Every finding on record at Edmonson Nursing and Rehabilitation Center

Based on interview, record review, review of facility policy and investigation documentation, it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #4). On 09/06/2021 at approximately 6:32 PM, Resident #4 activated the pull fire alarm on the 100 Hall on the East Unit, causing the magnetic locking mechanism on the facility doors to automatically disengage. This allowed Resident #4 to exit the facility without the staff's knowledge and supervision. Per the facility's protocol, facility staff proceeded to check all rooms and closed doors, discovering Resident #4 was not on his/her unit. The facility's receptionist observed Resident #4 outside the building, walking towards a fast-food restaurant located approximately three hundred and fifty (350) feet from the front of the facility. Staff were immediately deployed to retrieve Resident #4 and returned him/her to the facility at 6:38 PM. The facility's failure to have an effective system in place to ensure residents were supervised and monitored to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 04/27/2022 and determined to exist on 09/06/2021, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, F689 and determined to continue until 09/09/2021. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. The findings include: Review of facility policy titled, Elopement of Patient, revised 02/28/2021, revealed residents were to be evaluated/assessed for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process, and as defined by the Resident Assessment Instrument (RAI) manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. Per review, elopement was defined as occurring when a resident left the premises without authorization. Continued review revealed those residents determined to be at risk were to receive appropriate interventions to reduce risk and minimize injury. Further review revealed for residents identified as at risk, an interdisciplinary elopement prevention resident-centered care plan was to be developed with the resident's participation and his/her representative as applicable Closed record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia without Behavioral Disturbance, Delusional Disorder, and Agitation. Review of Resident #4's initial Elopement Evaluation, embedded in the Nursing Admission Assessment, dated 05/18/2021, revealed the facility had assessed the resident as not at risk for elopement. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #4 to have exhibited wandering one (1) to three (3) days during the assessment period, and was independent with transfers and ambulation. Continued review of the MDS Assessment revealed the facility assessed Resident #4 to have a Brief Interview for Mental Status (BIMS) Score of five (5) indicating severe cognitive impairment. Review of the facility's Elopement Evaluation dated 06/15/2021, completed by the Center Nurse Executive (CNE) revealed it was the facility's risk assessment document utilized to determine a resident's risk for elopement. Resident #4 was independent with ambulation, had diagnoses of Dementia and Depression and had expressed the desire to leave, e.g., going home, talked about going on a trip, and attempted to pack his/her belongings. Further review revealed the areas stating exhibiting one (1) or more emotional states or behavior that might result in exit seeking behavior, i.e. hovering near exits, restlessness or agitation had not been checked on the Evaluation; however, the none of the above area had been checked. Review of the Elopement Evaluation, dated 08/25/2021 and completed by Licensed Practical Nurse (LPN) #6, revealed Resident #4 had expressed the desire to leave the facility, e.g., going home, talked about going on a trip, attempted to pack his/her belongings and had been hovering near exits. Review of a General Progress Note completed by LPN #6, on 08/25/2021 at 5:01 PM, revealed the nurse documented Resident #4 had been hovering near the front door and talked about going home one way or another, and orders received for Wander Guard placement received. Further review of the General Progress Note revealed a Wander Guard bracelet was placed on Resident #4's left ankle; however, there was no documented evidence of other interventions implemented related to the supervision and monitoring of the resident to prevent elopement. Review of Resident #4's Comprehensive Care Plan dated 05/24/2021, revealed the facility had care planned the resident as at risk for elopement related to Cognitive Loss/ Dementia. Per review, the care plan goal for Resident #4 was the resident would not attempt to leave the facility without an escort through the next review, with a target date of 09/15/2021. Continued review of the risk for elopement care plan revealed the interventions in place as of 05/24/2021 included: for staff to encourage the resident's participation in activity preferences; allow time for expression of his/her feelings; provide empathy, encouragement, and reassurance; divert the resident by giving alternative objects or activities; and as appropriate re-direct the resident if he/she was near exits or doorways. Additionally, review of the care plan revealed on 08/25/2021 a Wander Guard monitoring device had been initiated. Further review revalued however, no documented evidence of interventions to address the need for supervision and monitoring of Resident #4 regarding his/her elopement risk; nor, was there documented evidence of the supervision level required to keep the resident safe. Review of the Certified Nursing Assistant (CNA) Kardex/Care Plan (a facility document utilized to notify the CNAs of the care their residents' required) dated 09/05/2021 revealed no documented evidence of interventions related to the supervision needs of Resident #4 or of the Wander Guard bracelet placed on the resident's ankle. Review of the General Nursing Note dated 09/05/2021 at 5:56 PM for Resident #4 signed by Licensed Practical Nurse (LPN) # 3 revealed Resident wandering throughout the building looking for a way out, wants to go home. Continued review revealed LPN #3 documented the resident ' s wander guard was in place to the right of his/her ankle. She further noted the resident got agitated with redirection, requesting for staff to call the cops to come get him/her. Additionally, the review revealed LPN #3 documented Resident #4 had been checking all the doors. Review of the facility's Timeline/Investigation dated 09/06/2021, revealed Resident #4 eloped on 09/06/2021 at approximately 6:32 PM after activating a fire alarm pull station on the 100 Hall on the East Unit. Review revealed Resident #4 was witnessed by staff within minutes of pulling the alarm ambulating in the parking lot. Continued review revealed staff paged the facility's code red as per policy to 100 Hall and staff initiated searching for the fire by checking all rooms and outside the therapy door with no concerns. Per review, at 6:34 PM, staff noted Resident #4 was not in the vicinity, and between 6:34 PM and 6:36 PM, staff began searching for the resident. Review revealed at 6:36 PM, the front desk staff notified nursing of having observed Resident #4 in the parking lot walking towards a restaurant located in front of the facility and staff were immediately deployed to retrieve the resident. Further review revealed at 6:37 PM the Center Nurse Executive (CNE) was notified, and at 6:38 PM, Resident #4 was put in a staff member's car and returned to the facility. The Timeline/Investigation documentation revealed at 6:43 PM, Resident #4 exited the staff member's car and re-entered the facility, and his/her Wander Guard bracelet was tested and determined to be functioning properly. Review further revealed a nurse assessed Resident #4 at 6:45 PM, who had been wearing long sleeves, pants, and shoes at the time of elopement, with no injuries noted. In addition, review revealed at 6:49 PM, the resident's family was made aware of his/her elopement, with the Advanced Practice Registered Nurse (APRN) notified at 6:55 PM. The review of the facility's Timeline/Investigation documentation revealed the facility's root cause analysis determined Resident #4 exited the facility after activating the pull fire alarm on the 100 Hall of the East Unit, which rendered the resident's Wander Guard bracelet inactive causing it not to alarm. Review of the Weather History for the facility's location on 09/06/2021, revealed the temperature had been eighty-two (82) degrees Fahrenheit at 5:56 PM and seventy-seven (77) degrees Fahrenheit at 6:56 PM, with fair conditions. On 04/20/2022 at 1:15 PM, the State Survey Agency (SSA) Representative walked from the facility to the restaurant parking lot where Resident #4 had been located on 09/06/2021. The SSA Representative determined the distance from the facility to the restaurant where Resident #4 was located was approximately three hundred and fifty (350) feet. Interview with Licensed Practical Nurse (LPN) #1 on 04/20/2022 at 10:38 AM, revealed Resident #4 wandered and paced the facility every day. She revealed Resident #4 had anxiety and agitation, was constantly up doing something, and often looked out the door making comments about going home, checking on his/her family and getting home to check on the kids. Continued interview revealed Resident #4 had a Wander Guard bracelet on which had been checked every shift. According to LPN #1, she had never seen Resident #4 make any attempts to get out of the facility before 09/06/2021. She revealed on 09/06/2021 her shift was ending when the fire alarm sounded so she assisted with the code and started checking rooms and closing doors on 100 Hall. Per LPN #1, there had been no fire identified on the unit; however, she and Certified Nursing Assistant (CNA) #2 noticed that they had not seen Resident #4 and informed LPN #5. Further interview revealed staff began searching the facility for Resident #4 and had not located the resident. LPN #1 further stated when staff returned to the facility's lobby area the receptionist told them Resident #4 had been found walking towards the restaurant and other staff were bringing him/her back to the facility. Interview with Certified Nursing Assistant (CNA) #2 on 04/20/2022 at 11:02 AM, revealed she was working on the facility's East Unit on 09/06/2021 when Resident #4 exited the building. She revealed she last saw Resident #4 when they were passing the residents' supper meal trays. CNA #2 stated she was in a resident's room making a bed when the fire alarm sounded and was paged for the 100 Hall. Per CNA #2, staff checked the rooms and Resident #4 was not located on the unit. Further interview revealed she informed Licensed Practical Nurse (LPN) #5 of that information, and then she and LPN #1 started a room-to-room search looking for the resident. In addition, she stated after searching the East Unit she was told Resident #4 was outside the building, walking to the restaurant in front of the facility and LPN#2 and LPN #5 had gone to get him/her. Interview with Licensed Practical Nurse (LPN) #2, on 04/20/2022 at 11:48 AM, revealed Resident #4 had wandered all the time and was all over the building. She revealed in the beginning when first admitted Resident #4 would pack up his/her belongings daily and would want to go home. Continued interview revealed she was working 09/06/2021 on the facility's West Unit when the fire alarm sounded. LPN #2 stated all the residents on the West Unit had been accounted for and she had gone to the East Unit to assist. According to the LPN, she entered the lobby area and heard the receptionist say there the resident is. Further interview revealed Resident #4 had been walking to the restaurant in front of the facility, and she and LPN #5 ran out the door after the resident. In addition, she revealed Resident #4 was in the parking lot of the restaurant and had been upset because he/she thought they could make it home. Interview with LPN #3 on 04/21/2022 at 2:54 PM, revealed she had worked on 09/06/2021; however, had not been working at the time of the incident. Per LPN #3, Resident #4 had wandered daily, and often made comments about going home, but she had never seen the resident go to a door and try to get out it. Further interview revealed Resident #4 also would pack up his/her belongings daily; however, that had gotten better. She additionally stated the day after the elopement Resident #4 had seemed fine like nothing had ever happened. Interview with LPN #5 on 04/22/2022 at 8:30 AM, revealed she was familiar with Resident #4's wandering throughout the facility. She revealed Resident #4 often made statements about going home to get his/her dog, and frequently looked out the door, but she has never seen the resident try to push on the doors in attempts to exit the facility. Continued interview revealed LPN #5 had been working on 09/06/2021 when Resident #4 pulled the fire alarm and exited the facility at approximately 6:30 PM. Per LPN #5, she had just come on her shift at 6:00 PM and was standing at the medication cart, and Resident #4 had been sitting in a chair talking about wanting the state police called to bring his/her dog. She stated she had been preparing Resident #4's medications when the telephone rang, and she stepped away from the medication cart to answer it. According to the LPN, the next thing she knew the fire alarm was going off, and she checked the panel and followed the facility's protocol. LPN #5 revealed staff checked the rooms and realized Resident #4 was no longer on the unit. Interview revealed the receptionist came and told staff Resident #4 was walking to the restaurant in front of the facility. Further interview revealed LPN #2 and LPN #5 immediately ran out the door to go get Resident #4 and return him/her to the facility. She revealed when they reached Resident #4 he/she had been weak so she (LPN #5) had called a staff member to come and pick all of them up in his/her vehicle. In addition, she stated she assessed Resident #4 upon return to the facility and had observed no injuries. She further stated she had notified the CNE, Resident #4's family and the Physician, and the resident had been placed one to one (1:1) supervision by staff until his/her family arrived. Interview further revealed Resident #4's family left the resident had been in bed, and he/she was placed on every fifteen (15) minute checks. Interview with LPN #6 on 04/22/2022 at 3:48 PM, revealed Resident #4 was not someone who liked to sit still. She stated Resident #4 had always been up doing something and enjoyed looking out the door. Per LPN #6, she had never seen Resident #4 attempt to exit the facility; however, on 08/25/2021 she observed the resident hovering at the door, talking about going home and wondering where his/her son was. She revealed she informed the APRN and CNE and received an order for a Wander Guard bracelet to be placed on the resident. Further interview revealed she completed an elopement assessment and updated Resident #4's care plan with the Wander Guard placement; however, could not recall if she included any interventions related to supervision of the resident. She further revealed all staff were aware of residents who were at risk of elopement, and they all knew to keep an eye on those residents. Interview with CNA #6 on 04/25/2022 at 9:45 AM, revealed she recalled Resident #4 often walked around on the West Unit. She revealed Resident #4 had a Wander Guard bracelet in place, and that's how staff knew to keep an eye on him/her. Further interview revealed the Wander Guard bracelet might have been on the Kardex; however, would definitely have been in the elopement binder at the nurse's station. In addition, she further revealed Resident #4 had always been easily redirected, but sometimes needed assistance to return to the East Unit. Interview with CNA #5 on 04/25/2022 at 10:01 AM, revealed she remembered Resident #4 wandered but had never seen the resident doing any exit seeking. CNA #5 stated Resident #4 had made statements about going home or missing his/her dog, and she tried to distract or redirect the resident at those times by giving him/her snacks or just sitting and talking to him/her. Further interview revealed Resident #4 had a Wander Guard in place, and staff knew to keep an eye out for residents with Wander Guard bracelets on. Interview with the Center Nurse Executive (CNE) on 04/20/2022 at 2:00 PM, revealed he had received a call from LPN #5 on 09/06/2021, who told him Resident #4 had pulled the fire alarm and went out the door on 100 Hall. He revealed LPN #5 had informed him Resident #4 had gotten to the parking lot of the restaurant in front of the facility and LPN #2 and LPN #5 had ran to get him/her. Per the CNE, he immediately went to the facility, where LPN #5 had assessed Resident #4 with no concerns identified, after his/her return to the facility. Continued interview revealed he assessed Resident #4 and completed a skin assessment, and had completed a change in condition/Situation, Behavior, and Assessment-Recommendation (SBAR). Per the CNE, staff had made the Advanced Practical Registered Nurse (APRN), Physician and resident's family aware of the event. The CNE further revealed after Resident #4 eloped, the facility ensured there was 1:1 supervision with family or a staff member; and then every fifteen (15) minute checks of the resident had been initiated. Additional interview revealed the CNE was aware Resident #4 had wandered but had been easily redirected. He also stated he had not been aware of Resident #4 had a history of elopement prior to admission. Interview with the Center Executive Director (CED) on 04/20/2022 at 1:28 PM, revealed he had received a notification from the fire alarm company via a phone call that a facility fire alarm had been triggered. He revealed he called the facility immediately and the receptionist informed him that a resident had gotten outside. Per the CED, he immediately went to the facility and initiated an action plan after the incident occurred. Continued interview revealed there had been an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting with the staff and Medical Director on 09/07/2021. He stated no other residents had attempted elopement and the facility had placed a covering on the door to distract a resident from what was going on outside. The CED revealed he and the CNE initiated an elopement investigation on the day of the elopement and interviewed the staff on duty. Further interview revealed it had been determined Resident #4 pulled the fire alarm which deactivated the locked doors allowing the resident to access the outside. The CED further revealed Resident #4 wandered the facility prior to the elopement; however, had made no attempts to exit the facility as he/she had been easily redirected. In addition, he stated the facility had no knowledge Resident #4 had ever attempted to elope. The facility alleged the following was implemented to remove the Immediate Jeopardy and correct the deficiency on 09/09/2021: 1. Resident #4 was returned to the facility on [DATE] and was assessed for injuries. No injuries were identified, and the Physician and responsible party were notified. 2. A body audit was completed on 09/06/2021 by a licensed nurse with no injuries noted. The Physician and responsible party were notified by a licensed nurse on 09/06/2021 with new orders received. 3. An assessment was completed of Resident #4 by a licensed nurse which included vital signs which had been in the usual range for the resident. Resident #4 was noted by a licensed nurse to move all extremities without difficulty and without complaints of pain or discomfort. 4. Resident #4's elopement assessment was reviewed and updated on 09/07/2021 by the Center Nurse Executive. The Wander Guard on the resident had been checked to ensure it was working properly by the licensed nurse on 09/07/2021. 5. Social Services, the CNE or CED interviewed Resident #4 and the resident stated he/she just wanted to go home to see his/her dog. Resident #4 had a BIMS score of five (5). 6. Resident #4's care plan/Kardex was updated on 09/06/2021 by the CNE to include review of elopement evaluation and Wander Guard. 7. RN and LPN Charge Nurses immediately completed a visual validation of the facility's resident census check. All residents, 69 of 69 were present inside the facility. This was completed on 09/06/2021 at 7:20 PM. 8. Maintenance director checked all doors to ensure they were functioning correctly. 9. Staff interviews regarding the elopement were conducted by the CNE and or CED with staff who had been working at the time of the event on 09/06/2021. 10. Record review of elopement assessments, care plans, and Kardex's was conducted on all residents residing in the facility. 69 of 69 facility residents records were reviewed starting 09/07/2021 and completed on 09/07/2021 by the CNE, Unit Managers, RN and/or LPN to identify any new elopement risks and determine whether the care plan and Kardex reflected the current needs of the resident. The elopement risk evaluations for all at risk residents, care plans and Kardex's were reviewed and updated by the licensed nurse. 11. Staff re-education was immediately initiated by the CED, CNE, NPE, Unit Managers and Licensed Nurses beginning on 09/07/2021. All remaining staff members and newly hired staff members completed education prior to reporting for their next assigned shifts. The re-education for all staff included: (A.) Review of Center Policies on elopement prevention and management to include exiting the facility to determine that a resident was not outside the facility, and including securing the fire doors when the alarm was sounding. (B.) Supervision needs of residents assessed as at risk for elopement. (C.) Review of the facility policy for following each resident's person-centered care plan or Kardex regarding residents at risk for elopement. (D.) All employees including contract employees were to complete a posttest to validate their learning. A passing score of 100% was required. Staff and contract employees not available were to be provided the re-education by the CNE, Resource Nurse, Unit Managers and/or Licensed Nurses, and complete a posttest upon the day of their return to work before providing care. (E.) All newly hired employees and contract employees were to have the elopement education by the CNE, HR/Payroll, Resource Nurse, Unit Managers and or Licensed Nurses and complete a posttest during orientation. 12. Elopement drills were completed over three (3) different shifts from 09/07/2021 through 09/08/2021, with no concerns identified. Elopement Drills were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the facility's QAPI Committee. 13. Fire Drills were completed over three (3) shifts on 09/07/2021 with no concerns identified. Fire drills were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 14. Interviews of five (5) random staff members daily regarding interventions on care plan for residents who were at risk of elopement were to be completed by the CNE, CED, Charge Nurses and Unit Managers, daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 15. Visual Observation Audits were to be conducted by the CNE, CED Department Managers to determine if staff were following the residents' plan of care to ensure residents who were at risk for elopement were not allowed to exit the facility without supervision. The Visual Observation Audits were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 16. An Ad Hoc QAPI Committee meeting was held on 09/07/2021 with the Medical Director, for recommendations in developing the action plan including audits, re-education, and compliance monitors for residents at risk for elopement. Results of the elopement drills were to be reviewed daily by the Administrator and CNE for follow up with staff. 17. Elopement drills were to be reviewed at the QAPI Committee meetings monthly for six (6) months for any additional follow up and or in servicing until the issues were resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI Committee members might include Administrator, DON, ADON, Admissions and Marketing Coordinator, Social Services Director, Reimbursement Manager, Maintenance Director, Nurse Practice Educator, and Nutrition Services Director. The State Agency verified the facility's action plan had been implemented and the deficiency was corrected on 09/09/2021: 1. Review of the facility's investigation, timeline of events and Resident #4's every fifteen (15) minute check log initiated 09/06/2021 at 6:45 PM, confirmed staff assisted the resident back into the facility. Review of a Change in Condition (CIC) Evaluation dated 09/06/2021 revealed Resident #4 was assessed by the Center Nurse Executive (CNE) on 09/06/2021. Continued review of the CIC revealed the responsible party had been made aware of the incident on 09/06/2021 at 6:49 PM, and the APRN was made aware at 6:55 PM on that date. 2. Review of a Skin Check and a CIC Evaluation dated 09/06/2021 at 7:54 PM revealed LPN #5 and the CNE completed a full body audit of Resident #4. The resident's responsible party was made aware on 09/06/2021 at 6:49 PM and the APRN was made aware at 6:55 PM. 3. Review of the CIC dated 09/06/2021 at 7:54 PM revealed LPN #5 and the CNE completed a head-to-toe assessment of Resident #4, and the resident was found to have no injuries, and voiced no pain or concerns. The resident's vital signs were obtained and were within normal limits for him/her. 4. Review of Resident #4's Elopement Risk Evaluation dated 09/07/2021 and completed by the CNE, revealed the resident had been assessed as at risk for elopement. Review of the Progress Note dated 09/06/2021 at 7:00 PM and signed by the CNE, revealed Resident #4's Wander Guard bracelet had been checked and determined to be functioning properly when the resident was returned to the facility. 5. Review of the General Progress Note dated 09/07/2021 at 2:40 PM, revealed an interview with Resident #4 had been completed by Social Services. Interview with the Social Services staff person on 05/03/2022 at 2:40 PM, revealed she interviewed Resident #4 about exiting the facility and the resident told her he/she had recently lost his/her spouse and son, and the resident was feeling down. She revealed Resident #4 wanted to see his/her dog and was going to walk home. 6. Review of Resident #4's elopement care plan dated 05/24/2021 and the CNA Kardex dated 09/13/2021, revealed the care plan and the CNA Kardex were revised on 09/06/2021 by the CNE to include the following interventions: 1:1 monitoring as needed; visual checks of the resident every fifteen (15) minutes; compassionate care visits as needed; and activities to provide an animated puppy to comfort resident. 7. Review of the facility's Midnight Census Report dated 09/06/2021 at 7:00 PM, confirmed a head count of all facility residents had been conducted by licensed staff and the CNE. Review revealed the head count determined all 69 of 69 facility residents were present. 8. Review of the facility's Daily Check Sheet confirmed door checks had been completed by the Maintenance Director on 09/06/2021 through 09/10/2021. Interview with the Maintenance Director on 04/20/2022 at 2:07 PM, revealed he completed daily door checks beginning on 09/06/2021 through 09/10/2021 with no issues identified. 9. Review of the facility investigation revealed witness statements were obtained from staff who had been working when Resident #4 exited the facility on 09/06/2021. 10. Review of the Assessment History for Elopement revealed the Elopement Assessments were completed for 69 of 69 facility residents on 09/07/2021 by the CNE with no new elopement risks identified. 11. Review of the facility's education rosters revealed education had been provided for the facility staff by the CNE regarding the following facility policies and procedures: Elopement Prevention and Management; Supervision needs for residents at risk for elopement; and Person-Centered Care Plan. Review of the facility education post-tests, dated 09/07/2021 through 09/09/2021, revealed education had been provided for facility staff with a posttest completed and this was ongoing with new hires and or contracted staff. Interview on 05/03/2022: at 1:20 PM with LPN #3; LPN #9 at 1:25 PM; with CNA #3 at 1:30 PM; CNA #11 at 4:05 PM; and CNA #12 at 4:18 PM revealed they had all received education provided by the NPE and CNE on what to do if there was a missing resident, on updating residents' care plans/Kardexes, on elopement drills, and fire drills. The staff interviewed revealed all had completed a posttest after receiving the education. Interview with the NPE on 05/03/2022 at 2:49 PM revealed she provided education on the facility's policy and procedure regarding resident elopement and the educated staff had taken a posttest. Per interview, she had also provided the education and posttests for new employees as well as agency/contracted staff during their orientation process. Interview with RN #2 at 3:05 PM, revealed he had a hire date of 04/25/2022 and was currently in orientation. He revealed he had received education from the CNE, NPE and the maintenance person who all had gone over the facility's elopement process and drills, and fire drills. Interview with CNA #13 on 04/25/2022 at 10:24 AM, revealed she was hired on 04/22/2022, and was a contract agency employee. Per interview, 04/25/2022 was her third day of working at the facility. She stated she had received education from the NPE during her orientation process on the facility's elopement process, on following the residents' Kardex and on supervising residents who wandered. 12. Review of the facility's Logbook Documentation revealed Elopement Drills had been conducted 09/07/2021 through 03/10/2022 across all shifts including weekends as outlined in the facility's allegation of compliance. Further review revealed the Elopement Drills had been completed as of 03/10/2022. 13. Review of the facility's Logbook Documentation revealed Fire Drills were conducted 09/07/2021 through 03/10/2022 across all shifts including weekends as outlined in the facility's allegation of compliance. Further review revealed the Fire Drills had been completed as of 03/10/2022. Interview with the Maintenance Director on 04/20/2022 at 2:07 PM, confirmed the elopement and fire drills were conducted over three (3) shifts o [TRUNCATED]

Based on observation, interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs which had been identified in the comprehensive assessment. Review of Resident #4's Comprehensive Care Plan revealed the facility care planned the resident as at risk for elopement with interventions which included encouraging the resident's participation in activity preferences; allowing him/her to express his/her feelings, providing empathy and reassurance, and diverting the resident attention if he/she was near exits or doorways. On 09/06/2021 at approximately 6:32 PM, Resident #4 pulled the fire alarm on the 100 Hall on the East Unit, which caused the magnetic locking mechanism on the doors to automatically disengage allowing he resident to leave the facility without supervision of staff. The facility's staff followed its protocol for fire alarms, checked rooms discovering Resident #4 was not present on his/her unit. The facility's receptionist observed Resident #4 outside the front of the building walking towards a fast-food restaurant located there which was approximately three hundred and fifty (350) feet from the facility. Staff immediately went to assist Resident #4 to return to the facility, and staff helped the resident back into the building at 6:38 PM. The facility's failure to ensure the Comprehensive Care Plan was developed and implemented has caused or is likely to cause serious injury, harm impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 04/27/2022 and determined to exist on 09/06/2021, at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F689. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, F689 and determined to continue until 09/09/2021. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. The findings include: Review of the facility policy titled, Person Centered Care Plan, revised 07/01/2019, revealed the facility would develop and implement a baseline person centered care plan within forty-eight (48) hours for each resident admitted which instructions needed to provide effective care and person centered care that met the professional standards for quality care, Per review, the Comprehensive Person Centered Care Plan was the individualized care plan developed within seven (7) days of the completion of the comprehensive assessment of each resident. Further review revealed the Comprehensive Care Plan was to include measurable objectives and timetables to meet a resident's medical, nursing, nutrition and mental and psychosocial needs identified during the comprehensive assessments. Review of Resident #4's closed record revealed the facility admitted the resident on 05/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #4 as severely cognitively impaired as evidenced by the Brief Interview for Mental Status (BIMS) score of five (5). Continued review of the Admission MDS Assessment revealed the facility additionally assessed Resident #4 as independent with transfers and ambulation, and to have exhibited wandering for one (1) to three (3) days during the assessment period. Review of Resident #4's Comprehensive Care Plan, dated 05/24/2021, revealed the facility had care planned the resident to be at risk for elopement related to Dementia and Cognitive Loss. Review of the care plan revealed the goal was for Resident #4 to not attempt to leave the facility without an escort through the next review's target date of 09/15/2021. Continued review revealed interventions dated 05/24/2021, which included encouraging Resident #4 to participate in activities of his/her preference, for staff to encourage the resident's participation in activity preferences and allow him/her time to express his/her feelings. Continued review of the interventions revealed staff were to divert Resident #4's attention if he/she was near exits or doorways by giving the resident alternative objects or activities. Further review of the care plan revealed an intervention dated 08/25/2022 noting a Wander Guard monitoring device had been initiated. However, further care plan review revealed no documented evidence the facility had implemented interventions which addressed the need for additional supervision and monitoring required to keep the resident safe. Review of the facility's Certified Nursing Assistant (CNA) Kardex/Care Plan, dated 09/05/2021, revealed no documented evidence of interventions for the Wander Guard bracelet which had been initiated for Resident #4, nor of the supervision level required to keep the resident safe. Review of the facility's initial Elopement Evaluation, dated 05/18/2021, which part of the Nursing Admission Assessment, revealed the facility evaluated Resident #4 as not at risk for elopement. Review of the facility's 06/15/2021 Elopement Evaluation documented by the Center Nurse Executive (CNE) revealed Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the 06/15/2021 Elopement Evaluation revealed the area that asked about a resident exhibiting one (1) or more emotional states or behavior which might result in exit seeking behavior, such as hovering near exits, restlessness or agitation had not been checked; however, none of the above had been checked on the document. Continued review of the Elopement Evaluations for Resident #4, revealed an Evaluation dated 08/25/2021 completed by Licensed Practical Nurse (LPN) #6. Per review, LPN #6 documented Resident #4 had expressed the desire to leave the facility to go home and talked about going on a trip. Review revealed the resident had also attempted to pack his/her personal belongings and had hovered near the facility's exits. Review of Resident #4's General Progress Note, dated 08/25/2021 at 5:01 PM, completed by LPN #6, revealed the resident had been hovering near the facility's front door and talked about going home one way or another. Per review of the 08/25/2021 Note, a Wander Guard bracelet had been initiated and placed on Resident #4. Further review of the Note revealed however, no documented evidence of interventions having been implemented regarding the necessary monitoring and supervision and monitoring of Resident #4 to assist further with preventing the resident from eloping from the facility. Review of the General Nursing Note, dated 09/05/2021 at 5:56 PM documented by LPN #3 revealed Resident #4 had been wandering throughout the building looking for a way out and the resident wanted to go home. Continued review of the 09/25/2021 Note revealed Resident #4 had a Wander Guard bracelet in place to right ankle, and the resident got agitated when staff provided redirection. Further review revealed Resident #4 had requested staff call the cops to come get him/her. In addition, review further revealed Resident #4 had talked to his/her son which had not improved his/her agitation or wandering, checking all doors. Interview on 04/25/2022 at 10:54 AM, with Certified Nursing Assistant (CNA) # 9, revealed Resident #4 had always walked around and been on the go. CNA #9 stated Resident #4 had a Wander Guard bracelet on and staff knew to keep an eye on him/her. Continued interview revealed staff often sat and talked with Resident #4, and took turns sitting with him/her to keep the resident busy. Per CNA #9, the facility's CNE, Center Executive Director (CED), and the Assistant Director of Nursing (ADON) also sat with Resident #4 to keep the resident occupied. Further interview revealed the facility's CNA Care Plan/Kardex was a reference tool for CNAs to know the care they needed to provide for residents. She further revealed however, she could not recall what Resident #4's Kardex had said. Interview on 05/03/2022 at 4:05 PM, with Certified Nurse Assistant (CNA) #11, revealed she remembered Resident #4 wandering around the facility. She revealed Resident #4 had worn a Wander Guard, and his/her name had been in the facility's elopement book in order for staff to know to keep an eye on the resident. Per CNA #11, the facility's CNA Care Plan/Kardex was a reference tool for CNAs to assist with providing care of the residents. Further interview revealed she did not recall any interventions for Resident #4 related to supervision needs/levels or for monitoring the resident having been in place prior to the elopement. She further revealed she thought supervision needs for wandering residents would have been located on the Kardex though. Interview on 05/03/2022 at 4:18 PM, with CNA #12 revealed Resident #4 wandered around the facility; however, she had never seen Resident #4 trying to exit seek. She revealed Resident #4 had worn a Wander Guard and had been at risk for elopement so staff kept an eye on the resident when he/she had wandered. Further interview revealed a wandering resident should have been on increased supervision and that should have been on the resident's Kardex. She further revealed she could not remember what Resident #4's Kardex said though regarding supervision Interview on 05/03/2022 at 2:36 PM, with the Business Office Manager (BOM) and former Activity Director, revealed the facility had provided Resident #4 with an activity apron to keep him/her busy, but the resident seldom used it. She revealed the activity and nursing staff fixed Resident #4's hair by rolling or curling it. She revealed Resident #4 had nails done often more than weekly. She revealed Resident #4 liked sitting out on the veranda and staff would sit with him/her. The BOM revealed the CED, CNE, ADON and other staff would sit with her on most days. Interview on 05/03/2022 at 2:10 PM, with MDS Nurse #2 revealed MDS staff were responsible for developing and revising residents' care plans on admission, quarterly, annually, and with a significant change in the resident(s). Per interview, the staff nurses updated residents' care plans if there were changes in a resident's status or condition between the MDS Assessment intervals. She revealed all Physician's orders were reviewed daily and residents' care plans revised if needed. Continued interview revealed there had been an at risk for elopement care plan in place for Resident #4; however, no interventions were in place on the care plan to address supervision and monitoring of the resident even though he/she wandered constantly daily and had made remarks about going home. MDS Nurse #2 further stated Resident #4 should have had those types of interventions in place. Interview on 05/03/2022 at 2:21 PM, with the Center Nurse Executive (CNE) revealed Resident #4 wandered the facility, but was easily redirected by staff. He stated he felt Resident #4's care plan had contained the appropriate interventions prior to the elopement as the resident had not tried to actually exit the building. Interview on 05/03/2022 at 2:35 PM, with the Center Executive Director (CED) revealed Resident #4's risk for elopement care plan supervision level had been adequate prior to the resident's elopement from the facility. The CED stated the supervision level was adequate as the the facility had no knowledge of Resident #4 having ever attempted to elope before. The facility alleged the following was implemented to remove the Immediate Jeopardy and correct the deficiency on 09/09/2021: 1. Resident #4 was returned to the facility on [DATE] and was assessed for injuries. No injuries were identified, and the Physician and responsible party were notified. 2. A body audit was completed on 09/06/2021 by a licensed nurse with no injuries noted. The Physician and responsible party were notified by a licensed nurse on 09/06/2021 with new orders received. 3. An assessment was completed of Resident #4 by a licensed nurse which included vital signs which had been in the usual range for the resident. Resident #4 was noted by a licensed nurse to move all extremities without difficulty and without complaints of pain or discomfort. 4. Resident #4's elopement assessment was reviewed and updated on 09/07/2021 by the Center Nurse Executive. The Wander Guard on the resident had been checked to ensure it was working properly by the licensed nurse on 09/07/2021. 5. Social Services, the CNE or CED interviewed Resident #4 and the resident stated he/she just wanted to go home to see his/her dog. Resident #4 had a BIMS score of five (5). 6. Resident #4's care plan/Kardex was updated on 09/06/2021 by the CNE to include review of elopement evaluation and Wander Guard. 7. RN and LPN Charge Nurses immediately completed a visual validation of the facility's resident census check. All residents, 69 of 69 were present inside the facility. This was completed on 09/06/2021 at 7:20 PM. 8. Maintenance director checked all doors to ensure they were functioning correctly. 9. Staff interviews regarding the elopement were conducted by the CNE and or CED with staff who had been working at the time of the event on 09/06/2021. 10. Record review of elopement assessments, care plans, and Kardex's was conducted on all residents residing in the facility. 69 of 69 facility residents' records were reviewed starting 09/07/2021 and completed on 09/07/2021 by the CNE, Unit Managers, RN and/or LPN to identify any new elopement risks and determine whether the care plan and Kardex reflected the current needs of the resident. The elopement risk evaluations for all at risk residents, care plans and Kardex's were reviewed and updated by the licensed nurse. 11. Staff re-education was immediately initiated by the CED, CNE, NPE, Unit Managers and Licensed Nurses beginning on 09/07/2021. All remaining staff members and newly hired staff members completed education prior to reporting for their next assigned shifts. The re-education for all staff included: (A.) Review of Center Policies on elopement prevention and management to include exiting the facility to determine that a resident was not outside the facility and including securing the fire doors when the alarm was sounding. (B.) Supervision needs of residents assessed as at risk for elopement. (C.) Review of the facility policy for following each resident's person-centered care plan or Kardex regarding residents at risk for elopement. (D.) All employees including contract employees were to complete a posttest to validate their learning. A passing score of 100% was required. Staff and contract employees not available were to be provided the re-education by the CNE, Resource Nurse, Unit Managers and/or Licensed Nurses, and complete a posttest upon the day of their return to work before providing care. (E.) All newly hired employees and contract employees were to have the elopement education by the CNE, HR/Payroll, Resource Nurse, Unit Managers and or Licensed Nurses and complete a posttest during orientation. 12. Elopement drills were completed over three (3) different shifts from 09/07/2021 through 09/08/2021, with no concerns identified. Elopement Drills were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the facility's QAPI Committee. 13. Fire Drills were completed over three (3) shifts on 09/07/2021 with no concerns identified. Fire drills were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 14. Interviews of five (5) random staff members daily regarding interventions on care plan for residents who were at risk of elopement were to be completed by the CNE, CED, Charge Nurses and Unit Managers, daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 15. Visual Observation Audits were to be conducted by the CNE, CED Department Managers to determine if staff were following the residents' plan of care to ensure residents who were at risk for elopement were not allowed to exit the facility without supervision. The Visual Observation Audits were to be conducted daily for two (2) weeks including weekends, then three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly for one (1) month then as determined by the QAPI Committee. 16. An Ad Hoc QAPI Committee meeting was held on 09/07/2021 with the Medical Director, for recommendations in developing the action plan including audits, re-education, and compliance monitors for residents at risk for elopement. Results of the elopement drills were to be reviewed daily by the Administrator and CNE for follow up with staff. 17. Elopement drills were to be reviewed at the QAPI Committee meetings monthly for six (6) months for any additional follow up and or in servicing until the issues were resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI Committee members might include Administrator, DON, ADON, Admissions and Marketing Coordinator, Social Services Director, Reimbursement Manager, Maintenance Director, Nurse Practice Educator, and Nutrition Services Director. The State Agency verified the facility's action plan had been implemented and the deficiency was corrected on 09/09/2021: 1. Review of the facility's investigation, timeline of events and Resident #4's every fifteen (15) minute check log initiated 09/06/2021 at 6:45 PM, confirmed staff assisted the resident back into the facility. Review of a Change in Condition (CIC) Evaluation dated 09/06/2021 revealed Resident #4 was assessed by the Center Nurse Executive (CNE) on 09/06/2021. Continued review of the CIC revealed the responsible party had been made aware of the incident on 09/06/2021 at 6:49 PM, and the APRN was made aware at 6:55 PM on that date. 2. Review of a Skin Check and a CIC Evaluation dated 09/06/2021 at 7:54 PM revealed LPN #5 and the CNE completed a full body audit of Resident #4. The resident's responsible party was made aware on 09/06/2021 at 6:49 PM and the APRN was made aware at 6:55 PM. 3. Review of the CIC dated 09/06/2021 at 7:54 PM revealed LPN #5 and the CNE completed a head-to-toe assessment of Resident #4, and the resident was found to have no injuries, and voiced no pain or concerns. The resident's vital signs were obtained and were within normal limits for him/her. 4. Review of Resident #4's Elopement Risk Evaluation dated 09/07/2021 and completed by the CNE, revealed the resident had been assessed as at risk for elopement. Review of the Progress Note dated 09/06/2021 at 7:00 PM and signed by the CNE, revealed Resident #4's Wander Guard bracelet had been checked and determined to be functioning properly when the resident was returned to the facility. 5. Review of the General Progress Note dated 09/07/2021 at 2:40 PM, revealed an interview with Resident #4 had been completed by Social Services. Interview with the Social Services staff person on 05/03/2022 at 2:40 PM, revealed she interviewed Resident #4 about exiting the facility and the resident told her he/she had recently lost his/her spouse and son, and the resident was feeling down. She revealed Resident #4 wanted to see his/her dog and was going to walk home. 6. Review of Resident #4's elopement care plan dated 05/24/2021 and the CNA Kardex dated 09/13/2021, revealed the care plan and the CNA Kardex were revised on 09/06/2021 by the CNE to include the following interventions: 1:1 monitoring as needed; visual checks of the resident every fifteen (15) minutes; compassionate care visits as needed; and activities to provide an animated puppy to comfort resident. 7. Review of the facility's Midnight Census Report dated 09/06/2021 at 7:00 PM, confirmed a head count of all facility residents had been conducted by licensed staff and the CNE. Review revealed the head count determined all 69 of 69 facility residents were present. 8. Review of the facility's Daily Check Sheet confirmed door checks had been completed by the Maintenance Director on 09/06/2021 through 09/10/2021. Interview with the Maintenance Director on 04/20/2022 at 2:07 PM, revealed he completed daily door checks beginning on 09/06/2021 through 09/10/2021 with no issues identified. 9. Review of the facility investigation revealed witness statements were obtained from staff who had been working when Resident #4 exited the facility on 09/06/2021. 10. Review of the Assessment History for Elopement revealed the Elopement Assessments were completed for 69 of 69 facility residents on 09/07/2021 by the CNE with no new elopement risks identified. 11. Review of the facility's education rosters revealed education had been provided for the facility staff by the CNE regarding the following facility policies and procedures: Elopement Prevention and Management; Supervision needs for residents at risk for elopement; and Person-Centered Care Plan. Review of the facility education post-tests, dated 09/07/2021 through 09/09/2021, revealed education had been provided for facility staff with a posttest completed and this was ongoing with new hires and or contracted staff. Interview on 05/03/2022: at 1:20 PM with LPN #3; LPN #9 at 1:25 PM; with CNA #3 at 1:30 PM; CNA #11 at 4:05 PM; and CNA #12 at 4:18 PM revealed they had all received education provided by the NPE and CNE on what to do if there was a missing resident, on updating residents' care plans/Kardexes, on elopement drills, and fire drills. The staff interviewed revealed all had completed a posttest after receiving the education. Interview with the NPE on 05/03/2022 at 2:49 PM revealed she provided education on the facility's policy and procedure regarding resident elopement and the educated staff had taken a posttest. Per interview, she had also provided the education and posttests for new employees as well as agency/contracted staff during their orientation process. Interview with RN #2 at 3:05 PM, revealed he had a hire date of 04/25/2022 and was currently in orientation. He revealed he had received education from the CNE, NPE and the maintenance person who all had gone over the facility's elopement process and drills, and fire drills. Interview with CNA #13 on 04/25/2022 at 10:24 AM, revealed she was hired on 04/22/2022, and was a contract agency employee. Per interview, 04/25/2022 was her third day of working at the facility. She stated she had received education from the NPE during her orientation process on the facility's elopement process, on following the residents' Kardex and on supervising residents who wandered. 12. Review of the facility's Logbook Documentation revealed Elopement Drills had been conducted 09/07/2021 through 03/10/2022 across all shifts including weekends as outlined in the facility's allegation of compliance. Further review revealed the Elopement Drills had been completed as of 03/10/2022. 13. Review of the facility's Logbook Documentation revealed Fire Drills were conducted 09/07/2021 through 03/10/2022 across all shifts including weekends as outlined in the facility's allegation of compliance. Further review revealed the Fire Drills had been completed as of 03/10/2022. Interview with the Maintenance Director on 04/20/2022 at 2:07 PM, confirmed the elopement and fire drills were conducted over three (3) shifts on 09/07/2021 and 09/08/2021 and continued until 03/10/2022 as outlined in the facility's plan. Further interview revealed the elopement and fire drills were conducted on different shifts and weekends. Interview on 05/03/2022: at 1:20 PM with LPN #3; at 1:25 PM with LPN #9; with CNA #3 at 1:30 PM; with CNA #11 at 4:05 PM and CNA #12 at 4:18 PM, confirmed they had all participated in the facility's fire and elopement drills. 14. Review of the facility's Staff Interviews Form confirmed five (5) random staff members had completed an interview sheet regarding interventions on the care plan for residents who are at risk for elopement. Review revealed this had completed on 02/21/2022 by the CNE. 15. Review of the facility's form, Visual Observation of Staff Caring for Elopement Risk Residents, revealed audits had been completed by the CNE to determine that staff were following the residents' plan of care to ensure residents who were at risk of elopement were not allowed to exit the facility without supervision. Review revealed this had been completed on 02/21/2022. 16. Review of the facility's QAPI Committee meeting roster, dated 09/07/2021 revealed an ad-hoc QAPI meeting was held to obtain recommendations for developing the action plan including audits, re-education of staff, and compliance monitors for residents at risk for elopement. Interview with the CED on 05/03/2022 at 2:18 PM, revealed an ad-hoc QAPI meeting was held with facility staff and the Medical Director on 09/07/2021. He revealed the QAPI Committee met on a monthly basis. 17. Review of additional QAPI meeting rosters for meetings held on 10/20/2021, 11/17/2021, 12/15/2021, 01/27/2022, 02/15/2022 and 03/16/2022 revealed elopement drills were reviewed. Continued review revealed the QAPI Committee members present for the various monthly meetings included all or some of the following staff: the Administrator, DON, Assistant DON (ADON), Admissions and Marketing Coordinator, Social Services Director, Reimbursement Manager, Maintenance Director, NPE, and Nutrition Services Director. In addition, review revealed the Medical Director had been present for all of the QAPI Committee meetings.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure its abuse policies were implemented for one (1) of eighteen (18) sampled residents (Residents #54). State Registered Nurse Aide (SRNA) #2 alleged she witnessed SRNA #1 putting her hand against Resident #54's mouth and nose pushing down, while stating, Do not [***] ing spit on me again, on 01/12/2020 at approximately 1:15 PM. However, SRNA #2 failed to immediately notify the Charge Nurse or administrative staff of what she had witnessed as per facility Policy. SRNA #2 did inform SRNA #3 of what she had witnessed, and SRNA #3 informed SRNA #4 of the allegation. SRNA #4 then reported the allegation to Licensed Practical Nurse (LPN) #1 on 01/12/2020 at approximately 2:20 PM. LPN #1 notified the Assistant Director of Nursing (ADON) via telephone on 01/12/2020 at approximately 2:53 PM. However, there was no documented evidence the facility Policy was implemented related to reporting the allegation to State Agencies within the two (2) hour timeframe, conducting a thorough investigation or protecting residents from abuse pending an investigation. The allegation was not reported to the State Agencies until 01/15/2020, when the allegation was further investigated, three (3) days after the alleged abuse was witnessed. Additionally, the alleged perpetrator, SRNA #1, continued to work on 01/12/2020 and 01/13/2020, providing direct care, allowing for the potential for further abuse. (Refer to F-609 and F-610) The facility's failure to implement its policies and procedures regarding reporting, and investigating allegations of abuse, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy had been removed 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19, revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. All reports of suspected abuse must also be reported to the patient's family and attending physician. Upon receiving the information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will enter the allegation into the Risk Management System (RMS) and report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made. Further, an investigation will be initiated within twenty-four (24) hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented within RMS and the facility will ensure documentation of witnessed interviews. The Center will protect patients from further harm during an investigation. Review of Resident #54's medical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) indicating severe cognitive impairment. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse allegedly occurred on 01/12/2020 at approximately 1:15 PM involving Resident #54 . According to the Investigation, LPN #1 called the ADON on 01/12/2020 at 2:53 PM, and asked him to speak with SRNA #1 and SRNA #2 about the care provided to Resident #54. Per the Investigation, on 01/12/2020, after the call from LPN #1, the ADON phoned SRNA #2, who alleged SRNA #1 put her hand to Resident #54's mouth and said, Don't spit on me. On 01/12/2020, the ADON also phoned SRNA #1, and SRNA #3 and obtained verbal Statements. After obtaining the Verbal Statements, the ADON and CED felt the allegation was a lack of professionalism, and did not identify this as an allegation of abuse. The facility failed to further investigate and failed to report the allegation to State Agencies. In addition, SRNA #1, the alleged perpetrator, continued to work as scheduled. Further review of the facility's Investigation, revealed on 01/14/2020, SRNA #2 notified the CED of a different version of the situation related to Resident #54, which included profane language and possible physical abuse. SRNA #2 was instructed to come to the facility for further interview and to give a written Statement. Per the Investigation, SRNA #2's Written Statement obtained on 01/15/2020, was inconsistent with the Verbal Statement obtained on 01/12/2020. Further the Investigation revealed on 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 said to Resident #54, Do not [***] ing spit on me again. SRNA #2 further alleged SRNA #1 put her hands on the resident's mouth and nose and it looked like she pushed onto the resident's face. Continued review of the Investigation, revealed on 01/15/2020, when the ADON and the CED determined this was an allegation of abuse, the alleged perpetrator, SRNA #1, was suspended, which was three (3) days after the alleged incident was witnessed. SRNA #2 was also suspended on 01/15/2020 for not immediately reporting the allegation of abuse to her direct supervisor on 01/12/2020. The facility reported the allegation to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM; the Office of Inspector General (OIG/ the SSA) on 01/15/2020, at 3:49 PM; and Resident #54's Physician and Son on 01/15/2020 at 4:00 PM. The State Agencies were notified of the allegation, three (3) days after the alleged incident was witnessed. Interview on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), revealed he was the ADON at the time of the alleged violation on 01/12/2020, involving Resident #54. Per interview, the facility Abuse Prohibition Policy was not implemented related to reporting, and investigating allegations of abuse, nor was the Policy implemented related to protecting residents after the allegation of abuse related to Resident #54. Per interview, during the facility's investigation it was identified SRNA #2 failed to immediately notify the Charge Nurse or administrative staff of the allegation on 01/12/2020, as per Policy. Continued interview with the Interim DON, revealed the facility's Policy was not implemented related to initiating a thorough investigation as Verbal Statements obtained on 01/12/2020 from staff involved (SRNA #1, SRNA #2, and SRNA #3) were not validated by these staff members in order to ensure accuracy, and neither he or the CED identified the allegation as an abuse allegation from the Verbal Statements. Per interview, therefore the allegation was not reported to State Agencies within two (2) hours as per Policy. He stated, after further investigation on 01/15/2020, Written Statements were obtained which were inconsistent with the Verbal Statements obtained on 01/12/2020, and the facility did identify the incident as an allegation of abuse. Additional interview revealed as a result of the facility failing to implement the written facility policy related to abuse, SRNA #1, the alleged perpetrator continued to work the rest of her shift on 01/12/2020 and also worked her scheduled shift on 01/13/2020, allowing for the potential for further abuse. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed he acknowledged the facility's written Policy was not implemented related to reporting abuse, investigating abuse, and protecting residents from further potential abuse related to the allegation of abuse for Resident #54. Per interview, the alleged abuse witnessed on 01/12/2020 related to Resident #54 should have been immediately reported to the Charge Nurse, and CED, as per Policy. Further, the allegation should have been reported to State Agencies within two (2) hours, as per Policy. Additional interview revealed there should have been a thorough investigation immediately initiated and SRNA #1, the alleged perpetrator, should have been immediately removed from direct resident care and suspended on 01/12/2020 pending an investigation. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional Vice President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, Admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the RMS Event Summary Report, dated 01/15/2020, revealed the Interim DON (previous ADON) entered the alleged allegation of abuse related to Resident #54. The Summary Report also included Resident #54's date of birth, room number, primary nurse's name, event location, and notification to the Physician, family and the Police Department. Interview with the Interim DON (previous ADON), on 03/06/2020 at 2:56 PM, revealed he did in fact enter the event into the Risk Management System on 01/15/2020. 7. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, revealed OIG was notified on 01/15/2020 at 3:00 PM, of the 01/12/2020 alleged incident of physical/verbal abuse involving Resident #54. The allegation was also reported to APS and the Ombudsman on 01/15/2020 at 3:00 PM. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did fax the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, related to the allegation involving Resident #54 to the appropriate State Agencies on 01/15/2020. 8. Review of the AdHOC QAPI Meeting Minutes and Signature Page dated 01/15/2020, revealed the CED, ADON, Medical Director, and Social Services did meet to discuss and review the 01/12/2020 incident of alleged abuse involving Resident #54. Per the Meeting Minutes, discussion included interventions to resolve potential Immediate Jeopardy (IJ) situation; immediate action plan for IJ removal; review of the investigation; review of the QAPI Audits; review of the Education; and review of the Abuse Policy and reporting guidelines with emphasis on a thorough investigation, timely reporting, and following policy. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she did attend the QAPI meeting on 01/15/2020. She stated there was discussion related to the allegation of abuse related to Resident #54 from the 01/12/2020 incident. Per interview, the team discussed a plan to resolve the situation. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he did attend the QAPI meeting on 01/15/2020 related to the allegation of abuse involving Resident #54. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he conducted the QAPI Meeting on 01/15/2020 to review the initial report of the allegation of abuse, and come up with a plan to abate the immediacy of the potential Jeopardy. He further stated QAPI also reviewed the Abuse policy and reporting guidelines. 9. Review of the Skin Check Assessment, dated 01/16/2020 at 7:23 PM, revealed LPN #7 completed the assessment with no concerns noted. Phone interview was attempted with LPN #7 on 03/06/2020 at 10:00 AM; however, the nurse could not be reached. 10. Review of Resident #54's Comprehensive Centered Care Plan, revealed an update by the CRC on 01/17/2020, to state if the resident exhibits increased behaviors such as spitting or hitting, ensure safety of resident and reproach as resident allows. Further review revealed provide resident with opportunities for choice during care/activities to provide sense of control. Review of Resident #54's Kardex, revealed an update on 01/17/2020 to include behaviors of spitting and interventions if spitting occurs. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she updated Resident #54's Comprehensive Centered Care Plan and Kardex on 01/17/2020. She stated she added interventions related to the resident's increase in behaviors related to spitting. 11. Review of Resident Interviews Sheets, revealed all residents that were interviewable were interviewed on 01/15/2020. The following questions were asked to interviewable residents: 1) Do staff meet your needs?; 2) Do staff treat you like you would want to be treated?; 3) Are staff friendly when meeting your needs?; 4) Has any staff member ever spoken harshly to you?; and 5) Are you fearful of any staff member? The Resident Interviews Sheets included: Interviewer name; Resident name; and the date. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she assisted with resident interviews on 01/15/2020. She stated none of the residents she interviewed had any concerns with care. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he assisted with interviewing residents on 01/15/2020, and the residents had no concerns. Interview with LPN #4, on 03/06/2020 at 12:10 PM, revealed she assisted with interviewing residents on 01/15/2020. She further stated no residents voiced concerns related to any abuse at the facility. 12. Review of skin assessments completed on 01/16/2020, revealed thirty-three (33) resident skin assessments were completed out of a total of seventy-two (72) residents with no concerns noted. The skin assessments were completed for all residents with a BIMS score of seven (7) or below. Interview with LPN #6, on 03/06/2020 at 12:10 PM, revealed she assisted with performing skin assessments on residents on 01/16/2020. She further stated there were no signs of abuse with the skin assessments she completed. Interview with Registered Nurse (RN) #1, on 03/06/2020 at 1:03 PM, revealed she helped perform skin assessments on residents on 01/16/2020. She stated all shifts were helping. Per interview, she saw no signs of abuse for residents with the skin assessments she completed. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed on 01/16/2020, he and the licensed nurses performed skin assessments on all residents with a BIMS score of seven (7) or below to determine injury associated with possible abuse. 13. Review of the education and post-test documents, revealed the CDE and ADON received education related to the Abuse Policy and reporting requirements on 01/17/2020, which was provided by the CQS. Interview with Interim DON (previous ADON) on 03/06/2020 at 1:56 PM, revealed he was educated by the CQS on 01/17/2020. He stated the education included the Abuse Policy, and reporting requirements, Per interview, he also had to complete a pre and post-test. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he received education regarding the Abuse Policy and reporting requirements on 01/17/2020 by the CQS. Further interview revealed he also completed pre and post tests. Interview with the CQS, on 03/06/2020 at 2:15 PM, revealed she did provide education on the Abuse Policy and reporting requirements to the ADON and CDE on 01/17/2020. She stated they also had to also complete pre and post tests. 14. Review of the education and post-test documents, revealed the CRC and NPE were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and the ADON. Interview with the with the NPE, on 03/06/2020 at 12:13 PM; and the CRC on 03/06/2020 at 1:47 PM, revealed the Interim DON (previous ADON) and CDE re-educated them related to the Abuse Policy and reporting requirements on 01/17/2020. Per interview they also had to complete a pre and post test. 15. Review of Education sign in sheets and Pre-Test and Post-Test for nursing, therapy, dietary, housekeeping, laundry and maintenance staff related to Abuse and reporting requirements, validated seventy-four (74) out of one-hundred (100) staff were educated on 01/16/2020 and 01/17/2020. The education was completed by the CED, CRC, NPE, Social Services, and ADON. Further review revealed staff that were not educated during that timeframe were not able to work until they had been educated. The facility did not have any agency staff. Interview with the CRC, on 03/06/2020 at 2:47 PM, revealed she provided education to staff on all shifts related to the Abuse policy and reporting requirements. Per interview, education started on 01/16/2020 and by 01/17/2020 seventy-four (74) out of one-hundred (100) staff members had received the education. She further stated any staff member who had not been educated by 01/17/2020 had to receive the education prior to working their next shift. She stated she came in at 10:00 PM at night and worked until 1:00 AM to ensure staff on the off shifts were educated on some dates in January 2020. Interview with LPN #6, on 03/06/2020 at 12:10 PM; Housekeeper #1, on 03/06/2020 at 12:25 PM; SRNA #5, on 03/06/2020 at 12:28 PM; and Maintenance, on 03/06/2020 at 1:36 PM, revealed they received education related to the facility Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff revealed they completed a post-test to validate understanding of the Abuse policy and reporting requirements. Interview with the CED, on 03/06/2020 at 3:30 PM, revealed the facility had no agency staff at this time. Review of the Staff Education for new employee orientation, revealed training related to the facility Abuse policy and reporting requirements was included. Interview with the CRC, on 03/06/2020 at 2:47 PM, revealed new staff will receive training related to the facility Abuse policy and reporting requirements during orientation. 16. Review of Education Sheets signed by the CNE, revealed the CNE did receive re-education on Abuse Policy and reporting requirements along with a pre and post test on 01/27/2020. The CNE was unavailable for interview as she had resigned and no longer worked at the facility. 17. Review of the Abuse/Neglect Employee Interview Sheets, revealed starting on 01/17/2020, Social Services, CED, ADON, CRC, NPE and Licensed Nurses, performed interviews with five (5) employees daily across all shifts x two (2) weeks, then interviewed employees as per the outlined schedule in the AoC. Interview with the Social Worker, on 03/06/2020 at 1:40 PM, revealed she assisted with staff interviews, and if there were any concerns she would report them to her CED immediately. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she assisted with staff interviews on all three (3) shifts and any concerns were being brought to the CED to be addressed immediately. Interview with the CED, on 03/06/2020 on 2:03 PM, revealed employee interview audits were brought to the morning meeting to discuss any concerns and address any issues with the employee interviews related to abuse. Interview with Registered Nurse (RN) #2, on 03/06/2020 at 12:13 PM; SRNA #6, on 03/06/2020 at 12:16 PM; Dietary Manager, on 03/06/2020 at 12:30 PM; Dietary Aide #1, on 03/06/2020 at 12:50 PM; and RN #1, on 03/06/2020 at 1:03 PM, revealed they had been interviewed by administration regarding the facility Abuse Policy and reporting requirements. 18. Review of the Resident Body Audit Sheets, starting 01/17/2020, revealed the audits for all residents were completed for two (2) weeks daily. Review of the Weekly Skin Assessments, for the months of February and March 2020, revealed they were completed for all residents ongoing. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed the facility had a schedule of which residents were due for weekly skin assessments. Per interview, the licensed nurse performed the skin assessment and entered it into the electronic health record. Further, several administrative staff members were reviewing the skin assessments to ensure they were completed and addressing any concerns. He stated this was an ongoing compliance audit. Interview with the NPE, on 03/06/2020 at 2:10 PM, revealed she was auditing skin assessments completed by the licensed nurses and was utilizing the audit form provided by administration. She further stated if there were any concerns she ensured the CED or Interim DON (previous ADON) were aware in order for the concern to be addressed immediately. 19. Review of the Abuse/Neglect Resident Interview Sheets, completed by administration or licensed nurses, revealed on 01/17/2020 the facility started interviewing five (5) residents daily across all shifts and this was ongoing per the schedule outlined in the AoC. Per review, residents had no reports of abuse or neglect. Interview with the NPE, on 03/06/2020 at 12:13 PM; Social Services, on 03/06/2020 at 1:40 PM; and the CRC, on 03/06/2020 at 1:47 PM, revealed they had been assisting with the resident abuse interviews as per the schedule outlined in the AoC. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he was ensuring the interviews for the residents were being completed. Per interview, the r (TRUNCATED)

Based on interview, record review, review of the facility's Policy, and review of the Kentucky Revised Statues (KRS), it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility and to State Agencies for one (1) of eighteen (18) sampled Residents (Resident #54). State Registered Nurse Aide (SRNA) #2 alleged she witnessed SRNA #1 put her hand against Resident #54's mouth and nose, push down, and say, Do not [***] ing spit on me again, on 01/12/2020 at approximately 1:15 PM. However, SRNA #2 failed to report the alleged violation to Licensed Practical Nurse (LPN) #1, (assigned nurse) or to administrative staff. SRNA #2 did inform SRNA #3 of the alleged violation and SRNA #3 reported the alleged violation to SRNA #4. SRNA #4 reported the alleged violation to LPN #1 on 01/12/2020 at approximately 2:20 PM. LPN #1 immediately notified the Assistant Director of Nursing (ADON) of the allegation, and the ADON obtained Verbal Statements from SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020. However, from the Verbal Statements obtained on 01/12/2020, the Center Executive Director (CED) and the ADON did not identify there was an allegation of abuse. On 01/14/2020, SRNA #2 heard SRNA #1 worked at the facility on 01/13/2020, and questioned the CED as to why SRNA #1 had not been suspended. Subsequently, Written Statements were obtained from staff on 01/15/2020, and Administration identified the incident as an allegation of abuse. SRNA #1, the alleged perpetrator, worked the remainder of her shift on 01/12/2020, and worked on 01/13/2020, providing direct resident care, allowing for the potential for further abuse until she was suspended on 01/15/2020. The State Agencies were notified of the alleged abuse on 01/15/2020, three (3) days after SRNA #1 witnessed the alleged abuse. (Refer to F-607, and F-610). The facility's failure to ensure all allegations of abuse were reported immediately to the Administrator and to State Agencies within two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy had been removed 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19 revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. All reports of suspected abuse must also be reported to the patient's family and Attending Physician. Upon receiving the information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will enter the allegation into the Risk Management System (RMS) and report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made to local law enforcement, and other agencies as required. The Center will protect patients from further harm during an investigation. Review of KRS Chapter 209.020, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of Resident #54's clinical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) which indicated severe cognitive impairment. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, faxed to the Office of Inspector General (OIG, the SSA) on 01/15/2020 at 3:00 PM, revealed an alleged incident of physical/verbal abuse occurred on 01/12/2020 involving Resident #54. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse related to Resident #54 allegedly occurred on 01/12/2020 at approximately 1:15 PM. LPN #1 called the ADON on 01/12/2020 at 2:53 PM requesting him to reach out to SRNA #1 and SRNA #2 related to the care provided to Resident #54. Per the Investigation, on 01/12/2020 after talking to LPN #1, the ADON called SRNA #2 who explained she and SRNA #1 assisted Resident #54 to bed and while SRNA #1 was assisting the resident to sit up in the bed, the resident spit on SRNA #1. SRNA #2 alleged SRNA #1 then put her hand to the resident's mouth and stated, Don't spit on me. SRNA #2 did not report what she had witnessed to the nurses. Further, the ADON called SRNA #1 who stated she put her hand up in the air close to the resident's mouth in order to deflect further attempts to spit on her and told the resident, Stop trying to spit on me. Continued review of the Investigation Report, revealed after obtaining Verbal Statements from LPN #1, SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020, the ADON and CED did not identify there was an allegation of abuse, but felt it was a lack of professionalism. However, Written Statements were not obtained in order to ensure correct information was received. Per the Investigation, on 01/14/2020, SRNA #2, notified the CED of a different version of the situation related to Resident #54 involving profane language and possible physical abuse. SRNA #1 was then instructed to come to the facility for further interview and to give a Written Statement. Per the Investigation, SRNA #2's Written Statement dated 01/15/2020, was inconsistent with the Verbal Statement obtained on 01/12/2020. On 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 put her hands on Resident #54's mouth and nose and it looked like she pushed onto the resident's face. After receiving this allegation from SRNA #2, the ADON and the CED determined this was an allegation of abuse. Additional review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 01/15/2030 after the allegation was reported to the CED. SRNA #2 was also suspended on 01/15/2020 for not reporting the allegation of abuse to her direct supervisor on 01/12/2020. Per the Investigation, Resident #1 was interviewed on 01/15/2020 and did not recall anyone being physically or verbally mean to him/her. The facility reported the allegation to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM, and reported the allegation to Resident #54's Physician and Son on 01/15/2020 at 4:00 PM. Interview with SRNA #3, on 03/04/2020 at 9:18 AM, revealed on the afternoon of 01/12/2020 at approximately 2:00 PM, SRNA #2 told her SRNA #1 had put her hand over Resident #54's mouth and cursed at the resident. She stated she advised SRNA #2 to report the incident to the charge nurse. SRNA #3 further stated she (SRNA #3) did not report the incident to the nurse, but she did repeat what SRNA #2 told her to SRNA #4 and SRNA #4 immediately told LPN #1. SRNA #3 stated the ADON called her shortly after that and took a Verbal Statement. Further interview revealed she felt this was an allegation of verbal and physical abuse. Interview with LPN #1, on 03/04/2020 at 9:45 AM, revealed, she was approached by SRNA #4, on 01/12/2020 at approximately 2:20 PM, who reported an alleged incident involving Resident #54, SRNA #1 and SRNA #2. She stated SRNA #4 reported that SRNA #1 allegedly put her hand over Resident #54's mouth because the resident was trying to spit. LPN #1 stated SRNA #4 did not witness the incident, but was notified of the incident by SRNA #3. LPN #1 further stated she immediately called the ADON to report the allegation. Continued interview with LPN #1, verified she was assigned to Resident #54 on the afternoon of 01/12/2020; however, she stated SRNA #2 did not report any allegation of abuse to her on the afternoon of 01/12/2020, nor was she aware Resident #54 was having behaviors that afternoon. Per interview, it was not okay to put your hand over a resident's mouth, as this would be considered physical abuse and any allegation of abuse of any kind should be reported immediately to the direct Supervisor, the ADON, Director of Nursing (DON) or CED and the perpetrator should be immediately removed from resident care. Per interview, SRNA #1 had already clocked out for the day when SRNA #4 notified her of the incident on 01/12/2020. Further interview revealed any allegation of abuse was to be reported to the CED and then to State Agencies within two (2) hours. Phone interview with SRNA #2, on 03/04/2020 at 10:50 AM, revealed on 01/12/2020, she (SRNA #2) and SRNA #1 were assigned to Resident #54. Per interview, on that date at approximately 1:15 PM, they were using the Hoyer lift (mechanical lift) to transfer the resident to bed, and once the resident was in the bed, SRNA #1 asked the resident to sit up so she could remove the lift pad. Per interview, when the resident sat up he/she spit on SRNA #1. SRNA #2 stated, SRNA #1 then put her hand over the resident's mouth and nose and pushed down and said, Do not ever [***] ing spit on me again. SRNA #2 further stated she told SRNA #3 what happened, but she did not report the incident to LPN #1 because she and SRNA #1 were best friends inside and outside of work, and she did not think LPN #1 would do anything. Per interview, she realized now she should have notified another nurse in the building or called the ADON to report the incident. Additional interview with SRNA #2, revealed she did receive a call later that day on 01/12/2020 at approximately 3:30 PM, from the ADON asking for her Verbal Statement via telephone. She stated she told the ADON, that SRNA #1 put her hand over the resident's mouth and nose and pushed down and said, Do not ever [***] ing spit on me again. SRNA #2 further stated, on 01/14/2020, she found out SRNA #1 had worked the previous day and then called the CED to inquire as to why SRNA #1 had not been suspended. Per interview, the CED then went to find the ADON, and both the CED and ADON spoke to her on the phone. SRNA #2 stated during the three (3) way phone conversation she again re-iterated what she witnessed on 01/12/2020, and was then accused of giving a different Statement as compared to the Verbal Statement she gave the ADON on 01/12/2020. Per interview, she was instructed to come to the facility the following day on 01/15/2020 to provide a Written Statement. Interview with SRNA #1, on 03/05/2020 at 8:11 AM, revealed on 01/12/2020, she was assigned to Resident #54 and SRNA #2 assisted her with transferring the resident to bed with the Hoyer Lift. Per interview, once the resident was in the bed, she asked the resident to sit up so she could remove the lift pad out from under him/her and the resident sat up and spit in her face. She further stated she placed her hand up between her and the resident's mouth to prevent her/him from spitting on her, and told the resident not to spit on her again. Further interview revealed she received a call from the ADON on 01/12/2020, after she had left the facility and he told her it was reported that she put her hands on a resident's mouth. SRNA #1 denied she put her hand over the resident's mouth and nose, and also denied using foul language or abusing Resident #54. Additional interview revealed she was suspended a few days later on 01/15/2020. Review of the time clock data revealed SRNA #1 continued to work on 01/12/2020 until clocking out at 1:59 PM and also worked 01/13/2020 from 05:53 AM until 1:58 PM. Interview on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), revealed he was the ADON at the time of the alleged violation on 01/12/2020 involving Resident #54. Per interview, on 01/12/2020 at approximately 2:53 PM, he received a call from LPN #1 who reported SRNA #4 informed her that SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and also witnessed SRNA #1 to tell the resident not to spit on her. He stated LPN #1 told him that SRNA #4 heard this from SRNA #3. Continued interview revealed he then phoned SRNA #1, SRNA #2 and SRNA #3 for Verbal Statements. He stated based on his interviews with SRNA #1, SRNA #2 and SRNA #3, on 01/12/2020, he and the CED did not identify this as an abuse allegation, and therefore did not report the allegation to State Agencies or ensure SRNA #1 was suspended. However, he stated on 01/14/2020, there was a three (3) way phone conversation with the Interim DON, SRNA #2 and the CED, and SRNA #2 alleged during the phone conversation that SRNA #1 put her hand over Resident #54's mouth and nose and told the resident to stop [***] ing spitting on her. Additional interview revealed SRNA #2 should have immediately reported the allegation of abuse on 01/12/2020, and the alleged perpetrator, SRNA #1, should have been immediately removed from resident care and suspended to prevent further potential abuse to Resident #54 or other residents. The Interim DON verified SRNA #1 did continue to work the rest of the shift on 01/12/2020 after the alleged abuse was witnessed and also worked on 01/13/2020 before she was suspended on 01/15/2020. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed the alleged abuse witnessed on 01/12/2020 related to Resident #54 should have been reported to the charge nurse or administrative staff immediately by SRNA #2. Further, SRNA #1, the alleged perpetrator, should have been immediately removed from direct care and suspended pending an investigation. Per interview, the State Agencies should have been notified of the allegation within two (2) hours, as per Policy and as per State Regulation. However, the CED stated when the incident was relayed to him on 01/12/2020, by the Interim DON, who was the ADON at the time, abuse was not mentioned. Additional interview revealed as a result of staff failing to immediately report the allegation of abuse, SRNA #1 continued working on 01/12/2020 and on 01/13/2020 allowing for the potential for further abuse. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional Vice President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, Admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the RMS Event Summary Report, dated 01/15/2020, revealed the Interim DON (previous ADON) entered the alleged allegation of abuse related to Resident #54. The Summary Report also included Resident #54's date of birth, room number, primary nurse's name, event location, and notification to the Physician, family and the Police Department. Interview with the Interim DON (previous ADON), on 03/06/2020 at 2:56 PM, revealed he did in fact enter the event into the Risk Management System on 01/15/2020. 7. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, revealed OIG was notified on 01/15/2020 at 3:00 PM, of the 01/12/2020 alleged incident of physical/verbal abuse involving Resident #54. The allegation was also reported to APS and the Ombudsman on 01/15/2020 at 3:00 PM. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did fax the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, related to the allegation involving Resident #54 to the appropriate State Agencies on 01/15/2020. 8. Review of the AdHOC QAPI Meeting Minutes and Signature Page dated 01/15/2020, revealed the CED, ADON, Medical Director, and Social Services did meet to discuss and review the 01/12/2020 incident of alleged abuse involving Resident #54. Per the Meeting Minutes, discussion included interventions to resolve potential Immediate Jeopardy (IJ) situation; immediate action plan for IJ removal; review of the investigation; review of the QAPI Audits; review of the Education; and review of the Abuse Policy and reporting guidelines with emphasis on a thorough investigation, timely reporting, and following policy. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she did attend the QAPI meeting on 01/15/2020. She stated there was discussion related to the allegation of abuse related to Resident #54 from the 01/12/2020 incident. Per interview, the team discussed a plan to resolve the situation. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he did attend the QAPI meeting on 01/15/2020 related to the allegation of abuse involving Resident #54. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he conducted the QAPI Meeting on 01/15/2020 to review the initial report of the allegation of abuse, and come up with a plan to abate the immediacy of the potential Jeopardy. He further stated QAPI also reviewed the Abuse policy and reporting guidelines. 9. Review of the Skin Check Assessment, dated 01/16/2020 at 7:23 PM, revealed LPN #7 completed the assessment with no concerns noted. Phone interview was attempted with LPN #7 on 03/06/2020 at 10:00 AM; however, the nurse could not be reached. 10. Review of Resident #54's Comprehensive Centered Care Plan, revealed an update by the CRC on 01/17/2020, to state if the resident exhibits increased behaviors such as spitting or hitting, ensure safety of resident and reproach as resident allows. Further review revealed provide resident with opportunities for choice during care/activities to provide sense of control. Review of Resident #54's Kardex, revealed an update on 01/17/2020 to include behaviors of spitting and interventions if spitting occurs. Interview with the CRC, on 03/06/2020 at 1:47 PM, revealed she updated Resident #54's Comprehensive Centered Care Plan and Kardex on 01/17/2020. She stated she added interventions related to the resident's increase in behaviors related to spitting. 11. Review of Resident Interviews Sheets, revealed all residents that were interviewable were interviewed on 01/15/2020. The following questions were asked to interviewable residents: 1) Do staff meet your needs?; 2) Do staff treat you like you would want to be treated?; 3) Are staff friendly when meeting your needs?; 4) Has any staff member ever spoken harshly to you?; and 5) Are you fearful of any staff member? The Resident Interviews Sheets included: Interviewer name; Resident name; and the date. Interview with the SSD, on 03/06/2020 at 1:40 PM, revealed she assisted with resident interviews on 01/15/2020. She stated none of the residents she interviewed had any concerns with care. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed he assisted with interviewing residents on 01/15/2020, and the residents had no concerns. Interview with LPN #4, on 03/06/2020 at 12:10 PM, revealed she assisted with interviewing residents on 01/15/2020. She further stated no residents voiced concerns related to any abuse at the facility. 12. Review of skin assessments completed on 01/16/2020, revealed thirty-three (33) resident skin assessments were completed out of a total of seventy-two (72) residents with no concerns noted. The skin assessments were completed for all residents with a BIMS score of seven (7) or below. Interview with LPN #6, on 03/06/2020 at 12:10 PM, revealed she assisted with performing skin assessments on residents on 01/16/2020. She further stated there were no signs of abuse with the skin assessments she completed. Interview with Registered Nurse (RN) #1, on 03/06/2020 at 1:03 PM, revealed she helped perform skin assessments on residents on 01/16/2020. She stated all shifts were helping. Per interview, she saw no signs of abuse for residents with the skin assessments she completed. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:56 PM, revealed on 01/16/2020, he and the licensed nurses performed skin assessments on all residents with a BIMS score of seven (7) or below to determine injury associated with possible abuse. 13. Review of the education and post-test documents, revealed the CDE and ADON received education related to the Abuse Policy and reporting requirements on 01/17/2020, which was provided by the CQS. Interview with Interim DON (previous ADON) on 03/06/2020 at 1:56 PM, revealed he was educated by the CQS on 01/17/2020. He stated the education included the Abuse Policy, and reporting requirements, Per interview, he also had to complete a pre and post-test. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he received education regarding the Abuse Policy and reporting requirements on 01/17/2020 by the CQS. Further interview revealed he also completed pre and post tests. Interview with the CQS, on 03/06/2020 at 2:15 PM, revealed she did provide education on the Abuse Policy and reporting requirements to the ADON and CDE on 01/17/2020. She stated they also had to also complete pre and post tests. 14. Review of the education and post-test documents, revealed the CRC and NPE were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and the ADON. Interview with the with the NPE, on 03/06/2 (TRUNCATED)

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to initiate a thorough investigation in response to an alleged violation of abuse, allowing for further potential abuse for one (1) of eighteen (18) sampled residents (Residents #54). On 01/12/2020 at approximately 1:15 PM, State Registered Nursing Aide (SRNA) #1 and SRNA #2 entered Resident #54's room to assist the resident to bed after lunch. SRNA #2 alleged Resident #54 spit on SRNA #1, and then SRNA #1 put her hand against the resident's mouth and nose, pushed down, and stated, Do not [***] ing spit on me again. SRNA #2 failed to report the allegation to Licensed Practical Nurse (LPN) #1 (assigned nurse), or to Administration, but did tell SRNA #3 what she had witnessed. SRNA #3 apprised SRNA #4 of the allegation, and SRNA #4 reported the allegation to LPN #1 on 01/12/2020 at approximately 2:20 PM. Although LPN #1 immediately notified the Assistant Director of Nursing (DON) of the allegation, only Verbal Statements were obtained from staff including SRNA #1, SRNA #2, and SRNA #3, with no validation from these staff members that the Verbal Statements written down by the ADON were accurate. From the Verbal Statements obtained on 01/12/2020, the Center Executive Director (CED) and the Assistant DON felt there was lack of professionalism and did not identify there was an allegation of abuse, and did not further investigate. Facility Policy was not followed related to initiating a thorough investigation within twenty-four (24) hours as to whether abuse or neglect occurred, nor was facility Policy followed related to thoroughly documenting the investigation into the Risk Management System (RMS) to include documentation of witnessed interviews. On 01/14/2020, when SRNA #2 heard SRNA #1 worked at the facility on 01/13/2020, she questioned the CED as to why the SRNA had not been suspended. Subsequently written Statements were obtained from staff on 01/15/2020, and Administration identified the incident as an allegation of abuse and suspended SRNA #1 on that date. Due to the facility's failure to initiate a thorough investigation, SRNA #1, the alleged perpetrator, continued to work the remainder of her shift on 01/12/2020, and on 01/13/2020, providing direct resident care, allowing for the potential for further abuse (Refer to F-607, and F-609). The facility's failure to ensure thorough investigations were initiated for alleged violations of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy was removed on 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance. The findings include: Review of the facility's Abuse Prohibition Policy, dated 07/01/19 revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. An investigation will be initiated within twenty-four (24) hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management System with documentation of witnessed interviews. Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. Further, the Center will protect patients from further harm during an investigation. Review of Resident #54's medical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (05) out of fifteen (15) indicating severe cognitive impairment. Observation of Resident #54, on 03/04/2020 at 8:30 AM, revealed the resident was sitting up in a geriatric chair, watching television, with no behaviors noted. Interview was attempted with the resident; however, the resident was not interviewable. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, faxed to the Office of Inspector General (OIG) on 01/15/2020 at 3:00 PM, revealed an alleged incident of physical/verbal abuse occurred on 01/12/2020 involving Resident #54. Review of the facility's Investigation Report, dated 01/15/2020, signed by the CED, revealed an incident of physical/verbal abuse related to Resident #54 allegedly occurred on 01/12/2020 at approximately 1:15 PM. Per the Investigation, LPN #1 called the ADON on 01/12/2020 at 2:53 PM, and asked him to reach out to SRNA #1 and SRNA #2 about the care provided to Resident #54. On 01/12/2020, after the call from LPN #1, the ADON called SRNA #2, who stated that she and SRNA #1 were assisting Resident #54 to bed and the resident spit on SRNA #1 while she was helping the resident to sit up in order for the Hoyer lift pad to be removed. SRNA #2 alleged SRNA #1 put her hand to Resident #54's mouth and stated, Don't spit on me. SRNA #2 finished her shift and did not report any allegations to the nurses. On 01/12/2020, the ADON called SRNA #1 and she informed the ADON, that she (SRNA #1) put her hand up in the air close to the resident's mouth to deflect any further attempts to spit on her and told the resident, Stop trying to spit on me. Further review of the facility's Investigation Report, revealed after speaking with LPN #1, SRNA #1, SRNA #2 and SRNA #3 on 01/12/2020 and obtaining Verbal Statements, the ADON and CED did not identify this as an allegation of abuse, but felt it was a lack of professionalism. However, there was no documented evidence SRNA #1, SRNA #2 and SRNA #3 validated or signed the Statements obtained by the ADON on 01/12/2020. Per the Investigation, on 01/14/2020, SRNA #2 called and notified the CED of a different version of the situation related to Resident #54 which involved profane language and possible physical abuse. SRNA #2 was instructed to come to the facility for further interview and to give a Written Statement. SRNA #2's Written Statement on 01/15/2020 was inconsistent with the Verbal Statement obtained on 01/12/2020. On 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 stated to Resident #54, Do not [***] ing spit on me again. SRNA #2 further alleged that SRNA #1 put her hands on the resident's mouth and nose and it looked like she pushed onto the resident's face. On 01/15/2020, the ADON and the CED determined this was an allegation of abuse. The allegation was reported to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM. Resident #54's Physician and Son were notified on 01/15/2020 at 4:00 PM. Continued review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 01/15/2020, after the allegation was reported to the CED. In addition, SRNA #2 was suspended on 01/15/2020 for not immediately reporting the allegation of abuse to her direct supervisor on 01/12/2020. Per the Investigation, Resident #1 was interviewed on 01/15/2020, and could not recall anyone being physically or verbally mean to him/her. Further review of the Investigation, revealed the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation, and Resident #1 had no signs of injury. Review of SRNA #2's Verbal Statement obtained from the ADON over the phone, dated 01/12/2020, untimed, revealed on 01/12/2020, after SRNA #1 and SRNA #2 assisted the resident to lye down, SRNA #1 asked the resident to sit up, and the resident spit at SRNA #1. SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and tell the resident not to spit on her (SRNA #1), and this was done in a manner which was unprofessional. This Statement was not signed by SRNA #2. Review of SRNA #2's Written Statement, dated 01/15/2020 at 1:47 PM, revealed on 01/12/2020 at 1:15 PM, SRNA #2 witnessed SRNA #1 to put her hand against the resident's mouth and nose, push down, and state, Do not [***] ing spit on me again. Phone interview with SRNA #2, on 03/04/2020 at 10:50 AM, revealed on the afternoon of 01/12/2020, she (SRNA #2) and SRNA #1 were assigned to Resident #54. Per interview, on that date at approximately 1:15 PM, they were using the Hoyer lift (mechanical lift) to transfer the resident to bed. SRNA #2 stated Resident #54 was asked to sit up in order for the lift pad which was under the resident to be removed, and when the resident sat up he/she spit on SRNA #1. Per interview, SRNA #1 then put her hand over the resident's mouth and nose and pushed down and said, Do not ever [***] ing spit on me again. SRNA #2 further stated she informed SRNA #3 of what happened, but she did not report what she had witnessed to LPN #1 because LPN #1 and SRNA #1 were best friends. Further interview with SRNA #2, revealed she did receive a call later that day on 01/12/2020 at approximately 3:30 PM, from the ADON asking for her Verbal Statement via telephone. Per interview, she told the ADON, that SRNA #1 put her hand over the resident's mouth and nose and pushed down and said, Do not ever [***] ing spit on me again. SRNA #2 further stated, on 01/14/2020, she heard that SRNA #1 had worked the previous day and she called the CED to inquire as to why SRNA #1 had not been suspended. She stated the CED then went to find the ADON, and both the CED and ADON spoke to her on the phone. Per interview, during the three (3) way phone conversation she again re-iterated what she witnessed on 01/12/2020, and was accused of giving a different Statement as compared to the Verbal Statement she gave the ADON on 01/12/2020. Per interview, she was asked to come in the following day on 01/15/2020 to provide a Written Statement. Review of SRNA #1's Written Statement, dated 01/15/2020 at 12:45 PM, revealed when she (SRNA #1) and SRNA #2 were assisting Resident #54 to bed, she raised him/her up to remove the lift pad and the resident spit on her. SRNA documented she raised her hand up between her face and the resident to block the resident from spitting and told the resident, Do not spit on me again, and continued with care. Interview with SRNA #1, on 03/05/2020 at 8:11 AM, revealed on 01/12/2020, she was working with SRNA #2 and was assigned to Resident #54. She stated the resident required the use of a Hoyer lift to be transferred to bed. Per interview, once the resident was in the bed, she asked the resident to sit up so she could remove the lift pad out from under him/her. SRNA #1 stated when Resident #54 sat up, he/she spit in her face, so she placed her hand up between herself and the resident's mouth to prevent him/her from spitting on her again, and told the resident not to spit. She stated she received a call from the ADON on 01/12/2020, after she left the facility and he told her it was reported that she put her hands on a resident's mouth. SRNA #1 denied putting her hand over the resident's mouth and nose, and denied using foul language towards the resident. Continued interview revealed she was suspended a few days later on 01/15/2020. Review of the time clock data revealed SRNA #1 continued to work on 01/12/2020 until clocking out at 1:59 PM and also worked 01/13/2020 from 5:53 AM until 1:58 PM. Review of LPN #1's Written Statement, dated 01/15/2020 at 9:06 AM, revealed SRNA #2 reported to SRNA #3, that SRNA #1 had put her hand over Resident #54's mouth, raised her voice and said something to the resident. Further review revealed the allegation was reported to SRNA #4 by SRNA #3, and subsequently SRNA #4 reported the allegation to LPN #1. Interview with LPN #1, on 03/04/2020 at 9:45 AM, revealed, on 01/12/2020 at approximately 2:20 PM, she was approached by SRNA #4, who reported an alleged incident that happened earlier involving Resident #54, SRNA #1 and SRNA #2. LPN #1 stated SRNA #4 reported that SRNA #1 allegedly put her hand over Resident #54's mouth because the resident was trying to spit. Per interview, SRNA #4 had not witnessed the incident, but was notified of the incident by SRNA #3. LPN #1 stated she immediately went back to the nurse's station and called the ADON to report the allegation in order for him to further investigate. She further stated she assessed the resident and saw no injuries or redness. LPN #1 confirmed she was assigned to Resident #54 on the afternoon of 01/12/2020, but SRNA #2 did not report any allegation of abuse to her on the afternoon of 01/12/2020, nor was she aware Resident #54 was having behaviors that afternoon. LPN #1 confirmed she did not obtain written Statements from any staff after being informed of the allegation on 01/12/2020. Further interview revealed SRNA #1 had already left to go home by the time she was notified of the alleged incident. She stated any allegation of abuse was to be reported immediately to the Supervisor, ADON, Director of Nursing (DON) or CED and the perpetrator was to be immediately removed from resident care. Review of SRNA #3's Verbal Statement, undated and untimed, and documented on a paper with no name of the person taking the Statement, revealed, Not seen anything. This Statement was obtained by the ADON on 01/12/2020 per the facility Investigation. This Statement was not signed by SRNA #3. Review of SRNA #3's Written Statement, dated 01/15/2020 at 9:20 AM, revealed SRNA #2 reported to her that SRNA #1 grabbed Resident #54's face and yelled at him/her. Per the Statement, she had no further comments to add, nor did she witness any type of abuse. Interview with SRNA #3, on 03/04/2020 at 9:18 AM, revealed on the afternoon of 01/12/2020 at approximately 2:00 PM, SRNA #2 informed her SRNA #1 had put her hand over Resident #54's mouth and cursed at the resident. Per interview, she advised SRNA #2 to report what she had witnessed to the Charge Nurse. SRNA #3 stated she (SRNA #3) did not report the incident to the nurse, but did tell SRNA #4. SRNA #3 further stated the ADON called her shortly afterwards and took a Verbal Statement. Per interview, it was not okay to put your hands on a resident or curse a resident. She stated she felt this was an allegation of verbal and physical abuse and no one deserved to be abused. Review of SRNA #4's Written Statement, dated 01/15/2020 at 1:00 PM, revealed SRNA #3 reported to her that when SRNA #1 and SRNA #2 were providing care, SRNA #1 grabbed Resident #54's face and yelled at the resident. Per the Statement, SRNA #4 was not there when the incident happened. Phone interview with SRNA #4, on 03/05/2020 at 8:33 AM, revealed on 01/12/2020 at 2:20 PM, SRNA #3 informed her that SRNA #2 had witnessed SRNA #1 grab Resident #54's jaws and scream at the resident. Per interview, she felt it was verbal and physical abuse and immediately reported what she had been told to LPN #1. She stated LPN #1 then called the ADON. She further stated she did not receive a call from anyone on 01/12/2020 asking her for a Statement. Per interview, she was told to submit a Statement on 01/15/2020 via telephone and she signed it the following day on 01/16/2020. Review of the ADON's Written Statement, dated 01/13/2020, untimed, revealed he received a phone call at home on 01/12/2020 at 2:53 PM, regarding an incident that occurred at the facility from LPN #1 on East Station. After the conversation with LPN #1, he placed phone calls to parties involved (SRNA #1, SRNA #2 and SRNA #3) as well as the facility's CED. According to LPN #1, the incident in question was reported to her by SRNA #4, who had heard information from SRNA #3, who was apprised of the situation from SRNA #2. Per the Statement, the event transpired at approximately 1:15 PM to 1:25 PM on 01/12/2020. Further review of the ADON's Statement, revealed a phone interview was conducted on 01/12/2020 at approximately 2:45 PM with SRNA #2, which revealed SRNA #1 asked the resident to sit up, and at that moment the resident spit on SRNA #1. SRNA #2 informed the ADON she saw SRNA #1 put her hand over the resident's mouth and say, Don't you spit on me, in a manner that she felt was unprofessional. Per the Statement, the ADON discussed with SRNA #2 about the delay in reporting any type of incident that she felt was unprofessional. SRNA #2 explained LPN #1 and SRNA #1 were friends, and she felt if it was reported to LPN #1, nothing would transpire as a result. The ADON informed SRNA #2 that there were three (3) other nurses in the facility at the particular time as well as a phone listing of all department heads that were available to be contacted at any time. Additional review of the ADON's Statement, revealed a phone interview was conducted with SRNA #1, on 01/12/2020. SRNA #1 explained Resident #54 spit on her and she put her hand in the air close to the resident's mouth to deflect any further attempts to spit, and at no time did her hand come in contact with the resident's mouth. SRNA #1 informed the ADON, she told the resident, Stop trying to spit on me, and then continued providing care. Per the Statement, the facility CED was notified of the incident via telephone on 01/12/2020 at 3:45 PM. Interview was conducted on 03/04/2020 at 3:17 PM, with the Interim Director of Nursing (DON), who was the ADON at the time of the alleged violation on 01/12/2020, involving Resident #54. The Interim DON stated, on 01/12/2020 at approximately 2:53 PM, he received a call from LPN #1 who reported SRNA #4 informed her that SRNA #2 witnessed SRNA #1 put her hand over Resident #54's mouth and also witnessed SRNA #1 to tell the resident not to spit on her. Per interview, LPN #1 told him that SRNA #4 heard this from SRNA #3. The Interim DON stated he told LPN #1 he would call the staff involved to find out the facts. Continued interview with the Interim DON, revealed he phoned SRNA #2 on 01/12/2020 and was told after Resident #54 spit on SRNA #1, she witnessed SRNA #1 put her hand over the resident's mouth and say, Don't you spit on me, in an unprofessional manner. Per interview, he then phoned SRNA #1 and SRNA #3 for Verbal Statements. Further interview revealed based on his interviews with SRNA #1, SRNA #2 and SRNA #3, on 01/12/2020, he and the CED did not identify this as an abuse allegation, but did identify lack of professionalism. However, he stated on 01/14/2020, there was a three (3) way phone conversation with the Interim DON, SRNA #2 and the CED, and SRNA #2 informed them what the ADON had typed up as her Verbal Statement was incorrect. Per interview, SRNA #2 alleged during the phone conversation that she had already informed the Interim DON, that SRNA #1 put her hand over Resident #54's mouth and nose and told the resident to stop [***] ing spitting on her. Continued interview with the Interim DON, revealed SRNA #2 should have immediately reported the allegation of abuse on 01/12/2020, and the alleged perpetrator, SRNA #1 should have been immediately removed from resident care and suspended to prevent further potential abuse to Resident #54 or other residents. He further verified SRNA #1 did continue to work the rest of the shift on 01/12/2020 after the alleged abuse was witnessed and also worked on 01/13/2020 before she was suspended on 01/15/2020. Additional interview with the Interim DON, revealed the investigation involving Resident #54 was his first abuse investigation and he should have investigated further as to whether abuse or neglect may have occurred as per facility Policy. He stated the Witness Statements he obtained over the phone on 01/12/2020 should have been reviewed and signed by the staff in order to ensure the correct information was documented after the incident. Further, facility Policy was not followed related to thoroughly documenting the investigation into the Risk Management System (RMS) to include documentation of witnessed interviews. Per interview, after the incident, he received re-education related to conducting abuse investigations and also received tools for completing an abuse investigation. Interview with the CED, on 03/06/2020 at 9:06 AM, revealed he acknowledged the facility's written Policy was not implemented related to investigating abuse. Per interview, the alleged abuse witnessed on 01/12/2020 related to Resident #54 was conveyed as lack of professionalism, and abuse was not identified until 01/15/2020 as a result of the facility's failure to ensure a thorough investigation was initiated in a timely manner with Written Statements obtained from staff involved. Additional interview revealed as a result of staff failing to identify the allegation as abuse and failing to promptly initiate a timely and thorough investigation on 01/12/2020, SRNA #1, the alleged perpetrator, continued working on 01/12/2020 and on 01/13/2020, allowing for the potential for further abuse. Per interview, there should be no deviation from the facility's Abuse Prohibition Policy. The facility provided and acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020 that alleged removal of the Immediate Jeopardy (IJ) on 01/18/2020. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On 01/12/2020, the Assistant Director of Nursing (ADON) interviewed SRNAs involved (SRNA #1 and SRNA #2) regarding the incident related to Resident #54. 2. On 01/12/2020, Licensed Practical Nurse (LPN) #2 completed a head to toe assessment of Resident #54 for any signs of abuse with no corrective action required. Resident #54 was calm and resting quietly at the time of the skin assessment, and the resident did not make any statements. 3. On 01/15/2020, the Center Executive Director (CED) notified the Physician and Resident #54's family member of the allegation and the pending investigation. 4. On 01/15/2020, Resident #54 was interviewed by the Social Service Director (SSD) and the resident stated he/she was well taken care of and had no fear of anyone at the facility. 5. On 01/15/2020, Written Witness Statements were obtained from LPN #1, SRNA #1, SRNA #2, SRNA #3 and SRNA #4. 6. On 01/15/2020, the ADON entered the allegation related to Resident #54 that allegedly occurred on 01/12/2020, into the Risk Management System (RMS). 7. On 01/15/2020, the CED reported the allegation involving Resident #54 to Adult Protective Services (APS), Ombudsman, and the Office of Inspector General (OIG). 8. On 01/15/2020, an AdHOC Quality Assurance/Performance Improvement (QAPI) meeting was held related to the allegation of abuse towards Resident #54. Members in attendance included the CED, ADON, Medical Director, and Social Services. Discussion included development of an action plan including assessment and re-education as well as audits and compliance monitors. The Abuse Policy was discussed, with emphasis on a thorough investigation, timely reporting, and following policy. 9. On 01/16/2020, Resident #54 was re-assessed by LPN #7 with no concerns or corrective action. 10. On 01/17/2020, the Clinical Reimbursement Coordinator (CRC) updated Resident #54's Comprehensive Care Plan and Kardex (Nurse Aide Care Plan) to include interventions to safely care for the resident when behaviors such as spitting occurs. 11. On 01/15/2020, the ADON, SSD, Activity Director and Licensed Nurses interviewed all interviewable residents with a Brief Interview for Mental Status (BIMS) of eight (8) and above to determine if they had experienced or witnessed any abuse in the center including physical abuse. No further concerns were noted. 12. On 01/16/2020, the ADON and Licensed Nurses completed skin assessments for all non-interviewable residents with a Brief Interview for Mental Status (BIMS) of seven (7) or below to determine injury associated with possible abuse. There were no abnormal findings from these skin assessments. 13. On or before 01/17/2020, the CED, and ADON, were re-educated related to the Abuse Policy and reporting requirements and completed post-test by the Regional Vice President of Operations (RVPO) or Clinical Quality Specialist (CQS). 14. On or before 01/17/2020, the CRC and Nurse Practice Educator (NPE) were re-educated related to the Abuse Policy and reporting requirements and completed post-tests. The education was provided by the CED and ADON. 15. Starting on 01/16/2020, re-education was provided by the ADON, NPE and CRC for all administrative staff, nursing, therapy, dietary, housekeeping, laundry, and maintenance staff related to the Abuse policy and reporting requirements, to include what constitutes physical and verbal abuse. All staff completed a post-test to validate understanding of the Abuse policy and reporting requirements. By 01/17/2020, seventy four (74) of one hundred (100) employees had been re-educated. Staff not available during this timeframe will be provided re-education and complete a post-test upon day of return to work before providing care by the CED, CRC, NPE, Social Services, or ADON. New staff will be provided education and complete post-tests by the CED, Social Services, CRC, NPE, ADON or CNE during orientation. The facility does not utilize agency staffing at this time. 16. The Center Nurse Executive (CNE) will be re-educated on day of return from Medical Leave by the CED and CQS. 17. On 01/17/2020, Social Services, CED, ADON, CRC, NPE or Licensed Nurses will interview five (5) employees daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then two (2) x per week x four (4) weeks and then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to ensure staff understand the abuse policy including reporting allegations to the CED immediately. Any concerns identified will be addressed at that time. 18. Starting on 01/17/2020, the CNE, ADON, CRC, NPE or Licensed Nurses will complete body audits of all residents daily for two (2) weeks then weekly for ten (10) weeks to ensure no evidence of abuse with corrective action upon discovery. 19. Starting on 01/17/2020, the CNE, Social Services, ADON, CRC, NPE, Activity Director, Admission Director, or Licensed Nurse will interview five (5) residents daily across all shifts x two (2) weeks including weekends and holidays, then three (3) x per week x two (2) weeks, then weekly x four (4) weeks, then every other week x eight (8) weeks, then monthly x one (1) month, then ongoing thereafter as determined by the QAPI committee to determine any issues with staff treatment or abuse while in the center. Any concerns identified will be addressed at that time. 20. Starting on 01/17/2020 and ongoing, the CED and/or CNE will audit abuse investigations daily x two (2) weeks including weekends and holidays; then three (3) per week x two (2) weeks; then weekly x four (4) weeks; then every other week x eight (8) weeks; then monthly x two (2) months; then ongoing thereafter as determined by the QAPI committee to determine that Abuse allegations are reported timely as per the Abuse Policy. Any concerns identified will be addressed at that time. 21. The Regional Executive Director (RED) will review for implementation of the Abuse Policy including reporting abuse allegations timely monthly for six (6) months and ongoing thereafter as determined by QAPI. 22. The QAPI Committee met on 02/19/2020 and discussed the following to ensure ongoing compliance: initial report and information; the abatement plan for IJ removal; resident interviews and findings; staff interviews; AdHOC QAPI; skin checks; staff education; abuse policy; self-reported incidents, and guidelines regarding timely reporting. Findings related to the audits and interviews will be reported to the QAPI committee monthly x six (6) months for further review and recommendation for any additional follow up and/or in-servicing until the concern is resolved and ongoing thereafter as determined by the QAPI Committee. The QAPI committee consists of the CED, CNE, ADON, Medical Director, Social Service, Director Food Service, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and SRNAs. The State Survey Agency validated the implementation of the facility's AoC/IJ Removal Plan as follows: 1. Review of the Written Statement, signed by the ADON, dated 01/13/2020, revealed the ADON phoned SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with the Interim DON (previous ADON), on 03/06/2020 at 1:30 PM, revealed he called SRNAs #1, #2, and #3 on 01/12/2020 to obtain verbal witness statements related to the incident involving Resident #54. Interview with SRNA #1, on 03/05/2020 at 8:01 AM; SRNA#2, on 03/04/2020 at 9:45 AM; and SRNA #3, on 03/04/2020 at 10:05 AM, revealed they received a phone call from the Interim DON (previous ADON) on the afternoon of 01/12/2020 and gave Statements over the phone regarding the 01/12/2020 incident related to Resident #54 2. Review of the Attestation Statement, signed by LPN #2, dated 01/12/2020, revealed she completed a head to toe assessment on Resident #54 for any signs of abuse. Per the Statement, she explained the procedure to the resident, and the resident was calm and resting quietly at the time of the assessment. Further review revealed Resident #54 did not make any statements at the time of the assessment. Review of the Skin Assessment, dated 01/12/2020 at 4:00 PM, completed by LPN #2, revealed no skin issues were noted, and no injuries were noted. Phone interview was attempted with LPN #2, on 03/06/2020 at 8:00 AM; however, the nurse was unable to be reached. 3. Review of Resident #54's Progress Notes, dated 01/15/2020 at 4:00 PM, revealed the CED called the resident's Physician and family member to inform them of the allegation and pending investigation. Interview with the CED, on 03/06/2020 at 2:03 PM, revealed he did call the Physician and Resident #54's family member on 01/15/2020, to report the allegation and pending investigation. 4. Review of the Progress Note, dated 01/15/2020, revealed the SSD interviewed Resident #54 regarding the incident, with no concerns noted. Interview with the SSD, on 03/06/2020 at 2:40 PM, revealed she did interview Resident #54 on 01/15/2020, and had visited him/her several times since the incident. The SSD stated Resident #54 had no concerns, and was pleasant, smiling and had no changes in his/her behavior. 5. Interview with SRNA #2 on 03/04/2020 at 10:46 AM revealed on 01/14/2020 she was asked to come to the facility to write a Written Statement and give an interview related to the incident regarding Resident #54. Interview with SRNA #4 on 03/05/2020 at 8:33 AM; SRNA #1, on 03/05/2020 at 8:06 AM; and SRNA #3 on 03/05/2020 at 9:18 AM, revealed they were asked to provide a written Statement of what they witnessed on 01/12/2020, related to the incident regarding Resident #54. 6. Review of the R (TRUNCATED)

Based on observation, interview, record review, and review of facility policy/procedure, it was determined the facility failed to ensure drugs and biologicals stored in two (2) of three (3) medication carts were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation of the 200 Hall and 300 Hall medication carts, on 01/23/19, revealed eye drops and inhalers were not dated when opened per facility policy. In addition, during an observation of wound care for Resident #15, on 01/24/19, a used multi-use bottle of Normal Saline (NS) was not dated when opened. The findings include: Review of the facility's policy/procedure titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, last revised 10/31/16, revealed once any medication or biological was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication had a shortened expiration date once opened. 1. Observation of the 300 Hall medication cart, on 01/23/19 at 10:00 AM, revealed one (1) [MEDICATION NAME] Inhaler, one (1) vial of Azelastine eye drops, and one (1) vial of Saline nasal spray not dated when opened; and, observation of the 200 Hall medication cart revealed one (1) vial of [MEDICATION NAME] eye drops and one (1) tube of Soothe eye lubrication ointment not dated when opened. Interviews, on 01/23/19, with Licensed Practical Nurse (LPN) #1 at 10:30 AM, LPN #2 at 10:35 AM, and Certified Medication Tech (CMT) at 10:40 AM, revealed the multi-use vials of medications such as eye drops, inhaler, insulin's, etc., were to be dated when opened per facility policy and it was the responsibility of the nurse who opened the medication to date it. Interview with Registered Nurse (RN) #1 at 1:30 PM, revealed eye drops, insulins and inhalers should be dated when opened per the facility's policy. Interview with the Director of Nursing (DON), on 01/24/19 at 12:17 PM, revealed she expected whomever opened the eye drops, insulin or inhalers to date them when opened, and it was the responsibility of whomever opened the medication to date it. 2. Record review revealed the facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed he/she was not interviewable due to moderately impaired cognition with no BIMS score. Further review of the MDS revealed the resident is rarely/never understood. Observation of a wound dressing change for Resident #15, on 01/24/19 at 8:39 AM, revealed a multi-use bottle of Normal Saline (NS) was approximately three/fourths (3/4) empty and was used to clean the wound. Further observation revealed the NS bottle was not dated when opened. Interview with RN #1 at this time revealed she had opened the bottle yesterday, but had not dated it, per policy. She stated she should have dated the bottle. Interview with the DON, on 01/24/19 at 12:22 PM, revealed she expected all multi-dose bottles of irrigations to be dated when opened per facility policy.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure it established and maintained 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 related to hand washing, trash handling or glove changes, for three (3) of twenty-five (25) sampled residents (Residents #3, #15, and #58). Observation during wound care for Resident #3, on 01/23/19, revealed multiple breaks related to aseptic technique during his/her dressing changes. Observation during wound care for Resident #15, on 01/24/19, revealed Registered Nurse (RN) #1 did not wash her hands or change gloves after removing a soiled dressing, or before putting a clean dressing on the resident's wound. Observation during wound care for Resident #58, on 01/24/19, revealed RN #2 failed to follow the facility's policy/procedure regarding hand washing and wound care. The findings include: Review of the facility policy Hand Hygiene, last revised 11/28/17, revealed adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled and after exposure to known or suspected [MEDICAL CONDITION] or infectious diarrhea (i.e., Norovirus) and the use of alcohol based hand rubs for routine decontamination in clinical situations. Per the Centers for Disease Control and Prevention (CDC), when hands are not visible dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. Alcohol based rubs will be placed near entrances and in common areas. The purpose is to improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. Further review revealed to perform hand hygiene: before patient care; before an aseptic procedure; after any contact with blood or other body fluids, even if gloves are worn; and after patient care and after contact with the patient's environment. Review of the facility policy for Wound Dressings, last reviewed 03/01/16, revealed wound dressings are performed using aseptic technique as directed by physician/mid-level provider or standard of practice. The purpose of the policy is to decrease the risk of wound contamination and cross-contamination during dressing changes and to prevent contamination during dressing change. Further policy review revealed to follow the following order for wound dressing change: Use personal protective equipment as indicated, clean over-bed table, place clean barrier on the over-bed table and place supplies on the barrier, introduce yourself to the patient and verify patient identification, explain the procedure and provide privacy, evaluate pain and treat as indicated, position the area to be treated, place a plastic bag for soiled dressing supplies within easy reach, cleanse hands, if the patient has multiple wounds, treat the less contaminated wound first, treat each as a separate procedure, if a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves, open dressing without contamination, keep the dressing/gauze within the open packet and place it directly on top of the barrier, prepare medication/ointment, if indicated, by placing on inner sterile package, expose area to be treated, apply clean gloves, discard dressing and gloves, cleanse hands, apply gloves. Cleanse or irrigate wound as ordered, wipe any excess fluid from the surrounding skin using a dry, gauze wipe. Using a swab or applicator, apply treatment medication as ordered. Apply and secure clean dressing, remove gloves and discard, apply and secure clean dressing, remove gloves and discard. Apply prepared label. Cleanse hands. Unused supplies are discarded or remain dedicated to the patient and stored properly. Open dressings are discarded. Reusable dressing care equipment, like bandage scissors, must be cleaned and disinfected. 1. Record review revealed the facility admitted Resident #3 on 05/11/17 with [DIAGNOSES REDACTED]. Observation of Resident #3's wound care to his/her arterial/venous ulcers on his/her right foot, left foot, and right lower leg, and pressure ulcers to his/her buttocks, on 01/23/19 at 10:04 AM provided by RN #1, revealed she failed to ensure the dressings were placed on a barrier per facility policy. She placed a small piece of wax paper that was not large enough on the overbed table, and the dressings failed to be contained on the wax paper. Further observation revealed RN #1 failed to wash her hands after removing her soiled gloves, and prior to gloving again; prior to donning gloves after returning from outside the room to obtain tape; and in between completing the dressing changes to the resident's legs, and completing dressing changes to pressure ulcers on the resident's buttocks. In addition, she contaminated the dressings on the overbed table by placing a plastic trash bag, that she pulled from her uniform pocket, over the dressings when she realized she had forgotten the tape and had to leave the room. She did not address the contamination when she returned to the room, and instead, observation revealed she added more dressings to the contaminated overbed table/barrier. Further observation revealed RN #1 continued to contaminate pressure wounds on his/her bilateral buttocks by not washing her hands after soiling her gloves, removing her gloves, or donning clean gloves. Also, observation during pressure ulcer care revealed she reached into the resident's bed side table and pulled out skin wipes while still wearing soiled gloves. Interview with RN #1, on 01/24/18 at 12:00 PM, revealed she should have washed her hands more often. She stated she should not have reached into the resident's drawer with dirty gloves. She stated she should not have taken a plastic bag out of her pocket and placed it over the aseptic clean dressing on the overbed table, whenever she had to leave the room. She revealed she should have followed the hand hygiene and dressing change policies, as written. 2. Record review revealed the facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed he/she was not interviewable due to moderately impaired cognition with no BIMS score. Further review of the MDS revealed the resident is rarely/never understood. Observation of wound care, on 01/24/19 at 8:39 AM, revealed a dime size wound to the resident's right forehand, with no drainage noted. RN #1 brought an overbed table into the room and placed the resident's dressing on the table without cleaning the table. She washed her hands, removed the dressing, and cleaned the wound with Normal Saline. Observation revealed she did not wash her hands or change gloves after removing the soiled dressing, or before putting a clean dressing on the wound. Interview with RN #1, on 01/24/19 at 8:45 AM, revealed she should have cleaned the overbed table prior to placing the dressing on it and should have used a barrier. She revealed she should have washed her hands and changed gloves after removing the dirty dressing. Interview with the Infection Control Nurse, on 01/24/19 at 9:27 AM, revealed the staff were educated yearly on Infection Control matters including handwashing, as well as any time during the year if needed. She stated she expected staff to follow the Hand Hygiene and Wound Dressings policy, as written. Interview with the Director of Nursing (DON), on 01/24/19 at 12:22 PM, revealed staff should wash their hands prior to giving care, before applying clean dressings, when gloves were dirty, going from dirty to clean, after care, or prior to touching a resident's personal effects, such as curtains, bed clothes, call light, etc. Always knock on door prior to entering the resident's room. Remove all soiled dressings from the trash can after dressings are completed. She stated she also expected staff to follow the Hand Hygiene and Wound Dressings policy, as written. 3. Record review revealed the facility admitted Resident #58 on 10/26/16 with [DIAGNOSES REDACTED]. Observation of Resident 58's Peg tube dressing change completed by RN #2, on 01/24/19 at approximately 10:30 AM, revealed RN #2 entered Resident #58's room without knocking or identifying herself. Further observation revealed RN #2 did not wash her hands prior to handling the 4x4 gauze for the dressing change. In addition, RN #2 failed to change her gloves or wash her hands after removing the dirty soiled dressing surrounding her/his Peg tube. Further observation revealed RN #2 placed the dirty soiled material in the trash can of the resident's room. She left the dirty soiled material there without disposing of it properly. Interview with RN #2, on 01/24/19 at approximately 10:45 AM, revealed she should have knocked on Resident #58's door prior to entering her/his room. RN #2 stated she should have washed her hands prior to handling the 4x4 gauze, and should have washed her hands and changed gloves after handling the dirty soiled dressing. RN #2 also stated she did not dispose of the dirty soiled materials properly in the waste bins. Interview with the DON, on 01/24/19 at 12:22 PM, revealed staff should wash their hands prior to providing care, before and during changing dressings, when gloves are dirty, going from dirty to clean, and after care. She stated staff should remove all soiled dressings from the resident's trash can after dressings are completed. She stated she also expected staff to follow the Hand Hygiene and Wound Dressings policy, as written.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for one (1) of twenty-five (25) sampled residents (Resident #28). Observation during the survey, on 01/22/19, revealed Resident #28 was sitting upright in his/her bed in a visible puddle of urine for a period of fifteen (15) minutes, after he/she requested assistance from the staff. The findings include: Review of the facility policy, Treatment: Considerate and Respectful, dated 06/01/96, and revised 09/01/13, revealed Genesis Healthcare Center's will promote care for patients in a manner and in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality. Dignity means that in their interactions with patients, staff carry out activities that assist the patient to maintain and enhance his/her self-esteem and self-worth. Purpose: To provide patients the right to a quality of life that supports independent expression, decision making, and respect. Review of the facility policy, Call Lights, dated 06/01/96, and revised 09/01/12, revealed all Genesis Healthcare patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. Record review revealed the facility admitted Resident #28 on 08/11/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/16/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Interview with Resident #28, on 01/22/19 at approximately 11:30 AM, revealed he/she used the call light approximately fifteen (15) minutes ago; however, staff had not come to his/her room to check on him/her. Further interview with the resident revealed it was common to have to wait this long for assistance. He/she stated it bothered him/her to have to wait long periods of time for assistance, and replied What can I do about it? That's just the way it is and it can't be changed. Observation during the interview process revealed he/she was sitting in a small puddle of urine in the bed. Interview with the Administrator, on 01/24/18 at approximately 1:30 PM, revealed he felt like a resident having to wait ten (10) or fifteen (15) minutes for incontinent care was not unreasonable, and was the average amount of time residents usually waited for assistance. The Administrator also stated however, if it bothered the resident to have to wait that long, then that could be a dignity issue.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for one (1) of twenty-five (25) sampled residents (Resident #4). Observation, on 01/22/19 and 01/23/19, revealed Resident #4 did not have his/her call light in reach and was unable to access it in the event he/she needed to call for assistance. The findings include: Review of the facility policy, Call Lights, last reviewed 03/01/16, revealed All Genesis Healthcare patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. Record review revealed the facility admitted Resident #4 on 11/10/17 with [DIAGNOSES REDACTED]. Observation of Resident #4, on 01/22/19 at approximately 10:45 AM, revealed he/she was up in his/her wheelchair and unable to reach his/her call light. During an interview with the resident, a Certified Nurse Aide (CNA) walked into the resident's room to check on him/her. Resident #4 asked the CNA to give him/her the call light, which was hanging off the bed out of his/her reach. The CNA then placed the call light in Resident #4's lap so he/she could reach it. Observation of Resident #4, on 01/23/19 at approximately 8:55 AM, revealed he/she was sitting up in his/her bed. Observation revealed the resident's call light was laying across his/her wheelchair, out of the resident's reach. Interview with the resident revealed he/she did not know where his/her call light was located. Further observation revealed a CNA entered Resident #4's room at approximately 9:06 AM and spoke with the resident briefly, then left the room. Further observation revealed the resident's call light was still in the same location and out of reach after the CNA left the room. Interview with the Administrator, on 01/24/18 at approximately 1:40 PM, revealed it was his expectation that staff ensure all residents have his/her call light in reach at all times, and staff should check to ensure all call lights are in place.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure it must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for one (1) of twenty-five (25) sampled residents (Resident #28). Upon Resident #28's admission to the facility on [DATE], he she was continent of bladder; however, review of the current Minimum Data Set (MDS), dated [DATE], revealed the resident was listed as occasionally incontinent of bladder. The findings include: Review of the facility's policy/procedure Person Centered Care Plan, dated 11/28/16, and revised 03/01/18, revealed a comprehensive, individualized care plan will be developed within seven (7) days after the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. Further review of the facility policy revealed the purpose was to attain and maintain the patient's highest practicable physical, mental and psychosocial well-being. Record review revealed the facility admitted Resident #28 on 08/11/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/16/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of Resident #28's Comprehensive Care Plan, initiated on 09/05/17, and revised 09/05/18, revealed no evidence the facility listed bladder continence/incontinence as a focus area with measurable goals or interventions to ensure goals were met. An attempt to interview the MDS Coordinator, on 01/24/19 at approximately 1:30 PM, revealed she was unable to provide any information. Interview with the Director of Nursing (DON), on 01/24/19 at approximately 2:00 PM, revealed it was her expectation that Resident #28's bladder incontinence should have been care planned to address his/her bladder continence decline, in order to prevent any further decline. She revealed it was the MDS Coordinator's responsibility to ensure the care plan was updated based on the resident's MDS information.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team after each assessment, to include both the comprehensive and quarterly review assessments, for four (4) of twenty-five (25) sampled residents (Residents #1, #48, #51, and #54). The findings include: Review of the facility's policy/procedure Person Centered Care Plan, dated 11/28/16, and revised 03/01/18, revealed a comprehensive, individualized care plan will be developed within seven (7) days after the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. Further review of the facility's policy revealed care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. 1. Record review revealed the facility admitted Resident #1 on 12/22/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/10/19, revealed he/she had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G, revealed he/she required extensive assist of two (2) for transfer and ambulation; however, did not occur during the assessment period. Review of the Comprehensive Care Plan, dated 09/30/16, and revised 01/05/18, revealed the resident was at risk for injury related to a history of falls related to Cardiopulmonary Disease ([MEDICAL CONDITION]), muscle weakness, decreased endurance, attempts to transfer unassisted, and impaired safety awareness. Further review of the care plan revealed the resident does not call for assistance, and prefers to lay close to the edge of the bed. Additional review of the care plan revealed revisions for falls, dated 11/05/18, 11/15/18 and 11/27/18; however, further record review revealed no evidence the care plan was revised after a fall on 11/29/18, according to a Review of the POS [REDACTED] 2. Record review revealed the facility admitted Resident #48 on 08/01/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/18/18, revealed he/she had a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of Section G of the MDS assessment revealed he/she required assist of two (2) staff for transfer and assist of (2) staff with ambulation. Review of the Comprehensive Care Plan, dated 09/21/18, revealed the resident was care planned for injury related to a history of falls, related to impaired standing and gait. Review of the Falls Investigation report, dated 08/04/18, 10/18/18, 11/10/18, and 12/26/18, revealed the resident had falls with injury. Further review of the Comprehensive Care Plan revealed no evidence revisions were made in regard to any of the resident's falls. 3. Record review revealed the facility admitted Resident #51 on 03/28/11 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/18/18, revealed he/she had a BIMS score of three (3), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G, revealed he/she required extensive assist of two (2) for transfer and ambulation; however, did not occur during the assessment period. Review of the Comprehensive Care Plan, dated 05/02/14, and revised 01/13/16, revealed the resident was at risk for injury related to a history of falls, a progressive decline with Dementia with poor safety awareness, increased risk with increased anxiety and agitation, impaired balance, and attempts to self-transfer. Review of the care plan revealed a fall occurred on 08/03/18, with no revisions until 08/28/18. Additional review of the care plan revealed revisions for falls, dated 10/04/18, 10/29/18, and 11/03/18; however, further record review revealed no evidence the care plan was revised after a fall on 12/08/18, according to a Review of the POS [REDACTED] 4. Record review revealed the facility admitted Resident #54 on 02/05/09 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/21/18, revealed he/she had a BIMS score of ninety-nine (99), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G, revealed he/she required extensive assist of three (3) for transfers and ambulation; however, did not occur during the assessment period. Review of the Comprehensive Care Plan, dated 05/30/14, and revised 12/18/18, revealed the resident was at risk for injury related to a history of falls and impaired mobility, lack of safety awareness, and highly impaired hearing. Further review of the care plan revealed no new revisions had been implemented after a fall, dated 10/30/18. An attempt to interview the MDS Coordinator, on 01/24/19 at approximately 1:30 PM, revealed she was unable to provide any information. Interview with the Director of Nursing (DON), on 01/24/18 at approximately 2:00 PM, revealed her expectation was that staff complete an assessment after every fall and new interventions be identified to help prevent falls in the future. She stated the care plan should be updated to reflect these new interventions and just changing the date of revision on current interventions was not sufficient.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for two (2) of twenty-five (25) sampled residents (Resident #3 and Resident #15). Observation, on 01/23/19 and 01/24/19, revealed Registered Nurse (RN) #1 failed to follow the facility's policy/procedure regarding hand washing and wound care. The findings include: Review of the facility policy Hand Hygiene, last revised 11/28/17, revealed adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled and after exposure to known or suspected [MEDICAL CONDITION] or infectious diarrhea (i.e., Norovirus) and the use of alcohol based hand rubs for routine decontamination in clinical situations. Per the Centers for Disease Control and Prevention (CDC), when hands are not visible dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. Alcohol based rubs will be placed near entrances and in common areas. The purpose is to improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. Further review of the facility policy revealed to perform hand hygiene: before patient care; before an aseptic procedure; after any contact with blood or other body fluids, even if gloves are worn; and after patient care and after contact with the patient's environment. Review of the facility policy for Wound Dressings, last reviewed 03/01/16, revealed wound dressings are performed using aseptic technique as directed by physician/mid-level provider or standard of practice. The purpose of the policy is to decrease the risk of wound contamination and cross-contamination during dressing changes and to prevent contamination during dressing change. Further review of the facility policy revealed to follow the following order for wound dressing change: Use personal protective equipment as indicated, clean over-bed table, place clean barrier on the over-bed table and place supplies on the barrier, introduce yourself to the patient and verify patient identification, explain the procedure and provide privacy, evaluate pain and treat as indicated, position the area to be treated, place a plastic bag for soiled dressing supplies within easy reach, cleanse hands, if the patient has multiple wounds, treat the less contaminated wound first, treat each as a separate procedure, if a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves, open dressing without contamination, keep the dressing/gauze within the open packet and place it directly on top of the barrier, prepare medication/ointment, if indicated, by placing on inner sterile package, expose area to be treated, apply clean gloves, discard dressing and gloves, cleanse hands, apply gloves. Cleanse or irrigate wound as ordered, wipe any excess fluid from the surrounding skin using a dry, gauze wipe. Using a swab or applicator, apply treatment medication as ordered. Apply and secure clean dressing, remove gloves and discard, apply and secure clean dressing, remove gloves and discard. Apply prepared label. Cleanse hands. Unused supplies are discarded or remain dedicated to the patient and stored properly. Open dressing are discarded. Reusable dressing care equipment like bandage scissors must be cleaned and disinfected. 1. Record review revealed the facility admitted Resident #3 on 05/11/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/10/19, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Observation of Resident #3's wound care to his/her arterial/venous ulcers on the right foot, left foot, right lower leg, and pressure ulcers to his/her buttocks, on 01/23/19 at 10:04 AM provided by RN #1, revealed she failed to ensure the dressings were placed on a barrier per facility policy. She placed a small piece of wax paper that was not large enough on the bedside table, and the dressings failed to be contained on the wax paper. Further observation revealed RN #1 failed to wash her hands after removing her soiled gloves, and prior to gloving again; prior to donning gloves after returning from outside the room to obtain tape; and in between completing the dressing changes to the resident's legs, and completing dressing changes to pressure ulcers on the resident's buttocks. Further observation revealed she contaminated the dressings on the overbed table by placing a plastic trash bag over the dressings when she realized she had forgotten the tape, and had to leave the room to get the tape. She did not address the contamination when she returned to the room; instead, an observation revealed she added more dressings to the contaminated overbed table/barrier. Further observation revealed RN #1 continued to contaminate pressure wounds on his/her bilateral buttocks by not washing her hands after soiling her gloves, removing her gloves, or donning clean gloves. Also, observation during pressure ulcer care revealed she reached into the resident's bedside table and pulled out skin wipes while still wearing soiled gloves. Interview with RN #1, on 01/24/18 at 12:00 PM, revealed she should have washed her hands more often. She stated she should not have reached into the resident's drawer with dirty gloves. She stated she should not have taken a plastic bag out of her pocket and placed it over the aseptic clean dressing on the overbed table, whenever she had to leave the room. She revealed she should have followed the hand hygiene and dressing change policies, as written. 2. Record review revealed the facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed he/she was not interviewable due to moderately impaired cognition with no BIMS score. Further review of the MDS revealed the resident is rarely/never understood. Observation of wound care, on 01/24/19 at 8:39 AM, revealed a dime size wound to the resident's right forehand, with no drainage noted. RN #1 brought an overbed table into the room and placed the resident's dressing on the table without cleaning the table. She washed her hands, removed the dressing, and cleaned the wound with Normal Saline. Observation revealed she did not wash her hands or change gloves after removing the soiled dressing, or before putting a clean dressing on the wound. Interview with RN #1, on 01/24/19 at 8:45 AM, revealed she should have cleaned the overbed table prior to placing the dressing on it and should have used a barrier. She revealed she should have washed her hands and changed gloves after removing the dirty dressing. Interview with the Infection Control Nurse, on 01/24/19 at 9:27 AM, revealed the staff were educated yearly on Infection Control matters including handwashing, as well as any time during the year if needed. She stated she expected staff to follow the Hand Hygiene and Wound Dressings policy, as written. Interview with the Director of Nursing (DON), on 01/24/19 at 12:22 PM, revealed staff should wash their hands prior to giving care, before applying clean dressings, when gloves were dirty, going from dirty to clean, after care, or prior to touching a resident's personal effects, such as curtains, bed clothes, call light, etc., and remove all soiled dressings from the trash can after dressings were completed. She stated she also expected staff to follow the Hand Hygiene and Wound Dressings policy, as written.

Based on observation, interview, record review, and review of the facility policy/procedure, it was determined the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for one (1) of twenty-five (25) sampled residents (Resident #3). Observation, on 01/23/19, revealed Registered Nurse (RN) #1 failed to follow the facility's policy/procedure regarding hand washing, gloving, and wound care. The findings include: Review of the facility policy for Wound Dressings, last reviewed 03/01/16, revealed wound dressings are performed using aseptic technique as directed by physician/mid-level provider or standard of practice. The purpose of the policy is to decrease the risk of wound contamination and cross-contamination during dressing changes and to prevent contamination during dressing change. Further policy review revealed to follow the following order for wound dressing change: Use personal protective equipment as indicated, clean over-bed table, place clean barrier on the over-bed table and place supplies on the barrier, introduce yourself to the patient and verify patient identification, explain the procedure and provide privacy, evaluate pain and treat as indicated, position the area to be treated, place a plastic bag for soiled dressing supplies within easy reach, cleanse hands, if the patient has multiple wounds, treat the less contaminated wound first, treat each as a separate procedure, if a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves, open dressing without contamination, keep the dressing/gauze within the open packet and place it directly on top of the barrier, prepare medication/ointment, if indicated, by placing on inner sterile package, expose area to be treated, apply clean gloves, discard dressing and gloves, cleanse hands, apply gloves. Cleanse or irrigate wound as ordered, wipe any excess fluid from the surrounding skin using a dry, gauze wipe. Using a swab or applicator, apply treatment medication as ordered. Apply and secure clean dressing, remove gloves and discard, apply and secure clean dressing, remove gloves and discard. Apply prepared label. Cleanse hands. Unused supplies are discarded or remain dedicated to the patient and stored properly. Open dressing are discarded. Reusable dressing care equipment like bandage scissors must be cleaned and disinfected. Record review revealed the facility admitted Resident #3 on 05/11/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/10/19, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Review of Resident #3's Comprehensive Care Plan for Actual Skin Breakdown related to shear and friction during independent bed mobility, history of pressure ulcer to right and left buttock, incontinent of bowel and bladder and multiple arterial ulcers to bilateral toes and right lower extremity, dated 10/05/17, revealed a goal for the resident to have no decline in arterial areas to bilateral toes and right lower extremity and no decline to Stage II areas on bilateral buttocks. Further review revealed interventions for treatment to buttocks as ordered. Review of the Physician Orders, dated 12/27/18, revealed to cleanse the left buttock with normal saline, apply collagen particles, cover with an ABD pad, then secure with Suresite every day and as needed; and, cleanse the right buttock with Normal Saline, pat dry and apply Exuderm every day and as needed. Observation of wound care completed by RN #1, on 01/23/19 at 10:04 AM, revealed the resident was asked to lay back on his/her side and there was stool noted on the scrotal sac and buttocks. The nurse reached into the resident's bedside table with gloved hands and retrieved the wipes and the wound cleanser. She then pulled the wipes and sprayed the buttocks area with the wound cleanser. She wiped the area with the feces soiled wipes, to include the open areas of the pressure wounds, and smeared stool across the open wounds. She washed the scrotal sac and again wiped across the open wounds. She removed her gloves, did not wash her hands per facility policy, put on more gloves and began to open the dressings for bilateral buttocks. She placed an Exuderm dressing on the left buttock, then placed collagen powder on the open areas of the right buttock and covered with an ABD dressing, and covered with an op-site. She did not wash her hands or change gloves between buttock wounds. Without removing the gloves, she put the wipes and skin cleanser back into the drawer and closed the drawer. She then helped the resident with a new moisture barrier under the resident and helped get him/her positioned in the bed. She removed the dressings from the table and removed the gloves. She went to the bathroom with the bath basin, emptied the basin, rinsed it, then took a bag from her pocket and placed the basin in the bag and put the basin in the upper shelf. She came back into the room, grabbed the trash and bed side table and went out into the hall, pushing the table to the dirty utility room where she disposed of the trash and dirty linen. She took a bleach wipe and cleaned the table, then washed her hands. Interview with RN #1, on 01/24/18 at 12:00 PM, revealed she should have washed her hands more often. She stated she should not have reached into the resident's drawer with dirty gloves and not have smeared feces across the wound field of pressure ulcers. She revealed she was not aware of what the wound care policy said specifically regarding wound dressing changes. Interview with the Director of Nursing (DON), on 01/24/19 at 12:22 PM, revealed the nurse should never smear feces across the wounds due to bacteria in the feces. She stated staff should wash their hands prior to giving care, before handling clean dressings, when gloves are dirty, going from dirty to clean, and after care prior to touching a resident's personal effects, such as curtains, bed clothes, call light, etc. She revealed staff should also remove all soiled dressings from room trash can after dressings are completed. She stated she expected staff to follow the Hand Hygiene policy and Wound Care policy as written.

Based on observation, interview, and review of the facility's Maintenance Supervisor Job Description, it was determined the facility failed to ensure all electrical equipment was maintained in a safe operating condition. Observation on 05/06/15 revealed three wall mounted light fixtures on an outside porch wall that was utilized for supervised resident smoking. Two (2) of the light fixtures had 120v (volt) lighter elements (for lighting cigarettes) in the sockets instead of a light bulb and one socket was void of anything and was open. The three light fixtures tested functional on 05/06/15. The findings include: Review of the facility's Maintenance Supervisor job description, (last revised 09/09/12) revealed the Maintenance Supervisor was responsible for the maintenance operation of the center, and he/she was responsible for performing repairs and maintenance operation of the center and on equipment. Other responsibilities of the Maintenance Supervisor listed were ordering and requisitioning supplies and equipment as needed and performing regular daily, weekly and monthly maintenance checks, as shown on the "Preventative Maintenance Calendar". Further review of the job description revealed the Maintenance Supervisor should follow established safety rules and policies and procedures of the maintenance department; keep required records and submit them to the Administrator and Property Manager when required, and cooperate with other employees and department heads. Observation, on 05/06/15 at 12:10 PM, revealed three (3) light sockets mounted one (1) on top of the other on the porch that was utilized as the supervised smoking area for residents. The light sockets had a push button on switches. Two (2) of the light sockets had electric cigarette lighter elements in the sockets and one socket was was open (no bulb or lighter element). Observation, on 05/06/15 at 2:32 PM, revealed the Property Manager tested the three (3) sockets and all three (3) sockets had 119 volts ac when the button was pushed. The two (2) lighter elements did not function. Interview with the Property Manager at the time revealed he had known about the light sockets for two (2) years and thought they were non-functional because he had been informed by previous maintenance staff that they no longer worked. He stated the facility had been without a maintenance man on staff for several months. Interview with the Administrator, on 05/06/15 at 3:00 PM, revealed as far as he knew the light sockets had not worked for years and had not been visible on the porch as a high back rocking chair had always been in place in front of them blocking any view of the sockets. The Administrator stated residents were supervised when on the porch for smoking and the door was locked (key code lock) with access to the porch by staff only. The Administrator revealed there had been no incidents related to the light sockets.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of ten (10) sampled residents (Resident #13), received the proper treatment and care for oxygen administration. Resident #13 was observed on 03/11/15 with oxygen being administered at five (5) Liters (L) per nasal cannula instead of the physician ordered 2.5/L. The findings include: Review of a facility policy titled, "Oxygen", last revised 12/08/14, revealed "Set liter flow per order". Record review revealed the facility readmitted Resident #13 on 02/04/15 after being discharged from an acute care hospital where he/she was treated for [REDACTED]. Resident #13 had additional [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 02/11/15, revealed the facility assessed Resident #13 as interviewable with a Brief Interview of Mental Status score of ten (10). In addition, the facility assessed he/she required extensive assistance with all activities of daily living. Observation and interview on 03/11/15 at 3:55 PM, revealed Resident #13 was in bed with oxygen being administered via nasal cannula and the oxygen concentrator was set at 5/L. Resident #13 stated she did not know what the oxygen concentrator was supposed to be on and did not know what it was set on. Review of Resident #13's Physician Order, dated 02/04/15, revealed an order to administer oxygen at 2.5 L.; however, review of the March 2015 Treatment Administration Record (TAR) revealed there was no documented evidence the resident had an order to be administered oxygen at 2.5 L. Review of Resident #13's Comprehensive Care Plan for at risk for complications related to Congestive Obstructive [MEDICAL CONDITION] Disease, Respiratory Abnormalities, [MEDICAL CONDITION] and Obstructive Sleep Apnea, last revised 02/06/15, revealed an intervention to "administer oxygen as ordered via nasal cannula". Interview on 03/11/15 at 3:56 PM with Licensed Practical Nurse (LPN) #4 revealed she was not aware what Resident #13's oxygen administration rate was. LPN #4 checked the physician's orders [REDACTED]. On 03/11/15 at 5:00 PM, an interview conducted with Registered Nurse (RN) #1, revealed on 02/04/15, RN #1 had verified Resident #13's orders from the hospital on readmission to the facility and typed them into the computer. RN #1 stated the computer should have automatically printed the TAR to include any oxygen administration orders. RN #1 could not explain why the oxygen administration had not printed on the resident's TAR, which was how licensed staff would check the oxygen administration rate and document to verify each shift. He also stated too much oxygen administration could cause a drop in Resident #13's respiratory drive causing a potential problem. According to an interview with LPN #5, on 03/11/15 at 4:45 PM, the TAR that was generated from the orders that were typed into the computer did not include the oxygen administration amount but did print the oxygen saturation checks every shift and the weekly oxygen tubing change. She stated the TAR and MAR indicated [REDACTED]. Interview with the Director of Nursing (DON), conducted on 03/11/15 at 4:30 PM, revealed licensed staff were to verify the rate of oxygen administration for each resident receiving oxygen therapy and document that verification on the resident's TAR. The DON stated Resident #13's rate of administration of oxygen was not on the resident's TAR and should have been. The DON revealed she oversees the morning meeting and all admissions and new orders were reviewed to verify the orders to the TARs and MARs; however, they failed to identify Resident #13's oxygen order was not on the TAR. The DON stated a first of the month check of orders to MARs and TARs was also completed for March, but also failed to identify the oxygen administration was not placed on the TAR.

Based on interview, record review, review of the hospital's History and Physical, the facility's policy and procedure and the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #27 "Components of Licensed Practical Nursing (LPN) Practice", it was determined the facility failed to ensure services provided by the facility met the professional standards of quality for one (1) of eighteen (18) sampled residents (Resident #4) when LPN #1 failed to assess the resident when staff reported a change in the resident's condition. On [DATE] at the beginning of the 10:00 PM to 6:00 AM shift, Certified Nurse Aide (CNA) #2 reported to Licensed Practical Nurse (LPN) #1 that there was something different about Resident #4. At 12:00 midnight, LPN #1 administered a scheduled medication to Resident #4 and the resident stated he/she was okay so LPN #1 felt there was nothing wrong. CNA #2 reported to LPN #1 again at 2:00 AM and 4:00 AM that the resident did not seem right. LPN #1 failed to assess Resident #4 according to professional standards of quality at the beginning of the shift and did not assess the resident at any other time the remainder of that shift. On [DATE] after shift change (after 6:00 AM), CNA #8 who works day shift, determined the resident was unresponsive, making grunting sounds and had a white foamy substance coming from the resident's mouth when she tried to get the resident up for breakfast. CNA #8 summoned the day shift nurse, LPN #4, who assessed the resident immediately, notified the resident's physician, and sent Resident #4 to the emergency room for evaluation. Resident #4 was admitted to the hospital and expired on [DATE] with the cause of death listed as [MEDICAL CONDITION] ([MEDICAL CONDITION]-stroke). The facility's failure to ensure care was provided according to the professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the IJ was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC). The findings include: Review of the KBN AOS #27 "Components of Licensed Practical Nursing (LPN) Practice", last revised ,[DATE], revealed components of the LPN practice included assessment and interpretation of data. Assessment includes observations of appearance and behavior; measurements of physical structure and physiologic function; and observations of a resident's subjective and objective signs and symptoms. Interpreting data includes recognizing existing relationships between data gathered and a resident's health status, established plan of care and medical treatment regimen; determining the resident's need for nursing intervention based upon data gathered regarding the resident's health status, ability to care for self, and established plan of care; and appropriate consultation. Review of a document titled, Nursing Philosophy (no date) revealed nurses were responsible to provide individualized, quality nursing care and support for residents and families. Review of Resident #4's closed record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #4 as non-ambulatory and required extensive assistance with all activities of daily living. The resident's Brief Interview of Mental Status (BIMS) assessment revealed a score of six (6) which indicated the resident's cognition was severely impaired and the resident was not interviewable. Interview with Certified Nurse Aide (CNA) #2, on [DATE] at 10:30 AM, revealed at the beginning of the 10:00 PM to 6:00 AM shift on [DATE] she told LPN #1 that Resident #4 was "not right" and asked if something was wrong with him/her. CNA #2 stated on [DATE] at 2:00 AM, she was working with CNA #3 during rounds. CNA #2 revealed the resident was "dead weight" and CNA #3 also noticed it and they reported it again to LPN #1 that something was wrong with Resident #4. CNA #2 stated she told LPN #1 again during the 4:00 AM rounds but she did not see LPN #1 go into Resident #4's room to assess him/her. Interview with CNA #3, on [DATE] at 4:10 AM, revealed during the early morning rounds on [DATE] at 4:00 AM, she was assisting CNA #2 and it was hard for two (2) people to roll Resident #4 to provide incontinent care. She stated Resident #4 would normally wake up, have a conversation and even eat a snack but he/she did not respond at that time. CNA #3 revealed she did a sternal rub on Resident #4 and got no response. She stated she told CNA #2 to report it to the nurse and CNA #2 said she already had reported it to the nurse. CNA #3 stated she heard CNA #2 telling LPN #1 about the resident but she did not think the LPN went to the resident's room. Review of Resident #4's Nursing Notes revealed there was no entry for [DATE]. A phone interview with LPN #1 on [DATE] at 11:15 AM revealed, on [DATE] at about 11:30 PM, CNA #2 had asked him if something was wrong with Resident #4. LPN #1 stated he went to the Resident #4's room about 12:00 AM to administer a routine medication. He stated he called Resident #4 by name and the resident had said he/she was "ok". He revealed he felt the resident was confused as usual and he/she didn't seem any different from the "norm" and he didn't document anything. LPN #1 stated he did not recall CNA #2 coming to him again that night and he had no further interaction with Resident #4 that night. Review of a Change of Condition Documentation form, dated [DATE] at 6:45 AM, revealed CNA #8 had reported to LPN #4 that she was unable to wake the resident. Further review revealed LPN #4 documented that the only response Resident #4 had to a sternal rub was "pushing hands away". The resident's pupils were sluggish to light, blood pressure was ,[DATE] (normal ,[DATE]), pulse was 94 (normal: 70), respirations 14 (normal: 20), temperature 97 degrees (normal 98.6) and; oxygen saturation was 94% (normal ,[DATE]%) and, blood sugar was 139 (normal ,[DATE]). The family was notified at 7:00 AM and arrived at the facility at 7:15 AM. The physician was notified at 7:45 AM with orders received to send the resident to the emergency room for evaluation. Resident #4 was transported by ambulance to the emergency room at 8:30 AM. At 1:00 PM, the family called the facility and reported Resident #4 had been admitted . Interview with CNA #8, on [DATE] at 11:00 AM, revealed on the morning of [DATE], Resident #4 was not responding when she attempted to get the resident up for the day. CNA #8 stated the resident had white "foamy stuff" on his/her mouth. She stated she notified LPN #4 and returned to the resident's room with her. CNA #8 revealed another nurse was summoned and the resident was sent out. Interview with LPN #4, on [DATE] at 10:15 AM, revealed on [DATE], the CNAs reported they could not get Resident #4 awake. LPN #4 stated she assessed Resident #4 and she couldn't wake him/her up. She stated LPN #1 had stated in report the resident had been "fine" all night. LPN #4 stated when she saw Resident #4, she felt the resident "had been that way for a long time". The resident was pale and was having snoring respirations and did not respond to a sternal rub and had pin point pupils. LPN #4 revealed vital signs were obtained, the family and physician were notified and the resident was sent to the hospital. Review of hospital History and Physical, dated [DATE] at 6:03 PM, revealed the resident had an Acute [MEDICAL CONDITION] involving the midline, large infarct bilaterally which involved the bilateral cerebella hemispheres, and bilateral thalami. Clinically, he/she was found unresponsive in the morning and the onset of the stroke could be any time back to yesterday evening ([DATE]) when he/she went to sleep. During an interview conducted in person with LPN #1, on [DATE] at 8:55 AM he stated, "It does seem bad the CNA voiced a concern and the resident went out the next morning". He stated he did not obtain vital signs because the resident was responsive and in hind sight he "should have assessed the resident due to what was said by the CNA". He revealed a Nurse's Note should have been documented and he should have gotten the CNA to elaborate more. Interview with the Director of Nursing (DON), on [DATE] at 3:00 PM, revealed she couldn't recall when she was first made aware of the concern of LPN #1 not assessing Resident #4 when CNA #2 had verbalized a concern about the resident's condition. She stated she wanted to be able to trust her nurses and, if there was a change in a resident they would act on it. Interview with the previous Administrator, on [DATE] at 11:00 AM, revealed she recalled Resident #4 was sent out of the facility with a massive stroke. She did not recall anything about a change of condition during the night prior to the resident being sent out. She stated she would have expected the nurse to go and evaluate a resident if a change was reported. Interview with the current Administrator, on [DATE] at 9:30 AM, revealed he was not the Administrator during the time of this event but he expected if a CNA went to a nurse saying something was not right, the nurse should assess and document. ** The facility implemented the following actions to remove the Immediate Jeopardy: Resident #4 no longer resides at the facility as he/she expired on [DATE] . 1. Change of condition forms were completed by Licensed Nurses, dated [DATE] through [DATE]. Licensed Nurses reassessed seventy-one (71 of 71) skilled residents to determine if a change of condition had occurred, results were documented in the resident's clinical records and physician/responsible party notification was completed if indicated. Care plans were revised as needed. No new issues were identified with the assessments being completed on [DATE]. 2. Re-education to all Registered Nurses (RNs), LPNs, CNAs, Non-certified nursing assistants (NAs), was provided beginning on [DATE] and was completed on [DATE]. Education was provided by the Administrator, DON, Assistant Director of Nursing (ADON), Manager of Clinical Operations (MCO), and the RN Nurse Practice Educator (NPE) regarding. Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and facility policy for following the resident plan of care. Post tests were completed with 100% pass rate expected before an employee was allowed to return to work. The Re-education was conducted on [DATE] and [DATE], with fifty-one (51) of sixty-eight (68) active RNs, LPNs, Certified Medication Techs (CMTs), CNAs, and Non-certified aides on the above listed areas of re-education. Any staff member not present for the education would receive it prior to returning to work. 3. Re-education was provided to the new Administrator and the DON, on [DATE], by the Regional Vice President of Operations (RVPO), Manager of Regulatory Compliance, and Regional Manager of Clinical Operations (RMCO), center policies on care plan, resident safety, quality assurance and administration requirements. Additional information was provided regarding CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the DON and Administrator on [DATE] with 100% pass rate noted. 4. An AD-HOC meeting, dated [DATE], revealed the PI Committee met to review the PI action plan for development of the AoC. The meeting was reviewed with the acting Medical Director on [DATE]. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 5. A new validation of learning tool, implemented on [DATE], revealed staff would be re-educated on who is the first line of reporting when there is an issue or concern; who is next on your chain of command; explain the elopement sign out procedure; what do you do if a resident has a change of condition; and explain the Stop and Watch tool and how to use it. The above listed re-education will be conducted by the Administrator, DON, ADON, Clinical Reimbursement Manager, Unit Manager, and RN NPE with five (5) Licensed Nurses and Certified staff members seven (7) days a week for fourteen (14) days, three (3) times a week for fourteen (14) days, then monthly for six (6) months. Licensed Nurses, CMAs and CNAs to determine continued competency with what do with a resident change of condition. Any areas of concern to be immediately corrected when identified and re-education provided as needed. All audits to be taken to the AD-HOC PI meetings for immediate recommendations. 6. Walking rounds audits, will be conducted to ensure residents were being assessed for change of condition seven (7) days a week for fourteen (14) days and continuing three (3) times a week for fourteen (14) days, then weekly for three (3) months and monthly for three (3) months. Any new areas of concerns were identified with immediate action taken. 7. QAPI meetings beginning [DATE] were being reviewed by the RMCO and to be continued reviewed for three (3) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: Resident #4 no longer resides at the facility. 1. Review of change of condition forms completed by Licensed Nurses, dated [DATE] through [DATE], revealed Licensed Nurses reassessed seventy-one (71 of 71) skilled residents to determine if a change of condition had occurred. Results were documented in the resident's clinical records and physician/responsible party notification was completed if indicated. Care plans were revised as needed. No new issues were identified with the assessments being completed on [DATE]. 2. Review of in-service sign in logs, dated [DATE] and [DATE], revealed fifty-one (51) of sixty-eight (68) active RNs, LPNs, Certified Medication Techs (CMTs), CNAs, and Non-certified aides received re-education and post testing from the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Manager of Clinical Operations (MCO), and the Nurse Practice Educator (NPE) related to the Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and, the facility policy for following the resident plan of care. Staff interviews conducted on [DATE] with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, the Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, the Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, the RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, the Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, the RN Unit Manager at 11:49 AM, the RN NPE at 8:15 AM, a Housekeeping Aide at 9:00 AM, the RMCO at 9:45 AM, the Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated and tested on the Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and, the facility policy for following the resident plan of care. 3. Review of re-education provided to the new Administrator and the DON, on [DATE], revealed the Regional Vice President of Operations (RVPO), Manager of Regulatory Compliance, and Regional Manager of Clinical Operations (RMCO), provided re-education regarding the center policies on care plan, resident safety, quality assurance and administration requirements. Additional information was provided regarding CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the DON and Administrator on [DATE] with 100% pass rate noted. 4. Review of AD-HOC meeting minutes, dated [DATE], revealed the PI Committee met to review the PI action plan for development of the AoC. The meeting was reviewed with the acting Medical Director on [DATE]. Members of the PI Committee included the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 5. Review of a validation of learning tool, implemented on [DATE], revealed staff will be re-educated regarding who is first line of reporting when there is an issue or concern; who is next on your chain of command; explain the elopement sign out procedure; what do you do if a resident has a change of condition; and explain the Stop and Watch tool and how to use it. The above listed re-education was to be conducted by the Administrator, DON, ADON, Clinical Reimbursement Manager, Unit Manager, and NPE with five (5) Licensed Nurses and Certified staff members seven (7) days a week for fourteen (14) days, three (3) times a week for fourteen (14) days, then monthly for six (6) months. Licensed Nurses, CMAs and CNAs to determine what do with a resident change of condition. Any areas of concern to be immediately corrected when identified and re-education provided as needed. All audits to be taken to the AD-HOC PI meetings for immediate recommendations. 6. Review of walking rounds audits, dated [DATE], [DATE], and [DATE], revealed residents were being assessed for change of condition seven (7) days a week for fourteen (14) days and continuing three (3) times a week for fourteen (14) days, then weekly for three (3) months and monthly for three (3) months. No concerns identified. 7. Review of QAPI meetings beginning [DATE], revealed the meetings were being reviewed by the RMCO and to be continued reviewed for three (3) months.

Based on interview, record review, and review of the hospital History and Physical and the facility's policy and procedures it was determined the facility failed to have an effective system to ensure one (1) of eighteen (18) sampled residents (Resident #4) was provided the necessary care and services when staff reported a change in the resident's condition. Certified Nurse Aide (CNA) #2 reported to Licensed Practical Nurse (LPN) #1 at the beginning of the 10:00 PM to 6:00 AM shift on [DATE] that there was something different about Resident #4. LPN #1 administered a scheduled medication to Resident #4 at 12:00 midnight and at that time felt there was nothing wrong with the resident because he/she said he/she was "okay". CNA #2 reported to LPN #1 again at 2:00 AM and at 4:00 AM that the resident did not seem right. LPN #1 failed to assess Resident #4 at the beginning of the shift and did not assess the resident at any other time the remainder of that shift. On [DATE] after shift change (after 6:00 AM), the day shift CNA #8 determined the resident was unresponsive, making grunting sounds and had a white foamy substance coming from his/her mouth when she tried to get the resident up for breakfast. CNA #8 summoned the day shift nurse, LPN #4, who assessed the resident immediately, notified the resident's physician, and sent Resident #4 to the emergency room for evaluation. Resident #4 was admitted to the hospital and expired on [DATE] with the cause of death listed as [MEDICAL CONDITION] ([MEDICAL CONDITION]- stroke). (Refer to F281 and F282) The facility's failure to have an effective system in place to ensure each resident was provided the necessary care and services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the IJ was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC). The findings include: Review of the facility's policy and procedure titled, "Stop and Watch Early Warning Tool", dated 2011, revealed if a staff member identified a change while caring for or observing a resident, the staff should circle the change on the tool and notify the nurse. The staff member should then either give the nurse a copy of the tool or review it with her/him as soon as possible. Review of a document titled, Nursing Philosophy (no date) revealed nurses were responsible to provide individualized, quality nursing care and support for residents and families. Review of Resident #4's closed record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #4 as non-ambulatory and required extensive assist with all activities of daily living and a Brief Interview of Mental Status (BINS) score of six (6) indicating the resident's cognition was severely impaired and he/she was not interviewable. Review of Resident #4's Nursing Notes revealed no entry of any kind dated [DATE]. Review of a Change of Condition Documentation form, dated [DATE] at 6:45 AM, revealed a CNA had reported to the nurse, LPN #4, that she was unable to wake the resident. LPN #4 documented that the only response Resident #4 had to a sternal rub was "pushing hands away". Further review revealed the resident's pupils were sluggish to light, blood pressure was ,[DATE] (normal ,[DATE]), pulse was 94 (normal: 70), respirations 14 (normal: 20), temperature 97 degrees (normal 98.6) and; oxygen saturation was 94% (normal ,[DATE]%) and, blood sugar was 139 (normal ,[DATE]). family was notified at 7:00 AM and was at the facility at 7:15 AM. The physician was notified at 7:45 AM with orders received to send the resident to the emergency room for evaluation. Resident #4 was transported by ambulance to the emergency room at 8:30 AM. At 1:00 PM, the family called the facility and reported Resident #4 had been admitted to the hospital. Review of the hospital History and Physical, dated [DATE] at 6:03 PM, revealed the resident had an acute [MEDICAL CONDITION] (stroke) involving the midline, large infarct bilaterally involving bilateral cerebellar hemispheres, and bilateral thalami. Further review of the History and Physical revealed the resident was unresponsive in the morning and the onset of the stroke could have occurred on the evening of [DATE] when the resident was asleep. Interview conducted with CNA #2, on [DATE] at 10:30 AM, revealed she told LPN #1 at the beginning of the 10:00 PM to 6:00 AM shift on [DATE] that Resident #4 was "not right" and asked (the nurse) if something was wrong with the resident. CNA #2 stated on [DATE] at 2:00 AM, she was working with CNA #3 during rounds. CNA #2 said the resident was "dead weight" and CNA #3 also noticed it and they reported it again to LPN #1 that something was wrong with Resident #4. CNA #2 revealed she told LPN #1 again during the 4:00 AM rounds but she did not see LPN #1 go into Resident #4's room to assess him/her. CNA #2 also stated she had passed information in the morning walking rounds with the on-coming day shift CNA because Resident #4 was "abnormal". Interview conducted with CNA #3, on [DATE] at 4:10 AM, revealed in the early morning rounds on [DATE] she was assisting CNA #2 on the 4:00 AM round and Resident #4 was hard for two (2) people to roll to provide incontinent care. She stated normally Resident #4 would wake up, have a conversation and even eat a snack, but he/she did not respond at that time. CNA #3 stated she did a sternal rub on Resident #4 and got no response. She told CNA #2 to report it to the nurse and CNA #2 said she already had reported it. CNA #3 stated she heard CNA #2 telling LPN #1 about the resident but did not think the LPN went to the resident's room. A phone interview, on [DATE] at 11:15 AM, with LPN #1 revealed at about 11:30 PM on [DATE], CNA #2 had asked him if something was wrong with Resident #4. LPN #1 stated he went to Resident #4's room about 12:00 AM to administer a routine medication. He said he called Resident #4 by name and the resident had said he/she was "ok". He revealed he gave the resident the scheduled medication, and felt the resident was confused as usual and didn't seem any different from the "norm" and he didn't document anything. LPN #1 stated he did not recall CNA #2 coming to him again that night and he had no further interaction with Resident #4 that night. On [DATE] at 11:00 AM, an interview with CNA #8 revealed on the morning of [DATE], Resident #4 was not responding when she attempted to get the resident up for the day. She stated the resident had "foamy stuff" which was white on his/her mouth. She stated she notified LPN #4 and returned to the resident's room with her. CNA #8 revealed another nurse was summoned and the resident was sent out to the hospital. Interview on [DATE] at 10:15 AM with LPN #4 revealed on [DATE], the CNAs reported they could not get Resident #4 awake. LPN #4 stated she assessed Resident #4 and she couldn't wake him/her up. She stated LPN #1 had stated in report the resident had been "fine" all night. LPN #4 stated when she saw Resident #4, she felt the resident "had been that way for a long time". The resident was pale and was having snoring respirations and did not respond to a sternal rub and had pin point pupils. LPN #4 revealed vital signs were obtained, the facility and physician were notified and the resident was sent to the hospital. LPN #1 stated during an interview, on [DATE] at 8:55 AM, "It does seem bad the CNA voiced a concern and the resident went out the next morning". He stated he did not obtain vital signs because the resident was responsive and in hind sight he "should have assessed the resident due to what was said by the CNA". He stated a Nurse's Note should have been documented and he should have gotten the CNA to elaborate more. Further interview with CNA #2, on [DATE] at 10:30 AM, revealed she spoke with another nurse, LPN #3, a few nights later because she "felt bad for the resident". CNA #2 stated LPN #3 had said her obligation stopped when she had reported the change in the resident to LPN #1. CNA #2 further revealed LPN #3 looked in the Nurse's Notes and told her no entries had been made in the resident's chart on [DATE]. CNA #2 stated she talked with the Staff Development Coordinator (SDC) a week or so after that and told her everything. CNA #2 revealed the SDC told her that she would speak with the Director of Nursing (DON) to get to the bottom of it. CNA #2 stated she also told the DON days later. An additional interview conducted on [DATE] at 2:15 PM, revealed CNA #2 did not tell the other nurse in the facility on the night of [DATE] because "she did not want to go over LPN #1's head". CNA #2 stated now she knows she should have gone over the nurse's head. Interview with LPN #3, on [DATE] at 4:45 AM, revealed CNA #2 had talked with her about Resident #4 a few nights after Resident #4 was sent out. She stated CNA #2 was crying to her and had stated she spoke with LPN #1 at 11:00 PM, but he (LPN #1) did not assess Resident #4 and she was feeling guilty about it. LPN #3 stated the next day she reported the incident to the SDC and asked if it had been reported and asked why it was not in the Nurse's Notes. LPN #3 stated she did not know what the SDC did later. Interview with the SDC, on [DATE] at 9:45 AM revealed she did not recall a CNA talking to her about Resident #4 but LPN #3 had come to her sometime after Resident #4 had been sent out, voicing a concern that CNA #2 had told LPN #1 that Resident #4 was "not him/herself" and LPN #1 did not check on the resident. The SDC stated she spoke with LPN #1 who said he had checked on Resident #4. The SDC stated she was not able to verify if LPN #1 had actually checked on Resident #4 and that she did not look at Resident #4's chart. She stated she did not recall what else LPN #1 said but it sounded "ok" to her and she didn't ask any other questions. An additional interview, on [DATE] at 2:25 PM, revealed LPN #1 had told her he had to call the resident's name two (2) times which was usual for the resident and the SDC could not say if LPN #1 went into the resident's room more that shift. She stated there definitely should have been documentation as it was an "exception" (the facility documents by if something occurs that is not normal) if staff reported a concern to a nurse. Interview with the DON, on [DATE] at 3:00 PM revealed she couldn't recall when she was first made aware of the concern of LPN #1 not assessing Resident #4 when CNA #2 had verbalized a concern about the resident. She stated she did not recall if the SDC had shared any information about the event and felt she (DON) would have addressed it. She stated she wanted to be able to trust her nurses and if there was a change in a resident condition they would act on it. Interview with the previous Administrator, on [DATE] at 11:00 AM, revealed she recalled Resident #4 was sent out of the facility with a massive stroke. She did not recall anything about a change of condition during the night prior to the resident being sent out. She stated she would have expected the nurse to go and evaluate a resident if a change was reported. She additionally stated she would expect some documentation to have been completed as it would have been "best practice". The former Administrator additionally stated she would have expected staff to inform her of such an event and the SDC should have shared this information and not doing so was "not acceptable". Interview with the current Administrator of the facility conducted on [DATE] at 9:30 AM revealed he was not the Administrator during the time of this event but he expected if a CNA went to a nurse saying something was not right, the nurse should assess and document. ** The facility implemented the following actions to remove the Immediate Jeopardy: Resident #4 no longer resides at the facility as he/she expired on [DATE] . 1. Change of condition forms were completed by Licensed Nurses, dated [DATE] through [DATE]. Licensed Nurses reassessed seventy-one (71 of 71) skilled residents to determine if a change of condition had occurred, results were documented in the resident's clinical records and physician/responsible party notification was completed if indicated. Care plans were revised as needed. No new issues were identified with the assessments being completed on [DATE]. 2. Re-education to all Registered Nurses (RNs), LPNs, CNAs, Non-certified nursing assistants (NAs), was provided beginning on [DATE] and was completed on [DATE]. Education was provided by the Administrator, DON, Assistant Director of Nursing (ADON), Manager of Clinical Operations (MCO), and the RN Nurse Practice Educator (NPE) regarding. Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and facility policy for following the resident plan of care. Post tests were completed with 100% pass rate expected before an employee was allowed to return to work. The Re-education was conducted on [DATE] and [DATE], with fifty-one (51) of sixty-eight (68) active RNs, LPNs, Certified Medication Techs (CMTs), CNAs, and Non-certified aides on the above listed areas of re-education. Any staff member not present for the education would receive it prior to returning to work. 3. Re-education was provided to the new Administrator and the DON, on [DATE], by the Regional Vice President of Operations (RVPO), Manager of Regulatory Compliance, and Regional Manager of Clinical Operations (RMCO), center policies on care plan, resident safety, quality assurance and administration requirements. Additional information was provided regarding CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the DON and Administrator on [DATE] with 100% pass rate noted. 4. An AD-HOC meeting, dated [DATE], revealed the PI Committee met to review the PI action plan for development of the AoC. The meeting was reviewed with the acting Medical Director on [DATE]. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 5. A new validation of learning tool, implemented on [DATE], revealed staff would be re-educated on who is the first line of reporting when there is an issue or concern; who is next on your chain of command; explain the elopement sign out procedure; what do you do if a resident has a change of condition; and explain the Stop and Watch tool and how to use it. The above listed re-education will be conducted by the Administrator, DON, ADON, Clinical Reimbursement Manager, Unit Manager, and RN NPE with five (5) Licensed Nurses and Certified staff members seven (7) days a week for fourteen (14) days, three (3) times a week for fourteen (14) days, then monthly for six (6) months. Licensed Nurses, CMAs and CNAs to determine continued competency with what do with a resident change of condition. Any areas of concern to be immediately corrected when identified and re-education provided as needed. All audits to be taken to the AD-HOC PI meetings for immediate recommendations. 6. Walking rounds audits, will be conducted to ensure residents were being assessed for change of condition seven (7) days a week for fourteen (14) days and continuing three (3) times a week for fourteen (14) days, then weekly for three (3) months and monthly for three (3) months. Any new areas of concerns were identified with immediate action taken. 7. QAPI meetings beginning [DATE] were being reviewed by the RMCO and to be continued reviewed for three (3) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: Resident #4 no longer resides at the facility. 1. Review of change of condition forms completed by Licensed Nurses, dated [DATE] through [DATE], revealed Licensed Nurses reassessed seventy-one (71 of 71) skilled residents to determine if a change of condition had occurred. Results were documented in the resident's clinical records and physician/responsible party notification was completed if indicated. Care plans were revised as needed. No new issues were identified with the assessments being completed on [DATE]. 2. Review of in-service sign in logs, dated [DATE] and [DATE], revealed fifty-one (51) of sixty-eight (68) active RNs, LPNs, Certified Medication Techs (CMTs), CNAs, and Non-certified aides received re-education and post testing from the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Manager of Clinical Operations (MCO), and the Nurse Practice Educator (NPE) related to the Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and, the facility policy for following the resident plan of care. Staff interviews conducted on [DATE] with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, the Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, the Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, the RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, the Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, the RN Unit Manager at 11:49 AM, the RN NPE at 8:15 AM, a Housekeeping Aide at 9:00 AM, the RMCO at 9:45 AM, the Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated and tested on the Interact-Stop & Watch tool used to communicate change of condition; change of condition and documentation in the clinical record; and, the facility policy for following the resident plan of care. 3. Review of re-education provided to the new Administrator and the DON, on [DATE], revealed the Regional Vice President of Operations (RVPO), Manager of Regulatory Compliance, and Regional Manager of Clinical Operations (RMCO), provided re-education regarding the center policies on care plan, resident safety, quality assurance and administration requirements. Additional information was provided regarding CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the DON and Administrator on [DATE] with 100% pass rate noted. 4. Review of AD-HOC meeting minutes, dated [DATE], revealed the PI Committee met to review the PI action plan for development of the AoC. The meeting was reviewed with the acting Medical Director on [DATE]. Members of the PI Committee included the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 5. Review of a validation of learning tool, implemented on [DATE], revealed staff will be re-educated regarding who is first line of reporting when there is an issue or concern; who is next on your chain of command; explain the elopement sign out procedure; what do you do if a resident has a change of condition; and explain the Stop and Watch tool and how to use it. The above listed re-education was to be conducted by the Administrator, DON, ADON, Clinical Reimbursement Manager, Unit Manager, and NPE with five (5) Licensed Nurses and Certified staff members seven (7) days a week for fourteen (14) days, three (3) times a week for fourteen (14) days, then monthly for six (6) months. Licensed Nurses, CMAs and CNAs to determine what do with a resident change of condition. Any areas of concern to be immediately corrected when identified and re-education provided as needed. All audits to be taken to the AD-HOC PI meetings for immediate recommendations. 6. Review of walking rounds audits, dated [DATE], [DATE], and [DATE], revealed residents were being assessed for change of condition seven (7) days a week for fourteen (14) days and continuing three (3) times a week for fourteen (14) days, then weekly for three (3) months and monthly for three (3) months. No concerns identified. 7. Review of QAPI meetings beginning [DATE], revealed the meetings were being reviewed by the RMCO and to be continued reviewed for three (3) months.

Based on interview, record review, review of the facility's policy and procedure, Creditable Allegation of compliance for the 09/18/14 Immediate Jeopardy; and, the 09/18/14 Plan of Correction it was determined the facility failed to provide adequate supervision for one (1) of eighteen (18) sampled residents (Resident #1). The facility failed to have an effective system in place to ensure staff was aware of which residents were signed out to leave the building. Resident #1 had previously left the faciity on [DATE] by following visitors out the main front doors of the facility without staff knowledge. Approximately three (3) months later, on 11/20/14 at approximately 1:30 PM, Resident #1 followed a visitor through the same main front doors of the facility again. The resident's wanderguard caused the alarm to sound but Certified Nursing Assistant (CNA) #1 and the Payroll/Benefits Coordinator failed to stop the resident when the alarm sounded because they believed the resident was leaving with the visitor for an appointment and CNA #1 silenced the alarm. The staff failed to verify the resident was signed out to leave the facility. The Visitor transported Resident #1 to a trailer park 0.7 miles away per the resident's directions because she thought the resident was a visitor to the facility. When she realized the resident was a resident of the facility she returned the resident to the facility. This was the second time Resident #1 had eloped from the facility through the same front doors. The facility's failure to provide supervision has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/26/14 and determined to exist on 11/20/14. The facility was notified of the Immediate Jeopardy on 11/26/14. An acceptable Allegation of Compliance (AoC) was received on 12/16/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 12/11/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled "Elopement of Patient", last revised 05/15/14, revealed residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a resident leaves the premises without authorization and/or any necessary supervision to do so, and the purpose of the policy was to provide a process for managing residents at risk for elopement. Sign in/out records will be maintained and used whenever a resident leaves the Center grounds alone, with family, or with recreational staff. Record review revealed the facility admitted Resident #1 on 05/29/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/17/14, revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Review of the Elopement Assessment, dated 08/26/14, revealed Resident #1 would frequently attempt to follow visitors out the doors and he/she frequently looked out the glass doors. Review of Resident #1's Comprehensive Care Plan, dated 08/12/14, revealed the resident was considered at risk for elopement related to Dementia, Cognitive Loss and a successful elopement on 08/26/14. Further review revealed a goal of "Resident will not leave the building without an escort" and "Resident will have no further episodes of elopement". There was an intervention for staff to utilize the Sign in/out Records when the resident left the Center with escort. Review of the "Change of Behavior" form, dated 11/20/14, revealed staff was notified of Resident #1 leaving the facility with another resident's family member after the resident asked Visitor #1 for a ride home. Interview with the Payroll/Benefit staff member, on 11/26/14 at 11:04 AM, revealed she was working at the front reception desk when she looked up and saw a female visitor (Visitor #1) wearing scrubs going through the front door and Resident #1 was behind the visitor. She stated she pressed the button to open the door when CNA #1 told her that the resident was wearing a bracelet. She revealed she and the CNA thought the resident was going to an appointment so CNA #1 deactivated the alarm; however, they did not verify with the visitor if she was taking the resident to an appointment and did not verify that the resident was signed out to leave the facility with an escort. The Payroll/Benefit staff member stated she had never been told to call the nursing desk to verify this information. She stated in approximately ten (10) minutes, Visitor #1 reappeared at the front doors with Resident #1 in front of her. She stated Visitor #1 reported she needed to see a staff member and it was at that point the staff realized Visitor #1 did not know the resident. She revealed the Registered Nurse (RN) Clinical Reimbursement Manager (RN #1), came out of her office when she realized what had happened and escorted Resident #1 to the East Nurse's Station. Interview with CNA #1, on 11/26/14 at 11:21 AM, revealed Visitor #1 came to the facility and she (the Visitor) and Resident #1 made eye contact and the resident was following Visitor #1 throughout the facility. CNA #1 stated Visitor #1 and Resident #1 came through the double doors and she thought Visitor #1, who was wearing scrubs, was taking the resident to an appointment; however, she did not verify this with the visitor or the unit staff. CNA #1 stated she had never been told to verify this information with the staff at the Nursing Station that a resident had been signed out to go to an appointment. CNA #1 revealed the Payroll/Benefits Coordinator hit the red button to open the doors and the alarm sounded due to the resident wearing a wanderguard. CNA #1 stated she got up and went to the keypad and disarmed the alarm and Resident #1 followed the visitor out the doors. CNA #1 revealed approximately ten (10) minutes later, the visitor returned to the facility with Resident #1. Review of the facility's Creditable Allegation of compliance for the 09/18/14 Immediate Jeopardy; and, review of the 09/18/14 Plan of Correction revealed the facility provided staff education on the facility's Elopement Policy and Procedure. Review of the facility's Elopement Policy, Section 10 Quality Assurance 10.2 revealed, "Sign in/out records will be maintained and used whenever a patient leaves the Center grounds alone, with family, or recreational staff." Section 10.3 stated, "Staff will be trained on the Center's door security and required response to a sounding alarm." However, interview with CNA #1 and the Payroll Benefit staff member revealed they had not be trained to verify that residents at risk for elopement had been signed out to leave the facility. Interview with Visitor #1, on 11/26/14 at 2:00 PM, revealed she was at the facility visiting another resident. She stated that she wore scrubs because she was a CNA for a home health company. Visitor #1 revealed she was at the facility at approximately 1:30 PM on 11/20/14 when Resident #1 (whom she thought was a visitor) was talking with her about going home. She revealed the resident and she both went through the double doors after a facility staff member pushed the button to open the doors. The Visitor stated she asked the resident if he/she had a coat and the resident said "no" then started walking down the driveway stating that he/she was going home. The Visitor revealed she told the resident she would see if she had a coat and the resident opened the car door and got inside the vehicle. Visitor #1 stated she told the resident that she would take him/her home and the resident told her the address and she drove to that location. Visitor #1 stated that after arriving at the trailer park, Resident #1 got out of the car and went to the door of a mobile home. As the visitor watched, it became apparent the resident did not have a key to get inside. The Visitor stated she questioned the resident when he/she was unable to access the door and the resident stated his/her son had the key and a staff member at the nursing home had a key. The Visitor stated the resident then got back into the car and she returned the resident to the nursing facility. The Visitor revealed when she returned to the facility she asked at the reception desk if the staff member was there and the staff told her Resident #1 was a resident at the facility. Visitor #1 revealed she told the facility's Administrator she was unaware that the person was a resident. The Visitor stated they were gone for approximately 15-20 minutes. Interview with RN #3, on 12/16/14 at 11:19 AM, revealed Resident #1 was at an activity in the East Lounge adjacent to the nurses station during lunchtime on 11/20/14. The RN stated she was doing rounds down the hall and thought the resident was still in the activity. She acknowledged she heard the alarm sound, but it was silenced quickly and she assumed that someone had taken care of it so she did not conduct a head count at that time. The RN stated she did not see Resident #1 follow the lady out the door. She stated the resident was usually in someone's sight and the resident participated in activities that day. She revealed she was notified by the Nurse Practitioner of the resident's elopement after the resident had returned with the visitor. She stated she conducted a resident head count at that time, completed a head-to-toe assessment on the resident, notified the physician and the family and completed a change of condition form for the incident. The resident was placed on 1:1 observation upon return to the facility. Interview with the Director of Nursing (DON), on 11/26/14 at 4:17 PM, revealed Resident #1 got out of the facility on 11/20/14 with a visitor. She stated there was not a formal system in place for the staff to verify that a resident had been signed out at the Nurse's Desk. She revealed she expected residents should only be granted access to the outside after verifying who the resident was leaving with to ensure they were leaving with an appropriate person. Interview with the former Administrator (Administrator at the time of the elopement), on 12/16/14 at 10:20 AM, revealed on 11/20/14, Resident #1 exited the facility as the staff at the reception desk did not realize that the resident was leaving with an unauthorized person. It was the wrong assumption by the staff. She stated that the staff didn't respond appropriately and should have inquired of the person why she was leaving with the resident. The former Administrator stated, "I can't believe it happened. We all knew to watch for the resident going through the doors and the staff made an assumption." **The Facility implemented the following the following actions to remove the Immediate Jeopardy: 1. The facility placed Resident #1 on one to one (1:1) supervision beginning on 11/20/14 at 2:30 PM, and continued through the remainder of his/her stay at the facility. Resident #1 was discharged to a Licensed Alzheimer's facility on 11/21/14 at 1:15 PM. 2. The Assistant Director of Nursing (ADON) completed an updated elopement evaluation for Resident #1 on 11/20/14. Resident #1's care plan was updated on 11/20/14 by the ADON to include review of elopement evaluation and 1:1 supervision. 3. The Administrator instructed the Maintenance Assistant to check all egress doors (the main exit door was evaluated first). The alarm function and sensitivity of all doors was found to be working properly. This was conducted on 11/20/14 at approximately 2:00 PM. 4. Alarm and Wander Guard function audits were completed on 11/20/14 by the Maintenance Assistant with all door locking mechanisms and alarms found to be working properly. 5. The RN Nurse Practice Educator (NPE) and Licensed Practical Nurses (LPNs) reviewed all residents (5 of 5) at risk for elopement on 11/20/14. The Elopement Risk Evaluations for at risk residents, care plans, and care cards were reviewed and updated as needed by the RN Nurse Practice Educator and LPN on 11/20/14. 6. Sixty- seven (67) of sixty-nine (69) Skilled Nursing Facility (SNF) residents were reviewed by a LPN or RN on 11/20/14 for elopement risks utilizing elopement risks evaluations. Two (2) residents were on hospital bed holds and were reviewed upon re-admission on 11/21/14 and 11/27/14 with no other residents identified for elopement risk. 7. A new, bright red notification sign was implemented by the Administrator to notify visitors and families that anytime a resident is being accompanied out of the facility, they must sign the resident out of the facility and notify a staff member before leaving. The sign was posted on all exit doors on 11/20/14. 8. On 11/21/14, the Administrator implemented a system to provide a copy of resident appointments to be maintained at the front reception desk. 9. The system for signing residents in and out of the facility was revised on 11/21/14 to include the following revisions: One of the following: CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator will be responsible for signing residents in and out at the nurse's station. Additionally, one of the staff listed above will be assigned to the receptionist desk and this person would be responsible for signing residents and family members out at the front desk, verifying appointments and sign-out at the nurse's station before a resident leaves the building. In addition, one of the above listed staff members will be assigned to the receptionist desk and to the nurses' station to ensure the resident is signed back into the facility upon return. 10. The Administrator mailed an informational letter (340) total, on 11/21/14, to active vendors, family members, churches, and volunteers to inform them they must sign residents out at the nursing stations and at the reception desk as well as to be mindful of the alarms and seek staff assistance when an alarm is sounding as well as be mindful of a resident attempting to exit the facility. 11. The RN NPE re-education the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, and the Administrator on 11/20/14. Then the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator reeducated 100% of staff beginning on 11/20/14. One-hundred and four (104) of one-hundred and six (106) active employees and/or contract employees completed re-education and post testing between 11/20/14 and 12/03/14. Re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 12. All new employees are to have elopement education provided during orientation including the procedure for allowing a resident to exit the facility, including signing out at the receptionist desk or nursing station as well as validating the credentials of the person accompanying the resident from the facility. This was added to new employee orientation on 11/21/14. 13. CNA #1 and the Payroll/Accounts Payable Clerk received final written warnings on 11/21/14 provided by the Administrator. 14. The Regional Vice President of Operations (RVPO) provided re-education to the Administrator and DON on 12/03/14 via phone conference and in person by the Regional Manager of Clinical Operations (RMCO) regarding his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administration requirements. In addition, specific information included the CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the Administrator and DON on 12/03/14 by the RDCO with 100% pass rating. 15. Beginning on 12/03/14, upon notification of an elopement, the Administrator will notify the RVPO, RMCO, or the Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to continue for six (6) months for any elopement that may occur. 16. On 12/10/14, the RMCO provided additional re-education to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator. In addition, the Regional Director of Food Services provided one on one re-education with the Dietary Manager. The re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Following the above training, on 12/10/14, employee re-education was initiated. Re-education began on 12/10/14 completed by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. This re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility; including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following each resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. Sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post testing on 12/10/14. Employees not available for this re-education will have re-education and post-tests completed with 100% pass rate prior to returning to or beginning work by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. 18. An AD-HOC Performance Improvement (PI) meeting was held on 11/20/14 to review the PI action plan with the acting Medical Director. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 19. Beginning on the day shift of 11/21/14, the Maintenance Assistant completed an elopement drill on each shift through 11/22/14 to audit training compliance with no concerns identified. 20. Charge Nurses (RNs/LPNs), Department Manager, or Maintenance Assistant will complete two (2) elopement drills on each shift monthly for three (3) months, 11/2014, 12/2014, and 01/2015, then two (2) quarterly for six (6) months. Corrective action will be provided for identified audit concerns. Findings will be reviewed by the PI Committee and recommendations for additional audits will be based on audit outcomes. 21. An AD HOC PI meeting was held on 11/21/14 with the PI Committee members to review the progress of the improvement plan with no other action steps determined to be required. 22. Beginning 12/10/14, appointment log and sign out audits were completed by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments for weekly for eight (8) weeks , then five resident appointments monthly for two (2) months. 23. Beginning 12/10/14, care plan audits were to be completed by RN or LPN Licensed Nurses, RN NPE, ADON, Minimum Data Set (MDS), or DON. The audits were completed on three (3) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks and then five (5) residents monthly for two (2) months. 24. Beginning 12/10/14, QAPI meetings will be reviewed by the RVPO or RMCO for the next three (3) months. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the one on one (1:1) monitoring logs, revealed Resident #1 was placed under 1:1 supervision beginning on 11/20/14 at 2:30 PM and the 1:1 supervision continued until the resident was discharged to a Licensed Alzheimer facility on 11/21/14 at 1:15 PM. 2. Review of an elopement evaluation completed on 11/20/14 by the ADON, revealed Resident #1 was on elopement risk and no other concerns were identified. Review of the care plan revealed it was updated on 11/20/14 by the ADON to include the updated elopement evaluation and 1:1 supervision. 3. Review of the Maintenance Assistant alarm check form, dated 11/20/14 at approximately 2:00 PM, revealed all egress doors (main exit door checked first), and all exit doors alarms were functioning appropriately. 4. Review of the audit of wander guards and alarms, conducted by the Maintenance Assistant on 11/20/14, revealed no concerns. 5. Review of the audits for 5 of 5 residents at risk for elopement revealed on 11/20/14 the RN, RN NPE and LPN reviewed the elopement risks evaluations, care plans, and care cards with revisions made as needed. 6. Review of the elopement risks evaluations completed on sixty-seven (67) of sixty-nine (69) SNF residents on 11/20/14 revealed all but two (2) residents (who were on bed hold), had elopement risk evaluations utilized to determine at risk residents. The two (2) residents on bed hold had evaluations completed on re-admission 11/21/14 and 11/27/14. 7. Observations on 12/19/14 revealed new signage created by the Administrator, was placed at all exit doors on 11/20/14 to inform visitors, vendors, and families they must sign a resident out at the reception desk or nursing station and notify staff before leaving with the resident. 8. Review of a new system to monitor resident appointments revealed an appointment log audit/sign in/out audit was placed at the front reception desk on 11/21/14. 9. Review of the revised system for signing residents in and out of the facility, revised on 11/21/14, revealed one of the following staff will be responsible for signing a resident in and out at the nursing station : CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator . Additionally, one of the staff members listed above will be responsible for signing a resident in and out at the reception desk. 10. Review of the informational letter sent to active vendors, family members, churches, and volunteers to inform them of the procedure of signing a resident in and out as well as being more mindful of an alarm sounding and of a resident attempting to exit the facility. Three hundred forty (340) letters were mailed on 11/21/14 by the Administrator. 11. Review of re-education conducted on 11/20/14 by the NPE and was continued by the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator, revealed education was completed on 12/03/14 on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and, the facility policy for following a resident's plan of care. Review of re-education listed above revealed one hundred four (104) of one hundred six (106) employees completed re-education and post-tests between 11/20/14 and 12/03/14. Staff interviews conducted on 12/19/14 with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, and RN Unit Manager at 11:49 AM, RN NPE at 8:15 AM, Housekeeping Aide at 9:00 AM, RMCO at 9:45 AM, Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated on center policies on elopement prevention and management; and the procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. 12. Review of three (3) new hire employees revealed they received the education on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. 13. Review of Individual Performance Improvement Plans for CNA #1 and the Payroll/Benefits Clerk, conducted on 11/21/14, by the Administrator and ADON, revealed they both received education related to closer monitoring of residents exiting the building and alarms sounding. Elopement education was provided on 11/20/14 and 11/21/14. 14. Review of education provided to the Administrator and DON, conducted on 12/03/14 by the RMCO and RVPO, revealed re-education was provided related to his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administrative requirements. Interviews conducted with the Administrator on 12/19/14 at 12:45 PM and DON at 12:40 AM, revealed they had re-educated by the RVPO and RMCO related to Quality Indicators, reporting, elopements, documentation, new visitors policy, new audit tools, care plans, root cause analysis, and notification of significant events. Both completed post-tests with 100 % pass rate. 15. No other elopements had occurred at the time of the verification of the AoC; however, interview with the Administrator on 12/19/14 at 12:45 PM revealed he was aware of his responsibility to inform the RVPO, RMCO, or the Regional Clinical Educator for validation a thorough investigation would be immediately initiated. 16. Review of re-education, conducted on 12/10/14, by the RMCO to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator, revealed all were re-educated, and the Regional Director of Food Services providing education one to one for the Dietary Manager. The education consisted of center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Review of additional training following the above training revealed, on 12/10/14, re-education was provided to staff by the RN NPE, DON, ADON, Maintenance Assistant, or the Administrator regarding the same topics listed above. Review of in-service/re-education sign-in logs, dated 12/10/14, revealed sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post-tests. 18. Review of AD-HOC PI meeting minutes, dated 11/20/14, (no time), and revealed the PI Committee met with the acting Medical Director to review the PI action plan. 19. Review of the in-service sign in sheets, dated 11/21/14 at 1:00 PM and at 3:00 PM, (day and second shift staff) revealed elopement drills (code yellow) were conducted by the Maintenance Assistant. Review of the in-service sign in sheets dated 11/22/14 at 3:00 AM to 3:20 AM, revealed elopement drills (code yellow) were conducted with night shift staff. 20. Review of elopement drill calendars revealed Charge nurses (RN/LPNs), Department Manager or Maintenance Assistant were to complete two (2) elopement drills on each shift monthly x 3 month beginning 11/14 through 01/15, then 2 quarterly 6 months. Corrective action/reeducation to be provided with issues identified. Findings reviewed by the PI Committee and recommendations will be made accordingly. 21. Review of AD-HOC meeting minutes, dated 11/21/14, (no time) revealed the PI Committee met to discuss the elopement of Resident #1. Issues of prevention, resident assessment, re-education of staff, initiation of new sign out procedures, resident appointment schedule posted at receptionist desk and possible referral to sister facility with a special dementia focus was discussed. The Medical Director attended via phone conference. 22. Review of the newly implemented Appointment Log and sign out sheets, revealed they were being audited by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 23. Review of care plan audit calendar revealed these were being completed as per the AoC, beginning on 12/10/14. Review of the Daily Chart Audit, dated 12/10/14 revealed care plans and care cards were being audited and updated as needed, by the RN, LPN, RN NPE, ADON, MDS, or DON. . The audits to be completed daily

Based on interview, record review, review of the Administrator's Job Description, Administrator's Responsibilities, and review of the facility's policy/procedure, Allegation of Compliance (AoC) and Plan of Correction (PoC) for the 09/18/14 Immediate Jeopardy abbreviated survey, it was determined the facility failed to have an effective system to ensure systemic changes were implemented to maintain residents' safety. This failure affected one (1) of eighteen (18) sampled residents (Resident #1). Resident #1 had previously left the faciity on [DATE] by following visitors out the main front doors of the facility without staff knowledge. The facility failed to ensure the safety of Resident #1 as the resident was allowed to leave the facility (approximately three (3) months later) a second time out the same doors with an unauthorized person. (Refer to F323) On 11/20/14 at approximately 1:30 PM, Resident #1 followed a visitor through the front door of the facility. The resident was wearing a wanderguard and Certified Nursing Assistant (CNA) #1 thought the resident was leaving the facility for an appointment and silenced the alarm; however, the staff failed to verify that the resident had been signed out to leave the facility with an escort. The Administrator failed to ensure staff was knowledgeable of the facility's policies and procedures. The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy was identified on 11/26/14 and was determined to exist on 11/20/14. The facility was notified of the Immediate Jeopardy on 11/26/14. An acceptable Allegation of Compliance (AoC) was received on 12/16/14 alleging the removal of IJ on 12/11/14. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. (Refer to F323) The findings include: Review of the facility's policy titled "Administrator Responsibilities", last revised 04/01/03, revealed the Administrator will be responsible for the day to day operations of the Center in accordance with Corporate Policies and Procedures and state, federal, and local regulations. Review of the Job Description for the Administrator, revised 08/01/12, revealed, "The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents." Review of the facility's policy titled "Elopement of Patient", last revised 05/15/14, revealed residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a resident leaves the premises without authorization and/or any necessary supervision to do so, and the purpose of the policy was to provide a process for managing residents at risk for elopement. Sign in/out records will be maintained and used whenever a resident leaves the Center's grounds alone, with family, or with recreational staff. Review of the facility's AoC and the PoC from the 09/18/14 Immediate Jeopardy Abbreviated Survey revealed one hundred (100%) percent of the staff was educated on the expected response to a door alarm. Per the AoC and PoC, all staff would respond when an alarm sounds. In addition, the AoC and PoC stated staff was educated on the facility's policy and procedures related to elopement prevention and management. Review of the facility's Elopement Policy revealed Sign in/out Records would be maintained and used whenever a resident left the Center grounds alone, with family, or with recreational staff. Further review revealed individual risk factors and patterns would be identified and addressed within the care plan. These interventions would be communicated to staff. Record review revealed the facility assessed Resident #1 as an elopement risk, with Resident #1 having a previous elopement on 08/26/14. Review of Resident #1's Comprehensive Plan of Care revealed interventions which included for all staff to utilize the Sign in/out Records when the resident left the Center with an escort. Record review also revealed this intervention was part of the facility's "Elopement of Patient" policy. Interview and record review revealed, on 11/20/14 at 1:30 PM, Resident #1 came through the double doors to the front of the facility with Visitor #1, who was wearing scrubs. Further review revealed staff assumed Visitor #1 was taking the resident to an appointment. Staff hit the red button to open the doors and the alarm sounded due to the resident wearing a wanderguard. Staff then disarmed the alarm and Resident #1 followed the visitor out the doors. Even though the alarm sounded other staff did not respond, as they should have according to the AoC and PoC. In addition, staff failed to verify that the resident had been signed out to leave the facility, as was required per the resident's Plan of Care and the facility's policy. The resident left the facility's property with Visitor #1 and was returned by the Visitor at approximately 1:45 PM. Interviews with the Payroll/Benefit staff member, on 11/26/14 at 11:04 AM and on 01/22/15 at 9:55 AM (post survey interview); and, with CNA #1, on 11/26/14 at 11:21 AM; and, on 01/22/15 at 10:35 AM (post survey interview), revealed they both thought Visitor #1 was taking Resident #1 to an appointment and CNA #1 deactivated the alarm. Per interview, Payroll/Benefit staff member and CNA #1 did not know they were to verify if the resident had been signed out to leave the facility. According to CNA #1 and Payroll/Benefit staff member, no other staff responded when the alarm sounded. Interview with Registered Nurse (RN) #3, on 12/16/14 at 11:19 AM, revealed she heard the alarm sound, but it was silenced quickly and she assumed that someone had taken care of it and she did not respond or conduct a head count at that time. Per the facility's AOC and POC, all staff should have responded to the alarm and determined the reason the alarm had sounded. Interview with the Director of Nursing (DON), on 11/26/14 at 4:17 PM, revealed Resident #1 exited the facility on 11/20/14 with an unauthorized person. She stated there was not a formal system in place for the staff to verify the resident was signed out at the nurse's desk even though this was part of the facility's policy and the resident's care plan. Interview, on 12/16/14 at 10:20 AM, with the former Administrator, (who was in charge when the resident left the facility) revealed she expected staff to react to the sounding alarm, go to the panel to look for the location of the breach, do a search and resident head count if unable to account for the reason of the alarm. She stated on 11/20/14, Resident #1 exited the facility as the staff at the reception desk did not realize that the resident was leaving with an unauthorized person. She stated it was the wrong assumption by the staff and the staff didn't respond appropriately and should have inquired of the person why she was leaving with the resident. The former Administrator stated, "I can't believe it happened. We all knew to watch for the resident going through the doors and the staff made an assumption." **The Facility implemented the following the following actions to remove the Immediate Jeopardy: 1. The facility placed Resident #1 on one to one (1:1) supervision beginning on 11/20/14 at 2:30 PM, and continued through the remainder of his/her stay at the facility. Resident #1 was discharged to a Licensed Alzheimer's facility on 11/21/14 at 1:15 PM. 2. The Assistant Director of Nursing (ADON) completed an updated elopement evaluation for Resident #1 on 11/20/14. Resident #1's care plan was updated on 11/20/14 by the ADON to include review of elopement evaluation and 1:1 supervision. 3. The Administrator instructed the Maintenance Assistant to check all egress doors (the main exit door was evaluated first). The alarm function and sensitivity of all doors was found to be working properly. This was conducted on 11/20/14 at approximately 2:00 PM. 4. Alarm and Wander Guard function audits were completed on 11/20/14 by the Maintenance Assistant with all door locking mechanisms and alarms found to be working properly. 5. The RN Nurse Practice Educator (NPE) and Licensed Practical Nurses (LPNs) reviewed all residents (5 of 5) at risk for elopement on 11/20/14. The Elopement Risk Evaluations for at risk residents, care plans, and care cards were reviewed and updated as needed by the RN Nurse Practice Educator and LPN on 11/20/14. 6. Sixty- seven (67) of sixty-nine (69) Skilled Nursing Facility (SNF) residents were reviewed by a LPN or RN on 11/20/14 for elopement risks utilizing elopement risks evaluations. Two (2) residents were on hospital bed holds and were reviewed upon re-admission on 11/21/14 and 11/27/14 with no other residents identified for elopement risk. 7. A new, bright red notification sign was implemented by the Administrator to notify visitors and families that anytime a resident is being accompanied out of the facility, they must sign the resident out of the facility and notify a staff member before leaving. The sign was posted on all exit doors on 11/20/14. 8. On 11/21/14, the Administrator implemented a system to provide a copy of resident appointments to be maintained at the front reception desk. 9. The system for signing residents in and out of the facility was revised on 11/21/14 to include the following revisions: One of the following: CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator will be responsible for signing residents in and out at the nurse's station. Additionally, one of the staff listed above will be assigned to the receptionist desk and this person would be responsible for signing residents and family members out at the front desk, verifying appointments and sign-out at the nurse's station before a resident leaves the building. In addition, one of the above listed staff members will be assigned to the receptionist desk and to the nurses' station to ensure the resident is signed back into the facility upon return. 10. The Administrator mailed an informational letter (340) total, on 11/21/14, to active vendors, family members, churches, and volunteers to inform them they must sign residents out at the nursing stations and at the reception desk as well as to be mindful of the alarms and seek staff assistance when an alarm is sounding as well as be mindful of a resident attempting to exit the facility. 11. The RN NPE re-education the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, and the Administrator on 11/20/14. Then the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator reeducated 100% of staff beginning on 11/20/14. One-hundred and four (104) of one-hundred and six (106) active employees and/or contract employees completed re-education and post testing between 11/20/14 and 12/03/14. Re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 12. All new employees are to have elopement education provided during orientation including the procedure for allowing a resident to exit the facility, including signing out at the receptionist desk or nursing station as well as validating the credentials of the person accompanying the resident from the facility. This was added to new employee orientation on 11/21/14. 13. CNA #1 and the Payroll/Accounts Payable Clerk received final written warnings on 11/21/14 provided by the Administrator. 14. The Regional Vice President of Operations (RVPO) provided re-education to the Administrator and DON on 12/03/14 via phone conference and in person by the Regional Manager of Clinical Operations (RMCO) regarding his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administration requirements. In addition, specific information included the CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the Administrator and DON on 12/03/14 by the RDCO with 100% pass rating. 15. Beginning on 12/03/14, upon notification of an elopement, the Administrator will notify the RVPO, RMCO, or the Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to continue for six (6) months for any elopement that may occur. 16. On 12/10/14, the RMCO provided additional re-education to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator. In addition, the Regional Director of Food Services provided one on one re-education with the Dietary Manager. The re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Following the above training, on 12/10/14, employee re-education was initiated. Re-education began on 12/10/14 completed by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. This re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility; including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following each resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. Sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post testing on 12/10/14. Employees not available for this re-education will have re-education and post-tests completed with 100% pass rate prior to returning to or beginning work by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. 18. An AD-HOC Performance Improvement (PI) meeting was held on 11/20/14 to review the PI action plan with the acting Medical Director. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 19. Beginning on the day shift of 11/21/14, the Maintenance Assistant completed an elopement drill on each shift through 11/22/14 to audit training compliance with no concerns identified. 20. Charge Nurses (RNs/LPNs), Department Manager, or Maintenance Assistant will complete two (2) elopement drills on each shift monthly for three (3) months, 11/2014, 12/2014, and 01/2015, then two (2) quarterly for six (6) months. Corrective action will be provided for identified audit concerns. Findings will be reviewed by the PI Committee and recommendations for additional audits will be based on audit outcomes. 21. An AD HOC PI meeting was held on 11/21/14 with the PI Committee members to review the progress of the improvement plan with no other action steps determined to be required. 22. Beginning 12/10/14, appointment log and sign out audits were completed by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments for weekly for eight (8) weeks , then five resident appointments monthly for two (2) months. 23. Beginning 12/10/14, care plan audits were to be completed by RN or LPN Licensed Nurses, RN NPE, ADON, Minimum Data Set (MDS), or DON. The audits were completed on three (3) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks and then five (5) residents monthly for two (2) months. 24. Beginning 12/10/14, QAPI meetings will be reviewed by the RVPO or RMCO for the next three (3) months. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the one on one (1:1) monitoring logs, revealed Resident #1 was placed under 1:1 supervision beginning on 11/20/14 at 2:30 PM and the 1:1 supervision continued until the resident was discharged to a Licensed Alzheimer facility on 11/21/14 at 1:15 PM. 2. Review of an elopement evaluation completed on 11/20/14 by the ADON, revealed Resident #1 was on elopement risk and no other concerns were identified. Review of the care plan revealed it was updated on 11/20/14 by the ADON to include the updated elopement evaluation and 1:1 supervision. 3. Review of the Maintenance Assistant alarm check form, dated 11/20/14 at approximately 2:00 PM, revealed all egress doors (main exit door checked first), and all exit doors alarms were functioning appropriately. 4. Review of the audit of wander guards and alarms, conducted by the Maintenance Assistant on 11/20/14, revealed no concerns. 5. Review of the audits for 5 of 5 residents at risk for elopement revealed on 11/20/14 the RN, RN NPE and LPN reviewed the elopement risks evaluations, care plans, and care cards with revisions made as needed. 6. Review of the elopement risks evaluations completed on sixty-seven (67) of sixty-nine (69) SNF residents on 11/20/14 revealed all but two (2) residents (who were on bed hold), had elopement risk evaluations utilized to determine at risk residents. The two (2) residents on bed hold had evaluations completed on re-admission 11/21/14 and 11/27/14. 7. Observations on 12/19/14 revealed new signage created by the Administrator, was placed at all exit doors on 11/20/14 to inform visitors, vendors, and families they must sign a resident out at the reception desk or nursing station and notify staff before leaving with the resident. 8. Review of a new system to monitor resident appointments revealed an appointment log audit/sign in/out audit was placed at the front reception desk on 11/21/14. 9. Review of the revised system for signing residents in and out of the facility, revised on 11/21/14, revealed one of the following staff will be responsible for signing a resident in and out at the nursing station : CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator . Additionally, one of the staff members listed above will be responsible for signing a resident in and out at the reception desk. 10. Review of the informational letter sent to active vendors, family members, churches, and volunteers to inform them of the procedure of signing a resident in and out as well as being more mindful of an alarm sounding and of a resident attempting to exit the facility. Three hundred forty (340) letters were mailed on 11/21/14 by the Administrator. 11. Review of re-education conducted on 11/20/14 by the NPE and was continued by the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator, revealed education was completed on 12/03/14 on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and, the facility policy for following a resident's plan of care. Review of re-education listed above revealed one hundred four (104) of one hundred six (106) employees completed re-education and post-tests between 11/20/14 and 12/03/14. Staff interviews conducted on 12/19/14 with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, and RN Unit Manager at 11:49 AM, RN NPE at 8:15 AM, Housekeeping Aide at 9:00 AM, RMCO at 9:45 AM, Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated on center policies on elopement prevention and management; and the procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. 12. Review of three (3) new hire employees revealed they received the education on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. 13. Review of Individual Performance Improvement Plans for CNA #1 and the Payroll/Benefits Clerk, conducted on 11/21/14, by the Administrator and ADON, revealed they both received education related to closer monitoring of residents exiting the building and alarms sounding. Elopement education was provided on 11/20/14 and 11/21/14. 14. Review of education provided to the Administrator and DON, conducted on 12/03/14 by the RMCO and RVPO, revealed re-education was provided related to his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administrative requirements. Interviews conducted with the Administrator on 12/19/14 at 12:45 PM and DON at 12:40 AM, revealed they had re-educated by the RVPO and RMCO related to Quality Indicators, reporting, elopements, documentation, new visitors policy, new audit tools, care plans, root cause analysis, and notification of significant events. Both completed post-tests with 100 % pass rate. 15. No other elopements had occurred at the time of the verification of the AoC; however, interview with the Administrator on 12/19/14 at 12:45 PM revealed he was aware of his responsibility to inform the RVPO, RMCO, or the Regional Clinical Educator for validation a thorough investigation would be immediately initiated. 16. Review of re-education, conducted on 12/10/14, by the RMCO to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator, revealed all were re-educated, and the Regional Director of Food Services providing education one to one for the Dietary Manager. The education consisted of center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Review of additional training following the above training revealed, on 12/10/14, re-education was provided to staff by the RN NPE, DON, ADON, Maintenance Assistant, or the Administrator regarding the same topics listed above. Review of in-service/re-education sign-in logs, dated 12/10/14, revealed sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post-tests. 18. Review of AD-HOC PI meeting minutes, dated 11/20/14, (no time), and revealed the PI Committee met with the acting Medical Director to review the PI action plan. 19. Review of the in-service sign in sheets, dated 11/21/14 at 1:00 PM and at 3:00 PM, (day and second shift staff) revealed elopement drills (code yellow) were conducted by the Maintenance Assistant. Review of the in-service sign in sheets dated 11/22/14 at 3:00 AM to 3:20 AM, revealed elopement drills (code yellow) were conducted with night shift staff. 20. Review of elopement drill calendars revealed Charge nurses (RN/LPNs), Department Manager or Maintenance Assistant were to complete two (2) elopement drills on each shift monthly x 3 month beginning 11/14 through 01/15, then 2 quarterly 6 months. Corrective action/reeducation to be provided with issues identified. Findings reviewed by the PI Committee and recommendations will be made accordingly. 21. Review of AD-HOC meeting minutes, dated 11/21/14, (no time) revealed the PI Committee met to discuss the elopement of Resident #1. Issues of prevention, resident assessment, re-education of staff, initiation of new sign out procedures, resident appointment schedule posted at receptionist desk and possible referral to sister facility with a special dementia focus was discussed. The Medical Director attended via phone conference. 22. Review of the newly implemented Appointment Log and sign out sheets, revealed they were being audited by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 23. Review of care plan audit calendar revealed these were being completed as per the AoC, beginning on 12/10/14. Review of the Daily Chart Audit, dated 12/10/14 revealed care plans and care cards were being audited and updated as needed, by the RN, LPN, RN NPE, ADON, MDS, or DON. . The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 24. Review of the QAPI meetings calendar revealed reviews to be completed by the RVPO or RMCO for the next three (3) months.

Based on interview, record review, review of the facility's Allegation of Compliance (AoC) and Plan of Correction (PoC) for the Immediate Jeopardy Abbreviated Survey on 09/18/14, and review of the facility's Quality Assurance (QA) Policy, it was determined the Quality Assessment and Assurance Committee failed to have an effective system to ensure appropriate action plans for quality deficiencies were developed and implemented to prevent recurrence related to elopement. This failure affected one (1) of eighteen (18) sampled residents (Resident #1). Resident #1 had previously left the faciity on [DATE] by following visitors out the main front doors of the facility without staff knowledge. The facility failed to ensure its QA monitoring was effective to prevent a recurrence. On 11/20/14 at approximately 1:30 PM, Resident #1 followed a visitor through the same main front doors of the facility again. The resident's wanderguard caused the alarm to sound; however, Certified Nursing Assistant (CNA) #1 and the Payroll/Benefits Coordinator believed the resident was leaving with the visitor for an appointment. CNA #1 silenced the alarm, allowing the resident to leave behind the visitor. This time the resident was off the facility's property with a visitor. (Refer to F323) The facility's failure to have an effective QA program to prevent the recurrence of quality deficiencies related to elopement has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy was identified on 11/26/14 and was determined to exist on 11/20/14. The facility was notified of the Immediate Jeopardy on 11/26/14. An acceptable Allegation of Compliance (AoC) was received on 12/16/14 alleging the removal of IJ on 12/11/14. The findings include: Review of the facility's policy titled, "Center Quality Improvement Process", last revised 04/01/03, revealed the Quality processes were to provide a framework for structuring and implementing data-driven quality improvement and to establish and maintain a quality improvement process that would satisfy internal standards of excellence and regulatory requirements. Interview with Certified Nursing Assistant (CNA) #1, on 11/16/14 at 11:21 AM; and, with the Payroll/Benefits Coordinator on 11/26/14 at 11:04 AM, revealed they believed Resident #1 was leaving with the visitor for an appointment on 11/20/14. Further interview revealed they disarmed the alarm system and allowed the resident to leave the facility, without ensuring the resident had been signed out, as per policy. CNA #1 and Payroll/Benefits Coordinator, both stated they had not been inservied on ensuring residents had been signed out before allowing them to leave the facility. Review of the facility's AoC and Plan of Correction (PoC), developed after Resident #1's first elopement on 08/26/14, with a compliance date of 10/02/14, revealed all staff received education on the Center's policy and procedures on elopement prevention and management. However, interview with the Nurse Practice Educator, on 01/22/15 at 8:25 AM (post survey interview), revealed when the facility educated the staff on its' Elopement Policy and Procedures, the part of the procedures that addressed the use of sign in/out records whenever the resident left the grounds alone, with family or staff was not included in the education. Further review of the facility's AoC and PoC, revealed the education included that all staff should respond when an alarm sounded and the facility's QA monitoring included the completion of Elopement Drills which included staff's response to the alarm. This was conducted on each shift for three (3) months; September, October, and November 2014. Record review revealed no issues had been identified related to staff response. However, interview and record review revealed the door alarm sounded on 11/20/14 when the resident attempted to leave with Visitor #1. Per interview, staff on the unit heard the alarm; but, they failed to respond. In addition, staff revealed they had not received any training related to verifying that a resident was signed out prior to letting the resident out the front doors of the facility. Interview with the former Administrator, on 12/16/14 at 10:20 AM, revealed she expected staff to react to the sounding alarm, go to the panel to look for location of the breach, do a search and resident head count if unable to account for the reason of the alarm. However, this was not done on 11/20/14. In addition, she stated the staff at the reception desk did not realize that the resident was leaving with an unauthorized person. She stated it was the wrong assumption by the staff and the staff didn't respond appropriately and should have inquired of the person why she was leaving with the resident. **The facility implemented the following the following actions to remove the Immediate Jeopardy: 1. The facility placed Resident #1 on one to one (1:1) supervision beginning on 11/20/14 at 2:30 PM, and continued through the remainder of his/her stay at the facility. Resident #1 was discharged to a Licensed Alzheimer's facility on 11/21/14 at 1:15 PM. 2. The Assistant Director of Nursing (ADON) completed an updated elopement evaluation for Resident #1 on 11/20/14. Resident #1's care plan was updated on 11/20/14 by the ADON to include review of elopement evaluation and 1:1 supervision. 3. The Administrator instructed the Maintenance Assistant to check all egress doors (the main exit door was evaluated first). The alarm function and sensitivity of all doors was found to be working properly. This was conducted on 11/20/14 at approximately 2:00 PM. 4. Alarm and Wander Guard function audits were completed on 11/20/14 by the Maintenance Assistant with all door locking mechanisms and alarms found to be working properly. 5. The RN Nurse Practice Educator (NPE) and Licensed Practical Nurses (LPNs) reviewed all residents (5 of 5) at risk for elopement on 11/20/14. The Elopement Risk Evaluations for at risk residents, care plans, and care cards were reviewed and updated as needed by the RN Nurse Practice Educator and LPN on 11/20/14. 6. Sixty- seven (67) of sixty-nine (69) Skilled Nursing Facility (SNF) residents were reviewed by a LPN or RN on 11/20/14 for elopement risks utilizing elopement risks evaluations. Two (2) residents were on hospital bed holds and were reviewed upon re-admission on 11/21/14 and 11/27/14 with no other residents identified for elopement risk. 7. A new, bright red notification sign was implemented by the Administrator to notify visitors and families that anytime a resident is being accompanied out of the facility, they must sign the resident out of the facility and notify a staff member before leaving. The sign was posted on all exit doors on 11/20/14. 8. On 11/21/14, the Administrator implemented a system to provide a copy of resident appointments to be maintained at the front reception desk. 9. The system for signing residents in and out of the facility was revised on 11/21/14 to include the following revisions: One of the following: CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator will be responsible for signing residents in and out at the nurse's station. Additionally, one of the staff listed above will be assigned to the receptionist desk and this person would be responsible for signing residents and family members out at the front desk, verifying appointments and sign-out at the nurse's station before a resident leaves the building. In addition, one of the above listed staff members will be assigned to the receptionist desk and to the nurses' station to ensure the resident is signed back into the facility upon return. 10. The Administrator mailed an informational letter (340) total, on 11/21/14, to active vendors, family members, churches, and volunteers to inform them they must sign residents out at the nursing stations and at the reception desk as well as to be mindful of the alarms and seek staff assistance when an alarm is sounding as well as be mindful of a resident attempting to exit the facility. 11. The RN NPE re-education the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, and the Administrator on 11/20/14. Then the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator reeducated 100% of staff beginning on 11/20/14. One-hundred and four (104) of one-hundred and six (106) active employees and/or contract employees completed re-education and post testing between 11/20/14 and 12/03/14. Re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 12. All new employees are to have elopement education provided during orientation including the procedure for allowing a resident to exit the facility, including signing out at the receptionist desk or nursing station as well as validating the credentials of the person accompanying the resident from the facility. This was added to new employee orientation on 11/21/14. 13. CNA #1 and the Payroll/Accounts Payable Clerk received final written warnings on 11/21/14 provided by the Administrator. 14. The Regional Vice President of Operations (RVPO) provided re-education to the Administrator and DON on 12/03/14 via phone conference and in person by the Regional Manager of Clinical Operations (RMCO) regarding his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administration requirements. In addition, specific information included the CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the Administrator and DON on 12/03/14 by the RDCO with 100% pass rating. 15. Beginning on 12/03/14, upon notification of an elopement, the Administrator will notify the RVPO, RMCO, or the Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to continue for six (6) months for any elopement that may occur. 16. On 12/10/14, the RMCO provided additional re-education to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator. In addition, the Regional Director of Food Services provided one on one re-education with the Dietary Manager. The re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Following the above training, on 12/10/14, employee re-education was initiated. Re-education began on 12/10/14 completed by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. This re-education included center policies on elopement prevention and management; procedure for allowing a resident to exit the facility; including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following each resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. Sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post testing on 12/10/14. Employees not available for this re-education will have re-education and post-tests completed with 100% pass rate prior to returning to or beginning work by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. 18. An AD-HOC Performance Improvement (PI) meeting was held on 11/20/14 to review the PI action plan with the acting Medical Director. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 19. Beginning on the day shift of 11/21/14, the Maintenance Assistant completed an elopement drill on each shift through 11/22/14 to audit training compliance with no concerns identified. 20. Charge Nurses (RNs/LPNs), Department Manager, or Maintenance Assistant will complete two (2) elopement drills on each shift monthly for three (3) months, 11/2014, 12/2014, and 01/2015, then two (2) quarterly for six (6) months. Corrective action will be provided for identified audit concerns. Findings will be reviewed by the PI Committee and recommendations for additional audits will be based on audit outcomes. 21. An AD HOC PI meeting was held on 11/21/14 with the PI Committee members to review the progress of the improvement plan with no other action steps determined to be required. 22. Beginning 12/10/14, appointment log and sign out audits were completed by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments for weekly for eight (8) weeks , then five resident appointments monthly for two (2) months. 23. Beginning 12/10/14, care plan audits were to be completed by RN or LPN Licensed Nurses, RN NPE, ADON, Minimum Data Set (MDS), or DON. The audits were completed on three (3) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks and then five (5) residents monthly for two (2) months. 24. Beginning 12/10/14, QAPI meetings will be reviewed by the RVPO or RMCO for the next three (3) months. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the one on one (1:1) monitoring logs, revealed Resident #1 was placed under 1:1 supervision beginning on 11/20/14 at 2:30 PM and the 1:1 supervision continued until the resident was discharged to a Licensed Alzheimer facility on 11/21/14 at 1:15 PM. 2. Review of an elopement evaluation completed on 11/20/14 by the ADON, revealed Resident #1 was on elopement risk and no other concerns were identified. Review of the care plan revealed it was updated on 11/20/14 by the ADON to include the updated elopement evaluation and 1:1 supervision. 3. Review of the Maintenance Assistant alarm check form, dated 11/20/14 at approximately 2:00 PM, revealed all egress doors (main exit door checked first), and all exit doors alarms were functioning appropriately. 4. Review of the audit of wander guards and alarms, conducted by the Maintenance Assistant on 11/20/14, revealed no concerns. 5. Review of the audits for 5 of 5 residents at risk for elopement revealed on 11/20/14 the RN, RN NPE and LPN reviewed the elopement risks evaluations, care plans, and care cards with revisions made as needed. 6. Review of the elopement risks evaluations completed on sixty-seven (67) of sixty-nine (69) SNF residents on 11/20/14 revealed all but two (2) residents (who were on bed hold), had elopement risk evaluations utilized to determine at risk residents. The two (2) residents on bed hold had evaluations completed on re-admission 11/21/14 and 11/27/14. 7. Observations on 12/19/14 revealed new signage created by the Administrator, was placed at all exit doors on 11/20/14 to inform visitors, vendors, and families they must sign a resident out at the reception desk or nursing station and notify staff before leaving with the resident. 8. Review of a new system to monitor resident appointments revealed an appointment log audit/sign in/out audit was placed at the front reception desk on 11/21/14. 9. Review of the revised system for signing residents in and out of the facility, revised on 11/21/14, revealed one of the following staff will be responsible for signing a resident in and out at the nursing station : CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM)and Accounts Payable/Benefits Coordinator . Additionally, one of the staff members listed above will be responsible for signing a resident in and out at the reception desk. 10. Review of the informational letter sent to active vendors, family members, churches, and volunteers to inform them of the procedure of signing a resident in and out as well as being more mindful of an alarm sounding and of a resident attempting to exit the facility. Three hundred forty (340) letters were mailed on 11/21/14 by the Administrator. 11. Review of re-education conducted on 11/20/14 by the NPE and was continued by the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator, revealed education was completed on 12/03/14 on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and, the facility policy for following a resident's plan of care. Review of re-education listed above revealed one hundred four (104) of one hundred six (106) employees completed re-education and post-tests between 11/20/14 and 12/03/14. Staff interviews conducted on 12/19/14 with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, and RN Unit Manager at 11:49 AM, RN NPE at 8:15 AM, Housekeeping Aide at 9:00 AM, RMCO at 9:45 AM, Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated on center policies on elopement prevention and management; and the procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility policy for following a resident's plan of care. 12. Review of three (3) new hire employees revealed they received the education on center policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. 13. Review of Individual Performance Improvement Plans for CNA #1 and the Payroll/Benefits Clerk, conducted on 11/21/14, by the Administrator and ADON, revealed they both received education related to closer monitoring of residents exiting the building and alarms sounding. Elopement education was provided on 11/20/14 and 11/21/14. 14. Review of education provided to the Administrator and DON, conducted on 12/03/14 by the RMCO and RVPO, revealed re-education was provided related to his/her job descriptions, the centers policies on care plan, resident safety, quality assurance and administrative requirements. Interviews conducted with the Administrator on 12/19/14 at 12:45 PM and DON at 12:40 AM, revealed they had re-educated by the RVPO and RMCO related to Quality Indicators, reporting, elopements, documentation, new visitors policy, new audit tools, care plans, root cause analysis, and notification of significant events. Both completed post-tests with 100 % pass rate. 15. No other elopements had occurred at the time of the verification of the AoC; however, interview with the Administrator on 12/19/14 at 12:45 PM revealed he was aware of his responsibility to inform the RVPO, RMCO, or the Regional Clinical Educator for validation a thorough investigation would be immediately initiated. 16. Review of re-education, conducted on 12/10/14, by the RMCO to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator, revealed all were re-educated, and the Regional Director of Food Services providing education one to one for the Dietary Manager. The education consisted of center policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nursing station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Review of additional training following the above training revealed, on 12/10/14, re-education was provided to staff by the RN NPE, DON, ADON, Maintenance Assistant, or the Administrator regarding the same topics listed above. Review of in-service/re-education sign-in logs, dated 12/10/14, revealed sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post-tests. 18. Review of AD-HOC PI meeting minutes, dated 11/20/14, (no time), and revealed the PI Committee met with the acting Medical Director to review the PI action plan. 19. Review of the in-service sign in sheets, dated 11/21/14 at 1:00 PM and at 3:00 PM, (day and second shift staff) revealed elopement drills (code yellow) were conducted by the Maintenance Assistant. Review of the in-service sign in sheets dated 11/22/14 at 3:00 AM to 3:20 AM, revealed elopement drills (code yellow) were conducted with night shift staff. 20. Review of elopement drill calendars revealed Charge nurses (RN/LPNs), Department Manager or Maintenance Assistant were to complete two (2) elopement drills on each shift monthly x 3 month beginning 11/14 through 01/15, then 2 quarterly 6 months. Corrective action/reeducation to be provided with issues identified. Findings reviewed by the PI Committee and recommendations will be made accordingly. 21. Review of AD-HOC meeting minutes, dated 11/21/14, (no time) revealed the PI Committee met to discuss the elopement of Resident #1. Issues of prevention, resident assessment, re-education of staff, initiation of new sign out procedures, resident appointment schedule posted at receptionist desk and possible referral to sister facility with a special dementia focus was discussed. The Medical Director attended via phone conference. 22. Review of the newly implemented Appointment Log and sign out sheets, revealed they were being audited by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 23. Review of care plan audit calendar revealed these were being completed as per the AoC, beginning on 12/10/14. Review of the Daily Chart Audit, dated 12/10/14 revealed care plans and care cards were being audited and updated as needed, by the RN, LPN, RN NPE, ADON, MDS, or DON. . The audits to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 24. Review of the QAPI meetings calendar revealed reviews to be completed by the RVPO or RMCO for the next three (3) months.

Based on interview, record review, and review of the hospital History and Physical and the facility's policies and procedures, it was determined the facility failed to provide services by qualified personnel according to the written plan of care for two (2) of eighteen (18) sampled residents. (Resident #1 and Resident #4). Two (2) separate Immediate Jeopardy situations were identified. Resident #1 had previously left the faciity on [DATE] by following visitors out the main front doors of the facility without staff knowledge. The facility assessed and care planned Resident #1 at risk for elopement; however, about three (3) months later on [DATE] at approximately 1:30 PM, Resident #1 followed a visitor through the same main front doors of the facility again. The resident's wanderguard caused the alarm to sound but Certified Nursing Assistant (CNA) #1 and the Payroll Benefits Coordinator failed to ensure Resident #1 was signed out to leave the facility, per the care plan. The resident had the visitor take him/her to a trailer park which was 0.7 miles away from the facility. When the visitor realized the resident didn't live at the trailer park, she returned the resident to the facility. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of IJ on [DATE]. The facility assessed Resident #4 with cognitive impairment and required extensive assist with all activities of daily living. The resident's care plan for Chronic Progressive Dementia, revealed an intervention to observe and report changes in the resident's cognitive status. On [DATE] during the 10:00 PM to 6:00 AM shift, CNA #2 reported to Licensed Practical Nurse (LPN) #1 that something was not right with Resident #4 at the beginning of the shift; and, again during the 2:00 AM and 4:00 AM rounds on [DATE]. LPN #1 failed to assess the resident for a change in cognitive status after the CNA reported something was wrong with him/her. Resident #4 was sent out the next morning (on [DATE] at 8:30 AM) and admitted to the hospital. The resident expired on [DATE] with the cause of death listed as [MEDICAL CONDITION] ([MEDICAL CONDITION]-stroke). The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility was notified of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the IJ had been removed on [DATE]. The State Survey Agency validated both AoCs and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: 1. First IJ situation identified on [DATE]: Review of the facility's policy titled, "Elopement of Patient" Section 1.3, last revised [DATE], revealed when a patient was identified as at risk, an Interdisciplinary elopement prevention care plan would be developed with family and patient participation. Individual risk factors and patterns would be identified and addressed within the care plan. Interventions would be communicated to staff. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Review of Elopement Assessment, dated [DATE], revealed Resident #1 would frequently attempt to follow visitors out the doors and frequently looked out the glass doors. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed the resident was considered at risk for elopement related to Dementia and Cognitive Loss. Further review revealed an update which noted the resident had a successful elopement on [DATE]. Care plan interventions included goals that "Resident will not leave the building without an escort" and, "Resident will have no further episodes of elopement". There was an intervention for staff to utilize the sign in and out records when the resident left the Center with an escort. Interview with Visitor #1, on [DATE] at 2:00 PM, revealed she was at the facility visiting another resident at approximately 1:30 PM on [DATE] when Resident #1 (she thought the resident was a visitor) was talking with her about going home. She revealed the resident and she both went through the double doors after a facility staff member pushed the button to open the doors. Interview with the Payroll/Benefit staff member, on [DATE] at 11:04 AM, revealed she saw a female visitor (Visitor #1) wearing scrubs going through the front door and Resident #1 was behind the visitor. She stated she pressed the button to open the door when CNA #1 told her that the resident was wearing a bracelet. She revealed she and the CNA thought the resident was going to an appointment so CNA #1 deactivated the alarm. She stated she did not utilize a sign in/out record when the resident left the Center because that was done at the nursing desk. Review of the facility's Creditable Allegation of compliance for the [DATE] Immediate Jeopardy and review of the [DATE] Plan of Correction revealed the facility provided staff education on the facility's Elopement Policy and Procedure. Review of the facility's Elopement Policy, Section 1 Assessment/Evaluation 1.3 revealed, "For patients identified as at risk, an interdisciplinary elopement prevention care plan will be developed ...". Review of the Comprehensive Plan of Care revealed interventions which stated staff would "Utilize sign in/out records when resident leaves Center with escort". However, during interview with the Payroll/Benefit staff member, she stated she had never been told to verify a resident had been signed out to leave the facility. Interview with CNA #1, on [DATE] at 11:21 AM, revealed Visitor #1 and Resident #1 came through the double doors and she thought Visitor #1, who was wearing scrubs, was taking the resident to an appointment. CNA #1 revealed the Payroll/Benefits Coordinator hit the red button to open the doors and the alarm sounded due to the resident wearing a wanderguard. CNA #1 stated she got up and went to the keypad and disarmed the alarm and Resident #1 followed the visitor out the doors. CNA #1 stated she did know if the resident was signed out because that was done at the nursing desk and she had never been told to verify the resident had been signed out. Interview with the Director of Nurses (DON), on [DATE] at 4:17 PM, revealed Resident #1 got out of the facility on [DATE] with an undesignated visitor. She stated she would have expected the staff to follow the care plan interventions as listed for the resident. However, per interview, there was no formal system in place for the staff to verify the resident was signed out at the nurse's desk, per the plan of care. Interview with the Interim Administrator, on [DATE] at 4:20 PM, revealed she wasn't working at the facility at the time of the incident on [DATE], but it was her understanding Resident #1 left the facility with a visitor. She also reported that the resident had previously eloped from the facility. She stated she expected staff to follow the interventions in place for the resident. Interview with the former Administrator, on [DATE] at 10:20 AM, revealed on [DATE], Resident #1 exited the facility as the staff at the reception desk did not realize that the resident was leaving with an unauthorized person. She stated that the staff didn't respond appropriately and should have inquired of the person why she was leaving with the resident. Interview with Administrator, on [DATE] at 2:22 PM, revealed the facility was not verifying residents' departures from the facility prior to the second elopement. The staff was re-educated following the second elopement. **The Facility implemented the following the following actions to remove the Immediate Jeopardy: 1. The facility placed Resident #1 on one to one (1:1) supervision beginning on [DATE] at 2:30 PM, and continued through the remainder of his/her stay at the facility. Resident #1 was discharged to a Licensed Alzheimer's facility on [DATE] at 1:15 PM. 2. The Assistant Director of Nursing (ADON) completed an updated elopement evaluation for Resident #1 on [DATE]. Resident #1's care plan was updated on [DATE] by the ADON to include review of elopement evaluation and 1:1 supervision. 3. The Administrator instructed the Maintenance Assistant to check all egress doors (the main exit door was evaluated first). The alarm function and sensitivity of all doors was found to be working properly. This was conducted on [DATE] at approximately 2:00 PM. 4. Alarm and Wander Guard function audits were completed on [DATE] by the Maintenance Assistant with all door locking mechanisms and alarms found to be working properly. 5. The RN Nurse Practice Educator (NPE) and Licensed Practical Nurses (LPNs) reviewed all residents (5 of 5) at risk for elopement on [DATE]. The Elopement Risk Evaluations for at risk residents, care plans, and care cards were reviewed and updated as needed by the RN Nurse Practice Educator and LPN on [DATE]. 6. Sixty- seven (67) of sixty-nine (69) Skilled Nursing Facility (SNF) residents were reviewed by a LPN or RN on [DATE] for elopement risks utilizing elopement risks evaluations. Two (2) residents were on hospital bed holds and were reviewed upon re-admission on [DATE] and [DATE] with no other residents identified for elopement risk. 7. A new, bright red notification sign was implemented by the Administrator to notify visitors and families that anytime a resident is being accompanied out of the facility, they must sign the resident out of the facility and notify a staff member before leaving. The sign was posted on all exit doors on [DATE]. 8. On [DATE], the Administrator implemented a system to provide a copy of resident appointments to be maintained at the front reception desk. 9. The system for signing residents in and out of the facility was revised on [DATE] to include the following revisions: One of the following: CNAs, LPNs, Certified Medication Aides (CMAs), Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM) and Accounts Payable/Benefits Coordinator will be responsible for signing residents in and out at the nurse's station. Additionally, one of the staff listed above will be assigned to the receptionist desk and this person would be responsible for signing residents and family members out at the front desk, verifying appointments and sign-out at the nurse's station before a resident leaves the building. In addition, one of the above listed staff members will be assigned to the receptionist desk and to the nurses' station to ensure the resident is signed back into the facility upon return. 10. The Administrator mailed an informational letter (340 total) on [DATE], to active vendors, family members, churches, and volunteers to inform them they must sign residents out at the nursing stations and at the reception desk as well as to be mindful of the alarms and seek staff assistance when an alarm is sounding, as well as be mindful of a resident attempting to exit the facility. 11. The RN NPE re-educated the Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager, and the Administrator on [DATE]. Then the RN NPE, Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager, or the Administrator reeducated 100% of staff beginning on [DATE]. One-hundred and four (104) of one-hundred and six (106) active employees and/or contract employees completed re-education and post testing between [DATE] and [DATE]. Re-education included the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nurse's station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility's policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 12. All new employees are to receive elopement education provided during orientation which will include the procedure for allowing a resident to exit the facility, signing the resident out at the receptionist desk or nurse's station as well as validating the credentials of the person accompanying the resident from the facility. This was added to the new employee orientation on [DATE]. 13. CNA #1 and the Payroll/Accounts Payable Clerk received final written warnings on [DATE] provided by the Administrator. 14. The Regional Vice President of Operations (RVPO) provided re-education to the Administrator and DON on [DATE] via phone conference and in person by the Regional Manager of Clinical Operations (RMCO) regarding his/her job descriptions, the Center's policies on care plan, resident safety, quality assurance and administration requirements. In addition, specific information included the CMS Guide for Developing Purpose, Guiding Principles, and Scope for Quality Assessment Performance Improvement (QAPI). Post-tests were conducted with the Administrator and DON on [DATE] by the RDCO with 100% pass rating. 15. Beginning on [DATE], upon notification of an elopement, the Administrator will notify the RVPO, RMCO, or the Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to continue for six (6) months for any elopement that may occur. 16. On [DATE], the RMCO provided additional re-education to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator. In addition, the Regional Director of Food Services provided one on one re-education with the Dietary Manager. The re-education included the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nurse's station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm and the facility's policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the RN NPE, Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Following the above training, on [DATE], employee re-education was initiated. Re-education began on [DATE] completed by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. This re-education included the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility; including being signed out at a nurse's station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility's policy for following each resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager, or the Administrator. Post tests were 100% pass rate prior to employees being released from training. Sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post testing on [DATE]. Employees not available for this re-education will have re-education and post-tests completed with 100% pass rate prior to returning to or beginning work by the RN NPE, DON, ADON, Maintenance Assistant or Administrator. 18. An AD-HOC Performance Improvement (PI) meeting was held on [DATE] to review the PI action plan with the acting Medical Director. Members of the PI Committee include the Administrator, DON, ADON, RN Clinical Case Manager, Admissions/Marketing Director, RN NPE, SSD, Nutritional Services Director, Activities Director, Maintenance Assistant, Medical Director and Nurse Practitioner. 19. Beginning on the day shift of [DATE], the Maintenance Assistant completed an elopement drill on each shift through [DATE] to audit training compliance with no concerns identified. 20. Charge Nurses (RNs/LPNs), Department Manager, or Maintenance Assistant will complete two (2) elopement drills on each shift monthly for three (3) months, ,[DATE], ,[DATE], and ,[DATE], then two (2) quarterly for six (6) months. Corrective action will be provided for identified audit concerns. Findings will be reviewed by the PI Committee and recommendations for additional audits will be based on audit outcomes. 21. An AD HOC PI meeting was held on [DATE] with the PI Committee members to review the progress of the improvement plan with no other action steps determined to be required. 22. Beginning [DATE], appointment log and sign out audits were completed by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits will be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five resident appointments monthly for two (2) months. 23. Beginning [DATE], care plan audits will be completed by RN or LPN, RN NPE, ADON, Minimum Data Set (MDS) Nurse, or the DON. The audits were completed on three (3) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks and then five (5) residents monthly for two (2) months. 24. Beginning [DATE], QAPI meetings will be reviewed by the RVPO or RMCO for the next three (3) months. ** The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the one on one (1:1) monitoring logs, revealed Resident #1 was placed under 1:1 supervision beginning on [DATE] at 2:30 PM and the 1:1 supervision continued until the resident was discharged to a Licensed Alzheimer facility on [DATE] at 1:15 PM. 2. Review of an elopement evaluation completed on [DATE] by the ADON, revealed Resident #1 was an elopement risk and no other concerns were identified. Review of the care plan revealed it was updated on [DATE] by the ADON to include the updated elopement evaluation and 1:1 supervision. 3. Review of the Maintenance Assistant alarm check form, dated [DATE] at approximately 2:00 PM, revealed all egress doors (main exit door checked first), and all exit doors alarms were functioning appropriately. 4. Review of the audit of wander guards and alarms, conducted by the Maintenance Assistant on [DATE], revealed no concerns. 5. Review of the audits for five (5) of five (5) residents at risk for elopement revealed on [DATE] the RN, RN NPE and LPN reviewed the elopement risks evaluations, care plans, and care cards with revisions made as needed. 6. Review of the Elopement Risks Evaluations completed on sixty-seven (67) of sixty-nine (69) SNF residents on [DATE] revealed all but two (2) residents (who were on bed hold), had elopement risk evaluations utilized to determine at risk residents. The two (2) residents on bed hold had evaluations completed on re-admission on [DATE] and [DATE]. 7. Observations on [DATE] revealed new signage created by the Administrator, was placed at all exit doors on [DATE] to inform visitors, vendors, and families they must sign a resident out at the reception desk or nursing station and notify staff before leaving with the resident. 8. Review of a new system to monitor resident appointments revealed an appointment log audit/sign in/out audit was placed at the front reception desk on [DATE]. 9. Review of the revised system for signing residents in and out of the facility, revised on [DATE], revealed one of the following staff will be responsible for signing a resident in and out at the nursing station: CNAs, LPNs, Certified Medication Aides (CMA)s, Restorative Aides, Administrator, Director of Nursing (DON), ADON, RN NPE, RN Clinical Case Manager, Admissions Director (AD), Social Services Director (SSD), Dietary Manager (DM), Activity Aide, Activity Director, Maintenance Assistant, Receptionist, Business Office Manager (BOM) and Accounts Payable/Benefits Coordinator. Additionally, one of the staff members listed above will be responsible for signing a resident in and out at the reception desk. 10. Review of the informational letter sent to active vendors, family members, churches, and volunteers to inform them of the procedure of signing a resident in and out as well as being more mindful of an alarm sounding and of a resident attempting to exit the facility. Three hundred forty (340) letters were mailed on [DATE] by the Administrator. 11. Review of re-education conducted on [DATE] by the NPE was continued by the Nutrition Director, Environmental Services Director, Rehab Program Manager, DON, Clinical Reimbursement Manager, or the Administrator, revealed education was completed on [DATE]. The education included the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nurse's station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and, the facility's policy for following a resident's plan of care. Review of re-education listed above revealed one hundred four (104) of one hundred six (106) employees completed re-education and post-tests between [DATE] and [DATE]. Staff interviews conducted on [DATE] with the Activity Director at 8:25 AM, CNA #18 at 8:34 AM, CNA #19 at 8:41 AM, LPN #2 at 8:57 AM, Dietary Manager at 9:20 AM, CNA #9 at 9:30 AM, Housekeeping Supervisor at 9:42 AM, CNA #20 at 10:02 AM, CNA #14 at 10:15 AM, LPN #5 at 10:29 AM, RN Clinical Case Manager at 10:40 AM, CNA #21 at 11:02 AM, Maintenance Assistant at 11:11 AM, CNA #22 at 11:36 AM, RN #1 at 11:40 AM, and RN Unit Manager at 11:49 AM, RN NPE at 8:15 AM, Housekeeping Aide at 9:00 AM, RMCO at 9:45 AM, Payroll/Bookkeeper at 9:47 AM, and CNA #12 at 10:15 AM revealed they were all re-educated on the Center's policies on elopement prevention and management; and the procedure for allowing a resident to exit the facility including being signed out at a nurse's station, signed out at the reception desk, validation of credentials of individuals accompanying the resident, expected employee response to a door alarm, and the facility's policy for following a resident's plan of care. 12. Review of three (3) new hire employees revealed they received the education on the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility including being signed out at a nurse's station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility's policy for following a resident's plan of care. 13. Review of Individual Performance Improvement Plans for CNA #1 and the Payroll/Benefits Clerk, conducted on [DATE], by the Administrator and ADON, revealed they both received education related to closer monitoring of residents exiting the building and alarms sounding. Elopement education was provided on [DATE] and [DATE]. 14. Review of education provided to the Administrator and DON, conducted on [DATE] by the RMCO and RVPO, revealed re-education was provided related to his/her job descriptions, the Center's policies on care plan, resident safety, quality assurance and administrative requirements. Interviews conducted with the Administrator on [DATE] at 12:45 PM and the DON at 12:40 AM, revealed they were re-educated by the RVPO and RMCO related to Quality Indicators, reporting, elopements, documentation, new visitor's policy, new audit tools, care plans, root cause analysis, and notification of significant events. Both completed post-tests with 100 % pass rate. 15. No other elopements had occurred at the time of the verification of the AoC; however, interview with the Administrator on [DATE] at 12:45 PM revealed he was aware of his responsibility to inform the RVPO, RMCO, or the Regional Clinical Educator for validation a thorough investigation would be immediately initiated. 16. Review of the re-education conducted on [DATE], by the RMCO to the Administrator, DON, ADON, RN NPE, RN Clinical Case Manager, Admissions Director, SSD, Dietary Manager, Rehabilitation Services Manager, Housekeeping Manager, Activity Aide, Maintenance Director, Receptionist, BOM, and Accounts Payable/Benefits Coordinator, revealed all were re-educated, and the Regional Director of Food Services providing education one to one for the Dietary Manager. The education included the Center's policies on elopement prevention and management; procedure for allowing a resident to exit the facility, including being signed out at a nurse's station, signed out at the reception desk, and validation of credentials of individuals accompanying the resident; expected employee response to a door alarm; and the facility's policy for following a resident's plan of care. Each employee completed a post-test to validate learning which was conducted prior to the conclusion of training by the NPE, Nutrition Director, Environmental Services Director, Rehabilitation Program Manager, DON, Clinical Reimbursement Manager or the Administrator. Post tests were 100% pass rate prior to employees being released from training. 17. Review of additional training revealed, on [DATE] re-education was provided to staff by the RN NPE, DON, ADON, Maintenance Assistant, or the Administrator regarding the same topics listed above. Review of in-service/re-education sign-in logs, dated [DATE], revealed sixty-seven (67) of one-hundred thirteen (113) active employees and/or contract employees completed re-education and post-tests. 18. Review of AD-HOC PI meeting minutes, dated [DATE], (no time), revealed the PI Committee met with the acting Medical Director to review the PI action plan. 19. Review of the in-service sign in sheets, dated [DATE] at 1:00 PM and at 3:00 PM, (day and second shift staff) revealed elopement drills (code yellow) were conducted by the Maintenance Assistant. Review of the in-service sign in sheets dated [DATE] at 3:00 AM to 3:20 AM, revealed elopement drills (code yellow) were conducted with night shift staff. 20. Review of elopement drill calendars revealed Charge Nurses (RN/LPNs), Department Manager or the Maintenance Assistant was to complete two (2) elopement drills on each shift monthly x 3 month beginning ,[DATE] through ,[DATE], then two (2) quarterly for six (6) months. Corrective action/reeducation to be provided with issues identified. Findings reviewed by the PI Committee and recommendations will be made accordingly. 21. Review of AD-HOC meeting minutes, dated [DATE], (no time) revealed the PI Committee met to discuss the elopement of Resident #1. Issues of prevention, resident assessment, re-education of staff, initiation of new sign out procedures, resident appointment schedule posted at receptionist desk and possible referral to a sister facility with a special dementia focus was discussed. The Medical Director attended via phone conference. 22. Review of the newly implemented Appointment Log and Sign Out Sheets, revealed they were being audited by the receptionist, ADON, Licensed Nurse, Maintenance Assistant, DON, RN NPE, RN Clinical Case Manager, Recreation Director, Recreation Assistant, or Administrator. The audits are to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 23. Review of the Care Plan Audit Calendar revealed audits were being completed as per the AoC, beginning on [DATE]. Review of the Daily Chart Audit, dated [DATE] revealed care plans and care cards were being audited and updated as needed, by the RN, LPN, RN NPE, ADON, MDS, or DON. The audits are to be completed daily on three (3) resident appointments for fourteen (14) days, then five (5) resident appointments weekly for eight (8) weeks, then five (5) resident appointments monthly for two (2) months. 24. Review of the QAPI meetings calendar revealed reviews to be completed by the RVPO or RMCO for the next three (3) months. 2. Second IJ situation identified on [DATE]: Review of the closed record of Resident #4 revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #4 as non- ambulatory and required extensive assistance with all activities of daily living. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was six (6) which indicated the resident was not interviewable. Review of Resident #4's Comprehensive Care Plan for Chronic Progressive Dementia, revealed an intervention initiated on [DATE], to "Observe and report changes in cognitive status". Review of Resident #4's Nursing Notes revealed no documentation for [DATE]. Review of a Change of Condition Documentation form, dated [DATE] at 6:45 AM, revealed a CNA had reported to LPN #4, that she was unable to wake the resident. LPN #4 documented that the only response Resident #4 had to a sternal rub was "pushing hands away". Pupils were sluggish to light, Blood pressure was ,[DATE], Pulse was 94, Respirations 14, Temperature was 97 degrees, O2 sat was 94%, and Blood Sugar was 139. Further review of the Change in Condition Form revealed the family was notified at 7:00 AM and arrived at the facility at 7:15 AM. The physician was notified at 7:45 AM with orders received to send the resident to the emergency room for evaluation. Resident #4 was transported by ambulance to the emergency room at 8:30 AM. At 1:00 PM, the family called the facility and reported Resident #4 had been admitted . Review of the hospital's History and Physical, dictated on [DATE] at 6:03 PM, revealed the resident had an acute [MEDICAL CONDITION] involving the midline, large infarct bilaterally involving bilateral cerebellar hemispheres and bilateral thalami. Further review revealed that clinically the resident "... was found unresponsive in the morning and the onset of the stroke could be any time back to yesterday evenin

Based on observation, interview and record review, it was determined the facility failed to provide services by qualified personnel according to the written plan of care for one (1) of three (3) sampled residents (Resident #1) related to supervision. The facility assessed and care planned Resident #1 at risk for elopement; however, on 08/26/14 at approximately 5:10 PM, Resident #1 followed two (2) visitors through the East Nurse's Station doors into the front lobby area of the facility. The resident continued to follow the visitors out the main front doors onto the front porch of the facility without staff knowledge. The resident's care plan revealed an intervention to redirect the resident when the security system sounds. However, the facility's investigation revealed a personal care resident (Unsampled Resident A), witnessed Resident #1 exit the East Nurses' Station, and then he/she turned off the security system after Resident #1 walked through the door without staff's knowledge because the alarm was immediately turned off. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/10/14 and determined to exist on 08/26/14. The facility was notified of the Immediate Jeopardy on 09/10/14. The findings include: Review of the facility's policy titled "NSG 102 Care Plans" last revised 01/02/14, revealed a comprehensive, individualized care plan would be developed by the interdisciplinary team for each patient. The care plan would include measurable objectives to meet patient needs and goals as identified by the assessment process. Review of the facility's policy titled, "Elopement of Patient" Section 1.3, last revised 05/15/14, revealed when a patient was identified as at risk, an interdisciplinary elopement prevention care plan would be developed with family and patient participation. Individual risk factors and patterns would be identified and addressed within the care plan. Record review revealed the facility admitted Resident #1 on 05/29/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/17/14, revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan, dated 08/12/14, revealed the resident was considered at risk for elopement related to Dementia and Cognitive Loss. Further review revealed a goal of "Resident will not leave the building without an escort". Interventions included for staff to redirect the resident when the security system sounded and/or the resident attempted to leave the building. Staff was to utilize and monitor the resident's security bracelet per protocol. Interview with the Activity Assistant, on 09/09/14 at 11:25 AM, revealed she had been working in the dining room and had come to the front lobby looking for something and was standing at the reception desk. She stated a family member/visitor came to her and informed her that Resident #1 was sitting outside and he was not sure if the resident needed to be alone. She stated she immediately asked the resident to come inside with her and she took the resident to the nurse for observation. The Activity Assistant stated she did not hear an alarm sound when the resident exited the facility to alert her that a resident may have exited the facility. Interview with Certified Nursing Assistant (CNA) # 1, on 09/09/14 at 3:00 PM, revealed she was working in the Personal Care Dining Room at the time and did not hear the door alarm sound. She stated Resident #1 was in the big dining room across from where she was working, the last time she saw him/her. She stated she should have been able to hear the alarm sound and it would have alerted her to the resident's attempt to leave the facility. Interview with Licensed Practical Nurse (LPN) #1, on 09/05/14 at 2:20 PM, revealed she was working in the dining room at the time and did not hear the door alarm go off. She stated the resident would follow staff and visitors at times. LPN #1 stated she had seen Resident #1 right after the evening meal in the main dining room, and did not realize he/she was missing until the Activity Assistant brought him/her back to her. She stated, that if she heard the alarm she would have responded to it. Interview with the MDS Coordinator, on 09/05/14 at 4:00 PM, revealed the resident was assessed for risk of elopement on admission and then reassessed on 07/22/14 as at risk due to an increase in wandering behavior as the resident had followed a visitor into the bathroom. The resident was evaluated and interventions were put in place and a care plan was initiated on 07/22/14. She revealed an alarm was placed on the resident's ankle as an intervention on 07/22/14. Interview with the Maintenance Director, on 09/05/14 at 2:15 PM, revealed he thought that the residents and family members looked over staff's shoulder when they put the code in to get the code to the East Nurses' Station to the main lobby so they would not have to wait on staff to let them out. He stated the same code was used to open the door and reset the door alarm. Interview with the Administrator, on 09/05/14 at 1:30 PM, revealed she received a call around 6:00 PM informing her Resident #1 has been found outside the facility by a visitor. The Administrator stated her investigation determined a Personal Care resident (Unsampled Resident A) was sitting at the East Nurses' Station and saw Resident #1 exit with the visitors and immediately reset the door alarm allowing the resident to exit the facility undetected by staff. She revealed the facility reset the door code every six (6) months or anytime it was determined necessary. The Administrator stated, prior to this incident, when they identified too many residents and visitors had access to the code she would have staff change the code at that time. She stated she determined through her investigation of the incident that other residents and family members observed the staff using the code and that was how the Personal Care Resident knew how to reset the door code alarm which prevented the staff from responding to the alarm. The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 performed a head to toe assessment on Resident #1 with no injuries identified. LPN #1 completed a Change of Condition document to include vital signs and oxygen saturation. Resident #1 was placed on direct line of observation beginning at 5:20 PM on 08/26/14. The Physician and responsible party were notified of the resident's elopement on 08/26/14 at 7:00 PM and 7:10 PM. All staff members present were instructed by the Administrator to know the location of Resident #1 at all times. 2. The Nurse Practice Educator completed an updated Elopement Evaluation for Resident # 1 on 08/26/14, and Resident # 1's Care Plan was updated and interventions were put in place. It was updated again on 08/27/14 after an Interdisciplinary Care Plan Meeting. 3. The Licensed Charge Nurses and Certified Nursing Assistants completed a visual census check on all residents. Eighty-eight (88) of eighty-eight residents were present in the building. A visual validation census form was signed by the Licensed Nurse at each nursing station on 08/26/14 at 6:25 PM. 4. On the evening of 08/26/14, the Administrator returned to the facility at approximately 6:00 PM and checked all egress doors. Upon review, the alarm function was found to be working properly. All other doors sensitivity and alarms functioned properly. 5. Further investigation including, resident interviews by the Administrator, determined that a resident from the Personal Care Unit was sitting outside of the East Lounge when Resident #1 exited the unit doors. The Personal Care Resident heard the alarm and immediately silenced the alarm by entering the code. The Administrator completed re-education at approximately 6:45 PM on 08/26/14, with the Personal Care Resident on the importance of not putting the code in for anyone and to notify staff for assistance with alarms. 6. Residents residing in the Center, who were at risk for elopement, were reviewed by the Nurse Practice Educator on 08/26/14. The Elopement Risk Evaluations for at risk residents, care plans and care cards were reviewed and updated as indicated. 7. The door key codes were changed by the Maintenance Director at approximately 10:35 AM on 08/27/14. The Administrator implemented a bright red notification sign to notify visitors/families on all exit doors to "Please see staff before allowing anyone to exit these doors" on 08/27/14. On 08/27/14, the Contractor for the Wander Guard system was contacted for a full system evaluation by the Maintenance Director. As an additional precaution, the two (2) sensitivity antennas were replaced on the front East Unit exit doors leading to the lobby area. An order was placed on 08/28/14 by the Administrator for an enunciator panel to be installed at each nurse's station. 8. 100% staff re-education was immediately initiated by the Nurse Practice Educator and all administrative staff, beginning on 08/26/14, and continuing with completion on 08/29/14. The re-education included, the Center's policies on elopement prevention and management, expected employee response to a door alarm, specific information regarding the doors at this facility and how each functions, instructions that alarm codes should not be given to residents or visitors. Each employee completed a post-test to validate learning with a 100% pass rate. 100 of 110 active employees completed re-education and post testing between 08/26/14 and 08/29/14. Employees not currently available during this time frame will have or have had education/re-education completed prior to returning or beginning work including a post test. All new employees will have elopement education provided during orientation. 9. The Personal Care Residents (18 of 18) were re-educated by the Nurse Practice Educator and/or Administrator beginning on 08/26/14 and completed on 08/28/14. The Skilled residents (39 of 39) with BIMS scores of eight (8) or higher were re-educated by the Administrator on 08/28/14. Resident re-education included, "if the door alarm is sounding, do not attempt to turn the alarm off, notify staff for assistance. If at any time you need assistance to exit the East Unit please ask staff for assistance and to please notify staff if you observe anyone other than staff entering the door key code." 10. Beginning on the day shift of 08/27/14, the Nurse Practice Educator completed an elopement drill on each shift through 08/29/14 to audit training compliance. No concerns were identified with these audits. Alarm and wander guard function audits were completed on each shift beginning 08/26/14 and ending on 08/29/14 by Licensed Nurses or the Administrator. All door locking mechanisms and alarms were found to be working properly during these audits. Alarm and wander guard function for all doors was tested daily by the Maintenance Director or the Licensed Charge Nurse. 11. No further elopements since implementing the original PI Plan on 08/26/14. Licensed staff or a department manager will complete an elopement drill on each shift monthly for three (3) months (September, October, November 2014), then quarterly for six (6) months. Corrective action and/or re-education will be provided at point of discovery of identified audit concerns. Findings will be reviewed by the Quality Improvement Committee (QIC), the QI Committee will make recommendations for additional audits based on audit outcomes. 12. An AD HOC PI meeting was held on 09/02/14, and on 09/05/14 with the Administrator, Medical Director and all Department Managers to review the progress of the Improvement Plan including, informational letters to 100% family members to be mindful of the alarms and seek staff assist when an alarm is sounding or residents may be trying to exit facility on 09/06/14. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #1's chart on 09/18/14 at 2:10 PM, revealed a change of condition document was initiated on 08/26/14 at 5:45 PM by LPN # 1. Vital signs were obtained along with a head to toe assessment. Documentation also revealed the resident was placed on direct line observation at that time. The Physician and family members were notified of the elopement on 08/26/14 at 7:00 PM and 7:10 PM by LPN #1. Interview with LPN #1, on 09/18/14 at 3:10 PM, revealed she was working the night Resident #1 was able to exit the building. LPN #1 completed a head to toe assessment on Resident #1 with no injuries noted. 2. Interview with the Nurse Practice Educator, on 09/18/14 at 4:30 PM, revealed she updated Resident #1's care plan on 08/26/14 after re-evaluating his/her elopement assessment evaluation, and again on 08/27/14 after the Interdisciplinary Care Plan meeting. 3. Interview with LPN #1, on 09/18/14 at 3:10 PM, revealed a Visual Validation Census Check was completed on all residents in the building on 08/26/14 at 6:35 PM. Review of the Visual Validation Census Check dated 08/26/14 confirmed this. 4. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed she returned to the facility at 6:00 PM on 08/26/14, and started an investigation to determine how the resident was able to exit the building undetected. She stated she immediately checked all egress door alarms to make sure they were functioning properly. 5. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed she returned to the facility at 6:00 PM on 08/26/14, and her investigation revealed a Personal Care Resident heard the alarm and immediately reset the alarm. The Administrator stated she re-educated the Personal Care Resident on the importance of not responding or resetting the door alarm on 08/26/14 at 6:45 PM. 6. Interview with the Nurse Practice Educator, on 09/18/14 at 4:30 PM, revealed she updated Resident #1's care plan on 08/26/14 after re-evaluating his/her elopement assessment evaluation, and again on 08/27/14 after the Interdisciplinary Care Plan meeting. Further interview revealed she then reviewed all residents identified as an elopement risk and updated the assessment, care cards and care plans as indicated on 08/26/14. 7. Observation on 09/18/14 at 2:00 PM, revealed the facility relocated the coded alarm system from the East Nurses Station to the front entrance of the facility. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed the door way was monitored daily from 7:00 AM until 7:00 PM. The Administrator stated, the new system required that anyone entering the facility or exiting the facility must be buzzed in by the receptionist. The front door will automatically lock at 7:00 PM; to enter the facility you must go to the back entrance. She revealed the enunciator panels were installed on each nurses' station to alert the staff which door the resident was attempting to exit. Interview with Maintenance Director on 09/18/14 at 3:15 PM, revealed he demonstrated the alarm by opening the veranda doors and looking at the enunciator panel to verify the location of the alarm. Interview with LPN #1 on 09/18/14 at 3:10 PM, revealed she was knowledgeable of the new system that was put in place, and was able to explain the use of the enunciator panels. Interview with Activity Director on 09/18/14 at 2:59 PM, revealed she was aware of the new system changes with the door code alarm, she stated after 7:00 PM visitors could enter through the service entrance and ring a door bell. She further stated they had to be let in by the staff, and they were required to verify their identity before letting them in the facility. 8. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed all staff was re-educated on the facility's policy for elopement. The re-education included the Center's policies on elopement prevention and management; expected employee response to a door alarm; specific information regarding the doors at this facility; and, how each functioned; and, instructions that alarm codes should not be given to residents or visitors. Each employee completed a post-test to validate learning with a 100% pass rate. 100 of 110 active employees completed re-education and post testing between 08/26/14 and 08/29/14. Employees not currently available during this time frame will have or have had education/re-education completed prior to returning or beginning work including a post test. All new employees will have elopement education provided during orientation. Education was verified by viewing the inservice sign-in sheets and post test packets were reviewed on 09/18/14. 9. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed all Personal Care Residents (18-18) were re-educated on the importance of the door alarms and not to re-set the door alarms, and to notify staff if they see another resident exiting the doors when the alarm sounds . The inservice was verified by a sign in sheet with Personal Care residents' signatures beginning 08/26/14 through 08/28/14. 10. Interview with the MDS Coordinator on 09/18/14 at 3:23 PM, revealed her normal shift was 7:00 AM-4:00 PM. She stated she was inserviced on 08/26/14 by the Nurse Practice Educator on the Center's policy on elopement prevention, the new process for entering and exiting the building, importance of keeping the door code confidential. She stated she completed the post test with 100% accuracy. Interview with Employee #1 on 09/18/14 at 3:28 PM, revealed she also attended an inservice on 08/26/14. She stated her normal work shift was 5:30 AM-9:00 PM. She stated the inservice contained information about the facility's elopement policy and the new process for entering and exiting the building. She also completed a post test with 100% accuracy. Interview with Employee #2 on 09/18/14, revealed she was employed as a Medication Tech and worked from 11:00 PM- 7:00 AM. She stated she also attended the inservice on 08/26/14 related to the elopement policy and the new process for entering and exiting the facility. She knew the importance of keeping the door code confidential and the use of the new alarm system. She indicated that she took a test with 100% accuracy after the training was completed. Interview with Employee #3 on 09/18/14 at 3:20 PM, revealed she was employed as a Certified Nurse Aide and worked from 2:00 PM -10:00 PM. She stated the inservice on 08/26/14 talked about the new door alarm system and the facility's policy on elopement. She was able to identify which residents were currently identified at risk for wandering and the importance of keeping the door code confidential. She also took a post test after the training with 100% accuracy. Interview with Employee #4 on 09/18/14 at 3:40 PM, revealed she attended the inservice on the facility's elopement policy on 08/27/14 and also participated in an elopement drill. She indicated the training covered the re-education on the elopement policy as well as the new door alarm system. Interview with Employee #5 on 09/18/14 at 2:34 PM, revealed she was inserviced on 08/27/14 at 8:00 PM on the new facility policy on elopement and also participated in an elopement drill. She stated she has a good understanding of the new door alarm system and realized the importance of keeping the code confidential. Interview with Resident #2 on 09/18/14 at 2:33 PM, revealed that he/she was not aware of the new door alarm code. Interview with Resident #3 on 09/18/14 at 2:20 PM. revealed he/she was aware of the door alarm code prior to installing the new alarm system, but did not know the new door alarm code. Interview with Resident #3's family member on 09/18/14 at 2:20 PM, revealed that she was aware the facility has made changes with the alarm system, prior to the changes she was aware of the door alarm code but she did not know the new code. Interview with Personal Care Resident #4 on 08/18/14 at 4:09 PM, revealed the staff had taught him/her about the exit doors and staff let him/her out when he/she wanted to go out with his/her family. The resident stated he/she did not have access to the door code anymore. Interview with Personal Care Resident #5 on 09/18/14 at 4:12 PM, revealed he/she did not have the door code anymore, and the staff let him/her out when he/she needed to go with family. He/she continued to say that someone talked to him/her about the exit doors, and the importance of not letting anyone out the doors or turning off the alarms. 11. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed that no further elopements had occurred. Licensed staff or a department manager would complete an elopement drill on each shift monthly for three (3) months (September, October, November 2014), then quarterly for six (6) months. Interview with the MDS Coordinator on 09/18/14 at 2:20 PM, revealed there has been no further elopements, and the new system was working properly. 12. Verification of the AD HOC PI meeting was obtained through interview on 09/18/14 at 2:10 PM with the Administrator, she revealed the facility started the Performance Improvement for the Elopement on 08/26/14 with the investigation process to assist the team with determining the root cause of the elopement. She stated they met again to include the Medical Director in the discussion on 08/27/14, and the entire team met again on 09/10/14. A copy of the notification letters mailed on 09/06/14, to all family members was reviewed during the interview on 09/18/14 at 2:10 PM. The Administrator continued to reveal that she has been in constant communication with the Medical Director through out the entire investigation either in meetings or phone conversations.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of three (3) residents (Resident #1). On 08/26/14, during the mealtime process, Resident #1 , who was assessed by staff as an elopement risk, followed two (2) visitors through the East Nurse's Station doors into the front lobby area of the facility and continued to follow them out the main front doors onto the porch of the facility without staff knowledge. The facility's investigation revealed a Personal Care Resident (Unsampled Resident A), witnessed Resident #1 exiting the East Nurses' Station, and turned off the door alarm after he/she walked through it. The facility was aware residents and visitors knew the code but had taken no action to make sure residents did not have access to the code. The facility's failure to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/05/14 and determined to exist on 08/26/14. The findings include: Review of the facility's policy titled "Elopement of Patient", last revised 05/15/14, revealed residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Elopement occurs when a resident leaves the premises without authorization and/or any necessary supervision to do so, and the purpose of the policy was to provide a process for managing residents at risk for elopement. Record review revealed the facility admitted Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Elopement Risk Assessment, dated 07/22/14, revealed the facility assessed the resident as at risk for elopement due to his/her increase in wandering behavior. Review of Resident #1's Comprehensive Care Plan, dated 08/12/14, revealed a goal that the resident would not leave the building without an escort and interventions included for staff to redirect the resident when the security system sounded and/or the resident attempted to leave the building and staff was to utilize and monitor the resident's security bracelet per protocol. Interview with a Visitor, on 09/05/14 at 3:00 PM, revealed he was sitting on the porch with his family members when he saw Resident #1 exit the building with two (2) women. He stated he first thought they were together and then he noticed the two (2) women walked to the parking lot and got in their car. He stated he asked Resident #1 if he/she was with the women and the resident did not answer. The Visitor stated the resident then started walking away in the direction of the parking lot. He stated he noticed the bracelet on the resident's ankle, and realized he/she was a resident, and thought the resident may not be allowed outside unsupervised. He then asked the resident to sit with him and visit, and then he went inside the facility to find someone to help. The Visitor stated the resident was outside unsupervised for four (4) or five (5) minutes and he was not sure what would have happened if he had not been out there, because the resident was walking in the direction of the parking lot and no one had come out of the facility to check on him/her. Interview with Activity Assistant, on 09/09/14 at 11:25 AM, revealed she had been working in the dining room and went to the front lobby looking for something and was standing at the reception desk. She stated a Family Member/Visitor came to her and said Resident #1 was sitting outside and he was not sure if the resident needed to be alone. She stated there was no one working at the reception desk at that time of day, and she was not sure how long the resident was outside. She stated she immediately asked the resident to come inside with her and she took the resident to the nurse for observation. She stated she did not hear an alarm sound when the resident exited the facility. Interview with Licensed Practical Nurse (LPN) #1, who was responsible for Resident #1, on 09/05/14 at 2:20 PM, revealed she was working in the dining room at the time and did not hear the alarm go off. She stated the resident did not have a history of trying to leave the building but would follow staff and visitors at times. LPN #1 stated she had seen Resident #1 right after the evening meal in the main dining room, and she did not realize he/she was missing until the Activity Assistant brought him/her back to her. Interview with Certified Nursing Assistant (CNA) #1 who was responsible for Resident #1, on 09/09/14 at 3:00 PM, revealed she was working in the Personal Care dining room at the time and did not hear the door alarm go off. She stated Resident #1 was in the big dining room across from where she was working, the last time she saw him/her. She stated she should have been able to hear the alarm go off. Interview with the Maintenance Director, on 09/05/14 at 2:15 PM, revealed the last time the door alarms were checked, prior to the elopement, was on 08/23/14 with no concerns identified. He stated the alarms were checked weekly. The Maintenance Director stated he thought the residents and family members looked over the shoulder of the staff when they use the code to obtain the code to get out of the East Nurses' station to the main lobby without waiting for staff to let them out. He stated the same code was used to open the door and reset the door alarm. Interview with the Administrator, on 09/05/14 at 1:30 PM, revealed she received a call around 6:00 PM informing her Resident #1 has been found outside the facility by a visitor. She stated the resident followed two (2) visitors through the doors and continued out the main door to the porch area and was found by a visitor/family member. The Administrator stated her investigation determined a Personal Care Resident (Unsampled Resident A) was sitting at the East Nurses' Station and saw Resident #1 exit with the visitors and immediately reset the door alarm allowing the resident to exit the facility undetected by staff. She revealed the facility reset the door code every six (6) months or anytime it was determined necessary. She stated, prior to this incident, when they identified too many residents and visitors had access to the code she would have staff change the code at that time. She stated she determined through her investigation of the incident other residents and family members observed the staff using the code and that was how Unsampled Resident A knew how to reset the door code alarm. The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 performed a head to toe assessment on Resident #1 with no injuries identified. LPN #1 completed a Change of Condition document to include vital signs and oxygen saturation. Resident #1 was placed on direct line of observation beginning at 5:20 PM on 08/26/14. The Physician and responsible party were notified of the resident's elopement on 08/26/14 at 7:00 PM and 7:10 PM. All staff members present were instructed by the Administrator to know the location of Resident #1 at all times. 2. The Nurse Practice Educator completed an updated Elopement Evaluation for Resident # 1 on 08/26/14, and Resident # 1's Care Plan was updated and interventions were put in place. It was updated again on 08/27/14 after an Interdisciplinary Care Plan Meeting. 3. The Licensed Charge Nurses and Certified Nursing Assistants completed a visual census check on all residents. Eighty-eight (88) of eighty-eight residents were present in the building. A visual validation census form was signed by the Licensed Nurse at each nursing station on 08/26/14 at 6:25 PM. 4. On the evening of 08/26/14, the Administrator returned to the facility at approximately 6:00 PM and checked all egress doors. Upon review, the alarm function was found to be working properly. All other doors sensitivity and alarms functioned properly. 5. Further investigation including, resident interviews by the Administrator, determined that a resident from the Personal Care Unit was sitting outside of the East Lounge when Resident #1 exited the unit doors. The Personal Care Resident heard the alarm and immediately silenced the alarm by entering the code. The Administrator completed re-education at approximately 6:45 PM on 08/26/14, with the Personal Care Resident on the importance of not putting the code in for anyone and to notify staff for assistance with alarms. 6. Residents residing in the Center, who were at risk for elopement, were reviewed by the Nurse Practice Educator on 08/26/14. The Elopement Risk Evaluations for at risk residents, care plans and care cards were reviewed and updated as indicated. 7. The door key codes were changed by the Maintenance Director at approximately 10:35 AM on 08/27/14. The Administrator implemented a bright red notification sign to notify visitors/families on all exit doors to "Please see staff before allowing anyone to exit these doors" on 08/27/14. On 08/27/14, the Contractor for the Wander Guard system was contacted for a full system evaluation by the Maintenance Director. As an additional precaution, the two (2) sensitivity antennas were replaced on the front East Unit exit doors leading to the lobby area. An order was placed on 08/28/14 by the Administrator for an enunciator panel to be installed at each nurse's station. 8. 100% staff re-education was immediately initiated by the Nurse Practice Educator and all administrative staff, beginning on 08/26/14, and continuing with completion on 08/29/14. The re-education included, the Center's policies on elopement prevention and management, expected employee response to a door alarm, specific information regarding the doors at this facility and how each functions, instructions that alarm codes should not be given to residents or visitors. Each employee completed a post-test to validate learning with a 100% pass rate. 100 of 110 active employees completed re-education and post testing between 08/26/14 and 08/29/14. Employees not currently available during this time frame will have or have had education/re-education completed prior to returning or beginning work including a post test. All new employees will have elopement education provided during orientation. 9. The Personal Care Residents (18 of 18) were re-educated by the Nurse Practice Educator and/or Administrator beginning on 08/26/14 and completed on 08/28/14. The Skilled residents (39 of 39) with BIMS scores of eight (8) or higher were re-educated by the Administrator on 08/28/14. Resident re-education included, "if the door alarm is sounding, do not attempt to turn the alarm off, notify staff for assistance. If at any time you need assistance to exit the East Unit please ask staff for assistance and to please notify staff if you observe anyone other than staff entering the door key code." 10. Beginning on the day shift of 08/27/14, the Nurse Practice Educator completed an elopement drill on each shift through 08/29/14 to audit training compliance. No concerns were identified with these audits. Alarm and wander guard function audits were completed on each shift beginning 08/26/14 and ending on 08/29/14 by Licensed Nurses or the Administrator. All door locking mechanisms and alarms were found to be working properly during these audits. Alarm and wander guard function for all doors was tested daily by the Maintenance Director or the Licensed Charge Nurse. 11. No further elopements since implementing the original PI Plan on 08/26/14. Licensed staff or a department manager will complete an elopement drill on each shift monthly for three (3) months (September, October, November 2014), then quarterly for six (6) months. Corrective action and/or re-education will be provided at point of discovery of identified audit concerns. Findings will be reviewed by the Quality Improvement Committee (QIC), the QI Committee will make recommendations for additional audits based on audit outcomes. 12. An AD HOC PI meeting was held on 09/02/14, and on 09/05/14 with the Administrator, Medical Director and all Department Managers to review the progress of the Improvement Plan including, informational letters to 100% family members to be mindful of the alarms and seek staff assist when an alarm is sounding or residents may be trying to exit facility on 09/06/14. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Resident #1's chart on 09/18/14 at 2:10 PM, revealed a change of condition document was initiated on 08/26/14 at 5:45 PM by LPN # 1. Vital signs were obtained along with a head to toe assessment. Documentation also revealed the resident was placed on direct line observation at that time. The Physician and family members were notified of the elopement on 08/26/14 at 7:00 PM and 7:10 PM by LPN #1. Interview with LPN #1, on 09/18/14 at 3:10 PM, revealed she was working the night Resident #1 was able to exit the building. LPN #1 completed a head to toe assessment on Resident #1 with no injuries noted. 2. Interview with the Nurse Practice Educator, on 09/18/14 at 4:30 PM, revealed she updated Resident #1's care plan on 08/26/14 after re-evaluating his/her elopement assessment evaluation, and again on 08/27/14 after the Interdisciplinary Care Plan meeting. 3. Interview with LPN #1, on 09/18/14 at 3:10 PM, revealed a Visual Validation Census Check was completed on all residents in the building on 08/26/14 at 6:35 PM. Review of the Visual Validation Census Check dated 08/26/14 confirmed this. 4. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed she returned to the facility at 6:00 PM on 08/26/14, and started an investigation to determine how the resident was able to exit the building undetected. She stated she immediately checked all egress door alarms to make sure they were functioning properly. 5. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed she returned to the facility at 6:00 PM on 08/26/14, and her investigation revealed a Personal Care Resident heard the alarm and immediately reset the alarm. The Administrator stated she re-educated the Personal Care Resident on the importance of not responding or resetting the door alarm on 08/26/14 at 6:45 PM. 6. Interview with the Nurse Practice Educator, on 09/18/14 at 4:30 PM, revealed she updated Resident #1's care plan on 08/26/14 after re-evaluating his/her elopement assessment evaluation, and again on 08/27/14 after the Interdisciplinary Care Plan meeting. Further interview revealed she then reviewed all residents identified as an elopement risk and updated the assessment, care cards and care plans as indicated on 08/26/14. 7. Observation on 09/18/14 at 2:00 PM, revealed the facility relocated the coded alarm system from the East Nurses Station to the front entrance of the facility. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed the door way was monitored daily from 7:00 AM until 7:00 PM. The Administrator stated, the new system required that anyone entering the facility or exiting the facility must be buzzed in by the receptionist. The front door will automatically lock at 7:00 PM; to enter the facility you must go to the back entrance. She revealed the enunciator panels were installed on each nurses' station to alert the staff which door the resident was attempting to exit. Interview with Maintenance Director on 09/18/14 at 3:15 PM, revealed he demonstrated the alarm by opening the veranda doors and looking at the enunciator panel to verify the location of the alarm. Interview with LPN #1 on 09/18/14 at 3:10 PM, revealed she was knowledgeable of the new system that was put in place, and was able to explain the use of the enunciator panels. Interview with Activity Director on 09/18/14 at 2:59 PM, revealed she was aware of the new system changes with the door code alarm, she stated after 7:00 PM visitors could enter through the service entrance and ring a door bell. She further stated they had to be let in by the staff, and they were required to verify their identity before letting them in the facility. 8. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed all staff was re-educated on the facility's policy for elopement. The re-education included the Center's policies on elopement prevention and management; expected employee response to a door alarm; specific information regarding the doors at this facility; and, how each functioned; and, instructions that alarm codes should not be given to residents or visitors. Each employee completed a post-test to validate learning with a 100% pass rate. 100 of 110 active employees completed re-education and post testing between 08/26/14 and 08/29/14. Employees not currently available during this time frame will have or have had education/re-education completed prior to returning or beginning work including a post test. All new employees will have elopement education provided during orientation. Education was verified by viewing the inservice sign-in sheets and post test packets were reviewed on 09/18/14. 9. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed all Personal Care Residents (18-18) were re-educated on the importance of the door alarms and not to re-set the door alarms, and to notify staff if they see another resident exiting the doors when the alarm sounds . The inservice was verified by a sign in sheet with Personal Care residents' signatures beginning 08/26/14 through 08/28/14. 10. Interview with the MDS Coordinator on 09/18/14 at 3:23 PM, revealed her normal shift was 7:00 AM-4:00 PM. She stated she was inserviced on 08/26/14 by the Nurse Practice Educator on the Center's policy on elopement prevention, the new process for entering and exiting the building, importance of keeping the door code confidential. She stated she completed the post test with 100% accuracy. Interview with Employee #1 on 09/18/14 at 3:28 PM, revealed she also attended an inservice on 08/26/14. She stated her normal work shift was 5:30 AM-9:00 PM. She stated the inservice contained information about the facility's elopement policy and the new process for entering and exiting the building. She also completed a post test with 100% accuracy. Interview with Employee #2 on 09/18/14, revealed she was employed as a Medication Tech and worked from 11:00 PM- 7:00 AM. She stated she also attended the inservice on 08/26/14 related to the elopement policy and the new process for entering and exiting the facility. She knew the importance of keeping the door code confidential and the use of the new alarm system. She indicated that she took a test with 100% accuracy after the training was completed. Interview with Employee #3 on 09/18/14 at 3:20 PM, revealed she was employed as a Certified Nurse Aide and worked from 2:00 PM -10:00 PM. She stated the inservice on 08/26/14 talked about the new door alarm system and the facility's policy on elopement. She was able to identify which residents were currently identified at risk for wandering and the importance of keeping the door code confidential. She also took a post test after the training with 100% accuracy. Interview with Employee #4 on 09/18/14 at 3:40 PM, revealed she attended the inservice on the facility's elopement policy on 08/27/14 and also participated in an elopement drill. She indicated the training covered the re-education on the elopement policy as well as the new door alarm system. Interview with Employee #5 on 09/18/14 at 2:34 PM, revealed she was inserviced on 08/27/14 at 8:00 PM on the new facility policy on elopement and also participated in an elopement drill. She stated she has a good understanding of the new door alarm system and realized the importance of keeping the code confidential. Interview with Resident #2 on 09/18/14 at 2:33 PM, revealed that he/she was not aware of the new door alarm code. Interview with Resident #3 on 09/18/14 at 2:20 PM. revealed he/she was aware of the door alarm code prior to installing the new alarm system, but did not know the new door alarm code. Interview with Resident #3's family member on 09/18/14 at 2:20 PM, revealed that she was aware the facility has made changes with the alarm system, prior to the changes she was aware of the door alarm code but she did not know the new code. Interview with Personal Care Resident #4 on 08/18/14 at 4:09 PM, revealed the staff had taught him/her about the exit doors and staff let him/her out when he/she wanted to go out with his/her family. The resident stated he/she did not have access to the door code anymore. Interview with Personal Care Resident #5 on 09/18/14 at 4:12 PM, revealed he/she did not have the door code anymore, and the staff let him/her out when he/she needed to go with family. He/she continued to say that someone talked to him/her about the exit doors, and the importance of not letting anyone out the doors or turning off the alarms. 11. Interview with the Administrator on 09/18/14 at 2:10 PM, revealed that no further elopements had occurred. Licensed staff or a department manager would complete an elopement drill on each shift monthly for three (3) months (September, October, November 2014), then quarterly for six (6) months. Interview with the MDS Coordinator on 09/18/14 at 2:20 PM, revealed there has been no further elopements, and the new system was working properly. 12. Verification of the AD HOC PI meeting was obtained through interview on 09/18/14 at 2:10 PM with the Administrator, she revealed the facility started the Performance Improvement for the Elopement on 08/26/14 with the investigation process to assist the team with determining the root cause of the elopement. She stated they met again to include the Medical Director in the discussion on 08/27/14, and the entire team met again on 09/10/14. A copy of the notification letters mailed on 09/06/14, to all family members was reviewed during the interview on 09/18/14 at 2:10 PM. The Administrator continued to reveal that she has been in constant communication with the Medical Director through out the entire investigation either in meetings or phone conversations.

Based on interview, review of the facility's policy and procedure, review of the Administrator's job description it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to protect the residents from abuse from Licensed Practical Nurse (LPN) #1, State Registered Nurse Aide (SRNA) #1, and Registered Nurse (RN) #1. ( Refer to F223; F225; F226; F241; and, F282). The facility's failure to be administered in a manner that enable it to use its resources effictively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/14/14 and determined to exist on 08/02/14. The facility was notified of the Immediate Jeopardy on 08/14/14. An acceptable Allegation of Compliance (AoC) was received on 08/29/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/29/14, as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure, titled "Abuse Prohibition", dated 07/01/13, revealed, "The Administrator, or designee, was responsible for operationalizing polices and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for patients". Review of the Administrators Job Description, dated 08/21/01, revealed the Administrator was responsible for the day to day functions in accordance with current Federal and State regulations, local standards and Corporate Policies as well as to maintain a friendly, respectful, helpful attitude toward residents, families, staff, corporate staff, volunteers, and visitors. Interviews with LPN #4 on 08/11/14 at 2:42 PM, LPN #2 on 08/13/14 at 11:11 AM, LPN #5 on 08/12/14 at 10:53 AM; SRNA #2 on 08/11/14 at 2:50 PM, SRNA #4 on 08/13/14 at 10:08 AM, and SRNA #9 on 08/15/14 at 11:10 AM, revealed they did not feel comfortable reporting concerns to the Administrator related to LPN #1 because the Administrator knew of LPN #1's mistreatment of [REDACTED]. Staff reported they did not report allegations because of the fear of retaliation from the alleged perpetrators and Administrative staff and did not feel it would do any good to report. Interview with the Administrator, on 08/14/14 at 1:00 PM, revealed LPN #1 was terminated on 08/14/14 after a suspension from work which occurred on 08/03/14 and was not allowed to return to work because he was accused of violating a resident's rights by not allowing Resident #1 to choose his/her bedtime and he denied the resident of the use of his/her personal computer. Additional interview with the Administrator, on 08/14/14 at 1:00 PM, revealed SRNA #1 and RN #1 was suspended on 08/03/14 and RN #1 was allowed to return to work on 08/14/14 and SRNA #1 was allowed to return to work on 08/15/14. (At which time the facility had an ongoing Immediate Jeopardy related to abuse; RN #1 and SRNA #1 had been identified as two (2) of the three (3) alleged perpetrators involved.) The Administrator stated she could substantiate abuse because there was no physical evidence of abuse of any residents which was determined through skin assessments on Residents #1 though #10 and Residents A, B, and C. However, staff including SRNA #3, SRNA #4, LPN #4, LPN #5 and LPN #8 stated they witnessed the alleged abusive behaviors toward the residents. Further interview on 08/20/14 at 1:00 PM, revealed she would expect staff to come to her with concerns and they should not have fear of retaliation. She revealed she had always encouraged staff to come to her and she felt the only reason they may not have was related to one incident when the Director of Nursing counseled LPN #1 and he left the office and returned to the floor to work telling staff "Oh they didn't do anything to me". She stated she inserviced staff on the importance of reporting any suspected abuse/neglect immediately. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/03/14, the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on 08/14/14 and 08/15/14 regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on 08/03/14 with no concerns identified. Pain assessments and Social Service assessments were also completed on 08/03/14 for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on 08/03/14 related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on 08/03/14, with any new concerns identified and addressed. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on 08/03/14 and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on 08/03/14 regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on 08/03/14 and ended on 08/06/14 and included all center and contract employees regarding effective systems that ensures each resident remains free of abuse: ? Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation. ? Reporting requirements including immediate reporting to the Administrator and appropriate state agencies. ? Promise of confidentiality and no fear of retribution. Employee competency assured using the Abuse Prevention post-test. Post-test reviewed and validated by the Nurse Practice Educator by 08/06/14. HIPPA Privacy Law. ? The prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of 08/06/14, nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of 08/06/14 and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending 08/22/14. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on 08/26/14 and 08/27/14. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on 08/22/14. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on 08/25/14 related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised 08/01/12 included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning 08/02/14, upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On 08/03/14, the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations are reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on 08/22/14 to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on 08/03/14, for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on 08/22/14 which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on 08/03/14 and the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on 08/19/14 to review all plans of compliance regarding the outstanding citations. **The State Survey Agency validated the Corrective action taken by the facility on 08/29/14 as follows: 1. LPN #1 was terminated, RN #1 and SRNA #1 remained suspended. 2. Review of audits dated 08/14/14 and 08/15/14, revealed the audits were completed on grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Review of skin assessments, change of condition forms, pain assessments, Social Service assessments and changes and mood and behavior assessments revealed Residents #3, #4, and #5 had skin assessments, change of condition forms, Social Service assessments and pain assessments performed on 08/03/14 with no concerns identified. In addition, further review of the assessments revealed Residents #1, #2, #6, #7, #8, and #9 had skin assessments and changes in mood/behavior assessment completed on 08/03/14 with no concerns identified. 4. Review of assessments and interviews, dated 08/03/14, revealed Unsampled Residents A, B, and C were assessed and interviewed related to abuse and changes of condition with no concerns identified. 5. Review of forty-one (41) interviews conducted with residents that had a Brief Interview Mental Status (BIMS) score between eight (8) and fifteen (15), revealed the interviews were conducted by the Director of Social Services and the Admission Director, on 08/03/14 with any concerns identified followed up on. 6. Review of skin assessments of forty-two (42) residents with a BIMS of less than twelve (12), dated 08/03/14 revealed there were no concerns identified. 7. Review of Education Documentation, dated 08/03/14, revealed the Director of Nurses (DON) and Administrator received education on the Abuse Policy and reporting requirements on 08/03/14 by the Regional Vice President (RVP). 8. Review of Education Documentation, dated from 08/03/14 through 08/06/14, revealed 100% of all center and contract employees received re-education and completed a post test related to the abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution, Health Information Privacy Protection Act (HIPPA) privacy law, cell phone privacy and prohibition of use of cell phones in resident care areas and prohibition of videos or photographs of residents. Review of Education Documentation, dated 08/22/14 revealed seventy-six (76) available employees were educated on following the resident's plan of care. Review of Education Documentation, dated 08/26/14-08/27/14, revealed the other thirty-two (32) employees were in-serviced with post tests completed. The staff who received the education on these late dates were as needed (PRN) employees, were not on the schedule at all, or not available. The education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Review of Re-education Documentation, dated 08/25/14, revealed the RVP and Manager of Clinical Operations (MCO) conducted education for the Administrator related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness Interviews with Dietary Aide, on 08/29/14 at 2:00 PM, LPN #4 on 08/29/14 at 2:03 PM, Occupational Therapist Assistant, on 08/29/14 at 2:05 PM, SRNA #12, on 08/29/14 at 2:08 PM, SRNA #13, on 08/29/14 at 2:10 PM, SRNA #8, on 08/29/14 at 2:15 PM, LPN #6, on 08/29/14 at 2:15 PM, LPN #10, on 08/29/14 at 2:20 PM, Housekeeping Aide #3, on 08/29/14 at 2:25 PM, LPN #3, on 08/29/14 at 2:26 PM, Assistant Activities Director, on 08/29/14 at 2:27 PM, LPN #9, on 08/29/14 at 2:35 PM, Assistant Director of Nursing, on 08/29/14 at 3:15 PM, Physical Therapy Assistant, on 08/29/14 at 3:16 PM, and Minimum Data Set (MDS) Coordinator, on 08/29/14 at 3:35 PM, revealed all had been inserviced related to abuse, privacy, and dignity and following the care plans. All were able to name the types of abuse, reporting abuse and understood the importance of following the care plans and providing privacy for residents as well as being respectful of a resident's dignity. 9. Review of the Administrator's Job Description, revealed the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Interviews conducted, on 08/29/14 with the MDS Coordinator at 8:55 AM, Dietary Manager at 4:45 PM, and, Social Services Director at 4:55 PM, revealed no other allegations of abuse had been presented since the initial allegations on 08/02/14. 10. Review of audits conducted on all three shifts on 08/03/14 through 08/17/14 revealed Department Managers or Nursing Supervisors observed staff/resident interactions. No concerns identified were identified. Audit tools ongoing. 11. Review of Audits Tools, revealed the Shift Supervisor was conducting audits to monitor for staff's cell phone usage, using appropriate language, resident's privacy, monitoring of bath temperatures and to determine that any allegations were reported immediately were completed for all three (3) shifts, five (5) days a week through 08/29/14. Review of the audits revealed no concerns. Audit tools ongoing 12. Review of the PI Tools revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager interviewed fifteen (15) employees from all departments weekly through 08/29/14 to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and all allegations or statements are kept confidential with no fear of retribution for reporting. No concerns were identified. PI tools ongoing. 13. Review of resident interviews revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager completed fifteen (15) resident interviews weekly through 08/29/14 related to staff treatment and abuse. Audit sheets ongoing. 14. Review of resident family interviews and skin assessments for residents with a BIMS of less than seven (7) revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager conducted five (5) family interviews and resident skin assessments on 08/28/14 and are to continue for four (4) weeks times one (1) month and then two (2) a week times six (6) months. 15. Review of psychosocial assessments, on 08/29/14, revealed the SSD, DON, or ADON completed these assessments for three (3) residents with a BIMS score of eight (8). The assessments were ongoing. 16. Review of the grievances, complaints, and allegation daily monitoring revealed starting on 08/03/14 the Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors monitored daily for fourteen (14) days and then for five (5) days a week up to 08/29/14. 17. Observation revealed posters for "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values" were on the walls throughout the facility and in the breakroom. 18. Review of Ad-Hoc meeting minutes dated 08/03/14 revealed the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. 19. Review of the QA Committee minutes, dated 08/19/14, revealed a meeting consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held and they reviewed all plans of compliance regarding the outstanding citations.

Based on interview, record review, and review of the facility's policy and procedure and the facility's investigation, it was determined the facility failed to ensure nine (9) of ten (10) sampled residents (Resident #1, #2, #4, #5, #6, #7, #8, #9 and #10) and two (2) unsampled residents (Unsampled Resident A and B) were free from abuse. The facility failed to have an effective system in place to ensure residents were free from abusive treatment by staff; and, failed to ensure staff reported the observed mistreatment of [REDACTED]. Licensed Practical Nurse (LPN) #1, State Registered Nurse Aide (SRNA) #1, and Registered Nurse (RN) #1 were alleged to have abused Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10. In addition, it was alleged RN #1 and SRNA #1 also abused Unsampled Resident A and Resident B. The allegations revealed the abuse occurred on the second shift but the facility was unable to determine specific dates. The allegations of abuse included verbal, physical and mental abuse. Although LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4 witnessed LPN #1, RN #1, and SRNA #1 exhibit abusive behaviors toward the residents, there was no evidence staff intervened to protect the residents. Abusive behaviors witnessed by LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4 included pinching the resident's breasts and noses; telling resident(s) to shut his/her mouth; dropping one (1) resident to the bed from face height; putting soap in a resident's mouth; video taping telling a resident to cluck like a chicken, placing a resident on a bare mattress and covering him/her with a fitted sheet; putting gloved fingers in a resident's mouth to aggravate the resident; jumping up and down on a resident's bed and pretending to vomit in his/her ear; slapping a resident; videotaping of residents being made to cluck like a chicken; and pouring bath water with ice cubes on one (1) resident during a bath leaving the resident cold and totally exposed. Interviews with the above listed staff members revealed the allegations of abuse were not reported to the Administrative Staff due to LPN #1 threatening if anyone told on him he would make their lives "a living hell" and he was untouchable. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure, titled "Abuse Prohibition", dated [DATE], revealed the facility would prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of residents during investigations; and, Reporting of incidents, investigations, and the Center's response to the results of their investigations. The Administrator, or designee, was responsible for operationalizing policies and procedures that prohibit and would protect residents from further harm during an investigation and provide the resident with a safe environment by identifying persons with whom he/she feels safe and conditions that he/she would feel safe. Interview with the Marketing/Admission Director, on [DATE] at 2:03 PM, revealed he got a call from an anonymous employee who told him he needed to come to the facility and speak with LPN #2. He stated he immediately called the Administrator and she asked him to initiate the investigation because she was an hour away. He stated he went to the facility and spoke with LPN #2 and was told about the alleged abuse by LPN #1 and SRNA #1. He stated part of the alleged abuse was supposed to have been recorded on SRNA #1's phone. Further interview revealed the Administrator arrived at the facility and took over the investigation. He stated the anonymous employee told him they did not call the Administrator as they did not want their voice recognized by her. Further interview with the Marketing/Admission Director revealed he was not given a reason why the anonymous employee did not want to speak with the Administrator. 1. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview Mental Status (BIMS) score of nine (9) indicating the resident was interviewable. SRNA #9 alleged LPN #1 would make Resident #1 go to bed at approximately 6:00 PM every night; would deny the resident the use of his/her computer, as well as tell the resident to shut his/her mouth when he/she asked for the computer. Additionally, she revealed she was unsure why LPN #1 was the way he was with Resident #1. Interview with SRNA #9, on [DATE] at 11:10 AM, revealed LPN #1 would tell her and the other aides to place Resident #1 outside his/her room door after dinner and put him/her to bed at 6:00 PM. LPN #1 would not allow the resident to use his/her computer. Additionally, she revealed she heard LPN #1 state, on several occasions, "I hate them all" referring to the residents. She stated she did not report the abuse because Resident #1 was the Administrator's relative and told her things all the time; therefore she was sure the Administrator knew how Resident #1 was being treated by LPN #1. Interview with the Social Service Director (SSD), on [DATE] at 9:49 AM, revealed on [DATE] the Administrator told her about the allegations of abuse and asked her to begin the investigation by conducting interviews along with the Admissions/Marketing Director. She revealed she interviewed Resident #1 and was told he/she did not like LPN #1 because he told him/her to shut up and would not let him/her use his/her computer. She stated she knew Resident #1 was telling the truth because he/she would begin to shake as if he/she was in fear and would state "he will be here tonight" and tears would come to his/her eyes. Interview with the Administrator, on [DATE] at 10:55 AM, revealed she had spoken with LPN #1 regarding making Resident #1 go to bed at 6:00 PM every night and thought she and LPN #1 had come to an agreement about Resident #1's schedule. Resident #1 was to be placed in bed at 8:00 PM on school nights and would be allowed to remain up until 8:30 or 9:00 PM on non-school nights. She revealed she explained to LPN #1 that Resident #1 liked to have access to his/her computer. Additionally, she revealed she was unaware of LPN #1 not complying with her wishes related to Resident #1's schedule. An interview was conducted with the Administrator rather than Resident #1 as the resident was not reliable in giving accurate information. 2. Record review revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of two (2) indicating the resident was not interviewable. SRNA #3 alleged LPN #1 scooped Resident #2 off of the commode after he/she refused to go to bed and carried the resident to the bed, held him/her like a baby, and dropped him/her on the bed (naked). LPN #1 fell on the bed and the resident landed on top of him. LPN #1 then told the SRNAs in the room to "get this [***] off of me". Interview with SRNA #3, on [DATE] at 12:00 PM revealed she witnessed SRNA #1 and SRNA #8 with Resident #2. The resident was on the commode and was resisting care not wanting to go to bed. She stated the SRNAs called LPN #1 to assist with Resident #2; the LPN scooped Resident #2 off the commode, pinched his/her breasts, walked to the bed and dropped the resident from face height down onto the bed with the resident completely naked. She stated the LPN fell to the bed with the resident landing on top of him. SRNA #3 stated LPN #1 then told SRNA #1 and SRNA #8 to "Get this [***] off of me". She stated the LPN proceeded to tell Resident #2 he/she was going to bed and if he/she didn't he was going to call his/her son and he/she (the resident) would not like how he talked to him. Further interview with SRNA #3 revealed she resigned because she could not work in that type of environment. SRNA #3 revealed she did not report the allegations of abuse to the Administrator because she told the Charge Nurse on duty and expected her to follow up with the Administrator. Interview with LPN #2, Charge Nurse, on [DATE] at 11:11 AM, revealed after SRNA #3 reported the abuse to her, she did not report the alleged abuse to Administration because she felt nothing would be done about it. LPN #2 stated LPN #1 threatened the staff with making their lives a "living hell" if they told on him, therefore the abuse went unreported. 3. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed Resident #4's cognition as severely impaired with a BIMS' score of six (6) indicating the resident was not interviewable. LPN #2 alleged SRNA #1 and LPN #1 pinched Resident #4's nose and breasts. She also alleges that this was recorded on SRNA #1's cell phone. Interview with LPN #2, on [DATE] at 11:11 AM, revealed she witnessed LPN #1 and SRNA #1 pinching Resident #4's breasts. LPN #2 also revealed she had witnessed videos on the phones of LPN #1 and SRNA #1 telling Resident #4 to cluck like a chicken. LPN #2 stated LPN #1 threatened the staff with making their lives a "living hell" if they told on him, therefore the abuse went unreported. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed RN #1 putting her gloved fingers in Resident #4's mouth; LPN #1 and SRNA #1 pinch Resident #4's breasts. Further interview revealed SRNA #4 felt threatened by LPN #1 as LPN #1 would tell staff that he and SRNA #1 were untouchable and if anyone told on them they would make their lives a "living hell"; therefore, the abuse went unreported. 4. Record review revealed the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed Resident #5's cognition as severely impaired. An anonymous caller as well as LPN #2 and SRNA #4 alleged LPN #1 and SRNA #1 pinched the resident's nose and breasts; LPN #1 jumped up and down, straddled the resident in bed, then put his mouth at the resident's ear and acted like he was vomiting. LPN #1 threw cold water on the resident as well. Interview with LPN #2, on [DATE] at 11:11 AM, revealed she also witnessed LPN #1 and SRNA #1 pinching Resident #5's breasts. She stated LPN #1 jumped up and down straddling Resident #5 on the bed and pretended to vomit in the resident's ear to make him/her scream. She also witnessed RN #1 place her gloved fingers in Resident #5's mouth to aggravate him/her. LPN #2 also revealed she had witnessed videos that were made of the alleged abuse of Resident #5. Further interview with LPN #2 revealed SRNA #3 had reported to her that the staff was abusing the residents and other staff had seen the abuse occurring but they did not report it or intervene because they was intimidated by LPN #1. LPN #2 stated LPN #1 threatened the staff with making their lives a "living hell" if they told on him, therefore the abuse went unreported. LPN #2 stated after SRNA #3 reported the abuse to her, she did not report the alleged abuse to Administration because she felt nothing would be done about it. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed LPN #1 and SRNA #1 pinch Resident #5's breast. She stated she received a video from RN #1's phone that revealed RN #1 putting her gloved fingers in Resident #5's mouth and LPN #1 pinching the resident's breasts. Further interview revealed SRNA #4 felt threatened by LPN #1 as he would tell staff that he and SRNA #1 were untouchable and if anyone told on them they would make their lives a "living hell"; therefore, the abuse went unreported. Interview with LPN #5, on [DATE] at 10:53 AM, revealed he had witnessed LPN #1 and RN #1 put gloves on and place their fingers in Resident #5's mouth to make him/her mad. He stated the resident would yell "quit it, stop, stop." Additionally, he revealed, on [DATE] at 10:53 AM, he witnessed SRNA #1 and LPN #1 refuse to take Resident #6 to his/her room and when he asked why the resident could not go to his/her room he was told by LPN #1 that Resident #6 was only asking to be a "pain in the ass". Additionally, he revealed another SRNA took the resident to his/her room and the resident was satisfied because that was all he/she wanted. He stated he should have reported the verbal abuse and mistreatment but felt nothing would be done about it because LPN #1 seemed to get away with everything. 5. Record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #6's cognition as severely impaired with a BIMS score of six (6) indicating the resident was not interviewable. LPN #5 alleged the resident was denied the opportunity to go to his/her room when he/she wanted and LPN #1 called him/her a "pain in the ass" for asking and he/she would wait and be the last one to be put to bed just for asking. 6. Record review revealed the facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #7's cognition as severely impaired with a BIMS score of seven (7) indicating the resident was not interviewable. LPN #8 alleged LPN #1 pinched the resident's nose with a reacher (metal grab assist bar). Interview with LPN #8, on [DATE] at 11:58 AM, revealed she witnessed LPN #1 using a reacher to pinch Resident #7's nose and when she entered the room LPN #1 stopped and left the room. She revealed she did not report this incident because she did not feel anyone would believe her as she had seen in meetings how LPN #1 spoke rudely to the Administration and got away with it. 7. Record review revealed the facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #8 as cognitively intact with a BIMS score of eleven (11) indicating the resident was interviewable. SRNA #10 alleged the resident was afraid of LPN #1 and SRNA #1 calling them "the gang" or the "cult". Interview with Resident #8, on [DATE] at 1:05 PM, revealed "Someone" on second (2nd) shift (a nurse) mistreated him/her and it was a man. He/She revealed the nurse said things to him/her (no specifics) and was rough with him/her at times. Resident #8 began to cry during the interview and stated, "I don't want to say anymore because 'he' has a lot of friends and sometimes they come in with him and are mean too." Further interview with Resident #8, on [DATE] at 2:35 PM, revealed he/she was afraid to go to bed at night after LPN #1 and the SRNA climbed through the window into his/her room. Additionally, he/she revealed after LPN #1 found out he had been reported he got really nice to him/her and prior to that he did not care how he treated him/her. Interview with Housekeeping Aide #3, on [DATE] at 2:30 PM, revealed Resident #8 told her she would be surprised at what went on at the facility on second (2nd) shift. Additionally, she revealed she had witnessed staff using cell phones for talking and texting in resident care areas. She revealed she had not witnessed any abuse and would report it immediately to her supervisor, the charge nurse, and the Administrator. 8. Record review revealed the facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]., Depression, Adult Failure to Thrive, Pain, and [MEDICAL CONDITION]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #9's cognition as severely impaired with a BIMS score of two (2) indicating the resident was not interviewable. An anonymous caller alleged SRNA #1 put soap in the resident's mouth. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed SRNA #1 putting soap in Resident #9's mouth. She revealed she did not report the abuse because LPN #1 told other staff members that he and SRNA #1 were untouchable and if anyone told on them their lives would be a living hell. 9. Record review revealed the facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #10's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Resident #10 expired in the facility on [DATE]. SRNA #4 alleged LPN #1 placed the resident on a bare mattress and placed a fitted sheet on top of him/her. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed LPN #1 placing a fitted sheet on top of Resident #10 while he/she lay on a bare mattress. She revealed she did not report the abuse because LPN #1 had told staff that he and SRNA #1 were untouchable and he would make life a living hell for anyone who told on him. 10. Record review revealed the facility admitted Unsampled Resident A on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Unsampled Resident A as cognitively intact with a BIMS score of twelve (12) indicating the resident was interviewable. SRNA #14 alleged RN #1 and SRNA #1 laid on the resident's bed and kissed him/her on the neck against the resident's will on more than one (1) occasion. Interview with Unsampled Resident A, on [DATE] at 9:58 AM, revealed RN #1 and SRNA #1 laid on the bed with him/her and kissed his/her neck and he/she asked them to stop. Unsampled Resident A revealed RN #1 and SRNA #1 started laughing and fell on his/her bed and began to kiss his/her neck. He/She stated when he/she asked them to stop, they continued to laugh at him/her and this had occurred two (2) or three (3) times in the past but he/she had never reported it to anyone. 11. Record review revealed the facility admitted Unsampled Resident B on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Unsampled Resident B's cognition as severely impaired with a BIMS score of three (3) indicating the resident was not interviewable. SRNA #3 alleged the resident received a cold bed bath by SRNA #1 and SRNA #8 and was told to shut the "F_ _ k up" and they did not "have all night to get the bath done" by SRNA #1 when the resident said he/she was cold. She revealed she reported the abuse to LPN #2 who was the Charge Nurse on duty at the time of the alleged incident. Interview with SRNA #3, on [DATE] at 12:00 PM, revealed she was asked by SRNA #1 to stand by and watch SRNA #1 give Resident B a bath because she was in orientation. She revealed she was shocked by what she had witnessed by SRNA #1 as she (SRNA #1) had poured water on the resident's head and then the rest of his/her body, leaving him/her exposed and cold, did not rinse the soap from the resident's body nor wash the resident's backside, rolled the resident over, dried the mattress, placed an adult protective device on the resident, and left him/her shaking and cold. SRNA #3 revealed she was told by SRNA #1 that she could do a bath her way after she was trained because SRNA #3 was apologizing to Resident B for the SRNA's actions. Interview with Housekeeping Aide #1, on [DATE] at 3:10 PM, revealed she entered a resident's room and the resident was nude sitting on the commode, crying because SRNA #1 was mad at her/him because she felt the resident had an incontinent episode on purpose. She revealed she never witnessed any abuse to the resident by SRNA #1 or anyone else. She stated she was in and out of resident's rooms so often they tell her things because she will listen to them. Interview with RN #2, on [DATE] at 2:00 PM, revealed she had witnessed LPN #1 being short tempered with some residents. An example given was LPN #1 would harshly tell one resident to "go sit down". RN #1 stated LPN #1 had "no patience" with another resident and she didn't report LPN #1's behavior because she didn't feel anything would be done about it. Interview with the Director of Nursing (DON), on [DATE] at 4:05 PM, revealed she had never witnessed any type of abuse conducted by SRNA #1, RN #1, or LPN #1, nor had any staff or resident ever complained of abuse to her. Interview with the Administrator, on [DATE] at 10:55 AM, revealed as part of the investigation, she looked through LPN #1, SRNA #1, and RN #1's phones and did not find any videos or pictures of the alleged abuse. She stated the Kentucky State Police and the local Sheriff were working together to retrieve any videos or pictures if there were any. Additionally, she revealed she suspended the three (3) suspected employees on [DATE] pending an investigation into the allegations of abuse; however, SRNA #1 and RN #1 were able to return to work on [DATE] because there was no apparent proof to substantiate the allegations of abuse. LPN #1 was later terminated from employment on [DATE] related to violating Resident #1's right, as the resident was denied access to his/her personal property (computer). The Administrator stated no disciplinary action was taken with the employees who failed to report the witnessed abuse but all staff were reeducated on the facility's abuse policy and procedure which included reporting. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on [DATE] and [DATE] regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on [DATE] with no concerns identified. Pain assessments and Social Service assessments were also completed on [DATE] for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on [DATE] with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on [DATE] with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on [DATE] related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on [DATE], with any new concerns identified and followed up on. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on [DATE] and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on [DATE] regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on [DATE] and ended on [DATE] and included all Center and contract employees regarding effective systems that ensures each resident remains free of abuse: Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation, Reporting requirements including immediate reporting to the Administrator and appropriate state agencies, Promise of confidentiality and no fear of retribution, Employee competency assured using the Abuse Prevention Post-test, the Post-test reviewed and validated by the Nurse Practice Educator by [DATE]. HIPPA Privacy Law, and the prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of [DATE], nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of [DATE] and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending [DATE]. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on [DATE] and [DATE]. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on [DATE]. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on [DATE] related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised [DATE] included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning [DATE], upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On [DATE], the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations were reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on [DATE] to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on [DATE], for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on [DATE] which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on [DATE] and the Medical Director was briefed on the meeting and signed off on the meeting minutes on [DATE] as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on [DATE] to review all plans of compliance regarding the outstanding c

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure staff reported observed incidents of abuse/mistreatment for [REDACTED].#1, #2, #4, #5, #6, #7, #8, #9, and #10) and two (2) of three (3) unsampled residents (Unsampled Residents A and B). (Refer to F223) Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #1, and State Registered Nurse Aide (SRNA) #1, were alleged to have abused and mistreated Residents #1, #2, #4, #5, #6, #7, #8, #9, and #10. In addition, it was alleged RN #1 and SRNA #1 abused three (3) unsampled residents, (Unsampled Residents A and B). The alleged abusers all worked on second (2nd) shift together and the alleged abuse occurred on the second shift with no particular dates. The allegations of abuse included verbal, physical and mental abuse. Staff was aware of the alleged abuse but failed to report the abuse to the Administrator for fear of retaliation from LPN #1 and the Administrator. The facility's failure to ensure staff reported observed incidents of abuse, neglect, and mistreatment has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/14/14 and determined to exist 08/02/14. The facility was notified of Immediate Jeopardy on 08/14/14. An acceptable Allegation of Compliance (AoC) was received on 08/29/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/29/14, as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Abuse Prohibition", dated 07/01/13, revealed any staff who witnessed an incident of suspected abuse or neglect should tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified Supervisor should report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Interviews with LPN #5 and SRNA #4, revealed alleged abuse had been witnessed involving LPN #1, SRNA #1 and RN #1 towards a total of twelve (12) residents. However, the alleged abuse was not reported to the Administrator or designee at the time of the witnessed incidents per the facility's policy and procedure for fear of retaliation from LPN #1 and the Administrator. Interview with LPN #5, on 08/12/14 at 10:53 AM, revealed he was aware of staff mistreating and abusing the residents but did not report the abuse because he felt nothing was going to be done about it and if he did report it the person who was reported would know who had reported him/her. Interview with LPN #2, on 08/13/14 at 11:11 AM, revealed she did not report the abuse she witnessed LPN #1 doing because she felt intimidated by him and he was allowed to do anything he wanted. Additionally, she reported LPN #1 told her if she told on him he would make her life a "living hell". LPN #2 further revealed when she had to work with someone who was repeatedly cursing and yelling at the Administrator, then she did not feel comfortable reporting that person (LPN #1) to the Administrator. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she did not report the alleged witnessed abuse by LPN #1 because she felt threatened by LPN #1 because he told staff he and SRNA #1 were untouchable and if they told on them their lives would "be a living hell". Interview with SRNA #9, on 08/15/14 at 11:10 AM, revealed she did not report the abuse because Resident #1 was the Administrator's relative and told her things all the time; therefore she was sure the Administrator knew how Resident #1 was being treated by LPN #1. Interview with SRNA #3, on 08/13/14 at 12:00 PM revealed she did not report the allegations of abuse to the Administrator because she told the Charge Nurse on duty and expected her to follow up with the Administrator. Interview with SRNA #2, on 08/11/14 at 2:50 PM, revealed she did not report the abuse by LPN #1 to anyone because LPN #1 had a history of [REDACTED]. She revealed she had reported him approximately one (1) year ago and he had made life miserable for her ever since. SRNA stated LPN #1 was her supervisor and she would not elaborate on what LPN #1 did to her. Interview with LPN #8, on 08/15/14 at 11:58 AM, revealed she did not report what she witnessed because she did not feel anyone would believe her as she had seen in meetings how LPN #1 spoke rudely to the Administration and got away with it. Interview with the Administrator, on 08/20/14 at 1:00 PM, revealed there had been no reports of mistreatment or abuse of residents until they received an anonymous call on 08/02/14 alleging abuse and they began questioning staff about the abuse. She stated she knew of no reason why any employee would not come to her or other administrative staff and report abuse. She revealed there was one time the Director of Nursing (DON) counseled LPN #1 and he returned to the floor telling co-workers, (no names), "they didn't do anything to me"; therefore, she felt the staff may feel it would not do them any good to report anything to her. She revealed SRNA #2 told staff she reported LPN #1 about a year ago and since then he had treated her badly. She stated even though she was aware of this she did not take any action to ensure staff would report any witnessed abuse/neglect. The Administrator further revealed she had always encouraged staff to come to her with any issues and if they did she would not reveal the person's name who came to her. Further interview with the Administrator, on 08/20/14 at 1:00 PM, revealed the alleged perpetrators were suspended pending the facility's completion of the investigation. However, the alleged perpetrators were allowed to return to work, while the facility was still in Immediate Jeopardy, during the survey. Per the Administrator, the facility did not substantiate any of the abuse allegations due to the lack of physical evidence of abuse. The Administrator revealed she would not substantiate abuse based on witness statements only. She stated LPN #1 was terminated for failing to follow facility policy and procedures for violating resident rights regarding Resident #1's computer and State Registered Nurse Aide (SRNA) #1 and Registered Nurse (RN) #1 were allowed to return to work on 08/14/14; while the survey was still in progress. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/03/14, the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on 08/14/14 and 08/15/14 regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on 08/03/14 with no concerns identified. Pain assessments and Social Service assessments were also completed on 08/03/14 for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on 08/03/14 related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on 08/03/14, with any new concerns identified and addressed. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on 08/03/14 and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on 08/03/14 regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on 08/03/14 and ended on 08/06/14 and included all center and contract employees regarding effective systems that ensures each resident remains free of abuse: ? Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation. ? Reporting requirements including immediate reporting to the Administrator and appropriate state agencies. ? Promise of confidentiality and no fear of retribution. Employee competency assured using the Abuse Prevention post-test. Post-test reviewed and validated by the Nurse Practice Educator by 08/06/14. HIPPA Privacy Law. ? The prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of 08/06/14, nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of 08/06/14 and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending 08/22/14. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on 08/26/14 and 08/27/14. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on 08/22/14. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on 08/25/14 related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised 08/01/12 included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning 08/02/14, upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On 08/03/14, the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations are reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on 08/22/14 to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on 08/03/14, for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on 08/22/14 which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on 08/03/14 and the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on 08/19/14 to review all plans of compliance regarding the outstanding citations. **The State Survey Agency validated the Corrective action taken by the facility on 08/29/14 as follows: 1. LPN #1 was terminated, RN #1 and SRNA #1 remained suspended. 2. Review of audits dated 08/14/14 and 08/15/14, revealed the audits were completed on grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Review of skin assessments, change of condition forms, pain assessments, Social Service assessments and changes and mood and behavior assessments revealed Residents #3, #4, and #5 had skin assessments, change of condition forms, Social Service assessments and pain assessments performed on 08/03/14 with no concerns identified. In addition, further review of the assessments revealed Residents #1, #2, #6, #7, #8, and #9 had skin assessments and changes in mood/behavior assessment completed on 08/03/14 with no concerns identified. 4. Review of assessments and interviews, dated 08/03/14, revealed Unsampled Residents A, B, and C were assessed and interviewed related to abuse and changes of condition with no concerns identified. 5. Review of forty-one (41) interviews conducted with residents that had a Brief Interview Mental Status (BIMS) score between eight (8) and fifteen (15), revealed the interviews were conducted by the Director of Social Services and the Admission Director, on 08/03/14 with any concerns identified followed up on. 6. Review of skin assessments of forty-two (42) residents with a BIMS of less than twelve (12), dated 08/03/14 revealed there were no concerns identified. 7. Review of Education Documentation, dated 08/03/14, revealed the Director of Nurses (DON) and Administrator received education on the Abuse Policy and reporting requirements on 08/03/14 by the Regional Vice President (RVP). 8. Review of Education Documentation, dated from 08/03/14 through 08/06/14, revealed 100% of all center and contract employees received re-education and completed a post test related to the abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution, Health Information Privacy Protection Act (HIPPA) privacy law, cell phone privacy and prohibition of use of cell phones in resident care areas and prohibition of videos or photographs of residents. Review of Education Documentation, dated 08/22/14 revealed seventy-six (76) available employees were educated on following the resident's plan of care. Review of Education Documentation, dated 08/26/14-08/27/14, revealed the other thirty-two (32) employees were in-serviced with post tests completed. The staff who received the education on these late dates were as needed (PRN) employees, were not on the schedule at all, or not available. The education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Review of Re-education Documentation, dated 08/25/14, revealed the RVP and Manager of Clinical Operations (MCO) conducted education for the Administrator related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness Interviews with Dietary Aide, on 08/29/14 at 2:00 PM, LPN #4 on 08/29/14 at 2:03 PM, Occupational Therapist Assistant, on 08/29/14 at 2:05 PM, SRNA #12, on 08/29/14 at 2:08 PM, SRNA #13, on 08/29/14 at 2:10 PM, SRNA #8, on 08/29/14 at 2:15 PM, LPN #6, on 08/29/14 at 2:15 PM, LPN #10, on 08/29/14 at 2:20 PM, Housekeeping Aide #3, on 08/29/14 at 2:25 PM, LPN #3, on 08/29/14 at 2:26 PM, Assistant Activities Director, on 08/29/14 at 2:27 PM, LPN #9, on 08/29/14 at 2:35 PM, Assistant Director of Nursing, on 08/29/14 at 3:15 PM, Physical Therapy Assistant, on 08/29/14 at 3:16 PM, and Minimum Data Set (MDS) Coordinator, on 08/29/14 at 3:35 PM, revealed all had been inserviced related to abuse, privacy, and dignity and following the care plans. All were able to name the types of abuse, reporting abuse and understood the importance of following the care plans and providing privacy for residents as well as being respectful of a resident's dignity. 9. Review of the Administrator's Job Description, revealed the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Interviews conducted, on 08/29/14 with the MDS Coordinator at 8:55 AM, Dietary Manager at 4:45 PM, and, Social Services Director at 4:55 PM, revealed no other allegations of abuse had been presented since the initial allegations on 08/02/14. 10. Review of audits conducted on all three shifts on 08/03/14 through 08/17/14 revealed Department Managers or Nursing Supervisors observed staff/resident interactions. No concerns identified were identified. Audit tools ongoing. 11. Review of Audits Tools, revealed the Shift Supervisor was conducting audits to monitor for staff's cell phone usage, using appropriate language, resident's privacy, monitoring of bath temperatures and to determine that any allegations were reported immediately were completed for all three (3) shifts, five (5) days a week through 08/29/14. Review of the audits revealed no concerns. Audit tools ongoing 12. Review of the PI Tools revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager interviewed fifteen (15) employees from all departments weekly through 08/29/14 to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and all allegations or statements are kept confidential with no fear of retribution for reporting. No concerns were identified. PI tools ongoing. 13. Review of resident interviews revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager completed fifteen (15) resident interviews weekly through 08/29/14 related to staff treatment and abuse. Audit sheets ongoing. 14. Review of resident family interviews and skin assessments for residents with a BIMS of less than seven (7) revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager conducted five (5) family interviews and resident skin assessments on 08/28/14 and are to continue for four (4) weeks times one (1) month and then two (2) a week times six (6) months. 15. Review of psychosocial assessments, on 08/29/14, revealed the SSD, DON, or ADON completed these assessments for three (3) residents with a BIMS score of eight (8). The assessments were ongoing. 16. Review of the grievances, complaints, and allegation daily monitoring revealed starting on 08/03/14 the Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors monitored daily for fourteen (14) days and then for five (5) days a week up to 08/29/14. 17. Observation revealed posters for "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values" were on the walls throughout the facility and in the breakroom. 18. Review of Ad-Hoc meeting minutes dated 08/03/14 revealed the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. 19. Review of the QA Committee minutes, dated 08/19/14, revealed a meeting consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held and they reviewed all plans of compliance regarding the outstanding citations.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure the implementation of the facility's Abuse/Neglect policy and procedures for nine (9) of ten (10) sampled residents (Residents #1, #2, #4, #5, #6, #7, #8, #9, and #10) and two (2) of three (3) unsampled residents (Unsampled Residents A and B). Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #1, and State Registered Nurse Aide (SRNA) #1, were alleged to have abused and mistreated Residents #1, #2, #4, #5, #6, #7, #8, #9, and #10 and unsampled Residents A and B. The alleged abusers all worked on second (2nd) shift together. The allegations of abuse included verbal, physical and mental abuse. LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4 were aware of the alleged abuse but failed to follow the facility's policy and report the allegations to the Administrator. The above mentioned staff failed to report the alleged abuse due to fear of retaliation from the alleged perpetrators. (Refer to F223 and F225) The facility's failure to implement the facility's Abuse/Neglect policy and procedures to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/14/14 and was determined to exist on 08/02/14. The facility was notified of Immediate Jeopardy on 08/14/14. An acceptable Allegation of Compliance (AoC) was received on 08/29/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/29/14, as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Abuse Prohibition", dated 07/01/13, revealed any staff who witnessed an incident of suspected abuse or neglect should tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified Supervisor should report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Interview and record review revealed twelve (12) allegations of alleged abuse towards residents by LPN #1, SRNA #1, and RN #1 were witnessed by staff which included LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4; however, these allegations of abuse were not reported to the Administrator or designee per the facility's policy. The above staff, who witnessed these allegations of abuse, stated they did not report the abuse, as they were afraid of retaliation by the alleged perpetrators. Interview with SRNA #2, on 08/11/14 at 2:50 PM, revealed she did not report the abuse by LPN #1 to anyone because LPN #1 had a history of [REDACTED]. She revealed she had reported him approximately one (1) year ago and he had made life miserable for her ever since. SRNA stated LPN #1 was her supervisor and she would not elaborate on what LPN #1 did to her. Interview with SRNA #3, on 08/13/14 at 12:00 PM revealed she did not report the allegations of abuse to the Administrator because she told the Charge Nurse on duty and expected her to follow up with the Administrator. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she did not report the alleged witnessed abuse because she felt threatened by LPN #1. Per interview, LPN #1 had told staff he and SRNA #1 were untouchable. Additionally, LPN #1 had told her that if she reported him he would make her life a "living hell". Interview with LPN #8, on 08/15/14 at 11:58 AM, revealed she did not report what she witnessed because she did not feel anyone would believe her as she had seen in meetings how LPN #1 spoke rudely to the Administration and got away with it. Interview with LPN #5, on 08/12/14 at 10:53 AM, revealed he did not report the abuse because the facility would do nothing and the alleged perpetrators would know who reported him. Interview with LPN #2, on 08/13/14 at 11:11 AM, revealed she did not report the abuse she witnessed because she felt intimidated by LPN #1. She stated the facility allowed LPN #1 to do anything he wanted and she did not feel comfortable reporting LPN #1 to the Administrator. Additionally, LPN #2 revealed LPN #1 told her if she reported him he would make her life "hell". Interview with the Director of Nursing (DON), on 08/20/14 at 2:50 PM, revealed the facility's policy should be followed for every resident and staff should report alleged incidents of abuse. Additionally, she stated there was a failure to follow policy related to Resident #1 being made to go to bed at 6:00 PM and LPN #1's refusal to grant the resident use of his/her personal computer. However, the DON stated this was not determined to be abusive. The other allegations of abuse were unsubstantiated by the facility. The DON stated she was not aware of staff being afraid of LPN #1 and afraid to report abuse. Interview with the Administrator, on 08/20/14 at 1:00 PM, revealed she expected employees to follow the facility's written policies and procedures for all residents and allegations of abuse were to be reported when witnessed. She stated she was not aware of any mistreatment or abuse of residents until they received an anonymous call on 08/02/14 alleging abuse. She revealed, based on the facility's investigation, there was a failure related to Resident #1 being denied use of his/her personal computer and being made to go to be at 6:00 PM. She stated the other allegations of abuse were unsubstantiated by the facility. The Administrator stated she was not aware of staff being afraid of LPN #1 and afraid to report abuse. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/03/14, the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on 08/14/14 and 08/15/14 regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on 08/03/14 with no concerns identified. Pain assessments and Social Service assessments were also completed on 08/03/14 for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on 08/03/14 related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on 08/03/14, with any new concerns identified and followed up on for correction. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on 08/03/14 and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on 08/03/14 regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on 08/03/14 and ended on 08/06/14 and included all center and contract employees regarding effective systems that ensures each resident remains free of abuse: ? Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation. ? Reporting requirements including immediate reporting to the Administrator and appropriate state agencies. ? Promise of confidentiality and no fear of retribution. Employee competency assured using the Abuse Prevention post-test. Post-test reviewed and validated by the Nurse Practice Educator by 08/06/14. HIPPA Privacy Law. ? The prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of 08/06/14, nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of 08/06/14 and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending 08/22/14. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on 08/26/14 and 08/27/14. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on 08/22/14. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on 08/25/14 related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised 08/01/12 included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning 08/02/14, upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On 08/03/14, the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations are reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on 08/22/14 to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on 08/03/14, for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on 08/22/14 which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on 08/03/14 and the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on 08/19/14 to review all plans of compliance regarding the outstanding citations. **The State Survey Agency validated the Corrective action taken by the facility on 08/29/14 as follows: 1. LPN #1 was terminated, RN #1 and SRNA #1 remained suspended. 2. Review of audits dated 08/14/14 and 08/15/14, revealed the audits were completed on grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Review of skin assessments, change of condition forms, pain assessments, Social Service assessments and changes and mood and behavior assessments revealed Residents #3, #4, and #5 had skin assessments, change of condition forms, Social Service assessments and pain assessments performed on 08/03/14 with no concerns identified. In addition, further review of the assessments revealed Residents #1, #2, #6, #7, #8, and #9 had skin assessments and changes in mood/behavior assessment completed on 08/03/14 with no concerns identified. 4. Review of assessments and interviews, dated 08/03/14, revealed Unsampled Residents A, B, and C were assessed and interviewed related to abuse and changes of condition with no concerns identified. 5. Review of forty-one (41) interviews conducted with residents that had a Brief Interview Mental Status (BIMS) score between eight (8) and fifteen (15), revealed the interviews were conducted by the Director of Social Services and the Admission Director, on 08/03/14 with any concerns identified followed up on for correction. 6. Review of skin assessments of forty-two (42) residents with a BIMS of less than twelve (12), dated 08/03/14 revealed there were no concerns identified. 7. Review of Education Documentation, dated 08/03/14, revealed the Director of Nurses (DON) and Administrator received education on the Abuse Policy and reporting requirements on 08/03/14 by the Regional Vice President (RVP). 8. Review of Education Documentation, dated from 08/03/14 through 08/06/14, revealed 100% of all center and contract employees received re-education and completed a post test related to the abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution, Health Information Privacy Protection Act (HIPPA) privacy law, cell phone privacy and prohibition of use of cell phones in resident care areas and prohibition of videos or photographs of residents. Review of Education Documentation, dated 08/22/14 revealed seventy-six (76) available employees were educated on following the resident's plan of care. Review of Education Documentation, dated 08/26/14-08/27/14, revealed the other thirty-two (32) employees were in-serviced with post tests completed. The staff who received the education on these late dates were as needed (PRN) employees, were not on the schedule at all, or not available. The education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Review of Re-education Documentation, dated 08/25/14, revealed the RVP and Manager of Clinical Operations (MCO) conducted education for the Administrator related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness Interviews with Dietary Aide, on 08/29/14 at 2:00 PM, LPN #4 on 08/29/14 at 2:03 PM, Occupational Therapist Assistant, on 08/29/14 at 2:05 PM, SRNA #12, on 08/29/14 at 2:08 PM, SRNA #13, on 08/29/14 at 2:10 PM, SRNA #8, on 08/29/14 at 2:15 PM, LPN #6, on 08/29/14 at 2:15 PM, LPN #10, on 08/29/14 at 2:20 PM, Housekeeping Aide #3, on 08/29/14 at 2:25 PM, LPN #3, on 08/29/14 at 2:26 PM, Assistant Activities Director, on 08/29/14 at 2:27 PM, LPN #9, on 08/29/14 at 2:35 PM, Assistant Director of Nursing, on 08/29/14 at 3:15 PM, Physical Therapy Assistant, on 08/29/14 at 3:16 PM, and Minimum Data Set (MDS) Coordinator, on 08/29/14 at 3:35 PM, revealed all had been inserviced related to abuse, privacy, and dignity and following the care plans. All were able to name the types of abuse, reporting abuse and understood the importance of following the care plans and providing privacy for residents as well as being respectful of a resident's dignity. 9. Review of the Administrator's Job Description, revealed the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Interviews conducted, on 08/29/14 with the MDS Coordinator at 8:55 AM, Dietary Manager at 4:45 PM, and, Social Services Director at 4:55 PM, revealed no other allegations of abuse had been presented since the initial allegations on 08/02/14. 10. Review of audits conducted on all three shifts on 08/03/14 through 08/17/14 revealed Department Managers or Nursing Supervisors observed staff/resident interactions. No concerns identified were identified. Audit tools ongoing. 11. Review of Audits Tools, revealed the Shift Supervisor was conducting audits to monitor for staff's cell phone usage, using appropriate language, resident's privacy, monitoring of bath temperatures and to determine that any allegations were reported immediately were completed for all three (3) shifts, five (5) days a week through 08/29/14. Review of the audits revealed no concerns. Audit tools ongoing 12. Review of the PI Tools revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager interviewed fifteen (15) employees from all departments weekly through 08/29/14 to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and all allegations or statements are kept confidential with no fear of retribution for reporting. No concerns were identified. PI tools ongoing. 13. Review of resident interviews revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager completed fifteen (15) resident interviews weekly through 08/29/14 related to staff treatment and abuse. Audit sheets ongoing. 14. Review of resident family interviews and skin assessments for residents with a BIMS of less than seven (7) revealed the Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager conducted five (5) family interviews and resident skin assessments on 08/28/14 and are to continue for four (4) weeks times one (1) month and then two (2) a week times six (6) months. 15. Review of psychosocial assessments, on 08/29/14, revealed the SSD, DON, or ADON completed these assessments for three (3) residents with a BIMS score of eight (8). The assessments were ongoing. 16. Review of the grievances, complaints, and allegation daily monitoring revealed starting on 08/03/14 the Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors monitored daily for fourteen (14) days and then for five (5) days a week up to 08/29/14. 17. Observation revealed posters for "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values" were on the walls throughout the facility and in the breakroom. 18. Review of Ad-Hoc meeting minutes dated 08/03/14 revealed the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. 19. Review of the QA Committee minutes, dated 08/19/14, revealed a meeting consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held and they reviewed all plans of compliance regarding the outstanding citations.

Based on interview, record review, and review of the facility's policy and procedure and the State Operations Manual (SOM)-Centers for Medicare and Medicaid Services, Task 6, Information Analysis for Deficiency Determination, it was determined the facility failed to ensure care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for nine (9) of ten (10) sampled residents (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10); and, two (2) of three (3) Unsampled residents (Resident A and Resident B). Licensed Practical Nurse (LPN) #1, State Registered Nurse Aide (SRNA) #1, and/or Registered Nurse (RN) #1 were witnessed by staff which included LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4 treating residents in a manner that did not maintain and enhance Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 and Unsampled Residents A's and B's dignity and respect. LPN #2, LPN #5, LPN #8, SRNA #2, SRNA #3, SRNA #4, SRNA #5, SRNA #9, SRNA #10, and RN #4 witnessed LPN #1, SRNA #1, and/or RN #1 pinching the resident's breasts and noses; telling him/her to shut his/her mouth; laid in bed with a resident and was kissing the resident on the neck; scooped a resident off the commode, and dropped the resident from face height down onto the bed with the resident completely naked; placing a resident on a bare mattress and covering him/her with a fitted sheet; placed gloved fingers in a residents' mouths to aggravate the residents; jumped up and down on a resident's bed and pretended to vomit in his/her ear; videotaping of residents being made to cluck like a chicken and having gloved fingers placed in the mouth of one (1) resident; and pouring water over one (1) resident during a bath. The facility's failure to promote care for each resident in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, "Treatment: Considerate and Respectful", revised [DATE], revealed "Dignity" means that in their interactions with patients, staff carry out activities that assist the patient (resident) to maintain and enhance his/her self esteem and self worth. The purpose was to provide patients the right to a quality of life that supports independent expression, decision making, and respect. The process included staff will show respect when communicating with, caring for, or talking about patients. Examples included grooming, clothing, dining, activities, respect patients by speaking respectfully, respect patient's private space and property, signage (do not post signs on patient's doors or visible to others with confidential information on them), privacy, and demeaning practices such as keeping urinary bags uncovered, refusing to comply with a patient's request for assistance during meal times, and restricting patients from use of common areas open to the general public such as lobbies and restrooms. Review of the State Operations Manual (SOM)-Centers for Medicare and Medicaid Services, Task 6, Information Analysis for Deficiency Determination, revealed the reasonable person concept should be used in cases where the residents were unable to speak for themselves. The "reasonable person concept" means to assess how most people would react to the situation in question. Review of the facility's policy and procedure, titled "Personal Cell Phones and Handheld Devices: Use of, last revised [DATE], revealed "Staff may not use cell phones, blue tooth ear pieces, ear buds, headphones, camera phones, digital cameras, video cameras, audio recorders, or any other personal communication, image, audio, text, and/or computer devices when in patient care areas including patient rooms, dining areas, community rooms, and adjacent hallways, or while attending in any area of the location. 1. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Interview with SRNA #9, on [DATE] at 11:10 AM, revealed LPN #1 would tell her or other SRNAs on duty to place Resident #1 outside his/her room door after dinner and put him/her to bed at 6:00 PM and would not allow the resident to use his/her computer. Additionally, she revealed she heard RN #1 state, on several occasions, "I hate them all" referring to the residents. She did not report the abuse of Resident #1 because the resident was the sibling of the Administrator and the resident spoke with the Administrator often telling her problems he/she was having with LPN #1. 2 Record review revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of two (2) indicating the resident was not interviewable. Interview with SRNA #3, on [DATE] at 12:00 PM revealed she witnessed SRNA #1 and SRNA #8 with Resident #2. SRNA witnessed Resident #2 on the commode and resisting care not wanting to go to bed. She stated the SRNAs called LPN #1 to assist with Resident #2; the LPN scooped Resident #2 off the commode, pinched his/her breasts, walked to the bed and dropped the resident from face height down onto the bed with the resident completely naked. She stated the LPN fell to the bed with the resident landing on top of him. SRNA #3 stated LPN #1 then told SRNA #1 and SRNA #8 to "Get this [***] off of me". She stated the LPN proceeded to tell Resident #2 he/she was going to bed and if he/she didn't he was going to call his/her son and he/she would not like how he talked to him. Interview with SRNA #3 revealed she did not report the abuse to the Administrator or Director of Nursing because she reported it to LPN #2, who was the Charge Nurse on duty. Interview with LPN #2, Charge Nurse, on [DATE] at 11:11 AM, revealed she did not report the abuse that SRNA #3 had reported to her because she felt nothing would be done about it. LPN #2 stated LPN #1 had threatened the staff with making their lives a "living hell" if they told on him, therefore the abuse went unreported. 3. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed Resident #4's cognition as severely impaired with a BIMS score of six (6) indicating the resident was not interviewable. Interview with LPN #2, on [DATE] at 11:11 AM, revealed she witnessed LPN #1 and SRNA #1 pinching Resident #4's breasts. LPN #2 stated she had witnessed videos of staff telling Resident #4 to cluck like a chicken. She stated she did not report the abuse because she felt intimidated because LPN #1 seemed to be able to do anything and get away with it. LPN #2 stated LPN #1 trained her on the job and told her he would make her life "hell". Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed RN #1 putting her gloved fingers in Resident #5's mouth; LPN #1 and SRNA #1 pinched Resident #4's breasts. She stated she received a video from RN #1's phone that showed RN #1 putting her gloved fingers in Resident #5's mouth and LPN #1 pinching the resident's breasts. She stated she did not report the abuse because she felt threatened by LPN #1 because he had told her and other staff members that he and SRNA #1 were untouchable and if anyone told on them he would make their lives a living hell. 4. Record review revealed the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed Resident #5's cognition as severely impaired and the resident was not able to complete the BIMS. Interview with LPN #2, on [DATE] at 11:11 AM, revealed she also witnessed LPN #1 and SRNA #1 pinching Resident #5's breasts. She stated LPN #1 jumped up and down straddling Resident #5 on the bed and pretended to vomit in his/her ear to make him/her scream, and RN #1 placed her gloved fingers in Resident #5's mouth to aggravate him/her. LPN #2 also stated she had witnessed videos that were made of the alleged abuse of Resident #5. She revealed she did not report the abuse because she felt intimidated because LPN #1 seemed to be able to do anything and get away with it. She further stated LPN #1 had trained her and told her he would make her life a living hell. Interview with LPN #5, on [DATE] at 10:53 AM, revealed he had witnessed LPN #1 and RN #1 put gloves on and place their fingers in Resident #5's mouth to make him/her mad. He revealed the resident would yell "quit it, stop/stop." Additional interview with LPN #5 revealed he should have reported the verbal abuse and mistreatment; however, he felt nothing would be done about it. 5. Record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #6's cognition as severely impaired with a BIMS score of six (6) indicating the resident was not interviewable. Interview with LPN #5, on [DATE] at 10:53 AM, revealed he witnessed SRNA #1 and LPN #1 refuse to take Resident #6 to his/her room and when he asked why the resident could not go to his/her room he was told by LPN #1 that Resident #6 was only asking to be a "pain in the ass". Additional interview with LPN #5 revealed he should have reported the verbal abuse and mistreatment but felt nothing would be done about it. 6. Record review revealed the facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #7's cognition as severely impaired with a BIMS score of seven (7) indicating the resident was not interviewable. Interview with LPN #8, on [DATE] at 11:58 AM, revealed she witnessed LPN #1 using a reacher to pinch Resident #7's nose and when she entered the room LPN #1 stopped and left the room. She stated she did not report this incident because she did not feel anyone would believe her as she had seen in meetings how LPN #1 spoke rudely to the Administration and got away with it. 7. Record review revealed the facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #8's cognition as cognitively intact with a BIMS score of eleven (11) indicating the resident was interviewable. Interview with Resident #8, on [DATE] at 1:05 PM, revealed "Someone" on second (2nd) shift (a nurse) mistreated him/her and it was a man. He/She revealed the nurse said things to him/her (no specifics) and was rough with him/her at times. Resident #8 began to cry during the interview and stated, "I don't want to say anymore because 'he' has a lot of friends and sometimes they come in with him and are mean too." Further interview with Resident #8, on [DATE] at 2:35 PM, revealed he/she was afraid to go to bed at night after LPN #1 and the SRNA climbed through the window into his/her room. Additionally, he/she revealed after LPN #1 found out he had been reported he got really nice to him/her and prior to that he did not care how he treated him/her. Interview with Housekeeping Aide #3, on [DATE] at 2:30 PM, revealed Resident #8 told her she would be surprised at what went on at the facility on second (2nd) shift. Additionally, she revealed she had witnessed staff using cell phones, talking and texting in resident care areas. She stated she had not witnessed any abuse and would report it immediately to her Supervisor, the Charge Nurse, and the Administrator. 8. Record review revealed the facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #9's cognition as severely impaired with a BIMS score of two (2) indicating the resident was not interviewable. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed SRNA #1 putting soap in Resident #9's mouth. She revealed she did not report the abuse because she felt threatened by LPN #1 because he told staff that he would make their lives hell if they told on him because he and SRNA #1 were untouchable. 9. Record review revealed the facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 expired in the facility on [DATE]. Interview with SRNA #4, on [DATE] at 10:08 AM, revealed she witnessed LPN #1 placing a fitted sheet on top of Resident #10 while he/she lay on a bare mattress. She stated she did not report the abuse because she felt threatened by LPN #1 because he told staff that he would make their lives hell if they told on him because he and SRNA #1 were "untouchable". 10. Record review revealed the facility admitted Unsampled Resident A on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident A's cognition as cognitively intact with a BIMS score of twelve (12) indicating the resident was interviewable. Interview with Unsampled Resident A, on [DATE] at 9:58 AM, revealed RN #1 and SRNA #1 lay on the bed with him/her and kissed his/her neck and he/she asked them to stop. Unsampled Resident A revealed the two (2) staff members (identified as RN #1 and SRNA #1) got to laughing and just fell on his/her bed and began to kiss his/her neck. He/She stated he/she did not like it and when he/she asked them to stop, they continued to laugh at him/her. 11. Record review revealed the facility admitted Unsampled Resident B on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Unsampled Resident B's cognition as severely impaired with a BIMS score of three (3) indicating the resident was not interviewable. Interview with SRNA #3, on [DATE] at 12:00 PM, revealed she worked at the facility for two (2) or three (3) days and was being trained by SRNA #1 and SRNA #8. She stated she witnessed abuse to Unsampled Resident B the first night she worked. She revealed SRNA #1 and SRNA #8 were giving a bath to Unsampled Resident B and asked her to stand by and watch because it was her first night working on the floor. SRNA #3 stated she witnessed SRNA #1 and SRNA #8 strip Unsampled Resident B totally leaving him/her uncovered. Further interview revealed they poured water on Unsampled Resident B's head and washed the resident's front side but not the backside. They did not rinse the soap off the resident. They turned the resident over and dried the bed leaving the resident crying and yelling he/she was cold. She stated SRNA #1 told Unsampled Resident B to "shut the 'F_ _ k' up" because they didn't have "all night to get the bath done". She revealed she attempted to get to the resident to dry him/her off as she was yelling he/she was cold and SRNA #1 told her when she was trained she could give a bath the way she wanted. Additional interview with SRNA #3 revealed she did not report the alleged abuse to the Administrative because she felt she should follow the chain of command and report to the Charge Nurse on duty which she did. Interview with RN #4, on [DATE] at 2:40 PM, revealed she had witnessed employees using cell phones at times in resident care areas. Interview with SRNA #5, on [DATE] at 1:53 PM, revealed she had seen a couple of employees using cell phones in resident care areas. Interview with the Director of Nursing (DON) on [DATE] at 2:50 PM, revealed she expected staff to treat the residents and their co-workers with dignity and respect. Additionally, she revealed Resident #1's dignity was jeopardized related to LPN #1 not following the facility's policy related to dignity in regards to Resident #1 being made to go to bed at 6:00 PM against his/her will and refusing to allow him/her to have access to his/her computer when he/she wanted it. Further interview, on [DATE] at 11:50 AM, revealed staff should not have cell phones in resident care areas and should only use the phones on breaks. Interview with the Administrator, on [DATE] at 1:00 PM, revealed she would not expect staff to have cell phones in resident care areas and to use them only on breaks. Further interview, on [DATE] at 2:54 PM, revealed she expected staff to treat the residents as they would want to be treated themselves. She revealed she expected the staff to respect the residents' choices and provide privacy when needed or desired and to comply with resident preferences. Additionally, she revealed LPN #1 did not follow the policy and procedure related to Resident #1 in regards to respecting the resident's choice on when to go to bed and the use of his/her own computer. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on [DATE] and [DATE] regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on [DATE] with no concerns identified. Pain assessments and Social Service assessments were also completed on [DATE] for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on [DATE] with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on [DATE] with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on [DATE] related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on [DATE], with any new concerns identified and followed up on for corrections. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on [DATE] and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on [DATE] regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on [DATE] and ended on [DATE] and included all center and contract employees regarding effective systems that ensures each resident remains free of abuse: ? Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation. ? Reporting requirements including immediate reporting to the Administrator and appropriate state agencies. ? Promise of confidentiality and no fear of retribution. Employee competency assured using the Abuse Prevention post-test. Post-test reviewed and validated by the Nurse Practice Educator by [DATE]. HIPPA Privacy Law. ? The prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of [DATE], nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of [DATE] and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending [DATE]. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on [DATE] and [DATE]. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on [DATE]. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on [DATE] related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised [DATE] included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning [DATE], upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On [DATE], the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations are reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on [DATE] to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on [DATE], for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on [DATE] which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on [DATE] and the Medical Director was briefed on the meeting and signed off on the meeting minutes on [DATE] as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on [DATE] to review all plans of compliance regarding the outstanding citations. **The State Survey Agency validated the Corrective action taken by the facility on [DATE] as follows: 1. LPN #1 was terminated, RN #1 and SRNA #1 remained suspended. 2. Review of audits dated [DATE] and [DATE], revealed the audits were completed on grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Review of skin assessments, change of condition forms, pain assessments, Social Service assessments and changes and mood and behavior assessments revealed Residents #3, #4, and #5 had skin assessments, change of condition forms, Social Service assessments and pain assessments performed on [DATE] with no concerns identified. In addition, further review of the assessments revealed Residents #1, #2, #6, #7, #8, and #9 had skin assessments and changes in mood/behavior assessment completed on [DATE] with no concerns identified. 4. Review of assessments and interviews, dated [DATE], revealed Unsampled Residents A, B, and C were assessed and interviewed related to abuse and changes of condition with no concerns identified. 5. Review of forty-one (41) interviews conducted with residents that had a Brief Interview Mental Status (BIMS) score between eight (8) and fifteen (15), revealed the interviews were conducted by the Director of Social Services and the Admission Director, on [DATE] with any concerns identified followed up on. 6. Review of skin assessments of forty-two (42) residents with a BIMS of less than twelve (12), dated [DATE] revealed there were no concerns identified. 7. Review of Education Documentation, dated [DATE], revealed the Director of Nurses (DON) and Administrator received education on the Abuse Policy and reporting requirements on [DATE] by the Regional Vice President (RVP). 8. Review of Education Documentation, dated from [DATE] through [DATE], revealed 100% of all center and contract employees received re-education and completed a post test related to the abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution, Health Information Privacy Protection Act (HIPPA) privacy law, cell phone privacy and prohibition of use of cell phones in resident care areas and prohibition of videos or photographs of residents. Review of Education Documentation, dated [DATE] revealed seventy-six (76) available employees were educated on following the resident's plan of care. Review of Education Documentation, dated [DATE]-[DATE], revealed the other thirty-two (32) employees were in-serviced with post tests completed. The staff who received the education on these late dates were as needed (PRN) employees, were not on the schedule at all, or not available. The education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Review of Re-education Documentation, dated [DATE], revealed the RVP and Manager of Clinical Operations (MCO) conducted education for the Administrator related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness Interviews with Dietary Aide, on [DATE] at 2:00 PM, LPN #4 on [DATE] at 2:03 PM, Occupational Therapist Assistant, on [DATE] at 2:05 PM, SRNA #12, on [DATE] at 2:08 PM, SRNA #13, on [DATE] at 2:10 PM, SRNA #8, on [DATE] at 2:15 PM, LPN #6, on [DATE] at 2:15 PM, LPN #10, on [DATE] at 2:20 PM, Housekeeping Aide #3, on [DATE] at 2:25 PM, LPN #3, on [DATE] at 2:26 PM, Assistant Activities Director, on [DATE] at 2:27 PM, LPN #9, on [DATE] at 2:35 PM, Assistant Director of Nursing, on [DATE] at 3:15 PM, Physical Therapy Assistant, on [DATE] at 3:16 PM, and Minimum Data Set (MDS) Coordinator, on [DATE] at 3:35 PM, revealed all had been inserviced related to abuse, privacy, and dignity and following the care plans. All were able to name the types of abuse, reporting abuse and understood the importance of following the care plans and providing privacy for residents as well as being respectful of a resident's dignity. 9. Review of the Administrator's Job Description, revealed the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Interviews conducted, on [DATE] with the MDS Coordinator at 8:55 AM, Dietary Manager at 4:45 PM, and, Social Services Director at 4:55 PM, revealed no other allegations of abuse had been presented since the initial allegations on [DATE]. 10. Review of audits conducted on all three shifts on [DATE] through [DATE] revealed Department Managers or Nursing Supervisors observed staff/resident interactions. No concerns identified were identified. Audit tools ongoing. 11. Review of Audits Tools, revealed the Shift Supervisor was conducting audits to monitor for staff's cell phone usage, using appropriate language, resident's privacy, monitoring of bath temperatures a

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. The facility failed to ensure care plan interventions were being followed related to psychosocial well being, physical, mental, and emotional status for nine (9) of ten (10) sampled residents (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10; and, two {2} of three {3} unsampled residents (Unsampled Resident A and B). Licensed Practical Nurse (LPN) #1, State Registered Nurse Aide (SRNA) #1, and Registered Nurse (RN) #1 were alleged to have abused Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10. In addition, it was alleged RN #1 and SRNA #1 abused Unsampled Resident A and Resident B. The residents were care planned to ensure their psychosocial, physical, mental, and emotional well being; however, it was determined staff's abusive behaviors toward the residents failed to ensure these needs were met in accordance with the care plans. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/14/14 and determined to exist on 08/02/14. The facility was notified of the Immediate Jeopardy on 08/14/14. An acceptable Allegation of Compliance (AoC) was received on 08/29/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 08/29/14, as alleged. The Scope and Severity was lowered to a "F" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, "Care Plans", last revised 01/02/14, revealed "A comprehensive, individualized care plan will be developed by the interdisciplinary team for each patient. The care plan will include measurable objectives to meet patient needs and goals as identified by the assessment process. The purpose was to provide necessary care and services to attain or maintain the patient's highest practicable physical, mental, and psychosocial well being. The comprehensive care plan is communicated to appropriate staff." 1. Record review revealed the facility admitted Resident #1 on 04/16/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview Mental Status (BIMS) score of nine (9) indicating the resident was interviewable. Review of the Comprehensive Care Plan, last revised 11/11/13, revealed Resident #1 was at risk for psychosocial distress about his/her own well being and/or social relationships related to decreased ability to express complaints or distrust in others related to impaired cognition. The care plan interventions included to allow the resident to make decisions independently, and offer support/reassurance for disappointments and/or frustrations. Review of the facility's investigation, dated 08/03/14, revealed SRNA #9 alleged LPN #1 would make Resident #1 go to bed at approximately 6:00 PM every night; would deny the resident the use of his/her computer, as well as told the resident to shut his/her mouth when he/she asked for the computer. Interview with SRNA #9, on 08/15/14 at 11:10 AM, revealed LPN #1 would tell her and other SRNAs on duty to place Resident #1 outside his/her room door after dinner and put him/her to bed at 6:00 PM and would not allow the resident to use his/her computer. Interview with the Administrator, on 08/15/14 at 10:55 AM, revealed she had spoken with LPN #1 in regards to Resident #1's preferences on bed times and computer use. She revealed she suggested to LPN #1 Resident #1 be put to bed at 8:00 PM on school nights and at 8:30 PM to 9:00 PM on the other nights and to always allow him/her the use of the computer. 2. Record review revealed the facility admitted Resident #2 on 09/16/10 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 05/12/14, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview of Mental Status score of two (2). Resident #2 had behaviors of becoming agitated at times. Review of the Comprehensive Care Plan, last revised 05/17/14, revealed the resident exhibited psychosocial distress about his/her own well being and/or social relationships related to the decreased ability to express complaints or distrust in others. The care plan interventions included to approach the resident in a calm, friendly manner and provide consistent daily routine and caregivers as possible to decrease distress. Review of the facility's investigation, dated 08/03/14, revealed SRNA alleged LPN #1 scooped the resident off the commode after he/she refused to go to bed and took him/her to the bed, holding him/her like a baby, dropped him/her on the bed (naked). LPN #1 fell on the bed and the resident landed on top of him. He told the SRNAs in the room to get that "[***] " off of him. Interview with SRNA #3, on 08/13/14 at 12:00 PM, revealed she witnessed SRNA #1 and SRNA #8 with Resident #2 on the commode and the resident was resisting care not wanting to go to bed. She stated the when the SRNAs called LPN #1 to assist, he scooped Resident #2 off the commode, pinched his/her breasts, walked to the bed and dropped the resident from face height down onto the bed with the resident completely naked. She stated the LPN fell to the bed with the resident landing on top of him. She stated the LPN proceeded to tell Resident #2 he/she was going to bed and if he/she didn't he was going to call his/her son and he/she would not like how he talked to him. 3. Record review revealed the facility admitted Resident #4 on 11/11/10 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 05/25/14, revealed the facility assessed Resident #4's cognition as severely impaired with a BIMS score of six (6) indicating the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 05/28/14, revealed Resident #4 had a history of [REDACTED]. Additional review revealed Resident #4 exhibited behaviors of agitation at times related to impaired cognition. The interventions included to approach the resident in a calm, friendly manner and observe for changes in mood and behaviors. Review of the facility's investigation, dated 08/03/14, revealed LPN #2 alleged SRNA #1 and LPN #1 pinched Resident #4's nose and breast and this was allegedly recorded on SRNA #1's cell phone. Interview with LPN #2, on 08/13/14 at 11:11 AM, revealed she witnessed LPN #1 and SRNA #1 pinching Resident #4's nose and breast. LPN #2 stated she had witnessed videos of staff telling Resident #4 to cluck like a chicken. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she witnessed RN #1 putting her gloved fingers in Resident #4's mouth and LPN #1 and SRNA #1 pinch Resident #4's breast. Additional interview with SRNA #4 revealed the allegations of abuse were not reported to the Administrative Staff due to LPN #1 threatening if anyone told on him he would make their lives a living hell. 4. Record review revealed the facility admitted Resident #5 on 08/04/09 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 07/08/13, revealed the facility assessed Resident #5's cognition as severely impaired and the resident was unable to complete the BIMS. Review of the Comprehensive Care Plan, last revised 06/10/14, revealed Resident #5 exhibited behaviors of resisting care and treatments by screaming and swinging at staff during a bath or incontinent care. He/She was also care planned for being at risk for psychosocial distress about his/her own well being and/or social relationships related to decreased ability to express complaints or distrust in others. The care plan interventions included to approach the resident in a calm, friendly manner, observe for changes in mood and behaviors, provide consistent care givers and daily routines as possible to decrease distress, and to identify behavior triggers and reduce exposure to triggers. Review of the facility's investigation, dated 08/03/14, revealed LPN #2 alleged LPN #1 and SRNA #1 pinched Resident #5's nose and breasts; LPN #1 jumped up and down on the resident's bed, then straddled the resident and placed his mouth at the resident's ear and acted like he was vomiting; and, LPN #1 threw cold water on the resident. Interview with LPN #2, on 08/13/14 at 11:11 AM, revealed she witnessed LPN #1 and SRNA #1 pinching Resident #5's breasts. She stated LPN #1 jumped up and down straddling Resident #5 on the bed and pretended to vomit in his/her ear to make the resident scream. She further stated RN #1 placed her gloved fingers in Resident #5's mouth to aggravate him/her. LPN #2 also stated she had witnessed videos of the alleged abuse on Resident #5. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she witnessed LPN #1 and SRNA #1 pinch Resident #5's breast. SRNA #4 stated she received a video from RN #1's phone that showed RN #1 putting gloved fingers in Resident #5's mouth and LPN #1 pinching the resident's breasts. Interview with LPN #5, on 08/12/14 at 10:53 AM, revealed he had witnessed LPN #1 and RN #1 put gloves on and place their fingers in Resident #5's mouth to make him/her mad. He stated the resident would yell "quit it, stop, stop." 5. Record review revealed the facility admitted Resident #6 on 03/13/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/01/14, revealed the facility assessed Resident #6's cognition as severely impaired with a BIMS score of six (6) indicating the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 06/03/14, revealed Resident #6 had a history of [REDACTED]. The care plan interventions included to assess the resident's response to a new situation, document incidents of anxiousness and tearfulness on the Behavior Flow Sheet, observe for changes in mood (absence of emotion in the resident's actions and facial expressions), behavior, and overall functioning. Review of the facility's investigation, dated 08/02/14, revealed LPN #5 alleged LPN #1 denied Resident #6 the opportunity to go to his/her room when he/she wanted and called the resident "a pain in the ass" for asking. Interview with LPN #5, on 08/12/14 at 10:53 AM, revealed he witnessed SRNA #1 and LPN #1 refuse to take Resident #6 to his/her room and when he asked why the resident could not go to his/her room he was told by LPN #1 that Resident #6 was only asking to be a "pain in the ass". He stated another SRNA took the resident to his/her room and the resident was satisfied because that was all he/she wanted. Additional interview with LPN #5 revealed he should have reported the mistreatment but felt nothing would be done about it. 6. Record review revealed the facility admitted Resident #7 on 05/10/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/24/14, revealed the facility assessed Resident #7's cognition as severely impaired with a BIMS score of seven (7) indicating the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 05/19/14, revealed Resident #7 exhibited distressed mood symptoms related to depression. The care plan interventions included to observe for changes in mood (absence of emotion in the resident's actions and facial expressions), behavior, and overall functioning. Observe for signs and/or symptoms of anxiety or depression. Review of the facility's investigation, dated 08/02/14, revealed LPN #8 alleged LPN #1 pinched the residents nose with a reacher (metal grab assist bar). Interview with LPN #8, on 08/15/14 at 11:58 AM, revealed she witnessed LPN #1 using a reacher to pinch Resident #7's nose and when she entered the room LPN #1 stopped and left the room. Additional interview revealed she did not report this incident because she did not feel anyone would believe her as she had seen in meetings how LPN #1 spoke rudely to the Administration and got away with it. 7. Record review revealed the facility admitted Resident #8 on 05/30/07 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/28/14, revealed the facility assessed Resident #8's cognition as cognitively intact with a BIMS score of eleven (11) indicating the resident was interviewable. Review of the Comprehensive Care Plan, last revised 06/27/14, revealed Resident #8 exhibited psychosocial distress about his/her own well being as evidenced by conflicted relationships with delusions of people out to get him/her. Additionally, Resident #8 exhibited anger related to having the desire to return home. The care plan interventions included to observe for changes in mood (absence of emotion in the resident's actions and facial expressions), behavior, and overall functioning, provide a daily structured routine to build trust and familiarity, and to approach the resident in a calm, friendly manner. Review of the facility investigation, dated 08/02/14, revealed SRNA #4 alleged the resident was afraid of LPN #1 and SRNA #1 because they were mean to him/her. Interview with Resident #8, on 08/11/14 at 1:05 PM, revealed "Someone" on second (2nd) shift (a nurse) mistreated him/her and it was a man. He/She revealed the nurse said things to him/her (no specifics) and was rough with him/her at times. Resident #5 began to cry during the interview and stated, "I don't want to say anymore because "He" has a lot of friends and sometimes they come in with him and are mean too." Further interview with Resident #8, on 08/12/14 at 2:35 PM, revealed he/she was afraid to go to bed at night after LPN #1 and the SRNA climbed through the window into his/her room. Additionally, he/she revealed after LPN #1 found out he had been reported he got really nice to him/her and prior to that he did not care how he treated him/her. 8. Record review revealed the facility admitted Resident #9 on 04/19/10 with [DIAGNOSES REDACTED]., Depression, Adult Failure to Thrive, Pain, and [MEDICAL CONDITION]. Review of the Quarterly MDS Assessment, dated 07/01/14, revealed the facility assessed Resident #9's cognition as severely impaired with a BIMS score of two (2) indicating the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 08/11/14, revealed Resident #9 exhibited psychosocial distress about his/her own well being and/or social relationships related to decreased ability to express complaints or distrust in others, inability to express emotion and share information, and nervousness when asked specific questions related to difficulty expressing words he/she wanted to use. The care plan interventions included for staff to repeat information as needed for understanding, ask resident questions that required yes or no response, and observe for changes in mood and/or behaviors. Review of the facility's investigation, dated 08/02/14, revealed SRNA #4 alleged SRNA #1 put soap in Resident #9's mouth. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she witnessed SRNA #1 putting soap in Resident #9's mouth. She revealed the allegations of abuse were not reported to the Administrative Staff due to LPN #1 threatening if anyone told on him he would make their lives a living hell. 9. Record review revealed the facility admitted Resident #10 on 11/07/08 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 03/14/14, revealed the facility assessed Resident #10's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 03/12/14, revealed Resident #10 had a history of [REDACTED]. The care plan interventions included to assess for physical needs that may alleviate signs of depression, convey acceptance of the resident and provide repeated honest appraisals of resident's strengths to the resident. Review of the facility's investigation, dated 08/02/14, revealed SRNA #4 alleged LPN #1 placed Resident #10 on a bare mattress and placed a fitted sheet on top of him/her. Interview with SRNA #4, on 08/13/14 at 10:08 AM, revealed she witnessed LPN #1 placing a fitted sheet on top of Resident #10 while he/she lay on a bare mattress. 10. Record review revealed the facility admitted Unsampled Resident A on 02/18/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 07/13/14, revealed the facility assessed Unsampled Resident A's cognition as cognitively intact with a BIMS score of twelve (12) indicating the resident was interviewable. Review of the Comprehensive Care Plan, revised 07/01/14, revealed Unsampled Resident A had a history of [REDACTED]. Additional history included behaviors of agitation and delusions by being verbally aggressive with staff (cursing and threats) when redirection was attempted. Unsampled Resident A also exhibited paranoid/suspicious behavior of telling staff they've brought his/her spouse there just to die (thinking another person was his/her spouse). The care plan interventions included to observe and report any changes in mental status, provide emotional support as needed upon tearfulness, praise and/or reward the resident for acceptable behaviors, and document any changes in mood and/or behaviors. Review of the facility's investigation, dated 08/02/14, revealed Unsampled Resident A alleged RN #1 and SRNA #1 laid in the resident's bed and kissed him/her on the neck against the resident's will on more than one occasion. He/She revealed RN #1 and SRNA #1 would start to laugh and fall down on the bed with him/her. Interview with Unsampled Resident A, on 08/13/14 at 9:58 AM, revealed RN #1 and SRNA #1 laid on the bed with him/her and kissed his/her neck and he/she asked them to stop. Unsampled Resident A stated the two (2) staff members were laughing and fell on his/her bed and began to kiss his/her neck. He/She revealed when he/she asked them to stop, they continued to laugh at him/her. He/she stated this had occurred two (2) or three (3) times in the past but he/she had never reported it to anyone. 11. Record review revealed the facility admitted Unsampled Resident B on 10/08/11 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/21/14, revealed the facility assessed Unsampled Resident B's cognition as severely impaired with a BIMS score of three (3) indicating the resident was not interviewable. Review of the Comprehensive Care Plan, last revised 07/02/14, revealed Unsampled Resident #B had a history of [REDACTED]. The care plan interventions included to document behaviors and interventions, encourage the resident to voice concerns and fears, give the resident a task or item in an attempt to distract him/her, and praise/reward the resident for demonstrating consistent desired/acceptable behaviors. Review of the facility's investigation, dated 08/02/14, revealed SRNA #3 alleged SRNA #1 and SRNA #8 gave Unsampled Resident B a cold bed bath then SRNA #1 told the resident "to shut the F_ _ k up" because they did not have all night to get the bath done" when the resident complained of being cold. Interview with SRNA #3, on 08/13/14 at 12:00 PM, revealed she worked at the facility for two (2) or three (3) days and was being trained by SRNA #1 and SRNA #8. She stated she witnessed abuse to Unsampled Resident B the first night she worked. SRNA #3 stated she witnessed SRNA #1 and SRNA #8 strip Unsampled Resident B totally leaving him/her uncovered. Further interview revealed they poured water on Unsampled Resident B's head and washed the resident's front side but not the backside. They did not rinse the soap off the resident. They turned the resident over and dried the bed leaving the resident crying and yelling he/she was cold. She stated SRNA #1 told Unsampled Resident B to "shut the 'F_ _ k' up" because they didn't have "all night to get the bath done". She revealed she attempted to get to the resident to dry him/her off as she was yelling he/she was cold and SRNA #1 told her when she was trained she could give a bath the way she wanted. Interview with LPN #4, on 08/15/14 at 11:09 AM, revealed she tried to make sure all interventions on the care plans were being implemented by staff. She stated it was her nursing responsibility to ensure the care plan interventions were being followed. Interview with RN #5, on 08/15/14 at 11:20 AM, revealed her responsibilities related to care plan interventions was to ensure the interventions were being followed. Interview with LPN #7, on 08/15/14 at 11:50 AM, revealed he followed the care plan to ensure resident care was received. Interview with LPN #8, on 08/15/14 at 11:58 AM, revealed she looked at the care plan prior to providing resident care. Interview with LPN #10, on 08/15/14 at 12:37 PM, revealed she ensured the care plans were followed to ensure the residents were receiving the proper care. She stated she made rounds to ensure staff was providing care according to the care plan. Interview with the Administrator, on 08/14/14 at 1:00 PM, revealed she expected staff to follow care plan interventions. Interview with the Director of Nursing (DON), on 08/15/14 at 11:50 AM, revealed she expected staff to follow care plan interventions and if the intervention was not effective then staff should contact the Advanced Registered Nurse Practitioner (ARNP) and/or the Physician for a different intervention. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/03/14, the facility suspended RN #1, LPN #1, and SRNA #1, and then terminated LPN #1. 2. Audits were completed on 08/14/14 and 08/15/14 regarding grievances voiced, complaints or concerns identified, allegations of abuse or neglect, and positive staff/resident interaction with no concerns identified. 3. Residents #3, #4, and #5 received skin assessments and had change of condition forms performed on 08/03/14 with no concerns identified. Pain assessments and Social Service assessments were also completed on 08/03/14 for the three (3) residents with no concerns noted. Skin assessments were also conducted on Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns identified related to abuse. Changes in moods/behaviors were assessed for Residents #1, #2, #6, #7, #8, and #9 on 08/03/14 with no concerns noted. 4. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C were assessed and interviewed on 08/03/14 related to abuse and changes of condition with no concerns identified. 5. Forty-one (41) residents with a BIMS score of greater than seven (7) were interviewed by the Director of Social Services and/or the Admission Director, on 08/03/14, with any new concerns identified and addressed. 6. Skin assessments of forty-two (42) residents with a BIMS of less than twelve (12) were conducted on 08/03/14 and no concerns identified. 7. Education was provided to the Director of Nurses (DON) and Administrator by the Regional Vice President (RVP) on 08/03/14 regarding the Abuse policy and reporting requirements. 8. One-hundred (100)% re-education began on 08/03/14 and ended on 08/06/14 and included all center and contract employees regarding effective systems that ensures each resident remains free of abuse: ? Center Abuse Policy including the need to protect the resident from potential risk at the time and during the investigation. ? Reporting requirements including immediate reporting to the Administrator and appropriate state agencies. ? Promise of confidentiality and no fear of retribution. Employee competency assured using the Abuse Prevention post-test. Post-test reviewed and validated by the Nurse Practice Educator by 08/06/14. HIPPA Privacy Law. ? The prohibition of cell phone usage in resident care areas, including video or photographs of residents. As of 08/06/14, nine (9) of one-hundred six (106) employees were not available for immediate re-education. Three (3) of the nine (9) employees were re-educated by phone as of 08/06/14 and were re-educated face to face prior to returning to work. Employees upon hire or who were not available during the timeframe received education, re-education prior to returning to work. Two (2) employees were on leave of absence (LOA) and had not received training, but were to receive the training prior to returning to work. Education was also provided to all available employees in regards to following the resident's plan of care beginning and ending 08/22/14. Seventy-six (76) of one-hundred nine (109) employees were re-educated. The other thirty-two (32) employees were in-serviced with post tests completed. The re-education was completed on 08/26/14 and 08/27/14. The staff who received the education on these late dates were as needed (PRN) employees, and were not on the schedule at all, or were not available. The re-education was provided by the DON, Assistant DON, Clinical Reimbursement Manager, Nutritional Services Director, Director of Social Services, Therapy Program Manager, Administrative Assistant, Registered Nurse, Licensed Practical Nurse, Environmental Services Manager or the Payroll Coordinator. Post tests were reviewed and approved by the RN Clinical Case Manager on 08/22/14. Re-education was conducted by the RVP and Manager of Clinical Operations (MCO) for the Administrator on 08/25/14 related to the Abuse Policy & Procedure and for conducting a thorough investigation which has the potential to be substantiated if the event was alleged by only one (1) witness. 9. The Administrator's Job Description last revised 08/01/12 included the Administrator was responsible for the implementation of and adherence to facility policy and procedures. Additional support will be provided and was to continue to be provided by the RVP, MCO, and Regional Clinical Educator and/or Regional Director of Human Resources. Beginning 08/02/14, upon notification of an alleged abuse/neglect the Administrator was to notify the RVP, MCO, and Regional Clinical Educator to validate a thorough investigation will be immediately initiated with continued support to be provided throughout the investigation and conclusion. This is to occur for every occasion for every allegation for three (3) months. 10. On 08/03/14, the Administrator and Director of Nursing (DON) assigned department managers or nursing supervisors across the three (3) shifts daily (including Saturday and Sunday x fourteen (14) days to observe staff/resident interaction to determine that any allegations are reported immediately to the Administrator. Any concerns regarding staff interaction or allegations of abuse or neglect would be called to the Administrator or DON by the Shift Supervisor for review to determine any action to be taken including staff suspension and/or reporting to the state agency, if indicated. 11. Audit tool utilized by the Shift Supervisor to observe staff/resident interactions was updated on 08/22/14 to include monitoring staff usage of cell phones, monitoring of using appropriate language, monitoring of staff providing resident's privacy, monitoring of bath temperatures and to determine that any allegations are reported immediately. The audits will be completed all three (3) shifts for five (5) days a week times thirty (30) days and then two (2) days a week across all three (3) shifts times six (6) months and then as recommended by the Quality Assurance Performance Improvement (QAPI) Committee. 12. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) employees from all departments weekly for four (4) weeks, then ten (10) per week times three (3) months, then five (5) per week for three (3) months to determine staff understanding of the abuse policy, reporting allegations to the Administrator immediately and that all allegations or statements are kept confidential with no fear of retribution for reporting. 13. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview fifteen (15) residents weekly for four (4) weeks and then ten (10) per week for three (3) months and five (5) per week for additional three (3) months to determine any issues with staff treatment or abuse. Concerns identified will be addressed immediately. 14. The Administrator, Social Service Director, Admission Director, Director of Nursing, Assistant Director of Nursing, Nurse Practice Educator, or Clinical Reimbursement Manager will interview five (5) family members of residents with a BIMS score less than eight (8) and review five (5) skin assessments weekly for four (4) weeks, then two (2) per week for six (6)months to determine any issue with staff treatment or abuse. 15. The Social Services Director, Director of Nursing and Assistant Director of Nursing will conduct Psychosocial Assessments of residents with a BIMS score of less than eight (8). This audit will be completed for three (3) residents a week for four (4) weeks then two (2) a week for six (6) months to determine any issues with staff treatment or abuse. 16. The Administrator, Director of Nursing, Registered Nurse or Licensed Practical Nurse Supervisors will review grievances, complaints, and allegation daily starting on 08/03/14, for fourteen (14) days and then for five (5) days a week times thirty (30) days then as determined by monthly Quality Assurance Committee. 17. Posters were placed throughout the facility and break room on 08/22/14 which included "We Care Dialogue Line", "Staff Promises", Eldercare, and "Core Values". 18. An Ad-Hoc meeting was held on 08/03/14 and the Medical Director was briefed on the meeting and signed off on the meeting minutes on 08/04/14 as he was unable to attend. Trending continues monthly and is to be conducted on any new issues as needed. 19. The QA Committee consisting of the Administrator, Director of Nursing, Social Services Director, Admissions Director, Dietary Manager, Activity Director, and Medical Director was held on 08/19/14 to review all plans of compliance regarding the outstanding citations. **The State Survey Agency validated the Corrective action taken by the facility on 08/29/14 as follows: 1. LPN #1 was terminated, RN #1 and SRNA #1 remained suspended. 2. Review of audits dated

Based on interview, record review and review of facility's policy and procedure it was determined the facility failed to revise the care plan for two (2) of three (3) sampled residents (Resident #1 and #2). Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident to lean to the left side while sitting and to have decreased safety awareness; however, the facility failed to use the results of the assessment to revise the care plan with interventions to address the supervision the resident would need when toileted. On 06/04/14, Resident #1 was placed on the commode in his/her room and left unattended by Certified Nurse Aide (CNA) #1 and the resident fell off the commode. The resident sustained [REDACTED]. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 sustained five (5) recurrent falls (04/20/14, 04/27/14, 05/21/14, 06/12/14 and 06/14/14) without any evidence of an assessment and investigation after each fall to identify the root cause of the fall so the care plan could be revised with interventions directed at fall prevention. On 06/14/14, Resident #2 had an unwitnessed fall in his/her room and sustained a [MEDICAL CONDITION] that required surgical intervention. The findings include: Review of the facility's policy titled, "Care Plans", last revised 01/02/14, revealed a comprehensive individualized care plan would be developed by the interdisciplinary team for each patient, The care plan would include measurable objectives to meet patient needs and goals as identified by the assessment process. Review of the facility's Falls Management Plan, last revised 05/15/14, revealed residents would be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. 1. Record review revealed the facility readmitted Resident #1 on 05/24/14 with [DIAGNOSES REDACTED]. Review of the resident's care plan, developed on admission, dated 05/24/14, and identified as the residents current Comprehensive Care Plan, revealed Resident #1 was at risk of falls related [MEDICAL CONDITION] impaired mobility due to a left [MEDICAL CONDITION] with interventions to assist the resident in and out of bed with extensive assist of two and to remind to use call light when attempting to ambulate or transfer. Review of the MDS Kardex Report, or Care Card used by Certified Nursing Staff as their plan of care for Resident #1, dated 05/24/14, revealed Resident #1 had no problems with short term or long term memory and was independent in decision making, required extensive to total assistance of two (2) for bed mobility, transfer, partial weight bearing, extensive assistance or total assist of two (2) for activities of daily living including toilet use. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/31/14, revealed the facility assessed Resident #1's cognition as moderately impaired and had a Brief Interview of Mental Status (BIMS) coded as "99" indicating the resident was unable to complete the interview. The facility assessed Resident #1 to have short term memory problems and moderately impaired decision making. He/she was totally dependent with two (2) plus physical assist for physical mobility and toilet use. Balance during transitions and walking was coded as a two (2), indicating not steady, and the resident was only able to stabilize with staff assistance. The resident had a history of [REDACTED]. Review of a Fall Risk Evaluation dated 05/31/14, revealed a score of fifteen (15), indicating the resident was at high risk for fall. Review of a Device Evaluation, dated 06/03/14, revealed Resident #1's was alert with short term memory impaired and decreased awareness of safety needs. He/she had impaired balance and leaned to the left side when sitting. The evaluation was completed to improve wheel chair positioning, an intervention was put in place to use a half tray to wheelchair to improve wheelchair positioning due to left sided weakness. Further review of the resident's Comprehensive Care Plan, dated 05/24/14, revealed there were no revisions made to the care plan after the 05/31/14 MDS Assessment and Fall Risk Assessment; and the 06/03/14 Device Assessment were completed. The care plan did not address the identified risk of a fall due to the resident leaning to left side while sitting, the resident's short term memory loss that might prevent the resident to remember to use a call light, and the resident's decreased awareness of safety needs. Review of Change of Condition Documentation Note, dated 06/04/14 at 7:45 AM, revealed Resident #1 had an unwitnessed fall and was found in the bathroom floor on his/her stomach. The resident's left foot noted to be internally rotated. The resident was placed in bed using a mechanical lift. The resident complained of pain in the left leg and ankle. Resident #1's family and medical provider were called. Mobile services x-rays were taken at the facility of Resident # 1's left leg, hip, ankle and knee. Further review of Resident #1's Nurses Notes, dated 06/04/14 at 2:05 PM, revealed Resident #1 was transferred to the local hospital for admission and treatment of [REDACTED]. Review of the Hospital Diagnostic Imaging Report, dated 06/05/15, revealed there were Oblique Comminuted Fractures present within the proximal one-third (1/3) of the tibia shaft with mild lateral displacement and anterior angulation of the distal fracture component. Non-displaced oblique proximal fibula shaft fractures were also noted. Review of the Hospital Operative Report, dated 06/05/14, revealed Resident #1 required a surgical procedure to repair a unstable comminuted left tibial shaft fracture. A closed intramedullary rodding of the left tibia fracture using a tibial nail size 13 millimeters (mm) diameter x 345 millimeter length, two (2) proximal locking screws and two (2) distal locking screws. Interview with CNA #1, on 07/09/14 at 11:40 AM, revealed she and CNA #2 assisted the resident to the bathroom, and the resident asked for privacy because he/she needed to have a bowel movement. CNA #1 stated the care plan did not indicate that Resident #1 needed supervision while on the commode so she left Resident #1 on the commode and stepped into the next room to make another resident's bed. Interview with CNA #2, on 07/10/14 at 08:55 AM, revealed she was familiar with Resident #1's plan of care, she stated it did not say he/she could not be left alone and she thought it was okay to leave him/her unattended. Interview with Licensed Practical Nurse (LPN) #1, on 07/09/14 at 11:25 AM, revealed Resident # 1's care plan did not indicate if the resident could be left alone on the commode or not. Interview with MDS Coordinator, on 07/10/14 at 1:50 PM, revealed all care plans were prepared by the Interdisciplinary Team using a team approach after looking at therapy notes, interdisciplinary team notes, and documentation from direct care staff . She stated the interventions were determined with a team approach. She revealed if there had been any restriction or changes made for Resident #1 it would have been documented on his/her care plan and nurse aide care card. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents care plan, developed on admission, dated 03/28/14, and identified as the residents current Comprensive Care Plan, revealed Resident #2 was considered a fall risk related to use of [MEDICAL CONDITION] medication, impaired balance, history of multiple falls, and generalized weakness. The resident ambulated with a walker and required one (one) assist with bed mobility, transfer, toileting, and dressing. However, review of the MDS Kardex Report, or Care Card used by Certified Nursing Staff as their plan of care for Resident #2, dated 03/28/14, revealed Resident #2 had modified independence in decision making, required supervision to independent in bed mobility, transfer, walk in room and corridor with limited assistance of one (1) for toilet use. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/04/14, revealed the facility assessed Resident #2's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of "7" and he/she required one (1) person physical assist with bed mobility, transfers, and walking in room and corridor. Review of the facility's Risk Management System Report, dated 04/20/14 at 1:00 PM, revealed Resident #2 fell while going to the bathroom unassisted. The resident was placed on a seventy-two (72) hour bowel/bladder evaluation. Review of the Risk Management System Report, dated 04/27/14 at 3:30 AM, revealed Resident #2 fell out of bed and received a one (1) centimeter (cm) laceration to his/her chin. The intervention put into place was a therapy referral for bed mobility and safety awareness. Review of Physical Therapy Note, dated 04/28/14, revealed Resident #2 was currently receiving therapy for strengthening and endurance training and the therapy had been initiated on 03/28/14. Further review of the Comprehensive Care Plan for risk for falls, dated 03/28/14, revealed there were no interventions initiated once therapy evaluated the resident. Review of Speech Therapy Progress Note, dated 04/29/14, revealed Resident #2 required skilled intervention to address cognitive linguistic deficits that hinders his/her ability to be safe in all environments. Further review of the Comprehensive Care Plan for risk for falls, dated 03/28/14, revealed there were no interventions initiated to address speech therapy's evaluation of the resident. Review of the Risk Management System Report, dated 05/21/14 at 11:00 PM, revealed Resident #2 was ambulating in his/her room unassisted and became weak and fell to the floor. The resident sustained [REDACTED]. The intervention put in place at that time was to encourage the resident to call for assistance with ambulation. Further review of the Care Plan for risk for falls, dated 03/28/14, revealed an intervention was initiated to encourage the resident to call for assistance with ambulation. However, as evidenced by the Comprehensive and CNA Care Plan the resident had a chronic/progressive decline characterized by deficit in memory, judgement, decision making and thought process. Review of the Risk Management System Report, revealed on 06/12/14 at 10:50 AM, Resident #2 was ambulating to the bathroom in his/her room without assistance and fell , resulting in a 1.2 centimeter (cm) skin tear to the left elbow. The resident stated he/she was weak and fell . The intervention put into place was a Bowel and Bladder observation and therapy referral. Further review of the Care Plan for risk for falls, dated 03/28/14, revealed an intervention was initiated to conduct a 72 hour bowel and bladder evaluation and refer to therapy for evaluation. However, the care plan interventions failed to address the resident's continued attempts to transfer and ambulate his/her self. Review of the Risk Management System Report, revealed on 06/14/14 at 1:50 AM, Resident #2 was ambulating to the bathroom without assistance and fell . The resident sustained [REDACTED]. Interview with MDS Coordinator, on 07/10/14 at 1:50 PM, revealed the care plans were revised using a Interdisciplinary Team (IDT) approach. She stated the IDT Team reviewed therapy notes, the MDS Assessments, and anything that happened on the unit during care through out the planning period, and the information obtained was used to revise or implement the residents Plan of Care. Interview with the Director of Nursing (DON), on 07/10/14 at 8:45 AM, revealed she felt the interventions put in place after Resident #2's falls were adequate due to the fact that Resident #2 was very independent. She stated she thought after the fall on 06/12/14 the resident's voiding pattern could have changed and that was why they implemented the bowel and bladder observation. Further interview with the DON revealed all fall and condition changes were discussed daily during the departmental stand up meetings, and interventions were discussed at that time by all department heads. She stated the care plans were revised at that time.

Based on observation, interview, record review, and review of the Hospital Diagnostic Report and Hospital Operative Report and the facility's policy and procedure it was determined the facility failed to ensure two (2) of three (3) residents (Resident #1 and Resident #2) received adequate supervision and assistive devices to prevent accidents. Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/04/14, Resident #1 was placed on the commode in his/her room and left unsupervised by the Certified Nurse Aide (CNA). Resident #1 fell off the commode and sustained a Lateral Displacement of the Tibia Shaft as well as a Non-displaced Oblique Proximal Fibula Shaft Fracture to the left leg. Resident #1 required surgical intervention to repair the fracture on 06/05/14. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 sustained five (5) recurrent falls (04/20/14, 04/27/14, 05/21/14, 06/12/14 and 06/14/14) without any evidence of an assessment and investigation after each fall to identify the root cause of the fall so adequate supervision and assistive devices could be provided to prevent accidents. On 06/14/14, Resident #2 had an unwitnessed fall in his/her room and sustained a fractured hip that required surgical intervention. The findings include: Review of the facility 's policy titled, "Falls Management", last revised 05/15/14, revealed the purpose of the policy was to reduce risk for falls and minimize the actual occurrence of falls, develop individualized plan of care, review Intrinsic/Extrinsic Fall Risk Factors and to implement new interventions or remove environmental risk factors to prevent further falls. Residents would be assessed for falls as part of the nursing assessment process. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause. 1. Record review revealed the facility readmitted Resident #1 on 05/24/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 05/31/14, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of "99" indicating the resident was unable to complete the interview. The facility assessed Resident #1 to have short term memory problems and moderately impaired decision making. Review of a Fall Risk Evaluation, dated 05/31/14, revealed a score of fifteen (15), indicating the resident was at high risk for falls. Review of the Nursing Assessment, dated 05/31/14, revealed Resident #1 was oriented to person, place, time, and situation with encouragement; decision making was moderately impaired and poor with supervision; and, the resident required the assist of two (2) people for transfers with functional limitations. Review of a Device Evaluation, dated 06/03/14, revealed the facility assessed Resident #1's short term memory was impaired and the resident had decreased awareness of safety needs. In addition, the resident was assessed to have impaired balance and would lean to the left side when sitting. The evaluation determined to improve wheel chair positioning a half tray to wheelchair would be implemented due to left sided weakness. Review of the residents care plan, developed on admission, dated 05/24/14, and identified as the residents current Comprehensive Care Plan, revealed there were no revisions made to the care plan to address the identified risk of a fall due to the resident leaning to left side while sitting, the short term memory loss that might prevent the resident to remember to use a call light, and the resident's decreased awareness to ensure the resident received adequate supervision and assistive devices to prevent accidents. Review of Change of Condition Documentation Note, dated 06/04/14 at 7:45 AM, revealed Resident #1 was found in the bathroom on the floor laying on his/her stomach with the left foot internally rotated. The resident was transferred to the bed with a mechanical lift and complained of pain in the left leg and ankle. Mobile services x-rays were conducted on the resident left leg, hip, ankle and knee. Further review of the Nurse's Notes, revealed at 2:05 PM, Resident #1 was diagnosed with [REDACTED]. Review of Hospital Diagnostic Imaging Report, dated 06/05/14, revealed the resident was identified as having Oblique Comminuted Fractures within the proximal one-third (1/3) of the Tibia Shaft with mild lateral displacement and anterior angulation of the distal fracture component. A Non-Displaced Oblique Proximal Fibula Shaft Fracture was also identified. Review of Hospital Operative Report, dated 06/05/14, revealed Resident #1 had surgery to repair the unstable Comminuted Left Tibial Shaft Fracture. A closed intramedullary rodding of the left tibia fracture using a tibial nail size 13 millimeters (mm) diameter x 345 millimeter length, two (2) proximal locking screws and two (2) distal locking screws. Interview with the Administrator, on 07/08/14 at 3:45 PM, revealed on 06/04/14, Resident #1 was assisted to the bathroom in room #204 by two (2) Certified Nursing Assistants (CNA). She stated Resident #1 had asked for privacy so CNA #1 left the resident unsupervised on the commode and went two (2) doors down to make a bed. She stated the resident was advised to use his/her call light when finished. She also stated Resident #1 had been more confused since his/her stroke. Interview with Certified Medication Tech (CMT) #1, on 07/09/14 at 11:15 AM, revealed she was standing at the nursing station in front of Resident #1's door, and heard the crash and ran to the bathroom and the resident was laying on the bathroom floor. The CMT stated she called for the nurse to help and CNA #1 came running from another room. CMT #1 stated CNA #1 had been making a bed in a room with the door closed. Interview with CNA #1, on 07/09/14 at 11:40 AM, revealed she and CNA #2 assisted the resident to the bathroom, and the resident asked for privacy because he/she needed to have a bowel movement. CNA #1, stated she left Resident #1 on the commode and went to the next room to make a bed. Interview with CNA #2, on 07/10/14 at 8:55 AM, revealed she and CNA #1 assisted Resident #1 to the commode. She stated she was coming out of the dining room and was asked by CNA #1 to help her take Resident #1 to the bathroom. The CNA revealed when they left the resident on the commode in the bathroom she thought CNA #1 would be waiting outside the bathroom door. She stated she told the resident to turn on his/her call light when he/she was done. She stated she was assigned to work on another hall that day and went back to the dining room after she helped put the resident on the commode. Interview with Licensed Practical Nurse (LPN) #1, on 07/09/14 at 11:25 AM, revealed the resident was alert and oriented at the time and the care plan did not indicate if the resident could be left alone on the commode or not. Interview with the Speech and Language Pathologist, on 07/10/14 at 8:30 AM, revealed she had worked with Resident #1 since his/her admission. She stated based on what she knew about the resident's balance and the resident's leaning she felt the resident could fall. She stated she did not think it would be safe to leave the resident unsupervised. She revealed therapy had been working on his/her left visual field because the resident had left visual field neglect due to his/her recent CVA. She stated it would not be safe to leave him/her unsupervised because of his/her inability to recognize anything on his left side. Interview with the Physical Therapist, on 07/10/14 at 10:25 AM, revealed based on Resident #1's status of being a total assist of two (2) staff for transfer and his/her cognitive impairment it would not be safe to leave him/her unsupervised in the bathroom. Interview with Director of Nursing (DON) , on 07/10/14 at 8:20 AM, revealed she was unsure if the admission assessment showed a true picture of Resident #1, as the resident had good days and bad days and was able to make his/her needs known that day. The DON stated CNA #1 left the room because the resident requested privacy and remained in "ear shot of the resident". The DON stated the CNA was only a room away and she felt comfortable with the CNA leaving the resident unsupervised on the commode. Interview with Resident #1's Physician, on 07/10/14 at 9:45 AM, revealed he was not aware Resident # 1 was left unsupervised in the bathroom on the day of the fall. He stated he thought the CNA was standing outside the bathroom door, and didn't realize she had left the room. The Physician stated he did not think it was safe to leave the resident considering he/she was a maximum assist of two (2) for transfers. He revealed he thought it would have been safer to have someone right there to supervise the resident. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/04/14, revealed the facility assessed Resident #2's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of "7" and he/she required one (1) person physical assist with bed mobility, transfers, and walking in room and corridor. Observation of Resident #2, on 07/09/14 at 10:50 AM, revealed the resident was on his/her back, with the head of the bed elevated slightly. The resident stated "I can't remember a lot about the fall, but it would be all right if hadn't fell , now I can't walk". Record review revealed, Resident #2 had sustained five (5) falls since admission. Review of the facility's Risk Management System report, dated 04/20/14 at 1:00 PM, revealed Resident #2 fell while going to the bathroom unassisted. Resident #2 reported he/she also fell on the previous day but got up and didn't tell staff until the next day. Further review revealed there was no documented evidence of an assessment or investigation to determine the root cause of the fall. The intervention put in place was to implement a seventy-two (72) hour bowel and bladder evaluation to determine a voiding pattern. Review of the Risk Management System Report, dated 04/27/14 at 3:30 AM, revealed Resident #2 fell out of bed and received a one (1) centimeter (cm) laceration to his/her chin. The intervention put into place was a therapy referral for bed mobility and safety awareness. Review of Physical Therapy note, dated 04/28/14, revealed Resident #2 was currently receiving therapy for strengthening and endurance training and the therapy had been initiated on 03/28/14. Resident #2 reported to the therapist he/she had fallen and had bruises on his/her forearm, wrist and a cut to his/her chin. In addition. Resident #2 complained of being sore from the fall. Review of Speech Therapy Progress Note, dated 04/29/14, revealed Resident #2 required skilled intervention to address cognitive linguistic deficits that hinders his/her ability to be safe in all environments. Review of the Risk Management System report, dated 05/21/14 at 11:00 PM, revealed Resident #2 was ambulating in his/her room unassisted and became weak and fell to the floor. The resident sustained [REDACTED]. The intervention put in place at that time was to encourage to call for assistance with ambulation; however, the facility had assessed the resident to have short term memory loss and cognitive deficits that hindered his/her ability to be safe in all environments. Review of the Risk Management System Report, revealed on 06/12/14 at 10:50 AM, Resident #2 was ambulating to the bathroom in his/her room without assistance and fell , resulting in a 1.2 centimeter (cm) skin tear to the left elbow. The resident stated he/she was weak and fell . The care plan intervention put into place was a Bowel and Bladder observation and therapy referral, which were previous interventions implemented after the resident's falls on 04/20/14 and 04/27/14, respectively. Further review revealed there was no documented evidence of an assessment/investigation to determine the root cause of the fall, if the resident had an unmet need or if other factors could have contributed to the residents decision to ambulate to the bathroom without assistance. The care plan interventions failed to address the resident's continued attempts to transfer and ambulate his/her self. Review of the Risk Management System report, revealed on 06/14/14 at 1:50 AM, Resident #2 was ambulating to the bathroom without assistance, fell and sustained a fractured right hip requiring surgical repair. Interview with Speech and Language Pathologist on 07/10/14 at 8:30 AM, revealed she had been working with Resident #2 for safety awareness and short term memory problems. She stated Resident # 2 did not have good safety awareness due to his/her short term memory problems. Interview with the Director of Nursing (DON), on 07/10/14 at 8:45 AM, revealed she felt the interventions implemented after Resident #2's falls were adequate due to the fact that Resident #2 was very independent. Further interview with the Director of Nursing, on 07/10/14 at 8:45 AM, revealed a departmental stand up meeting was held every day to discuss falls and condition changes for residents. She stated during the meetings interventions were discussed by all department heads and assessments were done to help determine the cause of the falls. She revealed interventions were then put in place that the department heads had determined would address the resident's falls. .