Every finding on record at Father Purcell Memorial Exceptional Children's CTR

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #2's quarterly Minimum Data Set (MDS) assessment was completed within three months of his/her prior assessment. This affected RI #2, one of 16 sampled residents for whom MDS assessments were 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 October 2019, revealed the following: .Chapter 2: Assessments for the RAI . 05. Quarterly Assessment . The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The ARD (A2300) (Assessment Reference Date) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility's Assessment Manager screen for RI #2 revealed the most recent MDS assessment completed by the facility was a quarterly assessment with an ARD of 07/24/2022. On 12/22/2022 at 2:50 PM, an interview was conducted with Employee Identifier (EI) #5, the facility's MDS Coordinator. When asked to review RI #2's most recent MDS assessment, EI #5 stated RI #2's last assessment was done on 07/24/2022 and indicated there should have been a more recent assessment done in October. EI #5 said she did not know why it was not done. EI #5 then went to her filing cabinet and found her handwritten copy of information collected for RI #2's 10/23/2022 assessment. EI #5 stated she uses the handwritten pages to enter the information into the computerized Assessment Manager. EI #2 said she was unsure what happened, but somehow RI #2's 10/2022 quarterly assessment never got entered into the computer.

Based on observation, interviews, record reviews and a review of facility policies titled Hand Washing Policy/Procedure and a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION the facility failed to ensure facility staff sanitized a blood pressure cuff and sanitized their hands in between Resident Identifier (RI) 15 and RI #26 on 12/20/2022. This affected RI #15 and RI #26 two of two residents observed during vital sign assessments and had the potential to affect 44 of 44 residents residing in the facility. Findings include: Review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 528, revealed the following: . Foundations for Nursing Practice . Measuring Blood Pressure---cont'd . 11. Perform hand hygiene. Wipe cuff with facility-approved cleaning agent if used between patients. A review of an undated facility policy titled Hand Washing Policy/Procedure revealed, Hand Washing Policy Staff and all employee working in the facility will follow proper hand washing practices in order to lower risk of spreading communicable disease. Procedure Staff shall wash their hands whenever hands come in contact . 3) Between handling of residents. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #26 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/20/2022 at 07:33 AM and observation of Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) was in RI #15 and RI #26 's room and assessing vital signs with electronic vital machine. Observation of EI #3 obtaining vital signs of RI #15 with machine blood pressure cuff, EI #3 removed the blood pressure cuff from left arm of RI #15 and then held blood pressure cuff with her right hand and walked over to RI #26's bed and then put the blood pressure cuff on RI #26's left lower arm without cleaning cuff or washing or sanitizing her hands in between residents, EI #3 removed the cuff and without cleaning the blood pressure cuff she put the blood pressure cuff in basket of portable vital machine. On 12/20/2022 at 07:37 AM an interview was conducted with EI #3 CNA. EI #3 was asked, when was she supposed to clean the vital machine after use. EI #3 replied, before care, between patients. EI #3 was asked, when did she clean it in between RI #15 and RI #26. EI #3 replied, she forgot to clean it that day. EI #3 was asked, why did she not clean the blood pressure cuff. EI #3 replied, she simply forgot. EI #3 was asked, when did she wash or sanitize her hands between RI #15 and RI #26. EI #3 replied, she did not. EI #3 was asked, why she did not wash or sanitize her hands in between RI #15 and RI #26. EI #3 replied, she did not think she had to. EI #3 was asked, what was the risk of not cleaning the blood pressure cuff in between RI #15 and RI #26. EI #3 replied, she thought it was ok. EI #3 was asked, should she have cleaned the blood pressure cuff in between RI #15 and RI #26. EI #3 replied, yes. EI #3 was asked, should she have washed or sanitized her hands between RI #15 and RI #26. EI #3 replied, yes ma'am. On 12/20/2022 at 07:46 AM an interview was conducted with EI #2 Director of Nursing. EI #2 was asked, what was the facility policy on washing and sanitizing hands. EI #2 replied, before and after work, bathroom any direct contact with kids, before and after procedures. EI #2 was asked, what was the policy on vital sign equipment cleaning. EI #2 replied, before and after. EI #2 was asked, what was policy for vital signs. EI #2 replied, wash off with wipes between each patient. EI #2 was asked, why would staff not wash or sanitize your hands in between residents. EI #2 replied, there would be no reason why not to wash your hands between patients. EI #2 was asked, why would staff not wash the blood pressure cuff in between residents. EI #2 replied, staff should not ever, not wash the blood pressure cuff between residents. EI #2 was asked, what was the risk of not cleaning the blood pressure cuff between residents. EI #2 replied, spreading diseases. EI #2 was asked, should EI #3 have sanitized her hands in between residents. EI #2 replied, yes. EI #2 was asked, should EI #3 have cleaned the blood pressure cuff in between residents. EI #2 replied, yes.

Based on record review and interviews, the facility failed to ensure: 1) Resident Identifier (RI) #3's diet orders were transcribed to the monthly Physician Orders; and 2) RI #144's catheter order was transcribed to the current Physician Orders following readmission to the facility with a catheter on 12/19/2022. This affected RI #3 and RI #144, two of 16 sampled residents for whom Physician Orders were reviewed. Findings include: 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Gastrostomy Status (feeding tube). Review of RI #3's October 2022, November 2022, and December 2022 Physician Orders revealed orders for as needed tube feeding if oral intake was less than 50 percent; however, further review of these orders revealed there were no Diet Orders listed. Employee Identifier (EI) #4, the Assistant Director of Nursing, was interviewed on 12/21/2022 at 11:40 AM. EI #4 stated RI #3 was fed by mouth and assisted by staff. When asked where in the chart the resident's diet orders were listed, EI #4 referred to an Annual Nutritional Evaluation dated 4/11/2022 that documented pureed diet with honey thickened liquids. After reviewing RI #3's Physician Orders in the chart, EI #4 said there were orders for RI #3's as needed tube feeding and flushes. EI #4 said she did not see an order for RI #3's diet. On 12/22/2022 at 10:02 AM the Pharmacy Technician responsible for Physician Orders at the facility's contract pharmacy, was interviewed. She stated the facility faxes in a Physician Order form, and the pharmacy then enters them into the system. She indicated the orders are printed on the 18th of each month and delivered to the facility, who then reviews them and notes any changes or updates on the yellow carbon copy, then sends the changes back to the pharmacy for updates. The Pharmacy Technician said when the Physician Orders are printed again the following month, the changes would be reflected and printed on the sheets. The Pharmacy Technician then pulled and reviewed the previous three months of Physician Orders for RI #3 and said the facility had not added anything to the Diet Order area. She further stated, had the facility provided the Diet Order information, she would have added it to the system so it would print out on the orders. On 12/22/2022 at 10:53 AM, EI #1, the facility's Administrator, was asked how diet orders should be transcribed and updated so they are reflected on the printed monthly Physician Orders. EI #1 said two nurses should sign-off on all monthly Physician Orders. EI #1 said the reviewing nurses should have picked up on it when they reviewed and sent it over to pharmacy to update RI #3's Diet Orders, so it could be printed and included on the next month's orders. EI #1 said this was considered a transcription problem. On 12/22/2022 at 1:58 PM, EI #6, Registered Dietitian, was asked why it would be important for diet orders to be included on the monthly Physician Orders. EI #6 said so staff know if they are serving the right thing. 2) RI #144 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Disorder of Urinary System. Review of RI #144's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 09/18/2022, indicated RI #144 had an indwelling urinary catheter. Review of RI #144's Discharge Summary from a 12/07-12/19/2022 hospital stay revealed .Foley catheter present . Status . Active . However, RI #144's NEW ADMISSION PHYSICIAN'S ORDERS, dated 12/19/2022, contained no order for RI #144's catheter. On 12/22/2022 at 12:08 PM, EI #1, the Administrator, was provided RI #144's chart and asked if she could assist in locating the order for RI #144's catheter. EI #1 reviewed the chart, flipped through each page of orders and shook her head no. EI #1 stated there was no order for the catheter listed. EI #1 said EI #4, the Assistant Director of Nursing, put in the admission (readmission) orders. EI #4, the Assistant Director of Nursing, was interviewed on 12/22/2022 at 12:24 PM. EI #4 was provided RI #144's chart and asked when RI #144 was readmitted to the facility. EI #4 said 12/19/2022. EI #4 indicated she was the one that prepared RI #144's Admission/Readmission Orders upon his/her return to the facility. When asked if she could show the surveyor the order for RI #144's catheter, EI #4 flipped through the chart and said the order was not there, but should have been. EI #4 said she guessed she just missed it when entering the orders from the hospital readmission paperwork. EI #4 said the order for RI #144's catheter should have been transcribed.

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #14 and RI #24's completed Minimum Data Set (MDS) assessments were transmitted to the CMS system. This affected RI #14 and RI #24, two of 16 sampled residents for whom MDS assessments were 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 October 2019, revealed the following: CHAPTER 5: SUBMISSION .OF THE MDS ASSESSMENTS Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . 5.2 Timeliness Criteria . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . RI #14 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/22/2022 at 2:37 PM, record review revealed RI #14's 10/02/2022 quarterly MDS assessment was still listed as OPEN. The completion date (Z0500B) was listed as 10/05/2022. The assessment did not indicate it had been transmitted to CMS. RI #24 was admitted to the facility on [DATE] and readmitted on [DATE]. On 12/22/2022 at 2:37 PM, record review revealed RI #24's 11/13/2022 annual MDS assessment was still listed as OPEN. The assessment did not indicate it had been transmitted to CMS. Review of a hard copy of RI #24's 11/13/2022 annual MDS assessment revealed the Care Plan Completion Date (V0200C2) was listed as 11/23/2022. Employee Identifier (EI) #5, the MDS Coordinator, was interviewed on 12/22/2022 at 2:50 PM. EI #5 was asked to review the most recent MDS assessment for RI #24. EI #5 reviewed and confirmed the assessment was done and had the appropriate signatures; however, she indicated she had not transmitted it. EI #5 also reviewed RI #14's MDS assessment and stated it also had not been transmitted. When asked when MDS assessments should be transmitted, EI #5 said she has 14 days after completing assessments to transmit them to CMS.

Based on observation, record review, interviews, and review of a facility policy titled Catheter Care, the facility failed to ensure Resident Identifier (RI) #144's catheter bag was not left uncovered and visible from the hallway on 12/20/2022. This affected RI #144, one of one resident sampled with an indwelling catheter. Findings include: Review of a facility policy titled Catheter Care, updated 10/07/2021, revealed the following: .Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . RI #144 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Disorder of Urinary System. Review of RI #144's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 09/18/2022, indicated RI #144 had an indwelling urinary catheter. On 12/20/2022 at 12:18 PM, RI #144's catheter bag was observed hanging on the side of the bed, visible from hallway with clear yellow urine noted in the drainage bag. On 12/22/2022 at 12:08 PM, Employee Identifier (EI) #1, the facility Administrator, was asked how catheter bags of residents with catheters should be maintained. EI #1 said the catheter bag should be inside of a bag, to cover it, due to dignity concerns.

Based on observations, an interview, and review of a facility assessment document for room occupancy, the facility failed to ensure that nine of sixteen resident rooms were not furnished and/or occupied by no more than four residents per room. This included Room Locator (RL) numbers (#): 1, 2, 3, 4, 5, 6, 7, 8, and 9. This affected 9 of 16 rooms in the facility. Findings Include: On 12/20/2022 beginning at 6:55 AM, during the initial tour of the facility, RL#s: 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for the occupancy of five residents. There were no concerns noted related to access to the residents by staff for care. Adequate space for resident's belongings and equipment was provided. 12/22/2022 02:35 PM, EI #1, the Administrator, provided the surveyor with a list of rooms that occupy more than four residents. A review of the document indicated the individual square footage of each room. 12/22/2022 03:17 PM, EI #1 reported there were no concerns related to access of the residents by staff to provide care. EI #1 stated the facility had 58 certified beds with a current census of 44. EI #1 stated the facility applied for a waiver annually for the rooms that occupy more than four residents.

Based on interviews and Review of the POS [REDACTED]{EI} #1, FATHER PURCELL MEMORIAL MEDICATION GASTROSTOMY CHECK OFF and Father Purcell Memorial In-Service Education Program, the facility's Administrator, responsible for directing all aspects of the facility, and the Director of Nursing (DON), responsible for the overall function of the nursing department, failed to ensure a thorough investigation was conducted after becoming aware that Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) had administered the wrong medications to Resident Identifier (RI) #14 and RI #43 on 10/29/2019. The administrative staff further failed to implement measures to ensure no other resident received the wrong medication after becoming aware RI #43 had been administered medications ordered for another resident, RI #14. During the 7:00 AM to 3:00 PM shift on 10/29/2019, EI #1, the LPN prepared medications for RI #14, who resided in the room next to RI #43. As she entered the room to administer the medications, she noticed RI #14 was not in the room; the resident was in the shower room. The LPN placed the unlabeled cup of medications in the top drawer of the medication cart. The LPN then proceeded to prepare RI #43's medications for administration. As the LPN entered RI #43's room, she noticed the resident was not in the room; the resident was in the shower room. The LPN then walked to the medication cart and placed another unlabeled cup of medications in the top drawer of the medication cart. When both residents were available, the LPN got the medication cups from the top drawer and administered them to each of the residents. RI #43 then left the facility via ambulance transport for a planned procedure at the hospital. When RI #43 arrived in the emergency room , the resident was noted to have a slow heart rate, slow breathing, and a low blood pressure. The resident was difficult to arouse with no spontaneous movement even to pain or sternal rub. RI #43 was admitted to the Pediatric Intensive Care Unit (PICU) due to the concern for serious illness in the setting of his/her altered mental status, risk of [MEDICAL CONDITION] and other comorbidities. A urine drug screen was done, and it revealed RI #43 had medications in his/her system that were not ordered for the resident. After RI #43 was readmitted to the facility, EI #1 informed the facility's administrative staff that she had administered medications that belonged to RI #14 to RI #43 on 10/29/2019. These deficient practices affected RI #14 and RI #43, two of six residents who received medications from EI #1 on 10/29/2019 and placed RI #43, one of six residents receiving medication from the medication cart assigned to EI #1 on 10/29/2019 in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 12/14/2019 at 10:33 AM, the Administrator and Director of Nursing were notified of the finding of immediate jeopardy in the area of Administration, F 835. Findings include: The POSITION DESCRIPTION DIRECTOR OF NURSING signed by EI #3, the Director of Nursing on 9/4/2018, documented SUMMARY: Under the general direction of the Administrator, the Director of Nursing is responsible for planning, organizing, staffing, directing. Managing and coordinating nursing staff, equipment and supplies in such a manner as to afford optimum nursing care for the children served by the Center. RESPONSIBILITIES AND DUTIES: 1. Develops, or causes to be developed, implements and oversees conformance with such written nursing services policies, standards, practices and procedures as are needed to ensure the optimum care of each child served . In an interview on 12/12/2019 at 10:18 AM, EI #3, the DON was asked when she became aware that RI #43 had received the wrong medication. EI #3 stated, she couldn't remember the exact date, but she was at home when the Administrator, EI #2, called and informed her that EI #1, the LPN said she thought she (EI #1) was the one who administered the wrong medication to RI #43. After speaking with the Administrator, EI #3 stated she called EI #1, the LPN and informed her not to come into work until she was called. When asked if an investigation was conducted, EI #3 replied that she and the Administrator talked with EI #1; had EI #1 to write a statement; completed a medication error report; and reported EI #1's actions to the Board of Nursing. EI #3 commented, that's all we did. When asked whose medication did the facility determine was administered to RI #43, EI #3 answered that EI #1 told her they were RI #14's medications. EI #3 was asked if EI #1 reported to her how the error occurred. EI #3 replied by reading the statement written by EI #1. When asked if EI #1 informed her of what specifically occurred, EI #3 stated EI #1 didn't say what specifically occurred other than the fact that she mixed RI #43's medications up with another resident's medications. EI #3 was asked, what was done with the nursing staff after the incident was discovered. EI #3 answered that an in-service was conducted with the nurses about preparing medications one at a time and not storing prepared medications in the cart. EI #3 stated she completed a medication pass check-off with EI #1 during the 11:00 PM to 7:00 AM shift. EI #3 stated she will also begin to complete random observations of medication administration. When asked if there had been any random observations of EI #1, EI #3 answered that she would have to look in the book. In a follow-up interview on 12/13/2019 beginning at 12:32 PM, EI #3, the DON was asked did she review lab results of other residents after being informed by EI #1 that she had administered RI #43 medications that belonged to RI #14. EI #3 replied, no. EI #3 stated the facility only monitored the two residents whose medications were mixed up. When asked if the facility checked other residents to see if they may have received medications not prescribed to them, EI #3 said not to her knowledge. When asked what preventative measures were put in place to ensure the identified deficient practice did not recur, EI #3 stated the nursing staff was in-serviced to only pull (prepare) one medication at a time and if they were unable to administer the medication, to discard it and prepare again when the resident was available. EI #3 further stated that medication pass check-off was completed with EI #1 before EI #1 returned to the floor. An undated document titled Time Line for (EI #1) documented Sunday, (MONTH) 10, 2019 3:14 p.m.: (EI #1) called the administrator and stated I have always been honest with you about everything except this one thing. I think I was the one that may have mixed (RI #43) medicine with (RI #14) medicine. I have been under a lot of stress lately but I know I did it. When the administrator asked why she waited so long to tell us what happened, (EI #1) then stated I don't know . The DON was notified immediately after I spoke with (EI #1) Sunday, (MONTH) 10, 2019 3:18 p.m.: DON called (EI #1) and stated Don't come to work at your regular time and that they would call her when to come back to work. Monday, (MONTH) 11, 2019 9:15 a.m.: . (EI #1) came into the facility she was asked to write out a statement about what happened. DON and Administrator made a report to the Board of Nursing of a medication error and medication error forms were completed. (EI #1) was suspended for 4 days . Friday, (MONTH) 15, 2019 11:00 p.m. (EI #1) returned back to work on the 11 to 7 shift and the DON came in and did a Medication Pass check off with (EI #1) The FATHER PURCELL MEMORIAL MEDICATION GASTROSTOMY CHECK OFF indicated on 11/16/2019, EI #3, the DON observed EI #1 perform medication administration by way of a gastrostomy tube on one of the five residents who reside in Room Locator (RL) #4. The Father Purcell Memorial In-Service Education Program indicated on 11/19/2019 during the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shift, 20 of the facility's 58 licensed nurses received education by EI #4, the Registered Nurse Supervisor on Each nurse is to review FPM (Father Purcell Memorial) Medication Administration policy and abide by it. When administering medication each nurse is to only pull and administer one patient at a time medication. If you pull and store patients medication on cart, disciplinary action will be taken . On 12/13/2019 at 3:42 PM, EI #3, the DON was asked why in-service education was not started immediately after being made aware that a medication error had occurred. EI #3 replied, she did not know. During an interview on 12/11/2019 at 3:37 PM, EI #4, a Registered Nurse (RN) Supervisor acknowledged that she became aware of RI #43's urine drug screen results when the hospital staff called the nursing facility on 11/5/2019 and informed her that RI #43 had medications in his/her system that he/she was ordered to receive. EI #4 stated on 11/6/2019, EI #5, another RN Supervisor, showed her the RI #43's urine drug screen results. When asked if she apart of the facility's investigation into how RI #43 tested positive for medications he/she was not ordered to receive, EI #4 said no. In an interview on 12/12/2019 at 5:50 PM, EI #5, a RN Supervisor was asked when she became aware that RI #43 had been administered the wrong medication. EI #5 stated on the evening on 11/6/2019 after RI #43 had returned to the facility, she removed from the fax machine RI #43's urine drug screen results that were sent to facility from the hospital. When asked what type of investigation was done to see how RI #43 tested positive for medications he/she was not prescribed, EI #5 stated the only thing she knew was that she reviewed the labs and saw on the report the medications that RI #43 tested positive for and knew those medications belonged to RI #14. EI #5 stated she was not a part of any investigation. According to the fax confirmation report, on 11/5/2019 at 4:11 PM, the nursing facility received from the hospital the results of RI #43's Comprehensive Drug Analysis. The fax confirmation report dated 11/6/2019 indicated on 11/6/2019, the hospital staff faxed to the facility four pages regarding RI #43. The notes section of the report documented In regarded to (RI #43) medical records. These are all the labs that we have at this time. Looks like there are some labs that are still pending. I will send you another fax when all labs have been uploaded into our system . The fax confirmation report dated 11/7/2019 indicated on 11/7/2019, the hospital staff faxed to the facility 29 pages regarding RI #43. The notes section of the report documented In regards to (RI #43) medical records. All lab results are now available and have been included . The undated Position Description ADMINISTRATOR documented SUMMARY The Administrator is responsible . for effectively and efficiently planning, organizing, directing and controlling all aspects of the operation of Father Purcell Children's Center in a manner assuring quality care for the children, concern for their parents and satisfaction of all federal, state, and local laws and regulation governing nursing homes . During an interview on 12/12/2019 at 3:11 PM, EI #2, the Administrator stated on 11/10/2019, EI #1, the LPN called and informed her (EI #2) that she thought she had administered the wrong medications to RI #43. EI #2 stated she asked EI #1 when did this occur and EI #1 stated it happened on 10/29/2019, the day RI #43 was sent to the hospital. When asked who received RI #43's ordered medications, EI #2 stated the LPN (EI #1) told her that RI #14 received RI #43's medications. When asked what she did after becoming aware RI #43 had received the wrong medication, EI #2 stated the licensed nursing staff was asked to assess RI #43, the facility's Medical Director was notified and EI #1 was asked to not come into work until called. When asked if she instructed the facility to check other residents to see if they may have received medications not prescribed to them, EI #2 she didn't. EI #2 was asked if she was able to determine what happened, how it happened and who all was affected after being notified by EI #1, the LPN, that she had administered the wrong medication to RI #43 on 10/29/2019. EI #2 stated the facility concluded that EI #1 administered RI #43 medications that were ordered for RI #14. EI #2 stated she asked EI #1 several times how this occurred and EI #1 never verbally responded. According to EI #2, EI #1 gave her names of residents she thought had a medication error. When asked what preventative measures were put in place to ensure this did not recur, EI #2 stated the nurses will be checked-off on medication pass and the Consultant Pharmacy had been asked to perform check-off as well. EI #2 stated the Registered Nurses (RN) will begin monitoring medication pass and EI #1's employment will be terminated. During an interview on 12/12/2019 at 12:13 PM, EI #8, the facility's Consultant Pharmacist was asked when she became aware that RI #43 had received the wrong medications. EI #8 replied, today (12/12/2019). When asked what she had done after becoming aware RI #43 had been administered the wrong medication, EI #8 stated the Administrator asked her to perform a medication pass observation with EI #1. EI #8 stated she was planning on doing that when the LPN came into work. ************************* On 12/14/19 at 6:35 PM, the facility submitted a Removal Plan for F 835 which documented: The alleged incident that occurred on 10/29/19 FPM submitted the report online to ADPH on 12/14/2019. 12/14/2019: Department heads counseled on the importance of Abuse, Neglect and Exploitation and reporting neglect immediately and implementing the policies and procedures of the facility. Director of Nursing counseled on the importance of following up with staff after any significant change in resident but not limited to Abuse, Neglect, and exploitation. The facility will in-service the staff on the importance of reporting to ADPH per the Abuse, Neglect & Exploitation policy to include results of all investigations state survey agency with 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 835 was lowered to a D level on 12/14/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 375.

Based on interviews and review of Resident Identifier (RI) #14's and RI #43's medical records, FUNDAMENTALS OF NURSING NINTH EDITION, the MEDICATION ERROR REPORT, Employee Identifier (EI) #1's EMPLOYEE STATEMENT FORM and a complaint received by the Alabama State Survey Agency, the facility failed to ensure EI #1, a Licensed Practical Nurse (LPN) administered medications to RI #43 in accordance with accepted standards of practice and the physician's orders [REDACTED]. The Alabama State Survey Agency received a complaint which alleged, the nursing staff administered the wrong medications to RI #43. According to the complainant, RI #43 tested positive for medications of which the resident was not ordered to receive. During the 9:00 AM medication pass on 10/29/2019, EI #1, an LPN prepared medications for RI #14. As the LPN entered RI #14's room to administer the medications, she noticed RI #14 was not in the room; the resident was in the shower room. EI #1 placed the unlabeled cup of medications in the drawer of the medication cart. EI #1 then prepared RI #43's medications for administration. As the LPN entered RI #43's room, she noticed the resident was not in the room; the resident was in the shower room. The LPN then walked to the medication cart and placed another unlabeled cup of medications in the top drawer of the medication cart. When both residents were available, the LPN removed the medication cups from the drawer and administered the medications to each of the residents, without verifying the right medications and the right resident. RI #43 was administered medications to include: [MEDICATION NAME], Naltrexone and [MEDICATION NAME]. RI #43 then left the facility via ambulance transport for a planned procedure at the hospital. When RI #43 arrived in the hospital's emergency room , the resident was noted to have a slow heart rate, slow breathing, and a low blood pressure. The resident was difficult to arouse with no spontaneous movement even to pain or sternal rub. RI #43 was admitted to the Pediatric Intensive Care Unit (PICU) due to the concern for serious illness in the setting of his/her altered mental status, risk of [MEDICAL CONDITION] and other comorbidities. A urine drug screen was done on 10/29/2019, and it revealed RI #43 had medications in his/her system that were not ordered for the resident. After RI #43 was readmitted to the facility, EI #1, the LPN informed the facility's administrative staff, 13 days later, that she had administered medications that belonged to RI #14 to RI #43 on 10/29/2019. This deficient practice affected and placed RI #43, one of six residents receiving medication from the medication cart assigned to EI #1 on 10/29/2019 in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 12/14/2019 at 10:33 AM, the Administrator and Director of Nursing were notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Pharmacy Services/Residents Are Free of Significant Med Errors, F 760. Findings include: Pages 624 - 627 of Chapter 32 titled Medication Administration of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of (YEAR), documented . Medication Errors A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include . administering the wrong medication, . Preventing medication errors is essential . Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors . When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible . Steps to Take to Prevent Medication Errors . * Follow the six rights of medication administration . When you have made an error, reflect on what went wrong and ask how you could have prevented the error. Complete an occurrence report per agency policy . Ensure that you are well rested when caring for patients. Nurses make more errors when they are tired . Standards are actions that ensure safe nursing practice. Standards for medication administration are set by health care agencies and the nursing profession . To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . Right Patient. Medication errors often occur because a patient gets a drug intended for another patient. Therefore an important step in safe medication administration is being sure that you give the right medication to the right patient . On 12/6/2019, the Alabama State Survey Agency received a complaint which alleged, the nursing staff administered the wrong medications to RI #43. According to the complainant, RI #43 tested positive for medications of which the resident was not ordered to receive. RI #14 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED].#14 has a medical history to include [DIAGNOSES REDACTED]. RI #43 was admitted to the facility on [DATE]. RI #43 has a medical history to include [DIAGNOSES REDACTED]. On 12/11/2019 at 9:21 AM, a telephone interview was conducted with the Pediatric Intensive Care Unit (PICU) Social Worker (SW) at the hospital RI #43 was transferred to on 10/29/2019. The SW stated the emergency room (ER) staff knew RI #43 well and realized he/she was not acting like his/her normal self and ordered a drug screen test. According to the SW, RI #43 had come to the ER to have his/her feeding tube replaced. The SW stated two urine drug screens were done in the ER and a comprehensive drug analysis was sent to an outside facility; all of which came back positive. The SW stated the physicians at the hospital were concerned for RI #43 because the resident was not prescribed any of the medications in which he/she tested positive for. RI #43 was admitted to the hospital with [REDACTED]. The SW stated on 10/29/2019 she called the nursing facility and spoke with RI #43's nurse, later identified as EI #1, an LPN. According to the SW, RI #43's nurse listed the medications RI #43 was administered but none of them were the ones the resident had tested positive for. On 12/11/2019 at 2:34 PM, an interview was conducted with EI #1, the LPN assigned to care for RI #43 during the 7:00 AM to 3:00 PM shift on 10/29/2019. When asked why RI #43 was being sent to the hospital, EI #1 stated because the resident's GJ (gastrostomy jejunostomy) tube was malfunctioning; it was leaking. When asked how medication was administered to RI #43, EI #1 replied, by way of the tube. EI #1 was asked if she administered medications to RI #43 on 10/29/2019. She replied, yes. EI #1 stated it was kind of a rush rush thing and she guessed this was how the mix up happened. When asked what mix up, EI #1 stated the medication for RI #14 was mixed up with RI #43's medications. EI #1 was asked what were RI #14's medications. EI #1 read from the Medication Administration Record [REDACTED]. When asked how she thought the mix up occurred, EI #1 said she prepared RI #14's medications for administration; however, when she went to administer the medications to RI #14, the resident was in the shower. EI #1 stated she then put the medications in the medication cart. EI #1 then prepared RI #43's medications for administration. When EI #1 went to administer RI #43's his/her medications, the resident was also in the shower, so she placed RI #43's medication in the medication cart alongside RI #14's medications. EI #1 stated when the residents became available she administered each of the resident's their medications and got them mixed up. When asked if it was normal procedure to prepare medication for administration before seeing the resident, EI #1 said yes. EI #1 explained that if the resident was not available, the medication would be placed back into the medication cart and locked up. When asked how she would know who the medication belonged to, EI #1 answered, she would put the resident's name on the medication cup. EI #1 was asked if she did this on 10/29/2019 and she stated this was probably one of those mornings that she did not. When asked if RI #43 was administered RI #14's medications, EI #1 answered yes. EI #1 was asked when she realized that she had administered the wrong medications to RI #43. EI #1 replied, when the hospital called back to the nursing facility saying RI #43 was lethargic. When asked when she notified the facility's administrative staff of the error, EI #1 stated it was about a week and a half later. EI #1 explained that RI #43 had come back to the facility and it was being said that the resident was administered the wrong medications; that is when EI #1 informed the Administrator of the error she had made. According to EI #1, the Administrator asked her to come into the facility and talk with her and the Director of Nursing (DON). EI #1 stated she was suspended, and a medication error report was completed. The MEDICATION ERROR REPORT dated 11/11/2019 indicated on 10/29/2019 at 9:00 AM, RI #43 was administered medications not prescribed for him/her. The report documented . REASON FOR MAKING ERROR See Attached Nurse Statement COULD THIS ERROR HAVE ENDANGERED THE LIFE OR WELFARE OF THE RESIDENT? Yes . WHAT IS THE ACTUAL EFFECT OF THE ERROR MADE ON THE RESIDENT? Patient became over sedated. HOW WAS THE ERROR DISCOVERED? By drawing lab to discover why patient was so sedated. Nurse reported that she felt like she might have mixed medications up . WHAT PRECAUTIONS CAN BE TAKEN TO PREVENT A SIMILAR ERROR? . Only set up one resident medication @ (at) a time . EI #1's EMPLOYEE STATEMENT FORM dated 11/11/2019, documented The morning of the incident I didn't sleep well suffering from [MEDICAL CONDITION] & had taken a bendryl ([MEDICATION NAME]) before coming in that morning, . I now (know) that day my judgement was impaired, I made mistake giving (RI #43) the wrong medication of another resident before (he/she) going (out) of the facility for a GJ tube replacement to the hospital . RI #14's physician's orders [REDACTED]. to treat anxiety, muscle spasms and [MEDICAL CONDITION]; Naltrexone (Vivitrol), used to prevent opiate effects; [MEDICATION NAME] ([MEDICATION NAME]), used to treat and prevent heartburn; [MEDICATION NAME] ([MEDICATION NAME]), an antipsychotic used to treat mental/mood disorders; and [MEDICATION NAME] HCL ([MEDICATION NAME]), used to treat [DIAGNOSES REDACTED]. RI #43's physician's orders [REDACTED]. flora. During an interview on 12/11/2019 at 3:37 PM, EI #4, the 7:00 AM to 3:00 PM shift Registered Nurse (RN) Supervisor was asked, what the standard of practice was nurses use when administering medications to a resident. EI #4 said make sure it is the right route, right dose, right time, right patient, right amount and the right medication. When asked how a nurse ensures this occurs, EI #4 replied, look at the resident's name, look at the medication and time, then pull the medications from the medication cart and prepare them for administration. When asked what a nurse should do if they have pulled (prepared) medications for administration and the resident was not available, EI #4 replied, first one should find out where the resident is before the medication is prepared. If the medication has been prepared and the resident is not in his or her room, have a Certified Nursing Assistant (CNA) find the resident and bring the resident to the room. If the resident is not available, the medication should be discarded. In an interview on 12/12/2019 at 3:11 PM, EI #2, the Administrator was asked, when EI #1, a LPN, administered the wrong medication to RI #43 on 10/29/2019, did it potentially endanger the life or welfare of the resident. EI #2 answered, yes. RI #43's hospital's History and Physical dated 10/29/2019, documented . Chief Complaint: HPI (History of Present Illness): (RI #43) . with history of congenital [DIAGNOSES REDACTED], . [MEDICAL CONDITION], spastic [MEDICAL CONDITIONS], communicating [DIAGNOSES REDACTED], chronic [MEDICAL CONDITIONS] G tube dependence who presents today with G tube issues but found to be significantly altered . In the ED (Emergency Department), (RI #43) was noted to be bradycardic to the 90s, bradypneic with a rate of 8-10, with an initial blood pressure of 66/49 . (RI #43) was difficult to arouse and had no spontaneous movements even to pain or sternal rub . Once (RI #43) reached the floor, due to (his/her) positive drug screen, (he/she) was given two doses of 2 mg (milligram) [MEDICATION NAME] with no response . A/P (Assessment/Plan): (RI #43) . presents with altered mental status secondary to [MEDICAL CONDITION] vs. medication polypharmacy vs overdose vs. subclinical [MEDICAL CONDITION] vs. meningitis vs. AKI (acute kidney injury). (RI #43) initial workup was reassuring against infection . We will plan to repeat UDS (urine drug screen) and send a comprehensive while attempting to obtain further information regarding these medications (neither are prescribed). (RI #43) remained admitted to the ICU (Intensive Care Unit) due to concern for serious illness in the setting of (his/her) altered mental status, risk of [MEDICAL CONDITION] and (his/her) other comorbidities . RI #43's COMPREHENSIVE DRUG ANALYSIS, UR (Urine) with a 10/29/2019 date of service indicated the following drugs were present in RI #43's system: [MEDICATION NAME][MEDICATION NAME] 648 [MEDICATION NAME] 176 [MEDICATION NAME] 990 [MEDICATION NAME][MEDICATION NAME] and [MEDICATION NAME] are benzodiazepine drugs, but may also be present as common metabolites of other benzodiazepine drugs, including [MEDICATION NAME] Naltrexone PRESENT [MEDICATION NAME] PRESENT Levetiracetam PRESENT [MEDICATION NAME] PRESENT [MEDICATION NAME] PRESENT [MEDICATION NAME] PRESENT [MEDICATION NAME] PRESENT . During an interview on 12/12/2019 at 12:13 PM, EI #8, the facility's Consultant Pharmacist was asked when she became aware that RI #43 had received the wrong medications. EI #8 replied, today (12/12/2019). When asked if she had the opportunity to review RI #43's COMPREHENSIVE DRUG ANALYSIS, UR, EI #8 said no. EI #8 was shown the results and asked what medication it stated [MEDICATION NAME][MEDICATION NAME] and [MEDICATION NAME] may be present as common metabolites of. EI #8 replied, [MEDICATION NAME]. When asked what that meant, EI #8 explained when [MEDICATION NAME] is taken the body breaks the medication down and it could show up in a drug screen as [MEDICATION NAME][MEDICATION NAME] and [MEDICATION NAME]. EI #8 was asked to review RI #14's ordered medications and asked which of the resident's medications could alter a person's mental status. EI #8 said [MEDICATION NAME] was an antianxiety medication which could cause confusion, somnolence (sleepiness) and fatigue. Naltrexone, an Opioid antagonist could cause dizziness. Risperadal, an antipsychotic medication could cause somnolence. [MEDICATION NAME], a muscle relaxant could cause somnolence. [MEDICATION NAME], a muscle relaxant could cause drowsiness. [MEDICATION NAME], a [MEDICAL CONDITION] medication could cause dizziness and drowsiness. [MEDICATION NAME], a blood pressure medication could cause drowsiness and decrease a person's blood pressure. When asked if these medications could endanger the life or welfare of someone who was administered the medication but not prescribed the medications, EI #8 said yes. EI #8 commented, with the blood pressure medication, especially a low blood pressure could be dangerous. The hospital's Discharge Plan for RI #43 dated 11/6/2019, documented . Post hospitalization Care Instructions: Pt (patient) was found to have ingested multiple medications that were not the patient's own medications. Please insure that whoever is giving (him/her) (his/her) medications is only giving (him/her) (his/her) own medications . ************************* On 12/14/2019 at 6:35 PM, the facility submitted a Removal Plan for F 760 which documented: 10/29/19: LPN #1 gave RI #14 medication's to RI #43 and vice versa. LPN #1 was disciplined with suspension. 11/11/19: LPN #1 was reported to Board of Nursing. Sponsors were notified and the Medical Director. Medical Director came to assess resident status and did progress notes in which they had no adverse reaction. Medication error report complete. The licensed staff will begin to review all recent labs on the residents for any significant changes. Medication error report completed. 11/19/19: Nurses were in serviced on medication errors by RN supervisors. Staff not in-serviced will be in-serviced upon returning to work. 12/13/19: Director of Nursing and/or Designee began an audit on medication pass observation to ensure medications are passed per physician orders. Random observation will start until medication error does not occur. Alleging the immediacy is removed on 12/14/19 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 760 was lowered to a D level on 12/14/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL 375.

Based on observation and interview, the facility failed to ensure nine residents' rooms were not set up and furnished for the occupancy of five residents in each room. This deficient practice affected Room Locator (RL) #1 through RL #9, nine of 16 resident rooms in the facility. Findings include: On 12/10/2019 beginning at 11:20 AM, RL #1 through RL #9 were observed set up and furnished for the occupancy of five residents in each room. There were no concerns identified related to access to the residents by staff for provision of care, or the space for each residents' belongings and/or equipment. In an interview on 12/13/2019 at 9:56 AM, Employee Identifier (EI) #2, the Administrator was asked how many beds the facility is certified for. EI #2 replied, 58 beds. When asked what the current census was of the facility, EI #2 said 47. When asked how many rooms accommodated more than four residents, EI #2 answered, nine.

Based on observation, an interview, and review of a facility assessment document for room occupancy, the facility failed to ensure that nine of sixteen resident rooms were not furnished and occupied by no more than four residents per room. This included Room Locator (RL) numbers (#): 1, 2, 3, 4, 5, 6, 7, 8, and 9. This affected 41 of 53 residents residing in the facility. Findings Include: On 10/16/18 at 8:04 AM, during the initial tour of the facility, RL#s: 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for the occupancy of five residents. There were no concerns noted related to access to the residents by staff for care. Adequate space for resident's belongings and equipment was provided. On 10/17/18 at 10:20 AM, EI #1, the Administrator, provided the surveyor with a list of rooms that occupy more than four residents. A review of the document indicated the individual square footage of each room and that each of the RL #s 1-9 were occupied by more than four residents. On 10/18/18 at 9:50 AM, EI #1 reported there were no concerns related to access of the residents by staff to provide care. EI #1 stated the facility had 58 certified beds with a current census of 53. EI #1 stated the facility applied for a waiver annually for the rooms that occupy more than four residents.

Based on an observation, review of the facility's policies titled, Hand Washing Policy/Procedure, Infection and Exposure Control Program, Infection and Prevention Control, medical record review, and interviews, the facility failed to ensure: 1. hand washing was performed and gloves were worn in a manner to prevent cross contamination, 2. gloves were worn when there was a potential for exposure to the employee and 3. an extension tube for a gastrostomy tube was cleaned and dried after use, prior to being placed in a zipper closed bag. The above observations were made of RI (Resident Indentifer) #28 receiving care by a Licensed Practical Nurse, during the administration of a nebulizer treatment on one of four survey days. This affected one of one residents observed receiving a nebulizer treatment. Findings Include: A review of a facility's policy & procedure titled, Infection and Prevention Control with a Revised/Reviewed Date of 10/30/17, revealed: Policy Explanation and Compliance Guidelines: . 8. Equipment Protocol: . b. Single-use disposable equipment is an alternative to sterilizing reusable medical instruments. Single-use devices must be discarded after use and are never used for more than one resident. A review of the facility policy titled, Hand Washing Policy/Procedure with a revision date of 7/15/17 revealed: Hand Washing Policy Staff and all employee working in the facility will follow proper hand washing practices in order to lower risk of spreading communicable disease. 8) Before and after handling and dressing, GT (Gastrostomy Tube), Catheters, Specimen. 9) Before any invasion procedure i.e. (in example) (GT, [MEDICAL CONDITION], Catheter, or Treatments). Wear gloves to protect hands. A review of the facility policy titled, ADMINISTRATION OF MEDICATION BY ENTERAL FEEDING TUBE with a revision date of 7/15/17 revealed: PURPOSE: Safe administration of medication by enteral feeding tube. Remove extension tubing/ clamp or secure tube with plug as indicated. If extension tubing is used - rinse with warm water, drain excess water from tubing and dry exterior with paper towel. Return to zip lock storage bag. A review of RI #28's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/08/17, revealed the resident had short term and long term memory problems and was severely impaired for cognitive skills for daily decision making. RI #28 was coded as being totally dependent on staff for all ADLs (Activities of Daily Living). On 12/05/17 at 10:32 a.m., an observation was made of EI (Employee Identifier) #3, a Licensed Practical Nurse (LPN), removing the extension tube for the gastrostomy tube and placing the extension tubing in a zipper sealed bag. The extension tubing was never cleaned prior to storage. On 12/05/17 at 12:01 p.m., an observation was made of EI #3 during the administration of a nebulizer treatment by [MEDICAL CONDITION]. EI #3 removed the elbow extension from the [MEDICAL CONDITION] shield with gloves on and took it to the sink. EI #3 washed the elbow extension with soap and water and dried it with a paper towel. EI #3 removed her gloves. EI #3 returned to the bedside of RI #28 without washing her hands or putting on gloves. EI #3 placed the elbow attachment on the [MEDICAL CONDITION] shield and administered the nebulizer treatment. EI#3 removed the nebulizer cup, washed and dried the nebulizer cup, returning it to a storage bag. All of the above referenced tasks were done with bare and unwashed hands. On 12/06/17 at 8:29 a.m., an interview was conducted with EI #3. EI #3 was asked what was done when she disconnected the extension tube from the gastrostomy tube. EI #3 replied, Disconnected the tube and put in a zip closed bag. EI #3 was asked what the facility policy was for cleaning the extension tubing after use. EI #3 replied she placed the tube in a closed zip lock bag. EI #3 was asked to look at the facility policy related to the extension tubing for a gastrostomy tube and what to do after use. EI #3 replied it was supposed to be rinsed and dried and placed in a closed zip lock bag. EI #3 was asked what was the potential concern if the tubing was not cleaned and dried after use. EI #3 replied it could cause infection or mold to grow. EI #3 was asked to describe how she cleaned and replaced the elbow extension to the [MEDICAL CONDITION] shield for administration of the nebulizer treatment for [REDACTED]. EI #3 replied she removed the attachment from the shield, washed it, and put it back on the shield. EI #3 was asked if she washed her hands and regloved after cleaning the elbow extension. EI #3 replied she thought she did, but she guess she did not. EI #3 was asked why she did not wash her hands and put clean gloves on. EI #3 replied she was real nervous. EI #3 was asked if she should have washed her hands and regloved. EI #3 replied yes. EI #3 was asked why. EI #3 replied to protect herself and infection control.

Based on record review, review of POTTER and PERRY's, FUNDAMENTALS OF NURSING, NINTH EDITION, an observation and interviews, the facility failed to ensure: a Licensed Practical Nurse (LPN) followed the physician's orders [REDACTED]. This affected RI (Resident Identifier) #28, one of three residents observed receiving medications by gastrostomy tube. Findings Include: A review of Potter and Perry's, Fundamentals of Nursing, Ninth Edition, Copyright 2017, Chapter 23, Legal Implications in Nursing Practice, page 311, Health Care Providers' Orders, revealed: The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. A review of RI #28's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/08/17 revealed the resident had short term and long term memory problems and was severely impaired for cognitive skills for daily decision making. RI #28 was coded as being totally dependent on staff for all ADLs (Activities of Daily Living). RI #28 was coded as having a feeding tube on the MDS. A review of the physician's orders [REDACTED]. On 12/05/2017 at 10:32 a.m., an observation was made of EI (Employee Identifier) #3, a LPN (Licensed Practical Nurse), preparing and administering medications to RI #28. EI #3 prepared all medications scheduled for a 10:00 a.m. administration at the medication cart. EI #3 entered RI #28's room and checked the gastrostomy tube for placement using an extension tube attached to the gastrostomy tube. EI #3 flushed the gastrostomy tube with 30 ML H20 prior to administering the medications. EI #3 administered all medications. Upon completion of the administration of all the medications, EI #3 flushed the gastrostomy tube with 45 ML of H2O. On 12/06/17 at 08:29 a.m. an interview was conducted with EI #3. EI #3 was asked what amount of water she used to flush the gastrostomy tube with prior to giving any medications to RI #28, and after giving all medication. EI #3 replied, 30 cc of water before (administering) and 30-45 cc after all were given. EI #3 was asked why 30 MLs before the medications were given and 45 MLs after the last medication was given. EI #3 replied, Clear the tube out. EI #3 was asked how she knew to use this amount of water for flushing the gastrostomy tube. EI #3 replied, Learned in school and MD (Medical Doctor) orders. EI #3 was given a copy of the physician's orders [REDACTED]. EI #3 was asked what did the physician's orders [REDACTED]. EI #3 replied, 100 cc before and after the medications. EI #3 was asked if the physician's orders [REDACTED]. EI #3 replied, No. On 12/07/17 at 03:10 p.m. an interview was conducted with EI #2, the DON (Director of Nursing) and Staff Development Coordinator. EI #2 was asked if giving medication per a gastrostomy tube, what amounts of water was to be used before medication administration and after medication administration was completed. EI #2 replied, Flush tube with doctor ordered amount of water, then final flush with ordered amount. If a doctor orders a specific amount, give what the doctor ordered. EI #2 read the physician's orders [REDACTED]. EI #2 was asked if the physician's orders [REDACTED].#28 if the nurse used 30 MLs before giving the medications and 45MLs after the medication administration was complete. EI #2 replied, No, they were not. RI #28- Did not follow physician order [REDACTED].>FACILITY Medication Administration

Based on observation, interviews, and record review the facility failed to ensure the appropriate amount of fluids was administered by a Licensed Practical Nurse before administration of medications and after the administration of medications. This affected RI (Resident Identifier) #28, one of three residents observed receiving medications by gastrostomy tube. Findings Include: A review of RI #28's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of a Medication Administration Record [REDACTED]. FLUSHES: 100ML H2O BEFORE AND AFTER MEDS AND FEEDINGS . A review of a quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/08/17, revealed the resident had short term and long term memory problems and was severely impaired for cognitive skills for daily decision making. RI #28 was coded as being totally dependent on staff for all ADLs (Activities of Daily Living). RI #28 was coded as having a feeding tube on the MDS. On 12/05/2017 at 10:32 a.m. an observation was made of EI (Employee Identifier) #3, a Licensed Practical Nurse (LPN) preparing and administering medications to RI #28. EI #3 prepared all medications scheduled for a 10:00 a.m. administration at the medication cart. EI #3 then entered RI #28's room, checked the gastrostomy tube for placement using an extension tube attached to the gastrostomy tube. EI #3 flushed gastrostomy tube with 30 ML H20 prior to administering the medications. EI #3 administered all medications. Upon completion of the administration of all the medications, EI #3 flushed the gastrostomy tube with 45 ML of H2O. On 12/06/17 at 08:29 a.m., an interview was conducted with EI #3. EI #3 was asked what was the amount of water she used to flush the gastrostomy tube with prior to giving any medications to RI #28, and after giving all medications. EI #3 replied, 30 cc (cubic centimeters) of water before (administering) and 30-45 cc after all were given. EI #3 was asked why 30 MLs before the medications were given and 45 MLs after the last medication was given. EI #3 replied, Clear the tube out. EI #3 was asked how she knew to use this amount of water for flushing the gastrostomy tube. EI #3 replied. Learned in school and MD (Medical Doctor) orders. EI #3 was given a copy of the physician's orders [REDACTED]. EI #3 was asked what did the physician's orders [REDACTED]. EI #3 replied, 100 cc before and after the medications. EI #3 was asked if the physician's orders [REDACTED]. EI #3 replied, No. On 12/07/17 at 3:10 p.m., an interview was conducted with EI #2, the DON (Director of Nursing) and Staff Development Coordinator. EI #2 was asked if giving medication per a gastrostomy tube, what amounts of water was to be used before medication administration and after medication administration was completed. EI #2 replied, Flush tube with doctor ordered amount of water, then final flush with ordered amount. If a doctor orders a specific amount, give what the doctor ordered. EI #2 read the physician's orders [REDACTED]. EI #2 was asked if the physician's orders [REDACTED].#28 if the nurse used 30 MLs before giving the medications and 45MLs after the medication administration was complete. EI #2 replied, No, they were not.

Based on observations, interview, and record review, the facility failed to ensure that nine of 16 residents' rooms were furnished and occupied by no more than four residents per room in Room Locator (RL) numbers (#): 1, 2, 3, 4, 5, 6, 7, 8, and 9. This affected 40 residents in the identified rooms and had the potential to affect 45 residents living in rooms with more than four beds. Findings Include: During the initial tour on 12/04/17, between 1:55 p.m. and 2:30 p.m., RL#s: 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for the occupancy of five residents. An interview was conducted with Employee Identifier (EI) #1, Administrator, on 12/06/17 at 8:06 a.m. EI #1 stated the facility had 58 certified beds with a current census of 52. EI #1 stated the facility applied for a waiver annually for the rooms that occupy more than four residents. On 12/06/17 at 8:06 a.m., EI #1 provided the surveyor with a list of rooms that occupy more than four residents. The document indicated the square footage of each room occupied by more than four residents. On 12/06/17 at 4:28 p.m., RL #s 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed with five beds. The rooms were decorated, furnished, and clean. There were no concerns noted related to access to the residents by staff for care. Adequate space for resident's belongings and equipment was provided.

Based on interviews and record review, the facility failed to ensure the Medical Director assisted with the coordination of medical care through his consistent attendance and active participation in the Quality Assurance and Assessment (QAA) meetings. This had the potential to affect all 54 residents in the facility at the time of this survey. Findings included: The facility Quality Assessment and Assurance Policy (undated) states the following: It is the policy of this facility to . monitor and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems . The Quality Assessment and Assurance (QAA) Committee members (by policy definition) consists of the Administrator, the Director of Nursing, the Medical Director and the QAA Coordinator, and should meet a minimum of quarterly, or at more frequent intervals as determined by the Committee . The attendance records of the facility's QAA Committee indicated the Medical Director attended only two of eleven meetings conducted (monthly) between 02/15/16 and 01/04/17. On 01/18/17 at 8:30 a.m., the Administrator (Employee Identifier/EI #1) confirmed the Medical Director had been able to attend only two QAA meetings last year due to his busy hospital medical schedule. On 01/18/17 at 4:00 p.m., the QAA Coordinator (EI #2) stated the Medical Director (MD) was invited to every meeting, but was supposed to attend (at least) quarterly meetings. EI #2 explained the QAA meetings were changed at times to accommodate the MD's schedule. When asked why it was necessary for each member (including the MD) to attend, EI #2 stated it was important to get input on the care of each child. EI #2 explained it took each person's involvement to care for all of the children and the MD wrote the orders. EI #2 explained the MD was very busy, and would address any issues or questions, but did not participate by conference call if unable to be present. EI #2 confirmed the MD knew each child well, provided good input, and added a lot to the committee. On 01/19/17 at 12:15 p.m., the Medical Director (EI #3) was interviewed by phone. EI #3 explained he was not able to make more of the meetings due to his busy hospital schedule (making rounds on his patients). EI #3 confirmed the facility notified him of the meetings and tried to work with his schedule, but his schedule would often change unexpectedly. EI #3 stated he was aware of his responsibility to attend the QAA meetings.

Based on record review and interviews, the facility failed to ensure the members of the Quality Assurance (QA) Committee consistently attended the meetings on at least a quarterly basis. This had the potential to affect the care of all 54 residents residing in the facility at the time of this survey. Findings included: The facility Quality Assessment and Assurance Policy (undated) designates the purpose as: . 1. To provide a centralized, coordinated approach and a comprehensive program of Quality Assessment and Assurance that meets the needs of the facility. 2. To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Program (QAA). 3. To provide a means whereby risk or potential risk to resident care can be identified and resolved through an interdisciplinary approach and positive outcomes can be reinforced through education and monitoring . The policy states the Committee membership will include the Administrator, the Director of Nursing, the Medical Director and the QAA Coordinator. The policy specifies the . Committee should meet a minimum of quarterly, or at more frequent intervals . On 01/17/17 at 2:30 p.m., the facility Administrator (Employee Identifier/EI #1) provided a copy of the facility's QAA Committee (monthly) attendance records for the previous six month period (07/13/16 through 01/04/17). The records indicated the Medical Director attended only one (08/15/16) of the six monthly meetings. On 01/18/17 at 8:30 a.m., the surveyor asked EI #1 to confirm the number of QAA meetings the Medical Director attended. EI #1 confirmed it had been two meetings over the previous 12 month period. On 01/18/17 at 4:00 p.m., the QAA Coordinator (EI #2) was interviewed. EI #2 stated the Medical Director was supposed to attend one QAA meeting each quarter, although he was invited to each monthly meeting. EI #2 explained the facility tried to accommodate the Medical Director's busy schedule and he was important to the Committee.

Based on observation, interview and record review, the facility failed to ensure that 9 of 16 residents' rooms were furnished and occupied by no more than four residents per room. This affected Room Locator (RL) numbers (#): 1, 2, 3, 4, 5, 6, 7, 8, and 9. This affected 41 residents in the identified rooms and had the potential to affect 45 residents living in rooms with more than 4 beds. Findings include: During the initial tour on 01/17/2017 between 2:15 and 3:33 p.m., RL #: 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for the occupancy of five residents in each room. An interview was conducted with Employer Identifier (EI) #1 on 01/17/2017 at 2:15 p.m. EI #1 stated the facility had 58 certified beds with a current census of 54. EI #1 confirmed the facility applied for and received a waiver annually for the occupancy of more than four residents per room. On 01/17/2017 at 2:30 p.m., EI #1 provided the surveyor with a document titled Room Measurements for the rooms set up and furnished for the occupancy of five residents. The measurements listed on this document identified the rooms provided at least 80 square feet of space for each resident in the rooms. During the survey 01/17/2017 through 01/19/2017, observations were made of the residents' rooms with five beds. There were no concerns identified related to access to the residents by staff for provision of care, or the space for each residents' belongings and/or equipment.

Based on observation, interview and record review, the facility failed to ensure that nine of 16 resident's rooms were furnished and occupied by no more than four residents per room. This affected Room Location Numbers (RL's) # 1, 2, 3, 4, 5, 6, 7, 8, and 9; and currently affected 30 residents residing in the identified rooms. This had the potential to affect 45 residents living in rooms with more than 4 residents. Findings include: An observation was made on the initial tour on 2/22/16 at 10:30 AM. RL's # 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for occupancy of five residents in each room. An interview was conducted with EI (Employee Identifier) #1, the Administrator on 2/24/16 at 8:29 AM. EI #1 stated the facility had 58 certified beds with a current census of 50 residents. EI #1 confirmed the facility applies for and receives a wavier annually for the room occupancy of more than four residents per room. On 2/24/16 at 5:30 PM, EI #1 provided the surveyor with a copy of a document titled Room Measurements for rooms set up and furnished for occupancy of five residents, including the measurements of each room. The room measurements provide by the facility identified the rooms provided at least 80 square feet of space for each resident residing in these rooms. During the survey, 2/22/16 through 2/25/16, observations were made of the resident's rooms, with five beds. There were no concerns identified related to access to the residents by staff for the provision of care, or the space for the resident's belongings and/or equipment.

Based on observations, record review and interview: 1) MACHINE DISHWASHING - The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms by maintaining the final rinse (sanitizing) water at 180 degrees Fahrenheit. Sub-standard temperatures were logged during operation of the machine during three days and seven meal times . 2) MANUAL DISHWASHING - The facility failed to follow correct manual dishwashing procedures in the pots/pan sinks by a failure to monitor and assure correct water temperature. 3) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code (11 of 28 days in February not covered). 4) The facility failed to assure facial hair (mustache) of a male employee was covered. 5) The facility failed to assure/prevent potential food contamination during storage by removing cans with compromised seals from the active inventory. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 18 residents receiving meal trays from dining services. Findings include: 1) MACHINE DISHWASHING The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms by maintaining the final rinse (sanitizing) water at 180 degrees Fahrenheit. Sub-standard temperatures were logged during machine operation for a period of three days and seven meal times . The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: " 4-501.112 Mechanical Warewashing Equipment. Hot Water Sanitation Temperatures. (A) ...the fresh hot water sanitizing rinse...(2) For all other machine, 82 degrees C (180 degrees F)." On 2/23/2015 at 2:35 PM, the maintenance man and ... (chemical representative) were observed at the dishmachine. It was determined that the machine had malfunctioned and the machine needed replacement parts. A review of the facility log titled "Dishwashing Temperature Chart February 2015" indicated on 2/21/2015 at 1:00 PM the final rinse temperature documented was 100, at 6:00 PM the final rinse recorded was 102. On 2/22/2015 staff recorded the 7:00 AM rinse as 118, the noon operation value was 105 and the evening rinse temperature was 107. The line employees failed to respond to a deviation in record keeping monitoring at a critical control point. The log failed to indicate any corrective actions taken. A request was made for a copy of the policy/procedure for the dishmachine. A document titled "Procedures for the pot and pan sink", no date of origin, but an update of 2/23/2015. Monitoring and documenting was not addressed. On 2/24/2015 at 3:20 PM, the CDM (Certified Dietary Manager), EI #2 was asked, what are staff directed to do if temperatures are sub-standard. EI #2 responded, notify the Dietary Manager. EI #2 was asked, was that done. EI #2 responded, no, Ma'am. 2) MANUAL DISHWASHING - The facility failed to follow correct manual dishwashing procedures in the pots/pan sinks by a failure to monitor and assure correct sanitizing water temperature. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "4-501.111 Manual Warewashing Equipment. Hot Water Sanitization Temperatures. If immersion in hot water is used for sanitizing in a manual operation, the temperature of the water shall be maintained at 77 degrees C (171 degrees F) or above." On 2/23/2015 at 2:40 PM staff was observed processing items through the pots/pan sinks. Employee Identifier (EI) # 4 was asked about the location of the temperature monitoring log for the pots/pan sink. EI #4, the PM Cook responded that there was not a log for monitoring. The facility lacked evidence to show that temperature standards were maintained. 3) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code (11 of 28 days in February not covered). The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: SUPERVISION "Responsibility 2-101.11 Assignment. (A) Except as specified in ? (B) of this section, the PERMIT HOLDER shall ...ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation ...The person in charge shall demonstrate this knowledge by: (A) complying with the Code by having no violations ...(B) Being a certified food protection manager who has shown proficiency of required information through passing a test (Serv-Safe)..." The employee work schedule for February 2015 was reviewed. The Certified Dietary (EI #2) was asked to identify employees with Serv-Safe credentialing. EI #2 provided certificates for credentialing for herself and one employee. After research a third employee (EI #4) was certified. The February work schedule was reviewed and it was determined that for 11 of the 28 days in February, there was no supervision from opening to closing by a knowledgeable (food code) employee. 4) PREVENT POTENTIAL CROSS-CONTAMINATION. HYGIENIC PRACTICES Staff failed to effectively utilize hair restraints (beard cover) to keep hair from contacting exposed food, clean equipment etc. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: " 2-402.11 Hair Restraints - Effectiveness. (A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair ..." On 2/24/2015 at 8:45 AM, a male food service employee (with facial hair on chin and above the lip) was observed in the food preparation/service area. The hair on the chin was covered with a restraint, but the mustache was not covered. During an interview on 2/24/2015 at 3:20 PM, the CDM, EI #2 was asked, was the facial hair restrained on a male employee. EI #2 responded, (the) mustache was not covered. 5) The facility failed to assure/prevent potential food contamination during storage by removing cans with compromised seals from the active inventory. On 2/24/2015 at 9:05 AM the food storage area was reviewed. Dented cans (2) were observed in the active inventory. The dents were located on the seals which compromised the risk of potential contamination. An interview was conducted on 2/24/2015 at 3:20 PM, with the CDM, EI #2. EI #2 was asked, were dented cans found in the active inventory. EI #2 responded, "Yes, Ma'am". EI #2 was asked, what was the potential risk. EI #2 responded, Biological Contamination.

Based on observation, interview and record review, the facility failed to ensure that nine of 16 resident rooms were furnished and occupied by no more than four residents per room. This affected Room Location Numbers (RL ' s) 1, 2, 3, 4, 5, 6, 7, 8, and 9. This had the potential to affect 40 residents currently residing in the identified nine rooms. Findings include: An observation was made on the initial tour on 2/23/15 at 2:58 PM, RL's 1, 2, 3, 4, 5, 6, 7, 8, and 9 were observed set up and furnished for occupancy of five residents in each room. An interview was conducted with EI (Employee Identifier) #1, the Administrator on 2/23/15 at 2:32 PM. EI #1 stated that the facility had 58 certified beds with a current census of 52 residents. EI #1 confirmed the facility applied for and received a wavier annually for room occupancy of more than four residents per room. On 2/23/15 at 5:30 PM, EI #1 provided the surveyor with a copy of a document titled "Room Measurements" of all rooms which was set up and furnished for occupancy of five residents and the measurements of each of these rooms. On 2/25/15 at 1:30 PM, EI #1, the Administrator and the surveyor measured the identified rooms. All rooms provided at least 80 square feet of space for each resident residing in the room. During the survey, 2/23/15 thru 2/25/15, random observations were made of the residents rooms furnished for occupancy of five residents. There were no concerns identified related to access of the resident by staff for the provision of care, or the space for the resident's belongings and/or equipment.

Based on interviews, record reviews, and review of the facility's abuse policy and procedure titled, "Resident Abuse Neglect Restraint Seclusion", the facility failed to prevent RIs (Resident Identifier) #2, #3, #4 and #5 from being physically and mentally/verbally abused by facility staff. Through interviews with Certified Nursing Assistants (CNA) it was determined three CNAs witnessed four residents being physically and/or verbally abused by two CNAs on multiple occasions. The CNAs who witnessed the abuse stated they were aware they observed physical, mental and/or verbal abuse. These incidents of verbal, physical and mental abuse were witnessed from 01/22/14 to 01/27/14. RI #2, a cognitively impaired quadriplegic resident totally dependent on staff, was physically and mentally/verbally abused by EI (Employee Identifier) #1, a male CNA. During a shower on 01/22/14, EI #1 sprayed water into RI #2's face causing the resident to gasp for air; pinched his arm; used profanity toward this resident; and left him unattended on the shower bed/trolley. During another shower on 01/27/14, EI #1 used profanity toward RI #2 again, after RI #2 complained to EI #1 the water was hot. RI #4, a cognitively impaired resident with a [MEDICAL CONDITION], was physically and mentally/verbally abused by EI #1. On 01/22/14, EI #1 slammed RI #4 onto the shower bed/trolley, slapped his head and used profanity toward RI #4. On 01/27/14, EI #1 slammed RI #4 onto the shower bed/trolley and used profanity toward RI #4 again. RI #3, a cognitively impaired resident unable to speak, was physically abused by EI #2, a male CNA. On 01/24/14, EI #2 punched RI #3 in the arm. On 01/24/14, EI #2 was providing RI #5 a shower. Another CNA (EI #9) stated she heard a loud sound, like a slap and observed RI #5's lips trembling and a sad look on RI #5's face. These deficient practices placed four of five sampled residents reviewed for abuse, RI #2, #3, #4, and #5 in immediate jeopardy, as it was likely to cause serious injury, harm, or death. On 02/25/14 at 6:00 PM, the facility's Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level of "L" in area of Resident Behavior and Facility Practices, F 223. Findings Include: The facility's policy titled "Resident Abuse Neglect Restraint Seclusion" reviewed and revised on 01/02/14, documented: "... TYPES OF ABUSE: Physical Abuse: is defined as willful actions that cause injury or pain to residents by staff, ... Examples of Physical abuse includes ... hitting, pinching ... pulling the resident, ... or any other intentional action by staff that causes injury or pain. Mental/Verbal Abuse: is defined as willful behavior by staff, ... who humiliates, harasses or provides for threats of punishment ... Mental abuse includes the use of oral, ... gestured language that willfully includes derogatory remarks to resident ... regardless of age, ability to comprehend or degree of disability. Examples of mental abuse includes; raising one's voice, yelling, belittling speech, the use of profanity or loud threatening, rude or aggressive language, that frightens or intimidates resident ... or the use of overt or implied threatened harm to residents ..." 1. RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Annual Minimum Data Set ((MDS) dated [DATE] documented RI #4 required total assistance with activities of daily living (ADL) and was incontinent of bowel and bladder. The MDS identified RI #4 had short of breath/trouble breathing. RI #4 was 44 inches tall and weighed 49 pounds. A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th (2014) respectively. Statements are attached for reference..." a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: On 1/21/14 Wednesday night on 11-7 shift I observed (EI #1) telling (RI #4) to shut the [***] up and slapping him upside the head and throwing him on the shower bed ... ." During an interview on 02/21/14 at 2:10 PM, EI #7 (CNA) confirmed that on 01/22/14 during AM (morning) showers around 5:00 AM, she witnessed EI #1 slam RI #4 onto the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling the resident to shut the "[***] up" and then slapped the resident hard on the head then, RI #4 jerked backwards and began to gasp, and scream loudly. b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: Monday morning [DATE] while I was giving showers (EI #1) brought (RI #4) in the shower room threw him on the shower bed & (and) when (RI #4) started crying (EI #1) said "[***] shut the [***] up before I slap you. ..." During an interview on 02/21/14 at 12:05 PM, another CNA, EI #8 confirmed that on 01/27/14 during AM showers around 5:00 AM, she heard a sound like someone slamming a child on the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling him [***] shut the [***] up before I slap the [***] out of you. 2. RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's current Quarterly MDS dated [DATE] revealed RI #2 had short term memory problems, no long term memory problems and moderately impaired in cognitive skills for daily decision making. The MDS also documented RI #2 required total assistance with all activities of daily living. A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th respectively. Statements are attached for reference..." a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... then (EI #1) started telling (RI #2) to shut the [***] up and pinching (RI #2) and pinching him ... (EI #1) always cursing the kids out telling them [***] shut the [***] up." On 02/21/14 at 4:10 PM, EI #7 also confirmed that on 01/22/14, after RI #4's shower, EI #1 entered the shower room with RI #2, who was hollering for the nurse. EI #7 witnessed EI #1 verbally abused the resident by telling the resident to "shut the [***] up" and pinched the resident on the arm. RI #2 began to scream and cry, then EI #1 sprayed water into RI #2's face, causing the resident to gasp for air. EI #7 stated RI #2 said that the water was hot. EI #1 told RI #2 to "shut up" and EI #1 hit the resident. The nurse walked into the shower room and EI #1 stopped. The nurse asked RI #2 what was wrong, but RI #2 did not respond. After the nurse left the area, EI #1 sprayed RI #2 in the face with water again and left RI #2 unattended on the shower bed/trolley. RI #2 was interviewed on 02/23/14 at 1:10 PM. RI #2 was asked if someone hurt him in the shower he stated, "That man." When asked if he knew the name of that man, he stated, "(First name of EI #1)". RI #2 was asked if EI #1 slapped him on the head and he stated, "Yeah". b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... Also while he was giving (RI #2) a shower I walked in on him (EI #1) telling (RI #2) to shut the hell and (RI #2) said the water hot then (EI #1) said shut the [***] the water ain't hot. ..." During an interview on 02/21/14 at 12:05 PM, EI #8 confirmed that on 01/27/14 during AM showers, she witnessed EI #1 start to shower RI #2. RI #2 started yelling the water was hot and EI #1 verbally abused the resident by telling RI #2, "[***] shut the [***] up, the water is not hot." EI #1 continued to shower RI #2 and the resident kept yelling the water was hot. 3. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual MDS dated [DATE] revealed RI #5 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The MDS documented RI #5 had no speech-absence of spoken word, and was rarely understood/ understand. The MDS also documented RI #5 required total assistance for all activities of daily living and was incontinent of bowel and bladder. A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th respectively. Statements are attached for reference..." EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... I heard a punch in the shower room on January 23, 2014 at approximately 5:00 in shower room I thought (EI #2) had punched the child (RI #5)." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers, EI #2 was showering RI #5. EI #9 stated she heard a loud slap and witnessed RI #5 looking fearful. EI #9 stated RI #5 looked like he was about to cry. 4. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS dated [DATE] revealed RI #3 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The MDS documented RI #3 had no speech-absence of spoken word, and rarely understood/understand. The MDS also documented RI #3 required total assistance for all activities of daily living except for supervision with bed mobility, and was incontinent of bowel and bladder. A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th respectively. Statements are attached for reference..." EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: I (EI #9) actually saw (EI #2) punch the patient (RI #3) on the arm on January 23, 2014 at approximately 5:30 AM inside the shower and room. ..." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers at approximately 5:30 AM, she witnessed RI #3 squirming on the shower bed/trolley. EI #2 gave a hard punch to RI #3's left arm. In a subsequent interview with EI #9 on 02/23/14 at 9:40 AM, she was asked to recall the 01/24/14 shower incident involving RI #3 and EI #2. During this interview EI #9 provided a hand written statement that documented EI #2 punched RI #3's arm causing the resident to jump. ******************** On 02/26/14 at 5:45 P, the Facility submitted an Allegation of Credible Compliance (AOCC). F225 483.13 (C)(1)(ii) Not employ individuals who have been (A) Found guilty of abusing neglecting or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aid registry concerning abuse, neglect, mistreatment, of residents, or misappropriation of their property and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility to the State nurse aide registry or licensing authorities. 483.13 (C)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(C)(3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. 483.13 (C)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. 1) Father Purcell Memorial's DON started in-servicing the staff on 2/24/2014 to 2/25/2014 on the following: ? Policy: Supervisor actions when abuse is suspected ? Resident Abuse Neglect Restraint Seclusion ? Resident Rights ? Abuse Prevention Policy and Procedure 2) The Social Worker was in-serviced on Abuse and Reporting by the local ombudsman, at 7pm on 2/25/14 by telephone conference with the Executive Director of the City of St. Jude present. 3) The local ombudsman in-serviced the staff on Abuse and the new Abuse Coordinator also in-serviced the staff on 2/26/2014. 4) All potential hires work record and references will be checked and cleared. 5) All potential hires must be cleared with the State Nurse Aide Registry before hire and at intervals throughout employment. 6) All employees whose actions and non-actions resulted in F223 tag were counseled on how important it is to report an allegation of abuse immediately. These employees were also advised that if this (failure to report) occurred again then they would be terminated immediately. 7) (Name of EI #1), CNA and (Name of EI #2), CNA was terminated. 8) The Executive Director of City of St Jude will in-service the administrative staff of Father Purcell Memorial's on Abuse Prevention Policy and Procedure on 2/26/2014. The follow-up will be to review FPM abuse policies with administrative staff biannually. The FPM Abuse Policy was reviewed and revised by the Executive Director of City of St. Jude on 2/25/2014. 9) A RN has been named the new Abuse Coordinator of Father Purcell Memorial Exceptional Children's Center. She was trained on Father Purcell Memorial's Abuse Policy and Procedure's by the Executive Director of the City of St. Jude on 02/26/2014. 10) The Abuse Coordinator and the Director of Nursing will be conducting the Abuse Prevention Policy and Procedure training inclusive of PRNs and contractual employees starting 02/26/2014 and completed by 3/7/2014. 11) The Abuse Coordinator and the Director of Nursing will be responsible for in-servicing all PRNs employees and contractual employees. 12) All staff will be interviewed by the Abuse Coordinator and the Director of Nursing regarding other allegations of abuse starting 2/26/2014 and completed by 2/28/2014. 13) When there are any allegations of abuse made the Abuse Coordinator and the Director of Nursing will interview the resident or at least make an attempt to. We only have one child that may be interviewable. He has short term memory problems but his long term is ok. The resident was interviewed on 2/26/2014 by the Abuse Coordinator and the Director of Nursing. 14) New hire files were reviewed for orientation Abuse policy and procedure for the past 3 months it was reviewed on 02/26/2014 by the Administrative Assistant. 15) Father Purcell Memorial's nursing staff started body audits on 2/26/2014 and will be completed on 2/26/2014 by LPNs and RNs looking for bruises, abrasions, and any injury of unknown origin. And if any suspect area will be investigated and reported to the state. 16) All staff will be interviewed regarding in any other allegation of abuse or witness of abuse by the Abuse Coordinator and the DON began 2/26/2014 and completed by 2/28/2014. ************************* After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 02/26/14 at 7:15 PM. The scope and severity was lowered to "F" level to allow the facility time to monitor/revise their corrective actions.

Based on interviews, and record reviews, including the facility's abuse policy and procedures, and abuse investigative files, the facility's administration failed to provide management and oversight to ensure all staff members including full-time, part-time, as needed staff (PRN) and contract, were inserviced on reporting allegations of abuse. Employee Identifier's (EI) #1 and #2 were witnessed by co-workers to verbally and/or physically abuse Resident Identifiers (RI) #2, #3, #4 and #5, four cognitively impaired residents, on multiple occasions from 01/22/14 to 01/27/14. Through staff interviews and a review of the Resident's Rights and Abuse training records, it was revealed EI #1 did not attend any of the mandatory abuse trainings since being hired on 01/23/13. EI #2, rehired on 04/29/13, had only attended one of two abuse trainings, provided by the facility since his rehire date. The facility's administration further failed to ensure Certified Nursing Assistants (CNA) immediately reported incidents of physical and verbal abuse to the Administrator or designee. These CNAs witnessed two of their coworkers inflict verbal and/or physical abuse to residents on 01/22/14, 01/24/14 and 01/27/14. These incidents of verbal and physical abuse were not reported until 01/28/14. On 01/22/14, a male CNA, Employee Identifier (EI) #1 sprayed water into Resident Identifier (RI) #2's face causing the resident to gasp for air; pinched his arm, used profanity toward this resident and left him unattended on the shower bed/trolley. On 01/22/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley, slapped his head and used profanity toward RI #4. On 01/24/14, a male CNA, EI #2 punched RI #3 in the arm. On 01/24/14, a male CNA, EI #2 was providing RI #5 a shower. A CNA stated she heard a loud sound, like a slap and observed RI #5's lips trembling and a sad look on his face. On 01/27/14, during a shower, a male CNA, EI #1 used profanity toward RI #2, after RI #2 told EI #1 the water was hot. On 01/27/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley and used profanity toward RI #4. This deficient practice placed four of five sampled residents reviewed for abuse, Resident Identifiers (RI) #2, #3, #4, and #5 in immediate jeopardy, as it was likely to cause serious injury, harm, or death. On 02/25/14 at 6:00 PM, the facility's Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level of "L" in area of Administration (F 490). The immediate jeopardy began on 01/22/14 and was abated onsite on 02/26/14 at 7:15 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any further recurrence. Findings Include: Cross Reference F 223, F 225 and F 226. A review of the facility's Position Description for the Administrator (ADM) revealed the following: "SUMMARY The Administrator is responsible to the Director of the City of St. Jude for effectively and efficiently planning, organizing, directing and controlling all aspects of the operation of Father Purcell Children's Center in a manner assuring quality care for the children, concern for their parents and satisfaction of all federal, state, and local laws and regulations governing nursing homes. Oversees, coordinates and ensures quality of care and services provided the resident children through staff meetings and/or personal conferences with department heads, ... Establishes and oversees employee ... suspension, termination, discharge ... Oversees conduct of orientation and continuing education and training of Center staff, ..." A review of the facility's Position Description for the Director of Nursing dated 10/03/08, revealed the following: "SUMMARY: ... 11. Respect resident rights to include free from abuse and neglect. Employee understands policy on abuse and how to report it to proper personnel if witnessed. ..." A review of the facility's policy and procedure signed and dated 01/02/14, titled "Policy: Abuse and Neglect" revealed the following: "It is the policy of Father Purcell Memorial Exceptional Children's Center that no resident will suffer from abuse while under our care. ... II. Training - Train employees, through orientation and on-going session related to abuse prohibition practices ... How staff should report their knowledge related to allegations ... (Attendance at training will be recorded ... III. Prevention ... During employee orientation: provide employees with information on how and to whom to report suspicion of abuse. Identify, correct and intervene in situations in which abuse ... is more likely to occur. ... The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, ... IV. Identification ... Any suspicions shall be immediately reported to Administrator or designated person in charge of facility at the time. ... VII. Reporting/Response The administrator or designated person shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation: ..." The facility's policy titled "Resident Abuse Neglect Restraint Seclusion" reviewed and revised on 01/02/14, documented: Types of Abuse Physical Abuse: is defined as willful actions that cause injury or pain to residents by staff, ... Examples of Physical abuse includes ... hitting, pinching ... pulling the resident, ... or any other intentional action by staff that causes injury or pain. Mental/Verbal Abuse: is defined as willful behavior by staff, ... who humiliates, harasses or provides for threats of punishment ... Mental abuse includes the use of oral, ... gestured language that willfully includes derogatory remarks to resident ... regardless of age, ability to comprehend or degree of disability. Examples of mental abuse includes; raising one's voice, yelling, belittling speech, the use of profanity or loud threatening, rude or aggressive language, that frightens or intimidates resident ... or the use of overt or implied threatened harm to residents ..." During an interview with EI #4 (Social Worker/Abuse Coordinator) on 02/23/14 at 2:20 PM, the surveyor asked who was responsible for conducting the abuse inservices. EI #4 explained that she was responsible for the facility abuse inservices that were provided quarterly. The surveyor asked what was the requirement for staff attendance. EI #4 stated all abuse inservices were mandatory. The surveyor asked EI #4 what was her responsibility as abuse coordinator. EI #4 stated to ensure each employee has received inservice on abuse, neglect and residents rights. The surveyor asked if each employee was inserviced on 01/03/14. EI #4 stated, "Each employee was not, I know they weren't." During an interview with EI #3 (ADM) on 02/23/14 at 1:50 PM, the surveyor asked what did she do regarding the abuse allegations involving staff members EI #1 and EI #2, and RI #2, #3, #4 and #5. EI #3 stated she reported the information to the State Agency, suspended the alleged employees, eventually fired EI #1 and EI #2 and obtained witness statements. The surveyor asked what did she do to ensure staff knew what to do regarding abuse. EI #3 stated, the facility had just inserviced the staff on January 3rd (2014) and she did not provide any further abuse inservices. The surveyor asked what should have been done to the staff, after three CNAs reported allegations of abuse involving staff members EI #1 and EI #2, and RI #2, #3, #4 and #5. The Administrator explained that all three staff, who witnessed the abuse, "Should have been inserviced again." The surveyor asked who was responsible overall for the safety and the well being of the residents. EI #3 stated, "I am." During an interview with EI #3 (ADM) on 02/25/14 at 1:00 PM, the surveyor asked if the abuse inservices were mandatory. EI #3 stated the inservices are mandatory in orientation and are ongoing. During an interview with EI #4 (Social Worker/Abuse Coordinator) on 02/25/14 at 4:42 PM, the surveyor provided a copy of the abuse policy and procedure for her review. When asked what does ongoing mean regarding training, EI #4 stated the facility attempts to do inservices quarterly, but last year the July inservice was missed because of staff vacations. The surveyor asked when was the July inservice rescheduled. EI #4 stated the inservice was not rescheduled. The surveyor asked who was responsible to ensure all staff attended the abuse inservices. EI #4 stated she and the administrator were responsible. During an interview with EI #3 (ADM) on 02/25/14 at 4:50 PM, the surveyor asked who was responsible for ensuring all staff attended abuse inservices. EI #3 stated she and EI #4 (Social Worker/Abuse Coordinator) were. The surveyor asked what happened if staff did not attend the mandatory abuse inservices. EI #3 stated, "We don't have anything or a policy if they don't attend." EI #3 stated she was responsible for ensuring EI #4 carried out her duties and responsibilities as Social Worker/Abuse Coordinator. On 02/24/14 at 12:00 PM, a review of the abuse inservice attendance records for EI #1 and EI #2, dated 01/04/13, 04/11/13, 10/11/13 and 01/03/14 revealed the following: EI #1 did not attend any of the mandatory abuse trainings since being hired on 01/23/2013. EI #1 did not attend the mandatory abuse trainings provided by the facility on 04/11/13, 10/11/13 and 01/03/14. EI #2, rehired on 04/29/13, had only attended two of three mandatory abuse trainings provided by the facility since his rehire date. EI #2 did not attend the mandatory abuse trainings provided by the facility on 10/11/13. On 02/21/14 at 4:10 PM, the surveyor asked EI #7, CNA, what was she suppose to do after witnessing abuse. EI #7 explained she was suppose to report abuse to her charge nurse. When asked why she did not report the abuse, EI #7 stated she did not know, because she had never experienced anything like this before. EI #7, hired 05/07/12, did not attend two of the four mandatory abuse training inservices on 10/11/13 and 01/03/14. During an interview on 02/20/14 at 3:20 PM, EI #9, CNA, was asked why she did not report the abuse she witnessed. EI #9 stated she was frightened and afraid that EI #2 might attack her. When asked what should she have done when RI #5 was hit, EI #9 stated that she should have told the charge nurse. When asked did she report the incident, EI #9 stated, "No." EI #7, hired 08/20/12, attended all four mandatory abuse training inservices held on on 01/04/13, 04/11/13, 10/11/13 and 01/03/14. During an interview on 02/23/14 at 9:12 AM, the surveyor asked EI #8, CNA, why she did not report the abuse witnessed on 01/27/14. EI #8 replied she was scared that other employees would think she was a tattletale. EI #8, hired 06/25/12, and attended two of the four mandatory abuse training inservices on 10/11/13 and 01/03/14. During an interview on 02/26/14 at 5:00 PM, EI #3, ADM, stated EI #7 and #8 will be terminated regarding abuse allegations not reported when they occurred. During an interview on 02/25/14 at 1:00 PM, EI #3 (ADM) was asked about the potential for harm when staff did not immediately report the abuse they witnessed. EI #3 stated it put those residents and other residents at risk. During three days of survey several attempts were made to contact EI #1. All attempts to interview EI #1 regarding allegations of abuse involving RI #2 and RI #4 were unsuccessful. The Administrator stated the facility did not have a phone number to contact EI #2. *********************** On 02/26/14, the Facility submitted an The facility submitted an Allegation of Credible Compliance (AOCC) on 2/26/14 at 5:45 PM. F226 483.13 (C)(1)(ii) Not employ individuals who have been (A) Found guilty of abusing neglecting or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aid registry concerning abuse, neglect, mistreatment, of residents, or misappropriation of their property and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility to the State nurse aide registry or licensing authorities. 483.13 (C)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(C)(3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. 483.13 (C)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. 1) Father Purcell Memorial's DON started in-servicing the staff on 2/24/2014 to 2/25/2014 on the following: ? Policy: Supervisor actions when abuse is suspected ? Resident Abuse Neglect Restraint Seclusion ? Resident Rights ? Abuse Prevention Policy and Procedure 2) The Social Worker was in-serviced on Abuse and Reporting by the local ombudsman, at 7pm on 2/25/14 by telephone conference with the Executive Director of the City of St. Jude present. 3) The local ombudsman in-serviced the staff on Abuse and the new Abuse Coordinator also in-serviced the staff on 2/26/2014. 4) All potential hires work record and references will be checked and cleared. 5) All potential hires must be cleared with the State Nurse Aide Registry before hire and at intervals throughout employment. 6) All employees whose actions and non-actions resulted in F223 tag were counseled on how important it is to report an allegation of abuse immediately. These employees were also advised that if this (failure to report) occurred again then they would be terminated immediately. 7) (Name of EI #1), CNA and (Name of EI #2), CNA was terminated. 8) The Executive Director of City of St Jude will in-service the administrative staff of Father Purcell Memorial's on Abuse Prevention Policy and Procedure on 2/26/2014. The follow-up will be to review FPM abuse policies with administrative staff biannually. The FPM Abuse Policy was reviewed and revised by the Executive Director of City of St. Jude on 2/25/2014. 9) A RN has been named the new Abuse Coordinator of Father Purcell Memorial Exceptional Children's Center. She was trained on Father Purcell Memorial's Abuse Policy and Procedure's by the Executive Director of the City of St. Jude on 02/26/2014. 10) The Abuse Coordinator and the Director of Nursing will be conducting the Abuse Prevention Policy and Procedure training inclusive of PRNs and contractual employees starting 02/26/2014 and completed by 3/7/2014. 11) The Abuse Coordinator and the Director of Nursing will be responsible for in-servicing all PRNs employees and contractual employees. 12) All staff will be interviewed by the Abuse Coordinator and the Director of Nursing regarding other allegations of abuse starting 2/26/2014 and completed by 2/28/2014. 13) When there are any allegations of abuse made the Abuse Coordinator and the Director of Nursing will interview the resident or at least make an attempt to. We only have one child that may be interviewable. He has short term memory problems but his long term is ok. The resident was interviewed on 2/26/2014 by the Abuse Coordinator and the Director of Nursing. 14) New hire files were reviewed for orientation Abuse policy and procedure for the past 3 months it was reviewed on 02/26/2014 by the Administrative Assistant. 15) Father Purcell Memorial's nursing staff started body audits on 2/26/2014 and will be completed on 2/26/2014 by LPNs and RNs looking for bruises, abrasions, and any injury of unknown origin. And if any suspect area will be investigated and reported to the state. 16) All staff will be interviewed regarding in any other allegation of abuse or witness of abuse by the Abuse Coordinator and the DON began 2/26/2014 and completed by 2/28/2014. ******************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 02/26/14 at 7:15 PM. The scope and severity was lowered to "F" level to allow the facility time to monitor/revise their corrective.

Based on interviews and record reviews, the facility failed to follow their policy and procedure on "Abuse and Neglect" by failing to implement the Training, Prevention, Identification, Protection and "Reporting/ Response" elements of the policy when verbal and physical abuse were witnessed by several Certified Nursing Assistants (CNA). Through interviews it was determined three CNAs witnessed four residents being physically and/or verbally abused by two CNAs on multiple occasions. All CNAs witnessing the abuse stated they were aware they had observed physical and/or verbal abuse. Also, they were aware the incidents should have been reported. The CNAs failed to protect the residents from the abuse by intervening or removing the residents from the abusers, and reporting the incident to the charge nurse on duty at the time of the incidents, as directed in the facility's abuse and neglect policy. Resident Identifiers (RI) #2, #3, #4, and #5 were involved in the following incidents of verbal and physical abuse witnessed from 01/22/14 to 1/27/14, but not reported to the Administrator until 01/28/14: On 01/22/14, a male CNA, Employee Identifier (EI) #1 sprayed water into Resident Identifier (RI) #2's face causing the resident to gasp for air; pinched his arm, used profanity toward this resident and left him unattended on the shower bed/trolley. On 01/22/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley, slapped his head and used profanity toward RI #4. On 01/24/14, a male CNA, EI #2 punched RI #3 in the arm. On 01/24/14, a male CNA, EI #2 was providing RI #5 a shower. Another CNA EI #9, stated she heard a loud sound, like a slap and observed RI #5's lips trembling and a sad look on his face. On 01/27/14, during a shower, a male CNA, EI #1 used profanity toward RI #2, after RI #2 told EI #1 the water was hot. On 01/27/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley and used profanity toward RI #4. Additionally, the facility's Administrator (ADM) and Director of Nursing (DON) failed to report an allegation of physical abuse to the State Agency when becoming aware of this allegation. During a meeting on 02/17/14, with the ADM and the DON, RI #1's mother alleged a CNA hit RI #1 in the left eye. This allegation was not reported to the State Agency. These deficient practices placed five of five sampled residents reviewed for abuse, RI #1, #2, #3, #4, and #5 in immediate jeopardy, as it was likely to cause serious injury, harm, or death. On 2/25/14 at 6:00 PM, the facility's Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level of "L" in area of Resident Behavior and Facility Practices (F 226). The immediate jeopardy began on 01/22/14 and was abated onsite on 02/26/14 at 7:15 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any further recurrence. Findings Include: Cross reference F 223 A review of the facility's policy and procedure signed and dated 01/02/14, titled "Policy: Abuse and Neglect" revealed the following: "It is the policy of Father Purcell Memorial Exceptional Children's Center that no resident will suffer from abuse while under our care. ... II. Training - Train employees through orientation and on-going session related to abuse prohibition practices ... How staff should report their knowledge related to allegations ... (Attendance at training will be recorded ... III. Prevention ... During employee orientation: provide employees with information on how and to whom to report suspicion of abuse. Identify, correct and intervene in situations in which abuse ... is more likely to occur. ... The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, ... IV. Identification ... Any suspicions shall be immediately reported to Administrator or designated person in charge of facility at the time. VI. Protection Protect residents from harm during an investigation. The suspected employee will be immediately suspended from the facility and away from residents while investigation is conducted. VII. Reporting/Response The administrator or designated person shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation: ..." The facility's policy titled "Resident Abuse Neglect Restraint Seclusion" reviewed and revised on 01/02/14, documented: "... TYPES OF ABUSE Physical Abuse: is defined as willful actions that cause injury or pain to residents by staff, ... Examples of Physical abuse includes ... hitting, pinching ... pulling the resident, ... or any other intentional action by staff that causes injury or pain. Mental/Verbal Abuse: is defined as willful behavior by staff, ... who humiliates, harasses or provides for threats of punishment ... Mental abuse includes the use of oral, ... gestured language that willfully includes derogatory remarks to resident ... regardless of age, ability to comprehend or degree of disability. Examples of mental abuse includes; raising one's voice, yelling, belittling speech, the use of profanity or loud threatening, rude or aggressive language, that frightens or intimidates resident ... or the use of overt or implied threatened harm to residents ..." A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th (2014) respectively. Statements are attached for reference..." 1. a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: On 1/21/14 Wednesday night on 11-7 shift I observed (EI #1) telling (RI #4) to shut the [***] up and slapping him upside the head and throwing him on the shower bed ... ." During an interview on 02/21/14 at 2:10 PM, EI #7 (CNA) confirmed that on 01/22/14 during AM showers around 5:00 AM, she witnessed EI #1 slam RI #4 onto the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling the resident to shut the "[***] up" and then slap the resident hard on the head then, RI #4 jerked backwards and began to gasp, and scream loudly. On 02/21/14 at 4:10 PM, the surveyor asked EI #7 what was she suppose to do after witnessing abuse. EI #7 explained she was suppose to report abuse to her charge nurse. When asked why she did not report the abuse, EI #7 stated she did not know, because she had never experienced anything like this before. b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: Monday morning [DATE] while I was giving showers (EI #1) brought (RI #4) in the shower room threw him on the shower bed & (and) when (RI #4) started crying (EI #1) said "[***] shut the [***] up before I slap you. ..." During an interview on 02/21/14 at 12:05 PM, another CNA, EI #8 confirmed that on 01/27/14 during AM showers around 5:00 AM, she heard a sound like someone slamming a child on the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling him [***] shut the [***] up before I slap the [***] out of you. During an interview on 02/23/14 at 9:12 AM, the surveyor asked EI #8 why she did not report the abuse on 01/27/14. EI #8 replied she was scared that other employees would think she was a tattletale. 2. a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... then (EI #1) started telling (RI #2) to shut the [***] up and pinching (RI #2) and pinching him ... (EI #1) always cursing the kids out telling them [***] shut the [***] up." On 02/21/14 at 4:10 PM, EI #7 also confirmed that on 01/22/14, after RI #4's shower, EI #1 entered the shower room with RI #2, who was hollering for the nurse. EI #7 witnessed EI #1 verbally abused the resident by telling the resident to "shut the [***] up" and pinched the resident on the arm. RI #2 began to scream and cry, then EI #1 sprayed water into RI #2's face, causing the resident to gasp for air. EI #7 stated RI #2 said that the water was hot. EI #1 told RI #2 to "shut up" and EI #1 hit the resident. The nurse walked into the shower room and EI #1 stopped. The nurse asked RI #2 what was wrong, but RI #2 did not respond. After the nurse left the area, EI #1 sprayed RI #2 in the face with water again and left RI #2 unattended on the shower bed/trolley. When asked who she reported the abuse to, EI #7 answered, "Nobody." When asked why she did not report the abuse, EI #7 stated she was afraid because of the way EI #1 "act, cursing and talking crazy calling people [***] es." RI #2 was interviewed on 02/23/14 at 1:10 PM. RI #2 was asked if someone hurt him in the shower he stated, "That man." When asked if he knew the name of that man, he stated, "(First name of EI #1)". RI #2 was asked if EI #1 slapped him on the head and he stated, "Yeah". b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... Also while he was giving (RI #2) a shower I walked in on him (EI #1) telling (RI #2) to shut the hell and (RI #2) said the water hot then (EI #1) said shut the [***] the water ain't hot. ..." During an interview on 02/21/14 at 12:05 PM, EI #8 confirmed that on 01/27/14 during AM showers, she witnessed EI #1 start to shower RI #2. RI #2 started yelling the water was hot and EI #1 verbally abused the resident by telling RI #2, "[***] shut the [***] up, the water is not hot." EI #1 continued to shower RI #2 and the resident kept yelling the water was hot. During an interview on 02/23/14 at 9:12 AM, the surveyor asked EI #8 why she did not report the abuse on 01/27/14. EI #8 replied she was scared that other employees would think she was a tattletale. 3. EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... I heard a punch in the shower room on January 23, 2014 at approximately 5:00 in shower room I thought (EI #2) had punched the child (RI #5)." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers, EI #2 was showering RI #5. EI #9 stated she heard a loud slap and witnessed RI #5 looking fearful. EI #9 stated RI #5 looked like he was about to cry. When the surveyor asked EI #9 why she did not report the abuse, EI #9 stated she was frightened and afraid that EI #2 might attack her. When asked what should she have done when RI #5 was hit, EI #9 stated that she should have told the charge nurse. When asked did she report the incident, EI #9 stated, "No." 4. EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: I (EI #9) actually saw (EI #2) punch the patient (RI #3) on the arm on January 23, 2014 at approximately 5:30 AM inside the shower and room. ..." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers at approximately 5:30 AM, she witnessed RI #3 squirming on the shower bed/trolley. EI #2 gave a hard punch to RI #3's left arm. The surveyor asked EI #9 why she did not report the abuse. EI #9 stated she was frightened and afraid that EI #2 would attack her. In a subsequent interview with EI #9 on 02/23/14 at 9:40 AM, she was asked to recall the 01/24/14 shower incident involving RI #3 and EI #2. During this interview EI #9 provided a hand written statement that documented EI #2 punched RI #3's arm causing the resident to jump. On 02/25/14 at 1:00 PM, the surveyor asked EI #3 (ADM) what would she have done if she had been made aware of allegations of abuse witnessed by EI #7, #8 and #9. EI #3 replied she would have suspended EI #1 and EI #2, pending an investigation, and then terminate the employees. The surveyor asked why. EI #3 stated she would not have wanted to put any child at risk. 5. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's current Quarterly MDS dated [DATE] indicated RI #1 required total assistance with activities of daily living and was incontinent of bowel and bladder. The State Agency received a complaint on 02/18/14. The complainant alleged that a CNA, EI #6, had done something to her son (RI #1) to cause redness and swelling to RI #1's eye. During an interview on 02/20/14 at 9:22 AM, the surveyor asked EI #3 (ADM) who reported the allegation involving EI #6 and RI #1. EI #3 stated RI #1's mother reported to her (EI #3) on Monday, 02/17/14, about 5:30 or 6:00 PM, regarding RI #1's left eye. EI #3 stated the mother told her she felt EI #6 had hit RI #1 in the eye. The surveyor asked would it be correct to say at that point an allegation of abuse had been made by RI #1's mother. EI #3 stated yes, but she did not report the allegation to the State. The surveyor asked what was the policy and the procedure for reporting an allegation of abuse. EI #3 reviewed the abuse policy and procedure and read from the facility's abuse policy, "The Administrator or designated person shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation ... ." EI #3 also stated she did not report within 24 hours like she should have and the abuse policy had not been followed. During an interview with EI #5 (DON) on 02/22/14 at 11:25 AM, the surveyor asked when was she made aware of the allegation involving EI #6 hitting RI #1 in the left eye. EI #5 stated either 02/17/14 or 02/18/14, around 4:30 of five, after EI #3 caller her into the office for a meeting with RI #1's mother. During the meeting RI #1's mother stated she believed EI #6 had hit RI #1 in the eye. EI #5 stated she did not think of the statement as an allegation of abuse, but that the mother was trying to get EI #6 out of the resident's room. The surveyor handed EI #5 a copy of the facility's abuse policy and procedure to review and asked what does the abuse policy and the procedure state regarding reporting. EI #5 reviewed the abuse policy and procedure and stated the allegation should have been reported. This tag is cited as a result on complaint #AL 475 ************************ On 02/26/14, the Facility submitted an The facility submitted an Allegation of Credible Compliance (AOCC) on 2/26/14 at 5:45 PM. F226 483.13 (C)(1)(ii) Not employ individuals who have been (A) Found guilty of abusing neglecting or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aid registry concerning abuse, neglect, mistreatment, of residents, or misappropriation of their property and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility to the State nurse aide registry or licensing authorities. 483.13 (C)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(C)(3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. 483.13 (C)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. 1) Father Purcell Memorial ' s DON started in-servicing the staff on 2/24/2014 to 2/25/2014 on the following: ? Policy: Supervisor actions when abuse is suspected ? Resident Abuse Neglect Restraint Seclusion ? Resident Rights ? Abuse Prevention Policy and Procedure 2) The Social Worker was in-serviced on Abuse and Reporting by the local ombudsman, at 7pm on 2/25/14 by telephone conference with the Executive Director of the City of St. Jude present. 3) The local ombudsman in-serviced the staff on Abuse and the new Abuse Coordinator also in-serviced the staff on 2/26/2014. 4) All potential hires work record and references will be checked and cleared. 5) All potential hires must be cleared with the State Nurse Aide Registry before hire and at intervals throughout employment. 6) All employees whose actions and non-actions resulted in F223 tag were counseled on how important it is to report an allegation of abuse immediately. These employees were also advised that if this (failure to report) occurred again then they would be terminated immediately. 7) (Name of EI #1), CNA and (Name of EI #2), CNA was terminated. 8) The Executive Director of City of St Jude will in-service the administrative staff of Father Purcell Memorial's on Abuse Prevention Policy and Procedure on 2/26/2014. The follow-up will be to review FPM abuse policies with administrative staff biannually. The FPM Abuse Policy was reviewed and revised by the Executive Director of City of St. Jude on 2/25/2014. 9) A RN has been named the new Abuse Coordinator of Father Purcell Memorial Exceptional Children's Center. She was trained on Father Purcell Memorial's Abuse Policy and Procedure's by the Executive Director of the City of St. Jude on 02/26/2014. 10) The Abuse Coordinator and the Director of Nursing will be conducting the Abuse Prevention Policy and Procedure training inclusive of PRNs and contractual employees starting 02/26/2014 and completed by 3/7/2014. 11) The Abuse Coordinator and the Director of Nursing will be responsible for in-servicing all PRNs employees and contractual employees. 12) All staff will be interviewed by the Abuse Coordinator and the Director of Nursing regarding other allegations of abuse starting 2/26/2014 and completed by 2/28/2014. 13) When there are any allegations of abuse made the Abuse Coordinator and the Director of Nursing will interview the resident or at least make an attempt to. We only have one child that may be interviewable. He has short term memory problems but his long term is ok. The resident was interviewed on 2/26/2014 by the Abuse Coordinator and the Director of Nursing. 14) New hire files were reviewed for orientation Abuse policy and procedure for the past 3 months it was reviewed on 02/26/2014 by the Administrative Assistant. 15) Father Purcell Memorial's nursing staff started body audits on 2/26/2014 and will be completed on 2/26/2014 by LPNs and RNs looking for bruises, abrasions, and any injury of unknown origin. And if any suspect area will be investigated and reported to the state. 16) All staff will be interviewed regarding in any other allegation of abuse or witness of abuse by the Abuse Coordinator and the DON began 2/26/2014 and completed by 2/28/2014. ******************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 02/26/14 at 7:15 PM. The scope and severity was lowered to "F" level to allow the facility time to monitor/revise their corrective actions.

Based on interviews and record reviews, the facility failed to ensure allegations of mental/verbal and physical abuse were reported immediately to the Administrator and to the State Agency within 24 hours of becoming aware of the allegations. Through interviews with Certified Nursing Assistants (CNA) it was determined three CNAs witnessed four residents being physically and/or verbally abused by two CNAs on multiple occasions. The CNAs witnessing the abuse stated they were aware that what they observed was physical and/or verbal abuse, but did not report the abuse to their Administrator because they were afraid. These incidents of verbal and physical abuse were witnessed from 01/22/14 to 01/27/14, but not reported to the Administrator until 01/28/14. On 01/22/14, a male CNA, Employee Identifier (EI) #1 sprayed water into Resident Identifier (RI) #2's face causing the resident to gasp for air; pinched his arm, used profanity toward this resident and left him unattended on the shower bed/trolley. On 01/22/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley, slapped his head and used profanity toward RI #4. On 01/24/14, a male CNA, EI #2 punched RI #3 in the arm. On 01/24/14, a male CNA, EI #2 was providing RI #5 a shower. Another CNA, EI #9, stated she heard a loud sound, like a slap and observed RI #5's lips trembling and a sad look on his face. On 01/27/14, during a shower, a male CNA, EI #1 used profanity toward RI #2, after RI #2 told EI #1 the water was hot. On 01/27/14, a male CNA, EI #1 slammed RI #4 onto the shower bed/trolley and used profanity toward RI #4. Additionally, the facility's Administrator (ADM) and Director of Nursing (DON) failed to report an allegation of physical abuse to the State Agency when becoming aware of this allegation. During a meeting on 02/17/14, with the ADM and the DON, RI #1's mother alleged a CNA hit RI #1 in the left eye. This allegation was not reported to the State Agency. These deficient practices placed five of five sampled residents reviewed for abuse, RI #1, #2, #3, #4, and #5 in immediate jeopardy, as it was likely to cause serious injury, harm, or death. On 02/25/14 at 6:00 PM, the facility's Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level of "L" in area of Resident Behavior and Facility Practices (F 225). The immediate jeopardy began on 01/22/14 and was abated onsite on 02/26/14 at 7:15 PM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any further recurrence. Findings Include: Refer to F 223 A review of the facility's policy and procedure signed and dated 01/02/14, titled "Policy: Abuse and Neglect" revealed the following: "It is the policy of Father Purcell Memorial Exceptional Children's Center that no resident will suffer from abuse while under our care. ... VII. Reporting/Response The administrator or designated person shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation: ..." The facility's policy titled "Resident Abuse Neglect Restraint Seclusion" reviewed and revised on 01/02/14, documented: "... TYPES OF ABUSE: Physical Abuse: is defined as willful actions that cause injury or pain to residents by staff, ... Examples of Physical abuse includes ... hitting, pinching ... pulling the resident, ... or any other intentional action by staff that causes injury or pain. Mental/Verbal Abuse: is defined as willful behavior by staff, ... who humiliates, harasses or provides for threats of punishment ... Mental abuse includes the use of oral, ... gestured language that willfully includes derogatory remarks to resident ... regardless of age, ability to comprehend or degree of disability. Examples of mental abuse includes; raising one's voice, yelling, belittling speech, the use of profanity or loud threatening, rude or aggressive language, that frightens or intimidates resident ... or the use of overt or implied threatened harm to residents ..." A review of the facility's "Summary of Investigation" dated 02/03/14 and signed by EI #4, the Abuse Coordinator revealed, "(Names of EI #s 7, 8, and 9) Certified Nursing Assistants, of Father Purcell Memorial reported on 1-28-14 that (EI #1) and (EI #2), Certified Nursing Assistants verbally and physically abused the above named children, residents of Father Purcell Memorial. They reported that (EI #1) verbally and physically abused (RI #4) and (RI #2) and (EI #2) physically abused (RI #3) and (RI #5). This occurred on January 21st, 23rd, and 27th (2014) respectively. Statements are attached for reference..." 1a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: On 1/21/14 Wednesday night on 11-7 shift I observed (EI #1) telling (RI #4) to shut the [***] up and slapping him upside the head and throwing him on the shower bed ... ." During an interview on 02/21/14 at 2:10 PM, EI #7 (CNA) confirmed that on 01/22/14 during AM showers around 5:00 AM, she witnessed EI #1 slam RI #4 onto the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling the resident to shut the "[***] up" and then slap the resident hard on the head then, RI #4 jerked backwards and began to gasp, and scream loudly. On 02/21/14 at 4:10 PM, the surveyor asked EI #7 what was she suppose to do after witnessing abuse. EI #7 explained she was suppose to report abuse to her charge nurse. When asked why she did not report the abuse, EI #7 stated she did not know, because she had never experienced anything like this before. b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: Monday morning [DATE] while I was giving showers (EI #1) brought (RI #4) in the shower room threw him on the shower bed & (and) when (RI #4) started crying (EI #1) said "[***] shut the [***] up before I slap you. ..." During an interview on 02/21/14 at 12:05 PM, another CNA, EI #8 confirmed that on 01/27/14 during AM showers around 5:00 AM, she heard a sound like someone slamming a child on the shower bed/trolley. RI #4 was crying and EI #1 verbally abused RI #4 by telling him [***] shut the [***] up before I slap the [***] out of you. During an interview on 02/23/14 at 9:12 AM, the surveyor asked EI #8 why she did not report the abuse on 01/27/14. EI #8 replied she was scared that other employees would think she was a tattletale. 2a. EI #7's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... then (EI #1) started telling (RI #2) to shut the [***] up and pinching (RI #2) and pinching him ... (EI #1) always cursing the kids out telling them [***] shut the [***] up." On 02/21/14 at 4:10 PM, EI #7 also confirmed that on 01/22/14, after RI #4's shower, EI #1 entered the shower room with RI #2, who was hollering for the nurse. EI #7 witnessed EI #1 verbally abused the resident by telling the resident to "shut the [***] up" and pinched the resident on the arm. RI #2 began to scream and cry, then EI #1 sprayed water into RI #2's face, causing the resident to gasp for air. EI #7 stated RI #2 said that the water was hot. EI #1 told RI #2 to "shut up" and EI #1 hit the resident. The nurse walked into the shower room and EI #1 stopped. The nurse asked RI #2 what was wrong, but RI #2 did not respond. After the nurse left the area, EI #1 sprayed RI #2 in the face with water again and left RI #2 unattended on the shower bed/trolley. When asked who she reported the abuse to, EI #7 answered, "Nobody." When asked why she did not report the abuse, EI #7 stated she was afraid because of the way EI #1 "act, cursing and talking crazy calling people [***] es." RI #2 was interviewed on 02/23/14 at 1:10 PM. RI #2 was asked if someone hurt him in the shower he stated, "That man." When asked if he knew the name of that man, he stated, "(First name of EI #1)". RI #2 was asked if EI #1 slapped him on the head and he stated, "Yeah". On 02/25/14 at 1:00 PM, the surveyor asked EI #3 (ADM) if she had been made aware of the allegation of abuse by EI #7 (CNA) regarding EI #1 involving RI #2 on 01/22/14, what would she have done. EI #3 replied she would have suspended EI #1 pending an investigation and then terminate the employee. The surveyor asked why. EI #3 stated she would not have wanted to put any child at risk. b. EI #8's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... Also while he was giving (RI #2) a shower I walked in on him (EI #1) telling (RI #2) to shut the hell and (RI #2) said the water hot then (EI #1) said shut the [***] the water ain't hot. ..." During an interview on 02/21/14 at 12:05 PM, EI #8 confirmed that on 01/27/14 during AM showers, she witnessed EI #1 start to shower RI #2. RI #2 started yelling the water was hot and EI #1 verbally abused the resident by telling RI #2, "[***] shut the [***] up, the water is not hot." EI #1 continued to shower RI #2 and the resident kept yelling the water was hot. During an interview on 02/23/14 at 9:12 AM, the surveyor asked EI #8 why she did not report the abuse on 01/27/14. EI #8 replied she was scared that other employees would think she was a tattletale. 3. EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: ... I heard a punch in the shower room on January 23, 2014 at approximately 5:00 in shower room I thought (EI #2) had punched the child (RI #5)." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers, EI #2 was showering RI #5. EI #9 stated she heard a loud slap and witnessed RI #5 looking fearful. EI #9 stated RI #5 looked like he was about to cry. When the surveyor asked EI #9 why she did not report the abuse, EI #9 stated she was frightened and afraid that EI #2 might attack her. When asked what should she have done when RI #5 was hit, EI #9 stated that she should have told the charge nurse. When asked did she report the incident, EI #9 stated, "No." 4. EI #9's hand written statement, signed and dated 01/28/14 documented, "...STATEMENT: I (EI #9) actually saw (EI #2) punch the patient (RI #3) on the arm on January 23, 2014 at approximately 5:30 AM inside the shower and room. ..." During an interview on 02/20/14 at 3:20 PM, EI #9 confirmed that on 01/24/14 during AM showers at approximately 5:30 AM, she witnessed RI #3 squirming on the shower bed/trolley. EI #2 gave a hard punch to RI #3's left arm. The surveyor asked EI #9 why she did not report the abuse. EI #9 stated she was frightened and afraid that EI #2 would attack her. In a subsequent interview with EI #9 on 02/23/14 at 9:40 AM, she was asked to recall the 01/24/14 shower incident involving RI #3 and EI #2. During this interview EI #9 provided a hand written statement that documented EI #2 punched RI #3's arm causing the resident to jump. 5. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's current Quarterly MDS dated [DATE] indicated RI #1 required total assistance with activities of daily living and was incontinent of bowel and bladder. The State Agency received a complaint on 02/18/14. The complainant alleged that a CNA, EI #6, had done something to her son (RI #1) to cause redness and swelling to RI #1's eye. During an interview on 02/20/14 at 9:22 AM, the surveyor asked EI #3 (ADM) who reported the allegation involving EI #6 and RI #1. EI #3 stated RI #1's mother reported to her (EI #3) on Monday, 02/17/14, about 5:30 or 6:00 PM, regarding RI #1's left eye. EI #3 stated the mother told her she felt EI #6 had hit RI #1 in the eye. The surveyor asked would it be correct to say at that point an allegation of abuse had been made by RI #1's mother. EI #3 stated yes, but she did not report the allegation to the State. The surveyor asked what was the policy and the procedure for reporting an allegation of abuse. EI #3 reviewed the abuse policy and procedure and read from the facility's abuse policy, "The Administrator or designated person shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective action depending on the results of the investigation ... ." EI #3 also stated she did not report within 24 hours like she should have and the abuse policy had not been followed. During an interview with EI #5 (DON) on 02/22/14 at 11:25 AM, the surveyor asked when was she made aware of the allegation involving EI #6 hitting RI #1 in the left eye. EI #5 stated either 02/17/14 or 02/18/14, around 4:30 of five, after EI #3 caller her into the office for a meeting with RI #1's mother. During the meeting RI #1's mother stated she believed EI #6 had hit RI #1 in the eye. EI #5 stated she did not think of the statement as an allegation of abuse, but that the mother was trying to get EI #6 out of the resident's room. The surveyor handed EI #5 a copy of the facility's abuse policy and procedure to review and asked what does the abuse policy and the procedure state regarding reporting. EI #5 reviewed the abuse policy and procedure and stated the allegation should have been reported. On 02/25/14 at 1:00 PM, the surveyor asked EI #3 (ADM) what would she have done if she had been made aware of allegations of abuse witnessed by EI #7, #8 and #9. EI #3 replied she would have suspended EI #1 and EI #2, pending an investigation, and then terminate the employees. The surveyor asked why. EI #3 stated she would not have wanted to put any child at risk. This tag is cited as a result on complaint #AL 475. ******************** On 02/26/14, the Facility submitted an Allegation of Credible Compliance (AOCC) on 2/26/14 at 5:45 PM. F225 483.13 (C)(1)(ii) Not employ individuals who have been (A) Found guilty of abusing neglecting or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aid registry concerning abuse, neglect, mistreatment, of residents, or misappropriation of their property and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility to the State nurse aide registry or licensing authorities. 483.13 (C)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(C)(3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. 483.13 (C)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. 1) Father Purcell Memorial's DON started in-servicing the staff on 2/24/2014 to 2/25/2014 on the following: ? Policy: Supervisor actions when abuse is suspected ? Resident Abuse Neglect Restraint Seclusion ? Resident Rights ? Abuse Prevention Policy and Procedure 2) The Social Worker was in-serviced on Abuse and Reporting by the local ombudsman, at 7pm on 2/25/14 by telephone conference with the Executive Director of the City of St. Jude present. 3) The local ombudsman in-serviced the staff on Abuse and the new Abuse Coordinator also in-serviced the staff on 2/26/2014. 4) All potential hires work record and references will be checked and cleared. 5) All potential hires must be cleared with the State Nurse Aide Registry before hire and at intervals throughout employment. 6) All employees whose actions and non-actions resulted in F223 tag were counseled on how important it is to report an allegation of abuse immediately. These employees were also advised that if this (failure to report) occurred again then they would be terminated immediately. 7) (Name of EI #1), CNA and (Name of EI #2), CNA was terminated. 8) The Executive Director of City of St Jude will in-service the administrative staff of Father Purcell Memorial's on Abuse Prevention Policy and Procedure on 2/26/2014. The follow-up will be to review FPM abuse policies with administrative staff biannually. The FPM Abuse Policy was reviewed and revised by the Executive Director of City of St. Jude on 2/25/2014. 9) A RN has been named the new Abuse Coordinator of Father Purcell Memorial Exceptional Children's Center. She was trained on Father Purcell Memorial's Abuse Policy and Procedure's by the Executive Director of the City of St. Jude on 02/26/2014. 10) The Abuse Coordinator and the Director of Nursing will be conducting the Abuse Prevention Policy and Procedure training inclusive of PRNs and contractual employees starting 02/26/2014 and completed by 3/7/2014. 11) The Abuse Coordinator and the Director of Nursing will be responsible for in-servicing all PRNs employees and contractual employees. 12) All staff will be interviewed by the Abuse Coordinator and the Director of Nursing regarding other allegations of abuse starting 2/26/2014 and completed by 2/28/2014. 13) When there are any allegations of abuse made the Abuse Coordinator and the Director of Nursing will interview the resident or at least make an attempt to. We only have one child that may be interviewable. He has short term memory problems but his long term is ok. The resident was interviewed on 2/26/2014 by the Abuse Coordinator and the Director of Nursing. 14) New hire files were reviewed for orientation Abuse policy and procedure for the past 3 months it was reviewed on 02/26/2014 by the Administrative Assistant. 15) Father Purcell Memorial's nursing staff started body audits on 2/26/2014 and will be completed on 2/26/2014 by LPNs and RNs looking for bruises, abrasions, and any injury of unknown origin. And if any suspect area will be investigated and reported to the state. 16) All staff will be interviewed regarding in any other allegation of abuse or witness of abuse by the Abuse Coordinator and the DON began 2/26/2014 and completed by 2/28/2014. ******************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on 02/26/14 at 7:15 PM. The scope and severity was lowered to "F" level to allow the facility time to monitor/revise their corrective actions.