Every finding on record at Friends Homes at Guilford

Based on record review, staff interviews, and Responsible Party interview, the facility failed to treat a resident in a dignified manner when Resident #1, a resident with severe cognitive impairment, was yelling out and Nurse Aide #1 loosely placed her hand over the resident's mouth and yelled at the resident to shut up in an effort to quiet the resident. The reasonable person concept was applied, as a reasonable person would expect to receive care without being yelled at. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #1).Findings included:Resident #1 was readmitted to the facility on [DATE] with diagnoses including vascular dementia, anxiety disorder, and depression.An annual Minimum Data Set assessment dated [DATE] documented Resident #1 as having severely impaired cognition with physical and verbal behaviors one to three days of the assessment period. Resident #1 was not coded as rejecting care and was not identified as having behaviors that significantly disrupted care or the living environment. Resident #1 was coded as frequently incontinent of bowel and bladder and was dependent on staff for toileting assistance, requiring supervision for toileting transfers. Record review of Resident #1's care plan, last revised on 8/12/2026, showed a focus area addressing confusion, easy distraction, and the need for redirection related to cognitive impairment. Interventions included reorienting Resident #1 to time, location, and events during an episode of confusion and providing explanations of tasks prior to assisting her.A health status note dated 8/14/2026, at 1:30 AM, written by Nurse #1, indicated Resident #1 was heard yelling from the hallway bathroom. Blood was observed on Resident #1's lip; however, a mouth assessment revealed no injuries. During an interview conducted on 8/25/2026 at 8:58 AM via the telephone, Nurse #1 stated she worked the 11:00 PM to 7:00 AM shift on 8/13/2026-8/14/2026 and was assigned to the unit where Resident #1 resided. Nurse #1 recalled that at the start of her shift at 11:00 PM, Resident #1 was in the common area with Nurse Aide (NA) #1. Nurse #1 reported that at 1:30 AM she heard yelling coming from the spa room adjacent to the nurse's station. Upon entering the spa room, she observed Resident #1 seated in a wheelchair yelling, while NA #1 was beside her. Nurse #1 noted Resident #1 was dressed but appeared to need her incontinence brief changed due to its bulky appearance. Nurse #1 stated she assisted NA #1 in calming Resident #1 down by talking to her and holding her hand. Nurse #1 stated Resident #1 repeatedly stated, No, No, No. Nurse #1 stated she advised NA #1 that Resident #1 needed time to calm down and that attempting to change her brief without allowing her to settle would cause continued agitation. Nurse #1 recommended waiting for another nurse aide to assist. Nurse #1 then returned to the nursing station. Nurse #1 stated that at 1:43 AM, she again heard Resident #1 yelling and returned to the spa room, where she observed NA #1 yelling Shut up, Shut up at Resident #1. Resident #1 was seated in the wheelchair wearing clean clothing, and her wet incontinence brief was in the trash can. Nurse #1 observed a smear of blood on Resident #1's teeth and she asked NA #1 what happened. Nurse #1 revealed NA #1 told her she had put her hand loosely over the mouth of Resident #1 to try to quiet her down so she would not wake the other residents. Nurse #1 stated she instructed NA #1 to leave the spa room due to her inappropriate interaction with Resident #1. Nurse #1 assessed Resident #1's mouth and observed no active bleeding. Nurse #1 stated she was not sure where the smear of blood on the teeth came from, but that Resident #1 had dry lips, jagged teeth in the front, and raw looking gums. Nurse #1 transported Resident #1 to the nurse's station for further assessment and contacted her supervisor.NA #1 was interviewed via the telephone on 8/25/2026 at 11:59 AM. NA #1 stated she was scheduled to work on 8/13/2026 from 7:00 PM to 8/14/2026 at 7:00 AM. NA #1 recalled that Resident #1 was sleeping in the common area on a couch when her shift began at 7:00 PM, but she woke up smiling and happy at 1:30 AM. NA #1 stated that NA #2 was on break, and because Resident #1 was in a good mood and needed her incontinence brief changed, she transported Resident #1 to the spa room. NA #1 stated Resident #1 agreed to go but started hollering upon entering the toilet area of the spa room. NA #1 confirmed that Nurse #1 responded immediately entering the spa room and assisted in calming Resident #1. NA #1 acknowledged that it was discussed that she should wait for Resident #1 to calm down and wait for NA #2 to return. NA #1 reported that Nurse #1 then left the spa room. NA #1 stated Resident #1 calmed within five to ten minutes and agreed to have her brief changed. NA #1 assisted Resident #1 to the toilet and removed her pants and wet brief. NA #1 reported Resident #1 again began hollering, and she professionally snapped, placing her left hand loosely over Resident #1's mouth, resulting in Resident #1 biting her pinky finger. NA #1 stated she then yelled Shut up, shut up. NA #1 confirmed Nurse #1 reentered the spa room, and they saw a small amount of blood in Resident #1's mouth. Nurse #1 asked NA #1 what had happened. NA #1 told Nurse #1 she had loosely put her hand over Resident #1's mouth because her hollering would wake the other residents. NA #1 said Nurse #1 left the spa room again while Resident #1 was still on the toilet. NA #1 stated she was frustrated and she knew she could not leave Resident #1 hollering while sitting on the toilet and she had everything she needed to dress her again except for a new incontinence brief. NA #1 stated she went to the closet directly outside the spa room, retrieved a new incontinence brief, returned to Resident #1 at toilet, assisted Resident #1 with a new incontinence brief, dressed her in a new shirt and pants, and assisted her to transfer to the wheelchair. NA #1 stated Resident #1 hollered throughout the care. NA #1 stated Nurse #1 returned to the spa room with a telephone in her hand, instructing her to leave the spa room. NA #1 stated she knew she was not supposed to yell at the residents and she should have waited for NA #2 to provide care if Nurse #1 was not willing to help her.Attempts to interview NA #2 were unsuccessful.The on-call supervisor, Nurse #2, was interviewed on 8/25/2026 at 10:36 AM. Nurse #2 reported Nurse #1 contacted her on the phone between 1:30 AM and 2:00 AM on 8/14/2026, stating Resident #1 had been hollering, and NA #1 was observed telling Resident #1 to shut up. Nurse #2 stated she came to the facility, the Director of Nursing (DON) was notified, Resident #1 was assessed with no injuries or mental status change, and NA #1 was escorted out of the facility.The responsible party for Resident #1 was interviewed via telephone on 8/25/2026 at 2:43 PM. The responsible party for Resident #1 stated that he was notified of an incident on 8/14/2026 regarding Resident #1 and had nothing but good things to say about the care Resident #1 received while at the facility.An interview was conducted with the DON on 8/25/2026 at 11:25 AM. The DON reported Resident #1 had poor dental care but was assessed with no injuries on 8/14/2026. The DON confirmed that NA #1's actions were inappropriate and stated that staff were not permitted to yell at residents.

Based on record review and staff interviews, the facility failed to develop and implement an abuse policy consistent with the regulatory requirements, resulting in staff not adhering to the required reporting timeframes to the state agency, adult protective services, and the Administrator. This failure affected 1 of 1 resident reviewed for abuse (Resident #1).Findings included:The facility's policy titled, Abuse Prohibition last revised 11/2017, stated that all reports of alleged incidents of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident property must be reported to the Administrator immediately. The policy further requires that reports be submitted to the state agency via the Healthcare Personnel Registry (HCPR) using the standardized reporting form, which includes an immediate report containing basic information. The policy specified the following initial reporting timelines: allegations of abuse must be reported immediately but no later than two hours following the allegation; allegations involving serious bodily injury must be reported immediately but no later than two hours following the allegation; other allegations not involving abuse require reporting within 24 hours of the allegation. Under investigative guidelines, the policy stated that suspected abuse would be reported according to state guidelines. Under the section Allegations occurring after hours or on weekends the policy stated the nurse initiating an incident report would notify the on call supervisor of any incidents or allegations of abuse, neglect, misappropriation, fraud, or neglect. A 24-hour report would be completed if allegations or evidence indicated any of these conditions occurred. The supervisor was responsible for reviewing information in person or by phone with the initiating nurse and ensuring the completed 24-hour report was faxed to the Healthcare Personnel Registry, and for notifying management for follow up the next business day.Resident #1 was readmitted to the facility on [DATE] with diagnoses including vascular dementia.A health status note dated [DATE], at 1:30 AM, written by Nurse #1, indicated Resident #1 was heard yelling from the hallway bathroom. Blood was observed on Resident #1's lip; however, a mouth assessment revealed no injuries. During an interview conducted on [DATE] at 8:58 AM via the telephone, Nurse #1 stated she worked the 11:00 PM to 7:00 AM shift on 8/13-14/2026 and was assigned to the unit where Resident #1 resided. Nurse #1 stated that at 1:43 AM, she heard Resident #1 yelling and she entered the spa room, where she observed Nurse Aide (NA) #1 yelling, Shut up, shut up at Resident #1. Resident #1 was seated in a wheelchair. Nurse #1 observed a smear of blood on Resident #1's teeth and she asked NA #1 what happened. Nurse #1 revealed NA #1 told her she had put her hand loosely over the mouth of Resident #1 to try to quiet her down so she would not wake the other residents. Nurse #1 stated she instructed NA #1 to leave the spa room due to her inappropriate interaction with Resident #1. Nurse #1 assessed Resident #1's mouth and observed no active bleeding. Nurse #1 stated she was not sure where the smear of blood on the teeth came from, but that Resident #1 had dry lips, jagged teeth in the front, and raw looking gums. Nurse #1 transported Resident #1 to the nurse's station for further assessment and contacted her the on-call supervisor, Nurse #2. Nurse #1 reported that Nurse #2 arrived while NA #1 remained in the common area. Nurse #1 revealed that Nurse #2 arrived with security and the Director of Nursing (DON) was notified via the telephone. Security escorted NA #1 out of the building while Nurse #1 remained at the nurse's station with Resident #1. The on-call supervisor, Nurse #2, was interviewed on [DATE] at 10:36 AM. Nurse #2 confirmed she was called while at home on [DATE] at approximately 1:30 AM or 2:00 AM. Nurse #1 informed her that NA #1 had placed her hand over Resident #1's mouth after the resident became loud while being assisted with toileting. Nurse #1 reported to her that she heard NA #1 tell Resident #1 to shut up, and that a small amount of blood was noticed. Nurse #2 reported she arrived at the facility within 5 to 10 minutes and noted Resident #1 was not actively bleeding and had no injury to her mouth. Nurse #2 noted NA #1 was in the common area when she arrived. Nurse #2 stated she contacted the DON and, at the DON's direction, had security escort NA #1 from the building and confiscate her badge. Nurse #2 stated that she considered the actions of NA #1 to be abuse because residents have a right to express themselves and should never be yelled at. Nurse #2 explained that she considered the DON to be administration and that was why she notified her of the incident. Nurse #2 further explained that it was her expectation that the DON would take care of any notifications of abuse allegations to the authorities or the state regulatory agency or guide her with what she needed to do.A review of the facility's initial report to the HCPR dated [DATE] completed by the Director of Nursing (DON), identified an allegation of resident abuse involving Resident #1, with the facility becoming aware of the incident at 3:08 AM. The report indicated on [DATE] at 1:30 AM Nurse #1 heard loud screaming while seated in the nurse's station. Upon arriving at the resident's room, Nurse #1 saw Resident #1 seated in her wheelchair, and Nurse Aide (NA) #1 reported she was trying to change Resident #1 after incontinence, and the resident was refusing. Nurse #1 instructed NA #1 to leave the room and reattempt later. Both exited the room. At approximately 1:43 AM, Nurse #1 heard loud screaming again, when arriving to Resident #1's room again, she saw and heard NA #1 yelling, Shut up, shut up several times. Nurse #1 noted bleeding around Resident #1's mouth, and when asked, NA #1 said she covered Resident #1's mouth with her hand. The HCPR received the initial allegation report on [DATE] at 2:48 PM.An interview was conducted with the DON on [DATE] at 11:25 AM. The DON confirmed she was contacted at approximately 2:00 AM on [DATE] by Nurse #1 and Nurse #2 regarding an incident in the building where Nurse #1 heard NA #1 yell shut up to Resident #1. The DON could not explain the discrepancy between her actual notification time and the time documented on the initial report. The DON reported she told Nurse #1 and Nurse #2 to call security, escort NA #1 out of the building, and to make sure an assessment of Resident #1 was completed. The DON stated that when she came into the building the next morning, she notified the Administrator at approximately 7:00 AM, she initiated an investigation, and reported to the state agency, adult protective services, and the local police out of due diligence considering NA #1's actions could be potential abuse. The DON explained that she waited until the morning to notify the Administrator because she, the DON, was the administrative person handling the incident. The DON stated it was her understanding that all reporting to the state agency, adult protective services, and the local police could be done within 24 hours if there was no bodily injury.During a second interview on [DATE] at 12:30 PM, the DON reported she notified the local police of the incident involving Resident #1 and NA #1 at 10:48 AM on [DATE]. The DON stated she reported the incident to adult protective services on [DATE] at 12:44 PM and confirmed she submitted the report to the state agency of the incident on [DATE] at 2:48 PM. The DON stated she believed the reporting timeframe was 24 hours because the incident did not involve serious bodily injury to Resident #1.During a third interview on [DATE] at 3:11 PM, the DON reported the facility needed to revise the abuse policies and educate staff on when and what needed to be reported to the state agency, law enforcement and adult protective services.The Administrator was interviewed on [DATE] at 2:47 PM. The Administrator stated that based on his interpretation of the abuse policy, staff believed the reporting timeframe was 24 hours if the allegation did not involve serious bodily injury. The Administrator stated he thought further clarification was needed to the abuse prohibition policy. The Administrator stated that according to Nurse #1's account, NA #1 had exercised poor judgement and was overwhelmed. The Administrator reported that he was notified of the abuse allegation in the early morning hours of [DATE] at approximately 6:00 AM or 7:00 AM and notification to the DON fulfilled the requirement of notification of administration immediately.

Based on record review and staff interviews, the facility failed to provide a safe transfer resulting in the resident falling to the floor. The resident sustained no injuries. This was for 1 of 3 (Resident #25) residents reviewed for accidents. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses of dementia, unsteadiness on feet, muscle weakness, localized edema, and cognitive communication deficit. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required substantial/maximal assistance with toileting and transfers. Review of the Resident #25's care plan revised on 09/17/24 revealed the resident required assistance with mobility due to weakness, unsteadiness on feet, and gate problem. The goal was staff would continue to assist Resident #25 in her current mobility status while she maintained comfort and safety. Interventions included Resident #25 required at times 2 person assist with transfers from sit to stand and to utilize the toilet grab bar for toilet transfer due to Resident #25's right knee giving out. Review of Resident #25's care guide as of 10/17/24 revealed Resident #25 required extensive assistance with toilet transfer and toileting care with toileting hygiene. The care guide further revealed Resident #25 was to utilize toilet grab bar for transfer and required extensive assist due to her right knee could give out. Review of progress note dated 10/17/24 completed by Nurse #1 revealed Resident #25 had a witnessed fall in the resident's bathroom where staff assisted the resident to the floor. The note further revealed Resident #25 was alert, vitals were taken, and skin was intact. Review of an incident report dated 10/17/24 and completed by Nurse #1 revealed Resident #25 had a witnessed fall with Nurse Aide #1. It further revealed Nurse #1 was called to Resident #25's room and observed Resident #25 sitting upright against the toilet with legs outstretched. Nurse Aide #1 had assisted Resident #25 with toileting and the resident lost balance and was assisted to the floor with NA #1. Resident #25 was unable to tell what had happened but was assessed and obtained no injuries. A phone interview conducted with Nurse Aide (NA) #1 on 10/23/24 at 11:30 AM revealed on 10/17/24 during third shift she assisted Resident #25 to the toilet. NA #1 further revealed she assisted Resident #25 up from the wheelchair and when the resident went to pivot to sit on the toilet the resident became weak and started to fall to the ground. NA #1 indicated she assisted Resident #25 to the ground and sat her up so she could retrieve the Nurse. NA #1 stated Resident #25 did not express or show any signs of pain or injury. NA #1 indicated she had worked with the resident for 2 months consistently and was educated by a nurse to have two people to assist with transfers for Resident #25. NA #1 indicated she had also been educated to check the residents' care guide for assist information. NA #1 revealed it was a busy day and she failed to retrieve another staff member to assist her when she took Resident #25 to the restroom. A phone interview conducted with Nurse #1 on 10/23/24 at 11:05 AM revealed she was the assigned Nurse for Resident #25 on 10/17/24. Nurse #1 further revealed NA #1 retrieved her and went to Resident #25's room and found her sitting up against the toilet in her restroom. Nurse #1 indicated she completed an assessment, and the resident did not show any signs of pain and did not obtain any injuries. Nurse #1 revealed Resident #25 often had weak legs and was unable to hold her weight. Nurse #1 stated Resident #1 required two people for transfers and NA #1 should have had another person with her to assist the resident. Nurse #1 reported she verbally educated NA #1. Nurse #1 revealed staff had been educated to look at the resident's care guide and care plan. Nurse #1 stated she educated staff that Resident #25 was a two-person assist for transfers due to having a decline and being weaker. Nurse #1 indicated NA #1 knew Resident #25 was a two person assist before the incident on 10/17/24. An interview conducted with Nurse #2 on 10/23/24 at 2:00 PM revealed she had cared for and assisted Resident #25 since April 2024 and the resident had always been a two person assist. Nurse #2 further revealed Resident #25 often was weak and unable to hold herself up. Nurse #2 indicated staff had been educated to look at the resident's care guide and care plan. Nurse #2 stated she had educated the aides she worked with that Resident #25 was a two person assist due to her muscle weakness and unable to hold her own weight. An interview conducted with the Director of Nursing on 10/24/24 at 9:00 AM revealed Resident #25's incident occurred during third shift on 10/17/24. It was further revealed Resident #1 often had fluid and edema in her legs which caused muscle weakness. The DON indicated she expected for nursing staff to follow the assistance that the resident is coded for the residents in the care plan and care guides.

Based on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 1 of 5 residents whose medications were reviewed (Resident #59). The findings included: 1. Resident #59 was admitted to the facility on [DATE]. Her cumulative diagnoses included dementia with mild anxiety. A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for Ativan (an antianxiety medication). Ativan is a psychotropic medication and a controlled substance medication. -A physician's order was received on 8/8/24 for 0.5 milligram (mg) Ativan to be given as one tablet by mouth every 4 hours as needed (PRN) for anxiety. The resident's most recent Minimum Data Set (MDS) was a significant change assessment dated [DATE]. Resident #59 was reported to have intact cognition with no behaviors nor rejection of care. The Medication section of the MDS revealed Resident #59 did not receive an antianxiety medication during the 7-day look back period. Resident #59's EMR indicated the physician's order for the PRN Ativan (ordered on 8/8/24) as active orders up through the date of the review on 10/24/24. A review of Resident #59's Medication Administration Records (MARs) revealed 2 doses (8/8/24 and 9/1/24) of PRN Ativan were administered to Resident #59 from 8/8/24 through the date of the review 10/24/24. The last dose of PRN Ativan was documented as having been administered on 9/1/24. Further review of Resident #59's EMR revealed no evidence of justification of the extended use of the PRN Ativan. An interview was conducted on 10/24/24 at 11:52 AM with nurse practitioner (NP #1) and she indicated that she ordered the 0.5 mg of Ativan PRN on 8/8/24 but failed to include an end date of 14 days. She further revealed that this was an oversight, and the order should have included a stop date of 14 days and then be reviewed for further orders. A telephone interview was conducted on 10/24/24 at 11:26 AM with the facility's consultant pharmacist. During the interview, the pharmacist reported she completed a medication regime review for Resident #59 on 9/5/24 but did not realize the PRN Ativan order that was started on 8/8/24 did not include a 14 day stop date. An interview was conducted on 10/24/24 at 12:05 PM with the facility's Director of Nursing (DON). During the interview, the DON reported that she was aware that orders for PRN psychotropic medications required a stop date, and that additional documentation was required to continue PRN psychotropic medications (other than antipsychotic medications) for an extended duration. She further revealed that Resident #59's PRN Ativan order should have been ordered with a 14 day stop date and that the consultant pharmacist should have caught the error during her September 2024 medication regimen review, and this was an oversight.

Based on observation, resident interviews, staff interviews and record review the facility failed to provide nursing staffing of sufficient quantity and quality to provide restorative nursing services for 1 of 1 resident that was reviewed for participation in the restorative program (Resident #7). Findings included: This tag is cross referenced to : F-676 Based on record review, resident interview and staff interviews the facility failed to provide restorative nursing services for 1 of 1 resident that was reviewed for participation in the restorative program (Resident #7) An interview with Resident #7 on 12/7/17 at 9:55 am revealed the facility had been short staffed and this had resulted in her not consistently receiving her restorative therapy. She stated that the restorative staff would often be pulled to work as a nursing assistant (NA) and they weren ' t available to provide her restorative exercises. A review of the restorative referral after discharge from OT dated 9/19/17 for Resident #7 identified she was to receive upper and lower extremity strengthening. A review the restorative treatment administration record (TAR) for Resident #7 identified a start date of 9/20/17. Treatments identified on the TAR were range of motion (ROM) to upper and lower extremities including a 2 to 3 pound weight bilaterally, wheelchair pushups, gluteal squeezes, theraband exercises abduction and retraction, 1 pound weight for flexion / biceps, diagonals and sponge ball treatment. There were no initials or documentation on the restorative TAR that the services had been completed. There was no documentation on the restorative TAR that Resident #7 had refused treatment. An interview on 12/07/17 at 2:30 pm with the restorative aide for Resident #7 revealed that the facility had been short staffed especially in September and she had been scheduled to be a NA about three times a week during that month. She explained that the NAs assigned to residents would try and ambulate and provide ROM for those residents on the restorative case load but she wasn ' t sure if Resident #7 received the restorative exercises she was scheduled for during that time. The restorative aide stated that staffing was better now, but she was still pulled to be a NA one to two times a week. She added that the Assistant Director of Nursing (ADON) provided her with the paperwork that identified who was on restorative and what exercises they were supposed to receive. She confirmed that Resident #7 was on the restorative program. The September 2017 restorative TAR was reviewed with her and she stated that if the exercises were completed with the resident she would have put a checkmark on the date they were completed. She acknowledged that the September 2017 restorative TAR was blank. The restorative aide explained that sometimes Resident #7 would refuse her exercises and she would have documented refusal if that had occurred. An interview on 12/07/17 at 2:45 pm with the ADON revealed she received the therapy referrals for restorative and she would transfer this information to the restorative TAR and provide this to the restorative aides. The September 2017 restorative TAR for Resident #7 was reviewed with the ADON and she stated she didn ' t know why it was blank. She added she would expect that if the services were provided the restorative aide would document that they were completed. The ADON stated the restorative aides had been pulled to work as NAs due to some staffing shortages. She added when this happened the residents NAs were supposed to try and provide the restorative care but there was no system in place to communicate the restorative plans for residents to their NAs. An interview on 12/07/17 at 4:30 pm with the DON revealed the restorative staff had been pulled to work assignments because of some staffing shortages. She stated the NAs would try and pick up some of the restorative work load for the residents on their assignment, but she wasn ' t able to say how this was accomplished and there was no documentation of this. The DON stated it was her expectation that residents receive restorative care per their referral from therapy and that provision of the restorative care was documented as being completed. During an interview with Administrator on 12/07/17 at 6:30 PM, the Administrator indicated that her expectation for staffing would be that all residents needs are being met and all services are provided by the facility.

Based on observations and staff interviews the facility failed to ensure hair restraints were worn while preparing food, failed to maintain clean kitchen equipment and failed to allow cook ware to air dry before being stored. Findings Included: An observation of the kitchen on 12/4/17 at 12:30 pm with the Chef revealed: 1. A male dietary worker with facial hair was dredging raw chicken livers in flour with no hair restraint or beard guard on. 2. The top convection oven had a significant build-up of black, burned on food particles. 3. Eleven steam table pans were stacked together wet on a clean storage shelf ready to be used. An interview with the Chef on 12/4/17 at 1:00 pm revealed the male employee should have had a hair net on while working in the kitchen He added that he did not believe the facility had any beard guards available. He stated the oven had not been cleaned because they had been short staffed. The Chef explained the steam table pans were supposed to be allowed to air dry on a different shelf before they were transferred to the storage shelf in the kitchen. An interview on 12/7/17 at 1:00 pm with the Director of Dining Services revealed it was her expectation that hair restraints, including those for facial hair were worn by staff while working in the kitchen and especially when they were preparing food. She stated it was also her expectation that all kitchen equipment was clean and that steam table pans were allowed to air dry before being stacked together and put away.

Based on staff interview, and record review of the Facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee put into place following the [DATE] annual recertification survey. This was for one recited deficiency in the areas of dietary services (F 371). This deficiency was cited again on the annual recertification survey on [DATE]. This continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA programs. Findings included: This tag is cross referenced to: F- 371 Based on observations and staff interviews the facility failed to ensure: expired foods were discarded in the walk-in refrigerator, opened food items were sealed, labeled and dated in the dry storage room, cookware were not stacked together wet and food preparation equipment was clean. During the recertification survey, the facility was cited for F812 the facility failed to ensure hair restraints were worn while preparing food, failed to maintain clean kitchen equipment and failed to allow cook ware to air dry before being stored. During an interview with the Administrator on [DATE] at 6:32 PM, the Administrator indicated her expectattion for repeat tags, we would re-examine system to find the root cause of the the issue and address it with team involvement and buy in to the solution with guidance from field expert.

Based on record review and staff interview the facility failted to accurately code Hospice services on the Minimum Data Set (MDS) for 1 of 3 residents reviewed who recieved Hospice services. (Resident #14) Findings included: Resident # 14 had cummulative [DIAGNOSES REDACTED]. Record review revealed Resident #14 was admitted into the Hospice program on 8/28/17. Review of the significant change MDS assessment dated [DATE] revealed Section O was not coded for Hospice. Interview on 12/07/17 at 4:25 PM with the MDS coordinator who stated I forgot. It was a mistake in not coding Hospice on the MDS assessment. Interview on 12/07/17 at 5:02 PM with the Administrator revealed she expected Hospice to be coded on the MDS assessment.

Based on record review, resident interview and staff interviews the facility failed to provide restorative nursing services for 1 of 1 resident that was reviewed for participation in the restorative program (Resident #7). Findings Included: A review of the restorative case load, provided by the Director of Nursing (DON) revealed there were 18 residents scheduled to receive restorative services during the time of the annual recertification survey. Resident #7 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A review of the minimum data set ((MDS) dated [DATE] for Resident #7 revealed she required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. She had not received any restorative nursing during the look back period and she was alert and oriented. A review of the care plan for Resident #7 dated 11/22/17 identified she needed assistance with personal hygiene, bathing, transfers and could no longer walk. Interventions included to allow resident to use motorized wheelchair and to follow physical therapy (PT) and occupational therapy (OT) instructions for toileting, transfers and locomotion. An interview with Resident #7 on 12/7/17 at 9:55 am revealed the facility had been short staffed and this had resulted in her not consistently receiving her restorative therapy. She stated that the restorative staff would often be pulled to work as a nursing assistant (NA) and they weren ' t available to provide her restorative exercises. A review of the restorative referral after discharge from OT dated 9/19/17 for Resident #7 identified she was to receive upper and lower extremity strengthening. A review the restorative treatment administration record (TAR) for Resident #7 identified a start date of 9/20/17. Treatments identified on the TAR were range of motion (ROM) to upper and lower extremities including a 2 to 3 pound weight bilaterally, wheelchair pushups, gluteal squeezes, theraband exercises abduction and retraction, 1 pound weight for flexion / biceps, diagonals and sponge ball treatment. There were no initials or documentation on the restorative TAR that the services had been completed. There was no documentation on the restorative TAR that Resident #7 had refused treatment. An interview on 12/7/17 at 2:30 pm with the restorative aide for Resident #7 revealed that the facility had been short staffed especially in September and she had been scheduled to be a NA about three times a week during that month. She explained that the NAs assigned to residents would try and ambulate and provide ROM for those residents on the restorative case load but she wasn ' t sure if Resident #7 received the restorative exercises she was scheduled for during that time. The restorative aide stated that staffing was better now, but she was still pulled to be a NA one to two times a week. She added that the Assistant Director of Nursing (ADON) provided her with the paperwork that identified who was on restorative and what exercises they were supposed to receive. She confirmed that Resident #7 was on the restorative program. The September 2017 restorative TAR was reviewed with her and she stated that if the exercises were completed with the resident she would have put a checkmark on the date they were completed. She acknowledged that the September 2017 restorative TAR was blank. The restorative aide explained that sometimes Resident #7 would refuse her exercises and she would have documented refusal if that had occurred. An interview on 12/7/17 at 2:45 pm with the ADON revealed she received the therapy referrals for restorative and she would transfer this information to the restorative TAR and provide this to the restorative aides. The September 2017 restorative TAR for Resident #7 was reviewed with the ADON and she stated she didn ' t know why it was blank. She added she would expect that if the services were provided the restorative aide would document that they were completed. The ADON stated the restorative aides had been pulled to work as NAs due to some staffing shortages. She added when this happened the residents NAs were supposed to try and provide the restorative care but there was no system in place to communicate the restorative plans for residents to their NAs. An interview on 12/7/17 at 4:30 pm with the DON revealed the restorative staff had been pulled to work assignments because of some staffing shortages. She stated the NAs would try and pick up some of the restorative work load for the residents on their assignment, but she wasn ' t able to say how this was accomplished and there was no documentation of this. The DON stated it was her expectation that residents receive restorative care per their referral from therapy and that provision of the restorative care was documented as being completed.

Based on observations and staff interviews the facility failed to ensure: expired foods were discarded in the walk-in refrigerator, opened food items were sealed, labeled and dated in the dry storage room, cookware were not stacked together wet and food preparation equipment was clean. This had the potential to affect 48 of the 48 residents who reside in the facility. Findings Included: An observation of the kitchen on 11/07/16 at 9:30 am revealed: 1. A 32 ounce container of yogurt with an expiration date of 11/1/16 and a 32 ounce container of sour cream with an expiration date of 11/5/16 were available for use in the walk-in-cooler. 2. 4 open packages of pasta were not labeled or dated in the dry storage room. 3. A case of chopped pecans and cocoa powder were not labeled or dated and were not sealed to prevent exposure to the air in the dry storage room. An observation of the kitchen on 11/09/16 at 10:00 am revealed: 1. 3 of 6 sheet pans with food particles on them were stored on shelf and ready for use. 2. 15 of 15 steam table pans were stacked together wet and stored on shelf and preparation table ready for use. 3. 3 of 3 ingredient bins had build-up of food particles around bases and labels. 4. The flame grill had a heavy build-up of blackened food particles and grease on the grill grates and around the base. 5. The under shelf of the cooks preparation table had sheet pans with spices stored on them and the sheet pans had food particles and food spills on them. An interview with the Dietary Manager and the Assistant Dietary Manager on 11/09/16 at 4:17 pm revealed that their expectation was that expired food products should not have been in the walk-in-cooler and available for the staff to use. They stated that their expectation was that food products are sealed, labeled and dated in all storage areas. The Assistant Dietary Manager stated that steam table pans should not have been stacked together wet and that the ingredient bins and under shelf with the spices should have been clean. He also stated that the flame grill should have been cleaned after use and that the cook had forgotten to clean it. An interview with the facility Administrator on 11/09/16 at 4:31 pm revealed that it was his expectation that expired products would not be in the walk-in-cooler and that all equipment is clean. He stated that he expected the steam table pans would be clean and allowed to air dry and that all food products should be stored appropriately with labels and dates.

Based on observations, record review and staff interviews, the facility failed to discard an expired medication as specified by the drug manufacturer in 1 of 4 medication carts (Oaks); and failed to securely store medications in 3 of 4 wound care treatment carts (Maples, Oaks, and Cedars). The findings included: 1) An observation of the Oaks medication cart on [DATE] at 4:13 PM revealed an opened bottle of calcitonin-salmon spray 200 Units per actuation (an intranasal spray used for the treatment of [REDACTED]. The bottle was labeled as opened on [DATE] and an expiration date of [DATE] was hand-written on the label. A review of Resident #29 ' s [DATE] Physicians Orders revealed there was a current order for the calcitonin-salmon spray dispensed as generic for Miacalcin in a 30-dose bottle delivering 200 Units per dose to be given as one spray in alternating nostrils every day. The manufacturer ' s product information indicated a bottle of calcitonin-salmon spray may be stored at room temperature for up to 35 days. Opened or unopened bottles left at room temperature for more than 35 days must be discarded. Additional information from the manufacturer indicated that more than 30 doses should not be used from one bottle. After 30 doses, the pump may not deliver the correct amount of medication with each spray. An interview was conducted with the nurse assigned to the Oaks medication cart (Nurse #1) on [DATE] at 4:13 PM. Upon inquiry, Nurse #1 stated, " If I had seen that (the expiration date) I would have re-ordered it. The nurse noted she did not see another bottle of calcitonin-salmon on the medication cart and subsequently reported none was found in the medication store room refrigerator. An interview was conducted with the Staff Development Coordinator (SDC) on [DATE] at 4:25 PM. The SDC reported that calcitonin-salmon spray should be labeled with the date the medication was opened and the date it expired. She also indicated it should be pulled from the medication cart upon expiration. When Nurse #1 inquired as to what to do with the expired calcitonin-salmon spray, the SDC instructed her to take it off of the medication cart as it could no longer be used. During an interview with the DON on [DATE] at 9:46 AM, the DON stated she was aware that expired calcitonin-salmon spray had been found on the Oaks medication cart and that this situation had been resolved. The DON indicated her expectation would be for an expired bottle of calcitonin-salmon spray to be promptly removed from the medication cart. 2a) A review of the facility ' s Policy entitled, " Storage and Expiration of Medications, Biologicals, Syringes and Needles, " dated [DATE] included the following statement: " Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. " The initial tour of the facility was conducted on [DATE] at 10:45 AM. During this tour, the door to room D111 (a clean utility room) on the Maples hall was observed to be open. A wound care treatment cart was observed in the room with the cart's locking mechanism in the out/unlocked position. There was no nurse or other staff member near the room or utilizing the cart. During the continued tour of the Maples hall from 10:45 AM to 11:00 AM, the door to room D111 remained open and the cart remained unlocked. Residents, visitors, and staff were observed to pass the open room containing the unlocked cart. Another observation was made on [DATE] at 12:10 PM which revealed the door to room D111 was open and the wound care treatment cart inside the room was unlocked. There was no nurse or staff member near the room or utilizing the cart. At 12:55 PM Nurse #6 was observed leaving room D111. Upon her exit, both the door to the room and the treatment cart inside were observed to be unlocked. An observation of the Maples treatment cart on [DATE] at 2:16 PM revealed the treatment cart was stored in Room D111. The door to the room was ajar (not latched). The room was unlocked and the treatment cart was noted to be unlocked and unattended. Prescription topical medications stored in the second drawer of the unlocked treatment cart included the following: 4 tubes of nystatin-triamcinolone cream (a prescription antifungal-steroidal cream); one bottle of ketoconazole shampoo (an anti-fungal agent); one tube of silver sulfadiazene cream (an antiseptic typically used for the treatment of [REDACTED]. Two tubes of over-the-counter (OTC) creams were also stored in the second drawer of the treatment cart. On [DATE] at 10:02 AM, the facility's Assistant Director of Nursing (ADON) was observed storing the unlocked wound care treatment cart in room D111 on the Maples hall. Room D111 was left unlocked. Residents, staff, and visitors were observed passing the unlocked room storing the unlocked wound care treatment cart. An observation of the Maples treatment cart on [DATE] at 9:25 AM revealed the treatment cart was stored in Room D111. The room was unlocked. The treatment cart was unlocked and unattended. Topical prescription medications were stored in the second drawer of the cart. An interview was conducted with Nurse #3 on [DATE] at 9:30 AM. Nurse #3 was the staff nurse on duty for the Maples neighborhood. Nurse #3 stated all staff nurses used the treatment cart. She indicated the treatment cart was kept in the clean utility room with the doors closed. She also stated that staff using the cart needed to make sure it was locked. During an interview with the DON (Director of Nursing) on [DATE] at 9:46 AM, the DON indicated that her expectation would be for the treatment carts to be kept in the clean utility room and locked unless it was in use. 2b) A review of the facility ' s Policy entitled, " Storage and Expiration of Medications, Biologicals, Syringes and Needles, " dated [DATE] included the following statement: " Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. " An observation of the Oaks treatment cart on [DATE] at 2:01 PM revealed the treatment cart was stored in Room B111 (a clean utility room). The room was unlocked. The treatment cart was unlocked and unattended. Two 60-gram tubes of nystatin-triamcinolone cream (a prescription antifungal-steroidal cream) were sitting on top of the treatment cart. Prescription topical medications stored in the second drawer of the unlocked treatment cart included the following: 1 tube of Nizoral cream (an anti-fungal agent); 2 tubes of nystatin-triamcinolone cream; one tube of a compounded prescription cream (a medication compounded by the pharmacy which contained 6 prescription ingredients formulated in accordance with a prescriber ' s specifications); one tube of Prudoxin (a topical cream typically used for nerve pain); and one tube of Voltaren gel (a nonsteroidal anti-inflammatory medication). Four tubes of over-the-counter (OTC) creams were also stored in the second drawer of the treatment cart and additional over-the-counter topical products were stored in the third drawer of the cart. An observation of the Oaks treatment cart on [DATE] at 9:50 AM revealed the treatment cart was stored in Room B111. The room was unlocked. The treatment cart was unlocked and unattended. Topical prescription medications were stored in the second drawer of the cart. An observation of the Oaks treatment cart on [DATE] at 9:25 AM revealed the treatment cart was stored in Room B111. The room was unlocked. The treatment cart was unlocked and unattended. Topical prescription medications were stored in the second drawer of the cart. An interview was conducted with Nurse #2 on [DATE] at 9:35 AM. Nurse #2 was the staff nurse on duty for the Oaks neighborhood. Nurse #2 stated the treatment cart was kept in the clean utility room. Upon entry into the utility room, the treatment cart was unlocked. Upon inquiry, Nurse #2 indicated the treatment cart should be locked but stated he had just used it. He locked the treatment cart prior to leaving the room. During an interview with the DON (Director of Nursing) on [DATE] at 9:46 AM, the DON indicated that her expectation would be for the treatment carts to be kept in the clean utility room and locked unless it was in use. 2c) A review of the facility ' s Policy entitled, " Storage and Expiration of Medications, Biologicals, Syringes and Needles, " dated [DATE] included the following statement: " Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. " An observation of the Cedars treatment cart on [DATE] at 2:10 PM revealed the treatment cart was stored in Room A135 (a clean utility room). The room was unlocked. The treatment cart was unlocked and unattended. Prescription topical medications stored in the second drawer of the unlocked treatment cart included the following: 8 tubes of nystatin-triamcinolone cream (a prescription antifungal-steroidal cream); two tubes of mupiricin ointment (an antibiotic medication); and one tube of hydrocortisone cream (a steroidal cream). An observation of the Cedars treatment cart on [DATE] at 9:35 AM revealed the treatment cart was stored in Room A135. The room was unlocked. The treatment cart was unlocked and unattended. Topical prescription medications were stored in the second drawer of the cart. An observation of the Cedars treatment cart on [DATE] at 9:25 AM revealed the treatment cart was stored in Room A135. The room was unlocked. The treatment cart was unlocked and unattended. Topical prescription medications were stored in the second drawer of the cart. An interview was conducted with Nurse #4 on [DATE] at 9:32 AM. Nurse #4 was the staff nurse on duty for the Cedars neighborhood. Nurse #4 stated each pod had a treatment cart and that cart was kept in the clean utility room. Upon entry into the clean utility room, the treatment cart was unlocked. Upon inquiry, Nurse #4 stated the treatment cart should be locked and she subsequently locked it. During an interview with the DON (Director of Nursing) on [DATE] at 9:46 AM, the DON indicated that her expectation would be for the treatment carts to be kept in the clean utility room and locked unless it was in use.

Based on record review and interview with staff the facility failed to code the annual (MDS) assessment for severe weight loss accurately. This was evident in 1 of 3 residents in the sample reviewed for nutrition. Resident #43 Findings included: Resident had cumulative [DIAGNOSES REDACTED]. Review of the monthly weight chart form revealed the resident ' s height was 5 feet. The monthly weight chart form indicated a weight history that included in part: 07/02/13 138 pounds (lbs) 07/31/13 134 lbs (weight for August) 09/02/13 128 lbs 10/02/13 121 lbs This represented an unplanned severe weight loss of 17 lbs within 3 months. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed under Section K swallowing and nutrition, the weight loss column was coded 0 (zero) which indicated the resident had not experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months or the data was unknown. This coding was inaccurate and did not reflect weight loss. Interview on 10/23/13 at 4:40 pm with (NCM#1) nutrition care manager revealed " I did the wrong math " in determining the degree of weight loss. Interview on 10/23/13 at 4:50 pm with the consultant dietitian the director of food services was held. The consultant dietitian indicated the weight loss should have been assessed. Interview on 10/24/13 at 5:10 PM with director of nurses (DON) and the Administrator regarding their expectations related inaccurate assessment. The DON indicated expectations would be that the assessment wasn ' t missed, and we will be revising the weight policy. The DON indicated it was just a human error.

Based on observation, interview with staff and record review the facility failed to develop a comprehensive careplan that addressed the low total protein and serum [MEDICATION NAME] levels. This was evident in 1 of 3 residents in the sampled reviewed for nutrition. Resident#63 Findings included: Resident#63 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed resident required supervision with Activities of daily living and was cognitively intact. Review of the hospital laboratory studies revealed on 6/18/13 a total protein level of 4.4 grams per deciliters (g/dl) milligrams per deciliter and with a serum [MEDICATION NAME] level 2.0 g/dl. The reference range for total protein level was 6.0-8.3 g/dl. The reference range for a serum [MEDICATION NAME] level was 3.5-5.5 g/dl. Review of the laboratory blood studies dated 7/1/13 revealed a total protein 5.1 g/dl and serum [MEDICATION NAME] of 3.1 g/dl. Review of the medical record revealed no careplan to address the low protein levels. Interview on 10/23/13 at 1:50 PM with the consultant dietitian via the phone revealed "we (referring to the facility) failed miserably, dropped the ball (indicating the facility failed to address the low protein and serum levels)" "We were focusing on the nurses concern of her blood sugars. " Interview on 10/23/13 at 4:50 pm with the consultant dietitian and the director of food services was held. The consultant dietitian indicated as the consultant she should have addressed the low [MEDICATION NAME] and total protein levels. Interview conducted on 10/24/13 at 5:20 PM with the director of nurses (DON) and administrator regarding the expectations related to care planning the resident ' s protein needs. The DON revealed the dietitian needs to monitor more closely. The administrator indicated he would reiterate and remind the dietitian once per month when we meet, to make sure the protein needs are addressed.

Based on record review and interview with staff the facility failed to update a nutritional care plan when a severe weight loss occurred. This was evident in 1 of 3 residents in the sample reviewed for nutrition. Resident #43 Findings included: Resident#43 had cumulative [DIAGNOSES REDACTED]. Review of the monthly weight chart form revealed the resident ' s height was 5 feet. The monthly weight chart form indicated a weight history that included in part: 07/02/13 138 pounds (lbs) 07/31/13 134 lbs 09/02/13 128 lbs 10/02/13 121 lbs This represented severe weight loss of 17 lbs within 3 months. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed under Section K swallowing and nutrition, the weight loss column was coded 0 (zero) which indicated the resident had not experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months or the data was unknown. Review of the careplan revised 7/9/13 addressing nutrition revealed in part the goals were met regarding being at risk for altered nutrition. Review of the revised care plans dated 10/17/13 revealed no written goals and approaches to address the unplanned severe weight loss. Interview on 10/23/13 at 4:16 pm with MDS coordinator#2 revealed the interdisciplinary team did not do a careplan regarding nutrition because it did not appear on the CAA (care area assessment) summary determine if the facility should make a decision to careplan. Interview on 10/23/13 at 4:40 pm with nutrition care manager (NCM#1) revealed " I did the wrong math " in determining the degree of weight loss on the Minimum Data Set (MDS) assessment form dated 10/2/13. Interview on 10/23/13 at 4:50 pm with the consultant dietitian and the director of food services was held. The consultant dietitian indicated the weight loss should have been assessed. The dietitian also indicated as the consultant she should have addressed the weight loss on the careplan Interview on 10/24/13 at 5:10 PM with the director of nurses (DON) and the Administrator regarding their expectations related to the resident ' s weight loss being Care Plan. The DON indicated her expectations would be that it wasn ' t missed and it was just a human error.

Based on observation, record review, and interviews with staff, consultant dietitian, and nurse practitioner, the facility failed to assess for and provide nutritional interventions for a severe weight loss, and for low protein and serum [MEDICATION NAME] levels, for 2 of 3 sampled residents reviewed for nutrition. (Resident#43 and #63) Findings included: 1. Record review indicated Resident #43 had cumulative [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had severely impaired cognition, was totally dependent on staff for eating and had not experienced a weight loss of 5 percent (%) or more in the last month or 10 % or more in the last 6 months. Review of the care plan revised 7/9/13, which addressed nutrition, revealed in part the goals were met regarding being at risk for altered nutrition. Review of the monthly weight chart form revealed the resident ' s height was 5 feet. The monthly weight chart form indicated a weight history which included in part: 07/02/13 =138 pounds (lbs.) 07/31/13 =134 lbs. 09/02/13 =128 lbs. 10/02/13 = 121 lbs. The seventeen pound weight loss experienced by Resident #43 from 07/02/13 to 10/02/13 equates to a 12.32 % percent severe weight loss during this three month period. Review of the revised care plan dated 10/17/13 revealed no written goals and approaches to address the unplanned weight loss. Review of Resident #43 ' s the October 2013 physician orders [REDACTED]. Review of the intake monitoring sheets from July 2013 through October 23, 2013 revealed the resident ' s food and fluid intake varied from 50 % to 100 % at different meals. Review of Resident #43 ' s physician orders [REDACTED]. This order was discontinued on 10/14/13, despite the resident consuming 100%. Review of the medical record revealed no documentation to determine why this liquid supplement was discontinued nor that other dietary interventions were implemented. Nurse#7 who discontinued the supplement on 10/14/13 was not available at the time of the survey for an interview Interview on 10/23/13 at 3:08 PM with Nurse# 2 revealed he provided a carton of chocolate liquid supplement with a straw to the resident and she consumed all of it. Nurse#2 indicated sometimes he gave her more when he administered her medications. Interview on 10/23/13 at 4:01 PM with nursing assistant (NA) #3 revealed, " The resident eats almost anything. " NA #3 indicated she had not had a problem feeding the resident. Observation of breakfast on 10/22/13 at 8:30 AM revealed the resident consumed 100 % of the eggs and hot cereal with the assistance of staff. Observation of lunch on 10/23/13 at 12:20 PM revealed the resident was being fed and consumed 75 % of her meal. Interview on 10/23/13 at 4:50 PM with the facility ' s consultant dietitian and the director of food services was held regarding Resident #43 ' s severe weight loss. The dietitian stated, " The weight loss should have been assessed, and as the consultant, I should have addressed the weight loss. " On 10/24/13 at 5:10 PM an interview with the Director of Nurses (DON) and the administrator was held regarding their expectations related to the resident ' s weight loss The DON indicated her expectations would be that it (referring to the weight loss) wasn ' t missed and the facility would be revising the weight loss policy. 2. Resident#63 had cumulative [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed resident required supervision with activities of daily living and was cognitively intact. Review of the medical record revealed no careplan to address the low protein levels. Review of the resident ' s hospital laboratory studies revealed on 6/18/13 a total protein level of 4.4 grams per deciliter (g/dl) and a serum [MEDICATION NAME] level 2.0 g/dl. The reference range for total protein level was 6.0-8.3 g/dl. The reference range for a serum [MEDICATION NAME] level was 3.5-5.5 g/dl. Review of the laboratory blood studies dated 7/1/13 revealed a total protein 5.1 g/dl and serum [MEDICATION NAME] of 3.1 g/dl. Review of the admitting nutritional assessment form dated 6/24/13 and authored by nutrition care manager (NCM#1) revealed a notation indicating a total protein level 5.1 g/dl and 3.1 g/dl serum [MEDICATION NAME] level. There was no assessment of the resident's estimated protein needs or recommendations to address the low protein markers. Interview on 10/23/13 at 10:21 AM with NCM#1 revealed the low [MEDICATION NAME] levels were not brought to her attention. NCM #1 revealed she was unaware of Resident #63 ' s low protein and [MEDICATION NAME] levels of 06/24/13, so she had not made any recommendations to address these abnormal laboratory results. Review of the 7/25/13 nutrition assessment form authored by NCM#2 revealed no indication of the low protein levels. Nor were the resident ' s low protein needs addressed. Interview on 10/23/13 at 11:30 AM via the phone with NCM#2 revealed she did not address the resident ' s low protein and [MEDICATION NAME] levels on the 07/25/13 nutritional assessment. Continued review of the nutritional assessment progress notes dated 9/25/13 and 10/4/13 revealed the facility still did not address the low protein levels or conducted an assessment of the resident's estimated protein needs. Interview on 10/23/13 at 1:50 PM with the consultant dietitian via the phone revealed a confirmation that the facility failed to address Resident #63 ' s low protein and [MEDICATION NAME] levels. An interview on 10/23/13 at 4:50PM with the consultant dietitian and the director of food services was held. The consultant dietitian specified she should have addressed the low [MEDICATION NAME] and total protein levels and should have assessed the resident ' s estimated daily protein needs. An interview was conducted on 10/24/13 at 5:20 PM with the director of nurses (DON) and the administrator regarding the expectations related to the assessment of the resident ' s protein needs. The DON revealed she would have expected the facility to implement measures to address Resident #63 ' s low [MEDICATION NAME] and total protein levels. Interview on 10/24/13 at 5:15PM with the Nurse Practitioner (NP) was conducted. The NP indicated she was unaware that a nutritional assessment had not been completed to address the low [MEDICATION NAME] levels.

Based on record review and staff interview the facility failed to protect 1 of 1 resident (Res. #1) from physical abuse and failed to intervene or call for assistance while witnessing 1 of 1 resident being abused. Findings include: Immediate Jeopardy began on 02/04/12 when NA #2 hit/punched Resident #1 two - three times in the stomach and NA#1 did not intervene or call for assistance. The Administrator was notified of the Immediate Jeopardy on 02/23/12 at 5:00 PM. The Immediate Jeopardy was removed on 02/24/12 at 9:20 PM. The facility remained out of compliance at a Scope and Severity level " D " (an isolated deficiency that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the policies and procedures implemented by the facility could be reviewed and evaluated by the Quality Assurance Committee. The facility was also in the process of ensuring the completion of the employee training. The facility was in the process of ensuring the completion of the investigation. Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the February 2012 physician 's orders revealed routine medications included [MEDICATION NAME] 100 mg(milligrams) twice daily, Tylenol 1000 mg three times daily for pain, [MEDICATION NAME] (an antidepressant)10 mg at bedtime, [MEDICATION NAME] 0.5 ML (1mg) IM (Intramuscular) Injection every 12 hours as needed for Agitation, and [MEDICATION NAME] 0.5 mg Tablet every 6 hours as needed for agitation. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short term and long term memory loss. The resident ' s cognitive skills for daily decision making were severely impaired. The resident had signs and symptoms of [MEDICAL CONDITION] such as inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION]. The resident had verbal behavioral symptoms which were directed toward others such as threatening others, screaming at others, cursing at others. The resident was totally dependent on staff for care with transfers, locomotion on and off the unit, bathing, and required extensive care for bed mobility, toilet use, and personal hygiene. The resident required limited assistance with dressing and needed set up help only for eating. The resident was frequently incontinent of bowel, and incontinent of bladder. Review of the Care Plan dated 02/02/12 revealed problems that included: Is at risk for altered mood state due to history of depression; exhibiting sign /symptoms of worsening depression: easily frustrated. The approaches included: If (resident) resists care, re-approach at a later time. If (resident) still resists, ask a co worker to approach (resident). Allow (resident) to refuse after second re-approach. Another problem included: Has TBI ([MEDICAL CONDITION]) and [DIAGNOSES REDACTED]. Becomes combative at times, hitting, kicking, & (and) fighting staff. The approaches included: explaining tasks before starting, approaching in a calm non-threatening manner, and not rushing. Offering choices as appropriate as safety allows. Monitor effectiveness of [MEDICAL CONDITION] medications. Review of the Documentation of Behavior record dated 02/03/12 revealed the resident had behaviors of yelling and screaming and kicking at 10:00 AM and at 6:00 PM, was resistive to incontinent care with clear threats of violence toward others/and/or staff, and anxiousness. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The results were documented as effective. Review of the Nurses notes dated 02/03/12 at 9:00 PM read "Increased agitation (medical sign for with) other residents and staff. Was able to give [MEDICATION NAME] Po (by mouth) 0.5 mg to help calm resident down." Review of the facility's Investigative Report read, "On February 7, 2012 an allegation of abuse was received indicating (the resident) was a victim of abuse perpetrated on Saturday February 4, 2012. The allegation consisted of a claim by NA #1 that (the resident) was struck in the midsection two or three times by NA #2/alleged perpetrator. NA #1 was the only witness to the alleged abuse. NA#1 stated that at approximately 9:30 AM February 4, 2012 NA#1 was assisting NA#2 in changing (the resident 's) brief. (The resident) was combative, so NA#2 held down (the resident 's) hands to prevent (the resident) from flailing. (The resident) put a knee into NA#2 - NA#2 proceeded to strike (the resident) with two or three blows to the stomach. (The resident) indicated that it hurt and NA#2 told (the resident) that what (the resident) felt is just like what NA#2 felt when (the resident) struck NA#2." According to the facility 's investigative report, NA#1 did not report the incident which occurred on February 4, 2012 to the facility until the morning of February 7, 2012. The facility Investigative Report read further, NA #1 "reported the incident to one of our nurses (MDS Coordinator) on the morning of February 7, 2012." The facility Investigative Report also indicated through an interview with (NA#2), the NA "Acknowledged that on February 4, 2012 at approximately 9:30 AM (NA#2) did assist providing care to (the resident). (The resident) had tried to knee (NA#2) who acknowledged (NA#2) had reacted to (the resident). The allegation of abuse concerning (the resident) is substantiated." Review of the facility Employee Disciplinary Report dated 02/07/12 read, "Date of the Incident: 2/4/12. Time of Incident: 9:15 AM - 10:00 AM. Supervisor's Remarks: Suspended pending abuse allegation investigation." This report was signed by the Assistant Director of Nurses (ADON). A nursing entry dated 02/07/12 at 3:30 PM read, "Skin assessment revealed 3.0 cm (centimeter) blue bruise noted to lower lateral back. No swelling, no s & s (signs and symptoms) of pain on palpation." An interview with the Administrator was conducted on 02/22/12 at 8:15 AM, "We train our staff not to react when a resident has behaviors. The Aide (NA#2) was reacting to something the resident was doing (putting knee into the Aide (NA#2) while the Aide (NA#2) was changing (the resident 's) brief. Although we train staff not to react to resident behaviors, the Aide (NA#2) did react in a negative manner, from all the facts that I could see. As soon as we knew (02/07/12), we took action to suspend the Aide (NA#2) and not allow the aide to work with the resident. I called the police at 3:15 PM on February 7, 2012 and they came out as soon as we contacted them. The police came on Thursday February 16, 2012 and interviewed (NA#1)." An interview with the MDS Coordinator was conducted on 02/22/12 at 8:30 AM. When asked when the assessment was done, the MDS Coordinator indicated, "My initial assessment was done on 02/07/12 about 9:30 AM and at that time I was unable to do a full body assessment because (the resident) was in the wheelchair (high back chair), I didn't document it in the Nurses notes. When (the resident) was laid down around 1:45 PM - 2:00 PM I did a full body assessment, I did not document it in the Nurses notes. That is when I found the bruise to (the resident 's) backside. It was reported to me on 02/07/12 between 8:35 AM - 8:45 AM by (NA#1) who witnessed the incident. The bruising was more on the lateral side of the right back." When asked to describe how the resident was hit, the MDS Coordinator stated, "It was two Aides (NA#1 and NA#2) in the room changing the resident, because (the resident) is a two person assist. (The resident) was in a fetal position and (the resident) kneed (NA #2) and (NA#2) was observed by the assigned Aide (NA #1) punching the resident in the stomach area. I'm not sure if it was the stomach or the side. (NA#1) said (NA#1) saw (NA#2) land two or three strikes to the stomach area or side. We monitored (the resident) specifically for the bruise after the incident, every shift until the eight of February. We monitor each shift up to three shifts after any incident has occurred." A Direct Care Staff interview with NA #1, who witnessed the abuse was conducted on 02/22/12 at 10:00 AM. When asked what the NA witnessed, NA#1 indicated, "The Aide (NA#2) was assisting me change (the resident), because (the resident) can be combative. As I was changing (the resident), (NA#2) had (the resident) held down by the hands and (the resident) was in fetal position. (The resident) was telling (NA#2), ' It hurts.' (The resident) was turned on (the resident 's) left side facing the window. (The resident) was trying to knee (NA #2). (NA #2) punched (the resident), it looked like (NA#2) was hitting (the resident ' s) stomach; it could have been (the resident 's) side. (NA#2) told (the resident) this is what it feels like when you do this to me. (The resident) was telling (NA#2), ' It hurts.' (NA#2) stated, 'I don't normally hit my residents, I've never hit any of my residents before.' " When asked what did (NA#1) do. (NA #1) stated, "We got (the resident) up." When asked did you report the incident? NA#1 stated, "I reported it that following Tuesday (February 7, 2012)." When asked if there was a reason NA#1 waited to report the incident. NA#1 stated, "I knew I needed to report it. I didn't feel comfortable reporting to my hall nurse because I didn't want all the Nursing Assistant staff knowing about it (referring to confidentiality being kept). The Nurse I felt comfortable reporting it to (MDS Coordinator), was not here. I worked the next couple of days. I reported it on Tuesday, February 7, 2012." When asked who NA#1 reported to? NA#1 indicated, "I actually reported it to the MDS Coordinator. I could have talked to the Social Worker (SW), but at the time the situation happened I didn't know I could talk to the SW)." When asked was (NA#2) working with the resident from the day (NA#2) hit the resident to the day you reported it? NA#1 indicated, "It happened on Saturday February 4, 2012. I worked with (the resident) on Sunday and (NA#2) worked with (the resident) on Monday the sixth, and Tuesday the seventh. I reported it Tuesday morning February 7, 2012 around 8:00 AM - 8:30 AM." Interviews with the Administrator and the ADON were conducted on 02/22/12 at 4:55 PM. When asked if the facility was able to establish exactly what happened, the ADON indicated, "On the seventh at 1:30 PM we (ADON, Human Resources (HR) Director, and the Administrator) met to discuss the incident, and to meet with the witness (NA #1). During that time we concluded the incident did happen as reported by (NA#1). We felt that (NA#1) was credible, because (NA #1) repeated the same story in the afternoon that (NA#1) had told the MDS Coordinator at 8:30 AM the morning of 02/07/12. The MDS Coordinator reported to me (ADON) then I reported to the HR Director, and to the Administrator." Per the Administrator on 02/22/12 at 5:00 PM, "We discussed the disciplinary action with the employee (Aide #2) at 2:00 PM on 02/07/12." The ADON indicated, "I walked her to the time clock on 02/07/12." An attempt was made to interview NA#2 / perpetrator on 02/23/12 at 12:00 Noon. The attempt was unsuccessful related to the phone number was no longer a working number. A second interview with NA # 1 was conducted on 02/23/12 at 2:15 PM. When asked how the resident was hit? NA#1 demonstrated," (NA#2) took (NA#2 's) fist and punched (the resident) at least two or three times. (NA #2) was holding (the resident 's) hands down, and extended (the resident 's) hands and held them down while the arms were extended over the mattress and on top of the bed rail. Bed rails were down. (The resident) was spitting and kicking." When asked what did you do while (NA#2) was punching (the resident)? NA #1 replied, "I walked away to the bathroom to get incontinent care supplies and completed the incontinent care." NA#1 was asked if she attempted to stop NA#2, and NA # 1 said "No." When asked why NA#1 did not attempt to stop NA#2, NA#1 indicated, "I guess I was too stunned, and I was not thinking." NA#1 was asked to demonstrate the position the resident was in. NA#1 indicated, "(The resident) was lying on (the resident 's) left side in a fetal position, with (the resident's) knees flexed." When asked, did (the resident) have the bruise on the back prior to the punching? NA#1 indicated, "I had (the resident) the whole week of January 30 through February 5, 2012. I did not notice a bruise during the incontinent care." When asked, is there a plan of what to do? NA#1 indicated, "Yes, we are to let (the resident) alone when agitated. We did let (the resident) alone and this was the second time we had tried to do incontinent care." The Administrator was notified of the Immediate Jeopardy on 02/23/12 at 5:00 PM. The facility provided an acceptable Credible Allegation of Compliance on 02/24/12 at 8:30 PM. Credible Allegation of Compliance A. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion For resident #1 found to be affected by the deficient practice; not being free from physical abuse as evidenced by: 2/4/12 At approximately 9:15 am CNA assigned to resident witnessed assisting CNA throw about 2 or 3 blows to Resident #1 ' s stomach. The assigned CNA was uncomfortable and did not report this incident immediately to the nurse. The assigned CNA and assisting CNA remained on assignment on 2/5/12, 2/6/12, and 2/7/12. 2/7/12 At approximately 8:30am was the first report to the MDS Coordinator assigned to Oaks. The MDS Coordinator informed the ADON at 9:45am who informed the administrator by telephone message at approximately 10:30 am. The Administrator and Director of Human Resources were informed via telephone of the of the alleged physical abuse by the CNA who assisted with care to Resident #1 and the ADON, Administrator and Director of Human Resources met at 11 am. After discussion, the Administrator, Director of Human Resources and ADON met with the assigned CNA then the assisting CNA. The assisting CNA was suspended at approximately 2:30pm 2/7/12. The assisting CNA was accompanied out of the building and off the property by the ADON. On 2/9/12 the assisting CNA was terminated 2/9/12 at 2pm. Corrective action was accomplished for resident 1 by removing SH from the unit at 2:00pm. Total body assessment on resident 1 done at 3:30pm on 2/7/12 2/7/12 at approximately 3:15 pm the Administrator contacted the local Police Department by telephone alerting the police of the alleged abuse. At approximately 4:00 pm a Police Officer came to the facility and took further information. At some point (we do not have the knowledge exactly what the police time table was) an investigation was opened by the police and the case was assigned a case number. A Detective was assigned to the case from the local Police Department. On 2/16/12 the Detective interviewed the assigned CNA who witnessed the alleged abuse. The investigation by the Police of the alleged abuse is still on-going. We are waiting to hear from the Police the final result of their investigation. Measures taken to ensure that staff appropriately responded to combative behavior of resident was accomplished by in services on " Handling Residents with Combative Behaviors " starting 2/9/12 completed on 2/13/12. Staff will not be able to work until completed in-service. The CNA assigned to the resident was instructed on 2/7/12 in what you should do if you suspect or witness the possible abuse of a resident including reporting the abuse immediately on 2/7/12. On 2/24/12 the CNA assigned to the resident and witness to the abuse was terminated at 2:15pm and escorted from the building by security and observed exiting the property in her car. B. The corrective action will be accomplished for those residents having potential to be affected by the same deficient practice by assisting CNA being removed from the unit. 1. Current skilled facility staff will be in serviced beginning 2/23/12at 10pm and completed on 2/24/12 to inform all staff of the abuse policy including reporting and that the charge nurse does have the ability to remove the alleged perpetrator immediately from the residents that may be involved in an allegation of abuse. If the staff witnessing the alleged abuse is uncomfortable reporting abuse to charge nurse, she may convey this information to other nurses in the building, administrative staff or the on-call nurse. Phone numbers are posted on each unit. 2. In order to address issues of staff burnout and dealing with residents with behavioral issues training was given starting on 2/9/12 and will be ongoing on the topic of Dementia, Behavior and Approaches. Training is by the Staff Development Coordinator. Staff has the opportunity to vent at weekly unit meetings presided over by the administrative nurse assigned to that Unit. 3. Current facility staff all departments will be in serviced beginning 2/23/12 at 10pm to inform all staff of the abuse policy, including reporting. The training will be done by department heads and completed by 2/24/12. The plan for employees who are not working will be that they will not be allowed to work until in service review is completed. Currently 95 staff in all departments have already been in serviced. 4. Resident Abuse and Reporting questionnaires were completed on all inter viewable and observations were made on non inter viewable residents on 2/24/12. Alert Residents (38) Non verbal residents (12) were visibly inspected. Questionable responses or observations will be investigated by the Abuse Officer to identify definite or probable causes of abuse. No identifiable evidence of abuse were ascertained. C. To ensure the deficient practice will not occur measures to be put in place will be a. Current skilled facility staff will receive ongoing in-services on abuse policy and reporting. b. Monitor potential abuse through resident abuse and reporting questionnaires, will be done on initial assessments, quarterly assessments and as needed. Any questionable concerns will be followed to the abuse officer who will further investigate for the possibility of abuse. If abuse is confirmed, the abuse policy will be into effect. c. The abuse policy will be included in the admission packet given to the resident/responsible party by social worker. d. Ongoing training by staff development coordinator or designee and monitoring will be done to address current issues and support to staff caring for residents with behavioral issues. D. The Facility plans to monitor its performance to assure that solutions are sustained by a. Audits by QA or designee with staff in all departments to assess their knowledge with regards to abuse and reporting will be conducted daily for two months and then every two weeks for two months then monthly indefinitely. b. Audits will be reviewed and evaluated at the daily sit down management meeting for two months and then every two weeks for two months then monthly indefinitely. c. Policies and procedures including abuse and reporting will be reviewed on new employees, at 90 days, 6 months, and annually on their performance evaluations. All employees ' performance is evaluated annually from the date of hire. d. Weekly unit meeting conducted by administrative nurses assigned to that POD create an open forum for staff to share frustrations and for suggestions and assignment adjustment to alleviate possible causes of stress. These meetings will be conducted indefinitely. E. Dates that corrective action will be completed by a. Current scheduled staff, all departments, will be in-serviced by the staff development coordinator or designee on abuse policy and reporting completed by 2/24/12 and will not be allowed on the unit until in-serviced. b. Staff scheduled, all departments, in the future will not be allowed in the unit until in-serviced by staff development coordinator or designee. New employees will be in-serviced at orientation. Validation of the facility 's Credible Allegation of Compliance was conducted on 02/24/12 at 8:30 PM - 9:10 PM through interviews with staff to make sure all residents were safe and abuse training had been accomplished.

Based on medical record review, review of the facility policies and procedures, and staff interviews the facility failed to protect resident #1 from abuse resulting in bruising to the lower lateral back. The facility staff failed to report a witnessed event of physical abuse. This was evident in 1 of 1 sampled resident (Res. #1). Findings included: Immediate Jeopardy began on 02/04/12. The Administrator was notified of the Immediate Jeopardy on 02/23/12 at 5:00 PM. The Immediate Jeopardy was removed on 02/24/12 at 9:20 PM. The facility remained out of compliance at a Scope and Severity level "D" (an isolated deficiency that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the policies and procedures implemented by the facility could be reviewed and evaluated by the Quality Assurance Committee. The facility was also in the process of ensuring the completion of the employee training. The facility was in the process of ensuring the completion of the investigation. A facility policy titled "Resident Rights/Abuse Policy" dated 01/22/04 was reviewed. The policy read in part: Guidelines for Abuse Altercations. Practice Guidelines: All staff is bound by facility policy to intervene when any type of abuse is suspected. All allegations of abuse are reported to the administrator or their designated representative. The Social Services Staff and Nursing Staff supports that all involved resident/staff are protected from further abuse. VI. Protection: Policy Statement: Our facility will protect residents from harm during investigations of abuse allegations. Employee(s) accused of participating in the alleged abuse will be asked to leave the unit immediately by their supervisor and will be suspended until the findings of the investigation have been reviewed by the administrator. IV. Identification: Policy Statement: To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Policy Interpretation and Implementation: 1. Some examples of potential abuse/neglect that should be promptly reported. a. Signs of potential/actual Physical Abuse: Welts or bruises. 2. All suspicious bruising of residents will be reported to the charge nurse. Review of the facility's Investigative Report read, "On February 7, 2012 an allegation of abuse was received indicating (the resident) was a victim of abuse perpetrated on Saturday February 4, 2012. The allegation consisted of a claim by NA #1 that (the resident) was struck in the midsection two or three times by NA #2/alleged perpetrator. NA #1 was the only witness to the alleged abuse. NA#1 stated that at approximately 9:30 AM February 4, 2012 NA#1 was assisting NA#2 in changing (the resident 's) brief. (The resident) was combative, so NA#2 held down (the resident 's) hands to prevent (the resident) from flailing. (The resident) put a knee into NA#2 - NA#2 proceeded to strike (the resident) with two or three blows to the stomach. (The resident) indicated that it hurt and NA#2 told (the resident) that what (the resident) felt is just like what NA#2 felt when (the resident) struck NA#2." The facility Investigative Report also indicated through an interview with NA#2, the NA "Acknowledged that on February 4, 2012 at approximately 9:30 AM (NA#2) did assist providing care to (the resident). (The resident) had tried to knee (NA#2) who acknowledged (NA#2) had reacted to (the resident). The allegation of abuse concerning (the resident) is substantiated." A nursing entry dated 02/07/12 at 3:30 PM read, "Skin assessment revealed 3.0 cm (centimeter) blue bruise noted to lower lateral back. No swelling, no s & s (signs and symptoms) of pain on palpation." Review of the facility Employee Disciplinary Report dated 02/07/12 read, "Date of the Incident: 2/4/12. Time of Incident: 9:15 AM - 10:00 AM. Supervisor's Remarks: Suspended pending abuse allegation investigation." This report was signed by the Assistant Director Director of Nurses (ADON). An interview with the MDS Coordinator was conducted on 02/22/12 at 8:30 AM. The MDS Coordinator indicated, "It was reported to me on 02/07/12 between 8:35 AM - 8:45 AM by (NA#1) who witnessed the incident. The bruising was more on the lateral side of the right back." A Direct Care Staff interview with NA #1 who witnessed the abuse, was conducted on 02/22/12 at 10:00 AM. NA#1 indicated the Aide (NA#2) was assisting NA#1 to change the resident, because he can be combative. NA#2 had the resident held down by the hands in fetal position during the change. The resident was telling NA#2, 'It hurts.' The resident was turned on his left side facing the window. The resident was trying to knee NA#2. NA#2 punched the resident. It looked like NA#2 was hitting the resident in the stomach or the resident 's side. NA#2 told the resident "this is what it feels like when you do this to me." NA#2 stated, " I don't normally hit my residents, I 've never hit any of my residents before. " During the interview on 02/22/12 at 10:00 AM, NA#1 indicated the incident happened on Saturday 02/04/12. NA#1 worked with the resident on Sunday (02/05/12) and NA#2 worked with the resident on Monday (02/06/12) and Tuesday (02/07/12). NA#1 reported the incident Tuesday morning (02/07/12) around 8:00 AM - 8:30 AM. An attempt was made to interview NA#2 / perpetrator on 02/23/12 at 12:00 Noon. The attempt was unsuccessful related to the phone number was no longer a working number. Interviews with the Administrator and the ADON were conducted on 02/22/12 at 4:55 PM. When asked if the facility was able to establish exactly what happened, the ADON indicated, "On the seventh at 1:30 PM we (ADON, Human Resources (HR) Director, and the Administrator) met to discuss the incident, and to meet with the witness (NA #1). During that time we concluded the incident did happen as reported by (NA#1). We felt that (NA#1) was credible, because (NA #1) repeated the same story in the afternoon that (NA#1) had told the MDS Coordinator at 8:30 AM the morning of 02/07/12. The MDS Coordinator reported to me (ADON) then I reported to the HR Director, and to the Administrator." Per the Administrator on 02/22/12 at 5:00 PM, "We discussed the disciplinary action with the employee (Aide #2) at 2:00 PM on 02/07/12." The ADON indicated, "I walked her to the time clock on 02/07/12." Interview with the Administrator on 02/24/12 at 12:40 PM indicated, "We have a zero tolerance for abuse. We had the Abuse Policy in place, but we didn't implement it." The Administrator was notified of the Immediate Jeopardy on 02/23/12 at 5:00 PM. The facility provided an acceptable Credible Allegation of Compliance on 02/24/12 at 8:30 PM. Credible Allegation ? The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ? ? The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. ? ? For resident #1 found to be affected by this deficient practice failure to implement current policies and procedures. Corrective actions will be accomplished for resident #1 by training on how and to whom incidents of abuse, neglect, and mistreatment should be reported to. ? ? ? 2/4/12 At approximately 9:15 am CNA assigned to resident witnessed assisting CNA throw about 2 or 3 blows to Resident #1 ' s stomach. The assigned CNA was uncomfortable and did not report this incident immediately to the nurse. The assigned CNA and assisting CNA remained on assignment on 2/5/12, 2/6/12, and 2/7/12. ? ? 2/7/12 At approximately 8:30am was the first report to the MDS Coordinator assigned to Oaks. The MDS Coordinator informed the ADON at 9:45am who informed the administrator by telephone message at approximately 10:30am. The Administrator and Director of Human Resources were informed via telephone of the of the alleged physical abuse by the CNA who assisted with care to Resident #1 and the ADON, Administrator and Director of Human Resources met at 11 am. After discussion, the Administrator, Director of Human Resources and ADON met with the assigned CNA then the assisting CNA. The assisting CNA was suspended at approximately 2:30pm 2/7/12. The assisting CNA was accompanied out of the building and off the property by the ADON. On 2/9/12 the assisting CNA was terminated 2/9/12 at 2pm. ? ? Corrective action was accomplished for resident 1 by removing SH from the unit at 2:00pm. Total body assessment on resident 1 done at 3:30pm on 2/7/12 ? ? Measures taken to ensure that staff appropriately responded to combative behavior of resident was accomplished by in services on " Handling Residents with Combative Behaviors " starting 2/9/12 completed on 2/13/12. Staff will not be able to work until completed.in-service. ? ? The CNA assigned to the resident was instructed on 2/7/12 in what you should do if you suspect or witness the possible abuse of a resident including reporting the abuse immediately on 2/7/12. ? ? On 2/24/12 the CNA assigned to the resident and witness to the abuse was terminated at 2:15pm and escorted from the building by security and observed exiting the property in her car. ? ? ? ? ? Corrective action will be accomplished for those residents having potential to be affected by the same deficient practice- assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents ' rooms, residents with self injurious behaviors, residents with communication disorders that require heavy nursing care and/or totally dependent on staff. ? ? 1. Current skilled facility staff will be in serviced beginning 2/23/12 at 10pm and completed 2/24/12 to inform all staff of the abuse policy including reporting and that the charge nurse does have the ability to remove the alleged perpetrator immediately from the residents that may be involved in an allegation of abuse. If the staff witnessing the alleged abuse is uncomfortable reporting abuse to charge nurse, she may convey this information to other nurses in the building, administrative staff or the on-call nurse. Phone numbers are posted on each unit. ? ? 2. In order to address issues of staff burnout and dealing with residents with behavioral issues training was given starting on 2/9/12 and will be ongoing on the topic of Dementia, Behavior and Approaches. Training is by the Staff Development Coordinator. Staff has the opportunity to vent at weekly pod meetings presided over by the administrative nurse assigned to that unit. ? ? 3. Current facility staff all departments will be in serviced beginning 2/23/12 at 10pm to inform all staff of the abuse policy, including reporting. The training will be done by department heads and completed by 2/24/12. The plan for employees who are not working will be that they will not be allowed to work until in service review is completed. Currently 95 staff in all departments have already been in serviced. ? ? 4. Resident Abuse and Reporting questionnaires were completed on all interviewable and observations were made on non inter viewable residents on 2/24/12. Alert Residents (38) ? Non verbal residents (12) visible inspection observed. Questionable responses or observations will be investigated by the Abuse Officer to identify definite or probable causes of abuse. No identifiable evidence of abuse were ascertained. ? ? ? To ensure the deficient practice will not occur measures to be put in place will be ? ? Current scheduled staff, all departments, will receive ongoing in-services on abuse policy and reporting. ? Monitor potential abuse through resident abuse and reporting questionnaires, will be done on initial assessments, quarterly assessments and as needed. Any questionable concerns will be followed to the abuse officer who will further investigate for the possibility of abuse. If abuse is confirmed, the abuse policy will be into effect. ? The abuse policy will be included in the admission packet given to the resident/responsible party by social worker. ? Ongoing training by staff development coordinator or designee and monitoring will be done to address current issues and support to staff caring for residents with behavioral issues. ? ? ? The Facility plans to monitor its performance to assure that solutions are sustained by ? ? Audits by QA or designee with staff in all departments to assess their knowledge with regards to abuse and reporting will be conducted daily for two months and then every two weeks for two months then monthly indefinitely. ? Audits will be reviewed and evaluated in the sit down meeting daily for two months and then every two weeks for two months then monthly indefinitely. ? Policies and procedures including abuse and reporting will be reviewed on new employees, at 90 days, 6 months, and annually on their performance evaluations. All employees ' performance is evaluated annually from the date of hire. ? Weekly unit meeting conducted by administrative nurses assigned to that unit create an open forum for staff to share frustrations and for suggestions and assignment adjustment to alleviate possible causes of stress. These meeting will be held indefinitely. ? ? ? Dates that corrective action will be completed by ? ? Current scheduled staff, all departments, will be in-serviced by the staff development coordinator or designee on abuse policy and reporting completed by 2/24/12 and will not be allowed on the unit until in-serviced. ? Staff scheduled, all departments, in the future will not be allowed in the unit until in-serviced by staff development coordinator or designee. ? New employees will be in-serviced at orientation. Validation of the facility 's Credible Allegation of Compliance was conducted on 02/24/12 at 8:30 PM - 9:10 PM through interviews with staff to make sure all residents were safe and abuse training had been accomplished.