Every finding on record at Elba Nursing and Rehabilitation Center, LLC

Based on observations, interviews, and review of the facility RESIDENT BILL OF RIGHTS, the facility failed to ensure Room Locator (RL) #1 was free of odors. This was affected one of 54 Room Locators. Findings Include: A review of the facility RESIDENT BILL OF RIGHTS , with a history date of 1/23 revealed, .A. Facility residents shall have the right to: . 32. A safe clean, comfortable home like environment. On 03/02/2023 at 8:40 AM during the surveyor's walk through of the facility observing various rooms, RL #1 was observed with a strong odor. The odor appeared to be that of urine. The facility Administrator, Employee Identifier (EI) #1 was observed in the hall and asked to come to RL #1. When EI #1 entered RL #1, she was asked what she noticed. EI #1 said the smell or urine. EI #1 was asked why there was a smell of urine in RL #1. EI #1 said she was not sure if it was the mattress. When asked if it was the mattress, would it have gotten that way overnight, and she said no. EI #1 was asked how noticeable the smell of urine was, and she replied it was noticeable. EI #1 was asked what the concern with RL #1 smelling of urine. EI #1 said it should not be like that it was the resident's home. On 03/02/2023 at 8:50 AM, EI #4, Certified Nursing Assistant (CNA), EI #4 was observed in RL #1. EI #4 was asked what she smelled in RL #1; she said urine. EI #4 was asked how often did RL #1 smell of urine and said often. EI #4 was asked what could help take the smell of urine away; she said clean linens and possibly wiping down the bed. EI #4 was asked what was the concern of RL #1 smelling of urine and she said it was the resident's home and should not smell that way. On 03/02/2023 at 9:00 AM, EI #3, the housekeeping supervisor was asked to come to RL #1, she was asked what she noticed. EI #3 said it smelled horrible, like urine. EI #3 was asked who was responsible for ensuring rooms did not smell like urine. EI #3 said all staff, CNAs, nurses and housekeeping. EI #3 was asked what was the concern with RL #1 smelling of urine. EI #3 said this was the resident's home and it should be a safe clean home like environment, the smell of urine was not clean. On 03/02/2023 at 9:10 AM an interview with EI #5, housekeeping staff revealed RL #1 smelled of urine often. EI #5 was asked what was the concerns with RL #1 smelling of urine. EI #5 said it was the resident's home and should not smell that way, it was not clean. On 03/02/2023 at 9:20 AM, a follow up interview with EI #3 revealed the concern with RL #1 smelling was that it was not a safe clean environment. On 03/02/2023 at 10:00 Am an interview was conducted with EI #2, the Director of Nursing, she was asked what was the policy on rooms being clean. EI #2 said it was the resident's rights, they should have a safe, clean comfortable homelike environment. When asked if urine odor should be strong in RL #1 she said it should not. EI #2 was asked what the concern was with a resident's room smelling horrible, be it of urine or other body fluids. She said it was not a clean comfortable environment. On 03/02/2023 at 10:30 AM a follow up interview was conducted with EI #1, the administrator. EI #1 was asked what the facility policy was on a clean comfortable environment. EI #1 said residents should have a clean comfortable homelike room with no uncomfortable odors. EI #1 was asked what was included in a clean homelike environment. EI #1 said no excessive clutter, floors clean, no overflowing trash and no uncomfortable odors. EI #1 was asked what would uncomfortable odors be and she said urine, bowel movement, saliva or trash. EI #1 was asked what the concern was with an uncomfortable odor. EI #1 said the residents could be uncomfortable and it was their home and should not smell that way. This was cited as a result of the investigation of complaint/report number AL00042790.

Based on interviews, discussion during the resident group meeting, and review of the facility's Admission Agreement, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 90 out of 90 residents residing in the facility. Findings Include: A review of the facility's ADMISSION AGREEMENT, with an effective date of 9/16/19, revealed: . RESIDENT BILL OF RIGHTS . A. Facility Residents shall have the right to: . 26. To send and receive mail promptly and unopened. On 5/16/22 at 10:00AM, a group meeting was held with 18 residents present. No one stated they received mail on Saturdays. In an interview on 5/16/22 at 11:29AM, Resident Identifier (RI) #40 stated no one received mail on Saturday because the main office staff were not present on Saturdays. On 5/16/22 at 03:44PM, Employee Identifier (EI) #4, Social Services Director, reported if resident mail is delivered by postal service on Saturday, the resident received the mail on Monday because the mail was given to the resident by Social Services and they do not work Saturdays or Sundays. EI #4 stated mail was delivered to the residents Monday through Friday and mail received on Saturday was delivered to the resident on Monday. EI #4 stated residents had a right to receive mail on Saturdays. EI #4 stated the Residents' Rights were not being followed on Saturdays. On 5/17/22 at 10:24AM, EI #7, Business Office Manager, reported she worked as the receptionist on some Saturdays. EI #7 stated if a resident received mail on Saturday, she put the resident's mail in the Social Services box. EI #7 stated she did not deliver the mail received on Saturdays to the residents. On 5/17/22 at 10:29AM, EI #5, Restorative Certified Nursing Assistant (CNA), reported she covered as the receptionist on some Saturdays. EI #5 stated if a resident received mail on Saturday, she would set it aside for Social Services. EI #5 stated if a resident asked for their mail, she would ask the nurse about it first. EI #5 stated residents had a right to receive mail on Saturdays. On 5/17/22 at 10:34AM, EI #8, Housekeeper, reported she worked as the receptionist on Saturdays. EI #8 stated if a resident received mail on Saturday, she would set it aside for Social Services. EI #8 stated Social Services did not work on Saturdays. It was EI #8's understanding that Social Services had to observe resident mail first. On 5/17/22 at 12:56PM, EI #6, Restorative CNA, stated she worked some Saturday mornings as the receptionist. EI #6 stated if residents received mail on Saturday, it would go into the box on the desk and Social Services would get it Monday and distribute it. EI #6 stated residents should get their mail on Saturdays.

Based on observation, interview and record review, the facility failed to ensure the Admission Minimum Data Set (MDS) for Resident Identifier (RI) #233 was completed in a timely manner. This deficient practice affected one out of 18 resident MDS's reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/19, page 2-16, revealed the following: . RAI OBRA-required Assessment Summary . Assessment Type/Item Set . Admission . MDS Completion Date (Item Z0500B) No Later Than . 14th calendar day of the resident's admission (admitted + 13 calendar days) . RI #233 was admitted to the facility on [DATE]. RI #233's Admission MDS had an Assessment Reference Date (ARD) of 4/27/22. The status of the MDS was Open. No information was entered at Z0500. On 5/17/22 at 09:09AM, Employee Identifier (EI) #2. RN/MDS Coordinator, reported she was working on the admission MDS for RI #233 and it had not been completed. EI #2 reported the MDS was started 4/27/22 and it should have been completed around 5/2/22. EI #2 stated RI #233's MDS was not be completed timely.

Based on record review, interview and review of a facility policy MDS ASSESSMENT, the facility failed to ensure the Minimum Data Set (MDS) for Resident Identifier (RI) #32 dated 2/25/22 was coded for anticoagulation medication. This affected one of one resident records reviewed for anticoagulation medication. Findings Include: A review of a facility policy titled MDS ASSESSMENT, with a date of 11/17 revealed POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets a .These assessments provide information on the resident's condition . RI #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #32's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 2.5 mg (milligram) . By MOUTH TWICE DAILY . A review of an admission MDS with an Assessment Reference Date of 2/25/22, Section N revealed not coded for anticoagulation medication. On 5/17/22 at 1:15 PM an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN), MDS Assistant. EI #3 was asked, how was RI #32 receiving anticoagulation medication. EI #3 replied, RI #32 was receiving [MEDICATION(S)] two times a day. EI #3 was asked when did the medication start. EI #3 replied 2/18/22. EI #3 was asked if [MEDICATION(S)] should be coded on the MDS, she replied, yes. EI #3 was asked, why was the anticoagulation medication not coded on the 2/25/22 MDS, EI #3 replied it was an oversight. EI #3 was asked, what would the concern be with anticoagulation medication not coded. EI #3 replied, possibly not an accurate assessment.

Based on record review, interview and a review of the facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure Resident Identifier (RI) #58 was care planned for a Urinary Tract Infection ([CONDITION(S)]) upon readmission to the facility on [DATE]. This affected one of 18 resident care plans reviewed. Findings Include: A review of a facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, with an effective date of 3/18 revealed POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan . will be updated . RI #58 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #58's Physician Orders List revealed . Order Date 3/23/22 Start Date 3/24/22 . Stop Date 3/30/22 . [MEDICATION(S)] DS tablet . A review of a facility form titled Departmental Notes revealed . 3/23/22 . Resident received back to the facility . for [CONDITION(S)] . 3/25/22 . ABT (antibiotic therapy) continues for [CONDITION(S)] . 3/28/22 . continues on ABT for [CONDITION(S)] . A review of RI #58's care plans did not reveal a care plan for [CONDITION(S)]. On 5/17/22 at 1:11 PM, an interview was conducted with the MDS (Minimum Data Set), Coordinator, Employee Identifier (EI) #2. EI #2 was asked when should a care plan be updated. EI #2 replied, when there was a new concern. EI #2 was asked, when was RI #58's care plan updated for a [CONDITION(S)]. EI #2 replied, it had not been. EI #2 was asked what was the concern with not having a care plan for [CONDITION(S)]. EI #2 replied, possible recurring infection.

Based on interviews, record review and a review of the facility policies titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, and GUIDE FOR WOUND EVALUATION, the facility failed to provide evidence Resident Identifier (RI) #74's responsible party was notified when: 1) RI #74 developed an open area to the right ankle on 6/15/2021; and 2) when the area to RI #72's right ankle was observed to have worsened on 6/27/2021. These deficient practices affected RI #74, one of three residents sampled for notification. Findings include: Review of a facility policy titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, with a HISTORY date of 11/2017, revealed the following: POLICY: . the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulation. RESPONSIBILITY: All Licensed Nursing Personnel. PROCEDURE: . 2. Document in the Interdisciplinary Team (IDT) notes: . c. Notification of responsible party. Another facility policy titled GUIDE FOR WOUND EVALUATION, with a HISTORY date of 11/2017, revealed the following: . COMMENTS: Other considerations: . Family notification . PROCEDURE: . 3. Contact . family members . as indicated . RI #74 was admitted to the facility on [DATE] and discharged to the ER (emergency room ) on 06/29/2021. RI #74's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #74's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 06/02/2021, revealed RI #74 did not have a Pressure Ulcer or Diabetic Foot Ulcer during this assessment period. 1) RI #74's June 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date . 06/15/21 . CLEAN WOUND TO RT (Right) OUTER ANKLE WITH NS (Normal Saline), PAT DRY W (With)/4X (by)4, APPLY ZEROFORM, COVER W/[MEDICATION(S)] BORDER FOAM AS NEEDED . A review of RI #74's Departmental Notes revealed there was no evidence RI #74's responsible party had been notified of the new wound care order. On 07/06/2021 at 7:52 PM, the surveyor conducted a telephone interview with RI #74's responsible party. When asked if RI #74 was admitted with any skin break down, RI #74's responsible party said no. The surveyor asked RI #74's responsible party was she notified about any opened areas on RI #74 or any skin breakdown on RI #74's ankles. RI #74's responsible party said no. RI #74's responsible party said she was never notified that the facility was providing any type treatment to RI #74's ankles. On 07/08/2021 at 11:41 AM, the surveyor conducted an interview with Employee Identifier (EI) #2, LPN (Licensed Practical Nurse) who provided care to RI #74 on the 7 A - 7 P shift. The surveyor asked EI #2, when RI #74 was admitted what was on RI #74's ankles. EI #2 said nothing that she could recall. EI #2 was asked when she first noticed RI #74 had an open area on his/her right ankle. EI #2 replied, it was about mid-June. When asked where would it be documented that the responsible party had been notified, EI #2 said it should be in the nurses notes. A review of RI #74's June 2021 eTAR (electronic Treatment Administration Record) revealed the treatment to RI #74's right outer ankle began on 06/15/2021. On 07/08/2021 at 03:11 PM, the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1, according to RI #74's treatment record, when did RI #74 develop the open area to his/her right outer ankle. EI #1 said 06/15/2021. The surveyor asked EI #1 where would there be evidence the responsible party was notified of the new wound, and the care order. EI #1 said it should have been in the nurse notes. When asked to show the surveyor where the responsible party was notified of the new order, EI #1 looked in RI #74's Departmental Notes and said she did not see where the responsible party had been notified. 2) A review of RI #74's Departmental Notes dated 06/27/2021 at 8:23 PM, revealed the following: . Wound care provided as ordered. Wound to right heel degressing. Area around wound is red and inflammed (Inflamed). Right foot is slightly swollen . On 07/08/2021 at 7:15 PM, the surveyor conducted an interview with EI #3, the RN (Registered Nurse) documenting the above Departmental Note. The surveyor showed EI #3 the Departmental Notes and asked what she meant when she documented the wound to RI #74's right heel was degressing. EI #3 said it should have been documented to the right ankle not heel and what she meant was the wound was getting worst. When asked was the responsible party notified that the wound was getting worst, EI #1 said she did not see where it was documented the responsible party was notified RI #74's wound was getting worse. The surveyor asked EI #3 should the responsible party have been notified. EI #3 said yes. When asked when you notify responsible parties of new changes occurring with the resident, where would there be evidence of that, EI #3 said it should be documented in the nurse's notes.

Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #82's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/21/2021, did not code RI #82 as receiving an Anticoagulant medication during this assessment period. This deficient practice affected RI #82, one of 31 residents whose MDS assessments were reviewed. Findings include: A review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed the following: . Coding Instructions . NO410E, Anticoagulant (e.g. (for example), [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medication such as . [MEDICATION(S)] here . RI #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #82's Quarterly MDS assessment, with an ARD of 06/21/2021, revealed RI #82 received an Anticoagulant during this 7-day look back assessment period. A review of RI #82's June 2021 eTAR (electronic Treatment Administration Record) revealed RI #82 received the following: . [MEDICATION(S)] 75 MG (milligrams) TAKE ONE (1) TABLET BY MOUTH EVERY DAY . [MEDICATION(S)] BISULFATE . Other specified peripheral vascular diseases . According the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual ([MEDICATION(S)] ([MEDICATION(S)]) should not be coded as an anticoagulant medication. On 07/08/2021 at 2:58 PM, the surveyor conducted an interview with Employee Identifier (EI) #4, the RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #4, when looking at RI #82's medical records, which anticoagulant medication was RI #82 receiving. EI #4 said RI #82 was receiving [MEDICATION(S)], which was not an anticoagulant. When asked what the RAI classified [MEDICATION(S)] as, EI #4 said an Antiplatelet. EI #4 said whoever completed the MDS did not know it should not be coded as an anticoagulant. The surveyor asked EI #4 why it would be important to code the MDS accurately. EI #4 said to show the continuous care the resident is receiving.

Based on interview, record review and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to initiate an Instant Care Plan when Resident Identifier (RI) #74 developed an open area to his/her right ankle on 06/15/2021. This deficient practice affected RI #74, one of three residents sampled for pressure ulcers. Findings include: A review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, with a History date of 03/2018, revealed the following: POLICY: Each resident will have a person centered plan to care to identity problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. RESPONSIBILITY: All members of the Interdisciplinary team DEFINITIONS: . Instant Care Plan - utilized with a change in resident condition not addressed on the comprehensive care plan. PROCEDURE: . 9. Upon a change in condition . an Instant Care Plan will be initiated if applicable: a. A Instant Care Plan can be completed with a change in resident condition if there is no care plan available or until the Comprehensive Person Centered Care Plan is updated. d. Use the Instant Care Plan to reflect an isolated occurrence/problem or several. RI #74 was admitted to the facility on [DATE] and discharged to the ER (emergency room ) on 06/29/2021. RI #74 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #74's Admission Minimum Data Set assessment, with an Assessment Reference Date of 06/02/2021, revealed RI #74 did not have a Pressure Ulcer or Diabetic Foot Ulcer during this assessment period. Review of a Physician's Telephone Order for RI #74, dated 06/15/2021, revealed the following order: . CLEAN WOUND TO RT (Right) OUTER ANKLE WITH NS (Normal Saline), PAT DRY W (With)/4X (by)4, APPLY ZEROFORM, COVER W/[MEDICATION(S)] BORDER FOAM DAILY . On 07/08/2021 at 03:11 PM, the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing. The surveyor asked EI #1 according to RI #74's treatment record, when did RI #74 develop the open area to his/her right outer ankle. EI #1 said 06/15/2021. The surveyor asked EI #1 when RI #74 developed the opened area to his/her right outer ankle should a care plan have been initiated. EI #1 said yes. When asked where the evidence was that an instant care plan had been initiated, EI #1 said she did not see evidence of one. The surveyor asked EI #1 why it would be important to initiate a plan of care when there were changes in a residents condition or new concerns were identified, EI #1 said basically it would tell you what was going on with the resident and what staff are supposed to do concerning their care.

Based on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled, MEDICATION DESTRUCTION the facility failed to ensure the Medication Destruction forms contained the required signatures. This was observed on four out of fifteen months of non-controlled drug destruction forms viewed. Findings include: Review of the facility policy titled, MEDICATION DESTRUCTION with a HISTORY date of ,d+[DATE] revealed, POLICY: When medications are discontinued by physician order, expired, or a resident is transferred or discharged and does not take medications with them, or in the event of a resident's death, the medications are destroyed. RESPONSIBILITY: . Director of Nursing Services PROCEDURE: . 3. Two nurses are to witness the destruction and sign on the Record of Medication Destruction-Non-Controlled Medication sheet. A review of the facility's forms titled, RECORD OF MEDICATION DESTRUCTION - NON-CONTROLLED MEDICATIONS revealed on [DATE] there were five entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were eleven entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were eight entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were three entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were four entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were six entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] there were seven entries for drugs destroyed with only one signature as witnessing the destruction. On [DATE] at 5:04 PM an interview was conducted with Employee Identifier #1 the Director of Nursing Services (DNS). EI #1 was asked how many signatures were required to be on the record of medication destruction for Non-Controlled medications. She answered two. EI #1 was asked as she reviewed the medication destruction pages from ,d+[DATE] through ,d+[DATE], how many pages do not have the required signatures. She answered seven. EI #1 was why it was necessary to have the required signatures on the record of medication destruction for Non-Controlled medications. She answered for accountability.

Based on observation, interviews and review of facility policies tithed, Tube feeding and Resident Rights, the facility failed to ensure (Resident Identifier) RI #5 was treated with dignity while a nurse provided nutritional care. This affected 1 of 32 residents who was observed for dignity. Findings Include: A review of a document titled Resident Bill of Rights revealed: Each resident has a right to a dignified existence. A. Facility Residents shall have the right to: .33 To personal privacy . in his or her personal care. A review of a facility policy titled, Tube Feeding with a history date of 11/17, revealed, . Procedure: 1. Provide privacy. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's (MONTH) 2019 Physician order [REDACTED]. On 03/17/2019 at 10:07 p.m., the surveyor observed a nurse pouring water and milk down a tube attached to the resident's stomach. The nurse had the door opened the entire time she fed the resident. The resident was lying on the floor on a mattress with the stomach and thigh exposed. The resident had on a thin plastic like brief with a blue pad under him/her. On 03/17/2019 at 02:18 p.m., the surveyor conducted an interview with Employee Identifier (EI) #7, the Licensed Practical Nurse who provided the nutritional feeding to RI #5. EI #7 was asked why did she feed the resident with the door opened. EI #7 replied, she liked to keep an eye on everything. EI #7 was asked should the door be closed when bolus feeding a resident. EI #7 replied, yes. EI #7 was asked why should the door be closed. EI #7 replied for privacy. On 8/18/2019 at 3:24 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing. EI #2 was asked when should a resident, who required bolus feeding, be fed with the door opened. EI #2 replied, they would not be fed with the door opened. EI #2 was asked what did the facility policy say regarding feeding a resident who required bolus feeding. EI #2 was asked why should the door be closed when feeding a resident who required bolus feeding. EI #2 replied it was a dignity issue. EI #2 was asked what was the harm to the resident when a nurse provided bolus feeding with the door opened. EI # replied, it was a dignity issue. EI # was asked when a nurse fed a resident with the door opened was this privacy. EI # replied, no.

Based on observation, interview, review of a facility policy Contact Precautions and record review, the facility failed to ensure staff put on Personal Protective Equipment (PPE) prior to entering Resident Identifier (RI) #89's room to provide care. This affected one of 4 residents on contact isolation. Findings Include: 1. A review of a undated facility policy titled, CONTACT PRECAUTIONS revealed: POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of transmission of epidemiologically important micro-organisms by direct of indirect contact. DEFINITION: Transmission Based Precautions are designed for residents documented or suspected to be infected or colonized with highly transmissible or . Three types of precautions utilized are Contact Precautions . PR[NAME]EDURE: . 3 Apply protective equipment as indicated upon entering the room. a. gloves . b. gowns . RI #89 was admitted to the facility 2/20/19 with a [DIAGNOSES REDACTED]. A review of a hospital laboratory report, with a collected date of 2/14/19, revealed . Specimen/ Source: Ulcer Buttocks Isolate Escherichia coli (ESBL - Positive) . On 3/17/19 at 3:20 PM, the surveyor observed two CNAs (Certified Nursing Assistants) entering RI #89's room. Neither of the CNAs put on PPE. The surveyor knocked on th door and was invited in. The surveyor observed both CNAs with gloves on providing care to RI #89. The surveyor asked what care was being provided. They replied they were checking and repositioning. The surveyor observed the CNAs making contact with the resident. The surveyor left the room and waited in the hall. Both CNAs then exited the room. At that time Employee Identifier (EI) #4 and EI #5 were asked if RI #89 was on isolation. EI #4 replied, yes. Both were asked what type of infection. EI #4 replied,[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in a wound. Both were asked what type isolation RI #89 was on. EI #4 replied, contact. EI #4 was asked what PPE were they to put on prior to care. EI #4 replied, gloves only. EI #4 was asked when they were turning or checking the resident, did they make contact by touching the resident. EI #4 replied, yes. Both were asked if touching was contact. EI #5 replied, yes. Both were asked what was the harm in not wearing proper PPE during provision of care. EI #4 and EI #5 replied, spread infection or germs, could pass to other residents. EI #4 and EI #5 were asked if they put on a gown. EI #4 replied, no. Both were asked why not. EI #4 replied, they were taught gloves only. On 3/19/19 at 10:05 AM, EI #3, Registered Nurse/ Infection Control, was interviewed. EI #3 was asked how many residents were on isolation. EI #3 replied, four on precautions. EI #3 was asked what precautions. EI #3 replied, ESBL (Escherichia coli) in urine,[MEDICAL CONDITION] in wounds. EI #3 was asked what organism was RI #89 isolated for. EI #3 replied, ESBL in wound on sacrum. EI #3 was asked when should staff use PPE. EI #3 replied, anytime contact with resident. EI #3 was asked if staff was going in to turn a resident what PPE should they have on. EI #3 replied, gown and gloves. EI #3 was asked how was staff trained for contact isolation. EI #3 replied inservice. EI #3 was asked what was the harm in staff not putting on gowns when providing care for a resident on contact isolation. EI #3 replied, endanger to self and spreading infection to other residents.

Based on observation, interviews and a review of a facility document tiled, Garbage and Rubbish Disposal, the facility failed to ensure dumpsters number one and number three were closed tightly on 3/17/19. This was observed of 2 of 3 dumpsters and had the potential to affect all residents residing in the facility. Findings Include: A review of a policy titled, Garbage and Rubbish Disposal with an edition date of (YEAR) revealed: .Procedure: 1. All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent overfilling. This will assist in the prevention of odors, pets, and possible contamination. 6. Outdoor trash receptacles will be kept covered . On 3/17/19 at 11:00 a.m., the surveyor observed dumpsters number one and number three lids opened. The dumpsters had three compartments to them. Dumpster number one's lid in the first compartment was opened on the right and left side of the dumpster. There were 4 trash bags up out of the dumpster with the lids all the way up. There was no trash bags in compartment two and three. In dumpster number three, there were three compartments. On the backside of the dumpster compartment number one, the lids on the right and left side were up exposing trash bags. There was nothing in compartment two and three. On 3/19/19 at 9:13 a.m., an interview was conducted with Employee Identifier (EI) #8, dietary aide. EI #8 was asked to described what she saw at dumpster number one on 3/17/19. EI #8 replied, dumpster number one lid was not closed and trash was hanging out of it. EI #8 was asked how high were the lids up. EI #8 replied, the lids were standing all the way up. EI #8 was asked why were the lids up. EI #8 replied, trash were not placed in the dumpster properly. EI #8 was asked what was hanging out of the dumpsters. EI #8 replied, trash. EI #8 was asked which dumpsters were open. EI #8 replied, dumpsters one and three. EI #8 was asked who was responsible for making sure the dumpsters lids were closed. EI #8 replied, everybody in dietary. EI #8 was asked what did the facility policy say regarding keeping the dumpster lids closed. EI #8 replied, the dumpster lids must be closed at all times and trash must be placed in bins properly. EI #8 was asked what could happen when the dumpsters lids are not closed. EI #8 replied food and waste can spill over on to the ground, wild animals can come out of the woods because they are facing the woods. EI #8 was asked what was in dumpster number one's compartment two and three. EI #8 replied, the second compartment trash was overflowing and number three was not full, more trash could have been put in it. EI #8 was asked what was in dumpster number three's compartment two and three. EI #8 replied, in number two and three compartments there was no trash. EI #8 was asked to describe dumpster number three. EI #8 replied number one's compartment was full of trash with the lid raised up. EI #8 was asked how high was the lid raised. EI #8 replied, half way. EI #8 was asked in number one dumpster could trash bag be placed in compartment two and three to prevent an over flow in number one compartment. EI #8 replied, yes. EI #8 was asked in number three dumpster could trash bags be placed in compartment two and three to prevent an over flow in number one compartment. EI #8 replied, yes. On 03/20/19 at 8:48 a.m., an interview was conducted with EI #13 Dietary Manager. EI #13 was asked who was responsible for making sure the dumpsters were kept closed. EI #13 replied, dietary, everyone used it. EI #13 was asked why should the dumpsters be kept closed. EI #13 replied, because you have birds flying overs, cats, rats and mice all kind of animals that can get into it and it was a health hazard. EI #13 was asked when should the dumpsters be kept closed. EI #13 replied, at all time, and after each use. EI #13 was asked what did she observe on Sunday evening 3/17/19 when observing the dumpster. EI #13 replied, the lids were not completely covering the trash.

Based on a review of the FDA(Food and Drug Administration) Food Code, observations and interview, the facility failed to ensure: 1. two bags of dry cereal were sealed tightly within the packaged container to prevent the potential for contamination; 2. food products were discarded after the manufacture's expiration dates; and 3. a dietary staff member had hair contained under a hair restraint. This had the potential to affect all residents who received meals from the kitchen. The facility's Resident Census and Conditions of Residents form, dated [DATE], indicated a total facility census of 92, five of which received tube feedings. Findings include: 1. A review of the FDA 2013 Food Code revealed the following: . ,[DATE].15 Package Integrity. FOOD packages shall .protect the integrity of the contents so that the FOOD is not exposed to .potential contaminants. On [DATE] at 10:19 AM, an observation was made of one bag of raisin bran and one 35 oz (ounce) bag of corn flakes rolled in the middle of the bag, but not sealed securely. On [DATE] at 3:42 PM, one large bag of raisin bran and one 35 oz bag of corn flakes was rolled down in the middle, but not secured tightly. On [DATE] at 2:32 PM, an interview was conducted with EI (Employee Identifier) #4, Dietary Manager. EI #4 was asked when dry food products, such as dry cereal, were opened how should the package be sealed. EI #4 said, the package should be sealed with a tie. EI #4 was asked what was the potential harm of not sealing opened cereal bags tightly in the dry-storage area. EI #4 said, it was a potential for insects or rodents to get in them. 2. A review of the FDA 2013 Food Code revealed the following: XXX,[DATE].17 Ready-to-Eat, .(2) The day .may not exceed a manufacture's use-by-date if the manufacturer's determined the use-by-date . On [DATE] at 10:21 AM, an observation was made of two 46 oz containers of thickened orange juice with a manufacture's expiration date of [DATE]. On [DATE] at 10:27 AM, an observation was made of seven cans of Therapeutic Nutrition with a manufacturer's expiration date of [DATE]. [DATE] at 3:44 PM, an observation was made of four cans of Therapeutic Nutrition with a manufacture's expiration date of [DATE]. On [DATE] at 2:32 PM, an interview was conducted with EI #4, Dietary Manager. EI #4 was asked why should food products be discarded after the manufacture's expiration date. EI #4 said, because the manufacture gives that expiration date because that is how long the product is good for. EI #4 was asked who was responsible for ensuring food products were discarded after the manufacturers expiration date. EI #4 said, the Dietary Manager and dietary staff. EI #4 was asked what was the facility's policy on discarding expired food items. EI #4 explained the food item should be discarded on the expiration date or before. EI #4 was asked what was the potential harm of serving manufacture expired products to residents. EI #4 replied, it could be spoiled and could be harmful to the person. 3. A review of the FDA 2013 Food Code revealed the following: .Hair Restraints ,[DATE].11 Effectiveness. (A) .FOOD EMPLOYEES shall wear hair restraints .that covers .hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD . On [DATE] at 5:21 PM, during the dinner meal, an observation was made of the cook placing food on plates during the trayline, with hair hanging from under the hair restraint. On [DATE] at 2:32 PM, an interview was conducted with EI # 4, Dietary Manager. EI #4 was asked why should dietary staff have hair enclosed under their hairnets. EI #4 explained, because the hair could fall into the food, plus it was not sanitary. EI #4 was asked how were dietary staff to wear hairnets. EI #4 explained, before entering the kitchen they were to place a hairnet on and all of the hair was to be placed underneath the hairnet. EI #4 was asked, what was the facility's policy regarding the use of hair restraints/hairnets. EI #4 said, all hair should be completely covered before entering kitchen. EI #4 was asked, what was the potential harm of a dietary staff plating food during trayline with hair hanging from under their hairnet. EI #4 said, there was potential for hair to fall in the residents' food and it would not appealing.

Based on a review of a facility document Garbage and Rubbish Disposal, observations and interview, the facility failed to ensure the fenced in recycle area, containing boxes on a cement slab, was free of debris. This was observed three days of the survey and had the potential to affect all 92 residents residing in the facility. Findings include: A review of a facility document titled, Garbage Rubbish Disposal with an edition date of (YEAR) revealed the following: . Garbage and rubbish will be disposed of to insure a clean and sanitary kitchen does not encourage infest(insects) or rodents. All outside dumpsters will be maintained in clean and sanitary condition. Procedure: 1. All .rubbish is to be put into waste containers . This will assist in the prevention of odors, pest, and possible contamination. 3. All garbage and rubbish containing food waste are covered . as to be inaccessible to vermin. 5. Storage areas will be kept clean to discourage pests. 6. Outside trash receptacles will be kept covered and the surrounding area kept free of litter. On 03/20/18 at 10:33 AM, an observation was made of the outside dumpster area. On a concrete slab beside the garbage bins, the surveyor observed large boxes and debris; The debris included: two hairnets, plastic bags, candy wrappers, brown bags, french fries, and french fry container. On 03/21/18 at 3:36 PM, another observation was made of this outside fenced area beside the kitchen. The cement slab was observed with empty, folded boxes and debris which included: plastic bags, candy wrappers, french fries, and a cigarette carton. On 03/22/18 at 9:14 AM, an observation was made of the outside fenced area next to the kitchen. Debris was observed, such as hairnets, plastic bag, french fries, gloves and cigarette cartons. On 03/22/2018 at 1:37 PM, an interview was conducted with EI (Employee Identifier) #3, the Maintenance Supervisor. EI #3 was asked who was responsible for the fenced in area with cardboard boxes. EI #3 said maintenance. EI #3 was asked why should the recycled box area be free of debris such as cigarette butts, gloves, hairnets, uneaten food such as french fries, brown paper bags and other debris. EI #3 explained the area should be free from debris to prevent critters such as bugs and rats. EI #3 was asked how often was the recycle area observed to ensure debris was not present. EI #3 replied, apparently never.

Based on interview, record review and review of a facility policy titled MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure [MEDICATION NAME] was not coded as an Anticoagulant on Resident Identifier (RI) #47's 01/21/18 Quarterly MDS assessment This deficient practice affected RI #47, one of 24 sampled residents whose MDS assessments were reviewed. Findings Include: RI #47 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A facility policy titled MDS ASSESSMENT, with a reviewed date of 11/17, documented: . PR[NAME]EDURE: . 7. The Interdisciplinary Team member's signatures in Z0400 will attest to completion/accuracy of the assessment . A review of the Quarterly MDS assessment, with an Assessment Reference Date of 01/24/18, coded RI #47, under Section N - Medications, as having received an anticoagulant medication during this assessment period. Further review of the Quarterly MDS assessment revealed under section Z0400, Employee Identifier (EI) #1, the MDS Coordinator, had electronically signed that she completed Section N on 02/07/18. RI #47's (MONTH) (YEAR) Physician order [REDACTED]. On 03/22/18 at 1:35 p.m., the surveyor conducted an interview with EI #1, Registered Nurse/MDS Coordinator. The surveyor asked EI #1 was RI #47 coded on the 01/24/18 Quarterly MDS assessment as receiving an anticoagulant. EI #1 said yes. When asked what anticoagulant medication RI #47 was receiving, EI #1 said [MEDICATION NAME]. Initially EI #1 said RI #47's [MEDICATION NAME] should be coded as an anticoagulant, but after reviewing the RAI (Resident Assessment Instrument) Manual, EI #1 said, [MEDICATION NAME] should not be coded as an anticoagulant. The surveyor asked EI #1 was RI #47's 01/24/18, Quarterly MDS assessment coded accurately under the Anticoagulant section. EI #1 replied, no.

Based on interviews, record review and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure: (1) Resident Identifier (RI) #17 was care planned for the use of a diuretic medication, [MEDICATION NAME]; and (2) RI #47 was care planned for the use of an IV (Intravenous) medication, [MEDICATION NAME], and the medications Aspirin and [MEDICATION NAME]. These deficient practices affected RI #17 and #47, two of 27 sampled residents whose plans of care were reviewed. Findings Include: Review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, with a reviewed date of 03/18, documented: POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the disciplinary team will provide care. RESPONSIBILITY: All members of the Interdisciplinary Team . Comprehensive Person Centered Care Plan (CCP) - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines . Instant Care Plan - utilized with a change in resident condition not addressed on the comprehensive care plan . PR[NAME]EDURE: . 5. For each problem, need, strength a resident-centered goal is developed . 6. Staff approaches are to be developed for each problem/strength/need . 1) RI #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/18/17, revealed RI #17 was receiving a Diuretic medication. RI #17's (MONTH) (YEAR) Physician order [REDACTED]. On 03/22/18 at 1:58 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the MDS Coordinator. The surveyor asked EI #1 was RI #17 receiving a Diuretic medication. EI #1 said yes. The surveyor asked EI #1 was RI #17 care planned for the use of the Diuretic medication. EI #1 said no. When asked should a care plan have been developed for the use of the Diuretic medication, EI #1 replied, yes. 2) RI #47 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #47's (MONTH) (YEAR) Physician order [REDACTED]. 03/22/18 at 10:40 a.m., the surveyor conducted an interview with EI #2, the Registered Nurse Unit Manager for the unit RI #47 resided on. The surveyor asked EI #2 was RI #47 receiving an IV antibiotic. EI #2 said yes. EI #2 said RI #47 was receiving [MEDICATION NAME] 80 mg/100 ml (milliliter) once a day. When asked how long RI #47 had been receiving the IV antibiotic, EI #2 said RI #47 begin the IV medication on 03/18/18. The surveyor asked EI #2 was RI #47 care planned for the use of the IV antibiotic. EI #2 replied, no she did not see where RI #47 had a care plan for the antibiotic. The surveyor asked EI #2 should RI #47 be care planned for the use of the antibiotic. EI #2 said yes. When asked who would be responsible for ensuring the care plan was initiated. EI #2 said it would have been her. On 03/22/18 at 1:35 p.m., the surveyor conducted an interview with EI #1, the MDS Coordinator. The surveyor asked EI #1 was RI #47 care planned for the use of the Aspirin and [MEDICATION NAME]. EI #1 said no. When asked should RI #47 be care planned for the Aspirin and [MEDICATION NAME], EI #2 said yes. The surveyor asked EI #1 what was the purpose of having a plan of care. EI #2 replied, to make sure there is coordinated care.

Based on observation, interview and review of facility policy Resident Call System, the facility failed to ensure a functioning call system in resident bathrooms and bathing facility/shower rooms. This was observed on three days of the survey and affected Room Locator (RL) #'s 1, 3 and 4; three of four units in the facility. This deficient practice was cited as a result of the investigation of complaint # AL 331. Findings Includes: A review of facility policy Resident Call System with an effective date of 9/17 revealed: POLICY: The call system will provide a communication system to assist with resident needs.PR(NAME)EDURE: The facility will have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call to a staff member or to a centralized staff work area from resident care areas. On 9/12/17 from 3:30 p.m. until 4:00 p.m., the call system was observed not functioning in resident rooms at RL #1, residents were observed with individual hand bells. There was no call system available in RL #1's bathrooms. There was no call system available in RL #1's shower rooms. On 9/12/17 from 4:15 p.m. until 4:30 p.m., the call system was observed not functioning in resident rooms at RL #2, residents were observed with individual hand bells. There was no call system available in RL #2's bathrooms. There was no call system available in RL #2's shower rooms. On 9/12/17 from 5:00 p.m. until 5:15 p.m., the call system was observed not functioning in resident rooms at RL #3, residents were observed with individual hand bells. There was no call system available in RL #3's bathrooms. There was no call system available in RL #3's shower rooms. On 9/13/17 at 10:00 a.m., the call system was observed not functioning at RL #1, RL #2 and RL #3, residents were observed with individual hand bells. There was no call system available in RL #1, RL #2 and RL #3's bathrooms or shower rooms. On 9/14/17 at 10:00 a.m., the call system was observed not functioning at RL #1, RL #2 and RL #3, residents were observed with individual hand bells. There was no call system available in RL #1, RL #2 and RL #3's bathrooms or shower rooms. On 9/12/17 at 5:20 p.m., a brief interview was conducted with Employee Identifier (EI) #1, Executive Director. EI #1 was asked if there was a problem with the call system. EI #1 replied, yes the call system was hit by lightening, the residents have hand call bells. EI #1 was asked if all rooms were affected. EI #1 replied, no only RL #1, RL #2 and RL #3. EI #1 was asked how residents were calling for assistance. EI #1 replied, residents ring their bells. On 9/14/17 at 9:30 a.m., an interview was conducted with EI #2, Director of Nursing. EI #2 was asked if the call system was currently working. EI #2 replied, only on the 200 hall. It was not working on RL #1, RL #2 and RL #3. EI #2 was asked what system was currently used. EI #2 replied,residents had hand bells. EI #2 was asked if there should be a call system in resident bathrooms. EI #2 replied, she imagined so. EI #2 was asked if there should be a call system in the shower rooms. EI #2 replied, yes, however, none of the residents go to the shower unattended. On 9/14/17 at 10:00 a.m., an interview was conducted with EI #1, Executive Director; she was asked when did the call system go out. EI #1 replied, September 1, 2017 it was hit by lightening, the Assistant Director of Nursing was working, she notified EI #1 and an immediate plan was placed with the individual hand bells. EI #1 was asked what call system was used in residents bathrooms and shower rooms. EI #1 replied, other than the every 15 minute room check, there was not one. EI #1 was asked if there was a functioning communication system in resident bathrooms and shower rooms which residents call and were answered by. EI #1 replied no. EI #1 was asked what was in place to aid with the system not working . EI #1 replied, there was an every 15 minute round check in place. EI #1 was asked what units were affected. EI #1 replied, RL #1, RL #2 and RL #3. EI #1 was asked what was staff doing about no call system in residents bathrooms and shower rooms, if there was a situation and they needed to alert other staff. EI #1 replied, there was nothing in place. EI #1 was asked what the harm was in the call system not functioning. EI #1 replied, if a resident was to need help and the staff did not hear them.

Based on observation, interviews, record review and review of facility form INCONTINENT CARE COMPETENCY AUDIT, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands between glove changes and did not use gloves she took from her pocket to complete incontinent care for Resident Identifier (RI) #7. Incontinent care was observed as a result of the investigation of complaint # AL 331. This affected one of two residents observed for incontinent care. Findings Include: A review of facility policy INCONTINENT CARE COMPETENCY AUDIT Perineal (Skin) Care for Incontinent Resident with an effective date of 11/10 revealed: .PR(NAME)EDURE .9. Discard soiled gloves, wash hands and re-glove. RI #7 was admitted to the facility 6/19/13 and readmitted [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Quarterly Minimum Data Set with an Assessment Reference Date of 7/26/17 revealed RI #7 was totally dependent for toilet use. On 9/13/17 at 2:00 p.m., Employee Identifier (EI) #5, CNA was observed providing incontinent care for RI #7. EI #5 cleaned RI #7's buttocks area then removed her gloves and put on a clean pair of gloves. EI #5 did not wash her hands between glove changing. EI #5 then placed a clean brief, removed her gloves and put on a pair she removed from her uniform pocket. EI #5 used gloves she had in her uniform pocket and again did not wash her hands between changing gloves. On 9/13/17 at 2:40 p.m., an interview was conducted with EI #5. EI #5 was asked when should she wash her hands during incontinent care. EI #5 replied after cleaning dirty and when she changed gloves. EI #5 was asked if she washed her hands between glove changes. EI #5 replied no. EI #5 was asked if she took gloves from her uniform pocket . EI #5 replied yes. EI #5 was asked if gloves from her pocket were clean or dirty. EI #5 replied dirty. EI #5 was asked why were gloves from her pocket dirty. EI #5 replied because her uniform was dirty. EI #5 was asked what the harm was in not washing her hands between changing gloves. EI #5 replied contamination. EI #5 was asked what the harm was in using gloves from her pocket. EI #5 replied contamination. On 9/14/17 at 4:15 p.m., an interview was conducted with EI #4, Infection Control Nurse. EI #4 was asked when should staff wash hands during the provision of incontinent care. EI #4 replied when they start, after handling soiled, between glove changes and once completed. EI #4 was asked if staff should wash hands between glove changes. EI #4 replied yes. EI #4 was asked if staff should use gloves from their pocket. EI #4 replied no, never, once gloves are in their pocket they become contaminated. EI #4 was asked what was the potential harm in staff not washing hands between glove changes and using gloves from their uniform pocket. EI #4 replied contamination.

Based on record reviews, observations and interviews, the facility failed to ensure: 1) A staff member washed their hands after touching the lid on a trash can with bare hands, 2) food items on the tray line were documented and 3) two bags of chicken wings in the freezer were labeled. This had the potential to affect 64 of 83 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Glove and Hand Washing Procedures with no revised date revealed: Guideline: All employees will use proper hand washing procedure and glove usage in accordance with State and Federal Sanitation Guideline: Procedures: . 6. Hands are washed before donning gloves and after removing gloves . On 1/31/2017 at 5:00 p.m., the surveyor observed the evening tray line meal. The cook, (Employee Identifier) EI #4 pulled off the gloves she was wearing and lifted the lid on the trash can with her bare hands. She put on long pot holder gloves and went to the steamer to remove a pan of regular ham. She never stopped to wash her hands at any point before placing the ham on the steam table. On 2/2/2017 at 2:53 p.m., an interview was conducted with EI #4. EI #4 was asked when should she wash her hands. EI #4 replied, everytime she walked away from where she was. EI #4 was asked why should she wash her hands. EI #4 replied, because she could get stuff on her hands. EI #4 was asked should she have washed her hands after touching the lid on a trash can. EI #4 replied, yes ma'am. EI #4 was asked what was the facility policy on handwashing. EI #4 replied, wash hands everytime they leave somewhere going to somewhere else. EI #4 was asked did she wash her hands when pulling off her gloves and dumping her gloves into the trash. EI #4 replied, she did not. EI #4 was asked what was the potential harm in not washing her hands after touching the trash lid. EI #4 replied, she could give someone germs or make them sick, especially touching the trash lid. On 2/2/2017 at 3:22 p.m., an interview was conducted with EI #3, dietary manager. EI #3 was asked when should she wash her hands. EI #3 replied, when you enter the kitchen. EI #3 was asked why should she wash her hands. EI #3 replied, to cut down germs and bacteria that may be on your hands. EI #3 was asked what was the facility policy on handwashing. EI #3 replied, when you start your job, wet your hands and arms, use soap vigorous for 20 second. She continue to explain dry hands and use towel to turn the water off. EI #3 further said everytime you do something different you should wash your hands. EI #3 was asked what was the potential harm in not washing your hands after touching the lid of a trash can. EI #3 replied, contamination of hands, contamination of food, and contamination to the person served. 2) A review of a policy titled, Monitoring Food Temperatures for Meal Service with no revised date revealed: .Procedure: 1. Food temperature will be taken and recorded for all hot and cold foods prior to service . A review of another document titled, Production Sheet .2016-17 with a list of foods that was served the evening of 1/31/2017. The only food items that was recorded for the evening meal was the milk and dessert. On 1/31/2017 at 4:15 p.m., the surveyor observed the cook taking temperatures of the food on the tray line. She took the temperatures of the regular food and alternate food for that evening. She did not write any of the food temperatures down on the temperature log sheet. On 2/2/2017 at 2:59 p.m., the surveyor conducted an interview with EI #4. EI #4 was asked when did she write the food temperatures down when tempting food on the tray line on 1/31/2017. EI #4 replied, she did not. EI #4 was asked why not. EI #4 replied, she was nervous. EI #4 was asked what does the facility policy say about writing food temperatures down. EI #4 replied, check it and write it down. EI #4 was asked when should she write down food temperatures. EI #4 replied, when you put it on the tray line, check tempts, and write it down. EI #4 was asked why should food temperatures be written down. EI #4 replied, so she would know food was cooked at the right temperature. 3) A review of a policy titled, Date Marking with no revised date revealed: .Procedure: .3. Date marking for freezer storage food items .once a package is opened, it will be re-dated with the use by or discard date . On 1/31/2017 at 1:30 p.m., the surveyor along with the dietary manager toured the freezer. There was a large and medium bags of chicken wings in the freezer with no identifying information on the bags. There was no open date or a use by date on the bags. There was no label on the bag identifying what was in the bag. One bag had ice crystal around the chicken. On 2/2/2017 at 3:09 p.m., an interview was conducted with EI #3. EI #3 was asked what food items in the freezer did not have an open date or use by date on it. EI #3 replied, chicken wings. EI #3 was asked why was there no dates on it. EI #3 replied, there was no reason why it was like that. EI #3 was asked who was responsible for dating items once opened. EI #3 replied, each employee who used it. EI #3 was asked what was the facility policy in opening food items and dating them. EI #3 replied, all open items must have the name of the product, and a use by date. EI #3 was asked to describe what was in the bags of chicken wings. EI #3 replied, one bag of chicken wings looked like it had formed water crystal on it, and did not have a label on it. EI #3 was asked what was the potential harm when there was no use by date on food items. EI #3 replied, you would not know how long the food had being in there and putting a label on everything protects the resident from getting old food.

Based on observation, interview and record review, the facility failed to ensure a licensed staff member pulled the privacy curtain when performing a blood glucose finger stick and administering an insulin injection to RI (Resident Identifier) #1 on 02/01/2017. RI #1's roommate was present in the room. This deficient practice affected one of six residents observed during medication administration. The facility further failed to ensure a CNA (Certified Nursing Assistant) pulled the privacy curtain during the incontinent care of RI #4 on 02/01/2017, with the roommate in the next bed. This affected one of one sampled residents observed during incontinent care. Findings Include: 1) A review of a facility policy titled, INSULIN INJECTIONS with a date of 01/2015 revealed: .PROCEDURE: .4. Identify the resident and maintain privacy. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent 14-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/20/2016, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 6, which indicated the resident was severely impaired for daily decision making. On 02/01/2017 at 11:35 A.M., EI (Employee Identifier) #6, LPN (Licensed Practical Nurse) was observed performing medication administration. EI #6 entered RI #1's room and performed a blood sugar finger stick on RI #1 without pulling the privacy curtain. RI #1's roommate was present in the room sitting in the wheelchair looking at the nurse perform the finger stick. EI #6 exited the room and prepared an insulin injection for RI #1. EI #6 re-entered RI #1's room and administered the insulin injection to the back of RI #1's upper left arm. EI #6 did not pull the privacy curtain. RI #1's roommate was present in the room sitting in the wheelchair looking at the nurse administer the insulin injection to RI #1. On 02/01/2017 at 6:00 P.M., an interview was conducted with EI #6. EI #6 was asked what she should have done when she gave RI #1 an insulin injection and the roommate was present in the room. EI #6 said to pull the privacy curtain. EI #6 was asked what she should have done when she pricked RI #1's finger and the roommate was present in the room. EI #6 said to pull the privacy curtain. EI #6 was asked if she pulled the privacy curtain. EI #6 said no. EI #6 was asked why she did not pull the privacy curtain. EI #6 said she forgot. EI #6 was asked what the potential harm was in not pulling the privacy curtain when pricking RI #1's finger. EI #6 said feeling exposed. EI #6 was asked what the potential harm was in not pulling the privacy curtain when administering an insulin injection and the roommate was present. EI #6 said the resident could feel like they were under a microscope and exposed. 2) A review of a facility policy titled, INCONTINENT CARE with a date of 07/2012, revealed: .PROCEDURE: . 6. Provide privacy. 9. Avoid unnecessary exposure of the resident during the procedure. RI #4 was re-admitted to the facility on [DATE]. A review of RI #4's most recent Quarterly MDS with an ARD of 12/02/2016 revealed the resident was severely impaired for daily decision making and was always incontinent bowel and bladder. On 02/01/2017 at 4:48 P.M., EI #8, CNA, was observed performing incontinent care for RI #4. EI #8 pulled RI #4's brief down and performed front perineal incontinent care. RI #4's roommate was in the room in the next bed. EI #8 did not pull the privacy curtain. EI #8 rolled RI #4 on the right side with the buttocks exposed and facing toward the roommate in bed. EI #8 performed incontinent care on the resident's buttocks. EI #8 walked away from the bed, leaving RI #4's buttocks uncovered and exposed as she went into the bathroom to wash her hands. On 02/01/2017 at 5:01 P.M., an interview was conducted with EI #8. EI #8 was asked if she pulled the privacy curtain during RI #4's incontinent care. EI #8 said, No ma'am. EI #8 was asked if she should have pulled the privacy curtain. EI #8 said, Yes ma'am. EI #8 was asked why she did not pull the privacy curtain. EI #8 said, It slipped my mind. EI #8 was asked what part of RI #4's body was exposed when she went to wash her hands and came back to bed. EI #8 said, RI #4's bottom was showing. EI #8 was asked what the potential harm was in not pulling the privacy curtain and leaving RI #4's buttocks exposed during incontinent care. EI #8 said the resident may feel embarrassed and mad.

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency within 24 hours. Resident Identifier (RI) #1, an alert resident, reported to facility staff on 01/28/2014, then RI #1 reported the allegation to two Hospice Certified Nursing Assistants (CNAs) on 01/29/2015 that a CNA thumped his penis during care on the evening of 01/28/2015. Even though several facility staff member (CNAs, Licensed Practical Nurse (LPN) Charge Nurse, Director of Nursing Services (DNS) and Administrator) were aware of RI #1's allegation, the facility failed to report RI #1's allegation to the State Agency. Furthermore, the facility failed to suspend EI #3, the CNA who RI #1 alleged "thumped" his penis, pending the completion of the investigation to protect RI #1, from any further potential abuse. EI #3 continued to care for RI #1 during the remainder of the shift and to work her assigned schedule. This deficient practice placed RI #1, one of two residents sampled for review of abuse allegations, in immediate jeopardy as it was likely to cause serious injury, harm, or death. On 02/20/2015 at 4:15 PM, the Administrator and Director of Nursing were notified of the Immediate Jeopardy in the area of Resident Behavior and Facility Practices at F225. The Immediate Jeopardy began on 01/28/2015 until the facility implemented immediate corrective actions on 02/22/2015 at 12:06 PM. The scope and severity was lowered to a "D" level to allow the facility time to monitor and if necessary revise their corrective actions to achieve substantial compliance. Findings Include: On 02/12/2015 the State Agency received an anonymous complaint that on 01/28/2015, a resident of Elba Nursing and Rehabilitation Center complained to their Hospice aide that a specific CNA assigned to RI #1 thumped his penis and the resident asked the CNA to stop. The Hospice CNA reported the issue to the DNS on 01/28/2015. Review of the facility's undated policy titled "Abuse Prevention" revealed the following: "... SUBJECT: ABUSE PREVENTION POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff... Definitions: ... c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault. d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking... PROCEDURE: A. STEPS TO PREVENT, DETECT AND REPORT... PREVENTION: 1. Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse... When an incident of resident abuse is suspected or determined, such incident must be reported to facility management... Reporting procedures should be followed as outlined in this policy... IDENTIFICATION: ... 2. The Executive Director (Administrator) and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Executive Director and Director of Nursing Services must be called at home or must be paged and informed of such incident... INVESTIGATION: The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Executive Director, or designee, will report any allegation of abuse, neglect... PROTECTION: 1. Any allegation of abuse or neglect against any employee must result in his/her immediate suspension to protect the resident. 2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and / or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of a crime... In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency..." RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the Entrance Conference on 02/17/2015 at 12:45 PM with Employee Identifier (EI) #1, the Administrator, the surveyors requested all abuse investigations since the facility's last survey on 11/14/2014. At 1:15 PM the Administrator provided 6 investigative files and stated that was all of the "[MEDICATION NAME]" he had. "[MEDICATION NAME]" are investigative files the facility has investigated and reported to the State Agency. Since no file was noted for RI #1, the surveyors asked for all investigations of abuse, whether reported to the State Agency or not. The Administrator provided the investigative file for RI #1's allegation of abuse on 02/17/2015 at 1:55 PM and stated two statements were not included because the nurse failed to write one and one of the CNAs in the room had not provided one. The investigative file contained the following: 1. A Resident Incident Report 2. An undated typed narrative signed by the Administrator 3. An interview with RI #1 dated 01/29/2015 signed by the Administrator 4. An interview with RI #1's son dated 01/30/2015 signed by the Administrator 5. A second interview with RI #1 dated 01/30/2015 noting the DNS, ED, and Social Services Director (SSD) were present during the interview (unsigned) 6. A signed statement by EI #6 (CNA assigned to RI #1 on 01/29/2015) dated 01/29/2015 7. RI #1's Quarterly Minimum (MDS) data set [DATE] 8. A signed statement from EI #3(the CNA RI #1 alleged thumped his penis and laughed about it during care) dated 01/30/2015 9. An interview with RI #1's roommate dated 01/30/2015 signed by the Director of Nursing Review of the facility's investigation revealed there was no evidence the two Hospice Aides, who RI #1 made the allegation thumped his penis during care, had been interviewed. There were no statements from EI #4, one of the CNAs present in RI #1's room when RI #1 alleged EI #3 thumped his penis. There were no statements from the LPNs who were assigned to care for RI #1 on 01/28 and 01/29. There were no interviews with other staff working from 01/28-01/29/2015 or residents on RI #1's unit. The Resident Incident Report documented the following: "... Date/Time: 1/28/15 05:30 PM... Narrative of incident and description of injuries: Hospice staff reported to DNS (Director of Nursing Services) on 1-29-2015 @ (at) 1:00pm that (RI #1) had made some statements to them while they were providing care to him they thought she should be aware of. They stated that he told them that there several "girls" in his room the evening before that were bathing him and one of them "flicked" in penis with her finger then laughed about it. He also said she did it several times and they all laughed..." The typed narrative was a summary of events signed by EI #1, the Administrator, which referenced conversations with Hospice staff, EI #4 (one of the 2 CNAs), and EI #2 (LPN). EI #1's narrative documented the following explanation as to why RI #1's statement was not reported to the State Agency: "... The decision to not report the incident was made based on interview and review of collected information, which indicate the events were distorted due to his dementia..." Review of the time sheet for EI #3, the CNA RI #1 alleged thumped his penis, revealed she worked on 01/28/2015, the date of the alleged incident, from 2:09 PM until 9:40 PM. EI #3 continued to work the remainder of her shift. The Staffing Plans for January and February 2015 indicated EI #3 continued to work in the facility. During an interview on 02/19/2015 at 8:42 AM, the surveyor asked RI #1 how staff treated him. RI #1 stated, "OK except this one girl who works here. She messed with my privates. She was cleaning me and she thumped me on the privates (pointing to penis). I told her to stop and she went to get a cloth and came back and thumped it again and laughed..." RI #1 further stated he became upset and told her not to do it again. RI #1 said he reported the incident to the nurse and everyone who would listen. A follow-up interview was conducted with RI #1 on 02/20/2015 at 9:45 AM. When asked what he meant when he said the girl thumped his privates, RI #1 demonstrated what he saw the girl do to his penis by gesturing with his hand using his middle finger and thumb and made a thumping/flicking motion. When asked what it felt like, RI #1 stated it was an "awful feeling" and that area is sensitive. RI #1 added, "It hurt like the dickens." When asked who was in the room, RI #1 said people were coming and going, trays were being passed, and they were checking and changing him because he wears a brief. RI #1 said he was just about to have supper and his Hospice Nurse had just left, when the girl came in his room. RI #1 explained the staff joke and tease and he jokes and teases back but, "You don't touch the privates like that. Not a joke." EI #3, the CNA who RI #1 alleged thumped his penis during care on 01/28/2015, was interviewed on 02/18/2015 at 4:20 PM. When asked about the incident with RI #1, EI #3 stated it was on the 28th while getting RI #1 ready for bed, RI #1 said they were hurting him. EI #3 explained RI #1 stated she had "thumped his pecker (penis)". EI #3 said she went to get EI #2, the LPN, and told her what RI #1 had alleged. EI #3 said she felt this would be considered an allegation of abuse. EI #4, the other CNA assigned to care for RI #1 on 01/28/2015, was interviewed on 02/18/2015 at 6:08 PM. When asked what she recalled about the incident at the end of January regarding RI #1, EI #4 stated that while she and EI #3 were providing incontinent care to RI #1, EI #3 was laughing with RI #1 at the things he was saying and RI #1 was getting irritated. EI #4 explained that at the end of care, RI #1 stated EI #3 had "thumped his pecker". EI #4 stated that when EI #2, the LPN, came into the room, RI #1 stated something about "busting" his penis. When asked who she discussed RI #1's allegation with, EI #4 said she and EI #3 had been called into the Director of Nursing Services' (DNS) office together about the incident. EI #4 said that she had informed the DNS that RI #1 had alleged to the LPN the CNAs had "busted his pecker". EI #4 said that the DNS and Administrator then tried to correct her, but she stated she did not recall him saying anything about his leg. On 02/17/2015 at 3:07 PM, during an interview with EI #2, the LPN Charge Nurse who cared for RI #1 on 01/28/2015, EI #2 denied any knowledge of RI #1 alleging the CNA had thumped his penis. EI #2 said that at about 6:00 PM on 01/28/2015 the CNAs had asked her to come into RI #1's room because he was talking and acting out. Hospice Aide #1 was interviewed on 02/17/2015 at 1:28 PM. The Hospice staff recalled, while she and Hospice Aide #2 were in RI #1's room on the morning of 01/29/2015, the resident stated he hoped they (the facility) got rid of the girl who had thumped his "balls". The Hospice Aide said they notified the nurse on the hall (EI #5). Hospice Aide #1 said she did not feel the nurse took the statement seriously because of RI #1's dementia. She further stated that after she informed EI #5 of RI #1's allegation, EI #5 laughed, so she reported the allegation to the Director of Nursing, EI #7. When asked what types of things were considered allegations of abuse, the Hospice Aide stated that in this case, she felt it would be sexual abuse. In a follow-up interview on 02/20/2015 at 9:56 AM, Hospice Aide #1 was asked what she and Hospice Aide #2 reported to the DNS. Hospice Aide #1 stated she and Hospice Aide #2 reported exactly what the resident said, that a dark headed girl on evening shift had come in and thumped him on his penis while changing him. Hospice Aide #2 was interviewed on 02/17/2015 at 1:40 PM. She explained while she and Hospice Aide #1 were bathing RI #1 the resident told them about the girl from the night before. RI #1 alleged that the girl had been "flicking" his penis. Hospice Aide #2 notified EI #5, LPN, who stated RI #1 had dementia, so they had notified EI #7, the DNS. When asked what she considered abuse, she replied, "Playing around with somebody's penis, I think that is abuse." Hospice Aide #2 further stated she felt like it would be sexual abuse. In a follow-up interview with Hospice Aide #2, on 02/20/2015 at 9:05 AM, the surveyor asked what had been discussed with the Director of Nursing (DNS) about RI #1's allegation. The Hospice Aide stated they (Hospice Aide #1 and #2) told the DNS a CNA from the night before had thumped RI #1 on his penis. EI #6, the CNA caring for RI #1 the morning on 01/29/2015, was interviewed on 02/19/2015 at 9:20 AM. When asked what knowledge she had of the incident with RI #1 at the end of January, EI #6 stated she was providing care to RI #1 on the morning of 01/29/2015 at about 10:00 AM. RI #1 told her one of the CNAs from the night before had thumped his penis more than once. EI #6 notified EI #5, the LPN Charge Nurse, and EI #8, the Social Services Worker, because she considered the statement an allegation of abuse. EI #5, the LPN Charge Nurse who EI #6 reported RI #1's allegation to on 01/29/2015, was interviewed on 02/18/2015 at 3:30 PM. When asked what she recalled about an incident at the end of January when the Hospice Aides asked her to come into RI #1's room, she stated that RI #1 said there was someone in dark blue at night that thumped his penis. EI #5 stated she notified EI #8, the Social Services Worker. EI #5 stated it was hers to report but felt like if the Hospice Aides were concerned why were they referring it to her. EI #5 further stated she was confused because she thought the Hospice Nurse had been made aware. When asked if it would be the Hospice Nurse's responsibility, EI #5 stated no. EI #5 also stated, "I know it is my responsibility..." When asked what had been done to protect the resident when she became aware of his abuse allegation, EI #5 stated nothing had been done because she did not know if there was a reason to protect him. EI #9, the Social Services Director, was interviewed on 02/19/2015 at 9:45 AM. When asked what involvement she had with RI #1's incident at the end of January, EI #9 explained she had been off at the time of the allegation, but after returning she and the Administrator and Director of Nursing interviewed RI #1 together about the incident. According to EI #9, RI #1 alleged a CNA pulled his brief down and thumped the end of his penis then went behind the curtain, came back and did it again. EI #9 stated she would consider RI #1's statement of someone thumping his penis an allegation of abuse but stated it was not her decision to make. When asked whose decision it was, EI #9 stated the Administrator and a team consisting of herself and the DNS. When asked which allegations of abuse should be reported to the state, EI #9 stated she would have reported this. When asked why it was important to report allegations of abuse, EI #9 stated for the safety of the resident as well as others. When asked what should be done if a resident accuses a staff member of abuse, EI #9 stated the staff member should be suspended pending the outcome of the investigation to prevent them from doing it again or doing something to another resident. On 02/20/2015 at 5:55 PM, the Hospice Social Worker was interviewed. When asked what knowledge she had of an incident involving RI #1 at the end of January, she stated the Hospice Chaplain visited RI #1. During the visit the resident reported to the Hospice Chaplain that a CNA at the facility had inappropriately touched him. The Chaplain was uncertain of what had occurred and what was being done. He expressed his concern about how upset RI #1 was. The Hospice Social Worker went to the facility and performed a Mini Mental Assessment on RI #1 that indicated moderate cognitive impairment. However, the Hospice Social Worker said that RI #1 was alert and oriented to events. The Hospice Social Worker further explained RI #1 was very consistent in telling the events that more than one person had been in his room but only one had touched his penis. When asked if she felt RI #1's statements were reportable, the Social Worker said yes. The Social Worker explained, when she spoke with the Administrator, he informed her that he had decided not to report the incident due to RI #1's mental status and dementia. EI #7, the Director of Nursing Services, was interviewed on 02/19/2015 at 10:50 AM. When asked which allegations of abuse should be reported to the State Agency, EI #7 stated if there is reasonable suspicion that something had occurred, it should be reported. When asked what she meant by "reasonable suspicion", EI #7 explained that if after initiating your investigation and it is determined within 24 hours that something has occurred, it is reported. EI #7 considered an allegation of abuse anything that could make a resident feel threatened. When asked what the regulation stated, EI #7 read the regulation and stated she thought that because State was getting so many reports the facility had 24 hours to investigate before reporting. The surveyor asked EI #7 if the facility became aware of RI #1's allegation at approximately 1:00 PM on 01/29/2015 and began interviewing CNAs on 01/30/2015, how did they determine the incident was not reportable. EI #7 did not know. EI #7 agreed the statement RI #1 made that someone thumping his penis was an allegation of abuse. When asked why it was important to report allegations of abuse, EI #7 stated to protect your residents. EI #7 explained that after an allegation of abuse, steps should be taken to protect the resident. When asked how the resident should be protected, EI #7 stated it could involve suspension or reassigning the alleged employee. When asked what the facility's policy said regarding employees accused of abuse, EI #7 again stated suspend or reassign. The surveyor then provided a copy of the facility Abuse Prevention Policy for EI #7 to review. After reviewing the facility's Abuse Policy, EI #7 stated the policy said the employee should immediately be suspended. When asked if EI #3 had been suspended, EI #7 said EI #3 was reassigned. EI #1, the Administrator/Abuse Coordinator, was interviewed on 02/19/2015 at 2:00 PM. When asked about the facility's policy and procedure when a resident alleges abuse, EI #1 stated it would have to be determined if it was reportable or not. When asked how it was determined if an allegation of abuse was reportable, EI #1 explained how each case was different. He based his decision not to report RI #1's allegation on the fact that things kept changing. EI #1 also stated RI #1's cognitive status played a role in his decision. EI #1 felt the allegation was an exacerbation of RI #1's dementia. When asked if a resident with dementia could still be abused, EI #1 said yes. When asked what demographic of residents was most highly abused, EI #1 stated dementia residents. When asked what is considered an allegation of abuse, EI #1 stated somebody doing willful infliction of abuse with intent behind it. When asked if RI #1 stating a CNA had thumped his penis would be an allegation of abuse, EI #1 said, "Again I have to say I have to measure what he is saying based on his mental status and the circumstances." EI #1 further stated, "I do not want to call this an allegation because this is him (RI#1)." The surveyor again stated RI #1 claimed someone thumped him on his penis and asked if that was an allegation of abuse. EI #1 replied that it would have been different if it had been a cognitively intact resident and would have been reported. When asked what the facility policy said about reporting allegations of abuse, EI #1 stated it should mirror the regulation and if there is an allegation it should be reported within 24 hours. The surveyor then asked if RI #1's allegation should have been reported. EI #1 stated he still felt he had made the right decision in not reporting. The surveyor again asked what the policy stated. EI #1 then read the following from the "PROTECTION" section of the facility abuse policy: "...2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be reported... as required by state guidelines..." When asked if that mirrored the regulation, EI #1 stated it was worded "kind of weird" and was confusing. He then stated that in another section it said to report any allegation. The surveyor asked EI #1 if the facility became aware of RI #1's allegation at approximately 1:00 PM on 01/29/2015 and began interviewing CNAs on 01/30/2015, how did they determine the incident was not reportable. EI #1 stated that after talking with some staff and the resident, he felt the story was different every time, which made it less credible. EI #1 then clarified by stating that in dealing with RI #1 and knowing the accused staff member had no history of problems, he just did not believe it had occurred. When asked again what the regulation specified, EI #1 stated, "That you have to report reasonable suspicions of allegations of abuse. " EI #1 then added that he was "having a very hard time with this". When asked if the regulation had been followed, EI #1 said no, not for reporting. When asked about the facility's policy when a resident alleges abuse, EI #1 stated the priority is to protect the resident from anything further. When asked what steps are taken to protect the resident during an investigation, EI #1 stated in most cases he would suspend the employee until a determination is made. The surveyor then asked which situations would not require the employee to be suspended. EI #1 stated this one, referring to RI #1's allegation. EI #1 stated there were circumstances that influenced his decision not to suspend the employee. When asked what those circumstances were, EI #1 stated RI #1's cognitive status played a role in his decision. EI #1 further explained that after talking to RI #1, he determined RI #1 was referring to EI #3, the CNA. EI #1 said that after determining who the perpetrator was, the facility relied on the policy to make a decision as to how to protect the resident. When asked what the facility policy said regarding protection of the resident, EI #1 stated it said to suspend the alleged employee. EI #1 was asked what was done to protect RI #1 following his allegation of abuse. EI #1 stated he reviewed the staffing plan and determined EI #3 was scheduled to be off on 01/29 and came back on 01/30. EI #1 further stated EI #3 had been reassigned upon her return to eliminate any stress to RI #1 or EI #3. When asked why it was important to suspend the alleged employee, EI #1 stated it was a means of protecting the resident. When asked if EI #3 had been suspended, EI #1 said no. This deficiency was cited as a result of the investigation of complaint/report #AL 782. ************************************ Allegation of Compliance (AoC) F225 On 02/21/2015 at 4:05 PM, the surveyors notified the Administrator and Clinical Operations Consultant that the AoC had been accepted. The AoC documented the following: "Allegation of Compliance for Elba Nursing and Rehabilitation F225 On 2/20/15 at 11:56 pm the facility reported to Alabama Department of Public Health (ADPH) an allegation of abuse on RI #1. On 2/20/15 the facility reopened the investigation alleging abuse of RI #1 to include interviews with staff that worked on 1/28/15,1/29/15, including any hospice staff. Facility staff consists of nursing, dietary, therapy, activity, housekeeping/laundry and maintenance. Facility is conducting these interviews seeking to ascertain any knowledge regarding the alleged abuse of RI #1. Facility employees, therapy staff and hospice staff interviews consist of probing questions specific to the alleged event. As of 2/21/15 both CNAs and the Licensed Practical Nurse who were in RI #1's room were suspended pending outcome of the investigation. As of 2/21/15 the hospice nurse was advised that she is not to return to the facility pending outcome of the investigation. As of 2/21/15 a Clinical Consultant in serviced all department heads on reporting and understanding abuse. The facility in serviced noted the following will be reported: all alleged abuse, verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, misappropriation of resident property and involuntary seclusion. This reporting to the state agency will occur within 24 hours of the incident on line. A written report to the state agency will occur within 5 working days. An allegation of abuse is defined as a statement or claim that someone has been abused. Abuse is defined as the willful of infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This in service notes staff will initiate an investigation at the time of finding any alleged abuse or neglect. Any allegation of abuse or neglect against anyone must result in his immediate suspension to protect the resident. Reporting and understanding abuse consist of residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, corporal punishment, involuntary seclusion, and implementing these procedures. Department Heads initiated an in-service to all other facility staff on the same information. This in service also consisted of F223, F224, F225, and F226. No staff will be allowed to work until they have in-serviced. Any newly hired employees will be in-serviced upon hire. As of 2/20/15 a Clinical Consultant in serviced all Quality Assurance Team on the Employee Questionnaire. This questionnaire is to ascertain whether staff are aware of any allegations of abuse or neglect. On 2/20/15 the Employee Questionnaire was initiated by the Quality Assurance Team. No staff will be allowed to work until they have completed the questionnaire. Any newly hired employees will complete the questionnaire. On 2/20/15 Human Resources (HR) verified all active employees against the abuse registry. No adverse results were found." ****************************************** After receiving an acceptable AoC on 02/21/2015 at 4:05 PM, various staff members including Housekeeping, CNAs, LPNs, RNs, the Business Office Manager, Business Office Assistant, Director of Admissions, DNS, and the Administrator were interviewed regarding the definition of an allegation of abuse, investigating and reporting allegations of abuse. Abuse Registry checks on all current facility staff were reviewed and no adverse findings were noted. The documentation of the report to ADPH was reviewed, as well as the progress on the re-investigation of RI #1's allegation. The facility provided documentation that involved staff had been suspended pending the outcome of the re-investigation.

Based on interviews and review of facility policy, the facility failed to implement three of seven components of the facility's "Abuse Prevention " policy: Identification, Reporting, and Protection. On 01/28/2015 Resident Identifier (RI) #1, an alert resident, alleged to two facility Certified Nursing Assistants (CNAs), Employee Identifier (EI) #s 3 and 4, that EI #3 thumped his penis during the provision of care on the evening of 01/28/2015. CNAs (EI #s 3 and 4) notified the Licensed Practical Nurse (LPN) Charge Nurse, EI #2, of RI #1's allegation. However, EI #2 failed to document or report RI #1's allegation or initiate suspension of EI #3, the alleged CNA, to protect RI #1 from any further potential abuse in accordance with facility policy. On 01/29/2015 RI #1 repeated the same allegation to two Hospice Aides. The two Hospice Aides reported RI #1's allegation of abuse to EI #7, the Director of Nursing Services (DNS) at approximately 1:00 PM on 01/29/2015, who notified the Administrator/Abuse Coordinator, EI #1, of the allegation. Upon becoming aware of RI #1's allegation, EI #1,the Administrator/Abuse Coordinator, failed to identify RI #1's statement as an allegation of abuse. EI #1 also failed to report the allegation to the State Agency. This deficient practice placed RI #1, one of two residents sampled for review of abuse allegations, in immediate jeopardy as it was likely to cause serious injury, harm, or death. On 02/20/2015 at 4:15 PM, the Administrator and Director of Nursing were notified of the Immediate Jeopardy in the area of Resident Behavior and Facility Practices at F226. The Immediate Jeopardy began on 01/28/2015 until the facility implemented immediate corrective actions on 02/22/2015 at 12:06 PM. The scope and severity was lowered to a " D " level to allow the facility time to monitor and if necessary revise their corrective actions to achieve substantial compliance. Findings Include: Cross reference to F225. On 02/12/2015 the State Agency received an anonymous complaint that on 01/28/2015, a resident of Elba Nursing and Rehabilitation Center (RI #1)complained to their Hospice aide that a specific CNA that was assigned to him thumped his penis and the resident asked the CNA to stop. The Hospice CNA reported the issue to the DNS on 01/28/2015. Review of the facility's undated policy titled "Abuse Prevention" revealed the following: " ... SUBJECT: ABUSE PREVENTION POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff... Definitions: ... c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault. d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking... PROCEDURE: A. STEPS TO PREVENT, DETECT AND REPORT... PREVENTION: 1. Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse... When an incident of resident abuse is suspected or determined, such incident must be reported to facility management... Reporting procedures should be followed as outlined in this policy... 3. Identify, correct, and intervene in situations in which abuse, neglect... Is more likely to occur... IDENTIFICATION: 1. Identify events, such as...patterns, and trends that may constitute abuse... ... 2. The Executive Director (Administrator) and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Executive Director and Director of Nursing Services must be called at home or must be paged and informed of such incident... PROTECTION: 1. Any allegation of abuse or neglect against any employee must result in his/her immediate suspension to protect the resident. 2. Suspected or substantiated cases of resident abuse, neglect, ... or mistreatment shall be ... documented ...reported...as required by state guidelines... " During the Entrance Conference on 02/17/2015 at 12:45 PM with Employee Identifier (EI) #1, the Administrator, the surveyors requested all abuse investigations since the facility's last survey on 11/14/2014. At 1:15 PM the Administrator provided 6 investigative files and stated that was all of the "[MEDICATION NAME]" he had. " [MEDICATION NAME] " are investigative files the facility has investigated and determined a need to report to the State Agency. Since no file was noted for RI #1, the surveyors asked for all investigations of abuse whether reported or not. The Administrator provided the investigative file for RI #1's allegation of abuse on 02/17/2015 at 1:55 PM. The Resident Incident Report documented the following: "... Date/Time: 1/28/15 05:30 PM... Narrative of incident and description of injuries: Hospice staff reported to DNS (Director of Nursing Services) on 1-29-2015 @ (at) 1:00pm that (RI #1) had made some statements to them while they were providing care to him they thought she should be aware of. They stated that he told them that there several "girls" in his room the evening before that were bathing him and one of them "flicked" in penis with her finger then laughed about it. He also said she did it several times and they all laughed..." During an interview on 02/19/2015 at 8:42 AM, the surveyor asked RI #1 how staff treated him. RI #1 stated, "OK except this one girl who works here. She messed with my privates. She was cleaning me and she thumped me on the privates (pointing to penis). I told her to stop and she went to get a cloth and came back and thumped it again and laughed..." RI #1 further stated he became upset and told her not to do it again. RI #1 said he reported the incident to the nurse and everyone who would listen. A follow-up interview was conducted with RI #1 on 02/20/2015 at 9:45 AM. When asked what he meant when he said the girl thumped his privates, RI #1 demonstrated what he saw the girl do by gesturing with his hand using his middle finger and thumb and made a thumping/flicking motion. When asked what it felt like, RI #1 stated it was an "awful feeling" and that area is sensitive. RI #1 added, "It hurt like the dickens." When asked who was in the room, RI #1 said people were coming and going, trays were being passed, and they were checking and changing him because he wears a brief. RI #1 said he was just about to have supper and his Hospice Nurse had just left, when the girl came in his room. RI #1 explained the staff joke and tease and he jokes and teases back, but said, "You don't touch the privates like that. Not a joke." Review of the time sheet for EI #3, the CNA RI #1 alleged thumped his penis, revealed she worked from 2:09 PM to 9:40 PM shift 01/28/2015. EI #3 worked the remainder of her shift after RI #1 made an allegation of abuse. The Staffing Plans for January and February 2015 indicated EI #3 continued to work in the facility. EI #3, the CNA alleged by RI #1 thumped his penis, was interviewed on 02/18/2015 at 4:20 PM. When asked about the incident that occurred at the end of January with RI #1, EI #3 stated it was the 28th. She further stated that night, while getting RI #1 ready for bed, RI #1 said they were hurting him. EI #3 explained RI #1 stated she had "thumped his pecker (penis)". EI #3 said she went to get EI #2, the LPN, and told her what RI #1 had alleged. EI #3 said she felt this would be considered an allegation of abuse. EI #4, the other CNA assigned to care for RI #1 on 01/28/2015, was interviewed on 02/18/2015 at 6:08 PM. When asked what she recalled about the incident at the end of January regarding RI #1, EI #4 explained that at the end of care, RI #1 stated EI #3 had "thumped his pecker ". EI #4 was asked if EI #2, the LPN, was aware of RI #1's allegation, and EI #4 said yes because they called her into the room. EI #4 said when EI #2 came into the room, RI #1 stated something about "busting" his penis. On 02/17/2015 at 3:07 PM, during an interview with EI #2, the LPN Charge Nurse who cared for RI #1 on 01/28/2015, EI #2 denied any knowledge of RI #1 alleging the CNA had thumped his penis. EI #2 said about 6:00 PM on 01/28/2015 the CNAs had asked her to come into RI #1's room because he was acting out. Review of RI #1's medical record revealed the following entry by EI #2, LPN Charge Nurse, dated and timed 1/28/2015 at 10:51 PM, "RESIDENT RESTING IN BED, RESPIRATIONS EVEN AND UNLABORED, SKIN WARM AND DRY TO TOUCH. NO ACUTE DISTRESS NOTED. NO C/O (complaints of) PAIN OR DISCOMFORT VOICED THIS SHIFT. CONTINUES ON IN HOUSE HOSPICE CARE. STAFF IN TO PROVIDE INCONTINENT CARE AND REPOSITION EVERY TWO HOURS AND AS NEEDED. CALL LIGHT WITHIN REACH. WILL CONTINUE TO MONITOR FOR ANY CHANGES IN STATUS." There was no documentation of the resident acting out or of EI #2's assessment of RI #2 after called to the room by the CNAs (EI #3 and EI #4) to report the allegation RI #1 expressed while the CNAs were providing care. Hospice Aide #1 was interviewed on 02/17/2015 at 1:28 PM. The Hospice staff recalled while she and Hospice Aide #2 were in RI #1's room on the morning of 01/29/2015, the resident stated that he hoped they (the facility) got rid of the girl who had thumped his "balls". The Hospice Aide said they then notified the nurse on the hall (EI #5). Hospice Aide #1 said that she did not feel the nurse took the statement seriously because of RI #1's dementia. She further stated that after she informed EI #5 of RI #1's allegation, EI #5 laughed, so she reported the allegation to the DNS, EI #7. When asked what types of things were considered allegations of abuse, the Hospice Aide stated that in this case, she felt it would be sexual abuse Hospice Aide #2 was interviewed on 02/17/2015 at 1:40 PM. She explained while she and Hospice Aide #1 were bathing RI #1 told them about the girl from the night before. Hospice Aide #2 stated RI #1 alleged that the girl had been "flicking" his penis. Hospice Aide #2 notified EI #5, LPN, who stated RI #1 had dementia, so they had notified EI #7, the Director of Nursing. When asked what she considered abuse, she replied, "Playing around with somebody's penis, I think that is abuse." Hospice Aide #2 further stated she felt like it would be sexual abuse. EI #6, the CNA caring for RI #1 the morning on 01/29/2015, was interviewed on 02/19/2015 at 9:20 AM. When asked what knowledge she had of the incident with RI #1 at the end of January, EI #6 stated she was providing care to RI #1 on the morning of 01/29/2015 at about 10:00 AM. RI #1 told her one of the CNAs from the night before had thumped his penis more than once. EI #6 notified EI #5, the LPN Charge Nurse, and EI #8, the Social Services Worker, because she considered the statement an allegation of abuse. EI #5, the LPN Charge Nurse who EI #6 reported RI #1's allegation to on 01/29/2015, was interviewed on 02/18/2015 at 3:30 PM. When asked what she recalled about an incident at the end of January when the Hospice Aides asked her to come into RI #1's room, she stated that RI #1 said there was someone in dark blue at night that thumped his penis. EI #5 stated she notified EI #8, the Social Services Worker. EI #5 stated it was hers to report but felt like if the Hospice Aides were concerned why were they referring it to her. EI #5 further stated she was confused because she thought the Hospice Nurse had been made aware. When asked if it would be the Hospice Nurse's responsibility, EI #5 stated no. EI #5 also stated, "I know it is my responsibility..." When asked what had been done to protect the resident when she became aware of his abuse allegation, EI #5 stated nothing had been done because she did not know if there was a reason to protect him. EI #9, the Social Services Director, was interviewed on 02/19/2015 at 9:45 AM. When asked what involvement she had with RI #1's incident at the end of January, EI #9 explained she had been off at the time of the allegation, but after returning she and the Administrator and Director of Nursing interviewed RI #1 together about the incident. According to EI #9, RI #1 alleged a CNA pulled his brief down and thumped the end of his penis then went behind the curtain, came back and did it again. EI #9 stated she would consider RI #1's statement of someone thumping his penis an allegation of abuse but stated it was not her decision to make. When asked whose decision it was, EI #9 stated the Administrator and a team consisting of herself and the DNS. When asked which allegations of abuse should be reported to the state, EI #9 stated she would have reported this. When asked why it was important to report allegations of abuse, EI #9 stated for the safety of the resident as well as others. When asked what should be done if a resident accuses a staff member of abuse, EI #9 stated the staff member should be suspended pending the outcome of the investigation to prevent them from doing it again or doing something to another resident. On 02/20/2015 at 5:55 PM, the Hospice Social Worker was interviewed. When asked what knowledge she had of an incident involving RI #1 at the end of January, she stated the Hospice Chaplain visited RI #1. During the visit the resident reported to the Hospice Chaplain that a CNA at the facility had inappropriately touched him. The Chaplain was uncertain of what had occurred and what was being done. He expressed his concern about how upset RI #1 was. The Hospice Social Worker went to the facility and performed a Mini Mental Assessment on RI #1 that indicated moderate cognitive impairment. However, the Hospice Social Worker said that RI #1 was alert and oriented to events. The Hospice Social Worker further explained RI #1 was very consistent in telling the events that more than one person had been in his room but only one had touched his penis. When asked if she felt RI #1's statements were reportable, the Social Worker said yes. The Social Worker explained, when she spoke with the Administrator, he informed her that he had decided not to report the incident due to RI #1's mental status and dementia. EI #7, the Director of Nursing Services (DNS), was interviewed on 02/19/2015 at 10:50 AM. During the interview, EI #7 said none of her staff members had reported RI #1's allegation to her, and she (DNS) had been the first person to notify the Abuse Coordinator of the allegation. When asked which allegations of abuse should be reported to the State Agency, EI #7 stated if there is reasonable suspicion that something had occurred, it should be reported. When asked what she meant by "reasonable suspicion", EI #7 explained that if after initiating your investigation and it is determined within 24 hours that something has occurred, it is reported. EI #7 considered an allegation of abuse anything that could make a resident feel threatened. When asked what the regulation stated, EI #7 read the regulation and stated she thought that because State was getting so many reports the facility had 24 hours to investigate before reporting. The surveyor asked EI #7 if the facility became aware of RI #1's allegation at approximately 1:00 PM on 01/29/2015 and began interviewing CNAs on 01/30/2015, how did they determine the incident was not reportable. EI #7 did not know. EI #7 agreed the statement RI #1 made that someone thumping his penis was an allegation of abuse. When asked why it was important to report allegations of abuse, EI #7 stated to protect your residents. EI #7 explained that after an allegation of abuse, steps should be taken to protect the resident. When asked how the resident should be protected, EI #7 stated it could involve suspension or reassigning the alleged employee. When asked what the facility's policy said regarding employees accused of abuse, EI #7 again stated suspend or reassign. The surveyor then provided a copy of the facility Abuse Prevention Policy for EI #7 to review. After reviewing the facility's Abuse Policy, EI #7 stated the policy said the employee should immediately be suspended. When asked if EI #3 had been suspended, EI #7 said EI #3 was reassigned. EI #1, the Administrator/Abuse Coordinator, was interviewed on 02/19/2015 at 2:00 PM. When asked what the facility policy said about reporting allegations of abuse, EI #1 stated it should mirror the regulation and if there is an allegation it should be reported within 24 hours. When asked what is considered an allegation of abuse, EI #1 stated somebody doing willful infliction of abuse with intent behind it. The surveyor again asked what the policy stated. EI #1 then read the following from the "PROTECTION" section of the facility abuse policy: "...2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be reported... as required by state guidelines..." When asked if that mirrored the regulation, EI #1 stated it was worded "kind of weird" and was confusing because in another section it said to report any allegation. When asked what the regulation stated, EI #1 stated, "That you have to report reasonable suspicions of allegations of abuse", and then added that he was "having a very hard time with this". EI #1 explained he did not want to consider RI #1's statement an allegation of abuse. EI #1 explained it would have been different if the resident was cognitively intact. When asked about the facility policy for when a resident alleges abuse, EI #1 stated the priority is to protect the resident from anything further. He stated in most cases he would suspend the employee until a determination is made. EI #1 was asked which situations would not require the employee to be suspended. EI #1 stated this one, referring to RI #1's allegation. EI #1 stated there were circumstances that influenced his decision not to suspend the employee. When asked what those circumstances were, EI #1 stated RI #1's cognitive status played a role in his decision. EI #1 explained the first step in investigating an allegation of abuse was to know who the perpetrator was, and the second step was to protect the resident. EI #1 further explained that after talking to RI #1, he determined RI #1 was referring to EI #3, the CNA. EI #1 said that after determining who the perpetrator was, the facility relied on the policy to make a decision as to how to protect the resident. When asked what was done to protect RI #1 following his allegation of abuse, EI #1 stated EI #3 had been reassigned 01/30/2015. When asked what the facility policy said regarding employees alleged of abuse, EI #1 stated it said to suspend them as a means of protecting the resident. EI #1 said EI #3, the alleged CNA, had not been suspended. When asked what his responsibilities were as the abuse coordinator, EI #1 said he was responsible for ensuring the seven steps for abuse were implemented. During a follow-up interview with EI #1, the Abuse Coordinator/Administrator, on 02/20/2015 at 2:57 PM, EI #1 stated facility staff had not reported RI #1's allegation to him as they should have. This deficiency was cited as a result of the investigation of complaint/report #AL 782. ************************************ Allegation of Compliance (AoC) F226 On 02/22/2015 at 10:55 AM, the surveyors notified the Administrator and Clinical Consultant that the AoC had been accepted. The AoC documented the following: "F226 On 02/20/15 the QA team met and developed the Abuse Investigation Protocol which is an 8 step guidance tool of the investigative process to include the components of a complete and thorough investigation. The Abuse Investigation Protocol was implemented on 02/21/15. As of 2/21/15 the facility revised the policy on Abuse Prevention to include the definition of allegation and any and all allegations of abuse shall be reported to the state agency. The revised Abuse Prevention policy and the Abuse Investigation Protocol was reviewed and approved and implemented by the Quality Assurance Committee on 2/21/15. The facility in service of Reporting and Understanding Abuse and the Abuse Investigation Protocol and the revised Abuse Policy noted the following will be reported: all alleged abuse, verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, misappropriation of resident property and involuntary seclusion. This reporting to the state agency will occur within 24 hours of the incident on line. A written report to the state agency will occur within 5 working days. An allegation of abuse is defined as a statement or claim that someone has been abused. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This in service notes staff will initiate an investigation at the time of finding any alleged abuse or neglect. Any allegation of abuse or neglect against anyone must result in his immediate suspension to protect the resident. Reporting and understanding abuse consist of residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, corporal punishment, involuntary seclusion, and implementing these procedures. This in service also consisted of F223, F224, F225, and F226. No staff will be allowed to work until they have been in-serviced. Any newly hired employees will be in-serviced upon hire." ************************ After receiving an acceptable AoC on 02/22/2015 at 10:55 AM, various staff members including Housekeeping, CNAs, LPNs, RNs, the Business Office Manager, Business Office Assistant, Director of Admissions, DNS, and the Administrator were interviewed regarding the definition of an allegation of abuse, investigating and reporting allegations of abuse. The Abuse Investigation Protocol and the revised Abuse Prevention Policy were reviewed and no concerns were noted.

Based on record review and interviews, Employee Identifier (EI) #1, the Administrator/Abuse Coordinator, failed to provide management and oversight to ensure the facility's abuse policies and procedures were implemented. The Administrator also failed to demonstrate knowledge of and follow Federal and State regulations for reporting and protection of residents after becoming aware of an allegation of possible sexual abuse and/or physical abuse expressed by RI #1. On 01/28/2015 Resident Identifier (RI) #1, an alert resident, reported to EI #3 and EI #4, both Certified Nursing Assistants (CNAs), during care that EI #3 thumped his penis and laughed about it. The resident repeated the allegation to two Hospice Aides the next day on 1/29/2015. After becoming aware of the allegation of possible sexual abuse and/or physical abuse, EI #1 did not identify RI #1's statement as an allegation of abuse and failed to report the allegation to the State Agency. EI #1 also failed to follow the facility's policy and procedure to protect RI #1 while conducting an investigation into the allegation. EI #3, the CNA RI #1 alleged thumped his penis during care, was allowed to remain at work for the remainder of her shift and care for RI #1 following the allegation on 01/28/2015. Although EI #1 reassigned EI #3 following his investigation, EI #5 concluded RI #1's allegation was not credible based on his [DIAGNOSES REDACTED]. This deficient practice placed RI #1, one of two residents sampled for review of abuse allegations, in Immediate Jeopardy as it was likely to cause serious injury, harm, or death. On 02/20/2015 at 4:15 PM, the Administrator and Director of Nursing Services (DNS) were notified of the Immediate Jeopardy in the area of Administration, F490. The Immediate Jeopardy began on 01/28/2015 until the facility implemented immediate corrective actions on 02/22/2015 at 12:06 PM. The scope and severity was lowered to a "D" level to allow the facility time to monitor and if necessary revise their corrective actions to achieve substantial compliance. Findings Include: Refer to F225 and F226. Review of the Administrator, EI (Employee Identifier) #1's, job description, dated 8/1/12 revealed the following: "Job Description Job Title: Executive Director... Supervised By: Facility Vice President... General Description: The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations, and Facility policies... Essential Duties: ...13. Demonstrates knowledge of all State Department of Health rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff... Standard Requirements: ... 6. Immediately reports incidents of alleged resident abuse or neglect or alleged violations of residents' rights to appropriate authorities..." During an interview on 02/19/2015 at 8:42 AM, the surveyor asked RI #1 how staff treated him. RI #1 stated, "OK except this one girl who works here. She messed with my privates. She was cleaning me and she thumped me on the privates (pointing to penis). I told her to stop and she went to get a cloth and came back and thumped it again and laughed..." RI #1 further stated he became upset and told her not to do it again. RI #1 said he reported the incident to the nurse and everyone who would listen. A follow-up interview was conducted with RI #1 on 02/20/2015 at 9:45 AM. When asked what he meant when he said the girl thumped his privates, RI #1 demonstrated what he saw the girl do by gesturing with his hand using his middle finger and thumb and made a thumping/flicking motion. When asked what it felt like, RI #1 stated it was an "awful feeling" and that area is sensitive. RI #1 added, "It hurt like the dickens." When asked who was in the room, RI #1 said people were coming and going, trays were being passed, and they were checking and changing him because he wears a brief. RI #1 said he was just about to have supper and his Hospice Nurse had just left, when the girl came in his room. RI #1 explained the staff joke and tease and he jokes and teases back, but said, "You don't touch the privates like that. Not a joke." EI #7, the Director of Nursing Services (DNS), was interviewed on 02/19/2015 at 10:50 AM. During the interview, EI #7 said none of her staff members had reported RI #1's allegation to her, and she (DNS) had been the first person to notify the Abuse Coordinator of the allegation. EI #1, the Administrator/Abuse Coordinator, was interviewed on 02/19/2015 at 2:00 PM. When asked about the facility's policy and procedure when a resident alleges abuse, EI #1 stated it would have to be determined if it was reportable or not. When asked how it was determined if an allegation of abuse was reportable, EI #1 stated each case was different. EI #1 stated he had based his decision not to report RI #1's allegation on the fact that things kept changing. EI #1 further explained RI #1's cognitive status played a role in his decision. EI #1 felt the allegation was an exacerbation of RI #1's dementia. When asked if a resident with dementia could still be abused, EI #1 said yes. EI #1 was asked what demographic of residents was most highly abused. EI #1 stated dementia residents. EI #1 stated an allegation of abuse was somebody doing willful infliction of abuse with intent behind it. When asked if RI #1 stating a CNA had thumped his penis would be an allegation of abuse, EI #1 said, "Again I have to say I have to measure what he (RI #1) is saying based on his mental status and the circumstances." EI #1 further stated, "I do not want to call this an allegation because this is him (RI#1)." The surveyor again stated RI #1 alleged someone thumped him on his penis and asked if that was an allegation of abuse. EI #1 replied that it would have been different if it had been a cognitively intact resident and would have been reported. When asked what the facility policy said about reporting allegations of abuse, EI #1 said the facility policy should mirror the regulation and if there is an allegation it should be reported within 24 hours. The surveyor then asked if RI #1's allegation should have been reported to the State Agency. EI #1 stated he still felt he made the right decision in not reporting. The surveyor asked EI #1 how it was determined RI #1's allegation had not occurred or was not reportable. EI #1 stated after talking with some of the staff and the resident, he felt the story was different every time, which made it less credible. EI #1 then clarified by stating that in dealing with RI #1 and knowing the accused staff member had no history of problems, he just did not believe it had occurred. When asked what the regulation stated, EI #1 said, "That you have to report reasonable suspicions of allegations of abuse", and then added that he was "having a very hard time with this". When asked if the regulation had been followed, EI #1 said no, not for reporting. EI #1 was asked what his responsibility was as Abuse Coordinator for the facility. EI #1 explained he was responsible for educating staff and implementing the seven steps for abuse. When asked who was ultimately responsible for ensuring allegations of abuse are reported, EI #1 stated the Administrator. During the interview with EI #1, the surveyor asked about the facility policy for when a resident alleges abuse. EI #1 stated the priority is to protect the resident from anything further. EI #1 stated in most cases he would suspend the alleged employee until a determination is made. The surveyor then asked which situations would not require the employee to be suspended. EI #1 stated this one, referring to RI #1's allegation. EI #1 stated there were circumstances that influenced his decision not to suspend the employee such as RI #1's cognitive status. EI #1 explained that upon EI #3's return to work on 01/30/2015 she was assigned to a different unit to eliminate any stress on RI #1 or EI #3. The surveyor asked what the facility's policy stated regarding employees alleged of abuse. EI #1 stated per policy the alleged employee should be suspended as a means of protection for the resident. When asked if EI #3, the alleged CNA, had been suspended, EI #1 said no, he would have suspended EI #3 if he felt the allegation actually occurred. On 02/20/2015 at 8:30 AM, EI #1 stated he intended to go back and redo a thorough investigation. He further stated it was the facility's responsibility to protect their residents and felt the need to go back and investigate because it was the right thing to do. EI #1 stated he would expect CNAs to report to their supervisor if a resident alleged abuse and the supervisor to notify him or the DNS. This deficiency is cited as a result of the investigation of complaint/report #AL 782. ************************************ Allegation of Compliance (AoC) F490 "F 490 On 2/20/15 at 11:56 p.m. the facility reported to Alabama Department of Public Health (ADPH) an allegation of abuse on RI #1. On 02/20/15 the QA team met and developed the Abuse Investigation Protocol which is an 8 step guidance tool of the investigative process to include the components of a complete and thorough investigation. The Abuse Investigation Protocol was implemented on 02/21/15. As of 2/20/15 the ED and DNS was in-serviced by a Clinical Consultant on Reporting and Understanding Abuse and the Abuse Investigation Protocols. On 2/21/15 the ED and DNS were in-serviced by a Clinical Consultant on the Revised Abuse Policy, revised 2/21/15. The DNS was appointed as the abuse coordinator as of 2/20/15. The DNS signed a letter accepting the responsibility of the abuse coordinator effective 2/20/2015 at 5 PM. As of 2/20/15 the Executive Director (ED) is no longer the abuse coordinator. On 2/20/15 the facility reopened the investigation alleging abuse of RI #1 to include interviews with staff that worked on 1/28/15, 1/29/15, including any hospice staff. Facility staff consists of nursing, dietary, therapy, activity, housekeeping/laundry and maintenance. Facility is conducting these interviews seeking to ascertain any knowledge regarding the alleged abuse of RI #1. Facility employees, therapy staff and hospice staff interviews consist of probing questions specific to the alleged event. As of 2/21/15 both CNAs and the Licensed Practical Nurse who were in RI #1 ' s room were suspended pending outcome of the investigation. As of 2/21/15 the hospice nurse was advised that she is not to return to the facility pending outcome of the investigation. As of 2/20/15 the Vice President (VP) was in-serviced by a Clinical Consultant on Reporting and Understanding Abuse and the Abuse Investigation Protocols. On 2/21/15 the VP was in-serviced by a Clinical Consultant on the Revised Abuse Policy, revised 2/21/15. It was established and implemented on 2/21/15. The facility in service of Reporting and Understanding Abuse and the Abuse Investigation Protocol and the revised Abuse Policy noted the following will be reported: all alleged abuse, verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, misappropriation of resident property and involuntary seclusion. This reporting to the state agency will occur within 24 hours of the incident on line. A written report to the state agency will occur within 5 working days. An allegation of abuse is defined as a statement or claim that someone has been abused. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This in service notes staff will initiate an investigation at the time of finding any alleged abuse or neglect. Any allegation of abuse or neglect against anyone must result in his immediate suspension to protect the resident. Reporting and understanding abuse consist of residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, corporal punishment, involuntary seclusion, and implementing these procedures. This in service also consisted of F223, F224, F225, and F226. No staff will be allowed to work until they have been in-serviced. Any newly hired employees will be in-serviced upon hire." ************************************ After receiving an acceptable AoC on 02/22/2015 at 10:55 AM, various staff members including Housekeeping, CNAs, LPNs, RNs, the Business Office Manager, Business Office Assistant, Director of Admissions, DNS, and the Administrator were interviewed regarding the definition of an allegation of abuse, investigating and reporting allegations of abuse. The documentation of the report to ADPH was reviewed, as well as the progress on the re-investigation of RI #1's allegation. The facility provided documentation that involved staff had been suspended pending the outcome of the re-investigation. Documentation was provided appointing the DNS to Abuse Coordinator, following an in-service. The Abuse Investigation Protocol and the revised Abuse Policy were reviewed and no concerns were noted.