3 revealed that R4 routinely was not repositioned as needed to relieve pressure and promote healing of her facility-acquired pressure ulcer. (Refer to F686.)In an interview on 07/24/2025 at 2:20 PM, SRNA4 stated aides could not access the full care plans with resident specific interventions. She further stated the binder with resident information sheets in it showed some resident problem areas, but not resident specific interventions. SRNA4 continued to state she did not know what was in R4's care plan, so she relied on her previous experience with the resident, what she was told in report, and what the nurse told her the resident needed.In an interview on 07/24/2025 at 3:46 PM, SRNA5 stated she did not have access to resident care plans. She further stated the only way she had to tell what resident specific interventions were in place was to check the tablets on the walls where the aides would chart tasks. If a repositioning task did not populate, she would not know what resident-specific repositioning needs the resident had. She demonstrated R4's task list did not include repositioning. b. Additional review of R4's CCP revealed the facility failed to include specific interventions related to care and maintenance of R4's indwelling urinary catheter. Review of the CCP revealed the intervention listed was for staff to follow the facility policy. A request was made for this policy; however, the facility was unable to produce the policy referred to in the care plan prior to exit on 07/25/2025. 2. Review of R46's admission Record revealed the facility admitted the resident on 09/24/2024 with diagnoses including spastic hemiplegia (muscle stiffness and spasms) of the left dominant side, need for assistance with personal care, and anxiety disorder.Review of R46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2025 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for toileting hygiene.Review of R46's Comprehensive Care Plan (CCP) dated 10/25/2024 revealed the facility assessed R46 as dependent with toileting hygiene and included the intervention of assisting the resident as needed.Observation on 07/23/2025 at 3:23 PM revealed R46 sitting in her wheelchair in the doorway to her room, angrily talking with her neighbor. In an immediate interview, R46 stated she was incontinent, and her brief was wet. She further stated she asked SRNA5 to change her brief less than five minutes prior to the interview, but the SRNA had said I just changed you. In further interview, the R46 stated she was mad, and she did not believe it should matter how long ago staff changed her brief, if she was wet, she wanted to be changed.Observation on 07/23/2025 at 3:25 PM revealed R46 told SRNA 5 that she needed to be changed. Further observation revealed SRNA5 told the resident she had just changed her and went on to talk to the resident about getting her a drink. SRNA5 walked away without providing incontinence care. Continued observation revealed SRNA5 came back and told the resident she would check to see if she was wet later. SRNA5 then walked away from the resident. Additional observation revealed R46 again asked to be changed at 3:58 PM, SRNA nodded, but walked past the resident. At 4:04 PM, SRNA5 looked at the state surveyor standing in the hall, then told the resident she would change her. Per observation of incontinence care at this time, R46's brief was significantly wet with urine.In an immediate interview, SRNA5 stated she had just changed R46 prior to her asking and she had other residents who also needed to be changed. She stated it was the facility expectation to change residents if they ask and she should have changed R46 when she asked. In an additional interview on 07/24/2025 at 3:46 PM, SRNA5 stated she did not have access to resident care plans.3. Review of R36's admission Record revealed the facility admitted the resident on 05/21/2018. Further review revealed her diagnoses included Huntington's disease (a severe neurological disorder), Alzheimer's disease, restless leg syndrome, and dysphagia (difficulty swallowing).Review of R36's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025 revealed the facility completed the staff assessment of daily and activity preferences due to the resident's inability to complete the interview. Further review revealed the staff assessed that R36 liked listening to music.Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2025 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15, indicating the resident was severely cognitively impaired, and non-interviewable.Review of R36's Comprehensive Care Plan (CCP) dated 01/07/2025 revealed the facility assessed the resident as dependent on staff to meet emotional, intellectual, and social needs due to her major neurocognitive disorder. Further review revealed the facility listed R36's known favorite activities to include listening to music and watching TV.Observations on 07/23/2025 at 2:23 PM, on 07/24/2025 at 10:41 AM, and 07/25/2025 at 3:34 PM revealed R36 was awake in her room with no music or television, and no one providing social interaction. Observations throughout survey revealed no occasion where R36 was provided with or participated in an activity appropriate for her level of cognitive function. Observation on 07/23/2025 at 10:26 AM revealed R36 was not in the dining room for coffee social.In an interview on 07/24/2025 at 1:54 PM, the Activities Director stated R36 enjoyed Elvis and gospel music, but did not have anything in her room staff could use to play music for her. Per interview, the Activity Director stated she played music for R36 once or twice per month. In continued interview, the Activity Director stated it was important for each resident to have their favorite activities for their emotional health and quality of life, and R36 would benefit from increased stimulation.In an interview on 07/23/2025 at 1:58 PM, SRNA 9 stated she was an agency aide, and she did not know where to find a facility document of any kind that she could use to know what resident-specific interventions each resident required. She further stated she could not access a care plan, had not been shown any facility policies, and the only information facility staff had shared with her was to tell her which residents were dependent diners.In an interview on 07/22/2025 at 11:41 AM, Registered Nurse (RN)3 stated care plans were kept in a binder at the nurse's station. She proceeded to pull the binder off the shelf and show it to the state surveyor. In further interview, RN3 was unable to demonstrate how the information in the binder, which contained the residents' information sheets, but not care plans with the residents' specific interventions, communicated each resident's plan of care. In continued interview, RN3 stated the facility used to keep another binder at the nurse's station with MDS information, but she was unsure if that included a care plan. Additionally, RN3 stated staff usually just know what residents need because they were familiar with them. Per interview, RN3 stated the many agency staff working at the facility could ask other staff what interventions were appropriate for a resident rather than reference a care plan.In an interview on 07/25/2025 at 2:40 PM, the Director of Nursing (DON) stated the facility process for ensuring each resident's plan of care was implemented was for staff to do walking rounds to get information about each resident at the start of shift. She further stated the binders at the nurse's stations contained further information, including facility policies. In continued interview, the DON stated no one verified with new agency staff that they read the policies and reviewed resident information sheets at the start of their shifts.In an interview on 07/25/2025 at 11:02 AM, the Administrator stated she expected staff to follow the care plan 100%. She further stated the care plan interventions should have been listed on the patient [resident] information sheets in the binders at the nurse's station. In continued interview, the Administrator accompanied the state surveyor to the nurse's station, looked at R4's information sheet as an example, and was unable to indicate where resident-specific interventions, particularly for wound care, were located. In additional interview, the Administrator stated staff could look at the 24-hour report sheets and discuss resident issues in report, but she acknowledged that those two methods were not likely to cover areas, such as individual resident preferences, that had not been of immediate concern beyond the past week.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide treatment and services to prevent development of pressure ulcers for one (Resident (R) 4) of four residents reviewed for pressure ulcers. R4, who required staff assistance with turning and repositioning, was not care-planned with specific intervention for these services. The resident then developed a facility-acquired Stage III pressure ulcer in 01/2025. The Stage III pressure ulcer failed to heal as expected, and was present for 175+ days, as R4 failed to receive pressure relief as needed. The findings include:Review of R4's admission Record revealed the facility admitted the resident on 05/18/2019. Further review revealed her diagnoses at the time of the 07/25/2025 survey included unspecified dementia, neuromuscular dysfunction of the bladder, and a Stage III pressure ulcer of the right buttock. Per this face sheet, the pressure ulcer diagnosis was classified as occurring During Stay and was added to this face sheet on 06/10/2025,Review of R4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed the facility assessed the resident as being free from pressure ulcers. The facility identified that the resident was at risk for developing pressure ulcers, and documented R4 had a pressure relieving devices for her bed and wheelchair. Per the MDS, the resident was not on a turning and repositioning program although she required moderate to maximal assistance with mobility. Review of R4's Comprehensive Care Plan (CCP), dated 04/18/2024, revealed the facility assessed the resident as being at risk for pressure ulcer development and included the intervention for staff to assist R4 to reposition according to facility protocol. These protocols were requested; however, the facility failed to provide any such protocols prior to exit on 07/25/2025. Review of the care plan revealed that it did not include resident-specific interventions related to turning and repositioning prior to the resident developing a facility-acquired Stage III pressure ulcer on 01/14/2025. (Refer to F656.)Review of the facility document Initial Wound Evaluation and Management Summary, dated 01/14/2025, revealed the wound doctor assessed R4 to have a new Stage III pressure ulcer on her right buttock. Further review revealed this wound measured 1.5 centimeters (cm) by 1.5 cm by 0.1 cm with a surface area of 1.65 cm squared. The wound doctor removed dead tissue from the wound and recommended application of a barrier cream on the wound. Per the wound doctor's note, the estimated time for the wound to heal with proper intervention was 27 days. Review of R4's CCP, dated 04/18/2024 revealed no evidence that the facility developed new interventions at the time of the development of the facility-acquired Stage III pressure ulcer with no specific interventions for repositioning to relieve the resident's pressure.Review of the facility document Wound Evaluation and Management Summary, dated 03/11/2025, revealed the wound doctor documented that R4's Stage III pressure ulcer was exacerbated due to multi-factorial, discussed orders with nursing staff, incontinence. Further review revealed that, rather than healing in the 27 days estimated by the physician on 01/14/2025, the wound now measured 3.1cm by 5.5cm by 0.2 cm that day, with a surface area of 17.05 cm squared. Continued review revealed the wound had been present for greater than 57 days. Although the wound had not healed as anticipated, the care plan did not mention the facility-acquired pressure ulcer until 06/17/2025, over five months since it was first identified. Even when the presence of the facility-acquired pressure ulcer was documented on the care plan on 06/17/2025, the care plan did not include resident-specific interventions for repositioning. Review of R4's Comprehensive Care Plan (CCP) dated 06/17/2025 revealed that in response to R4's Stage III pressure ulcer on her right buttock, interventions were for staff to follow facility protocols for the prevention and treatment of skin breakdown and to administer treatment as ordered. The facility protocol referenced in the care plan was requested for review; however, none was provided prior to exit on 07/25/2025Review of the facility document, Wound Evaluation and Management Summary, dated 07/07/2025, revealed R4's wound measured 2cm by 0.5 cm, and the depth was not measurable due to nonviable tissue. Further review revealed the wound doctor documented the wound had worsened due to prolonged sitting. Continued review revealed the wound doctor listed close monitoring and offloading as recommended approaches to wound healing. Review of R4's care plan revealed no evidence that the facility responded to the wound doctor's recommendations, developed a care plan to reflect the recommended approaches, or re-enforced with staff the importance of the previous care plan approaches to promote healing of the facility-acquired pressure ulcer which the wound doctor document had now been present for greater than 175 days.Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/08/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15, indicating the resident was severely cognitively impaired. Per the MDS, the resident had a Stage III pressure ulcer that was not present on admission or re-entry, no refusals of care, and required maximal assistance (helper does more than half of the effort) for bed mobility, sit to lying, lying to sitting, and chair to bed transfers and moderate assistance (helper does less than half the effort) to go from sitting to standing. Further review of this MDS revealed the resident continued to not be on a turning/repositioning schedule.Review of the facility policy Wound Care Policies and Procedures Patient Care Meetings, dated 01/14/2007, revealed the policy did not address turning/repositioning or pressure relief for resident who were at risk for, or who had developed a pressure ulcer. The policy did state that facility staff, as led by the Director of Nursing, would meet weekly to discuss residents with extraordinary care needs. Further review revealed the facility included residents with pressure wounds in that group. Continued review revealed the facility was to keep minutes for the meeting to review in subsequent weeks to determine the effectiveness of care. Additional review revealed the policy provided no information on repositioning, assessment of risk factors, pressure relief devices, or any other guidance on preventing or treating wounds. The State Survey Agency (SSA) requested notes from the facility interdisciplinary team meetings described in this policy; however, per the Administrator's response to the request on 07/25/2025 at 3:09 PM, the facility did not have any such documentation.Observation on 07/23/2025 at 8:53 AM revealed the Therapy Director removed R4's standard wheelchair cushion and replaced it with a thick specialty cushion. Further observation revealed the old cushion was worn and thinning in places. In an immediate interview, the Therapy Director stated the wound doctor had recommended R4 receive the specialty cushion because the resident's wound was not healing as expected, so she needed additional pressure relief while in her wheelchair.Observation on 07/23/2025 from 8:56 AM to 11:28 AM revealed R4 was seated in her wheelchair. During this 2.5 hour observation, the resident did not reposition herself in the chair, and no staff assisted or encouraged the resident to change positions for pressure offloading.Observation on 07/25/2025 at 9:32 AM revealed R4 had an open area of skin approximately 1cm by 1cm with negligible depth on her right buttock. In further observation, R4 stated it hurt when Registered Nurse (RN) 3 touched the area to apply barrier cream per physician orders.In an interview on 07/24/2025 at 4:16 PM, R46 (R4's roommate), stated she never saw staff reposition R4 in her wheelchair. She further stated staff got R4 up first thing in the morning and left her in her chair until evening, except for an occasional afternoon nap. Review of R46's quarterly MDS, with an ARD of 04/23/2025, revealed the facility assessed R46 with a BIMS score of 15/15, indicating she was cognitively intact.In an interview on 07/24/2025 at 3:46 PM, State Registered Nurse Aide (SRNA) 5 stated the facility had not trained her on a policy for repositioning, and there was no way for the staff to know what the resident required beyond word of mouth and their own professional judgement. SRNA5 stated she knew from her previous experience as an aide, residents who could not reposition themselves should be repositioned every two hours. She further stated the common practice for offloading pressure for residents in a wheelchair was to encourage them to lay down after meals, but staff did not regularly reposition residents in their wheelchairs. In continued interview, SRNA5 stated if a resident did not want to lay back down, they were not getting pressure relief from their wheelchair.In an interview on 07/24/2025 at 2:20 PM, SRNA4 stated she was frequently the aide who was responsible for R4, and she would encourage her to stand up as often as she had the chance, during her shift. She further stated that the resident was not repositioned as often as other residents because her indwelling urinary catheter meant her briefs did not need to be changed as often. In continued interview, SRNA4 stated the standard expectation for turning and repositioning when a resident was in bed was every two hours. SRNA4 added that repositioning needed to occur more often when the resident was in the wheelchair, because all their weight was on their buttocks. SRNA4 stated she liked to encourage R4 to stand up and grip the hand rails a couple times during the shift to offload pressure and to maintain the resident's mobility. Per interview, SRNA4 had never seen anyone else assist the resident to stand for offloading. In further interview, SRNA4 stated it was not feasible for staff to be able to encourage R4 to reposition as often as needed when the resident was up in her wheelchair because the facility was frequently short staffed. (Refer to F725.)During the interview on 07/24/2025 at 2:20 PM with SRNA4, she stated she did not know what was in R4's care plan, so she relied on her previous experience with the resident, what she was told in report, and what the nurse told her the resident needed. During the interview on 07/24/2025 at 3:46 PM, SRNA5 also stated she did not have access to resident care plans. She stated the only way she had to tell what resident-specific interventions were in place was to check the tablets on the walls where the aides would chart tasks. If a repositioning task did not populate, she would not know what resident-specific repositioning needs the resident had. At this time, she demonstrated R4's task list did not include repositioning. (Refer to F656.)In an interview on 07/23/2025 at 1:16 PM, Contract Staff (CS)1 stated she was frequently working in the halls of the facility while R4 was up in her wheelchair. She stated she never saw staff encourage R4 to stand or to offload pressure in any way.In an interview on 07/24/2025 at 4:29 PM, Registered Nurse (RN) 3 stated R4 should have been repositioned at least every two hours when up in her wheelchair to prevent skin breakdown. She stated she tried to pitch in to help the aides and make sure residents were repositioned with incontinence care and other duties; however, with so many agency aides who did not always do what they were supposed to, she did not believe residents were always repositioned as often as they should be.In an interview on 07/25/2025 at 2:40 PM, the Director of Nursing (DON) stated it was her expectation that R4 be repositioned by assisting the resident to lay in her bed and take a break from her wheelchair. She further stated R4 often did not want to go back to her room, but staff could assist the resident to stand up at a grab bar for pressure relief while still honoring the resident's preference not to go back to her room during the day. In continued interview, the DON stated the facility's interdisciplinary team process was to follow the wound care doctor's recommendations, but she was unable to describe any additional action taken by the facility to audit facility practices to determine why R4's wound developed and why it took many times longer to heal than was expected per the wound doctor.In an interview on 07/25/2025 at 11:02 AM, the Administrator stated it was her expectation that staff implement pressure reduction interventions so no residents in the facility would develop an unavoidable pressure wound. She further stated she expected residents to be repositioned every two hours if they were laying in the bed. The Administrator added that that residents like R4, who were up in their wheelchairs for extended periods of time, needed to be repositioned more often than every two hours because the resident's weight was distributed across a smaller area than if they were lying down. She stated it was unacceptable for an aide to say they did not reposition R4 due to a lack of time. In continued interview, the Administrator stated she did not recall the facility's interdisciplinary team conducting a root cause analysis on R4's facility-acquired pressure ulcer to see why it developed. However, the Administrator added, the facility did identify process problems with turning and repositioning not being followed. Further interview revealed the Administrator was unable to describe what actions the facility had taken in response to the problem. The Administrator further stated she was not out on the floor constantly but looked to her DON to ensure staff implemented care planned interventions and followed facility processes. The Administrator stated she expected staff to follow the care plan 100%. She further stated the care plan interventions should have been listed on the patient [resident's] information sheets in the binders at the nurse's station. After this statement, the Administrator accompanied the state survey team to the nurse's station, looked at R4's information sheet, and was unable to indicate where resident-specific interventions for wound care were located.

Based on observation, interview, and record review, the facility failed to post notice of the availability of the most recent survey results and failed to post those results in a place that was readily accessible to residents. The deficient practice had the potential to affect all residents' rights to be fully informed by being able to review that information upon request. The findings Include:Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed residents have the right to receive all forms of communication while residing within the facility, and the facility would assist residents in exercising his/her rights.Observation during a tour of the facility on 07/22/2025 at 10:00 AM revealed there was no notice that indicated the location of the most recent state survey results and there was no visible physical account of the previous survey results.During an interview with the resident council on 07/22/2025 at 10:30 AM, they stated a majority of residents in attendance had never seen the facility's survey results. They stated they were not aware of the location to find the survey results. During interview with Residents (R) 1, R9, R37, and R64 on 07/22/2025 at 10:30AM, they stated the residents were unaware that survey results were available to view or where they were located in the facility.During an interview with the facility's Ombudsman on 07/22/2025 at 11:00 AM, she stated the survey results were not in a proper place. She stated the residents had inquired about survey results during previous conversations. During an interview with the Administrator on 07/25/2025 at 1:00 PM, she stated all residents had the right to review previous survey results. She stated it was the responsibility of the facility to ensure residents were educated on the survey findings and had access to the location where the findings were kept.

Based on observation, interview, record review, and review of National Weather Service records, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents. The facility failed to promptly respond to problems with its cooling system and ensure that the facility was maintained at a safe, comfortable temperature, with temperatures in resident areas noted as high as 90 degrees Fahrenheit (F). The failure to provide safe, comfortable temperatures had the potential to affect all residents of the facility and constituted Substandard Quality of Care (SQC). In addition, multiple resident rooms (Rooms 209, 302, 317, and 320), a common resident gathering area, and the main dining hall needed repair and/or or cleaning. The findings include: In an interview with Ombudsman1 on 07/23/2025 at 9:32 AM, she stated she was first made aware that the facility's air conditioning (AC) was broken on 06/19/2025, which was also when the first family complaint about the AC being broken was called in to her office. She stated that she went to the facility at 8:30 PM at night and it was “like a sauna” in the facility. Ombudsman1 stated she was told by the Administrator that the AC repair person would be coming the next day. Continued interview revealed she called Ombudsman2 who came to the facility that evening and offered four large industrial fans for use in the interim. However, the Administrator declined this offer. Per interview, the following morning Ombudsman1 went back to the facility, and using her personal thermometer, found that the temperature was 83 degrees F (Fahrenheit) at 9:00 AM. By 5:30 PM when she went again it was even higher: 86-87 degrees F in the common area where the residents were eating. She stated the cook came out of the kitchen which was even hotter and almost passed out. She stated Ombudsman2 came to the facility again and the residents began saying that it was very hot. When they visited on Saturday at 2:00 PM, the facility had a large industrial fan in the hallway and had residents sitting in the hallway because the rooms had no air flow. She stated the vents were closed in many of the rooms, and one resident's room was extremely hot, at 88-89 degrees F. As part of the investigation of this concern, the survey team requested all documentation related to any issues with the cooling system. Although the Ombudsman stated she began receiving phone calls on 06/19/2025 and went to the facility that day to personally verify the complaints, the first “Work Order” from the Heating, Ventilation, and Air Conditioning (HVAC) repair company was not until 06/26/2025, one week later. Review of the National Weather Service Records revealed that, during the time from when the AC problem was first identified on 06/19/2025 until 06/26/2025, temperatures ranged as high as 91 degrees F on 06/23/2025, with a heat index of 104 degrees F. Review of the HVAC Work Order revealed that upon arrival on 06/26/2025, the repair person found the air temperature was 90 degrees F on the hallway where the HVAC unit the company was there to repair was located. In addition, there were two other units that were not cooling that the company was to also assess. Further review revealed that the HVAC systems were running properly but that the return drops on both systems in the attic were disconnected. It was found that the plenum (a piece of ductwork attached to the air handler) had major air leaks and the ductwork needed repair. Review of a “Work Order” from the HVAC repair company, dated 06/27/2025, revealed the facility had five units that the repair person was not able to look at and the work order stated they needed to get them cooling as best they could until they could return to finish the repair. Further review revealed that the repair company cleaned the condenser coils and added refrigerant, but they could not test fully until the systems were thoroughly cleaned. Per the work order, they scheduled a return appointment for performance of all units, indicating the need for spring maintenance. Review of a “Work Order” from the HVAC repair company, dated 06/30/2025, revealed the HVAC unit for the kitchen was not cooling and it was 91 degrees F. Inspection found the condensing coils for the unit that supplied the air conditioning (AC) to the kitchen was 80% blocked. The repair company cleaned the coil and placed more refrigerant and stated they would be back to do maintenance on the other units. Review of a “Work Order” from the HVAC repair company, dated 07/07/2025, revealed the kitchen HVAC unit was still having issues with temperatures reaching 110 degrees F in the kitchen. Review of a “Work Order” from the HVAC repair company, dated 07/10/2025, revealed system maintenance and cleaning was performed, and the system was now functioning as required, 21 days after the HVAC issues were first identified . Review of Resident (R) 27’s “Face Sheet” revealed a quarterly “Minimum Data Set (MDS),” with an assessment reference date (ARD) of 05/30/2025, which documented the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. In an interview with R27 on 07/23/2025 at 1:12 PM, she said that it had been hot during the time that the AC system was not working properly. She stated staff did not bring extra water and ice for residents that she remembered during this time. She stated that in the previous year during “hot spells” fans were purchased for residents by the facility and now she did not know where the facility put her fan. In an interview with State Registered Nurse Aide (SRNA) 2 on 07/23/2025 at 8:33 AM, she stated the facility’s AC broke down back at the end of June when there was a heat wave. She stated that the facility did not have fans on until the last two days that the AC was broken. She thought the AC was out for two weeks and noted that there was hot air coming out of the vents. SRNA2 stated the resident were complaining about the heat, and when staff mentioned how hot it was in the facility, the Administrator told staff they were complaining. In an interview with Registered Nurse (RN) 3 on 07/23/2025 at 9:05 AM, she stated that the AC was out about a month ago and the heat was “bad.” RN3 stated that only one large fan was brought in the facility, and it was placed in the East hallway. Residents were educated to leave their room door open and to sit in their doorways or in the hallway if possible. She stated that temporary AC units were never brought in to help cool the facility. In an interview with Contract Services (CS) 1 on 07/23/2025 at 10:49 AM revealed that during the time the HVAC was not functioning correctly, it would work on and off. She said that during this time, there was only one facility fan, which was blowing on the Back Hallway. She indicated that because of the heat, she educated residents to keep their doors open and sit in the hallway. She added that during morning meeting, staff were instructed to provide extra fluids and popsicles; however, she was unsure of this was effective due to the large number of agency staff who did not know the residents. In an interview with the Director of Maintenance on 07/23/2025 at 3:16 PM, he stated that the AC system never went completely out; however, six units had lower output than they should have and were not cooling the facility as well as needed during the time daily temperatures were in the high 80’s and 90’s. The facility called the repair man because the AC was not working well and because they needed it serviced and cleaned since the routine cleaning/maintenance which should have been completed in the Spring of 2025 had not occurred. Although interviews with the Ombudsman and review of work orders revealed problems with the HVAC system lasted 21 days, the Director of Maintenance stated he thought they were only having problems with the AC for a week. Further interview with the Director of Maintenance revealed he had no written evidence of verify his claim that the system was only down for a week. The Director of Maintenance added that although no portable AC units were provided during this time, large fans were brought in to cool down the facility. However, the Maintenance Director also had no evidence of verify this claim or the number of fans actually provided. He stated that he checked the temperature of the facility daily, but did not keep written logs of the temperatures, and as a result, had no evidence of how hot it became during the time that the HVAC system was not fully functioning. In an interview with the Director of Nursing (DON) on 07/24/2025 at 7:58 AM, she stated that the AC never stopped working completely and that the repair people were there several times throughout the week working on the AC. She stated there were fans and that staff gave out extra water and popsicles, and residents were able to get extra fluids anytime they requested them. In an interview with the Administrator on 07/24/2025 at 9:24 AM, she stated that the AC repair people were at the facility multiple times over the week the AC was not working, starting on 06/20/2025. However, review of all HVAC work records provided by the facility no work orders until 06/26/2025, one week after the AC issues were first noted. She stated that due to electrical plug issues, there could only be one large industrial sized fan, and this was why she did not accept the fans offered by Ombudsman2. Further interview with the Administrator revealed that the Director of Maintenance was supposed to be taking temperatures and recording them. The Administrator stated that it was never over 76 degrees in the facility during the time period in question. However, the Administrator could provide no evidence that this was, in fact, accurate. The Administrator confirmed that the Director of Maintenance failed to document and maintain a log of any temperatures during the period in which the AC system was not fully functioning and temperatures as high as 90 degrees in a residential area and 110 degrees in the kitchen were documented by the facility’s own contractor. Additional interview with the Administrator revealed that the facility had no policies/procedures related to mechanical failure of the HVAC system or temperature monitoring in the event of such a failure. This interview revealed that the lack of policies related to these areas was present at the time of the HVAC problems starting 06/19/2025, and continued as of the time of the survey, with no policies developed in response to this recent incident to ensure that in the future, appropriate temperatures were maintained, temperatures were monitored and recorded, and all necessary actions were taken to ensure both the comfort and health of residents. 2. Observation on 07/24/2025 at 1:00PM of resident rooms and common areas revealed the following: a. room [ROOM NUMBER] had large water stains and peeling paint on the ceiling above the bed area. Additionally, the baseboards were heavily scuffed and covered in visible dust and debris. b. room [ROOM NUMBER] had numerous cracks in the ceiling with brownish-yellow decolorization. c. room [ROOM NUMBER] had a wall behind the headboard of the bed with a large area (½ wall panel) of brownish-yellow discoloration, indentions, and holes. d. The hallway near room [ROOM NUMBER] had a cracked ceiling with remnants of water damage and decaying infrastructure, with multiple cracks and dust collection. e. In the common area where residents gather, the wall behind the television set had no baseboard, and exposed drywall and screws. Additionally, there were pieces of drywall present along the wall base and floor. Observation on 07/25/2025 at 11:00 AM in the main dining hall revealed the areas along the baseboard and corner panels had dust build up, peeling/cracks in the ceiling, chipped paneling, and old discoloration stains consistent with previous water damage. During an interview with R1 on 07/24/2025 at 2:30 PM, she stated the walls had looked like that for a while and it did not feel clean. During an interview with R37 on 07/24/2025 at 3:00 PM, he stated the facility's disrepair made him feel like nobody cares. During an interview with the Director of Maintenance on 07/24/2025 at 1:30 PM, he acknowledged that some of the damaged areas had been present for several months. He stated they tried to get to the repairs when they could, but there was a backlog of repairs, and they were short-staffed. He further stated he had no autonomy to make the repairs, and a day-to-day work list was given by the Administrator. During a concurrent interview with RN1 and SRNA1 on 07/25/2025 at 1:30PM, they revealed the damages were known to the administration, as residents and family had made multiple complaints due to the conditions of the facility. However, they continued, nothing was ever done to repair them. During an interview with the DON on 07/25/2025 at 2:00PM, she confirmed repairs were needed for multiple resident rooms. She stated a plan was in place, but it was not progressing as fast as the facility had hoped. The DON stated continued deterioration could lead to safety and health hazards for all residents, staff, and visitors. During an interview with the Administrator on 07/25/2025 at 2:30PM, she stated that a lot of work was needed to be done on the older building. The Administrator confirmed that the facility was aware of the conditions in the building and indicated a plan was in place to refurbish areas. However, no specific timeline was provided to indicate when needed repairs/cleaning would occur. Further interview with the Administrator revealed that all residents had the right to a safe and clean environment that was homelike.

Based on observation, interview, record review, and review of the facility assessment, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations (including nights and weekends) and emergencies. The facility assessment failed to provide documented information to inform staffing decisions to ensure sufficient staffing to meet residents' needs for each shift and unit, develop and maintain a plan to maximize recruitment and retention of direct care staff, and inform contingency planning for events that did not require activation of the facility's emergency plan, but did have the potential to affect resident care, such as the availability of direct care nurse staffing or other resources for resident care. The deficient practice had the potential to affect all residents, with a census of 65.The findings include: Review of the facility assessment, dated 2025, revealed the facility failed to include information on how they determined the staffing levels needed for specific shifts, including evenings and weekends. Further review revealed the facility failed to include information about contingency planning for events that did not require activation of the emergency plan, such as a mild snowstorm, that could affect resident care due to a lack of availability of direct care staff. Review of the Payroll Based Journal (PBJ) for Fiscal Year Quarter 2, 01/2025 through 03/2025, revealed the facility triggered for one-star staffing and excessively low weekend staffing. Review of the facility's staffing agency invoices and the facility document Calculated Time by Calendar Day, dated 02/01/2025 through 02/10/2025 revealed the facility was short of the Administrator's stated target staffing for five of the 10 sampled days. Further review revealed on 02/01/2025 and 02/02/2025, a Saturday and Sunday, the facility only had four SRNAs present on day shift. Review of the facility document Daily Direct Care Nurse Staffing Information, dated 02/01/2025 revealed the facility census was 64 that day. In an interview on 07/21/2025 at 3:33 PM, Resident (R)1stated facility staffing was always worse if there was bad weather, including snow or even rain. She further stated the short staffing caused residents to have to wait longer for assistance with toileting and other needs, and they also might not get a shower. In an interview on 07/24/2025 at 11:05 AM, SRNA4 stated the facility relied heavily on agency staff because no one wanted to work for the Administrator full time because of the demeaning way she treated staff. In an interview on 07/25/2025 at 9:36 AM, RN3 stated the facility had so few regular staff, especially on night shift, because the Administrator stirred up conflict where it was not necessary. She further stated she was worried the Administrator would fire her in retaliation for speaking honestly with the State Survey Agency, but she knew speaking up was best for the residents. In an interview on 07/25/2025 at 11:02 AM, the Administrator stated the facility assessment was not as complete as it would have been if she would have used one of the tools out to develop it. She further stated she did it on her own. Per interview, the Administrator stated the current facility assessment could not be used to determine specific staffing needs on particular halls or on particular shifts, including nights and weekends. In further interview, the Administrator acknowledged there was no information in the facility assessment that could inform a contingency plan if there were not enough direct care staff present in the building, such as in the case of weather-related call-ins. The Administrator continued to state the facility had not conducted a recent staff satisfaction survey to identify areas that could be improved to retain staff, though she acknowledged the facility had been having major problems retaining staff. Per interview, the Administrator was aware staff had left because they reported abusive treatment from her and other management staff, however, the Administrator's response was to say that staff either loved it at the facility, or they hated it and she could not explain why.

Based on observation, interview, staff time punch data, and Payroll Based Journal (PBJ) data, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The deficient practice had the potential to affect all residents in the facility with a census of 65.The findings include: Review of the Payroll Based Journal (PBJ) for Fiscal Year Quarter 2, 01/2025 through 03/2025, revealed the facility triggered for one-star staffing and excessively low weekend staffing. Review of the facility's staffing agency invoices and the facility's document Calculated Time by Calendar Day, dated 02/01/2025 through 02/10/2025 revealed the facility was short of the Administrator's stated target staffing for five of the 10 sampled days. Further review revealed on 02/01/2025 and 02/02/2025, a Saturday and Sunday, the facility only had four SRNAs (State Registered Nurse Aide) present on day shift. Review of the facility's document Daily Direct Care Nurse Staffing Information, dated 02/01/2025 revealed the facility's census was 64 that day. 1) Review of Resident (R)4's admission Record revealed the facility admitted the resident on 05/18/2019. Further review revealed R4's diagnoses, at the time of survey, included unspecified dementia, neuromuscular dysfunction of the bladder, and stage three pressure ulcer of the right buttock. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/08/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of zero out of 15. This score indicated the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as having a stage three pressure ulcer that was not present on admission or re-entry Continuous observation on 07/23/2025 from 8:56 AM to 11:28 AM revealed R4 was seated in her wheelchair and no staff members came to encourage the resident to change positions for pressure offloading. In an interview on 07/24/2025 at 4:16 PM, R4's roommate stated she never saw staff reposition R4 in her wheelchair or encouraged her to stand up while holding onto a grab bar. She stated staff got R4 up first thing in the morning and left her in her chair until evening, except for an occasional afternoon nap. In an interview on 07/24/2025 at 2:20 PM, State Registered Nurse Aide (SRNA)4 stated it was not feasible for staff to be able to encourage R4 to reposition in her wheelchair as often as needed because the facility was frequently short staffed. In an interview on 07/23/2025 at 4:32 PM, SRNA5 stated staffing was typically barely enough to do the absolute minimum for residents, which she defined as performing incontinence care and feeding dependent residents. She stated she had to rush to get tasks done. In continued interview, SRNA5 stated she typically did not have time to reposition R4 in her wheelchair as often as she needed because there were too many other tasks she needed to complete. 2) Observation on 07/23/2025 at 3:23 PM revealed R46 sitting in her wheelchair in the doorway to her room, angrily talking with her neighbor. In an immediate interview, R46 stated she was incontinent, and her brief was wet. She stated she asked SRNA5 to change her brief less than five minutes prior to the interview, but the SRNA had said I just changed you. R46 stated she was mad, and she did not believe it should matter how long ago staff changed her brief, if she was wet, she wanted to be changed. Observation on 07/23/2025 at 3:25 PM revealed R46 told SRNA 5 that she needed to be changed. Further observation revealed SRNA5 told the resident she had just changed her and went on to talk to the resident about getting her a drink. SRNA5 did not provide incontinence care at that time. Continued observation revealed SRNA5 came back and told the resident she would check on later and left. Additional observation revealed R46 again asked to be changed at 3:58 PM, again the SRNA walked away, but nodded her head. At 4:04 PM, SRNA5 told the resident she would change her. Per observation of incontinence care, the R46's brief was significantly wet. In an immediate interview, SRNA5 stated she had just changed R46 prior to her asking. SRNA5 stated she had other residents who also needed to be changed. 3) In an interview on 07/21/2025 at 3:33 PM, R1 stated she asked for help to get to the bathroom around 1:00 PM, but staff did not get to her until almost 3:00 PM. She stated she had to use her brief, which made her feel angry. She stated staff told her they were too busy to get to her timely. She stated that facility staffing was always worse if there was bad weather, including snow or even rain. In continued interview, R1 stated short staffing caused residents to have to wait longer for assistance with toileting and other needs, and they also might not get a shower. R1 stated she felt frustrated when this occurred. 4) In an interview on 07/24/2025 at 10:05 AM, SRNA4 stated there were a lot of days there would be six SRNAs scheduled to work and only four would show up. She stated management would then post additional shifts for agency staff, but sometimes that did not get enough staff in the building, so they just worked short. She stated when this happened, residents were more likely to get a bed bath rather than a shower, regardless of their preferences, because that could be done more quickly. SRNA4 stated that in recent weeks, there had not been less than five SRNAs on day shift but working with five aides was still a heavy workload for staff and some things might not get done at that level. She stated the Administrator, and the Social Services Director would talk in a demeaning manner to staff and ignore their concerns, so no one wanted to leave agency and work at the facility full time. She stated agency staff would frequently work a couple shifts and then not come back because of management. In an interview on 07/24/2025 at 4:29 PM, Registered Nurse (RN)3 stated it was not unusual for the facility to work with only four SRNAs on day shift. She stated that left too little time for aides to care for each resident, especially when there were multiple dependent diners in an assignment, along with incontinent residents. Per interview, RN3 stated she believed the facility needed seven aides on day shift to meet the residents' needs. In continued interview, she stated she often helped the aides by changing incontinent residents and assisting dependent diners. RN3 stated on days when a physician was rounding, she would have to spend a significant amount of time writing their orders in multiple places in the paper chart, so on those days, she would not be available to do resident care tasks the aides were responsible for. She stated staffing was worse on night shift because there were fewer aides and no medication assistant, so the nurse was responsible for administering all medications. Additionally, RN3 stated staffing at the facility was inadequate. In an interview on 07/25/2025 at 2:40 PM, the Director of Nursing (DON) stated the facility's goal for staffing was for six to seven SRNAs, two nurses, and one medication aide for day shift. She stated night shift should be staffed with five SRNAs, two nurses, and a medication aide. The DON stated they had not had a night shift medication aide since their last one quit. In continued interview, the DON stated the facility used several different staffing agencies to reach these numbers since they did not have enough regular staff to do so. Per interview, the DON stated she was not aware of the facility having a staffing issue in February and did not know why the PBJ would have triggered for low staffing. In an interview on 07/25/2025 at 11:02 AM, the Administrator stated her expectations for staffing levels was six to seven SRNAs on day shift. She further stated her goal for night shift was to have four aides, which would average out to a little over 15 residents per aide, but staffing should never go below each aide assignment having more than 20 residents. In continued interview, the Administrator stated she never sat down to estimate how much time it would take an SRNA to care for a dependent resident each shift, nor could she state how many dependent residents were in each SRNAs assignment. Per interview, the Administrator stated it was unlikely the SRNAs would be able to meet resident needs as care planned if there were only four or five SRNAs on day shift. The Administrator stated it was common for there to be call-ins and short staffing if the weather was bad, but she could not describe a contingency plan to cover staffing absentees for affected shifts. She stated the facility had not conducted a recent staff satisfaction survey to identify areas that could be improved to retain staff, though she acknowledged the facility had been having major problems retaining staff and relied heavily on agency. Per interview, the Administrator was aware staff had left because they reported abusive treatment from her and other management staff. However, she stated that staff either loved it at the facility, or they hated it, and she could not explain why. In additional interview, the Administrator stated she believed the data the facility submitted for PBJ was incomplete and she would have to compare the PBJ submission to the staffing agency invoices. The Administrator further stated it was important to have adequate staff to care for residents and that consistent staff provided the best care.

Based on observation, interview, record review and facility policy review, the facility failed to properly label drugs and biologicals in accordance with currently accepted professional principles. They did not include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts. The findings include: Review of the facility's policy titled, Storage of Drugs and Biologicals, not dated, revealed that it was the policy of the facility that all drugs and biologicals be properly stored in the containers in which they were received. Further review revealed the policy did not mention dating opened multi use medications upon opening them. Observation on 07/22/2025 at 7:55 AM of the medication cart from the 100/200 Hallway labeled RN revealed the medication cart had seven bottles of eye drops, two inhalers, two bottles of cough syrup, two bottles of lactulose, two bottles of polyethylene glycol, and two bottles of nasal spray. Further review revealed all of these medications were opened without dates to when they were opened documented on the bottles. In an interview with Licensed Practical Nurse (LPN)1 on 07/22/2025 at 7:55 AM she stated that if a multi-use vial of medication was not dated as to when it was opened it could be outdated and no longer effective. In an interview with the Director of Nursing (DON) on 07/24/2025 at 7:58 AM, she stated all opened multi use medications should have a date written on the bottle as to when they were opened. The DON stated if a medication was not dated when opened an expired medication could be given and this could result in an infection. During an interview with the Administrator (ADM) on 07/24/2025 at 9:24 AM, she stated she was unsure if it was the facility's practice/policy to date multi-use containers of medications with the date they were opened. She stated she thought it was a good idea to do so to prevent administering expired medications. In an interview with the Medical Director on 04/25/2025 at 10:35 AM he stated it was his expectation that staff date multi use medications when opened to prevent use of expired medications thus ensuring their efficacy.

Based on observation, interview and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's Infection Control Plan policy, not dated, revealed the purpose of the infection control plan was to provide a safe, sanitary, and comfortable environment for all residents and staff. Review of the facility's Handwashing policy, not dated, revealed all personnel shall follow the established handwashing procedure to prevent the spread of infections and disease to other personnel, residents, and visitors. Wash hands for approximately 10-15 seconds, performed under the following conditions: h) After handling items potentially contaminated with blood, body fluids, excretions, or secretions: The use of gloves does not replace handwashing. 1. Observation of wound care for Resident (R)32 on 07/23/2025 at 1:30 PM revealed Registered Nurse (RN)1 and State Registered Nurse Aide (SRNA)3 went into R32's room to position her in bed for wound care. Observation revealed an Enhanced Barrier Signage on R32's door. However, RN1 and SRNA 3 did not don (put on) a gown. Further observation of wound care for R32 on 07/23/2025 at 1:50 PM revealed that RN1 did not don a gown when performing wound care. In an interview with RN1 on 07/23/2025 at 1:50 PM she stated that the Enhanced Barrier Signage on R32's door was for residents that had pressure ulcers, wounds, catheters, etc. and that a gown and gloves should be worn during direct resident care. RN1 stated that direct resident care was when she performed wound care and that she should have donned a gown when doing wound care. She stated that pulling a resident up in bed and positioning them for wound care did not constitute direct resident care. In an interview with SRNA3 on 07/23/2025 at 2:05 PM she stated that the Enhanced Barrier Signage meant that any time direct resident care was performed she should put on gown and gloves. She stated that she questioned the nurse (RN1) about donning a gown and gloves when pulling up R32 but RN1 stated that they did not need to do so because they were not performing direct resident care. In an interview with the Director of Nursing on 07/24/2025 at 7:58 AM she stated that Enhanced Barrier Signage meant that staff needed to don a gown and gloves when providing direct resident care such as wound care or catheter care. She stated they did not need to don the gown when pulling a resident up in bed. In an interview with the Administrator (ADM) on 07/24/2025 at 9:24 AM she stated it was her expectation that staff donned a gown when performing any direct care for a resident with Enhanced Barrier Precautions. This included pulling a resident up in bed or positioning them in bed for wound care. 2. Observation of dinner service on 07/21/2025 at 5:43 PM revealed that State Registered Nurse Aide (SRNA)1 passed drinks to the entire 100/300 Hallway, without performing hand hygiene. In an interview with SRNA1 she stated that it was the facility's practice to perform hand hygiene after passing three residents' beverages. In an interview with the Director of Nursing on 07/24/2025 at 7:58 AM she stated that staff should perform hand hygiene after passing a tray or a drink. They should hand sanitize with alcohol-based hand rub after each tray or drink and wash their hands after every third tray or drink. In an interview with the Administrator (ADM) on 07/24/2025 at 9:24 AM she stated that her expectation was that staff perform hand hygiene after each tray. At first, she stated that they were to use alcohol-based hand rub after every third tray, then stated staff should wash their hands washing after every third tray. 3. Observation on 07/21/2025 at 4:51 PM revealed Registered Nurse (RN)2 completed glucose checks on Resident (R)21. After checking the glucose, she left the room wearing gloves. She opened the door to the nurse's station and wrote the glucometer reading on a paper. She then removed her gloves and washed her hands. During interview with RN2 at the time of the observation, she stated she has had training in infection control, she thought maybe last year. She stated she was taught about hand hygiene, and to clean her hands after removing her gloves. Observation on 07/21/2025 at 5:04 PM, revealed RN2 complete glucose check on R2. After checking the glucose, she left the room wearing gloves. She opened the door to the nurse's station and wrote the glucometer reading on a paper. She then removed her gloves and washed her hands. During interview with RN2, at the time of the observation, she stated a resident was in the bathroom, so she came to the nurse's station to remove her gloves and wash her hands. 4. Review of the facility's Respiratory Equipment Cleaning Schedule, not dated, revealed, oxygen-tubing and nasal cannulas were to be changed weekly on Thursday nights. Review of R58's Face Sheet, revealed the facility admitted R58 on 02/08/2019. R58's diagnoses included pulmonary embolism, muscle weakness, and heart disease. Review of R58's Minimum Data Set, Assessment Reference Date 06/09/2025 revealed R58 had a Brief Interview Mental Status score of 15. This score indicated R58 was able to be interviewed. Observation on 07/21/2025 at 5:13 PM revealed R58's oxygen tubing was dated as 07/04/2025. On 07/24/2025 at 8:23 PM during interview with RN2, she stated she changed the oxygen tubing every Thursday. She stated she had been off for the last two Thursdays and that was why the tubing did not get changed. She stated if the tubing was not changed it could cause the resident to get sick and the tubing may deteriorate, and the oxygen may not be effective. During an interview with the Administrator on 07/25/2025 at 2:10 PM, she stated her expectation on the oxygen tubing was for staff to change it weekly. She stated she did not know why a tubing was out of date. She stated the DON was responsible for assuring the oxygen tubing was changed in the correct time frame. On 07/25/2025 at 11:24 AM during interview with the Director of Nursing (DON)/Infectious Control Nurse, she stated new staff did not get training in infection control. She stated new staff followed another staff member and there was a check off list; staff were trained on the floor. The DON stated she expected staff to wash or sanitize their hands between providing resident care and prior to putting on gloves and after removing their gloves. She stated staff were to wash their hands for one minute. She would have to look at the Centers for Disease Control (CDC) recommendations to see what their recommendations were. On 07/25/2025 at 2:11 PM during interview with the Administrator, she stated new staff were educated on abuse and other courses. She stated there was a new hire packet that they were going to use to teach the new hires. She stated the DON was supposed to teach new hires. She stated staff sign off on the education. The Administrator stated the hand hygiene and infection disease policy were reviewed in the Quality Assurance Performance Improvement (QAPI) meeting. She stated the current policy was old and needed to be updates. She stated she did not know if the policy was addressed in QAPI.

Based on observation, interview and review of the facility's Plan of Correction (POC), it was determined the facility failed to maintain a Quality Assessment and Assurance (QA) Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies in regards to failure to ensure abuse policies were implemented for two (2) of eleven (11) residents (Resident #3 and Resident #9) and one (1) unsampled resident (Unsampled Resident A). The facility failed to investigate Resident #3's allegation of verbal abuse against Certified Nursing Assistant (CNA) #3 which resulted in the facility's failure to identify other residents who were victims of verbal abuse and/or staff who had witnessed verbal abuse by CNA #3. Interview with residents and staff revealed allegations of verbal abuse involving Resident #9 and Unsampled Resident A by CNA #3 which had not been reported by staff. The facility also failed to prevent further potential abuse by failing to investigate Resident #3's allegation. (Refer to F-223, F-225, F-226, and F-490) The facility's failure to ensure the Quality Assessment and Assurance (QA) Program developed and implemented appropriate plans of action to correct quality deficiencies was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 01/14/14, and determined to exist on 11/29/13. The facility was notified of the Immediate Jeopardy on 01/14/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 with the facility alleging removal of the Immediate Jeopardy on 01/16/14. The Immediate Jeopardy was verified to be removed on 01/16/14, prior to exiting the facility on 01/17/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-520, with a Scope and Severity of "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the Plan of Correction (POC) dated and signed by the Administrator on 12/03/13, with a compliance date of 09/16/13, revealed the facility's Quality Improvement (QI) team, who were members of the Quality Assurance (QA) team, reviewed Social Services' Grievance Reports to ensure reporting had occurred as of 09/15/13. Continued review of the POC revealed the QI team was to perform daily monitoring rounds daily to include monitoring for resident concerns and to individually in-service staff to include abuse. QA meetings were to be held every thirty (30) days to discuss the POC and interventions implemented. Review of the QA meeting sign-in sheets revealed meetings were held in September, October, November and December 2013. Further review revealed a QA meeting was also held on 01/08/14. Further review revealed the QA Committee had met to address concerns within the POC, which included implementation of facility policies and QA. Interview with Resident #3 and review of Resident #3's record revealed Certified Nursing Assistant (CNA) #3 yelled at him/her on 11/29/13; and this had made the resident feel afraid and angry. Resident #3 was observably "upset", as reported by facility staff. CNA #3 reported the incident involving her and Resident #3 to Registered Nurse (RN) #1; however, there was no documented evidence the resident and staff were interviewed until 12/02/13. After investigating Resident #3's concerns as a grievance and collecting statements from Resident #3 and facility staff, the facility failed to implement the "Abuse Policy" and notify State Agencies. Interview with Resident #9 on 01/14/14 at 4:56 PM, revealed CNA #3 was "hateful" to him/her and verbally abusive at times. Resident #9 stated he/she was afraid of CNA #3. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed some staff got "smart" with him/her and were "rude" at times. Interview on 01/13/14 at 6:30 PM with CNA #4 revealed she had witnessed CNA #3 become verbally abusive to Unsampled Resident A; however, she had not reported the incident to the Charge Nurse. Interview with the DON on 01/17/14 at 3:38 PM, revealed she attended QA meetings which had been held monthly since August 2013. She stated daily QI rounds were performed by the Department Managers/Managers on Duty (MOD)/QI/QA members. The DON stated the QI rounds were conducted to identify any issues residents might be having regarding their care and to ensure residents felt safe. According to the DON, any issues identified were taken to QA to ensure a plan was implemented and to ensure auditing was done. She stated she thought the POC had been effective "for the most part". However, the QI rounds failed to identify residents' concerns with CNA #3. Interview with the Medical Director on 01/16/14 at 3:35 PM; and, on 01/17/14 at 9:19 AM, revealed he participated in the facility's QA Committee monthly. He stated "everything" was discussed including grievances and Incident Reports. The Medical Director stated the QA Committee attempted to determine the "root cause" of any issues brought to the meeting and develop interventions. According to the Medical Director, the interventions were discussed at the next meeting to determine if they were effective and if not, they would go back and look at the issue again and implement new interventions if necessary. He stated since August 2013 the QA Committee had reviewed the "Abuse Policy" and felt no changes were required. In regards to the incident involving Resident #3, the Medical Director stated he had been informed the incident was "isolated" and the CNA no longer had responsibility for the resident. He stated he had been told the incident was a "volume issue", in that CNA #3 spoke loudly. The Medical Director stated the POC didn't "catch it" or "we wouldn't have the subsequent issues we have now". Interview on 01/17/14 at 4:35 PM with the Administrator, revealed the QA Committe had been meeting monthly and during the meeting the Social Services Grievance Reports were discussed. She indicated she thought the incident involving Resident #3 and CNA #3 had been discussed in the December 2013 meeting. The Administrator stated QI/QA members were performing twice daily monitoring rounds that included interviewing residents about their care and performing individual in-services with staff. She stated these rounds had failed to identify Resident #9's and Unsampled Resident A's concerns regarding alleged verbal abuse by CNA #3. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 that alleged removal of the Immediate Jeopardy (IJ) effective 01/16/14. Review of the AOC revealed the facility implemented the following: 1) On 01/14/14, the CED in-serviced the Administrator, DON and SW on the facility's "Abuse Policy". The Medical Director was notified of the Immediate Jeopardy on 01/15/14. Human Resources reviewed facility personnel files to ensure the files contained criminal background checks, reference checks and abuse registry checks. Additionally, Department Managers who were Quality Improvement (QI) members and Managers on Duty (MOD) questioned/in-serviced staff individually on appropriate communication versus verbal abuse on 01/14/14 and ongoing. Staff who were on extended leave were to be re-in-serviced prior to returning to work. Investigation into the cause of the event was reviewed/completed on 01/14/14 by the Administrator, DON, Nurse Managers, Department Managers who were also QI members and MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. 2) Forty-nine (49) verbal/interviewable residents were interviewed by Nurse Managers and Department Managers/QI members on 01/14/14 to ensure no additional reports of abusive conduct or concerns related to staff members. Two (2) reports of alleged verbal abuse were received during the interviews; one being from Resident #9 and a new report from Unsampled Resident B. The two (2) reports of verbal abuse were immediately reported, the Physician and family/Power of Attorney (POA) and State Agency were notified on 01/14/14. One (1) allegation (Resident #9) involved CNA #3 who had been terminated from the facility on 01/14/14. The other (Unsampled Resident B) involved another staff member (CNA #11) who was suspended pending investigation. Unsampled Resident A was also interviewed regarding his/her concerns related to CNA #3. 3) Nine (9) non-interviewable residents were assessed by completion of an entire body skin assessment by Nurse Managers on 01/14/14 and 01/15/14. No evidence of physical or psychological abuse was noted during the skin assessments. 4) QI members met on 01/14/14 and reviewed the "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. The Administrator re-in-serviced the DON, Nurse Managers, Department Managers/MOD/QI members again on 01/14/14 regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Return demonstrations were conducted on the above staff by the completion of an investigation process on paper to ensure competency in the completion and reporting and identifying abuse. The Medical Director was notified, on 01/14/14 and 01/15/14, of the new findings regarding two (2) additional reports of alleged verbal abuse discovered which had been reported to the State Agencies. 5) All nursing staff (Nurses, CNAs and KMAs) present and working on 01/14/14 were re-inserviced on the abuse policy by the DON and Nurse Managers to include reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. To ensure competency staff voiced understanding of the policy and voiced no concerns. The re-inservice was to be repeated to ensure all employees had been re-inserviced on the "Abuse Policy". 6) All staff (nursing, dietary, housekeeping and laundry) were re-in-serviced on the facility's "Abuse Policy" on 01/15/14 by the SW, to ensure proper reporting procedures were followed and residents safety ensured. Staff voiced understanding and competency on policy and procedures was ensured at that time by the SW role-playing scenarios with staff to illustrate the difference between appropriate communications with residents and verbal abuse. Additionally, a Licensed Clinical Social Worker (LCSW) performed an in-service on 01/15/14 for all general staff which included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff, on "Residents and Their Emotions: How Can We Help". 7) Individual re-in-services were initiated on 01/14/14 and were to be ongoing and to be completed by Department Managers/QI members to ensure competency in appropriate communication with residents, the difference between appropriate communication and verbal abuse, to ensure staff knew to report immediately if they observed verbal abuse and to treat residents with respect and dignity even during re-direction. The Governing Body was to be notified to assure grievances, documentation, reporting, resident rights and Quality Assurance (QA) all adhered to Federal and State regulations. 8) The Administrator repeated in-services, duty responsibilities, audits, QA, resident rights with all Department Managers/QI/QA members, as well as, the Medical Director to ensure understanding of previous in-services held on 01/14/1/4. 9) Nurses were to continue passing information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring. New interventions were to be discussed in the daily QI meeting held Monday through Friday. On weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD "rounds sheet". Charts, grievance reports, care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. This information was to be transferred to an audit sheet and signed off on by the Administrator or designee (SW). 10) The two (2) residents', who voiced concerns regarding allegations of abuse, care plans were revised as needed and updated on 01/14/14 by the DON and Nurse Managers to ensure the care plans met the specific needs of the residents. Unsampled Resident B's care plan was revised to indicate he/she did not want CNA #11 caring for him/her to honor his/her staff preference. Resident #3's and #9's care plans regarding staff preferences was not revised as CNA #3 was terminated from employment in the facility on 01/14/14. Care plans were to continue to be updated quarterly and as needed with appropriate interventions, especially for residents who were at high risk for safety, abuse, wandering or behaviors after completion of an investigation. 11) An informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Department Managers/MOD/QI members were to continue monitoring with QA rounds twice daily to ensure resident safety needs were met. Complaints were to be addressed with QA team and Medical Director and another QA meeting was to be held thirty (30) days later to assure QA compliance. Issues or concerns were to be documented on the QI monitoring tool for the Administrator/designee (SW) review and follow-up on a daily basis. Ongoing issues were to be monitored by CED on a daily basis and the Medical Director on a monthly basis and through the QA process. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview, on 01/17/14 at 6:21 PM, with the CED revealed on 01/14/14, she in-serviced the Administrator, DON and SW on the facility's "Abuse Policy" in regards to the seven (7) components of abuse, reporting, training, signs and symptoms of abuse, the investigation process, protection of resident and prevention of abuse. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had been in-serviced by the CED on the facility's "Abuse Policy". She stated the in-service included the seven (7) components of abuse, allegations, signs and symptoms of abuse, notification, resident rights, prevention, importance of open communication, appropriate communication versus verbal abuse, how to complete an investigation, timeliness, what to do to ensure residents were protected, if staff was involved ensure they were suspended until the investigation was completed, interviewing all staff and residents, notifying the Physician, responsible party and on monitoring residents' emotional well-being. Interview, on 01/17/14 at 3:55 PM, with the DON revealed she had been in-serviced by the CED on 01/14/14 and everyday since on the facility's "Abuse Policy". She stated the CED went over "the whole policy" which included the seven (7) components of abuse, reporting, screening, reporting, taking statements, interviewing all staff and verbal residents, suspending staff until investigations were concluded, performing skin assessments on non-verbal residents for signs and symptoms of abuse, the investigation process and prevention of abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had been in-serviced by the CED on 01/14/14 on the entire "Abuse Policy". Interview, on 01/16/14 at 3:35 PM, with the Medical Director revealed he had been notified of the Immediate Jeopardy on 01/15/14. Review of a written statement dated 01/15/14, signed by the Human Resources (HR) staff person, revealed she documented she had completed an audit of personnel files on 01/14/14 and 01/15/14 to ensure all employees had abuse registry checks, criminal background checks and reference checks. Continued review of the statement revealed the HR staff person documented all employees were found to have all the documentation in their files. Review of thirteen (13) personnel files revealed they contained contained criminal background checks, reference checks and abuse registry checks. Review of individual in-service documentation dated 01/14/14 through 01/16/14 revealed individual staff were being in-serviced on appropriate communication and verbal abuse by Department Managers/QI members/MOD. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual staff was in-serviced on appropriate communication and verbal abuse by the Department Managers/QI members/MOD. The Administrator stated staff who were on extended leave would be re-in-serviced on the facility's "Abuse Policy" and appropriate communication versus verbal abuse prior to returning to work. She stated an investigation into the cause of the event was reviewed and completed on 01/14/14 by herself, the DON, the Nurse Managers and Department Managers/QI members/MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had talked to Resident #3 and #9 on 01/14/14 and no negative psychological effects were noted. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses and the SW had assessed Residents #3 and #9 on 01/14/14 and no negative effects were noted or observed. 2) Review of resident interview sheets dated 01/14/14 revealed forty-nine (49) residents were interviewed by Nurse Managers or Department Managers/QI members. Review of this documentation revealed two (2) reports of alleged verbal abuse were received during the interviews. Review of the facility's "Initial Report of Incident/Allegation" forms revealed two (2) forms dated 01/14/14, one (1) involved Resident #9 reporting CNA #3 was "hateful" to him/her; the other involved Unsampled Resident B who had reported CNA #11 had laughed at him/her and was a "smartie pants". Continued review of these forms revealed they were faxed to the State Agencies on 01/14/14. One (1) allegation involved CNA #3 who had been terminated from the facility on 01/14/14; and, the other involved CNA #11 who was suspended pending investigation. Review of the medical record for these two (2) residents revealed the Physician and family/POA were notified of the allegations. Interview, on 01/17/14 with Resident #10 at 3:08 PM; Unsampled Resident A at 4:35 PM; Unsampled Resident C at 4:40 PM; Resident #8, Unsampled Resident D and Resident #3 at 4:00 PM; Resident #11 at 4:39 PM; Unsampled Resident B at 4:25 PM; and, Resident #9 at 4:43 PM revealed they all stated that facility staff had talked with them recently regarding any concerns they had with the care provided by staff. Unsampled Resident B stated he/she had told staff about CNA #11 being a "smartie pants" and he/she was told this CNA would no longer provide care for him/her. Resident #9 stated he/she had told staff about CNA #3 yelling at him/her, and slamming doors and the bedside commode lid. Resident #9 stated he/she was informed CNA #3 no longer worked at the facility. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed forty-nine (49) interviewable residents were interviewed on 01/14/14. She stated two (2) residents had made allegations and these were reported to the State Agencies and notifications made to the Physician and responsible parties. According to the Administrator, CNA #3 was terminated from employment at the facility on 01/14/14 and CNA #11 had been suspended pending investigation. 3) Review of the "Weekly Skin Assessment" forms provided revealed nine (9) residents had head to toe skin assessments completed by Nurse Managers on 01/14/14 and 01/15/14. Continued review of these forms revealed no documented evidence of any signs of physical or psychological abuse noted during the skin assessments. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nine (9) complete body assessments were completed on non-verbal resident; with no signs of abuse noted. 4) Review of the In-Service Attendance form dated 01/14/14 revealed the QI members/Department Managers/MOD, Nurse Managers and DON were in-serviced/re-in-serviced by the Administrator on the facility's "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. Further review of this form revealed the Administrator re-in-serviced regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Review of the "Mock Investigation Initial Report of Incident/Allegation" forms revealed the QI members/Department Managers/MOD, Nurse Managers completed mock abuse investigations. Review of the "Initial Report of Incident/Allegation" form revealed dated 01/14/14 regarding Unsampled Resident B's allegation revealed the DON had completed the form and it was reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 1:58 PM with the MDS Coordinator #1; at 2:19 PM with MDS Coordinator #2; at 2:47 PM with the SW; at 3:25 PM with the Food Service Director; at 3:30 PM with the Activity Director; at 3:55 PM with the DON; and at 5:24 PM with the Medical Record person who were all QI members revealed they had been re-inserviced and performed mock investigations. The DON stated she had completed an investigation into Unsampled Resident B's allegation and this had been reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI members were re-in-serviced and had performed mock investigations, and the DON who had completed an investigation into Unsampled Resident B's allegations. She stated she reviewed the DON's investigation and signed off on it. Interview, on 01/17/14 at 9:19 AM with the Medical Director revealed he had been in communication with the facility and had been notified of the two (2) additional residents' complaints and investigation into these complaints on 01/14/14 and 01/15/14. 5) Review of the In-Service Attendance forms dated 01/14/14 revealed Nurses, CNAs and KMAs were re-inserviced on the facility's a"Abuse Policy" by the DON and Nurse Managers. Continued review of these forms revealed the in-service included reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. Interview on 01/17/14 with RN #2 at 6:07 PM and RN #1 at 6:20 PM revealed they had been re-inserviced on 01/14/14 on the "Abuse Policy"; and, interview with CNA #20 at 4:00 PM and CNA #19 at 4:30 PM revealed they had received in-services on the "Abuse Policy" that week. These staff indicated the in-services had covered policy items such as, abuse reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. 6) Review of the "Master List for Inservices" revealed all but five (5) facility staff had received in-servicing on the facility's "Abuse Policy" on 01/15/14. Review of the "Master List for Inservices" revealed the facility staff in-serviced included nursing, dietary, housekeeping and laundry personnel. Review of the In-Service sign-in sheets revealed staff were in-serviced on proper reporting procedures to be followed and ensuring residents safety. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she performed in-services with staff on 01/15/14. She stated staff were able to voice understanding of the "Abuse Policy" after the in-services. The SW stated she role-played different scenarios with staff to show the difference between appropriate communications and verbal abuse. Interviews on 01/17/14 with CNA#16 at 2:30 PM; CNA #10 at 2:35 PM; CNA #7 at 2:40 PM; CNA #1 at 2:45 PM; CNA #14 at 2:50 PM; CNA #13 at 2:55 PM; CNA #18 at 3:00 PM; CNA #9 at 4:20 PM; CNA #19 at 4:30 PM; CNA #21 at 4:35 PM; CNA #17/KMA at 2:25 PM; CNA #17/KMA at 4:30 PM; CNA #20/KMA at 2:18 PM; CNA #2/KMA at 2:18 PM; CNA #22/KMA at 4:20 PM; the Night Cook at 1:50 PM; Dietary Aide #2 at 1:35 PM; Dietary Aide #1 at 1:45 PM; Dietary Aide #3 at 4:15 PM; Housekeeper #1 at 2:04 PM; Housekeeper #2 at 2:08 PM; Housekeeper #3 at 2:15 PM; Housekeeper #4 at 4:10 PM; Laundry Personnel #1 at 1:57 PM; LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed these staff had been in-serviced on the facility's "Abuse Policy" regarding proper reporting procedures and ensuring residents safety. Staff stated the SW role-played scenarios with them related to the difference between appropriate communications with residents and verbal abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed only five (5) staff had not received the in-service on the "Abuse Policy". She stated these employees would not work until they had received it. The Administrator stated all other facility staff had received the in-service. She indicated the SW had performed role-playing with staff to ensure their understanding. Review of a letter dated 01/15/14, signed by a consultant LCSW revealed an in-service was performed on that date for the "entire team" to help address issues with communication. Further review revealed the in-service was titled, "Residents and Their Emotions: How Can We Help". Review of the in-service sign-in sheet dated 01/15/14 revealed fifty-two (52) facility staff from all disciplines had attended the in-service. Further review of the sign-in sheet revealed the staff signatures included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff. Interview, on 01/17/14 at 3:22 PM, with the consultant LCSW revealed he had performed an in-service on 01/15/14 per request of the facility. He stated the in-service was held to address communication issues within the facility. The consultant LCSW stated the in-service was titled, "Residents and Their Emotions: How Can We Help". 7) Review of In-Service Attendance forms revealed individual re-in-services related to abuse were performed on 01/14/14 and 01/15/14 completed by Department Managers/QI members. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual re-in-services had been performed by QI members and this would be ongoing to ensure staff's understanding of appropriate communication and the "Abuse Policy". Continued interview with the Administrator revealed the Governing Body, which constituted the facility Owner and her father, would be notified of grievances, documentation, reporting, resident rights and the Quality Assurance (QA) meeting findings. 8) Review of the In-Service Attendance form dated 01/14/14 revealed all Department Managers/QA/QI members had received training on responsibilities, audits, QA and resident rights. Interview, on 01/17/14 MDS Coordinator #1 at 1:58 PM; MDS Coordinator #2 at 2:19 PM; the SW at 2:47 PM; the Food Services Manager at 3:25 PM; the Activity Director at 3:30 PM; the DON at 3:55 PM; and the Medical Records person at 5:24 PM, (who were all Department Managers/QI members) revealed they had all be re-in-serviced by the Administrator on their duties and responsibilities, on the audits, QA, the "Abuse policy" and resident rights. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had performed the in-service/re-in-service on 01/14/14 and had been re-in-servicing Department Managers/QI members ongoing since then regarding their duties and responsibilities, on audits, the facility's QA and on resident rights. She stated an informal QA meeting was held on 01/14/14 and the Medical Director had been contacted on 01/14/15 and 01/15/14 regarding the inservices/re-in-services conducted. 9) Review of QI Rounds sheets revealed QI members were conducting rounds twice daily which included any complaints or concerns noted by residents. Interview, on 01/17/14 with LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed nurses continued passing information along in the change of shift report. They indicated changes in condition and issues or concerns were discussed to address any monitoring that was required. These nurses indicated new interventions were implemented as necessary. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses passed information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring required. She stated audits were being completed to ensure the twenty-four (24) hour report sheet and Physician order [REDACTED]. The Administrator stated any issues or concerns were being taken to the daily Monday through Friday QI meeting and discussed, with new interventions implemented as necessary. She indicated residents' charts, any grievance reports and their care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. According to the Administrator, on weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD "rounds sheet". She stated this information was to be transferred to an audit sheet and signed off on by herself or her designee, the CED or SW. 10) Review of Unsampled Resident B's care plan revealed it was revised to include an intervention indicating the resident did not want CNA #11 caring for him/her. Review of Resident #3's and #9's care plan revealed no revisions made related to staff preferences. Interview, on 01/17/14 at 3:38 PM, with the DON revealed Unsampled Resident B's care plan had been revised to indicate he/she did not want CNA #11 caring for him/her. She indicated there had been no reason to revise Resident #3's and #9's care plan for staff preferences as CNA #3 had been terminated on 01/14/14. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed care plans of residents had been reviewed by the DON and Nurse Managers, and revised as necessary to ensure residents' needs were met. She stated Unsampled Resident B's care plan had been revised to include the information that he/she did not want CNA #11 caring for him/her. She indicated residents' care plans would continue to be updated quarterly and as needed with appropriate interventions. 11) Interview, on 01/17/14 at 2:19 PM with MDS Coordinator #1/QI member; at 3:30 PM with the Activity Director/QI member; an at 5:24 PM with the Medical Records personnel/QI member revealed an informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Review of QI Rounds sheets revealed QI members were conducting rounds twice daily which included any complaints or concerns noted by residents. Interview, on 01/17/14 MDS Coordinator #1 at 1:58 PM; MDS Coordinator #2 at 2:19 PM; the SW at 2:47 PM; the Food Services Manager at 3:25 PM; the Activity Director at 3:30 PM; the DON at 3:55 PM; and the Medical Records person at 5:24 PM, (who were all Department Managers/QI members) revealed they were completing twice daily rounding to observe and note any complaints or concerns residents might have. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI rounds were being completed twice daily by QI members to ensure resident safe

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse. The facility failed to protect one (1) of nine (9) sampled residents from abuse (Resident #1). On 08/03/13 at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. Interview and record review revealed Resident #1 was not assessed for injury, nor was the resident's Physician or Legal Representative immediately notified of the incident. (Refer to F157) Interview and record review revealed the facility failed to investigate the incident and report the incident to the appropriate State Agencies (Refer to F225 and F226) Interview also revealed Resident #2 had a history of [REDACTED]. Record review revealed Resident #2 would stare into other residents' rooms, cuss in the hallways, and make sexual comments; however, there was no documented evidence the facility had addressed Resident #2's behavior. (Refer to F250, F280) The facility's failure to ensure an effective system was in place to ensure each resident remained free from abuse, was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 08/15/13, and determined to exist on 08/03/13. The facility was notified of the Immediate Jeopardy on 08/15/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-223 Abuse, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure Residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse Reporting" undated, revealed the facility will not condone resident abuse by anyone, including staff members legal guardians, sponsors, friends, or other individuals. Further review revealed the definitions of abuse were provided to assist staff members in recognizing incidents of abuse. Further review revealed sexual abuse defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. Continued review of the facility's policy revealed, upon receiving a report of suspected abuse, the charge nurse shall examine and interview the resident with findings of the examination recorded in the resident's medical record. Further review revealed when sexual abuse is suspected, the resident is not to be bathed and clothing or linens should not be washed. Further review revealed the charge nurse should complete an incident form, notify the resident's physician, responsible party, and the administrator or designee. Review of the facility's policy titled, "Resident Rights" undated, revealed residents have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #1 to be unable to complete a Brief Interview for Mental Status (BIMS) and to be severely cognitively impaired. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) summary score of 11/15, indicating the resident was moderately impaired in cognition. Review of the Nursing Notes, dated 08/03/13 at 4:00 AM, revealed staff entered the closed door to Resident #1's room and found Resident #2 in his/her room with the resident. Interview with Resident #1's primary nurse and charge nurse, Licensed Practical Nurse (LPN) #5, on 08/15/13 at 7:06 PM, revealed she found Resident #2 in Resident #1's room with the door closed. Further interview revealed Resident #1's left hip and buttocks were exposed and the blanket had wet spots on it. LPN #5 stated she had seen Resident #2 approximately five (5) or ten (10) minutes prior to the event. LPN #5 stated upon finding Resident #2 in Resident #1's room, she notified her Manager On Duty (MOD) who notified the Corporate Executive Officer (CEO) who called her for further information. Interview with Certified Nursing Aide (CNA) #3, on 08/20/13 at 10:05 AM, revealed she entered Resident #1's room immediately behind LPN #5. CNA #3 stated LPN #5 went to Resident #2 and she went to Resident #1. LPN #5 removed Resident #2 from Resident #1's room. Further interview revealed CNA #3 found Resident #1 lying on his/her right side in a fetal position with his/her pajama pants and adult brief pulled down under the buttocks with his/her buttocks completely exposed. Further interview revealed Resident #1 was found to have a wet substance on his/her hip, on the outer side of his/her adult brief, and on the resident's blanket. CNA #3 reported she stayed with Resident #1 briefly until CNA #2 bathed Resident #1. Continued interview revealed CNA #3 reported to LPN #5 that Resident #1's pajama pants and adult brief were pulled down and a wet substance was found on Resident #3's hip, on the outside of his/her brief, and on the blanket. Interview with LPN #2, on 08/14/13 at 6:53 PM, revealed she was the third person into the room and Resident #1 was lying on his/her right side in the fetal position with his/her pajama pants and adult brief pulled down under the buttocks exposing Resident #1's buttocks. Further interview revealed she did not think Resident #1 was capable of pulling his/her own pajama pants and adult briefs down. LPN #2 stated Resident #1 did not appear to be in distress. Resident #1 was facing the wall with his/her eyes closed. LPN #2 stated she then went back to care for her assigned residents. Further interview with LPN #2, on 08/14/13 at 8:25 PM, revealed CNA #2 asked LPN #2 if she should bathe Resident #1. LPN #2 told CNA #2 to bathe Resident #1 because "I would want a bath if it happened to me", I would feel dirty". Interview with CNA #2, on 05/15/13 at 7:47 PM, revealed she was on duty the night of 08/03/13. CNA #2 stated she was in Resident #1's room immediately after Resident #2 was removed. Further interview revealed Resident #1's pajama pants and adult brief were pulled down below Resident #1's buttocks. Further interview revealed CNA #2 pulled Resident #1's adult brief up. Continued interview revealed a wet substance was found on Resident #1's blanket, hip and outer surface of the adult brief. Continued interview revealed she asked LPN #2 if she should bathe Resident #1. Further interview revealed Resident #1 was bathed because Resident #2 could have sexually assaulted Resident #1. CNA #2 stated if this happened to her she would want someone to bathe her because she would feel dirty. CNA #2 stated she was not aware that she should not have bathed Resident #1. Interview with CNA #1, on 08/14/13 at 7:54 PM, revealed she was the CNA that monitored Resident #2 immediately after LPN #5 removed the resident from the room. Further interview revealed Resident #2's zipper of his/her pants was down when the resident was found in the room. Interview with the Manager of Duty (MOD), on 08/16/13 at 3:34 PM, revealed she was notified by LPN #5 on 08/03/13 at approximately 4:30 AM of an incident involving Resident #2 being found in Resident #1's room with the door closed. Further interview revealed LPN #5 told her Resident #1's adult brief had been pulled down exposing his/her buttocks and the adult brief and linens had a wet sticky substance on them. The MOD stated she reported the information she received from LPN #5 to the CEO and also reported the staff were very upset. The MOD stated she was advised by the CEO that she (the CEO) would call LPN #5. Interview with the Corporate Executive Officer (CEO), on 08/14/13 at 8:55 PM, revealed she was advised of the incident on 08/03/13 at approximately 4:45 AM. Further interview revealed she was advised Resident #1 was found with his/her pajama pants and adult brief pulled down exposing Resident #1's buttocks and a wet substance was found on Resident #1's blanket. However, the CEO stated she did not think anything had happened after talking to LPN #5. Further interview,on 08/15/13 at 7:06 PM, with LPN #5 revealed she did not think anything had happened because Resident #2 could walk but he was in a wheel chair, Resident #1 had a fall mat beside his/her bed, Resident #2 could not remove his/her own pants, and Resident #2 was not in the room but maybe five (5) or ten (10) minutes and did not have enough time to do anything to Resident #1. Continued interview revealed Resident #2 could have gotten out of his/her wheel chair touched Resident #1 inappropriately and gotten back into his/her wheel chair. Interview with the Owner of the facility, on 08/15/13 at 2:01 PM, revealed the incident of 08/03/13 was just "gossip" from a staff member that was now afraid for his/her job. The Owner stated Resident #2 was "just a wandering resident", she (the owner) was "one hundred (100%) percent certain, no way" a sexual assault happened. Further interview revealed "people were assuming the worst" and stated there was no evidence an altercation or anything had occurred. Interview with two resident(s), whom the facility had assessed as being interviewable, revealed Resident #2 had a history of [REDACTED]. Interview with Resident #4, on 08/16/13 at 12:59 PM, revealed Resident #4 had witnessed Resident #2 put his/her hand between Resident #1's legs. Continued interview revealed, Resident #4 advised staff to "keep an eye on" Resident #2 and keep him/her out of Resident #1's room. Further interview revealed Resident #4 did report his/her concerns to the Assistant Administrator/Social Services Director. Interview with Resident #5, on 08/16/13 at 1:10 PM, revealed Resident #5 recalled specific incidents when Resident #2 would reach towards Resident #1's breast and Resident #5 would intervene prior to any actual touching. Resident #5 stated the residents had to look out for Resident #1 and keep Resident #2 away from Resident #1. Interview with the Assistant Administrator/Social Service Director (AA/SSD), on 08/21/13 at 10:44 AM, revealed she was not aware of Resident #2 making sexually inappropriate comments gestures or touching others. Interview with a State Police Detective on 08/16/13 at 2:30 PM revealed the State Police responded to the facility the evening of 08/03/13 after receiving an anonymous call to report an allegation of sexual assault. Continued interview revealed the Police Officers found no documented evidence related to the allegation, and no documented evidence Resident #1 had been evaluated by a physician. Further interview revealed during the process of the Police investigation the State Police requested the sexual assault examination. Further review of Resident #1's Nursing Notes revealed on 08/04/13 at 12:30 AM, Resident #1 was transferred to the emergency department for evaluation and labs, approximately twenty and a half (20 1/2) hours after staff was aware of the incident. Review of the Emergency Department notes, dated 08/04/13 at 1:05 AM, revealed Resident #1 presented to the Emergency Department for a possible sexual assault. Continued review revealed a sexual assault evidence collection examination was completed. The emergency Physician noted the nursing facility staff had bathed Resident #1 and changed and washed Resident #1's clothing and linens prior to seeking emergency care. Evidence from the sexual assault collection examination had not been processed at the time of the State Survey Agency's investigation. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure an alleged incident of sexual abuse was thoroughly investigated and reported immediately to the appropriate State Agencies for one (1) of nine (9) sampled residents (Resident #1). On 08/03/13 at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. The facility was unable to produce an incident report for the occurrence of the alleged sexual abuse; proof of an investigation; nor documented evidence the appropriate agencies were notified regarding the alleged sexual abuse. (Refer to F223) Based on the above findings, it was determined the facility's failure to investigate an alleged incident of sexual abuse and to immediately report the incident to the appropriate State Agencies, was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 08/15/13 and was determined to exist on 08/03/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-225 Abuse, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure all allegations of abuse were immediately reported to the appropriate State law authorities and all allegations of abuse were thoroughly investigated. The findings include: Review of the facility's policy titled,"Abuse Reporting" undated, revealed upon receiving suspected reports of abuse, misappropriation of property, or neglect, the Administrator or designee should report the incident to the appropriate authorities. Review of the facility's policy titled, "Accidents and Incidents" undated, revealed regardless of how minor an accident or incident may be, it should be reported to the department supervisor, and an Accident/Incident Report Form should be completed on the shift that the accident or incident occurred. Further review revealed the charge nurse and/or the department supervisor shall conduct an immediate investigation and submit it to the Director of Nursing Services. The State Survey Agency requested the incident report and investigation; however, the facility denied all requests. Review of Resident #1's Nursing Notes, dated 08/03/13 at 4:00 AM, revealed staff entered the closed door to Resident #1's room and found another resident in his/her room with the resident. Further record review revealed on 08/03/13 at 11:00 PM, an order was received from Resident #1's physician to transport Resident #1 to the emergency department for evaluation. Review of the Emergency Department notes, dated 08/04/13 at 1:05 AM, revealed Resident #1 presented to the emergency department for a possible sexual assault and a sexual assault evidence collection examination was completed. However, interview and record review revealed no documented evidence the facility completed an incident report; conducted a thorough investigation of the incident; or notified the appropriate State Agencies. Interview with Licensed Practical Nurse (LPN) #5, on 08/15/13 at 7:06 PM, revealed LPN #5 was Resident #1's primary nurse and charge nurse, Further review revealed she found Resident #2 in Resident #1's room and notified her Manager on Duty who notified the Corporate Executive Officer (CEO). Interview with the Manager of Duty (MOD), on 08/16/13 at 3:34 PM, revealed she was notified by LPN #5 on 08/03/13 at approximately 4:30 AM of an incident involving Resident #2 being found in Resident #1's room with the door closed and that Resident #1's adult brief had been pulled down exposing his/her buttocks and the adult brief and linens had a wet sticky substance on them. The MOD stated she reported the information she received from LPN #5 to the CEO and she was advised by the CEO that she (the CEO) would call LPN #5. Further interview with Licensed Practical Nurse (LPN) #5, on 08/15/13 at 7:06 PM, revealed the CEO called her for further information, but LPN #5 was not directed to complete an incident report. Further interview revealed, she was aware of the abuse policy, and did not follow the facility's policy to conduct an immediate investigation and document the incident because she did not think anything had happened. Interview with the CEO, on 08/14/13 at 8:55 PM, revealed she did not report the incident to the appropriate State Agencies because she was told by the reporting nurse (LPN #5), nothing happened. Continued interview revealed she was told Resident #2 was found in Resident #1's room with the door closed. Further interview revealed she was told Resident #1's pajama pants and adult briefs were pulled down and exposed his/her buttocks. She was also advised a wet substance was found on Resident #1's blanket. Further interview revealed when the State Police initiated their investigation, she requested witness statements from immediate care providers for the night of 08/03/13; however, a thorough investigation was not completed because she did not think anything had happened. Interview with CNA #1, on 08/14/13 at 7:54 PM, revealed the Corporate Executive Officer (CEO) requested witness statements from staff after the State Police initiated their investigations. However, interview revealed the CEO refused to take CNA #1's witness statement requesting CNA #1 re-write the statement including only facts of what she saw when she looked into the room. She stated the CEO wanted only what she saw, which was Resident #1 with his/her adult brief pulled down and blanket off. Further interview revealed CNA #1 was advised by the CEO, what Resident #2 had been doing before and after the incident was not relevant. CNA #1 stated she revised her statement; however, she gave her original statement to the State Police. Interview with Resident #1's legal guardian, on 08/21/13 at 1:58 PM, revealed she received a call on 08/04/13, with her phone's caller ID system identifying the caller to be from the facility, with a male voice stating he was a detective and the case (involving Resident #1) was closed. However, the Legal Representative confirmed with the police detective that he had not called her to advise the case was closed. Interview with the Assistant Administrator who was also Social Services Director, on 08/21/13 at 10:44 AM, revealed she was notified of the incident on 08/03/13 at approximately 9:30 AM. Further interview revealed she did not think anything had happened because Resident #2 was in a wheel chair and unable to walk and Resident #1 had a fall mat beside his/her bed. However, review of Resident #2's Nursing Notes dated 08/03/13 at 4:30 AM, revealed Resident #2 became agitated, got up out of his/her wheel chair, yelling foul curse words at staff, and was unable to be redirected. Interview with the Administrator, on 08/21/13 at 2:42 PM, revealed the Corporate Executive Officer (CEO) was on-call for 08/03/13. Further interview revealed the CEO notified her on 08/04/13 around 10:30 AM or 10:45 AM that Resident #2 was found in Resident #1's room with the door closed but had only been in the room less than five (5) minutes and staff removed Resident #2 immediately upon finding him/her. However, interview revealed she was not informed Resident #1's pajama pants and adult brief were pulled down and the blanket was wet with an unidentified substance. Continued interview revealed an incident report and investigation should have been completed. Further interview revealed the incident should have been reported per the facility's policy to the appropriate State Agencies. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review and review of the facility's policy and grievance forms, it was determined the facility failed to have an effective system to ensure alleged incidents of abuse were investigated and reported immediately to the appropriate State Agencies for two (2) of eleven (11) sampled residents (Resident #3 and Resident #9) and one (1) unsampled residents (Unsampled Resident A). The facility failed to investigate Resident #3's allegation of verbal abuse which resulted in the facility's failure to identify other residents who were victims of verbal abuse and/or staff who had witnessed verbal abuse by Certified Nursing Assistant (CNA) #3. Interview with residents and staff revealed allegations of verbal abuse involving Resident #9 and Unsampled Resident A by CNA #3 which had not been reported by staff. The facility also failed to prevent further potential abuse by failing to investigate Resident #3's allegation. Resident #3 reported verbal abuse by Certified Nursing Assistant (CNA) #3 to facility staff on 11/29/13; however the allegation was viewed as a grievance by facility staff, not as possible verbal abuse. Therefore, the incident was not investigated and reported to State Agencies. Resident #9 was not interviewed on 11/29/13 or 11/30/13 by facility staff regarding CNA #3's care. In interview on 01/13/14 Resident #9 reported he/she was afraid of CNA #3 who had told him/her to shut-up and had slammed the door, bedside commode lid and closet door. Therefore, Resident #9's concerns with CNA #3 were not investigated or reported to State Agencies until 01/14/14, after the facility was notified of the Immediate Jeopardy. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed some staff were "rude" to him/her; either would not reply to the resident or would get "smart" with him/her. Unsampled Resident A stated he/she would rather not provide any names of staff. However, CNA #4 reported she had witnessed CNA #3 become verbally abusive to Unsampled Resident A in the past; however had not reported the incident to the Charge Nurse or any other facility staff. Therefore, the incident was not investigated or reported to the State Agencies. (Refer to F223) Based on the above findings, it was determined the facility's failure to investigate alleged incidents of verbal abuse, to prevent further potential abuse, and to immediately report the incident to the appropriate State Agencies was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 01/14/14 and was determined to exist on 11/29/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 01/17/14 with the facility alleging removal of the Immediate Jeopardy on 01/16/14. The Immediate Jeopardy was verified to be removed on 01/16/14, prior to exiting the facility on 01/17/14, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-225 Abuse, with a Scope and Severity of "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure all allegations of abuse were immediately reported to the appropriate State law authorities and all allegations of abuse were thoroughly investigated. The findings include: Review of the facility's policy titled, "Abuse Reporting", undated, revealed that all personnel were to promptly report any incident or suspected incident of resident abuse. The facility policy stated if a person(s) observed an incident of resident abuse or suspected resident abuse the person was to immediately report such incident to the Charge Nurse who would report to the Administrator or designee as soon as practicable. Further review of the policy revealed employees accused of resident abuse were to be removed from resident care duties immediately pending investigation or until the results of the investigation was reviewed by the Administrator. Upon receiving a report of suspected abuse, neglect, or misappropriation of property the Administrator or designee was to report the incident to the State Regulatory and Protection Agencies. An investigation was to be completed and a copy of the findings of the investigation provided to the Administrator within five (5) working days of the alleged abuse, neglect or misappropriation. Review of CNA #3 personnel file revealed she was hired on 11/14/12 and an Abuse Registry check was completed on 11/12/12. Review of the "Prevention and Reporting of Resident Abuse: Acknowledgement of Responsibilities", undated, revealed CNA #3 signed the form on 11/12/12. Review of this form revealed by signing the form CNA #3 was aware of the definitions on abuse "set down" in policy and had the opportunity to discuss definitions and ask questions. Additionally, review of the form revealed it was CNA #3's responsibility as an employee to abstain from any commission of any act, which might be abusive (verbally, mentally, or physically) to any resident, staff member, or other individual related to the facility. Continued review of personnel files revealed the "Prevention and Reporting of Resident Abuse: Acknowledgement of Responsibilities" form for Registered Nurse (RN) #1 revealed the RN signed the form on 03/28/06; a review of the form for CNA #4 revealed she had signed the form on 11/14/12; and, a review of the form for Nursing Assistant (NA) #1 revealed she had signed the form on 11/15/13. Review of the form revealed by signing it, RN #1, NA #1, and CNA #4 were indicating they were aware it was their responsibility as employees to immediately report any incidents of actual or suspected abuse to their supervisor and/or Administrator or designee. 1. Interview with Resident #3 on 12/27/13 at 3:15 PM revealed on 11/29/13 CNA #3 yelled at him/her for going into the nurse's station to obtain food out of refrigerator and the resident told CNA #3 he/she was going to report the CNA to the Social Worker (SW). Resident #3 stated she was afraid of CNA #3 as he/she couldn't be sure what CNA #3 might do and did not want CNA #3 to care for him/her ever again. Interview with Nursing Assistant (NA) #1 on 01/14/14 at 12:30 PM, revealed she had worked on 11/29/13 with CNA #3 and had witnessed the incident involving CNA #3 and Resident #3. NA #1 revealed CNA #3 was "loud", but she did not consider this to be verbal abuse, and thought Resident #3 was over reacting. NA #1 stated CNA #3 told Resident #3, "don't threaten me with the SW". Per interview, NA #1 and CNA #3 reported the incident to RN #1, who was Charge Nurse that night. However, per interview, they only reported Resident #3 was upset and threatening to report CNA #3 to the SW. NA #1 revealed she and CNA #3 continued working throughout the night on Resident #3's hall answering his/her call light. Interview with the Kentucky Medical Assistant (KMA) #2 on 01/13/14 at 3:16 PM, revealed she worked the night of 11/29/13 and heard CNA #3 stating, "don't threaten me". KMA #2 revealed CNA #3 had a "loud" voice and it came across as "harsh". According to the KMA, she had not viewed the incident as "verbal" abuse, but stated CNA #3's statements to Resident #3 had been a fine line between being abusive or not and she informed RN #1 about the incident. Interview with the RN #1, Charge Nurse, on 01/14/14 at 3:09 PM, revealed CNA #3 and NA #1 informed her Resident #3 had been in the nurse's station and CNA #3 had told the resident to get of there. RN #1 reported CNA #3 stated she had told her because Resident #3 was "upset" with the CNA, and Resident #3 had threatened to tell the SW. However, RN #1 stated she did not recall KMA #2 informing her of the incident which occurred on 11/29/13. RN #1 revealed she did not report the incident to the Director of Nursing (DON) because when she checked on Resident #3 later that evening, the resident never said anything to her about the incident. However, RN #1 stated she did not ask Resident #3 about the incident. Interview with the Activity Director on 01/15/14 at 4:20 PM, revealed Resident #3 told her the morning of 11/30/13 that CNA #3 yelled at her on 11/29/13 when he/she was attempting to get his/her dinner out of the nurses' refrigerator. According to the Activity Director, she did not document Resident #3's statement, but had told the Charge Nurse, RN #2 about Resident #3's statements. The Activity Director stated she called the SW at home to report the resident's statements as she did not know how to handle the situation. Interview with the Social Worker (SW) on 12/27/13 at 4:15 PM and 01/15/14 at 4:00 PM , revealed the Activity's Director had contacted her at home on 11/30/13 regarding the incident involving Resident #3 and CNA #3. The SW stated she called the DON at home and informed her of the incident, which had occurred on 11/29/13 at approximately 7:00 PM. The SW stated she had originally considered the incident involving Resident #3 as a complaint; therefore, she did not initiate an investigation or report the incident to State Agencies. She stated she would now classify the incident as an allegation of "abuse" and the incident should have been reported to the State Agencies as per facility policy. Interview with DON on 12/26/13 at approximately 3:57 PM and on 12/27/13 at 5:30 PM, intially revealed an Incident Report had been completed regarding the incident. The DON stated she initiated an investigation of the incident on 11/30/13 and conducted staff interviews by phone on that date. Continued interview with the DON revealed when she talked to Resident #3 on 11/30/13, the resident felt he/she had been verbally abused by CNA #3. The DON stated CNA #3 had completed her shift on 11/29/13 but did not work on 11/30/13 after the investigation had been initiated. However, review of the facility's time clock sheet revealed CNA #3 clocked in to work on 11/30/13 at 6:29 PM and clocked out at 6:41 AM on 12/01/13. Further interview with the DON on 01/13/14, revealed an Incident Report had not been completed regarding the incident involving Resident #3 and CNA #3. Per interview, the facility had viewed the incident on 11/29/13 involving Resident #3 as a grievance, not as abuse; even though in a prior interview the DON stated Resident #3 had told her he/she felt verbally abused by CNA #3. She stated as a result of considering the incident a grievance CNA #3 was allowed to work the rest of her shift and to work on Saturday night; though the DON's previous interview revealed CNA #3 had not worked during her investigation. Further interview revealed CNA #3 "definitely" should have been off and not allowed to work that weekend. The DON stated she had talked to other residents to see if they had concerns, but did not ask specifically about CNA #3's care. However, further interview, on 01/15/14 at 5:53 PM, with the DON revealed she had no documented evidence of the investigative work she had indicated was initiated on 11/30/13. She stated all she had was typewritten statements from staff, dated 12/02/13, that were attached to the "Resident/Family Concern" grievance form. The DON stated she understood now the incident should have been viewed as an abuse allegation, reported to State Agencies, and the facility's policy followed. Interview with CNA #3 on 01/13/14 at 7:02 PM revealed she worked the rest of her shift on 11/29/13 and her scheduled shift on 11/30/13 on Resident #3's unit. Interview with the Administrator on 12/26/13 at approximately 4:00 PM, on 12/27/13 at 1:06 PM, and 12/27/13 at 5:40 PM, revealed staff had not completed an Incident Report regarding the incident involving Resident #3 as the facility had not considered the incident as abuse. Therefore, the incident was not reported to the State Agencies. The Administrator stated the facility should have been investigated and reported the incident. 2. Interview with Resident #9 on 01/13/14 at 4:56 PM, revealed CNA #3 had been verbally abusive to him/her on several occasions. CNA #3 would yell at him/her at times saying, "shut-up" or "what the hell do you want", and was "hateful". Resident #9 also stated CNA #3 slammed the room door, the bedside commode lid and closet door at times. Resident #9 stated he/she was afraid of CNA #3. The resident revealed it didn't do "any good to tell anyone here anything" as they believed staff over residents. Review of the grievance form or attached statements dated 12/02/13 revealed no documented evidence other residents were interviewed regarding CNA #3's care. The facility was unaware of Resident #9's fear of CNA #3 until they interviewed him/her on 01/14/14 after notification of the Immediate Jeopardy. 3. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed a few staff were "rude" to him/her and staff would get "smart" with him/her. Unsampled Resident A reported he/she would rather not provide any names of staff. However, interview with CNA #4 on 01/13/14 at 6:30 PM, revealed she had witnessed CNA #3 being verbally abusive to Unsampled Resident A around Thanksgiving. CNA #4 stated she did not report the incident to the Charge Nurse or anyone; but indicated she should have. Further interview on 01/17/14 at 4:35 PM with the Administrator revealed had other residents been interviewed after the incident involving Resident #3 and CNA #3 the facility would have been aware of Resident #9's fear of CNA #3 and actions taken. Additionally, she stated CNA #4 should have reported the incident immediately involving CNA #3 and Unsampled Resident A. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 that alleged removal of the Immediate Jeopardy (IJ) effective 01/16/14. Review of the AOC revealed the facility implemented the following: 1) On 01/14/14, the CED in-serviced the Administrator, DON and SW on the facility's "Abuse Policy". The Medical Director was notified of the Immediate Jeopardy on 01/15/14. Human Resources reviewed facility personnel files to ensure the files contained criminal background checks, reference checks and abuse registry checks. Additionally, Department Managers who were Quality Improvement (QI) members and Managers on Duty (MOD) questioned/in-serviced staff individually on appropriate communication versus verbal abuse on 01/14/14 and ongoing. Staff who were on extended leave were to be re-in-serviced prior to returning to work. Investigation into the cause of the event was reviewed/completed on 01/14/14 by the Administrator, DON, Nurse Managers, Department Managers who were also QI members and MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. 2) Forty-nine (49) verbal/interviewable residents were interviewed by Nurse Managers and Department Managers/QI members on 01/14/14 to ensure no additional reports of abusive conduct or concerns related to staff members. Two (2) reports of alleged verbal abuse were received during the interviews; one being from Resident #9 and a new report from Unsampled Resident B. The two (2) reports of verbal abuse were immediately reported, the Physician and family/Power of Attorney (POA) and State Agency were notified on 01/14/14. One (1) allegation (Resident #9) involved CNA #3 who had been terminated from the facility on 01/14/14. The other (Unsampled Resident B) involved another staff member (CNA #11) who was suspended pending investigation. Unsampled Resident A was also interviewed regarding his/her concerns related to CNA #3. 3) Nine (9) non-interviewable residents were assessed by completion of an entire body skin assessment by Nurse Managers on 01/14/14 and 01/15/14. No evidence of physical or psychological abuse was noted during the skin assessments. 4) QI members met on 01/14/14 and reviewed the "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. The Administrator re-in-serviced the DON, Nurse Managers, Department Managers/MOD/QI members again on 01/14/14 regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Return demonstrations were conducted on the above staff by the completion of an investigation process on paper to ensure competency in the completion and reporting and identifying abuse. The Medical Director was notified, on 01/14/14 and 01/15/14, of the new findings regarding two (2) additional reports of alleged verbal abuse discovered which had been reported to the State Agencies. 5) All nursing staff (Nurses, CNAs and KMAs) present and working on 01/14/14 were re-inserviced on the abuse policy by the DON and Nurse Managers to include reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. To ensure competency staff voiced understanding of the policy and voiced no concerns. The re-inservice was to be repeated to ensure all employees had been re-inserviced on the "Abuse Policy". 6) All staff (nursing, dietary, housekeeping and laundry) were re-in-serviced on the facility's "Abuse Policy" on 01/15/14 by the SW, to ensure proper reporting procedures were followed and residents safety ensured. Staff voiced understanding and competency on policy and procedures was ensured at that time by the SW role-playing scenarios with staff to illustrate the difference between appropriate communications with residents and verbal abuse. Additionally, a Licensed Clinical Social Worker (LCSW) performed an in-service on 01/15/14 for all general staff which included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff, on "Residents and Their Emotions: How Can We Help". 7) Individual re-in-services were initiated on 01/14/14 and were to be ongoing and to be completed by Department Managers/QI members to ensure competency in appropriate communication with residents, the difference between appropriate communication and verbal abuse, to ensure staff knew to report immediately if they observed verbal abuse and to treat residents with respect and dignity even during re-direction. The Governing Body was to be notified to assure grievances, documentation, reporting, resident rights and Quality Assurance (QA) all adhered to Federal and State regulations. 8) The Administrator repeated in-services, duty responsibilities, audits, QA, resident rights with all Department Managers/QI/QA members, as well as, the Medical Director to ensure understanding of previous in-services held on 01/14/1/4. 9) Nurses were to continue passing information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring. New interventions were to be discussed in the daily QI meeting held Monday through Friday. On weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD "rounds sheet". Charts, grievance reports, care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. This information was to be transferred to an audit sheet and signed off on by the Administrator or designee (SW). 10) The two (2) residents', who voiced concerns regarding allegations of abuse, care plans were revised as needed and updated on 01/14/14 by the DON and Nurse Managers to ensure the care plans met the specific needs of the residents. Unsampled Resident B's care plan was revised to indicate he/she did not want CNA #11 caring for him/her to honor his/her staff preference. Resident #3's and #9's care plans regarding staff preferences was not revised as CNA #3 was terminated from employment in the facility on 01/14/14. Care plans were to continue to be updated quarterly and as needed with appropriate interventions, especially for residents who were at high risk for safety, abuse, wandering or behaviors after completion of an investigation. 11) An informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Department Managers/MOD/QI members were to continue monitoring with QA rounds twice daily to ensure resident safety needs were met. Complaints were to be addressed with QA team and Medical Director and another QA meeting was to be held thirty (30) days later to assure QA compliance. Issues or concerns were to be documented on the QI monitoring tool for the Administrator/designee (SW) review and follow-up on a daily basis. Ongoing issues were to be monitored by CED on a daily basis and the Medical Director on a monthly basis and through the QA process. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview, on 01/17/14 at 6:21 PM, with the CED revealed on 01/14/14, she in-serviced the Administrator, DON and SW on the facility's "Abuse Policy" in regards to the seven (7) components of abuse, reporting, training, signs and symptoms of abuse, the investigation process, protection of resident and prevention of abuse. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had been in-serviced by the CED on the facility's "Abuse Policy". She stated the in-service included the seven (7) components of abuse, allegations, signs and symptoms of abuse, notification, resident rights, prevention, importance of open communication, appropriate communication versus verbal abuse, how to complete an investigation, timeliness, what to do to ensure residents were protected, if staff was involved ensure they were suspended until the investigation was completed, interviewing all staff and residents, notifying the Physician, responsible party and on monitoring residents' emotional well-being. Interview, on 01/17/14 at 3:55 PM, with the DON revealed she had been in-serviced by the CED on 01/14/14 and everyday since on the facility's "Abuse Policy". She stated the CED went over "the whole policy" which included the seven (7) components of abuse, reporting, screening, reporting, taking statements, interviewing all staff and verbal residents, suspending staff until investigations were concluded, performing skin assessments on non-verbal residents for signs and symptoms of abuse, the investigation process and prevention of abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had been in-serviced by the CED on 01/14/14 on the entire "Abuse Policy". Interview, on 01/16/14 at 3:35 PM, with the Medical Director revealed he had been notified of the Immediate Jeopardy on 01/15/14. Review of a written statement dated 01/15/14, signed by the Human Resources (HR) staff person, revealed she documented she had completed an audit of personnel files on 01/14/14 and 01/15/14 to ensure all employees had abuse registry checks, criminal background checks and reference checks. Continued review of the statement revealed the HR staff person documented all employees were found to have all the documentation in their files. Review of thirteen (13) personnel files revealed they contained contained criminal background checks, reference checks and abuse registry checks. Review of individual in-service documentation dated 01/14/14 through 01/16/14 revealed individual staff were being in-serviced on appropriate communication and verbal abuse by Department Managers/QI members/MOD. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual staff was in-serviced on appropriate communication and verbal abuse by the Department Managers/QI members/MOD. The Administrator stated staff who were on extended leave would be re-in-serviced on the facility's "Abuse Policy" and appropriate communication versus verbal abuse prior to returning to work. She stated an investigation into the cause of the event was reviewed and completed on 01/14/14 by herself, the DON, the Nurse Managers and Department Managers/QI members/MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had talked to Resident #3 and #9 on 01/14/14 and no negative psychological effects were noted. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses and the SW had assessed Residents #3 and #9 on 01/14/14 and no negative effects were noted or observed. 2) Review of resident interview sheets dated 01/14/14 revealed forty-nine (49) residents were interviewed by Nurse Managers or Department Managers/QI members. Review of this documentation revealed two (2) reports of alleged verbal abuse were received during the interviews. Review of the facility's "Initial Report of Incident/Allegation" forms revealed two (2) forms dated 01/14/14, one (1) involved Resident #9 reporting CNA #3 was "hateful" to him/her; the other involved Unsampled Resident B who had reported CNA #11 had laughed at him/her and was a "smartie pants". Continued review of these forms revealed they were faxed to the State Agencies on 01/14/14. One (1) allegation involved CNA #3 who had been terminated from the facility on 01/14/14; and, the other involved CNA #11 who was suspended pending investigation. Review of the medical record for these two (2) residents revealed the Physician and family/POA were notified of the allegations. Interview, on 01/17/14 with Resident #10 at 3:08 PM; Unsampled Resident A at 4:35 PM; Unsampled Resident C at 4:40 PM; Resident #8, Unsampled Resident D and Resident #3 at 4:00 PM; Resident #11 at 4:39 PM; Unsampled Resident B at 4:25 PM; and, Resident #9 at 4:43 PM revealed they all stated that facility staff had talked with them recently regarding any concerns they had with the care provided by staff. Unsampled Resident B stated he/she had told staff about CNA #11 being a "smartie pants" and he/she was told this CNA would no longer provide care for him/her. Resident #9 stated he/she had told staff about CNA #3 yelling at him/her, and slamming doors and the bedside commode lid. Resident #9 stated he/she was informed CNA #3 no longer worked at the facility. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed forty-nine (49) interviewable residents were interviewed on 01/14/14. She stated two (2) residents had made allegations and these were reported to the State Agencies and notifications made to the Physician and responsible parties. According to the Administrator, CNA #3 was terminated from employment at the facility on 01/14/14 and CNA #11 had been suspended pending investigation. 3) Review of the "Weekly Skin Assessment" forms provided revealed nine (9) residents had head to toe skin assessments completed by Nurse Managers on 01/14/14 and 01/15/14. Continued review of these forms revealed no documented evidence of any signs of physical or psychological abuse noted during the skin assessments. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nine (9) complete body assessments were completed on non-verbal resident; with no signs of abuse noted. 4) Review of the In-Service Attendance form dated 01/14/14 revealed the QI members/Department Managers/MOD, Nurse Managers and DON were in-serviced/re-in-serviced by the Administrator on the facility's "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. Further review of this form revealed the Administrator re-in-serviced regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Review of the "Mock Investigation Initial Report of Incident/Allegation" forms revealed the QI members/Department Managers/MOD, Nurse Managers completed mock abuse investigations. Review of the "Initial Report of Incident/Allegation" form revealed dated 01/14/14 regarding Unsampled Resident B's allegation revealed the DON had completed the form and it was reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 1:58 PM with the MDS Coordinator #1; at 2:19 PM with MDS Coordinator #2; at 2:47 PM with the SW; at 3:25 PM with the Food Service Director; at 3:30 PM with the Activity Director; at 3:55 PM with the DON; and at 5:24 PM with the Medical Record person who were all QI members revealed they had been re-inserviced and performed mock investigations. The DON stated she had completed an investigation into Unsampled Resident B's allegation and this had been reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI members were re-in-serviced and had performed mock investigations, and the DON who had completed an investigation into Unsampled Resident B's allegations. She stated she reviewed the DON's investigation and signed off on it. Interview, on 01/17/14 at 9:19 AM with the Medical Director revealed he had been in communication with the facility and had been notified of the two (2) additional residents' complaints and investigation into these complaints on 01/14/14 and 01/15/14. 5) Review of the In-Service Attendance forms dated 01/14/14 revealed Nurses, CNAs and KMAs were re-inserviced on the facility's a"Abuse Policy" by the DON and Nurse Managers. Continued review of these forms revealed the in-service included reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. Interview on 01/17/14 with RN #2 at 6:07 PM and RN #1 at 6:20 PM revealed they had been re-inserviced on 01/14/14 on the "Abuse Policy"; and, interview with CNA #20 at 4:00 PM and CNA #19 at 4:30 PM revealed they had received in-services on the "Abuse Policy" that week. These staff indicated the in-services had covered policy items such as, abuse reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. 6) Review of the "Master List for Inservices" revealed all but five (5) facility staff had received in-servicing on the facility's "Abuse Policy" on 01/15/14. Review of the "Master List for Inservices" revealed the facility staff in-serviced included nursing, dietary, housekeeping and laundry personnel. Review of the In-Service sign-in sheets revealed staff were in-serviced on proper reporting procedures to be followed and ensuring residents safety. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she performed in-services with staff on 01/15/14. She stated staff were able to voice understanding of the "Abuse Policy" after the in-services. The SW stated she role-played different scenarios with staff to show the difference between appropriate communications and verbal abuse. Interviews on 01/17/14 with CNA#16 at 2:30 PM; CNA #10 at 2:35 PM; CNA #7 at 2:40 PM; CNA #1 at 2:45 PM; CNA #14 at 2:50 PM; CNA #13 at 2:55 PM; CNA #18 at 3:00 PM; CNA #9 at 4:20 PM; CNA #19 at 4:30 PM; CNA #21 at 4:35 PM; CNA #17/KMA at 2:25 PM; CNA #17/KMA at 4:30 PM; CNA #20/KMA at 2:18 PM; CNA #2/KMA at 2:18 PM; CNA #22/KMA at 4:20 PM; the Night Cook at 1:50 PM; Dietary Aide #2 at 1:35 PM; Dietary Aide #1 at 1:45 PM; Dietary Aide #3 at 4:15 PM; Housekeeper #1 at 2:04 PM; Housekeeper #2 at 2:08 PM; Housekeeper #3 at 2:15 PM; Housekeeper #4 at 4:10 PM; Laundry Personnel #1 at 1:57 PM; LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed these staff had been in-serviced on the facility's "Abuse Policy" regarding proper reporting procedures and ensuring residents safety. Staff stated the SW role-played sc

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to ensure policy and procedures were implemented related to abuse for one (1) of nine (9) sampled residents (Resident # 1). On 08/03/13 at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. There was no documented evidence the facility assessed the resident for injury, conducted an investigation, or reported the incident to the appropriate State Agencies per the facility's policy and procedures. (Refer to F223 and F225) Based on the above findings, it was determined the facility's failure to implement it's abuse policy and procedures was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 08/15/13 and was determined to exist on 08/03/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-226 Abuse, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure abuse policy and procedures are implemented. The findings include: Review of the facility's policy titled, "Abuse Reporting" undated, revealed each person observing an incident of resident abuse or suspected resident abuse should immediately report the incident to the charge nurse. The charge nurse should complete an Incident Report Form and should examine and interview the resident and report all findings to the Administrator or designee. The policy stated if sexual abuse was suspected, DO NOT bathe the resident or wash the resident's clothes or linen. Further review revealed upon receiving suspected reports of abuse, misappropriation of property, or neglect, the Administrator or designee should report the incident to the appropriate authorities. Review of the facility's policy titled, "Abuse Investigation" undated, revealed all personnel were to promptly report any incident or suspected incident of resident abuse. Further review revealed when an incident or suspected incident of abuse is reported, the investigation should begin immediately. Continued review revealed the investigation should consist of the review of the completed incident report form; a review of the statement of the person reporting the incident; a review of the statements of any witnesses; an interview with the resident; a review of the resident's medical record; an interview with the resident's roommate; and, a review of all circumstances surrounding the incident. Review of Resident #1's Nursing Notes, dated 08/03/13 at 4:00 AM , revealed staff entered the closed door to Resident #1's room and found Resident #2 in his/her room with the resident. Staff interviews revealed Resident #1 was found lying on his/her right side in a fetal position with his/her pajama pants and adult brief pulled down under the buttocks with his/her buttocks completely exposed. There was a wet substance on his/her hip, on the outer side of his/her adult brief, and on the resident's blanket. However, record review revealed no documented evidence the resident was assessed for injury, an incident report was completed, an investigation of the incident was completed, or the appropriate State Agencies were notified per the facility's policies. Interview with Licensed Practical Nurse (LPN) #5, on 08/15/13 at 7:06 PM, revealed LPN #5 found Resident #2 in Resident #1's room and notified the Manager On Duty. Per interview she did not assess Resident #1 for any injuries related to the incident. LPN #5 stated LPN #2 assessed Resident #1. However, LPN #5 stated LPN #2's assessment of Resident #1 was he/she did not appear to be in distress and had his/her eyes closed. A skin assessment was not performed. LPN #5 also stated she was not directed to complete an incident report. Further interview revealed, she was aware of the abuse policy, however did not think anything had happened. In addition, review of the Emergency Department notes, dated 08/04/13 at 1:05 AM, revealed when Resident #1 presented to the emergency department for a possible sexual assault, the Emergency Department Physician documented the nursing facility staff had bathed Resident #1 and changed and washed Resident #1's clothing and linens prior to seeking emergency care. Interview with LPN #2, on 08/14/13 at 8:25 PM, revealed CNA #2 asked LPN #2 if she should bathe Resident #1. LPN #2 told CNA #2 to bathe Resident #1 although the facility's policy and procedures stated if sexual abuse was suspected, DO NOT bathe the resident or wash the resident's clothes or linen. Interview with the Director of Nursing, on 08/22/13 at 5:14 PM, revealed staff should have followed the facility's policy to not bathe or wash clothing or linens. Interview with the Corporate Executive Officer (CEO), on 08/14/13 at 8:55 PM, revealed she only obtained statements from the staff working on 08/03/13 after the State Police initiated their investigation. Per interview, she did not did not report the incident to the State Agencies, and did not complete a thorough investigation because she did not think anything had happened. Even though, the facility's policy and procedures revealed all suspected incidents of abuse were to be reported and upon receiving suspected reports of abuse, the Administrator or designee should report the incident to the appropriate State Agencies and investigations were to be conducted. Interview with the Administrator, on 08/21/13 at 2:42 PM, revealed an incident report and investigation should have been completed and the incident reported to the appropriate State Agencies per the facility's policy. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review and review of the facility's policy and grievance form, it was determined the facility failed to have an effective system in place to ensure policies and procedures were implemented related to abuse for two (2) of eleven (11) sampled residents (Residents #3 and #9) and Unsampled Resident A. The facility failed to ensure staff reported allegations of abuse, failed to investigated allegations of abuse, failed to prevent the potential for further abuse, and failed to report allegations to the appropriate State Agencies per the facility's policy and procedures. Resident #3 reported to the Activity's Director on 11/30/13, he/she was verbally abused by Certified Nursing Assistant (CNA) #3 on 11/29/13. In interview Resident #3 expressed he/she was afraid of CNA #3. However, the facility did not investigate the allegation and considered it a grievance. Due to the facility's failure to investigate Resident #3's allegation of verbal abuse, the facility also failed to identify other residents who were victims of verbal abuse and/or staff who had witnessed verbal abuse by Certified Nursing Assistant (CNA) #3. Interview revealed Resident #9 and Unsampled Resident A were victims of verbal abuse by CNA #3. (Refer to F-223 and F-225) Based on the above findings, it was determined the facility's failure to implement it's abuse policy and procedures was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 01/14/14 and was determined to exist on 11/29/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 01/17/14 with the facility alleging removal of the Immediate Jeopardy on 01/16/14. The Immediate Jeopardy was verified to be removed on 01/16/14, prior to exiting the facility on 01/17/14, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-226 Abuse, with a Scope and Severity of "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure abuse policy and procedures are implemented. The findings include: Review of the facility's policy titled, "Abuse Reporting", undated, revealed any incident or suspected incident of resident abuse was to be promptly reported. The alleged violations were to be reported to the Administrator or designee as soon as possible. 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 facility policy listed examples of verbal abuse as threats of harm; or saying things to frighten a resident. Review of the policy revealed if a person observed resident abuse or suspected resident abuse they were to immediately report the incident to the Charge Nurse who would report the incident to the Administrator of designee as soon as "practicable". Continued review of the facility's policy revealed the investigation would include a completed Incident Report, statement from the reporting individual, statements from any witnesses to the incident, interview with the resident if possible, review of the resident's medical record, interview with the resident's roommate if possible, and review of the circumstances surrounding the incident. According to the policy, staff accused of resident abuse were to be removed from resident care duties immediately pending investigation or until the results of the investigation was reviewed by the Administrator. Upon receiving a report of suspected abuse, the Administrator or designee was to report the incident to the State Regulatory and Protection Agencies. A completed copy of the Incident Report Form was to be given to the Administrator/designee. Review of the, "Resident/Family Concern" grievance form provided by the facility, revealed it was dated 12/02/13. Continued review revealed Resident #3 had informed staff that CNA #3 had raised her voice to him/her. Further review revealed documentation 12/03/13 written by the SW indicating the incident was "resolved" and Resident #3 felt there was a personality conflict between him/her and CNA #3. In addition, the SW documented "no other concerns". However, there was no documented evidence the SW or any other staff member followed up with Resident #3 on the cause of the personality conflict. Interview with Resident #3 on 12/27/13 at 3:15 PM, revealed on 11/29/13 CNA #3 yelled at the resident for going into the nurse's station. Resident #3 told CNA #3 he/she was going to report the CNA to the SW. Resident #3 stated CNA #3 told him/her, "Don't you threaten me with the Social Worker". The resident stated he/she was "angry" and "afraid" and couldn't be sure what CNA #3 might do. Resident #3 denied saying he/she had a personality conflict with CNA #3. Resident #3 stated he/she did not want CNA #3 to care for him/her ever again. Interview with Nursing Assistant (NA) #1 on 01/14/14 at 12:30 PM, revealed CNA #3 was training her and she worked the night of 11/29/13 and had witnessed the incident. NA #1 indicated she and CNA #3 reported the incident to RN #1. According to NA #1, she and CNA #3 continued to work throughout the night on Resident #3's hall, checking on all residents every two (2) hours. She stated CNA #3 took ice to Resident #3 at one (1) point during that night. However, per facility policy "staff accused of resident abuse were to be removed from resident care duties immediately pending investigation or until the results of the investigation was reviewed by the Administrator". Interview with the CNA #2, who was also a Kentucky Medication Aide (KMA), on 01/13/14 at 3:16 PM, revealed she worked the night of the incident, 11/29/13. She stated she heard CNA #3 state "you can't go in there". CNA #2 stated she then heard CNA #3 say, "don't threaten me". She stated CNA #3 had a "loud" voice and it came across as "harsh". CNA #2 stated she informed RN #1, who was Charge Nurse that night, of what she had heard. Interview with RN #1/Charge Nurse, on 01/14/14 at 3:09 PM, revealed CNA #3 and NA #1 came to her during the night of 11/29/13 and informed her Resident #3 had been in the nurse's station; and CNA #3 had told the resident he/she was not supposed to be in there. CNA #3 reported Resident #3 was going to report her to the SW. RN #1 stated she did not recall CNA #2 reporting anything related to the incident to her. She stated she was in Resident #3's room approximately thirty (30) minutes after CNA #3 and NA #1 had reported the resident being in the nurse's station. RN #1 stated Resident #3 "never said a word" to her about the incident and she did not question Resident #3 regarding what was reported. She indicated however, she should have talked to Resident #3 about the incident. Per the facility policy, the Charge Nurse would report the incident to the Administrator of designee as soon as "practicable"; however, RN #1 failed to do so. Interview with the Activity Director on 01/15/14 at 4:20 PM, revealed she was the Manger on Duty (MOD) on 11/30/13. She stated Resident #3 came to her the morning of 11/30/14 and told her CNA #3 had yelled at him/her on 11/29/13. The Activity Director stated she did not document the resident's statement, but did tell the RN #2, the Charge Nurse about what Resident #3 had told her. The Activity Director reported she then called the SW at home to report Resident #3's statements because she did not know how to handle the situation. Interview with RN #2 on 01/16/14 at 3:22 PM, revealed on 11/30/13, the Activity Director informed her Resident #3's had reported to her he/she and CNA #3 had "an altercation" on 11/29/13. According to the RN, she did not document what the Activity Director had told her; however, probably should have. RN #2 indicated she spoke with Resident #3 to make sure the resident was "okay". Resident #3 told her she did not want CNA #3 taking care of her anymore. However RN #2 did not document anything "because it was second hand information". Per interview, RN #2 thought she had to witness an incident before she would have to document anything. However, after reviewing the facility's "Abuse Policy", RN #2 stated she should have documented Resident #3's statements. In addition, RN #2 stated she did not remove CNA #3 from the unit or care of Resident #3 because the DON was in charge of the assignments. However, the facility's policy stated staff accused of resident abuse were to be removed from resident care duties immediately pending investigation or until the results of the investigation was reviewed by the Administrator. Interview with the Social Worker (SW) on 12/27/13 at 4:15 PM and on 01/15/14 at 4:00 PM, revealed the Activity Director had contacted her at home on 11/30/13 regarding the incident between Resident #3 and CNA #3. The SW stated after receiving the Activity Director's call, she called the DON at home and informed her of the incident which had occurred on 11/29/13. According to the SW, she spoke with the resident on Monday, 12/02/13 and Resident #3 thought there was a personality conflict between him/her and CNA #3. However, review of the "Resident/Family Concern" form revealed the SW documented she spoke with Resident #3 on 12/03/13. She stated Resident #3 did not want CNA #3 caring for him/her anymore because of the personality conflict and CNA #3 had "raised her voice" to him/her. Per interview, the incident should have been reported to the State Agencies and investigated as per facility policy. The SW stated the facility policy was "to report anything of allegations of abuse of any kind immediately". She stated in this case the facility policy had not been followed because the incident wasn't reported immediately. In an additional interview on 01/15/14 at 6:08 PM, the SW indicated she had not interviewed other residents regarding CNA #3's care per the facility's policy. Interview with the DON on 12/26/13 at approximately 3:57 PM, and 12/27/13 at 5:30 PM, revealed the Incident Report related to the incident on 11/29/13 involving Resident #3 and CNA #3 could not be reviewed due to being part of "Quality Assurance". However, later in the interview she revealed an Incident Report had not been completed regarding the incident involving Resident #3 and CNA #3. According to the DON, on 11/30/13, after being notified at home of the incident, she initiated an investigation, had gone to the facility to interview Resident #3, and had contacted staff by phone to interview them. However, review of the staff statement's revealed no documented evidence of interviews conducted until 12/02/13. Continued interview with the DON revealed when she talked to Resident #3 on 11/30/13, the resident had felt verbally abused by CNA #3. The DON stated CNA #3 was allowed to complete her shift that evening but did not work on the night of 11/30/13. However, in an interview with the DON on 01/15/14 at 4:45 PM, revealed CNA #3 did work on 11/30/13, because the facility considered the incident a grievance. Further interview revealed CNA #3 should have been off work and an investigation should have been completed as per facility policy. She stated she interviewed other residents to see if they had any concerns; however, had not specifically inquired about CNA #3's care. Review of the "Resident/Family Concern" grievance form and attached statements revealed no documented evidence other residents had been interviewed by the DON. Interview with Resident #9 on 01/13/14 at 4:56 PM, revealed CNA #3 had been "hateful" to him/her since he/she had been admitted to the facility. He/She reported CNA #3 told him/her to "shut-up"; asked him/her "what the hell do you want"; and slammed his/her door, bedside commode lid and closet doors. Resident #9 revealed he/she was fearful of CNA #3. Resident #9 stated he/she had reported this information to a staff person; however, could not recall who it was. Additionally, Resident #9 stated he/she did not recall ever being interviewed related to CNA #3's care. He/She stated if someone had asked he/she would have informed them of CNA #3's behaviors. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed a few staff were "rude" to him/her and staff would get "smart" with him/her. Interview with CNA #4 on 01/13/14 at 6:30 PM, revealed she had witnessed CNA #3 being verbally abusive to Unsampled Resident A sometime around Thanksgiving and Unsampled Resident A cried. CNA #4 stated she did not report the incident to the Charge Nurse or anyone else. However, review of the facility's policy revealed if a person observed resident abuse or suspected resident abuse they were to immediately report the incident to the Charge Nurse. Interview with the DON on 01/14/14 at approximately 2:30 PM, revealed CNA #4 had reported the incident of CNA #3 being verbally abusive to Unsampled Resident A on 01/13/14. She indicated CNA #4 should have reported the incident to the Charge Nurse at the time she observed it as per facility policy. Interview with the Administrator on 12/26/13 at approximately 4:00 PM, on 12/27/13 at 1:06 PM, and 12/27/13 at 5:40 PM, revealed the facility policy in regards to alleged abuse was to initiate and complete the five (5) page Incident Report, and notify State Agencies within twenty-four (24) hours. She stated as the incident involving Resident #3 and CNA #3 had not been determined to be an allegation of abuse, staff did not complete the five (5) page Incident Report as per facility policy on 11/29/13, and the incident was not reported to State Agencies as per facility policy. The Administrator indicated she now felt the facility should have reported the incident as per facility policy. Interview with the Corporate Executive Director (CED) on 01/14/14 at 1:48 PM, revealed a thorough investigation would include interviewing other residents, conducting skin assessments, and interviewing residents and staff that were familiar with an incident. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 that alleged removal of the Immediate Jeopardy (IJ) effective 01/16/14. Review of the AOC revealed the facility implemented the following: 1) On 01/14/14, the CED in-serviced the Administrator, DON and SW on the facility's "Abuse Policy". The Medical Director was notified of the Immediate Jeopardy on 01/15/14. Human Resources reviewed facility personnel files to ensure the files contained criminal background checks, reference checks and abuse registry checks. Additionally, Department Managers who were Quality Improvement (QI) members and Managers on Duty (MOD) questioned/in-serviced staff individually on appropriate communication versus verbal abuse on 01/14/14 and ongoing. Staff who were on extended leave were to be re-in-serviced prior to returning to work. Investigation into the cause of the event was reviewed/completed on 01/14/14 by the Administrator, DON, Nurse Managers, Department Managers who were also QI members and MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. 2) Forty-nine (49) verbal/interviewable residents were interviewed by Nurse Managers and Department Managers/QI members on 01/14/14 to ensure no additional reports of abusive conduct or concerns related to staff members. Two (2) reports of alleged verbal abuse were received during the interviews; one being from Resident #9 and a new report from Unsampled Resident B. The two (2) reports of verbal abuse were immediately reported, the Physician and family/Power of Attorney (POA) and State Agency were notified on 01/14/14. One (1) allegation (Resident #9) involved CNA #3 who had been terminated from the facility on 01/14/14. The other (Unsampled Resident B) involved another staff member (CNA #11) who was suspended pending investigation. Unsampled Resident A was also interviewed regarding his/her concerns related to CNA #3. 3) Nine (9) non-interviewable residents were assessed by completion of an entire body skin assessment by Nurse Managers on 01/14/14 and 01/15/14. No evidence of physical or psychological abuse was noted during the skin assessments. 4) QI members met on 01/14/14 and reviewed the "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. The Administrator re-in-serviced the DON, Nurse Managers, Department Managers/MOD/QI members again on 01/14/14 regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Return demonstrations were conducted on the above staff by the completion of an investigation process on paper to ensure competency in the completion and reporting and identifying abuse. The Medical Director was notified, on 01/14/14 and 01/15/14, of the new findings regarding two (2) additional reports of alleged verbal abuse discovered which had been reported to the State Agencies. 5) All nursing staff (Nurses, CNAs and KMAs) present and working on 01/14/14 were re-inserviced on the abuse policy by the DON and Nurse Managers to include reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. To ensure competency staff voiced understanding of the policy and voiced no concerns. The re-inservice was to be repeated to ensure all employees had been re-inserviced on the "Abuse Policy". 6) All staff (nursing, dietary, housekeeping and laundry) were re-in-serviced on the facility's "Abuse Policy" on 01/15/14 by the SW, to ensure proper reporting procedures were followed and residents safety ensured. Staff voiced understanding and competency on policy and procedures was ensured at that time by the SW role-playing scenarios with staff to illustrate the difference between appropriate communications with residents and verbal abuse. Additionally, a Licensed Clinical Social Worker (LCSW) performed an in-service on 01/15/14 for all general staff which included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff, on "Residents and Their Emotions: How Can We Help". 7) Individual re-in-services were initiated on 01/14/14 and were to be ongoing and to be completed by Department Managers/QI members to ensure competency in appropriate communication with residents, the difference between appropriate communication and verbal abuse, to ensure staff knew to report immediately if they observed verbal abuse and to treat residents with respect and dignity even during re-direction. The Governing Body was to be notified to assure grievances, documentation, reporting, resident rights and Quality Assurance (QA) all adhered to Federal and State regulations. 8) The Administrator repeated in-services, duty responsibilities, audits, QA, resident rights with all Department Managers/QI/QA members, as well as, the Medical Director to ensure understanding of previous in-services held on 01/14/1/4. 9) Nurses were to continue passing information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring. New interventions were to be discussed in the daily QI meeting held Monday through Friday. On weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD "rounds sheet". Charts, grievance reports, care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. This information was to be transferred to an audit sheet and signed off on by the Administrator or designee (SW). 10) The two (2) residents', who voiced concerns regarding allegations of abuse, care plans were revised as needed and updated on 01/14/14 by the DON and Nurse Managers to ensure the care plans met the specific needs of the residents. Unsampled Resident B's care plan was revised to indicate he/she did not want CNA #11 caring for him/her to honor his/her staff preference. Resident #3's and #9's care plans regarding staff preferences was not revised as CNA #3 was terminated from employment in the facility on 01/14/14. Care plans were to continue to be updated quarterly and as needed with appropriate interventions, especially for residents who were at high risk for safety, abuse, wandering or behaviors after completion of an investigation. 11) An informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Department Managers/MOD/QI members were to continue monitoring with QA rounds twice daily to ensure resident safety needs were met. Complaints were to be addressed with QA team and Medical Director and another QA meeting was to be held thirty (30) days later to assure QA compliance. Issues or concerns were to be documented on the QI monitoring tool for the Administrator/designee (SW) review and follow-up on a daily basis. Ongoing issues were to be monitored by CED on a daily basis and the Medical Director on a monthly basis and through the QA process. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview, on 01/17/14 at 6:21 PM, with the CED revealed on 01/14/14, she in-serviced the Administrator, DON and SW on the facility's "Abuse Policy" in regards to the seven (7) components of abuse, reporting, training, signs and symptoms of abuse, the investigation process, protection of resident and prevention of abuse. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had been in-serviced by the CED on the facility's "Abuse Policy". She stated the in-service included the seven (7) components of abuse, allegations, signs and symptoms of abuse, notification, resident rights, prevention, importance of open communication, appropriate communication versus verbal abuse, how to complete an investigation, timeliness, what to do to ensure residents were protected, if staff was involved ensure they were suspended until the investigation was completed, interviewing all staff and residents, notifying the Physician, responsible party and on monitoring residents' emotional well-being. Interview, on 01/17/14 at 3:55 PM, with the DON revealed she had been in-serviced by the CED on 01/14/14 and everyday since on the facility's "Abuse Policy". She stated the CED went over "the whole policy" which included the seven (7) components of abuse, reporting, screening, reporting, taking statements, interviewing all staff and verbal residents, suspending staff until investigations were concluded, performing skin assessments on non-verbal residents for signs and symptoms of abuse, the investigation process and prevention of abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had been in-serviced by the CED on 01/14/14 on the entire "Abuse Policy". Interview, on 01/16/14 at 3:35 PM, with the Medical Director revealed he had been notified of the Immediate Jeopardy on 01/15/14. Review of a written statement dated 01/15/14, signed by the Human Resources (HR) staff person, revealed she documented she had completed an audit of personnel files on 01/14/14 and 01/15/14 to ensure all employees had abuse registry checks, criminal background checks and reference checks. Continued review of the statement revealed the HR staff person documented all employees were found to have all the documentation in their files. Review of thirteen (13) personnel files revealed they contained contained criminal background checks, reference checks and abuse registry checks. Review of individual in-service documentation dated 01/14/14 through 01/16/14 revealed individual staff were being in-serviced on appropriate communication and verbal abuse by Department Managers/QI members/MOD. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual staff was in-serviced on appropriate communication and verbal abuse by the Department Managers/QI members/MOD. The Administrator stated staff who were on extended leave would be re-in-serviced on the facility's "Abuse Policy" and appropriate communication versus verbal abuse prior to returning to work. She stated an investigation into the cause of the event was reviewed and completed on 01/14/14 by herself, the DON, the Nurse Managers and Department Managers/QI members/MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had talked to Resident #3 and #9 on 01/14/14 and no negative psychological effects were noted. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses and the SW had assessed Residents #3 and #9 on 01/14/14 and no negative effects were noted or observed. 2) Review of resident interview sheets dated 01/14/14 revealed forty-nine (49) residents were interviewed by Nurse Managers or Department Managers/QI members. Review of this documentation revealed two (2) reports of alleged verbal abuse were received during the interviews. Review of the facility's "Initial Report of Incident/Allegation" forms revealed two (2) forms dated 01/14/14, one (1) involved Resident #9 reporting CNA #3 was "hateful" to him/her; the other involved Unsampled Resident B who had reported CNA #11 had laughed at him/her and was a "smartie pants". Continued review of these forms revealed they were faxed to the State Agencies on 01/14/14. One (1) allegation involved CNA #3 who had been terminated from the facility on 01/14/14; and, the other involved CNA #11 who was suspended pending investigation. Review of the medical record for these two (2) residents revealed the Physician and family/POA were notified of the allegations. Interview, on 01/17/14 with Resident #10 at 3:08 PM; Unsampled Resident A at 4:35 PM; Unsampled Resident C at 4:40 PM; Resident #8, Unsampled Resident D and Resident #3 at 4:00 PM; Resident #11 at 4:39 PM; Unsampled Resident B at 4:25 PM; and, Resident #9 at 4:43 PM revealed they all stated that facility staff had talked with them recently regarding any concerns they had with the care provided by staff. Unsampled Resident B stated he/she had told staff about CNA #11 being a "smartie pants" and he/she was told this CNA would no longer provide care for him/her. Resident #9 stated he/she had told staff about CNA #3 yelling at him/her, and slamming doors and the bedside commode lid. Resident #9 stated he/she was informed CNA #3 no longer worked at the facility. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed forty-nine (49) interviewable residents were interviewed on 01/14/14. She stated two (2) residents had made allegations and these were reported to the State Agencies and notifications made to the Physician and responsible parties. According to the Administrator, CNA #3 was terminated from employment at the facility on 01/14/14 and CNA #11 had been suspended pending investigation. 3) Review of the "Weekly Skin Assessment" forms provided revealed nine (9) residents had head to toe skin assessments completed by Nurse Managers on 01/14/14 and 01/15/14. Continued review of these forms revealed no documented evidence of any signs of physical or psychological abuse noted during the skin assessments. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nine (9) complete body assessments were completed on non-verbal resident; with no signs of abuse noted. 4) Review of the In-Service Attendance form dated 01/14/14 revealed the QI members/Department Managers/MOD, Nurse Managers and DON were in-serviced/re-in-serviced by the Administrator on the facility's "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. Further review of this form revealed the Administrator re-in-serviced regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Review of the "Mock Investigation Initial Report of Incident/Allegation" forms revealed the QI members/Department Managers/MOD, Nurse Managers completed mock abuse investigations. Review of the "Initial Report of Incident/Allegation" form revealed dated 01/14/14 regarding Unsampled Resident B's allegation revealed the DON had completed the form and it was reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 1:58 PM with the MDS Coordinator #1; at 2:19 PM with MDS Coordinator #2; at 2:47 PM with the SW; at 3:25 PM with the Food Service Director; at 3:30 PM with the Activity Director; at 3:55 PM with the DON; and at 5:24 PM with the Medical Record person who were all QI members revealed they had been re-inserviced and performed mock investigations. The DON stated she had completed an investigation into Unsampled Resident B's allegation and this had been reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI members were re-in-serviced and had performed mock investigations, and the DON who had completed an investigation into Unsampled Resident B's allegations. She stated she reviewed the DON's investigation and signed off on it. Interview, on 01/17/14 at 9:19 AM with the Medical Director revealed he had been in communication with the facility and had been notified of the two (2) additional residents' complaints and investigation into these complaints on 01/14/14 and 01/15/14. 5) Review of the In-Service Attendance forms dated 01/14/14 revealed Nurses, CNAs and KMAs were re-inserviced on the facility's a"Abuse Policy" by the DON and Nurse Managers. Continued review of these forms revealed the in-service included reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. Interview on 01/17/14 with RN #2 at 6:07 PM and RN #1 at 6:20 PM revealed they had been re-inserviced on 01/14/14 on the "Abuse Policy"; and, interview with CNA #20 at 4:00 PM and CNA #19 at 4:30 PM revealed they had received in-services on the "Abuse Policy" that week. These staff indicated the in-services had covered policy items such as, abuse reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. 6) Review of the "Master List for Inservices" revealed all but five (5) facility staff had received in-servicing on the facility's "Abuse Policy" on 01/15/14. Review of the "Master List for Inservices" revealed the facility staff in-serviced included nursing, dietary, housekeeping and laundry personnel. Review of the In-Service sign-in sheets revealed staff were in-serviced on proper reporting procedures to be followed and ensuring residents safety. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she performed in-services with staff on 01/15/14. She stated staff were able to voice understanding of the "Abuse Policy" after the in-services. The SW stated she role-played different scenarios with staff to show the difference between appropriate communications and verbal abuse. Interviews on 01/17/14 with CNA#16 at 2:30 PM; CNA #10 at 2:35 PM; CNA #7 at 2:40 PM; CNA #1 at 2:45 PM; CNA #14 at 2:50 PM; CNA #13 at 2:55 PM; CNA #18 at 3:00 PM; CNA #9 at 4:20 PM; CNA #19 at 4:30 PM; CNA #21 at 4:35 PM; CNA #17/KMA at 2:25 PM; CNA #17/KMA at 4:30 PM; CNA #20/KMA at 2:18 PM; CNA #2/KMA at 2:18 PM; CNA #22/KMA at 4:20 PM; the Night Cook at 1:50 PM; Dietary Aide #2 at 1:35 PM

Based on interview, record review, and review of facility's policy, it was determined the facility failed to be administered in a manner which enables it to attain or maintain the highest practicable physical well-being of each resident related to provision of care. The facility failed to ensure abuse and care plan policies and procedures were implemented by staff. The facility failed to develop and implement a behavior management program to ensure residents' behaviors that could lead to conflict were assessed, care planned, and monitored. The facility's administration failed to ensure Social Services related to residents' behaviors was involved in assessing and implementing interventions to ensure care plan revision to ensure resident behaviors were addressed to ensure resident safety. On 08/03/13 at 4:30 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. Interview and record review revealed Resident #1 was not assessed for injury, nor was the resident's Physician or Responsible Party immediately notified of the incident. Interview and record review revealed the facility failed to investigate the incident and report the incident to the appropriate State Agencies. Interview also revealed Resident #2 had a history of [REDACTED]. Record review revealed Resident #2 would stare into other residents' rooms, cuss in the hallways, and make sexual comments; however, there was no documented evidence the facility had addressed Resident #2's behavior. (Refer to F157, F223, F225, F226, F250, and F280) Based on the above findings it was determined the facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 08/15/13, and was determined to exist on 08/03/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.75, Administration, F-490 Effective Administration/Resident Well-Being, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Resident Rights" undated, revealed the residents had the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. Continued review revealed the facility must implement procedures that protect the resident from abuse, neglect or mistreatment, or misappropriation of property. Further review revealed in the event of an alleged violations involving resident treatment, the facility was required to report it to the appropriate officials and all alleged violations must be thoroughly investigated and the results reported. Further review revealed the facility must provide a safe environment. Review of the facility's policy titled, "Abuse Reporting" undated, revealed the definitions of Abuse, Verbal abuse, Sexual abuse, Physical abuse, Involuntary seclusion, Mental abuse, Neglect and Misappropriation of resident property were each defined in the policy. Further review revealed each person observing an incident of resident abuse or suspected resident abuse should be immediately reported to the charge nurse. Review further revealed the charge nurse should complete an Incident Report Form and should examine and interview the resident and report all findings to the Administrator or designee. Additionally, review of the facility's policy stated if sexual abuse was suspected, DO NOT bathe the resident or wash the resident's clothes or linen. Review of the facility's policy titled, "Care Plans - Comprehensive" undated, revealed the Comprehensive Care Plan was designed to incorporate identified problem areas and incorporate risk factors associated with the identified problem areas. Further review revealed the Care Plans were revised as changes in the resident's condition dictates. Review of the facility's policy titled, "Behavior Policy" dated 06/07, revealed Social Services (SS) should evaluate and document resident's mental health issues, past and present history of behavioral issues and shall incorporate said information with nursing information when documenting to develop an appropriate plan of care. Further review revealed SS should document at least quarterly thereafter and as needed regarding any noted changes in conditions, interventions implemented to assure appropriate plan of care is instituted. Further review revealed residents exhibiting behaviors that posed an immediate threat/harm to themselves or others will have physician/responsible party notified for request to discharge to hospital for assuring safety. Further review revealed the residents would receive individualized interventions based on behaviors until transportation could be arranged. Interview and record review revealed the facility had been knowledgeable of Resident #2's history of abusive/inappropriate behaviors since 02/28/13; however, failed to assess, care plan, and monitor Resident #2 related to these abusive behaviors. Record review revealed Resident #2 had made sexual comments to staff, and resident interviews revealed residents had witnessed Resident #2 inappropriately touch Resident #1. Residents reported they had told faciltiy staff and stated they were concerned for Resident #1. However, interviews with staff revealed they denied being informed of this behavior. Review of the Nursing Notes, dated 08/03/13 at 4:00 AM, revealed staff entered the closed door to Resident #1's room and found Resident #2 in his/her room with the resident. Staff interviews revealed Resident #1's left hip and buttocks were exposed and Resident #1 was found to have a wet substance on his/her hip, on the outer side of his/her adult brief, and on the resident's blanket. However, this incident was not immediately reported to Resident #1's physician or legal representative and the resident was not assessed by the facility for injury. In addition, the facility failed to conduct a thorough investigation, and failed to notify the appropriate State Agencies. Interview with the Corporate Executive Officer (CEO), on 08/14/13 at 8:55 PM, revealed she did not report the incident to the appropriate State Agencies because she was told by the reporting nurse (LPN #5), nothing happened. Further interview revealed when the State Police initiated their investigation, she requested witness statements from immediate care providers for the night of 08/03/13; however, a thorough investigation was not completed because she did not think anything had happened. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed her expectations would be to follow the facility's policies. Further interview revealed Resident #2 should have been care planned for behaviors with interventions in place to monitor Resident #2 and protect the other residents. Further interview revealed all incidents should be documented, investigated and reported to the appropriate State Agencies. Interview with the Administrator, on 08/21/13 at 2:42 PM, revealed facility policy and procedures should be followed; an incident report and investigation should be completed for all allegations of abuse; and, the allegation should be reported to the appropriate State Agencies. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review and review of facility policies and Plan of Correction it was determined the facility's Administration failed to ensure the facility had achieved substantial compliance per the facility's Plan of Correction (POC). The facility's Administration failed to ensure the facility's abuse policy was implemented by staff for two (2) of eleven (11) sampled residents (Resident #3 and #9) and one (1) unsampled resident (Unsampled Resident A). The facility failed to investigate Resident #3's allegation of verbal abuse against Certified Nursing Assistant (CNA) #3 which resulted in the facility's failure to identify other residents who were victims of verbal abuse and/or staff who had witnessed verbal abuse by CNA #3. Interview with residents and staff revealed allegations of verbal abuse involving Resident #9 and Unsampled Resident A by CNA #3 which had not been reported by staff. The facility also failed to prevent further potential abuse by failing to investigate Resident #3's allegation. (Refer to F-223, F225, and F226) Resident #3 reported verbal abuse by Certified Nursing Assistant (CNA) #3 to facility staff on 11/29/13; however the allegation was viewed as a grievance by facility staff, not as possible verbal abuse. Therefore, the incident was not investigated and reported to State Agencies. Resident #9 was not interviewed on 11/29/13 or 11/30/13 by facility staff regarding CNA #3's care. In interview on 01/13/14 Resident #9 reported he/she was afraid of CNA #3 who had told him/her to shut-up and had slammed the door, bedside commode lid and closet door. Therefore, Resident #9's concerns with CNA #3 were not investigated or reported to State Agencies until 01/14/14, after the facility was notified of the Immediate Jeopardy. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed some staff were "rude" to him/her; either would not reply to the resident or would get "smart" with him/her. Unsampled Resident A stated he/she would rather not provide any names of staff. However, CNA #4 reported she had witnessed CNA #3 become verbally abusive to Unsampled Resident A in the past; however had not reported the incident to the Charge Nurse or any other facility staff. Therefore, the incident was not investigated or reported to the State Agencies. The facility's Administration's failure to ensure the facility implemented and followed the facility's Plan of Correction (POC), was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 01/14/14, and determined to exist on 11/29/13. The facility was notified of the Immediate Jeopardy on 01/14/14. The facility provided an acceptable Credible Allegation of Compliance (AoC) on 01/17/14 with the facility alleging removal of the Immediate Jeopardy on 01/16/14. The Immediate Jeopardy was verified to be removed on 01/16/14, prior to exiting the facility on 01/17/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-490 Abuse, with a Scope and Severity of "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure substantial compliance with the Plan of Correction to ensure all allegations of abuse were immediately reported to the appropriate State Agencies and all allegations of abuse were thoroughly investigated. The findings include: Review of the facility's policy titled, "Abuse Reporting", undated, revealed upon receiving suspected abuse allegations, the Administrator or designee was to report the allegations to the State Regulatory and Protection Agencies. Continued review revealed a five (5) page Incident Report was to be completed and given to the Administrator/designee. Review of the facility's (POC), dated and signed by the Administrator on 12/03/13, with a compliance date of 09/16/13, revealed the Administrator and DON had given in-services on 09/09/13 and 09/13/13, to all staff which included in-services related to the abuse policy in regards to notification requirements, and regulatory and facility policy requirements. Review of the POC revealed the in-services were given to ensure staff was knowledgeable in prevention and in interventions related to abuse. The in-services included the reporting requirements and completion of Incident Reports. Further review of the POC revealed the Social Worker (SW) in-serviced staff on 09/04/13 and 09/15/13, related to abuse which included reporting requirements. Review of in-services dated 09/09/13 and 09/13/13 revealed CNA #3, CNA #4 and RN #1 had all been in-serviced on the facility's "Abuse Policy" which included reporting requirements, completion of Incident Reports, prevention and identification of abuse, and notification requirements. Interview with CNA #3 on 01/13/14 at 7:02 PM revealed she had been in-serviced on abuse a couple of months ago. Interview with Resident #3, on 12/27/13 at 3:15 PM, revealed CNA #3 yelled at him/her on 11/29/13 when he/she attempted to obtain food left in the refrigerator at the nurse's station. Resident #3 stated he/she was afraid of CNA#3 after she yelled at him/her. Resident #3 reported he/she recalled talking to the Director of Nursing (DON) about the incident; however, he/she felt the DON had downplayed the incident making him/her feel like his/her statements didn't matter. Interview with Resident #9 on 01/14/14 at 4:56 PM, revealed CNA #3 was "hateful" to him/her, had been verbally abusive at times, and came to the room and slammed the door, the bedside commode lid and closet doors which made him/her afraid. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed some staff got "smart" with him/her and were "rude" at times. Interview on 01/13/14 at 6:30 PM with CNA #4 revealed she had received abuse training recently about two (2) months prior. CNA #4 stated she had witnessed CNA #3 become verbally abusive once to Unsampled Resident A in the past; however she had not reported the incident to the Charge Nurse or any other facility staff even though she had received the in-service training's held in September 2013. Interviews with the Director of Nursing (DON), on 12/26/13 at approximately 3:57 PM and on 12/27/13 at 5:30 PM, revealed she was notified on 11/30/13 by the SW of the incident that occurred on 11/29/13, involving CNA #3 and Resident #3. She reported an Incident Report had not been completed on the incident because the incident was investigated as a grievance. She stated she talked to Resident #3 and the resident felt he/she had been verbally abused by CNA #3. The DON stated the incident should have been viewed as abuse, reported to State Agencies, and the facility's policy should have been followed. Interviews with the Administrator, on 12/26/13 at approximately 4:00 PM; on 12/27/13 at 1:06 PM; and, on 12/27/13 at 5:40 PM, revealed the facility had not considered the incident involving Resident #3 as abuse; therefore the five (5) page Incident Report was not initiated and completed. The Administrator stated the State Agencies were not notified as the incident was not considered abuse. However, the Administrator stated the incident should have been reported to State Agencies and the policy followed. Interview with Administrator on 01/17/14 at 4:35 PM, revealed she was ultimately responsible for ensuring the Plan of Correction had been implemented. She indicated all staff had been in-serviced in September 2013 in regards to the facility's "Abuse Policy" to include the reporting, prevention, and investigating of abuse. She stated in-services had continued to be provided every thirty (30) days for staff working on the day of the in-service to include abuse. She indicated the every thirty (30) days in-services were held with different staff working to try to ensure everyone had received them. The Administrator stated "anything" implemented was reviewed in the Quality Assurance meeting and revised if not working; however, she thought what was in place had been working. According to the Administrator, the facility had not identified Resident #3's concerns regarding CNA #3 as abuse at the time and had not interviewed other residents. She stated the facility were unaware of Resident #9's and Unsampled Resident A's concerns until 01/14/14; and were not aware of CNA #4 witnessing CNA #3 being verbally abusive to Unsampled Resident A. The Administrator stated had Resident #3's allegations been regarded as abuse at the time and other residents interviewed, Resident #9's concerns would have been identified and the facility could have addressed the matter in December. She stated the facility failed to ensure staff was "clear" on the specifics of the "Abuse Policy", how to identify and report verbal abuse, as noted in the POC. The Administrator stated "we haven't really got people to understand the process for reporting". She stated prior to 12/27/13, the facility had the "general" feeling it was up to them to determine if something needed to be reported or not; however, she indicated that was not in the "Abuse Policy". The Administrator stated she thought "we were misinterpreting the policy". The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 that alleged removal of the Immediate Jeopardy (IJ) effective 01/16/14. Review of the AOC revealed the facility implemented the following: 1) On 01/14/14, the CED in-serviced the Administrator, DON and SW on the facility's "Abuse Policy". The Medical Director was notified of the Immediate Jeopardy on 01/15/14. Human Resources reviewed facility personnel files to ensure the files contained criminal background checks, reference checks and abuse registry checks. Additionally, Department Managers who were Quality Improvement (QI) members and Managers on Duty (MOD) questioned/in-serviced staff individually on appropriate communication versus verbal abuse on 01/14/14 and ongoing. Staff who were on extended leave were to be re-in-serviced prior to returning to work. Investigation into the cause of the event was reviewed/completed on 01/14/14 by the Administrator, DON, Nurse Managers, Department Managers who were also QI members and MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. 2) Forty-nine (49) verbal/interviewable residents were interviewed by Nurse Managers and Department Managers/QI members on 01/14/14 to ensure no additional reports of abusive conduct or concerns related to staff members. Two (2) reports of alleged verbal abuse were received during the interviews; one being from Resident #9 and a new report from Unsampled Resident B. The two (2) reports of verbal abuse were immediately reported, the Physician and family/Power of Attorney (POA) and State Agency were notified on 01/14/14. One (1) allegation (Resident #9) involved CNA #3 who had been terminated from the facility on 01/14/14. The other (Unsampled Resident B) involved another staff member (CNA #11) who was suspended pending investigation. Unsampled Resident A was also interviewed regarding his/her concerns related to CNA #3. 3) Nine (9) non-interviewable residents were assessed by completion of an entire body skin assessment by Nurse Managers on 01/14/14 and 01/15/14. No evidence of physical or psychological abuse was noted during the skin assessments. 4) QI members met on 01/14/14 and reviewed the "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. The Administrator re-in-serviced the DON, Nurse Managers, Department Managers/MOD/QI members again on 01/14/14 regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Return demonstrations were conducted on the above staff by the completion of an investigation process on paper to ensure competency in the completion and reporting and identifying abuse. The Medical Director was notified, on 01/14/14 and 01/15/14, of the new findings regarding two (2) additional reports of alleged verbal abuse discovered which had been reported to the State Agencies. 5) All nursing staff (Nurses, CNAs and KMAs) present and working on 01/14/14 were re-inserviced on the abuse policy by the DON and Nurse Managers to include reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. To ensure competency staff voiced understanding of the policy and voiced no concerns. The re-inservice was to be repeated to ensure all employees had been re-inserviced on the "Abuse Policy". 6) All staff (nursing, dietary, housekeeping and laundry) were re-in-serviced on the facility's "Abuse Policy" on 01/15/14 by the SW, to ensure proper reporting procedures were followed and residents safety ensured. Staff voiced understanding and competency on policy and procedures was ensured at that time by the SW role-playing scenarios with staff to illustrate the difference between appropriate communications with residents and verbal abuse. Additionally, a Licensed Clinical Social Worker (LCSW) performed an in-service on 01/15/14 for all general staff which included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff, on "Residents and Their Emotions: How Can We Help". 7) Individual re-in-services were initiated on 01/14/14 and were to be ongoing and to be completed by Department Managers/QI members to ensure competency in appropriate communication with residents, the difference between appropriate communication and verbal abuse, to ensure staff knew to report immediately if they observed verbal abuse and to treat residents with respect and dignity even during re-direction. The Governing Body was to be notified to assure grievances, documentation, reporting, resident rights and Quality Assurance (QA) all adhered to Federal and State regulations. 8) The Administrator repeated in-services, duty responsibilities, audits, QA, resident rights with all Department Managers/QI/QA members, as well as, the Medical Director to ensure understanding of previous in-services held on 01/14/1/4. 9) Nurses were to continue passing information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring. New interventions were to be discussed in the daily QI meeting held Monday through Friday. On weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD "rounds sheet". Charts, grievance reports, care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. This information was to be transferred to an audit sheet and signed off on by the Administrator or designee (SW). 10) The two (2) residents', who voiced concerns regarding allegations of abuse, care plans were revised as needed and updated on 01/14/14 by the DON and Nurse Managers to ensure the care plans met the specific needs of the residents. Unsampled Resident B's care plan was revised to indicate he/she did not want CNA #11 caring for him/her to honor his/her staff preference. Resident #3's and #9's care plans regarding staff preferences was not revised as CNA #3 was terminated from employment in the facility on 01/14/14. Care plans were to continue to be updated quarterly and as needed with appropriate interventions, especially for residents who were at high risk for safety, abuse, wandering or behaviors after completion of an investigation. 11) An informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Department Managers/MOD/QI members were to continue monitoring with QA rounds twice daily to ensure resident safety needs were met. Complaints were to be addressed with QA team and Medical Director and another QA meeting was to be held thirty (30) days later to assure QA compliance. Issues or concerns were to be documented on the QI monitoring tool for the Administrator/designee (SW) review and follow-up on a daily basis. Ongoing issues were to be monitored by CED on a daily basis and the Medical Director on a monthly basis and through the QA process. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview, on 01/17/14 at 6:21 PM, with the CED revealed on 01/14/14, she in-serviced the Administrator, DON and SW on the facility's "Abuse Policy" in regards to the seven (7) components of abuse, reporting, training, signs and symptoms of abuse, the investigation process, protection of resident and prevention of abuse. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had been in-serviced by the CED on the facility's "Abuse Policy". She stated the in-service included the seven (7) components of abuse, allegations, signs and symptoms of abuse, notification, resident rights, prevention, importance of open communication, appropriate communication versus verbal abuse, how to complete an investigation, timeliness, what to do to ensure residents were protected, if staff was involved ensure they were suspended until the investigation was completed, interviewing all staff and residents, notifying the Physician, responsible party and on monitoring residents' emotional well-being. Interview, on 01/17/14 at 3:55 PM, with the DON revealed she had been in-serviced by the CED on 01/14/14 and everyday since on the facility's "Abuse Policy". She stated the CED went over "the whole policy" which included the seven (7) components of abuse, reporting, screening, reporting, taking statements, interviewing all staff and verbal residents, suspending staff until investigations were concluded, performing skin assessments on non-verbal residents for signs and symptoms of abuse, the investigation process and prevention of abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had been in-serviced by the CED on 01/14/14 on the entire "Abuse Policy". Interview, on 01/16/14 at 3:35 PM, with the Medical Director revealed he had been notified of the Immediate Jeopardy on 01/15/14. Review of a written statement dated 01/15/14, signed by the Human Resources (HR) staff person, revealed she documented she had completed an audit of personnel files on 01/14/14 and 01/15/14 to ensure all employees had abuse registry checks, criminal background checks and reference checks. Continued review of the statement revealed the HR staff person documented all employees were found to have all the documentation in their files. Review of thirteen (13) personnel files revealed they contained contained criminal background checks, reference checks and abuse registry checks. Review of individual in-service documentation dated 01/14/14 through 01/16/14 revealed individual staff were being in-serviced on appropriate communication and verbal abuse by Department Managers/QI members/MOD. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual staff was in-serviced on appropriate communication and verbal abuse by the Department Managers/QI members/MOD. The Administrator stated staff who were on extended leave would be re-in-serviced on the facility's "Abuse Policy" and appropriate communication versus verbal abuse prior to returning to work. She stated an investigation into the cause of the event was reviewed and completed on 01/14/14 by herself, the DON, the Nurse Managers and Department Managers/QI members/MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had talked to Resident #3 and #9 on 01/14/14 and no negative psychological effects were noted. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses and the SW had assessed Residents #3 and #9 on 01/14/14 and no negative effects were noted or observed. 2) Review of resident interview sheets dated 01/14/14 revealed forty-nine (49) residents were interviewed by Nurse Managers or Department Managers/QI members. Review of this documentation revealed two (2) reports of alleged verbal abuse were received during the interviews. Review of the facility's "Initial Report of Incident/Allegation" forms revealed two (2) forms dated 01/14/14, one (1) involved Resident #9 reporting CNA #3 was "hateful" to him/her; the other involved Unsampled Resident B who had reported CNA #11 had laughed at him/her and was a "smartie pants". Continued review of these forms revealed they were faxed to the State Agencies on 01/14/14. One (1) allegation involved CNA #3 who had been terminated from the facility on 01/14/14; and, the other involved CNA #11 who was suspended pending investigation. Review of the medical record for these two (2) residents revealed the Physician and family/POA were notified of the allegations. Interview, on 01/17/14 with Resident #10 at 3:08 PM; Unsampled Resident A at 4:35 PM; Unsampled Resident C at 4:40 PM; Resident #8, Unsampled Resident D and Resident #3 at 4:00 PM; Resident #11 at 4:39 PM; Unsampled Resident B at 4:25 PM; and, Resident #9 at 4:43 PM revealed they all stated that facility staff had talked with them recently regarding any concerns they had with the care provided by staff. Unsampled Resident B stated he/she had told staff about CNA #11 being a "smartie pants" and he/she was told this CNA would no longer provide care for him/her. Resident #9 stated he/she had told staff about CNA #3 yelling at him/her, and slamming doors and the bedside commode lid. Resident #9 stated he/she was informed CNA #3 no longer worked at the facility. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed forty-nine (49) interviewable residents were interviewed on 01/14/14. She stated two (2) residents had made allegations and these were reported to the State Agencies and notifications made to the Physician and responsible parties. According to the Administrator, CNA #3 was terminated from employment at the facility on 01/14/14 and CNA #11 had been suspended pending investigation. 3) Review of the "Weekly Skin Assessment" forms provided revealed nine (9) residents had head to toe skin assessments completed by Nurse Managers on 01/14/14 and 01/15/14. Continued review of these forms revealed no documented evidence of any signs of physical or psychological abuse noted during the skin assessments. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nine (9) complete body assessments were completed on non-verbal resident; with no signs of abuse noted. 4) Review of the In-Service Attendance form dated 01/14/14 revealed the QI members/Department Managers/MOD, Nurse Managers and DON were in-serviced/re-in-serviced by the Administrator on the facility's "Abuse Policy" to ensure allegations of abuse were immediately reported before completing the investigation. Further review of this form revealed the Administrator re-in-serviced regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Review of the "Mock Investigation Initial Report of Incident/Allegation" forms revealed the QI members/Department Managers/MOD, Nurse Managers completed mock abuse investigations. Review of the "Initial Report of Incident/Allegation" form revealed dated 01/14/14 regarding Unsampled Resident B's allegation revealed the DON had completed the form and it was reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 1:58 PM with the MDS Coordinator #1; at 2:19 PM with MDS Coordinator #2; at 2:47 PM with the SW; at 3:25 PM with the Food Service Director; at 3:30 PM with the Activity Director; at 3:55 PM with the DON; and at 5:24 PM with the Medical Record person who were all QI members revealed they had been re-inserviced and performed mock investigations. The DON stated she had completed an investigation into Unsampled Resident B's allegation and this had been reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI members were re-in-serviced and had performed mock investigations, and the DON who had completed an investigation into Unsampled Resident B's allegations. She stated she reviewed the DON's investigation and signed off on it. Interview, on 01/17/14 at 9:19 AM with the Medical Director revealed he had been in communication with the facility and had been notified of the two (2) additional residents' complaints and investigation into these complaints on 01/14/14 and 01/15/14. 5) Review of the In-Service Attendance forms dated 01/14/14 revealed Nurses, CNAs and KMAs were re-inserviced on the facility's a"Abuse Policy" by the DON and Nurse Managers. Continued review of these forms revealed the in-service included reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. Interview on 01/17/14 with RN #2 at 6:07 PM and RN #1 at 6:20 PM revealed they had been re-inserviced on 01/14/14 on the "Abuse Policy"; and, interview with CNA #20 at 4:00 PM and CNA #19 at 4:30 PM revealed they had received in-services on the "Abuse Policy" that week. These staff indicated the in-services had covered policy items such as, abuse reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. 6) Review of the "Master List for Inservices" revealed all but five (5) facility staff had received in-servicing on the facility's "Abuse Policy" on 01/15/14. Review of the "Master List for Inservices" revealed the facility staff in-serviced included nursing, dietary, housekeeping and laundry personnel. Review of the In-Service sign-in sheets revealed staff were in-serviced on proper reporting procedures to be followed and ensuring residents safety. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she performed in-services with staff on 01/15/14. She stated staff were able to voice understanding of the "Abuse Policy" after the in-services. The SW stated she role-played different scenarios with staff to show the difference between appropriate communications and verbal abuse. Interviews on 01/17/14 with CNA#16 at 2:30 PM; CNA #10 at 2:35 PM; CNA #7 at 2:40 PM; CNA #1 at 2:45 PM; CNA #14 at 2:50 PM; CNA #13 at 2:55 PM; CNA #18 at 3:00 PM; CNA #9 at 4:20 PM; CNA #19 at 4:30 PM; CNA #21 at 4:35 PM; CNA #17/KMA at 2:25 PM; CNA #17/KMA at 4:30 PM; CNA #20/KMA at 2:18 PM; CNA #2/KMA at 2:18 PM; CNA #22/KMA at 4:20 PM; the Night Cook at 1:50 PM; Dietary Aide #2 at 1:35 PM; Dietary Aide #1 at 1:45 PM; Dietary Aide #3 at 4:15 PM; Housekeeper #1 at 2:04 PM; Housekeeper #2 at 2:08 PM; Housekeeper #3 at 2:15 PM; Housekeeper #4 at 4:10 PM; Laundry Personnel #1 at 1:57 PM; LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed these staff had been in-serviced on the facility's "Abuse Policy" regarding proper reporting procedures and ensuring residents safety. Staff stated the SW role-played scenarios with them related to the difference between appropriate communications with residents and verbal abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed only five (5) staff had not received the in-service on the "Abuse Policy". She stated these employees would not work until they had received it. The Administrator stated all other facility staff had received the in-service. She indicated the SW had performed role-playing with staff to ensure their understanding. Review of a letter dated 01/15/14, signed by a consultant LCSW revealed an in-service was performed on that date for the "entire team" to help address issues with communication. Further review revealed the in-service was titled, "Residents and Their Emotions: How Can We Help". Review of the in-service sign-in sheet dated 01/15/14 revealed fifty-two (52) facility staff from all disciplines had attended the in-service. Further review of the sign-in sheet revealed the staff signatures included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff. Interview, on 01/17/14 at 3:22 PM, with the consultant LCSW revealed he had performed an in-service on 01/15/14 per request of the facility. He stated the in-service was held to address communication issues within the facility. The consultant LCSW stated the in-service was titled, "Residents and Their Emotions: How Can We Help". 7) Review of In-Service Attendance forms revealed individual re-in-services related to abuse were performed on 01/14/14 and 01/15/14 completed by Department Managers/QI members. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual re-in-services had been performed by QI members and this would be ongoing to ensure staff's understanding of appropriate communication and the "Abuse Policy". Continued interview with the Administrator revealed the Governing Body, which constituted the facility Owner and her father, would be notified of grievances, documentation, reporting, resident rights and the Quality Assurance (QA) meeting findings. 8) Review of the In-Service Attendance form dated 01/14/14 revealed all Department Managers/QA/QI members had received training on responsibilities, audits, QA and resident rights. Interview, on 01/17/14 MDS Coordinator #1 at 1:58 PM; MDS Coordinator #2 at 2:19 PM; the SW at 2:47 PM; the Food Services Manager at 3:25 PM; the Activity Director at 3:30 PM; the DON at 3:55 PM; and the Medical Records person at 5:24 PM, (who were all Department Managers/QI members) revealed they had all be re-in-serviced by the Administrator on their duties and responsibilities, on the audits, QA, the "Abuse policy" and resident rights. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had performed the in-service/re-in-service on 01/14/14 and had been re-in-servicing Department Managers/QI members ongoing since then regarding their duties and responsibilities, on audits, the facility's QA and on resident rights. She stated an informal QA meeting was held on 01/14/14 and the Medical Director had been contacted on 01/14/15 and 01/15/14 regarding the inservices/re-in-services conducted. 9) Review of QI Rounds sheets revealed QI members were conducting rounds twice daily which included any complaints or concerns noted by residents. Interview, on 01/17/14 with LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed nurses continued passing information along in the change of shift report. They indicated changes in condition and issues or concerns were discussed to address any monitoring that was required. These nurses indicated new interventions were implemented as necessary. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses passed information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring required. She stated audits were being completed to ensure the twenty-four (24) hour report sheet and Physician order [REDACTED]. The Administrator stated any issues or concerns were being taken to the daily Monday through Friday QI meeting and discussed, wit

2 Based on observation, interview and review of the facility's Plan of Correction (POC), it was determined the facility failed to maintain a Quality Assessment and Assurance (QA) Program that developed and implemented appropriate plans of action to correct quality deficiencies as evidenced by repeated deficiencies in regards to failure to ensure abuse policies were implemented for two (2) of eleven (11) residents (Resident #3 and Resident #9) and one (1) unsampled resident (Unsampled Resident A). The facility failed to investigate Resident #3's allegation of verbal abuse against Certified Nursing Assistant (CNA) #3 which resulted in the facility's failure to identify other residents who were victims of verbal abuse and/or staff who had witnessed verbal abuse by CNA #3. Interview with residents and staff revealed allegations of verbal abuse involving Resident #9 and Unsampled Resident A by CNA #3 which had not been reported by staff. The facility also failed to prevent further potential abuse by failing to investigate Resident #3's allegation. (Refer to F-223, F-225, F-226, and F-490) The facility's failure to ensure the Quality Assessment and Assurance (QA) Program developed and implemented appropriate plans of action to correct quality deficiencies was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 01/14/14, and determined to exist on 11/29/13. The facility was notified of the Immediate Jeopardy on 01/14/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 with the facility alleging removal of the Immediate Jeopardy on 01/16/14. The Immediate Jeopardy was verified to be removed on 01/16/14, prior to exiting the facility on 01/17/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-520, with a Scope and Severity of E, while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the Plan of Correction (POC) dated and signed by the Administrator on 12/03/13, with a compliance date of 09/16/13, revealed the facility's Quality Improvement (QI) team, who were members of the Quality Assurance (QA) team, reviewed Social Services' Grievance Reports to ensure reporting had occurred as of 09/15/13. Continued review of the POC revealed the QI team was to perform daily monitoring rounds daily to include monitoring for resident concerns and to individually in-service staff to include abuse. QA meetings were to be held every thirty (30) days to discuss the POC and interventions implemented. Review of the QA meeting sign-in sheets revealed meetings were held in September, October, November and December 2013. Further review revealed a QA meeting was also held on 01/08/14. Further review revealed the QA Committee had met to address concerns within the POC, which included implementation of facility policies and QA. Interview with Resident #3 and review of Resident #3's record revealed Certified Nursing Assistant (CNA) #3 yelled at him/her on 11/29/13; and this had made the resident feel afraid and angry. Resident #3 was observably upset, as reported by facility staff. CNA #3 reported the incident involving her and Resident #3 to Registered Nurse (RN) #1; however, there was no documented evidence the resident and staff were interviewed until 12/02/13. After investigating Resident #3's concerns as a grievance and collecting statements from Resident #3 and facility staff, the facility failed to implement the Abuse Policy and notify State Agencies. Interview with Resident #9 on 01/14/14 at 4:56 PM, revealed CNA #3 was hateful to him/her and verbally abusive at times. Resident #9 stated he/she was afraid of CNA #3. Interview with Unsampled Resident A, on 01/13/14 at 5:00 PM, revealed some staff got smart with him/her and were rude at times. Interview on 01/13/14 at 6:30 PM with CNA #4 revealed she had witnessed CNA #3 become verbally abusive to Unsampled Resident A; however, she had not reported the incident to the Charge Nurse. Interview with the DON on 01/17/14 at 3:38 PM, revealed she attended QA meetings which had been held monthly since August 2013. She stated daily QI rounds were performed by the Department Managers/Managers on Duty (MOD)/QI/QA members. The DON stated the QI rounds were conducted to identify any issues residents might be having regarding their care and to ensure residents felt safe. According to the DON, any issues identified were taken to QA to ensure a plan was implemented and to ensure auditing was done. She stated she thought the POC had been effective for the most part. However, the QI rounds failed to identify residents' concerns with CNA #3. Interview with the Medical Director on 01/16/14 at 3:35 PM; and, on 01/17/14 at 9:19 AM, revealed he participated in the facility's QA Committee monthly. He stated everything was discussed including grievances and Incident Reports. The Medical Director stated the QA Committee attempted to determine the root cause of any issues brought to the meeting and develop interventions. According to the Medical Director, the interventions were discussed at the next meeting to determine if they were effective and if not, they would go back and look at the issue again and implement new interventions if necessary. He stated since August 2013 the QA Committee had reviewed the Abuse Policy and felt no changes were required. In regards to the incident involving Resident #3, the Medical Director stated he had been informed the incident was isolated and the CNA no longer had responsibility for the resident. He stated he had been told the incident was a volume issue, in that CNA #3 spoke loudly. The Medical Director stated the POC didn't catch it or we wouldn't have the subsequent issues we have now. Interview on 01/17/14 at 4:35 PM with the Administrator, revealed the QA Committe had been meeting monthly and during the meeting the Social Services Grievance Reports were discussed. She indicated she thought the incident involving Resident #3 and CNA #3 had been discussed in the December 2013 meeting. The Administrator stated QI/QA members were performing twice daily monitoring rounds that included interviewing residents about their care and performing individual in-services with staff. She stated these rounds had failed to identify Resident #9's and Unsampled Resident A's concerns regarding alleged verbal abuse by CNA #3. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 01/17/14 that alleged removal of the Immediate Jeopardy (IJ) effective 01/16/14. Review of the AOC revealed the facility implemented the following: 1) On 01/14/14, the CED in-serviced the Administrator, DON and SW on the facility's Abuse Policy. The Medical Director was notified of the Immediate Jeopardy on 01/15/14. Human Resources reviewed facility personnel files to ensure the files contained criminal background checks, reference checks and abuse registry checks. Additionally, Department Managers who were Quality Improvement (QI) members and Managers on Duty (MOD) questioned/in-serviced staff individually on appropriate communication versus verbal abuse on 01/14/14 and ongoing. Staff who were on extended leave were to be re-in-serviced prior to returning to work. Investigation into the cause of the event was reviewed/completed on 01/14/14 by the Administrator, DON, Nurse Managers, Department Managers who were also QI members and MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. 2) Forty-nine (49) verbal/interviewable residents were interviewed by Nurse Managers and Department Managers/QI members on 01/14/14 to ensure no additional reports of abusive conduct or concerns related to staff members. Two (2) reports of alleged verbal abuse were received during the interviews; one being from Resident #9 and a new report from Unsampled Resident B. The two (2) reports of verbal abuse were immediately reported, the Physician and family/Power of Attorney (POA) and State Agency were notified on 01/14/14. One (1) allegation (Resident #9) involved CNA #3 who had been terminated from the facility on 01/14/14. The other (Unsampled Resident B) involved another staff member (CNA #11) who was suspended pending investigation. Unsampled Resident A was also interviewed regarding his/her concerns related to CNA #3. 3) Nine (9) non-interviewable residents were assessed by completion of an entire body skin assessment by Nurse Managers on 01/14/14 and 01/15/14. No evidence of physical or psychological abuse was noted during the skin assessments. 4) QI members met on 01/14/14 and reviewed the Abuse Policy to ensure allegations of abuse were immediately reported before completing the investigation. The Administrator re-in-serviced the DON, Nurse Managers, Department Managers/MOD/QI members again on 01/14/14 regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Return demonstrations were conducted on the above staff by the completion of an investigation process on paper to ensure competency in the completion and reporting and identifying abuse. The Medical Director was notified, on 01/14/14 and 01/15/14, of the new findings regarding two (2) additional reports of alleged verbal abuse discovered which had been reported to the State Agencies. 5) All nursing staff (Nurses, CNAs and KMAs) present and working on 01/14/14 were re-inserviced on the abuse policy by the DON and Nurse Managers to include reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. To ensure competency staff voiced understanding of the policy and voiced no concerns. The re-inservice was to be repeated to ensure all employees had been re-inserviced on the Abuse Policy. 6) All staff (nursing, dietary, housekeeping and laundry) were re-in-serviced on the facility's Abuse Policy on 01/15/14 by the SW, to ensure proper reporting procedures were followed and residents safety ensured. Staff voiced understanding and competency on policy and procedures was ensured at that time by the SW role-playing scenarios with staff to illustrate the difference between appropriate communications with residents and verbal abuse. Additionally, a Licensed Clinical Social Worker (LCSW) performed an in-service on 01/15/14 for all general staff which included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff, on Residents and Their Emotions: How Can We Help. 7) Individual re-in-services were initiated on 01/14/14 and were to be ongoing and to be completed by Department Managers/QI members to ensure competency in appropriate communication with residents, the difference between appropriate communication and verbal abuse, to ensure staff knew to report immediately if they observed verbal abuse and to treat residents with respect and dignity even during re-direction. The Governing Body was to be notified to assure grievances, documentation, reporting, resident rights and Quality Assurance (QA) all adhered to Federal and State regulations. 8) The Administrator repeated in-services, duty responsibilities, audits, QA, resident rights with all Department Managers/QI/QA members, as well as, the Medical Director to ensure understanding of previous in-services held on 01/14/1/4. 9) Nurses were to continue passing information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring. New interventions were to be discussed in the daily QI meeting held Monday through Friday. On weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD rounds sheet. Charts, grievance reports, care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. This information was to be transferred to an audit sheet and signed off on by the Administrator or designee (SW). 10) The two (2) residents', who voiced concerns regarding allegations of abuse, care plans were revised as needed and updated on 01/14/14 by the DON and Nurse Managers to ensure the care plans met the specific needs of the residents. Unsampled Resident B's care plan was revised to indicate he/she did not want CNA #11 caring for him/her to honor his/her staff preference. Resident #3's and #9's care plans regarding staff preferences was not revised as CNA #3 was terminated from employment in the facility on 01/14/14. Care plans were to continue to be updated quarterly and as needed with appropriate interventions, especially for residents who were at high risk for safety, abuse, wandering or behaviors after completion of an investigation. 11) An informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Department Managers/MOD/QI members were to continue monitoring with QA rounds twice daily to ensure resident safety needs were met. Complaints were to be addressed with QA team and Medical Director and another QA meeting was to be held thirty (30) days later to assure QA compliance. Issues or concerns were to be documented on the QI monitoring tool for the Administrator/designee (SW) review and follow-up on a daily basis. Ongoing issues were to be monitored by CED on a daily basis and the Medical Director on a monthly basis and through the QA process. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview, on 01/17/14 at 6:21 PM, with the CED revealed on 01/14/14, she in-serviced the Administrator, DON and SW on the facility's Abuse Policy in regards to the seven (7) components of abuse, reporting, training, signs and symptoms of abuse, the investigation process, protection of resident and prevention of abuse. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had been in-serviced by the CED on the facility's Abuse Policy. She stated the in-service included the seven (7) components of abuse, allegations, signs and symptoms of abuse, notification, resident rights, prevention, importance of open communication, appropriate communication versus verbal abuse, how to complete an investigation, timeliness, what to do to ensure residents were protected, if staff was involved ensure they were suspended until the investigation was completed, interviewing all staff and residents, notifying the Physician, responsible party and on monitoring residents' emotional well-being. Interview, on 01/17/14 at 3:55 PM, with the DON revealed she had been in-serviced by the CED on 01/14/14 and everyday since on the facility's Abuse Policy. She stated the CED went over the whole policy which included the seven (7) components of abuse, reporting, screening, reporting, taking statements, interviewing all staff and verbal residents, suspending staff until investigations were concluded, performing skin assessments on non-verbal residents for signs and symptoms of abuse, the investigation process and prevention of abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had been in-serviced by the CED on 01/14/14 on the entire Abuse Policy. Interview, on 01/16/14 at 3:35 PM, with the Medical Director revealed he had been notified of the Immediate Jeopardy on 01/15/14. Review of a written statement dated 01/15/14, signed by the Human Resources (HR) staff person, revealed she documented she had completed an audit of personnel files on 01/14/14 and 01/15/14 to ensure all employees had abuse registry checks, criminal background checks and reference checks. Continued review of the statement revealed the HR staff person documented all employees were found to have all the documentation in their files. Review of thirteen (13) personnel files revealed they contained contained criminal background checks, reference checks and abuse registry checks. Review of individual in-service documentation dated 01/14/14 through 01/16/14 revealed individual staff were being in-serviced on appropriate communication and verbal abuse by Department Managers/QI members/MOD. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual staff was in-serviced on appropriate communication and verbal abuse by the Department Managers/QI members/MOD. The Administrator stated staff who were on extended leave would be re-in-serviced on the facility's Abuse Policy and appropriate communication versus verbal abuse prior to returning to work. She stated an investigation into the cause of the event was reviewed and completed on 01/14/14 by herself, the DON, the Nurse Managers and Department Managers/QI members/MOD. On 01/14/14, the two (2) residents identified in the Immediate Jeopardy (Residents #3 and #9) were assessed by a nurse and the SW to ensure no adverse physical or psychological effect was noted. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she had talked to Resident #3 and #9 on 01/14/14 and no negative psychological effects were noted. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses and the SW had assessed Residents #3 and #9 on 01/14/14 and no negative effects were noted or observed. 2) Review of resident interview sheets dated 01/14/14 revealed forty-nine (49) residents were interviewed by Nurse Managers or Department Managers/QI members. Review of this documentation revealed two (2) reports of alleged verbal abuse were received during the interviews. Review of the facility's Initial Report of Incident/Allegation forms revealed two (2) forms dated 01/14/14, one (1) involved Resident #9 reporting CNA #3 was hateful to him/her; the other involved Unsampled Resident B who had reported CNA #11 had laughed at him/her and was a smartie pants. Continued review of these forms revealed they were faxed to the State Agencies on 01/14/14. One (1) allegation involved CNA #3 who had been terminated from the facility on 01/14/14; and, the other involved CNA #11 who was suspended pending investigation. Review of the medical record for these two (2) residents revealed the Physician and family/POA were notified of the allegations. Interview, on 01/17/14 with Resident #10 at 3:08 PM; Unsampled Resident A at 4:35 PM; Unsampled Resident C at 4:40 PM; Resident #8, Unsampled Resident D and Resident #3 at 4:00 PM; Resident #11 at 4:39 PM; Unsampled Resident B at 4:25 PM; and, Resident #9 at 4:43 PM revealed they all stated that facility staff had talked with them recently regarding any concerns they had with the care provided by staff. Unsampled Resident B stated he/she had told staff about CNA #11 being a smartie pants and he/she was told this CNA would no longer provide care for him/her. Resident #9 stated he/she had told staff about CNA #3 yelling at him/her, and slamming doors and the bedside commode lid. Resident #9 stated he/she was informed CNA #3 no longer worked at the facility. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed forty-nine (49) interviewable residents were interviewed on 01/14/14. She stated two (2) residents had made allegations and these were reported to the State Agencies and notifications made to the Physician and responsible parties. According to the Administrator, CNA #3 was terminated from employment at the facility on 01/14/14 and CNA #11 had been suspended pending investigation. 3) Review of the Weekly Skin Assessment forms provided revealed nine (9) residents had head to toe skin assessments completed by Nurse Managers on 01/14/14 and 01/15/14. Continued review of these forms revealed no documented evidence of any signs of physical or psychological abuse noted during the skin assessments. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nine (9) complete body assessments were completed on non-verbal resident; with no signs of abuse noted. 4) Review of the In-Service Attendance form dated 01/14/14 revealed the QI members/Department Managers/MOD, Nurse Managers and DON were in-serviced/re-in-serviced by the Administrator on the facility's Abuse Policy to ensure allegations of abuse were immediately reported before completing the investigation. Further review of this form revealed the Administrator re-in-serviced regarding abuse reporting, timeliness of reporting, how to complete an investigation, proper procedures for taking statements during investigations, all residents to be assessed for safety and interviewed to determine if any other alleged abuse had occurred, ensuring safety of residents during an investigation and procedures for reporting to ensure compliance with regulatory guidelines and facility policy. Review of the Mock Investigation Initial Report of Incident/Allegation forms revealed the QI members/Department Managers/MOD, Nurse Managers completed mock abuse investigations. Review of the Initial Report of Incident/Allegation form revealed dated 01/14/14 regarding Unsampled Resident B's allegation revealed the DON had completed the form and it was reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 1:58 PM with the MDS Coordinator #1; at 2:19 PM with MDS Coordinator #2; at 2:47 PM with the SW; at 3:25 PM with the Food Service Director; at 3:30 PM with the Activity Director; at 3:55 PM with the DON; and at 5:24 PM with the Medical Record person who were all QI members revealed they had been re-inserviced and performed mock investigations. The DON stated she had completed an investigation into Unsampled Resident B's allegation and this had been reviewed and signed off on by the Administrator. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed QI members were re-in-serviced and had performed mock investigations, and the DON who had completed an investigation into Unsampled Resident B's allegations. She stated she reviewed the DON's investigation and signed off on it. Interview, on 01/17/14 at 9:19 AM with the Medical Director revealed he had been in communication with the facility and had been notified of the two (2) additional residents' complaints and investigation into these complaints on 01/14/14 and 01/15/14. 5) Review of the In-Service Attendance forms dated 01/14/14 revealed Nurses, CNAs and KMAs were re-inserviced on the facility's aAbuse Policy by the DON and Nurse Managers. Continued review of these forms revealed the in-service included reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. Interview on 01/17/14 with RN #2 at 6:07 PM and RN #1 at 6:20 PM revealed they had been re-inserviced on 01/14/14 on the Abuse Policy; and, interview with CNA #20 at 4:00 PM and CNA #19 at 4:30 PM revealed they had received in-services on the Abuse Policy that week. These staff indicated the in-services had covered policy items such as, abuse reporting, investigating, assessment of residents for harm, identifying, notifications and what to do to ensure no other residents were abused. 6) Review of the Master List for Inservices revealed all but five (5) facility staff had received in-servicing on the facility's Abuse Policy on 01/15/14. Review of the Master List for Inservices revealed the facility staff in-serviced included nursing, dietary, housekeeping and laundry personnel. Review of the In-Service sign-in sheets revealed staff were in-serviced on proper reporting procedures to be followed and ensuring residents safety. Interview, on 01/17/14 at 2:47 PM, with the SW revealed she performed in-services with staff on 01/15/14. She stated staff were able to voice understanding of the Abuse Policy after the in-services. The SW stated she role-played different scenarios with staff to show the difference between appropriate communications and verbal abuse. Interviews on 01/17/14 with CNA#16 at 2:30 PM; CNA #10 at 2:35 PM; CNA #7 at 2:40 PM; CNA #1 at 2:45 PM; CNA #14 at 2:50 PM; CNA #13 at 2:55 PM; CNA #18 at 3:00 PM; CNA #9 at 4:20 PM; CNA #19 at 4:30 PM; CNA #21 at 4:35 PM; CNA #17/KMA at 2:25 PM; CNA #17/KMA at 4:30 PM; CNA #20/KMA at 2:18 PM; CNA #2/KMA at 2:18 PM; CNA #22/KMA at 4:20 PM; the Night Cook at 1:50 PM; Dietary Aide #2 at 1:35 PM; Dietary Aide #1 at 1:45 PM; Dietary Aide #3 at 4:15 PM; Housekeeper #1 at 2:04 PM; Housekeeper #2 at 2:08 PM; Housekeeper #3 at 2:15 PM; Housekeeper #4 at 4:10 PM; Laundry Personnel #1 at 1:57 PM; LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed these staff had been in-serviced on the facility's Abuse Policy regarding proper reporting procedures and ensuring residents safety. Staff stated the SW role-played scenarios with them related to the difference between appropriate communications with residents and verbal abuse. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed only five (5) staff had not received the in-service on the Abuse Policy. She stated these employees would not work until they had received it. The Administrator stated all other facility staff had received the in-service. She indicated the SW had performed role-playing with staff to ensure their understanding. Review of a letter dated 01/15/14, signed by a consultant LCSW revealed an in-service was performed on that date for the entire team to help address issues with communication. Further review revealed the in-service was titled, Residents and Their Emotions: How Can We Help. Review of the in-service sign-in sheet dated 01/15/14 revealed fifty-two (52) facility staff from all disciplines had attended the in-service. Further review of the sign-in sheet revealed the staff signatures included the Administrator, DON, SW, Activities Director, Dietary personnel, Housekeeping personnel and Nursing staff. Interview, on 01/17/14 at 3:22 PM, with the consultant LCSW revealed he had performed an in-service on 01/15/14 per request of the facility. He stated the in-service was held to address communication issues within the facility. The consultant LCSW stated the in-service was titled, Residents and Their Emotions: How Can We Help. 7) Review of In-Service Attendance forms revealed individual re-in-services related to abuse were performed on 01/14/14 and 01/15/14 completed by Department Managers/QI members. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed individual re-in-services had been performed by QI members and this would be ongoing to ensure staff's understanding of appropriate communication and the Abuse Policy. Continued interview with the Administrator revealed the Governing Body, which constituted the facility Owner and her father, would be notified of grievances, documentation, reporting, resident rights and the Quality Assurance (QA) meeting findings. 8) Review of the In-Service Attendance form dated 01/14/14 revealed all Department Managers/QA/QI members had received training on responsibilities, audits, QA and resident rights. Interview, on 01/17/14 MDS Coordinator #1 at 1:58 PM; MDS Coordinator #2 at 2:19 PM; the SW at 2:47 PM; the Food Services Manager at 3:25 PM; the Activity Director at 3:30 PM; the DON at 3:55 PM; and the Medical Records person at 5:24 PM, (who were all Department Managers/QI members) revealed they had all be re-in-serviced by the Administrator on their duties and responsibilities, on the audits, QA, the Abuse policy and resident rights. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed she had performed the in-service/re-in-service on 01/14/14 and had been re-in-servicing Department Managers/QI members ongoing since then regarding their duties and responsibilities, on audits, the facility's QA and on resident rights. She stated an informal QA meeting was held on 01/14/14 and the Medical Director had been contacted on 01/14/15 and 01/15/14 regarding the inservices/re-in-services conducted. 9) Review of QI Rounds sheets revealed QI members were conducting rounds twice daily which included any complaints or concerns noted by residents. Interview, on 01/17/14 with LPN #2/Charge Nurse at 2:54 PM; RN #2/Charge Nurse at 3:15 PM; LPN #3 at 5:11 PM; RN #3/Charge Nurse at 6:07 PM; and RN #1/Charge Nurse at 6:20 PM revealed nurses continued passing information along in the change of shift report. They indicated changes in condition and issues or concerns were discussed to address any monitoring that was required. These nurses indicated new interventions were implemented as necessary. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed nurses passed information along in the change of shift report regarding changes in condition, issues or concerns and addressing monitoring required. She stated audits were being completed to ensure the twenty-four (24) hour report sheet and Physician order [REDACTED]. The Administrator stated any issues or concerns were being taken to the daily Monday through Friday QI meeting and discussed, with new interventions implemented as necessary. She indicated residents' charts, any grievance reports and their care plans were to be brought to the daily QI meeting to assure documentation was appropriate and notifications had been made. According to the Administrator, on weekends the MOD was to discuss issues or concerns with nursing staff and document on the MOD rounds sheet. She stated this information was to be transferred to an audit sheet and signed off on by herself or her designee, the CED or SW. 10) Review of Unsampled Resident B's care plan revealed it was revised to include an intervention indicating the resident did not want CNA #11 caring for him/her. Review of Resident #3's and #9's care plan revealed no revisions made related to staff preferences. Interview, on 01/17/14 at 3:38 PM, with the DON revealed Unsampled Resident B's care plan had been revised to indicate he/she did not want CNA #11 caring for him/her. She indicated there had been no reason to revise Resident #3's and #9's care plan for staff preferences as CNA #3 had been terminated on 01/14/14. Interview, on 01/17/14 at 5:00 PM, with the Administrator revealed care plans of residents had been reviewed by the DON and Nurse Managers, and revised as necessary to ensure residents' needs were met. She stated Unsampled Resident B's care plan had been revised to include the information that he/she did not want CNA #11 caring for him/her. She indicated residents' care plans would continue to be updated quarterly and as needed with appropriate interventions. 11) Interview, on 01/17/14 at 2:19 PM with MDS Coordinator #1/QI member; at 3:30 PM with the Activity Director/QI member; an at 5:24 PM with the Medical Records personnel/QI member revealed an informal QA meeting was held on 01/14/14 related to the Immediate Jeopardy and to initiate interventions and monitoring. Review of QI Rounds sheets revealed QI members were conducting rounds twice daily which included any complaints or concerns noted by residents. Interview, on 01/17/14 MDS Coordinator #1 at 1:58 PM; MDS Coordinator #2 at 2:19 PM; the SW at 2:47 PM; the Food Services Manager at 3:25 PM; the Activity Director at 3:30 PM; the DON at 3:55 PM; an

Based on 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 the Physician was immediately notified of an incident which required transfer to an acute care facility for emergency treatment for one (1) of nine (9) sampled residents (Resident #1). Additionally, the facility failed to immediately notify the Legal Representative for Resident #1 when an incident occurred that required Physician intervention. On [DATE] at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. Interview and record review revealed the facility failed to immediately notify Resident #1's Physician and/or Legal Representative of the incident. (Refer to F223) The facility's failure to ensure an effective system was in place to ensure the Physician and Legal Representative were immediately notified of an potential incident of sexual abuse was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was verified to be removed on [DATE], prior to exiting the facility on [DATE], with remaining non-compliance at 42 CFR 483.10, Resident Rights, F-157 Notification of Changes with a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure Physicians and Legal Representatives are notified in the event of an incident, accident or change in the resident's condition. The findings include: Review of the facility's policy titled, "Accidents and Incidents" undated, revealed regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Accident/Incident Report Form must be completed on the shift that the accident or incident occurred with the time the resident's attending Physician was notified as well as the date and time the resident's Legal Representative was notified and by whom. Review of the facility's policy titled, "Physician Notification Policy/Procedure" revised ,[DATE], revealed the Physician should be notified within twenty-four (24) hours except in medical emergencies. Review of the facility's policy titled, "Family Notification Policy/Procedure" undated, revealed the resident's Legal Representative should be notified within twenty-four (24) hours except in emergencies. Record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Nursing Notes, dated [DATE] at 4:00 AM, revealed staff entered the resident's room and found another resident in his/her room. Review of the resident's Physician orders [REDACTED].#1's physician to transport Resident #1 to the emergency department for evaluation; approximately nineteen (19) hours after the incident. Review of the Social Service Notes, dated [DATE] at 12:30 AM, revealed the resident's Legal Guardian/Mother was informed of Resident #1's transfer to an Emergency Department for an evaluation and labs; approximately twenty and a half (20 ,[DATE]) hours after the incident. Review of the Emergency Department notes, dated [DATE] at 1:05 AM, revealed Resident #1 presented to the emergency department for a possible sexual assault. Continued review revealed, a sexual assault evidence collection examination was completed and the results were not available at the time of the survey. Interview on [DATE] at 7:06 PM, with Licensed Practical Nurse (LPN) #5 who was Resident #1's primary nurse and charge nurse, revealed she found Resident #2 in Resident #1's room with the door closed. Further interview revealed Resident #1's left hip and buttocks were exposed and the blanket had wet spots on it. LPN #5 stated she notified her Manager On Duty who notified the Corporate Executive Officer (CEO) who called her for further information. LPN #5 stated she was not directed to notify the Physician or family and for non-emergencies the policy was to notify within twenty-four (24) hours. Interview with the Assistant Administrator who was also Social Services Director (SSD), on [DATE] at 10:44 AM, revealed she was notified of the incident on [DATE] at approximately 9:30 AM. Further interview revealed she did not follow the facility's policy for notification because she did not think anything had happened. Interview with the CEO, on [DATE] at 12:33 PM, revealed the Physician and family should have been notified per the facility's policy. Interview with the Administrator, on [DATE] at 2:42 PM, revealed the Physician and family should have been notified when the incident occurred. Interview with Resident #1's legal guardian, on [DATE] at 1:58 PM, revealed she was notified by the SSD on [DATE] at 1:46 AM of Resident #1's transfer to the emergency department. Continued interview revealed she was advised the staff had found a resident of the opposite sex in Resident #1's room and the facility was transferring Resident #1 to the emergency department for his/her safety just to obtain a few swabs but that the facility was one hundred (100%) percent certain nothing had happened. Continued interview revealed the legal guardian was again notified by the SSD, after Resident #1 returned from the emergency department, and she was advised all examinations and labs were negative and that no sexual assault had occurred. However, evidence from the sexual assault collection examination had not been processed at the time of the State Survey Agency's investigation, concluding on [DATE]. The State Survey Agency was unable to obtain an interview with Resident #1's physician due to his death on [DATE]. Interview with Resident #2's Physician and the Physician that assumed Resident #1's care, on [DATE] at 8:36 PM, revealed his expectation would be for the staff to notify him and family members for resident behaviors. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] that alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of [DATE] to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on [DATE] after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on [DATE]. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of [DATE]. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On [DATE], the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on [DATE] regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of [DATE] to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on [DATE]. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of [DATE], were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on [DATE], revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on [DATE]. Interview with Resident #5, on [DATE] at 3:15 PM, revealed the Resident meeting was held on [DATE] and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on [DATE] at 3:15 PM, and Resident #9, on [DATE] at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for [DATE] regarding training for all employees on abuse. Interview with Housekeeper #1, on [DATE] at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on [DATE] at 2:05 PM, revealed she had training on abuse and attended the in-service on [DATE]. Interview with Laundry Staff, on [DATE] at 2:15 PM, revealed she had training on abuse on [DATE], which she stated was mandatory for all staff members. Interview with Dietary #1, on [DATE] at 2:20 PM, revealed she had attended the in-service on [DATE] related to abuse. Interview with Dietary #2, on [DATE] at 2:25 PM, revealed she has had training on abuse and attended the in-service on [DATE]. Interview with Certified Nursing Assistant #2, on [DATE] at 7:41 PM, revealed she has had training on abuse and attended the in-service on [DATE]. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on [DATE] at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on [DATE]. Interview with the Director of Nursing, on [DATE] at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on [DATE]. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on [DATE] at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on [DATE] at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on [DATE] at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on [DATE] at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of [DATE] through [DATE] were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, [DATE] at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of [DATE] through [DATE] was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, [DATE] at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review, review of Social Service Director Job Description, and the facility's policies, it was determined the facility failed to have an effective system to ensure residents in the facility received social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 08/03/13 at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his wheelchair with the zipper of his/her pants down. Interview also revealed Resident #2 had a history of [REDACTED]. Record review revealed Resident #2 would stare into other residents' rooms, cuss in the hallways, and make sexual comments; however, there was no documented evidence the facility had addressed Resident #2's behavior. In addition, record review revealed Resident #2 had a history of [REDACTED]. The facility's failure to ensure an effective system was in place to ensure social services were provided in order to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident was likely to cause risk for serious injury, harm or impairment or death. The Immediate Jeopardy was identified on 08/15/13, and determined to exist on 08/03/13. The facility was notified of the Immediate Jeopardy on 08/15/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.15, Quality of Life, F-250 Provision of Medically Related Social Services, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor compliance with systemic changes. The findings include: Review of the job description for Social Service Director (SSD) revealed Administrative Function of meeting with administration, medical and nursing staff, and other related departments in planning social services as needed. Further review revealed as a part of the Administrative Function, the Social Service Director was responsible for maintaining contact with the resident's family, involving them with non-medical progress reports and working with emotional problems including assisting resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. Review of facility's policy "Behavior Policy", dated 06/07, revealed assessing/documenting new onset of behaviors or those behaviors that were not improving with treatment, monitoring for side effects and providing staff with information regarding behavior management via care plan, etc. Further review revealed nursing staff shall document in nurses notes of any concerns/changes (improvement/decline) with behaviors that require additional intervention or monitoring. Further review of the facility's policy revealed Social Services Designee (SSD) shall evaluate and document resident's mental health issues, past and present history of behavioral issues and shall incorporate with nursing information when documenting admission notes for use with Resident Assessment Instrument (RAI) to develop an appropriate plan of care. Further review revealed the SSD shall document at least quarterly thereafter and as needed regarding any noted changes in conditions, interventions implemented to assure an appropriate plan of care was instituted. 1. Review of Resident #2's medical record revealed the facility admitted Resident #2 on 02/12/13 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 11/15, indicating the resident was moderately impaired in cognition. Also noted was no evidence of acute changes in mental status. Review of the Nursing Notes, dated 08/03/13 at 4:00 AM, revealed staff entered the closed door to Resident #1's room and found Resident #2 in his/her room with the resident. Interview with staff revealed Resident #1 was found lying on his/her right side in a fetal position with his/her pajama pants and adult brief pulled down under the buttocks with his/her buttocks completely exposed. A wet substance was found on his/her hip, on the outer side of his/her adult brief, and on the resident's blanket. Interview with Resident #5, on 08/16/13 at 1:10 PM, revealed Resident #5 thought Resident #2 "was a problem from the start". Resident #5 could not recall specific dates and times but did reveal specific incidents when Resident #2 would reach towards Resident #1's breast and Resident #5 would intervene prior to any actual touching. Resident #5 stated the residents had to look out for Resident #1 and keep Resident #2 away from Resident #1. Review of Resident #5's medical record revealed the facility admitted Resident #5 on 07/19/12 with [DIAGNOSES REDACTED]. Review of Annual MDS, dated [DATE], revealed BIMS summary score of 11/15, indicating the resident was interviewable. Also noted was no evidence of acute changes in mental status. Interview with Resident #4, on 08/16/13 at 12:59 PM, revealed Resident #4 had witnessed Resident #2 put his/her hand between Resident #1's legs. Continued interview revealed, Resident #4 advised staff to "keep an eye on" Resident #2 and keep him/her out of Resident #1's room. Further interview revealed Resident #4 did report his/her concerns to the Assistant Administrator/Social Services Director. Further interview with Resident #5, on 08/16/13 at 1:10 PM, revealed Unsampled Resident A had come into Resident #5's room and stated Resident #2 had come into his/her room and started talking about killing people. Unsampled Resident A told Resident #5 he/she was afraid of Resident #2. Resident #5 stated he/she encouraged Unsampled Resident A to report the incident to staff. Resident #5 stated she was present when Unsampled Resident A met with the Social Worker to inform of his/her fear of Resident #2. According to Resident #5, the Social Worker informed Unsampled Resident A not to worry about Resident #2 because he/she "wouldn't hurt anyone". Interview with Unsampled Resident A, on 08/20/13 at 4:55 PM, revealed Unsampled Resident A was upset by Resident #2 coming into his/her room. Unsampled Resident A stated he/she informed staff of the incident but couldn't remember to whom he/she reported it nor when it was reported. Review of Unsampled Resident A's medical record revealed the facility admitted Unsampled Resident A on 01/30/13 with [DIAGNOSES REDACTED]. Review of Quarterly MDS, dated [DATE], revealed BIMS summary score of 10/15, indicating the resident was interviewable. Interview with Social Services Director, on 08/21/13 at 10:45 AM, revealed she did not remember any resident discussing Resident #2 going into his/her room. The Social Worker further stated she didn't remember Resident #2 going into any other residents' room. The Social Worker stated if Resident #2 was in another resident's room, it was as a "wanted" visitor. The Social Worker stated she was not aware of Resident #2 making any sexual comments to staff or residents. 2. Review of Resident #2's medical record revealed documented evidence of Resident #2's behavior towards residents and staff. However, record review revealed no evidence these behaviors were addressed by Social Services. Review of the Nurse's Note, written on 02/28/13 at 9:10 AM, revealed Resident #2 was verbally abusive to residents and staff. Review of Resident #2's care plan revealed no documented evidence of revision or interventions put into place due to this behavior. Review of Nurse's Note, dated 04/10/13 at 9:00 PM, revealed Resident #2 was extremely upset, agitated and threatening to hurt his roommate. There was no documented evidence the Social Worker addressed Resident #2's behaviors. Review of Resident #2's care plan revealed no revision or interventions put into place due to this occurrence. Review of Nurse's Note, dated 04/27/13 at 12:15 PM, revealed Resident #2 was often found staring into other residents' rooms, cussing in the hallways, and making sexual comments. There was no documented evidence the Social Services Director addressed these behaviors. Review of Resident #2's care plan revealed no revision or interventions put into place due to this behavior. Interview with the Social Service Director, on 08/21/13 at 10:44 AM, revealed she was not aware of Resident #2's behaviors that were documented in the resident's medical record. Even though the facility's behavior policy stated Social Services would evaluate and document resident's mental health issues, past and present history of behavioral issues, and incorporate nursing information to develop an appropriate plan of care. Further review of Nurse's Note, dated 05/20/13 at 6:30 PM, revealed Resident #2 was on the patio for smoke break and was yelling, cursing, and running into other residents with his/her wheel chair. There was no documented evidence the Social Services addressed this behavior and review of Resident #2's care plan revealed no revision or interventions put into place due to this behavior. Interview with the Social Service Director, on 08/21/13 at 10:45 AM, revealed she was unaware of the incident on 05/20/13 at 6:30 PM. However, interview with the DON, on 08/23/13 at 1:35 PM, revealed the 24 Hour Report/Change of Condition Reports, which were completed every day, were read during the morning meetings by supervisors and department heads. Review of facility's 24 Hour Report/Change of Condition Report, dated 05/20/13, revealed documentation that Resident #2 was yelling, cursing staff, running into residents, and staff was unable to redirect. However, Social Services failed to address this behavior and revise the resident's plan of care to prevent recurrence of this behavior and protect other residents. Interview with the Social Service Director, on 08/21/13 at 10:47 AM, revealed she was responsible for talking with residents and families regarding incidents in an investigation. Further interview revealed she was responsible for coordination of care within the facility to ensure residents received needed and required services. Further interview revealed she attended the morning meetings to discuss resident condition changes or pertinent information; however, she was unaware any residents were concerned with their safety, was unaware Resident #2 wandered into other resident rooms, was unaware Resident #2 had a history of [REDACTED]. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to evaluate and revise residents' care plans when a resident's status changed for one (1) of nine (9) sampled residents (Resident #2). Resident #2 had a documented history of verbal outburst, inappropriate touching, wandering in other residents' rooms, and running into other residents with his/her wheel chair. However, review of Resident #2's Care Plan revealed no documented evidence the facility revised the care plan to include interventions to address these behaviors. On 08/03/13 at 4:00 AM, Resident #2 was found in Resident #1's room with the door closed. Interview revealed Resident #1 was found in a fetal position on his/her side with the pajama pants and adult brief pulled down below the buttocks and the buttocks were exposed. A wet substance was found on Resident #1's buttocks, blanket, and on the outside of the adult brief. Interview revealed Resident #2 was sitting in his/her wheelchair with the zipper of his/her pants down. (Refer to F223 and F250) Based of the above findings, it was determined the facility's failure to to evaluate and revise residents' care plans when a change in status occurred was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 08/15/13 and was determined to exist on 08/03/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/15 with the facility alleging removal of the Immediate Jeopardy on 08/20/13. The Immediate Jeopardy was verified to be removed on 08/23/13, prior to exiting the facility on 08/23/13, with remaining non-compliance at 42 CFR 483.20, Resident Assessment, F-280 Revision of Care Plans, with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of facility's policy "Behavior Policy", dated 06/07, revealed assessing/documenting new onset of behaviors or those behaviors that were not improving with treatment, monitoring for side effects and providing staff with information regarding behavior management via care plan, etc. Further review revealed nursing staff shall document in nurses notes of any concerns/changes (improvement/decline) with behaviors that require additional intervention or monitoring. Further review of the facility's policy revealed Social Services Director (SSD) shall evaluate and document resident's mental health issues, past and present history of behavioral issues and shall incorporate with nursing information when documenting admission notes for use with Resident Assessment Instrument (RAI) to develop an appropriate plan of care. Further review revealed the SSD shall document at least quarterly thereafter and as needed regarding any noted changes in conditions, interventions implemented to assure an appropriate plan of care was instituted. Review of facility's policy, "Care Plans - Comprehensive Policy", no date, revealed care plans should be revised as changes in the resident's condition dictated. Review of Resident #2's medical record revealed the facility admitted Resident #2 on 02/12/13 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) summary score of 11/15 indicating the resident was moderately impaired in cognition. Also noted was no evidence of acute changes in mental status. Interview with Resident #5, on 08/16/13 at 1:10 PM, revealed specific incidents when Resident #2 would reach towards Resident #1's breast and Resident #5 would intervene prior to any actual touching. Resident #5 stated the residents had to look out for Resident #1 and keep Resident #2 away from Resident #1. Interview with Resident #4, on 08/16/13 at 12:59 PM, revealed Resident #4 had witnessed Resident #2 put his/her hand between Resident #1's legs. Resident #4 advised staff to "keep an eye on" Resident #2 and keep him/her out of Resident #1's room and Resident #4 reported his/her concerns to the Social Services Director. Review of Resident #2's Care Plan for Aggression, dated 02/12/13, revealed nursing staff to monitor moods and behaviors and document daily on the Mood and Behavior Tracker. The goal was for Resident #2 to have no moods/behaviors go undetected within the next assessment period. The interventions were implemented as needed to redirect, convey acceptance of resident during period of inappropriate behavior, always ask for help if resident becomes abusive/resistive, keep environment calm and relaxed, remove from public area when behavior is unacceptable, encourage diversional activities, change staff if resident will allow another staff to complete care, avoid over stimulation, assist to toilet or change brief as needed, position for comfort and assess for hunger or thirst. The only revisions to the care plan noted were for medication changes. Further review revealed a notation in the comment section of the comprehensive plan of care dated 05/2013 "Goals Met cont. POC". The resident's care plan did not address inappropriate touching of other residents. Review of the Nursing Notes, dated 08/03/13 at 4:00 AM, revealed staff entered the closed door to Resident #1's room and found Resident #2 in his/her room with the resident. Interview with staff revealed Resident #1 was found lying on his/her right side in a fetal position with his/her pajama pants and adult brief pulled down under the buttocks with his/her buttocks completely exposed. A wet substance was found on his/her hip, on the outer side of his/her adult brief, and on the resident's blanket. 2. Review of Resident #2's medical record revealed Resident #2 exhibited behaviors towards residents and staff. However, review of the resident's plan of care revealed no changes in interventions to address these behaviors. Review of Resident #2's Mood and Behaviors Monthly Assessment, 02/2013, revealed verbal and physical abuse documented on 02/28/13. Other behaviors were also documented to include other behavioral symptoms not directed toward others, rejection of care, inattention and disorganized thinking. No documentation indicating intervention of medication was used. Outcomes were recorded as unchanged and the resident's care plan was not revised. Review of the Nurse's Note, dated 02/28/13 at 9:10 AM, revealed Resident #2 to be verbally abusive to other residents and staff and extremely upset and unable to be redirected. Further review of the medical record revealed Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. However, review of the Care Plan revealed no documented evidence the facility revised the care plan to included updated interventions to address the behaviors. Review of Resident #2's Mood and Behaviors Monthly Assessment, 04/2013, revealed no abusive behaviors documented although other behaviors such as inattention and disorganized thinking were documented. No documentation indicating intervention of medication was used. Outcomes were recorded as unchanged. However, review of Resident #2's Nurse's Notes, dated 04/09/13 at 7:00 AM, revealed Resident #2 was up in his/her wheel chair roaming the facility making sexual remarks to staff. Resident #2 was redirected with positive results. Review of Resident #2's Nurse's Note, dated 04/10/13 at 9:00 PM, revealed Resident #2 was extremely upset and agitated. Review revealed Resident #2 threatened to hurt his/her room mate. At this time Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. Review of Resident #2's Nurse's Notes, dated 04/27/13 at 12:15 PM, revealed Resident #2 was often found starring in other resident rooms, cussing in hallways and making sexual comments. Review of Resident #2's Nurse's Note, dated 04/28/13 at 5:30 PM, revealed Resident #2 was yelling and cussing in the hall, threatening to fight other residents and staff, packing his/her personal belongings. Further review revealed Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. However, review of the care plan revealed no documented evidence the care plan was revised to include any additional interventions to address Resident #2's behaviors. Review of Resident #2's Mood and Behaviors Monthly Assessment, 05/2013, revealed no abusive behaviors documented although other behaviors were documented to include inattention and disorganized thinking. No documentation indicating intervention of medication was used. Outcomes were record as unchanged. However, review of Resident #2's Nurse's Note, dated 05/13/13 at 11:00 PM, revealed Resident #2 required frequent redirection from conversation with staff regarding sexual overtones. Review of Resident #2's Nurse's Note, dated 05/20/13 at 6:30 PM, revealed Resident #2 was on the patio outside, very agitated, going through the trash can, yelling, cursing and running into other residents and unable to be redirected. Further review revealed Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety at 7:00 PM. Review of Resident #2's Nurse's Note, dated 05/31/13 at 2:45 PM, revealed Resident #2 was cussing and threatening staff and other residents. Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. However, review of the care plan revealed no documented evidence the care plan was revised with interventions to address the behaviors. Review of Resident #2's Mood and Behaviors Monthly Assessment, 07/2013, revealed physically abusive behaviors documented on 07/01/13. Other behaviors were noted on 07/01/13, 07/02/13, 07/20/13, 07/22/13, 07/23/13 and 07/24/13 to include other behavioral symptoms not directed toward staff, rejection of care, inattention, disorganized thinking and [MEDICAL CONDITION]. No documentation indicating intervention of medication was used. Outcomes were record as unchanged. However, review of Resident #2's Nurse's Note, dated 07/26/13 at 10:30 AM, revealed the Inter-Disciplinary Team (IDT) reviewed the resident's behaviors from evening shift. Further review stated Resident #2 became very angry and irate, cussing at other staff, throwing things. Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. Review of Resident #2's Nurse's Note, dated 07/26/13 at 8:15 PM, revealed Resident #2 was yelling and stating to staff to get away or he/she would hurt staff. Resident #2 was cursing other residents when they told him to shut up. Resident #2 was unable to be re-directed. Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety. However, review of the care plan revealed no documented evidence the care plan was revised to include addition interventions to address the behaviors. Review of Resident #2's Mood and Behaviors Monthly Assessment, from 08/01/13 to 08/03/13, revealed no abusive behaviors documented although other behaviors were documented to include inattention and disorganized thinking. No documentation indicating intervention of medication was used. Outcomes were record as unchanged. However, review of Resident #2's Nurse's Note, dated 08/03/13 at 4:30 AM, revealed Resident #2 was roaming in the hall and became agitated and unable to redirect. Further review revealed Resident #2 got up out of his/her wheel chair saying he/she was leaving, resident yelling and cursing staff unable to redirect. Resident #2 received PRN dose of [MEDICATION NAME] for agitation/anxiety at 4:50 AM. Interview with the Director of Nursing (DON), on 08/21/13 at 11:30 AM, revealed the Mood and Behavior Tracking sheets were probably not accurate due to not recording interventions of medications given and the effectiveness of the interventions. Interview with the Social Service Director, on 08/21/13 at 10:59 AM, revealed it was her responsibility to coordinate services in the facility to ensure residents received the care and services that they needed. She stated she did, at times revise care plans. Interview with the Chief Executive Officer (CEO), on 08/21/13 at 1230 PM, revealed she was not able to determine if the Mood and Behavior Tracking sheets were an accurate assessment of the resident's behavior if the sheets were missing important details, due to not having a medical background. Interview with the Administrator, on 08/21/13 at 2:40 PM, revealed she does not review the Mood and Behavior tracking sheets to assess residents. The Administrator stated she looked at the nurse's notes, medications, and physician's orders [REDACTED]. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/23/13 that alleged removal of the IJ effective 08/20/13. Review of the AOC revealed the facility implemented the following: 1. The facility had addition formal assessments completed per policy for 100% skin assessments (as with all residents in facility) as of 08/20/13 to remove IJ. There was no indication of injury or harm. 2. Resident #2 was placed on close observation on 08/03/13 after the incident, due to becoming agitated until resident was transferred to another facility. 3. Social Services Director conducted a resident meeting on 08/19/13. No other residents voiced any concerns. The facility's Ombudsman attended the meeting. 4. All interviewable residents were assessed/reassessed by Social Service Director regarding feeling safe and informed residents what to do in the event of another resident coming into their rooms. 5. All staff (nursing, dietary, and housekeeping/laundry) was re-in-serviced by Administrator/other designees on Abuse policy and procedures including Physician and family notifications of 08/15/13. All staff (nursing, dietary, and housekeeping/laundry) will be in-serviced/oriented to abuse policy, including reporting, prevention, intervention, notifications and detection upon hire. Additionally, staff will be re-in-serviced annually by Administration/Designee/Social Services Director. 6. On 08/15/13, the Administrator in-serviced/re-in-serviced Department Managers/Managers On Duty/QI Members (Activities, Social Services, Medical Records, General All Department Staff, Human Resources, Business Office Manager, Director of Nursing, Nursing Managers, CEO) regarding proper notifications of individuals of abuse allegations. 7. Nursing staff (CNAs, Nurses, and KMAs) in-serviced/re-in-serviced by the DON/designee on 08/15/13 regarding abuse policy/reporting, investigating abuse, assessment of residents for harm from abuse, and notifications to responsible parties regarding abuse and what to do to ensure other residents are not abused. 8. Resident safety monitoring policy was updated by Administrator, Social Services Director, and CEO as of 08/15/13 to ensure that residents who are at risk for safety, including resident who may have the potential to cause harm to themselves or others were assessed, Nursing staff (Nurses, CNAs, KMAs) were in-serviced on change/update to policy by DON on 08/19/13. 9. Nurses will continue to pass on at change of shift report any ongoing issues regarding changes in condition/issues/concerns and be discussed/addressed for monitoring, etc., and should be discussed daily (Mon. through Fri.) morning meetings held by Administrator/designee/QI team members/Department Managers. 10. Department Managers/QI members/Managers on Duty will continue to monitor residents daily to ensure resident safety needs are met and complaints are addressed. Issues/concerns are documented on QI monitoring tool for Administration/designee review and follow up. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for all residents currently residing in the facility, as of 08/20/13, were reviewed. No concerns revealed during review of skin assessments. 2. Interviews with Licensed Practical Nurse (LPN) #5 and Certified Nursing Assistant (CNA) #2, on 08/15/13, revealed Resident #2 was on close observation until transferred out of the facility. 3. The facility provided a copy of the Resident Council meeting held on 08/19/13. Interview with Resident #5, on 08/23/13 at 3:15 PM, revealed the Resident meeting was held on 08/19/13 and the Social Services Director asked if any residents had any concerns that had not been addressed. 4. Interview with Resident #5, on 08/23/13 at 3:15 PM, and Resident #9, on 08/23/13 at 3:25 PM, revealed the Social Services Director had come into residents' rooms and discussed safety concerns as well as guidelines to use in case another resident should come into their rooms. 5. The facility provided a copy of in-service sign in sheet for 08/15/13 regarding training for all employees on abuse. Interview with Housekeeper #1, on 08/23/13 at 2:00 PM, revealed she had attended the in-service discussing abuse. Interview with Housekeeper #2, on 08/23/13 at 2:05 PM, revealed she had training on abuse and attended the in-service on 08/15/13. Interview with Laundry Staff, on 08/23/13 at 2:15 PM, revealed she had training on abuse on 08/15/13, which she stated was mandatory for all staff members. Interview with Dietary #1, on 08/23/13 at 2:20 PM, revealed she had attended the in-service on 08/15/13 related to abuse. Interview with Dietary #2, on 08/23/13 at 2:25 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. Interview with Certified Nursing Assistant #2, on 08/15/13 at 7:41 PM, revealed she has had training on abuse and attended the in-service on 08/15/13. 6. The facility provided a copy of sign-in sheets regarding the abuse training given for Department Managers, QI members, and Managers On Duty. Interview with Social Service Director, on 08/22/13 at 5:14 PM, revealed she has had training on abuse to include proper notifications and attended the inservice on 08/15/13. Interview with the Director of Nursing, on 08/21/13 at 11:29 AM, revealed she has had training on abuse to include proper notifications and attended the in-service on 08/15/13. 7. The facility provided a copy of sign-in sheets regarding the abuse training given for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the abuse policies and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on abuse policy and procedures this morning at the start of her shift. 8. The facility provided a copy of sign-in sheets regarding the new monitoring policy training for nursing staff. Interview with LPN #4, on 08/23/13 at 2:10 PM revealed she attended training regarding the new monitoring policy and procedures. Interview with LPN #6, on 08/23/13 at 2:25 PM, revealed she has been on vacation and was just returning to work this date. LPN #6 stated she received training on the new monitoring policy and procedures this morning at the start of her shift. 9. The 24 Hour Report/Change of Condition Reports from dates of 08/20/13 through 08/23/13 were reviewed and revealed staff nurses were documenting and reporting events for their shift. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the 24 Hour Report/Change of Condition was utilized in the Stand Up meetings for management and administrative follow up. 10. The QI monitoring Tool, completed by management, from dates of 08/20/13 through 08/23/13 was reviewed and revealed managers were following up with areas of safety and resident needs noted on document tool. Interview with the Director of Nursing on, 08/23/13 at 11:35 AM, revealed the QI monitoring Tool was utilized by management staff while making rounds daily.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for one (1) of three (3) sampled residents (Resident #1). Although the Minimum Data Set (MDS) Assessment, dated 04/15/13, for Resident #1 revealed the facility assessed the resident as requiring the assistance of two (2) staff for transfers, there was no documented evidence the Comprehensive Plan of Care was revised with interventions for two (2) to transfer this resident. On 05/22/13, Resident #1 sustained a [MEDICAL CONDITION] Femur and Tibia after a State Registered Nurse Assistant (SRNA) attempted to transfer the resident independently, and had to lower the resident to the floor. (Refer to F-323) The findings include: Review of the facility "Care Plans-Comprehensive", Policy, undated, revealed it was the policy of the facility to develop a Comprehensive Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Further review revealed the Comprehensive Plan of Care had been designed to prevent declines in the resident's functional status. Care Plans were to be revised as changes in the resident's condition dictated. Review of Resident #1's clinical record revealed [DIAGNOSES REDACTED]. Review of the Care Area Assessment Summary dated 08/02/12, revealed the resident was not steady with surface to surface transfers and was unable to stabilize without human assistance. Review of the Quarterly MDS Assessment, dated 04/15/13, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a nine (9) out of fifteen indicating the resident was moderately impaired in cognition. Further review revealed the facility assessed the resident as requiring total dependence of two (2) staff for transfers. Although the MDS Assessment, dated 04/15/13, revealed the facility assessed the resident as requiring two (2) staff to transfer, the Comprehensive Plan of Care dated April 3013 revealed the resident was at risk for falls and required one (1) to two (2) persons to assist with transfers. Also, review of the Nurse Aide Flow Sheet/Care Plan dated May 2013 revealed the resident required one (1) to two (2) persons to assist with transfers. Review of the Nurse's Notes, dated 05/22/13 at 2:10 PM, revealed Resident #1 was lowered to the floor during a transfer due to the resident's knees giving way. Resident #1 was unable to sit up and complained of right lower extremity pain. The Physician and Emergency Medical Services (EMS) was notified. Review of the Nurse's Note, dated 05/22/13 at 2:20 PM, revealed the resident left the facility per EMS on a back board. Review of the hospital records revealed Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Interview, on 05/31/13 at 8:45 AM, with Resident #1, who was residing in another skilled facility, revealed she/he had "suffered unmerciful". The resident stated she/he was dropped and now her/his whole body was sore and she/he was in a lot of pain. Resident #1 stated the facility was to have two (2) staff to assist her/him with transfers and usually they did. However, she/he was transferred by a staff member whom she/he had never seen before and the staff member picked her/him up and let her/him drop. The resident stated, she/he landed on both knees which folded underneath her/him. Interview with State Registered Nursing Assistant (SRNA) #1 on 05/30/13 at 2:33 PM, revealed SRNA #3 told her Resident #1 required one (1) to transfer and could bear weight, and she was aware the Nurse Aide Care Plan stated one (1) to two (2) for transfers. Further interview revealed she was doing a pivot transfer with Resident #1 on 05/22/13 from the wheelchair to the bed when the resident's knees went out and she/he went down. She stated the resident landed on her/his knees and she assisted the resident to lay down and went to get the nurse who immediately assessed the resident and called the ambulance. Continued interview revealed the care plan should be specific to state two (2) to transfer if a resident sometimes needs two (2). She indicated the SRNA's did warn her that Resident #1 would sometimes need two (2) to transfer, but did not get specific as to when two (2) staff would be needed. Interview with SRNA #3, on 05/30/13 at 2:15 PM, revealed they used the Nurse Aide Care Plans which were kept in a folder on the outside of the resident's closet door as a reference for care including transfer technique. She stated she transferred the resident independently with a gait belt unless the resident told her she/he would need two (2) to transfer her/him that day. She further stated if the resident was tired or if the resident told her she may need help, she would get someone else to assist with the transfer. Continued interview revealed she had trained SRNA #1 on how to transfer Resident #1 and had specified the resident could be transferred with one (1) person and a gait belt; however, also warned her if the resident stated she/he would need more help, the resident should be transferred with two (2) staff. Interview with SRNA #4, on 05/30/13 at 2:24 PM, revealed Resident #1 required two (2) to transfer; however, sometimes she would transfer her/him by herself. She stated sometimes the resident did not help with the transfer and would require two (2) to assist from the bed to the wheelchair. Continued interview revealed transferring the resident from the wheelchair to bed depended on the resident's ability, because sometimes the resident was half asleep. She indicated the resident would let her know when she needed more help. Interview, on 05/31/13 at 12:00 PM, with Registered Nurse (RN) #1 revealed she was assigned to Resident #1 on 05/22/13 at the time of the fall. She stated she thought the resident was to be transferred with two (2) staff; however, after the incident when she checked the care plan it stated (1) to two (2) with transfers. Further interview revealed the nurses on the floor reviewed the Nurse Aide Care Plans each Sunday for any revisions needed and she had reviewed Resident #1's Nurse Aide Care Plan in the past but did not notice it said one (1) to two (2) for transfers. She indicated if a resident sometimes needed two (2) to transfer, it would be safer to ensure two (2) transferred the resident at all times. Interview, on 05/31/13 at 1:15 PM, with the MDS Nurse, revealed she had completed the latest MDS and Care Plan for Resident #1. She indicated she coded the residents for the most dependent on the MDS. She stated, prior to completing the Care Plans she interviewed the SRNA's as to how many staff it took to transfer the resident and was told sometimes one (1) person and sometimes two (2) persons depending on how the resident was doing that day. The MDS nurse stated, she also reviewed the ADL tracker which was completed by her after she interviewed the staff about the resident's ability for ADL's when completing the Care Plans. Continued interview revealed she noted the ADL tracker for the seven (7) day assessment period in April 3013 revealed the resident was coded for needing two (2) to transfer; however, thought the resident was only needing two (2) to transfer at that time because the resident was experiencing a Urinary Tract Infection. She stated the Care Plan should have been revised at time. She stated, the MDS Assessment was to guide the Care Plan, and she should have care planned the resident for two (2) assist for transfers. Interview, on 05/31/13 at 1:42 PM, with the Director of Nursing (DON), revealed the facility fall investigation indicated the root cause of Resident #1's fall was that her/his knees gave out. She further stated the SRNA's knew the residents and knew when either one (1) or two (2) was needed for transfers. However, SRNA #1, who transferred this resident on 05/22/13, was not as familiar with the resident. Further interview revealed the Plan of Care was to be generated from the MDS, which would indicate the Care Plan should have been revised with interventions for two (2) to transfer this resident.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed by the facility to require the assistance of two (2) staff for transfers according to the Minimum Data Set (MDS) assessment dated [DATE]; however, the Comprehensive Plan of Care and the Nurse Aide Care Plan revealed one (1) to two (2) staff was required for transfers. On 05/22/13 a State Registered Nurse Assistant (SRNA) attempted to transfer the resident independently, and had to lower the resident to the floor. The resident sustained [REDACTED]. The findings include: Review of the facility's "Falls" Policy, undated, revealed it was the policy of the facility to assess, monitor, and prevent resident injuries from falls. Review of Resident #1's medical record revealed [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment, dated 04/15/13 revealed the resident was assessed to be at high risk for falls related to intermittent confusion, chair bound, required assistance with elimination, poor vision, was unable to perform gait/balance function, health conditions, and medications. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/15/13, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a nine (9) out of fifteen (15), indicating the resident was moderately impaired in cognition and as requiring total dependence of two (2) staff for transfers. Review of the seven (7) day Activities of Daily Living (ADL's) Tracking for the MDS dated [DATE] revealed Resident #1 required two (2) staff to assist with transfers. However, review of the Comprehensive Plan of Care, dated April 2013, revealed the resident was at risk for falls related to being unsteady and having a history of falls and required one (1) to two (2) persons to assist with transfers. In addition, review of the Nurse Aide Flow Sheet/Care Plan, dated May 2013 revealed the resident required one (1) to two (2) persons to assist with transfers. Review of the Nurse's Notes, dated 05/22/13 at 2:10 PM, revealed Resident #1 was lying on the floor beside the bed and staff stated the resident was lowered to the floor during a transfer due to the resident's knees giving way. Further review revealed the resident was unable to sit up and complained of right lower extremity pain. The Physician and Emergency Medical Services (EMS) were notified. Review of the Nurse's Note, dated 05/22/13 at 2:20 PM, revealed the resident exited the facility per EMS on a back board. Review of the Hospital Discharge Summary, dated 05/29/13, revealed Resident #1 was admitted to the hospital on [DATE] after having a controlled fall. Further review revealed the resident was found to have a fractured distal Femur and Tibia and was seen by orthopedics who recommended conservative therapy of her/his fractures. Further review revealed the resident did not wish to go back to the previous facility and as result a bed was found for the resident in another skilled care facility. Review of the Hospital Radiology Report of the right lower leg, dated 05/24/13, revealed there was a spiral fracture proximal tibia, a nondisplaced fracture of the proximal neck of the fibula, and an oblique fracture through the base of the lateral femoral condyle. Interview, on 05/31/13 at 8:45 AM, with Resident #1 who was residing in another skilled facility revealed she/he had "suffered unmerciful". The resident stated she/he was dropped and now her/his whole body was sore and she/he was in a lot of pain. Continued interview revealed the facility was to have two (2) staff to assist her/him with transfers and usually they did. However, she/he was transferred by a staff member whom she/he had never seen before and the staff member picked her/him up and let her/him drop. The resident stated, she/he landed on both knees which folded underneath her/him. Continued interview revealed most of the time staff would say they needed to wait and get some help when she/he asked to go to bed. Interview, on 05/30/13 at 1:45 PM, with the Physical Therapist at the facility, revealed prior to the incident Resident #1 was able to bear weight and required two (2) staff to transfer or at least one (1) to transfer and one (1) for stand by assistance. She stated she thought two (2) staff members were always transferring this resident. Interview with State Registered Nursing Assistant (SRNA) #1, on 05/30/13 at 2:33 PM, who was assisting Resident #1 with the transfer on 05/22/13, revealed she had started at the facility 05/08/13 and received training about six (6) days with the other SRNA's who trained her on care plans, on how to use the gait belt, and how to transfer different residents. She stated SRNA #3 told her Resident #1 required one (1) to transfer and could bear weight and she was aware the Nurse Aide Care Plan stated one (1) to two (2) assist with transfers. She stated she was doing a pivot transfer with Resident #1 on 05/22/13 from the wheelchair to the bed when the resident's knees went out and she/he went down. She stated the resident landed on her/his knees and she helped lay the resident down and went to get the nurse who immediately assessed the resident and called the ambulance. SRNA #1 stated she did not get training on transfers from Physical Therapy (PT) or by the nurses; however, did get training on transfers after the incident from PT. Continued interview revealed the care plan should be specific to state two (2) to transfer if a resident sometimes needs two (2). She stated the SRNA's did warn her that Resident #1 would sometimes need two (2) to transfer, but were not specific as to when two (2) staff would be needed. Interview, on 05/31/13 at 12:00 PM, with Registered Nurse (RN) #1 revealed she was assigned to Resident #1 on 05/22/13 at the time of the fall. She stated SRNA #1 came to get her to let her know the resident was on the floor and when she assessed the resident she noted the resident's right leg was shorter and turned out and she immediately contacted the Physician and the ambulance. She said she thought the resident was to be transferred with two (2) staff; however, after the incident when she checked the care plan it stated one (1) to two (2) with transfers. Continued interview revealed the nurses on the floor reviewed the Nurse Aide Care Plans each Sunday for any revisions needed and she had reviewed Resident #1's Nurse Aide Care Plan in the past but did not notice it indicated one (1) to two (2) for transfers. She stated if a resident sometimes needed two (2) to transfer, it would be safer to ensure two (2) staff transferred the resident at all times. Interview with SRNA #3, on 05/30/13 at 2:15 PM, revealed they used the Nurse Aide Care Plans, which were kept in a file folder on the outside of the resident's closet door, as a reference for care including transfer technique. She stated she transferred the resident by herself with a gait belt unless the resident told her she/he would need two (2) to transfer her/him that day. She stated if the resident was tired or if the resident told her she may need help, she would get someone else to assist with the transfer. Continued interview revealed she had trained SRNA #1 on how to transfer Resident #1 and had specified the resident could be transferred with one (1) person and a a gait belt, but also warned her if the resident stated she/he would need more help, the resident should be transferred with two (2) staff. Interview, on 05/30/13 at 2:00 PM, with SRNA #2 revealed she would sometimes transfer Resident #1 by herself with a gait belt; however, sometimes she would need two (2) to transfer the resident. She indicated she relied on the resident to let her know when two (2) staff members were needed for the transfer. The SRNA stated, if the resident said that she/he needed two (2) people or if the resident said " I'll help you if I can", she would get someone else to help with the transfer. Continued interview revealed it would be safer for this resident to always have two (2) to transfer. Interview with SRNA #4, on 05/30/13 at 2:24 PM, revealed the resident required two (2) to transfer; however, sometimes she would transfer her/him by herself. She stated sometimes the resident did not help with the transfer and required two (2) to assist from the bed to the wheelchair. She further stated transferring the resident from the wheelchair to bed depended on the resident's ability, because sometimes the resident was half asleep. She stated the resident would let you know when she/he needed more help. Interview, on 05/31/13 at 12:10 PM, with SRNA #6 revealed there was usually two (2) needed to assist Resident #1 out of bed and one (1) needed to transfer the resident from the wheelchair to the bed. Continued interview revealed the resident's ability to transfer depended on how tired the resident was. Continued interview revealed she knew the resident would be tired on Tuesdays after sitting up a long time to get her/his hair done at the beauty shop and she would get someone to assist her to transfer Resident #1 from the wheelchair to the bed. Interview, on 05/31/13 at 1:15 PM, with the MDS Nurse, revealed she had completed the MDS and the Care Plan for Resident #1. She stated she coded the residents for the most dependent on the MDS. She further stated, prior to completing the Care Plans she interviewed the SRNA's as to how many staff it took to transfer the resident and was told sometimes one (1) person and sometimes two (2) depending on how the resident was doing that day. Continued interview revealed if the resident was participating in the transfer it would only require one (1) person to assist. The MDS nurse stated, she also went by the Activities of Daily Living (ADL) tracker which was completed by her after she interviewed the staff about the resident's ability for ADL's when completing the Care Plans. She stated she noted the ADL tracker for the seven (7) day assessment period in April 2013, revealed the resident was coded for needing two (2) to transfer each day; however, thought the resident was only needing two (2) to transfer at that time because the resident was experiencing a Urinary Tract Infection, and would not always need two (2) to transfer. Continued interview revealed the MDS Assessment was to guide the Care Plan, and she should have care planned the resident for two (2) assist for transfers. Interview, on 05/31/13 at 1:42 PM, with the Director of Nursing revealed all the training including transfers was done by the SRNA's for new SRNA's on hire and new SRNA's received at least three (3) twelve (12) hour shifts working with another SRNA on the floor before working by themselves. She stated the facility fall investigation indicated the root cause of Resident #1's fall was that her/his knees gave out. She stated prior to this fall there was no indication any other intervention was needed to prevent falls because this resident's last fall was in 2011. Continued interview revealed the SRNA's knew the residents and knew when either one (1) or two (2) was needed for this resident for transfers. However, SRNA #1, who transferred this resident on 05/22/13, was not as familiar with the resident. Further interview revealed the MDS was coded for the most dependent and the Care Plan was to be generated from the MDS and should be individualized and specific.