Every finding on record at Fulton Nursing and Rehabilitation, LLC

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The failure had the potential to affect all residents who consumed meals from the kitchen. The findings include: 1). Review of the facility's policy titled, Food Storage-Dry Goods, dated 10/2019, revealed all items were to be stored six inches above the floor on shelves. Review of the facility's policy titled, Food Storage-Cold, dated 10/2019, revealed the facility was to ensure frozen and refrigerated food items were appropriately stored in accordance with the guidelines of the Food and Drug Administration (FDA) Food Code. Continued review of the Food Storage-Cold policy revealed the facility was also to ensure all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Observation of the kitchen's dry pantry storage on 06/03/2026 at 10:35 AM, revealed two cases of boxed juices stored directly on the floor. Per observation, two cans of marinara sauce, 104 ounces (OZ); one can of 3-bean salad, 108 OZ; and one can of banana pudding, 112 OZ, were dented; however, remained on the active storage shelf to be served to residents. During an interview with the Dietary Manager (DM) on 06/03/2026 at 10:30 AM, he stated the food items stored on the floor had been part of a delivery. He reported however, he was aware food items were not to be placed directly on the floor. The DM said staff should have stored those items (on the floor) on the shelves immediately. He further stated the dented cans were not to be served to residents and should have been removed and discarded, but he had overlooked the dented cans. Observation of the kitchen on 06/04/2026 at 11:20 AM, revealed the 3-door refrigerator that previously had been observed to be at 45 degrees Fahrenheit (F), above the required temperature of 41 degrees F. Per continued observation of the 3-door refrigerator revealed the temperature was at 49 degrees F. Per observation, all food items previously stored in the refrigerator (on 06/03/2026) had been were removed, however, dietary staff still had residents' drinks stored in the refrigerator, even though the refrigerator temperature was above the required 41 degrees F. Further observation, of the outdoor freezer, revealed a box of sausage patties in it's original container, with the interior plastic uncovered. Continued observation, of the outdoor freezer, revealed a box of croissants with plastic wrapping uncovered and stored underneath the condenser and the box was covered with ice particles (from the condenser). In interview with the DM on 06/04/2026 at 11:40 AM, he stated all of the food items from the 3-door refrigerator had been removed. He reported he did not believe there was any concern for storing the residents' drinks at 49 degrees F, even though he knew cold items were required to be stored at 41 degrees F. The DM further reported his expectations for dietary staff, when storing food items, was for them to ensure all food containers were covered securely to prevent contamination. In addition, he said he expected dietary staff to follow the guidance received through their training and through the food safety policy. 2). Review of the facility's policy titled, Staff Attire, dated 10/2019, revealed all staff were to have their hair off their shoulders, confined in a hair net and facial hair properly restrained. Observation of the kitchen on 06/04/2026 at 2:30 PM, revealed the DM was observed with his beard net below his mustache while preparing residents' meal plates at the steam table. During an interview with DM on 06/04/2026 at 11:40 AM, he stated he was aware beard nets were to cover all facial hair; however, his beard net dropped down below his beard, and he failed to pull it back up. He reported if staff were not wearing beard or hair nets correctly there was potential for hair to fall into residents' food causing contamination concerns. During an interview with the Administrator, 06/04/2026 at 6:30 PM, she stated expectations for dietary staff ,wearing hairnets and beard nets, was for them to ensure they had completely covered all hair, including facial hair. She reported her expectations for all dietary staff was for them to ensure deliveries of food items were not left stored on the floor, but should immediately store all food delivered on the shelves in the pantry. The Administrator said she also expected all the dietary staff to follow the facility's policies and procedures on food safety, by properly dating, sealing, and covering any food items before placing the food in dry or cold storage. She further stated if staff were not following the facility's food safety policy and procedures there was always potential for harm, specifically cross contamination and food being exposed to air contaminants. In addition, the Administrator stated she would not want residents to be served unsafe, or freezer burnt foods.

Based on observation, interview, and facility policy review, the facility failed to ensure residents were provided a safe, functional, sanitary, and comfortable environment, which had the potential to affect all residents consuming food from the kitchen. The findings include: Review of the facility's policy titled, Master Cleaning Schedule, undated, revealed the cleaning and shift assignments required daily cleaning of floors, backsplash, walls, ice machine, sinks, and coolers. Further review of the policy revealed staff were required to initial when the tasks were completed. On 06/04/2026 at 2:30 PM, the State Survey Agency (SSA) Surveyor requested a facility policy related to cleaning and sanitation guidelines for the dietary department; however, no such policy was provided. Observation of the kitchen on 06/03/2026 at 10:35 AM, revealed the pantry door covered with grime. Per observation, the wall outside the dry pantry storage was soiled with brown colored liquid splatters. Observation of refrigerator 1 revealed the outside of the doors were covered in grime and soiled on the inside doors with food crumbs caked in the door seals. Observation of the ice machine revealed it was soiled with black grime on the side and front of the machine. Observation of the walls across from the dishwasher revealed the walls were covered with brown splatters and grime. Continued observation, throughout that area, revealed the floors caked with a black substance around the ice machine and metal dishwasher table, and open floor areas were grimy. Further observation revealed two white metal garbage cans both covered with food splatters and other brownish colored grime. In addition, observation of the kitchen area revealed the front of the metal sink and the wall above the sink covered with food and liquid splatters and a brownish colored grime. During an interview with the Dietary Manager (DM) on 06/23/2026 at 10:35 AM, he stated, If I'm being honest, I don't regularly follow-up on the monitoring of the cleaning (In the kitchen). He further stated he understood not ensuring cleanliness could potentially cause harm to residents if they were served food from an unsanitary kitchen environment. During an interview with Dietary Aide, on 06/04/2026 at 2:20 PM, he stated routine cleaning was part of his daily job duties in the kitchen and he received training. He further stated he was to sign off when those cleaning tasks were completed but stated they could be doing a better job to ensure the kitchen environment was safe and sanitary. He stated he did not recall cleaning the seals inside of the refrigerator doors to remove debris or food particles. During an interview with Cook2, on 06/04/2026 at 2:40 PM, she stated she only worked for about two weeks but recalled being educated on dietary responsibilities. She stated she believed the dietary staff were cleaning the kitchen areas. She stated there were sign-off sheets, however, when making observations and seeing the condition of the kitchen, she stated she understood the concerns with sanitation and contamination hazards. She stated she would not want her family members or the residents to be served food from an unsafe environment. During an interview with the Administrator, on 06/04/2026 at 6:30 PM, she stated her expectations of the overall cleanliness of the kitchen environment were that staff would be following a cleaning schedule. She stated the dietary staff had been recently educated. She stated her expectations were that the DM had ensured staff were completing deep cleaning as scheduled and signing off upon completion, but DM should monitor to verify staff were completing the work. Additionally, she stated her expectations were that the dietary staff should follow policies on providing a safe and sanitary environment in the kitchen to prevent any indirect concerns of contamination to the residents.

Based on observation, interview, and review of facility policy, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents consuming their meals in the dining room, which had the potential to affect those residents. Observation on 06/03/2026 and 06/04/2026, revealed red and brown dried splash marks were observed on the dining room walls.The findings include: Review of the facility policy titled, Safe and Homelike Environment, dated 06/01/2025, revealed it defined sanitary as including, but not limited to, preventing the spread of disease-causing organisms. Further review revealed preventing the spread of disease-causing organisms was noted as: by keeping resident care equipment clean. Review of the facility-provided document (from a contract housekeeping services provider) titled, Wall and Handrail Cleaning, undated, revealed painted walls were to be cleaned with quaternary disinfectants. Review of another facility-provided document (from the same contract housekeeping services provider) titled, EVS Manager- Daily Room Audit Sheet, undated, revealed common areas in the facility were to be checked in the AM (morning) and in the PM (afternoon). 1) Observation during lunch, of the dining room, on 06/03/2026 at 12:03 PM, revealed brown and red substances dried on the walls next to the dishwasher entrance door and the exit door. In interview on 06/04/2026 at 4:59 PM, the Housekeeping Supervisor reported there was no cleaning schedule for the dining room area. She said the last time the walls in that area were cleaned was about a month prior. The Housekeeping Supervisor further stated the dried substances was food that had been slung on the walls by kitchen staff during their post-meal cleanup. She additionally said the kitchen staff were to clean the dining room area after meals. 2). Further observation on 06/03/2026 at 12:03 PM, of the dining room area, revealed the fluorescent light covers had dark areas, which appeared to be on the inside of the lens. In interview on 06/04/2026 at 5:09 PM, the Director of Maintenance stated the light lens (in the dining area) were last cleaned in February 2026, and he was now working on replacing them. He reported however, he needed a taller ladder, which he had to borrow, to reach the top light to clean it. The Director of Maintenance said he tried to clean the light lens monthly, but there was no formal schedule for cleaning the lights. He further stated he ordered new lens, which had been too small. The Director of Maintenance additionally reported while cleaning one light lens, it fell and broke, and he place the remainder of the lens back up, leaving an opening where he could see the bulb. In interview on 06/04/2026 at 6:14 PM, the Administrator stated her expectation was for there to be nightly cleaning of the floors, tables, chairs, and walls. She further stated the dining area light fixtures were in the process of being replaced.

Based on observation, interview, and review of facility policy, the facility failed to store foods in accordance with professional standards for food service safety. Observation during the initial kitchen tour on [DATE] at 9:05 AM, with the Dietary Manager, revealed multiple items stored in the reach in cooler that were not labeled or dated or the use by date had passed. The findings include: Review of the facility policy, Food Storage: Cold, undated, revealed, it was the facility's policy to ensure all time temperature control for safety, frozen and refrigerated food items to be appropriately stored in accordance with the guidelines of the Food and Drug Administration's (FDA's) Food Code. Continued review revealed all food items were to stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Observation of the facility's kitchen area on [DATE] at 9:05 AM, revealed in the reach in cooler three opened containers of blackberries that were dried out, not labeled or dated and covered with a white substance. Continued observation of the reach in cooler revealed two (2) containers of opened blueberries, that were dried out, not labeled or dated and contained mold; a container with three hard boiled eggs that was not labeled or dated; and a bowl of white rice with a use by date of [DATE] (nine days prior to the observation). In interview with the Dietary Manager on [DATE] at 9:30 AM, he stated all items were to be labeled and dated prior to being stored in the coolers. He stated all kitchen staff were responsible for checking the coolers each day; however, it was not a task assigned to anyone specifically. The DM further stated he expected all kitchen staff to follow policies and guidelines. He also stated residents could become ill if served food that was expired or not stored properly. In interview with the Administrator on [DATE] at 4:08 PM, she stated she expected the food services staff to follow their guidelines. She stated all food items should be labeled and dated before being stored. The Administrator further stated outcomes for patients were that they could become sick if served food that was not stored properly.

Based on interview, record review, and review of the facility policy, the facility failed to complete a pre-admission screening and resident review (PASARR) for individuals with a mental disorder prior to admission for 1 of 3 residents (Resident (R)14). Additionally the facility failed to refer R14 for a Level II PASARR following inpatient psychiatric treatment on 11/01/2024, 2 days following admission to the facility, and again on 02/28/2025. The findings include: Review of the facility policy, Resident Assessment-Coordination with PASARR Program, revised on 03/14/2023, revealed the facility would coordinate assessments with the PASARR program. Per review, coordinating the assessments with the PASARR program was to ensure individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. Continued review revealed all applicants to the facility were to be screened for serious mental disorder or intellectual disabilities (ID) and related conditions in accordance with the state Medicaid rules for screening. Policy review revealed a PASARR Level 1 was the initial pre-screening that was completed prior to admission. Further review revealed, any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability or a related condition, was to be referred promptly to the state mental health or ID authority for a Level II resident review. In addition, review revealed examples listed included a resident exhibiting behavioral, psychiatric, or mood related symptoms, that suggested the presence of a mental disorder where dementia was not the primary diagnosis. Review further revealed a resident transferred, admitted or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment was also to be referred. Review of the Resident Face Sheet for R14, revealed the facility admitted the resident on 10/30/2024, with diagnoses to include: schizophrenia, unspecified; depression, unspecified; and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/04/2025, revealed the facility assessed R14 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. In interview with R14 on 05/20/2025 at 11:20 AM, she stated she had been at the facility for about six months. She said she previously lived at a personal care home; however, had gotten pneumonia and went to the hospital. R14 reported she came to the facility from the hospital. She stated the facility had sent her out for what they called behaviors twice since she had been admitted at the facility. R14 further stated she did not know what a PASARR assessment was. Interview with the Director of Nursing (DON) on 05/22/2025 at 3:37 PM, she stated she had been the facility's interim DON since 05/06/2025. She said she thought admissions staff and the social worker were supposed to do the PASARR assessments. The DON explained the Admission Director usually got the resident referral and was to check the resident's history. She stated a diagnosis of schizophrenia might trigger a Level II PASARR assessment; however, she did not think it meant they needed one. The DON further stated the facility had a mental health provider that took care of most of the mental health things. She additionally stated R14 probably should have had a Level II PASARR assessment completed. In interview with the Administrator on 05/22/2025 at 4:08 PM, she stated she was responsible for completing the PASARR Level I assessments, and that was completed on the day of a resident's admission. She said the PASARR asked about the resident's diagnoses, change in conditions or change in function. The Administrator stated hospitalization on a behavioral health unit (BHU) would not indicate a PASARR Level II assessment needed to be completed. She further stated she was unable to recall what R14's behaviors had been when she was sent to the BHU on 11/02/2024 and on 02/18/2025.

Based on interview, record review and review of the facility policy, the facility failed to review and revise the comprehensive care plan (CCP) following readmission to the facility from a behavioral health unit (BHU) for 1 of 24 sampled residents, (Resident (R)14). The findings include: Review of the facility policy, Comprehensive Care Plans revised 02/20/2025, revealed it was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights. Continued policy review revealed the comprehensive person-centered care plan was also to include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that had been identified in the resident's comprehensive assessment. Further review revealed the CCP was to be reviewed and revised by the interdisciplinary team (IDT) after each comprehensive and quarterly Minimum Data Set (MDS) Assessment. Review of the Resident Face Sheet for R14, revealed the facility admitted the resident on 10/30/2024, with diagnoses that included: generalized anxiety disorder; schizophrenia, unspecified and depression, unspecified. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/04/2025, revealed the facility assessed R14 as having a Brief Interview for Mental Status (BIMS) score of 15 of 15, that indicated the resident was cognitively intact. Review of the Comprehensive Care Plan dated 11/01/2024 for R14, revealed the facility had identified a focus problem for behavioral symptoms for the resident related to resisting care, activities of daily living (ADL) care, medications, treatments, showers, urinating on the floor, and liking to sit on the floor. Per review, the goals statement read, resident would not exhibit resistance to care. Continued review revealed the interventions dated 11/01/2024 included: involving R14 in her care; administering medications as ordered and observing for effectiveness; and reporting any adverse side effects. Further review of the 11/01/2024 interventions revealed: allowing R14 to choose options, explain the consequences of refusal of therapy, medications, and care; maintaining a calm approach and environment for the resident. In addition, review of the interventions revealed to obtain a psych consult/psychosocial therapy; praising R14 when her behavior was appropriate; and when the resident began to resist care, stop and try the task later, and do not force the resident to do the task. In interview on 05/20/2025 at 11:20 AM, R14 stated she had been admitted to the facility for about six months. R14 said she previously lived at a personal care home, but got pneumonia and was transferred to the hospital. She stated she was admitted to the facility after being discharged from the hospital. R14 reported the facility had sent her out (to a behavioral health unit) for what they called behaviors two times since she had been admitted to the facility. She further stated she did not know what a PASARR assessment was. Review of the hospital Discharge Summary dated 02/28/2025, revealed a referral had been made to the BHU from the patient's (P14's) skilled nursing facility (SNF) due to her, seeing people in her bathroom, threatening to kill her roommate, and threatening to harm herself. Per review, the SNF staff reported R14's Celexa (antidepressant) and risperidone (antipsychotic) were recently increased due to the patient's agitation, verbal impulsivity, and risk to self and others, with no change in her behavior. Continued review revealed R14 was admitted to the BHU for medical stabilization. Further review revealed under, My Safety Plan it was noted R14 had schizophrenia symptoms and confusion. Additional review of the My Safety Plan section the goals for R14's healthy behavior included: referring her to be seen by the in house psychiatric (psych) provider; encouraging her to participate in daytime activities; avoiding caffeine in the evening; pairing her with a roommate that she would get along with; and have others remind her she was in a safe place. Review of the Nursing Progress Note dated 02/15/2025 at 9:29 PM for R14, revealed the resident was convinced people were after her, and kept calling staff into her room saying someone was in the bathroom and trying to get her. Per review, staff reassured R14 no one was in the restroom and she was safe. Continued review revealed R14 began screaming that her roommate had a fork and was going to try to kill her and she was afraid. Further review revealed the nurse explained to R14 that her roommate had a fork to eat her food with. In addition, review revealed R14 then screamed no one needs a fork, and proceeded to exit the room to sit at the nurse's station. Review of the Nursing Progress Note dated 02/15/2025 at 9:36 PM for R14, revealed the resident kept asking for the phone to call the police, saying people were after her. Further review revealed staff continued to reassure R14 she was safe here: (at the facility) and no one was after her. Review of the Nursing Progress Note dated 2/16/2025 at 4:25 PM for R14, revealed the resident continued to act out towards employees by stating she was going to hurt them if she did not get what she asked for. Further review revealed R14 wanted the cordless phone which was being used by another resident. Review of the Nursing Progress Note dated 02/16/2025 at 10:01 PM for R14, revealed the resident continued with behaviors towards staff, threatening to harm staff if they did not do what she said. Further review revealed R14's anger was only directed at staff at that time, and had shown no anger toward other residents at the time. Review of the Nursing Progress Note dated 02/17/2025 at 9:57 AM for R14, revealed the resident's increased behaviors, aggression, and paranoia continue. Review of the Nursing Progress Note dated 02/18/2025 at 3:36 PM for R14, revealed a new order was received to send the resident to the behavioral health center for treatment secondary to hallucinations, delusions and threatening behavior towards staff and others. Per review, the nurse left a voicemail with a hospital BHU with no response received at the time. Further review revealed the nurse called another geriatric psychiatric behavioral health center and gave information on R14, as well as faxing the information, and was awaiting a return call. Review of the Nursing Progress Note dated 02/18/2025 at 5:37 PM for R14, revealed, I have called the ambulance to transport resident to the BHU's emergency room (ER) for evaluation for admittance to the BHU. Review of the Comprehensive Care Plan dated 11/01/2024 for R14, revealed the facility failed to revise the resident's care plan with her documented behaviors. In interview with the Interim Director of Nursing (DON) on 05/22/2025 at 3:37 PM, she stated a resident's care plan was to be reviewed and revised by the facility's interdisciplinary team (IDT) when the resident returned from a hospital stay. She said the care plan as a whole was to be reviewed, and said the purpose of the care plan was for it to reflect all of the care for the resident. The DON reported she expected residents' behaviors to be noted on their care plan, both current behaviors and the history of any behaviors. She further stated R14's care plan should have included documentation of her behaviors and her diagnosis of schizophrenia. The DON additionally said she thought residents' care plans should be followed, and the CNA's were told of new changes regardless. In interview with the Administrator on 05/22/2025 at 4:08 PM, she stated care plan were reviewed and revised daily in the facility's daily clinical meeting. She reported residents' care plans were based and built off of each resident's needs. The Administrator further stated if residents had specific problems those should be placed on their care plan. She also said she expected staff to residents' revise care plans when needed.

Based on observation, interview and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 sampled residents (Resident (R)3). The findings include: Review of the facility policy, Infection Prevention and Control Program, revised 01/2025, revealed the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Continued review revealed all staff should assume all residents were potentially infected or colonized with an organism that could be transmitted. Per review, during the course of providing resident care, hand hygiene should be performed in accordance with the facility's established hand hygiene procedures. Further review revealed all staff should use personal protective equipment (PPE) according to the established facility policy governing the use of PPE. Review of the facility policy, Hand Hygiene, dated 03/22/2022, revealed, all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Further review revealed that applied to all staff working in all locations within the facility. Review of the facility policy, Perineal Care, dated 12/20/2020, revealed, it was the practice of the facility to provide all incontinent residents' perineal care during routine bathing and as needed. Per review, the provision of incontinent care was in order to promote cleanliness and comfort; prevent infection to the extent possible; and prevent and assess for skin breakdown. Continued review revealed perineal care referred to the care of the external genitalia and anal areas. Further review revealed staff were to perform hand hygiene and put on gloves, and apply other PPE as appropriate. In addition, review revealed staff were to cleanse a resident's buttocks and anus from front to back, vagina to anus in females using a separate washcloth or wipe. Review of the facility policy, Handling Soiled Linen, revised on 06/12/2023, revealed it was the facility's policy to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Per review, all used linen should be handled using standard precautions and treated as potentially contaminated. Continued review revealed used or soiled linens should be collected at the bedside and placed in a linen bag or a designated lined receptacle. Review of the Admission Face Sheet for R3 revealed the facility admitted the resident on 02/23/2025, with diagnoses to include: unspecified dementia, mild without behavioral disturbance; hypertension; and depression. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/07/2025, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Observation on 05/21/2025 at 10:05 AM, revealed LPN 1 told the State Survey Agency (SSA) Surveyor R3 needed assistance, and the the SSA Surveyor knocked on the resident's door, and went in the room, R3 was observed standing and holding onto the overbed table. Per observation, R3 had no pant on and her socks appeared to be wet. When the SSA Surveyor observed the left side of R3's bed the floor was wet and the resident's pants were lying on the floor. LPN 1 was then observed to enter R3's room wearing PPE, which included a gown, face mask, and gloves, although the resident was not on any type of precautions. Per observation, LPN 1 wet two (2) washcloths in the sink; however, did not assist R3 to the bed or provide privacy for the resident. Continued observation revealed LPN 1 took a wet washcloth and wiped R3's buttock area, then using the same washcloth, she wiped between R3's legs, and threw the soiled washcloth to the floor. Further observation revealed LPN 1 dried R3 with a towel then threw the towel on the floor with the soiled washcloths. In addition, observation revealed LPN 1 went to the closet, and without removing her gloves, opened R3's closet and obtained a clean brief and proceeded to dress the resident in a facility gown. Observation further revealed LPN 1 then removed her face mask and gown, obtained the soiled linen from floor and placed it in a linen bag and doffed her soiled gloves. In interview with LPN 1 on 05/21/2025 at 3:49 PM, when asked about providing perineal care, she stated she had worked as a nurse's aide, but she had never gotten certified. LPN 1 stated she had worn PPE when providing R3's care as she thought it was required if the resident was on enhanced barrier precautions (EBP). She said she wiped R3 using a washcloth starting with the back (buttock area) then moved to the resident's front. LPN 1 reported she threw the soiled washcloths and towel on the floor; however, should not have done that. She stated she had not been paying attention to what she was doing and was just trying to get the job done. LPN 1 stated further stated she could not remember in what order she removed her PPE, but should have removed her gloves first. In interview with the Director of Nursing (DON) on 05/22/2025 at 3:37 PM, she stated she had been the DON since 05/06/2025. She said she expected all staff to provide care the residents needed in the proper manner. The DON further stated all staff were expected to follow the facility's infection control policy and guidelines when providing residents' incontinence care. She additionally said that included appropriately donning and doffing PPE, handling soiled linens and performing hand hygiene. In interview with the Administrator on 05/22/2025 at 4:08 PM, she stated she expected staff to provide proper incontinence care for residents, and follow the facility's infection control guidelines. She said she expected staff to follow the appropriate steps when donning (applying) and doffing (removing) their PPE. The Administrator reported soiled linens were not to be placed on the floor and she expected staff to dispose of soiled linens in the appropriate manner. She further stated all staff were expected to follow the facility's infection control policies and procedures.

Based on observation and interview, it was determined the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Observation on 09/21/2020 at 3:25 PM revealed Registered Nurse (RN) #1 left medication in a cup on top of the medication cart unsupervised, on the 300 hall. The Administrator provided a list of six (6) wandering residents in the facility. The findings include: Review of an email, dated 09/30/2020 at 8:57 AM, followed-up by an interview with the Administrator, on 09/30/2020 at 9:53 AM, revealed there was no facility policy that addressed leaving medication unattended on top of the medication cart. Observation during tour of the facility, on 09/21/2020 at 3:25 PM, revealed RN #1 left [MEDICATION(S)] 25 milligrams (mg) (for Hypertension) in a pill cup sitting on top of the medication cart, unsupervised, while he went into a resident's room on the 300 hall (Room 309). Further observation revealed the medication was left unsupervised for approximately five (5) minutes. Interview with RN #1, on 09/21/2020 at 3:30 PM, revealed [MEDICATION(S)] 25 mg was for a resident in Room 312-B due at 4:00 PM and when he tried to administer the [MEDICATION(S)] to the resident, the resident refused it. He stated when he left Room 312-B, he was called into Room 309 by an Aide or Housekeeping for a non-emergent issue, and left the medication on top of the medication cart. He revealed it was not his normal practice to leave the medication unattended, and he usually rolled the medication cart to each resident's door and kept the medication cart in view during a medication pass. Further interview with the Administrator, on 09/30/2020 at 9:53 AM, revealed medication should never be left unattended.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observation of the kitchen, on 01/27/19 at 11:05 AM, revealed food stored in the refrigerator was not dated. Review of the facility Census and Condition, dated 01/27/19, revealed forty (40) of forty-one (41) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Refrigerators and Freezers, last revised December 2014, revealed all food shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often if necessary. 1. Observation of the refrigerator, on 01/27/19 at 11:05 AM, revealed a tray containing fifteen (15) individual cups of applesauce with lids not dated. Further observation of the refrigerator revealed food debris on the bottom shelf. 2. Observation of the freezer, on 01/27/19 at 11:05 AM, revealed food debris on the floor of the freezer and blotches of dark black grime. Interview with Dietary Aide #1 on 01/28/19 at 12:03 PM, revealed kitchen staff clean food debris daily on the shelves, and all food items should be dated when opened or when prepared and placed in refrigerator for later use. Interview with the Dietary Manager on 01/28/19 at 12:50 PM, revealed she expected all food items stored in the refrigerator to be dated when dispensed into individual serving cups. She stated she expected the refrigerators and freezers to be kept clean. She further stated visible food debris or spills should be cleaned when staff see them.

Based on observation, interview, and record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of sixteen (16) sampled residents received an accurate assessment, reflective of the residents status (Resident #21). Observation revealed Resident #21 was independent with ambulation and transfers with a walker, and was observed coming out of the bathroom independently. However, review of the Significant Change Minimum Data Set (MDS) assessment, dated 12/23/18 revealed the resident required more assistance than the assessment reflected. Additionally, the therapy department had assessed the Resident and determined an improvement in functional ability on 01/10/19. However, there was not documented evidence a Significant Change in Status Improvement had been initiated. The findings include: Interview with the MDS Coordinator on 01/29/19 at 11:24 AM, revealed the facility does have a policy related to significant change MDS; the RAI Manual was used for reference. Review of the RAI Manual Version 3.0 User Manual, stated the Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that impacts more than one area of the resident's health status; and requires interdisciplinary review and /or revision of the care plan. When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to fourteen (14) days to determine whether the criteria are met. After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record. There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments. The Assessment Reference Date (ARD) must be less than or equal to fourteen (14) days after the IDT's determination that the criteria for the SCSA are met (determination date plus fourteen (14) days). Record review revealed the facility admitted Resident #21 on 09/14/18 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed the facility assessed Resident #21's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8) which indicated the resident was interviewable. Further review of the Significant Change MDS assessment, dated 12/23/18, revealed Resident #21 required limited assist of one (1) staff for bed mobility, transfers, ambulation in the corridor and toileting. In addition, the resident required extensive assistance of one (1) staff for personal hygiene, dressing, and bathing. Review of the MDS further revealed the resident was not steady and required human help to stabilize when moving seated to standing, walking with assistive devices, turning to fact the opposite direction, moving on and off the toilet, and surface to surface transfers. Review of the Physical Therapy Treatment Encounter Notes, dated 01/10/19, completed by Physical Therapy Assistant (PTA) #1, revealed Resident #21 progressed from using a wheelchair to ambulation in the facility, and the resident improved balance and functional activity level. Observation of Resident #21 on 01/27/19 at 10:22 AM revealed the resident was in his/her room sitting on the side of the bed. Using his/her walker, he/she rose to a standing position and walked out of the room and down the hallway independently with steady balance. Observation of Resident #21 on 01/28/19 at 9:07 AM revealed the resident was up ambulating in his/her room with the use of a walker independently. He/she entered the bathroom and exited a few minutes later, independently with steady balance. Observation of Resident #21 on 01/29/19 at 9:00 AM revealed the resident was sitting in the commons area, then rose from the chair and ambulated in the hallway with the use of a walker. He/she was able to rise from the chair and walk independently. Interview with Certified Nurse Assistant (CNA) #1 on 01/29/19 at 12:03 PM revealed Resident #21 needs very little assistance with bathing, dressing and grooming. CNA #1 stated she sets up the needed supplies for bathing, dressing, and grooming for the resident, and the resident completes his/her own bathing, dressing, and grooming every day. The CNA stated the resident also transfers and ambulates independently with a walker. Interview with PTA #1 on 01/29/19 at 11:40 AM, revealed she had been working with Resident #21 on safety awareness and making sure he/she uses the walker. PTA #1 stated the resident has had an improvement in physical abilities, however, his/her safety awareness is not good. The PTA further stated the resident had a significant improvement since 12/23/18 and the improvement was identified on 01/10/19. Interview with Certified Occupational Therapy Assistant (COTA), on 01/29/19 at 11:40 AM revealed Resident #21's improvement was discussed in the Interdisciplinary Team (IDT) meeting on 01/12/19. Interview with the MDS Coordinator on 01/29/19 at 11:24 AM and 12:06 PM revealed she is a member of the IDT and attends the meetings regularly. She stated a significant change in status improvement had not been initiated for Resident #21. She stated therapy usually alerts her to an improvement, however, she did not recall any discussion related to the resident's improvement in activities of daily living. Additionally, the MDS Coordinator stated she was not aware how long the resident had been ambulating independently as she did not recall any discussion in the IDT meetings. She further stated the initiation of significant change in status improvement was an oversight.

Based on observation, interview, and record review, it was determined the facility failed to revise the care plan for one (1) of sixteen sampled residents (Resident #21). Observation and staff interviews revealed Resident #21 was independent with ambulation and transfers with a walker, and was observed coming out of the bathroom independently. In addition, the resident was able to complete personal hygiene, and bathing, after supplies were set up by staff. However, the comprehensive care plans were not updated to accurately reflect the resident's improved abilities. The findings include: Interview with the Administrator on 01/29/19 at 10:19 AM, revealed the facility did not have policies for care plan revisions. She stated the facility was owned by another company at that time, and did not have policies. The Administrator further stated the facility followed federal and state guidelines when updating care plans. Interview with the Minimum Data Set (MDS) Coordinator on 01/29/19 at 11:24 AM, revealed the facility does have a policy related to care plan revision; the Resident Assessment Instrument (RAI) Manual is used for reference. Review of the RAI Manual Version 3.0 User Manual, Section 2.7 revealed the resident's care plan must revised based on changing goals, preferences and needs of the resident and in response to current interventions. Record review revealed the facility admitted Resident #21 on 09/14/18 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed the facility assessed Resident #21's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eight (8) which indicated the resident was interviewable. Further review of the Significant Change MDS, dated [DATE], revealed Resident #21 required limited assist of one (1) staff for bed mobility, transfers, ambulation in the corridor and toileting; extensive assistance of one (1) staff for personal hygiene, dressing, and bathing; and, was not steady and required human help to stabilize when moving seated to standing, walking with assistive devices, turning to face the opposite direction, moving on and off the toilet, and surface to surface transfers. Review of the Comprehensive Care Plan, initiated on 12/18/18, revealed Resident #21 had an Activities of Daily Living (ADL) self-care performance deficit related to confusion and impaired balance. Further review revealed the interventions were the resident required limited assistance with bathing/showering and for dressing; supervision/limited assist of one (1) staff for toileting; and the resident is independent with supervision and cues for transfers. However, observations of Resident #21 on 01/27/19 at 10:22 AM, 01/28/19 at 9:07 AM, and 01/29/19 at 9:00 AM revealed he/she was using his/her walker, and able to rise to a standing position and walk down the hallway independently with steady balance. In addition, the resident was observed to enter the bathroom and exit a few minutes later, independently with steady balance on 01/28/19 at 9:07 AM. Review of the Physical Therapy Treatment Encounter Notes, dated 01/10/19, completed by Physical Therapy Assistant (PTA) #1, revealed Resident #21 had progressed to ambulation in the facility, was no longer using wheel chair, and had improved balance and functional activity level. Interview with Certified Nurse Assistant (CNA) #1 on 01/29/19 at 12:03 PM revealed Resident #21 needs very little assistance with bathing, dressing and grooming. CNA #1 stated she sets up the needed supplies for bathing, dressing, and grooming, for the resident, and he/she complete his/her own bathing, dressing and grooming. The CNA revealed the resident also transfers and ambulates independently with a walker. Interview with PTA #1 on 01/29/19 at 11:40 AM, revealed she had been working with Resident #21 on safety awareness and making sure he/she uses the walker. PTA #1 stated the resident has had an improvement in physical abilities, however, his safety awareness is not good. The PTA additionally stated the resident has had a significant improvement since 12/23/18. Interview with Certified Occupational Therapy Assistant (COTA), on 01/29/19 at 11:40 AM revealed Resident #21's improvement was discussed in the Interdisciplinary Team (IDT) meeting on 01/12/19. Interview with the MDS Coordinator on 01/29/19 at 11:24 AM and 12:06 PM revealed she is a member of the IDT and attends the meetings regularly. She stated she had not updated the care plans to reflect the change in the resident's abilities. She stated therapy usually alerts her to an improvement, however, she did not recall any discussion related to the resident's improvement in activities of daily living. Additionally, the MDS Coordinator stated she was not aware how long the resident had been ambulating independently or requiring less assistance with ADL's. She further stated updating the care plans was an oversight.

Based on interview and record review, it was determined the facility failed to ensure a resident maintains acceptable parameters of nutritional status, such as usual body weight for one (1) of sixteen (16) sampled residents (Resident #17). Record review revealed Resident #17 had significant weight loss identified on the 12/13/18. On 12/20/18, the Registered Dietitian recommended Medpass (a dietary supplement) ninety (90) milliliters (mL) three (3) times per day with nursing medication passes to offset poor nutritional intakes; however, there was no documented evidence the Medpass supplement was ordered or initiated, and the resident had continued weight loss. The findings include: Interview with the Administrator on 01/29/19 at 10:19 AM, revealed the facility did not have policies for weight loss or nutritionally at-risk residents in (MONTH) (YEAR). She stated the facility was owned by another company at that time, and did not have policies. The Administrator further stated the facility followed federal and state guidelines when providing care to their residents. Record review revealed the facility admitted Resident #17 on 03/14/16 with [DIAGNOSES REDACTED]. Review of Significant Change Minimum Data Set (MDS) assessment, dated 12/13/18, revealed the facility assessed Resident #17's cognition as severely impaired with a Basic Interview of Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Further review revealed the resident had weight loss of five (5) percent in the last month or ten (10) percent in the last six (6) months; the resident was not on a physician-prescribed weight-loss regime; he/she received a mechanical altered diet; and required extensive assistance to eat. Review of the Monthly Weight Report revealed Resident #17 weighed 199.6 pounds in (MONTH) (YEAR); 188.9 pounds in (MONTH) (YEAR); and 187.5 pounds in (MONTH) 2019. From (MONTH) to (MONTH) (YEAR), the resident lost 10.7 pounds (5.3 percent); and from (MONTH) (YEAR) to (MONTH) 2019, the resident lost 1.5 pounds. Review of the Registered Dietitian's (RD's) Progress Note, dated 12/20/18 at 1:41 PM, revealed Resident #17 had a weight loss of 5.3 percent for thirty (30) days, currently with poor oral intake and was assisted with meals per nursing. Current weight is 188.9 pounds, (MONTH) 2, (YEAR) weight was 199.6 pounds. Recommend Medpass, ninety (90) mL, three (3) times per day with nursing medication passes to offset poor nutritional intakes at this time. However, review of the Physician order [REDACTED]. Review of the Nursing Progress Notes from 12/20/18 to 01/27/19 revealed no documented evidence of notification of the physician related to the RD's recommendations. In addition, review of Progress Notes revealed there was no documented evidence the RD re-assessed the resident for weight changes or the effectiveness of the recommended intervention again prior to the start of the survey on 01/27/19 (for over a month). Interview with Licensed Practical Nurse (LPN) #2 on 01/29/19 at 9:20 AM, revealed an order for [REDACTED].#2 stated she had not been administering the Medpass to Resident #17 because it was not on the MAR indicated [REDACTED] Interview with Registered Nurse (RN) #1, Unit Manager, on 01/29/19 at 9:55 AM revealed the RD's recommendations were passed on to her per the Director of Nursing. RN #1 stated when she receives the dietary recommendations, she notifies the physician to get orders for the recommended supplement or diet. RN #1 further stated she did not remember a recommendation for Medpass for Resident #17 in December. The RN stated the resident did not have a supplement or Medpass ordered. Interview with the Administrator on 01/29/19 at 9:35 AM and 9:50 AM revealed the RD is at the facility every week to two (2) weeks. The Administrator stated when the RD makes recommendations, she and the DON receive the paper work and pass along to the Unit Manager; and the Unit Manager follows up on the recommendations with a call to the physician to obtain orders. Interview with the Registered Dietitian (RD) on 01/29/19 at 11:44 AM revealed any recommendations she makes go to dietary, the DON, the MDS Coordinator, and the Administrator. The RD stated she reviews resident weights at the first of the month and any significant weight loss is monitored throughout the month. However, Resident #17 was identified with significant weight loss on 12/20/18 and a recommendation was made, but the effectiveness of the supplement was not reviewed for over one (1) month. Additionally, the RD stated she did not re-evaluate the resident because she had already assessed him/her and made recommendations. She did not realize the recommendation was still pending physician's orders [REDACTED]. Interview with the Physician on 01/29/19 at 3:28 PM revealed she was aware of the resident's weight loss, but had not ordered a supplement for him/her.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. On 01/28/19, observation of medication room refrigerator, revealed medication not dated when opened per facility policy. The findings include: Review of the facility's policy titled, Storage of Medication, last revised (MONTH) 2007, revealed medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. The policy further stated medications must be stored separately from food and must be labeled accordingly. Review of the facility's policy titled, Labeling of Medication Containers, last revised (MONTH) 2007, revealed all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulation. Observation of the refrigerator in the medication room, on 01/27/19 at 2:44 PM, revealed one (1) vial of [MEDICATION NAME] ([MEDICATION NAME] protein derivative) solution opened and not dated. Interview with the Pharmacy Consultant on 01/28/19 at 1:25 PM, revealed [MEDICATION NAME] should be dated when opened because it expires thirty (30) days from the date opened. Interview with Licensed Practical Nurse (LPN) #1, on 01/27/19 at 2:45 PM, revealed the vial of [MEDICATION NAME] should have been dated when opened. She stated all nursing staff are taught during their orientation to date multi-dose medications. She revealed the nurses should know to date the vials when opened as they are trained in orientation. Interview with the Director of Nursing (DON), on 01/29/19 at 3:14 PM, revealed she expected the nurses to date multi-dose vials such as [MEDICATION NAME] because the solution expires thirty (30) days after opening. She stated nursing staff are educated on dating of medications during their orientation upon hire.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status, for one (1) of three (3) sampled residents (Resident #1). The facility failed to accurately code Resident #1's Quarterly MDS assessment, dated 11/30/18, related to Activities of Daily Living (ADL) care. The findings include: Interview with the Regional MDS/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed the facility did not have a specific MDS policy. She stated the facility followed the RAI Manual and regulatory guidelines. Record review revealed the facility readmitted Resident #1 on 11/24/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/30/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) Score to be an eight (8), which indicated he/she was interviewable. Further review of the MDS assessment revealed he/she was coded as being able to participate in dressing, eating, toilet use, personal hygiene and bathing with only requiring extensive assistance of one (1) staff member. Interview with Certified Nurse Aide (CNA) #1, on 12/20/18 at 11:34 AM, revealed Resident #1 was totally dependent on staff for ADL care and was unable to participate in his/her care. Interview with CNA #3, on 12/22/18 at 7:00 PM, revealed Resident #1 had been dependent on staff to do his/her ADL care for a long time. She stated Resident #1 had been unable to participate in care and was totally dependent on staff for ADL care. Interview with CNA #4, on 12/25/18 at 4:35 PM, revealed Resident #1 had been dependent upon staff to do all of his/her ADL care. She further stated Resident #1 was unable to get out of bed or participate with ADL's. Interview with CNA #5, on 12/24/18 at 6:45 PM, revealed she had been working at the facility since (MONTH) (YEAR), and since that time Resident #1 had always been dependent upon staff for ADL care, and required total staff assistance. Interview with CNA #6, on 12/24/18 at 6:51 PM, revealed she had worked at the facility about seven (7) or eight (8) months. She stated Resident #1 had been dependent upon staff for ADL care since she started working at the facility. Interview with Licensed Practical Nurse (LPN) #2, on 12/26/18 at 2:57 PM, revealed Resident #1 had been totally dependent upon staff to complete ADL care for at least half of the year or longer. Interview with the MDS/Care Plan Coordinator, on 12/20/18 at 9:43 AM, revealed Resident #1's Quarterly MDS assessment, dated 11/30/18, was not an accurate reflection of Resident #1's true status. She stated she had coded it that way due to the information she received from the CNA's during the look back period, which had been coded inaccurately. She stated she had to code the MDS assessment according to the CNA's information/data, even though she knew it was not accurate or a true reflection of the resident. Interview with the Regional MDS/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed she expected the MDS assessments to be done accurately, and the MDS assessments should accurately reflect a resident's true status.

Based on interview and record review, it was determined the facility failed to develop a Comprehensive Care Plan, for one (1) of three (3) sampled residents (Resident #1). The facility failed to develop a care plan as a guide for staff to provide care for Resident #1 who sustained injuries, to include Cervical Vertebrae Fractures and an [MEDICAL CONDITION] to the right frontoparietal region, from a fall at the facility on 12/09/18. The findings include: Interview with the Regional Minimum Data Set (MDS)/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed the facility did not have a specific Care Plan policy. She stated the facility followed the Resident Assessment Instrument (RAI) Manual and regulatory guidelines. Record review revealed the facility readmitted Resident #1 on 11/24/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/30/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be an eight (8), which indicated the resident was interviewable. Review of Resident #1's Comprehensive Care Plans, initiated on 11/01/15, 01/01/16, 02/28/17, 04/18/17, and 11/24/17, revealed no evidence any resident care plans were developed to guide staff how to care for Resident #1's injuries of fractured cervical vertebrae and a subarachnoid hemorrhage. Review of a Nurse's Note, dated 12/09/18 at 8:05 PM, revealed Registered Nurse (RN) #1 documented at approximately 7:25 PM, that Cook #1 came to inform her Resident #1 was in the floor face down lying on his/her right side with blood noted on the floor around Resident #1's head. Review of Hospital Records, dated 12/09/18, revealed Resident #1 was brought to the Emergency Department (ED) with a complaint of a head and neck injury. Further review of the ED records revealed a Computed Tomography (CT) Scan was done on Resident #1's head and neck. Results of the CT Scan on Resident #1's head revealed there was a small area of [MEDICAL CONDITION] in the right frontoparietal region, either a parenchymal contusion or subarachnoid hemorrhage. Results of the CT Scan for Resident #1's neck revealed he/she had a [MEDICATION NAME] fracture through the base of the odontoid process (type two (2) odontoid fracture) with almost a bone width anterior displacement of the body of Cervical Vertebra 2, and also a displaced fracture through the anterior ring of Cervical Vertebra 1. Review of the MDS Entry Tracking Record, dated 12/11/18, revealed Resident #1 returned to the facility on [DATE] from the hospital. Review of Hospice Records, dated 12/12/18, revealed Resident #1 was placed on Hospice Care on 12/12/18. Further review of Hospice Records revealed Resident #1's life limiting conditions were a traumatic subarachnoid hemorrhage and a displaced [MEDICAL CONDITION] cervical vertebra. Interview with the MDS/Care Plan Coordinator, on 12/20/18 at 9:43 AM, revealed she was familiar with Resident #1. She stated when Resident #1 came back from the hospital on [DATE] she failed to update or develop any new care plans related to the resident's noted new injuries. She stated she had a significant change assessment scheduled to be done and was going to wait to update or review/revise care plans along with the significant change MDS. She stated she should have developed care plans when Resident #1 returned, related to the resident's injuries, so staff were aware of how to care for his/her fractured neck and brain bleed. Interview with the Regional MDS/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed she would have expected the MDS Coordinator to have developed care plans in regard to Resident #1's injuries, when Resident #1 returned to the facility.

Based on interview and record review, it was determined the facility failed to review and revise the Comprehensive Care Plan, for one (1) of three (3) sampled residents (Resident #1). The facility failed to review and revise Resident #1's Falls Risk Comprehensive Care Plan to reflect the resident's actual status. The findings include: Interview with the Regional Minimum Data Set (MDS)/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed the facility did not have a specific Care Plan policy. She stated the facility followed the Resident Assessment Instrument (RAI) Manual and the regulatory guidelines. Record review revealed the facility readmitted Resident #1 on 11/24/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment, dated 11/30/18, revealed the facility assessed his/her Brief Interview for Mental Status (BIMS) Score to be an eight (8), which indicated he/she was interviewable. Further review of the MDS assessment revealed the resident was coded as non-ambulatory and bedfast. Review of the Falls Risk Comprehensive Care Plan, initiated 01/01/16, revealed the care plan had not been updated to reflect the resident's actual status. Review of the care plan revealed interventions included to encourage the resident to wear non-skid shoes/socks when out of bed and to assist the resident to keep the room/area clutter free. However, the resident was non-ambulatory and bedfast. Interview with Certified Nurse Aide (CNA) #1, on 12/20/18 at 11:34 AM; CNA #3, on 12/22/18 at 7:00 PM; CNA #4, on 12/25/18 at 4:35 PM; CNA #5, on 12/24/18 at 6:45 PM; CNA #6, on 12/24/18 at 6:51 PM; Licensed Practical Nurse (LPN) #1, on 12/26/18 at 1:44 PM; and LPN #2, on 12/26/18 at 2:57 PM, revealed Resident #1 had been non-ambulatory and bedfast for several months. Interview with the MDS/Care Plan Coordinator, on 12/20/18 at 9:43 AM, revealed Resident #1's Falls Risk care plan was not up to date or reflective of the resident's actual status. She stated the care plan should have been reviewed and revised to reflect the resident's actual status. Interview with the Regional MDS/Care Plan Coordinator #1, on 12/21/18 at 12:21 PM, revealed she expected the care plans to be reviewed and revised ongoing with any changes in the residents' status, to ensure the care plans were reflective of the residents' actual status.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure Resident #1 was assessed for the safe use of a specialty low air loss mattress; the facility failed to ensure licensed staff were trained/educated on how to ensure low air loss mattresses were set up/functioning properly; and the facility failed to do a thorough post fall investigation to determine the most likely root cause of an unwitnessed fall. The resident had an unwitnessed fall, on 12/09/18, resulting in Cervical Vertebrae Fractures and an [MEDICAL CONDITION] to the right frontoparietal region. Resident #1 returned to the facility on [DATE] on comfort care, and was admitted to Hospice care on 12/12/18. The findings include: Review of the facility's policy Falls Management Program Guidelines, not dated, revealed the company strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Further review of the policy revealed should a resident experience a fall, the attending nurse shall complete a post fall assessment which includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of a repeat episode, and a review by the interdisciplinary team to evaluate thoroughness of the investigation. Record review revealed the facility readmitted Resident #1 on 11/24/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/30/18, revealed the facility assessed his/her Brief Interview for Mental Status (BIMS) score to be an eight (8), which indicated the resident was interviewable. Further record review revealed no evidence Resident #1 was assessed for the safe use of a specialty Low Air Loss Mattress. Review of the Fall Risk Assessment, dated 05/04/18, completed prior to the resident's fall on 12/09/18, revealed he/she was assessed as a falls risk. Further record review revealed there was no evidence a Quarterly Falls Risk Assessment had been completed since 05/04/18, or after the fall on 12/09/18. Review of the Comprehensive Risk for Falls Care Plan, initiated on 01/01/16, revealed the facility care planned the resident as being a risk for falls related to history of falls, gait/balance problems, altered mental state, [DIAGNOSES REDACTED]. Further review of the care plan revealed interventions included to observe for changes in condition that may warrant increased supervision/assistance and notify the Physician, encourage to wear non-skid shoes/socks when out of bed, put eyeglasses in place when awake, assist the resident to keep the bedside table within easy reach with frequently used objects, refer to restorative nursing program as recommended, assist in keeping the call light in reach and encourage to use, and assist in keeping the room/area free of clutter. Review of a Nurse's Note, dated 12/09/18 at 8:05 PM, revealed Registered Nurse (RN) #1 documented, that at approximately 7:25 PM, Cook #1 came to inform her Resident #1 was in the floor face down, lying on his/her right side with blood noted on the floor around his/her head. Further review of documentation revealed two (2) Certified Nurse Aides (CNA's) responded to assist RN #1, and before rolling Resident #1 to his/her back, RN #1 asked the resident where he/she was hurting, and the resident stated his/her arm was stuck and his/her head hurt. The staff then rolled Resident #1 onto a sheet to facilitate moving him/her back to bed. RN #1 documented Resident #1 had approximately a four (4) inch laceration to his/her left side of the forehead/head. RN #1 documented she had instructed the CNA's to hold pressure to the laceration while she called Emergency Services (EMS) and got paperwork ready to send him/her out to an emergency facility. RN #1 documented Resident #1 was alert and oriented at the time of the incident and staff were unsure how he/she got in the floor, as he/she had just been changed, turned, and positioned in the middle of the bed. Review of the facility's fall investigation, dated 12/09/18 and 12/10/18, revealed CNA #1 was in Resident #1's room on 12/09/18 at approximately 7:20 PM, providing care to Resident #1. On 12/09/18 at 7:25 PM, Cook #1 heard Resident #1 yelling for help, and Cook #1 observed Resident #1 laying in the floor beside his/her bed. Further review of the facility's fall investigation revealed a root cause analysis document, dated 12/10/18, which revealed Resident #1 was at risk for falls related to a history of [MEDICAL CONDITION]. Additional review of the facility's fall investigation revealed Resident #1 was observed in bed and positioned appropriately several minutes before the fall. Review of Hospital Records, dated 12/09/18, revealed Resident #1 was transported to the Emergency Department (ED) with a complaint of a head and neck injury. Further review of the ED records revealed a Computed Tomography (CT) Scan was completed on Resident #1's head and neck. Results of the CT Scan revealed the resident had a small area of [MEDICAL CONDITION] in the right frontoparietal region, either a parenchymal contusion or subarachnoid hemorrhage. Results of the CT Scan on his/her neck revealed the resident had a [MEDICATION NAME] fracture through the base of the odontoid process (type two (2) odontoid fracture) with almost a bone width anterior displacement of the of body of Cervical Vertebra 2, and also a displaced fracture through the anterior ring of Cervical Vertebra 1. Review of the MDS Entry Tracking Record, dated 12/11/18, revealed Resident #1 returned to the facility on [DATE], from the hospital. Review of Hospice Records, dated 12/12/18, revealed Resident #1 was placed on Hospice Care. Further review of Hospice Records revealed Resident #1's life limiting conditions were a traumatic subarachnoid hemorrhage and a displaced [MEDICAL CONDITION] cervical vertebra. Review of the MDS Discharge Tracking Record, dated 12/19/18, revealed Resident #1 passed away at the facility. Interview with Cook #1, on 12/26/18 at 10:35 AM, revealed she was walking down the hall on 12/09/18 and as she went by Resident #1's room, she heard someone calling for help from the resident's room. She stated she stepped into the resident's room and saw him/her laying face down on the floor beside his/her bed, and saw blood on the floor all around his/her head. She stated Resident #1 kept saying my arm, my arm, help me please, help me. She stated she immediately ran and got the nurse, who was RN #1. She stated RN #1 yelled out for CNA #1 and CNA #2 to come to the room. Interview with RN #1, on 12/20/18 at 1:46 PM, revealed she was the nurse on duty when Resident #1 fell on [DATE]. She stated Cook #1 found the resident in the floor at 7:25 PM and immediately came to her to report the fall. She recalled there was nothing in place on Resident #1's low air loss mattress to prevent him/her from coming out of the bed if he/she were having a [MEDICAL CONDITION]. She stated she had questioned, in the past, about fall mats or alarms not being in use at the facility. She stated Resident #1 was alert when she arrived to the resident's room and definitely did not think the resident had just had any type of [MEDICAL CONDITION]; however, she was not present when the resident fell . She stated a person was normally exhausted and confused after a [MEDICAL CONDITION], but the resident did not display any post [MEDICAL CONDITION] signs or symptoms. Further interview with RN #1, on 12/26/18 at 2:20 PM, revealed the DON brought her a copy of the low air loss mattress training a few days ago, but prior to that, she had not had any training on low air loss mattresses. She stated, on the night of the resident's fall, the Administrator called her and asked her if she thought Resident #1 had a [MEDICAL CONDITION], and she told the Administrator anything was possible, but the resident was conscious and alert, and she did not witness or observe any signs of a [MEDICAL CONDITION]. She stated when she yelled for CNA #1 and CNA #2 to come to Resident #1's room, both CNA's were on a different hall, but in the same area. She stated CNA #1 never mentioned to her that she was in Resident #1's room five (5) minutes before the resident's fall, and was not aware of that information until she saw CNA #1's written statement. Interview with CNA #1, on 12/20/18 at 11:34 AM, revealed Resident #1 was unable to roll himself/herself over or out of the bed, and was very constricted. She stated she had been in Resident #1's room around 7:20 PM on 12/09/18 to finish rounds. She stated Resident #1 seemed fine and appeared like his/her normal self. She revealed she had made sure Resident #1 was positioned properly in the middle of the bed because Resident #1 had an air mattress, and she knew air mattresses were slippery. She stated when she left Resident #1's room, she left him/her laying on his/her left side, looking at the door. She stated after she left the room she went to help another resident and when she heard staff yell for help, she ran back to Resident #1's room, and saw the resident on the floor. She stated Resident #1 did not seem to be confused, tired, exhausted, or anything like that, and he/she seemed like his/her normal self, just in a lot of pain. Interview with CNA #2, on 12/21/18 at 10:49 AM, revealed she was on duty when Resident #1 fell on [DATE]. She stated she and CNA #1 were the CNA's on duty, and that she and CNA #1 were in another resident's room, who required assistance of two (2) staff. She stated she and CNA #1 had been in the other resident's room for fifteen (15) or twenty (20) minutes when she sent CNA #1 to grab a sheet. She stated CNA #1 left the room to go get the sheet, then came running right back to the room informing her Resident #1 had fallen and was in the floor, and we needed to go help. She stated prior to CNA #1 leaving to get the sheet, CNA #1 had been working with her for fifteen (15) to twenty (20) minutes in another room, so CNA #2 could not figure out why it was said CNA #1 had just been in Resident #1's room five (5) minutes prior to the resident being found in the floor. She also stated Resident #1 was totally dependent upon staff and was unable to move himself/herself or roll himself/herself at all. She stated when she got to Resident #1's room, the resident was alert, and was not showing any signs of confusion or drowsiness, although Resident #1 was complaining of head pain. Interview with Licensed Practical Nurse (LPN) #1, on 12/26/18 at 1:44 PM, revealed she received a message at some point in the last few days about needing to read the training on low air loss mattress settings, and how to ensure appropriate functioning. She stated it was just a page to read with no type of demonstration provided. She stated prior to this time, there had been no education and/or training on how to set the low air loss mattresses up, or how to check the mattresses to ensure they were functioning properly. She also stated she did not feel that Resident #1 had a [MEDICAL CONDITION] and fell out of bed. She revealed the resident definitely could not roll himself/herself out of bed or even participate in bed mobility, and did not feel like the root cause of the fall was determined. Interview with LPN #2, on 12/26/18 at 2:57 PM, revealed it had been at least a half a year or more that Resident #1 had been totally dependent upon staff for care. She stated she would expect a resident who had [MEDICAL CONDITION] to have some post [MEDICAL CONDITION] signs or symptoms. She stated she had not had any training on the low air loss mattresses at the facility prior to 12/22/18, when the Director of Nursing (DON) had her read information on how to check the low air loss mattresses for proper functioning. Interview with the DON, on 12/20/18 at 12:01 PM, revealed Resident #1 was on a standard flat low air loss mattress when he/she fell on [DATE]. She stated the facility implemented a different low air loss mattress with bolsters after the fall, which was in place after Resident #1 returned from the hospital stay. She also stated the facility does not have a safety assessment to determine safety or appropriateness for the use of a low air loss mattress. She stated, based on the facility's investigation, the facility felt like Resident #1's fall was due to a [MEDICAL CONDITION] causing him/her to come out of the bed. She stated she had not spoken to the staff who were present when Resident #1 fell , to get his or her opinion of a possible [MEDICAL CONDITION] being the cause of the fall. She stated the facility did not consult the resident's Physician to see if the Physician thought the resident had a [MEDICAL CONDITION], causing the fall. Interview with the Medical Director, on 12/20/18 at 5:16 PM, who was the Primary Care Physician for Resident #1, revealed Resident #1 had a possible first [MEDICAL CONDITION] episode a year ago; however, it was most likely secondary due to Resident #1 being dehydrated. She stated Resident #1 had not had any further [MEDICAL CONDITION] activity since the isolated episode a year ago. She further stated she could not say a [MEDICAL CONDITION] did or did not occur unless she witnessed the [MEDICAL CONDITION]. She stated she did not think Resident #1 had a [MEDICAL CONDITION] which caused him/her to fall out of the bed and sustain injuries. She stated if a [MEDICAL CONDITION] occurred to the extent that a resident came out of the bed from it, it would have to be a very violent [MEDICAL CONDITION], and the resident would have post [MEDICAL CONDITION] signs and symptoms present, such as drowsiness and confusion. She stated the facility did not consult her as to her opinion if a [MEDICAL CONDITION] was what caused Resident #1's fall out of bed on 12/09/18. Interview with the Administrator, on 12/20/18 at 12:20 PM, revealed the facility did not believe Resident #1 rolled out of bed or had the ability to get out of bed by himself/herself, because he/she was dependent upon the staff for all mobility. She stated, based on the facility's investigation of the fall, they believed the root cause of Resident #1's fall was that he/she had a [MEDICAL CONDITION] and came out of the bed due to the [MEDICAL CONDITION]. She stated they had no reason to believe anything else happened, as CNA #1 had just been in the room approximately five (5) minutes before the fall occurred, and CNA #1 stated she had positioned Resident #1 properly.

Based on interview and record review, it was determined the facility failed to periodically review and revise the Comprehensive Care Plan for interventions to be put in place related to a resident's refusal of dressing changes for one (1) of four (4) sampled residents (Resident #1). The findings include: Interview with the Director of Nursing (DON), on [DATE] at 9:00 AM, revealed the facility did not have a Care Plan policy. Closed record review revealed the facility readmitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the MDS, under section E, revealed there was no presence of behavioral symptoms, including refusal of care. Review of the Comprehensive Care Plan titled, I sometimes choose to not follow the Medical Doctor's (MD) Plan of Care (PoC), revealed an approach to Reinforce with me the risk and benefits of wearing wraps per MD order, with no evidence of interventions to approach the resident later or to have another staff approach the resident regarding treatments. Review of Departmental Notes dictated by License Practical Nurse (LPN) #1, revealed on [DATE] at 12:37 PM, Resident refused to have dressings changed times two (2). On [DATE] at 11:51 AM, LPN #1 documented Resident continues to refuse dressing changes, meals and takes off oxygen at times. Resident is known to have periods of confusion and tearfulness. On [DATE] at 1:17 PM, LPN #1 documented Resident wound assessment will be attempted tomorrow as resident refused assessment and dressing changes today. No other documentation was noted by LPN #1, except on [DATE], related to new orders received for dressing changes, and again on [DATE] at 8:34 AM, that the resident had expired at 5:20 AM with notification to family, Hospice, and Physician. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed there were seven (7) scheduled days the dressing did not get changed. Review of the (MONTH) (YEAR) TAR revealed four (4) scheduled days the dressing did not get changed. Review of the (MONTH) (YEAR) TAR revealed two (2) scheduled days the dressing did not get changed; however, there was no documented evidence regarding the reason for the omission of the dressing change. Review of a Departmental Note, dated [DATE] at 12:36 PM, by Registered Nurse (RN) #2 revealed Resident continues on Hospice care due to gangrenous arterial wounds to right foot and leg. All wounds are black with exposed tendons noted to the underside of the right leg. Fifth toe on his/her right foot is now black as well. Wounds do cause him/her a significant amount of pain with dressing changes and pain medication is given prior to dressing changes and as needed throughout the day. Foul odor noted to the wound. Dressings are being changed every other day. Review of a Departmental Note, dated [DATE] at 12:42 PM, by RN #1 revealed Arterial wounds to the right foot continue to decline. Necrotic tissue noted to the right heel, back of right leg and around right fifth toe. Wounds to the right leg continue with foul smelling drainage. Dressing changes are every other day. Review of a Departmental Note, dated [DATE] at 9:06 AM, by RN #1 revealed Resident continues with severe arterial wounds to the right foot and leg. Entire right foot and leg are noted to be necrotic with foul odor. Dressing changes to all wounds done as ordered. Resident is medicated with [MEDICATION NAME] (pain killer) prior to dressing changes for pain management. There was no documented evidence the resident refused treatments. Review of a Departmental Note, dated [DATE] at 7:25 PM (Late entry for 4:15 PM), by LPN #2 revealed the Physician was notified of what appears to be maggots within an open area of the wound to Resident #1's medial right foot/ankle. The Physician ordered a one (1) time dose of [MEDICATION NAME], at the current dosage, to be given after the resident received a shower to remove the maggots. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 4:05 PM, revealed she created the care plan on [DATE] for the problem I sometimes choose to not follow the Medical Doctor's (MD) Plan of Care (PoC), with the approach to Reinforce with me the risk and benefits of wearing wraps per MD order; however, she stated she should have added other interventions to the care plan, such as if he/she refused, attempt to use a different approach, make multiple attempts to change the dressing, and ask a different staff member to attempt the dressing change. Interview with RN #1/Weekend Supervisor, on [DATE] at 12:00 PM, revealed Resident #1 would always refuse dressing change the first time he/she asked, but with a calm, gentle approach, along with a little encouragement and pre-medication, he/she would always agree to the dressing change. Interview with the DON, on [DATE] at 12:00 PM, revealed different approaches and interventions should have been attempted, as well as listed on the care plan if the resident refused care. Interview with the Administrator on [DATE] at 12:15 PM revealed she expected staff to follow the resident's plan of care, and if there were problems with the current approaches, to add different interventions as needed.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure a resident received the necessary care and services to attain/maintain the highest practicable, physical, mental, and psychosocial well-being in accordance with the Comprehensive Care Plan related to wound care for one (1) of four (4) sampled residents (Resident #1). Resident #1 had refused wound care at times; however, staff failed to utilize different approaches and interventions to ensure wound care was provided. The findings include: Review of the facility's policy titled, Resident's Rights in Nursing Homes-Providing Services and Activities, dated [DATE], revealed each nursing home is required to provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care which, is initially prepared, with participation to the extent practicable of the resident, the resident's family, or legal representative. Review of the the facility's Skin Care Guidance, dated (MONTH) (YEAR), revealed the purpose of the policy is to provide a system for evaluation of skin to identify risk and identify interventions to address risk and a process for care of changes/disruption in skin integrity. Closed record review revealed the facility readmitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Further review of the MDS, under section M, revealed the resident did not have any pressure wounds at this time. Additional MDS review revealed there were no venous or arterial ulcers present. Review of Resident #1's Comprehensive Care Plan, dated [DATE], titled, My Psychosocial Well Being, related to my cognition deficits, revealed I cry when I realize my cognitive deficits. I have extensive wounds on my lower extremities bilaterally. Approaches were to keep the room as odor free as possible and deep wounds completely covered. Further review of the Comprehensive Care Plan titled, I sometimes choose to not follow the Medical Doctor's (MD) Plan of Care (PoC), revealed an approach to reinforce with me the risk and benefits of wearing wraps per MD order, with no evidence of interventions to approach the resident later or to have another staff approach the resident regarding treatments. Review of Resident #1's Comprehensive Care Plan for My Skin Focus related to I am at risk for skin breakdown with a goal that I will not experience any unidentified complications or injury related to skin. Approaches on the care plan were encourage my good nutritional intake; report persistent areas of redness or open areas to the Charge Nurse; treatment to wounds per MD order; administer medications as ordered; refer me to the Dietician to evaluate my nutritional status as needed (PRN); skin audit PRN. Weekly skin assessments are too painful for me; pressure reduction air mattress bed setting to resident comfort; do not measure wounds due to pain and comfort measures; keep environment as clean and odor free as possible; and use charcoal/carbon diffusers in room. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to cleanse the right heel with normal saline, mix [MEDICATION NAME] (antibiotic) with [MEDICATION NAME] (numbing agent) and safe gel; apply to the wound bed and wrap with [MEDICATION NAME] every two (2) days starting on [DATE], order discontinued on [DATE]. Review of the TARs revealed when staff completed the treatment and dressing change, they put a check and initialed for that day, or would put a N and initialed, indicating the dressing was not changed. Further review of the TARs revealed the dressing was changed in (MONTH) (YEAR) a total of nine (9) times, and was not changed at all from [DATE] through [DATE], and changed a total of fourteen (14) times in (MONTH) (YEAR), and only one (1) time in (MONTH) (YEAR), prior to the resident's death on (MONTH) 4, (YEAR). Review of the Departmental Notes, dated [DATE] through [DATE], revealed there was no evidence of documentation to indicate the reason his/her dressing was not changed or action taken related to not being changed. Review of a Departmental Note, dated [DATE] at 12:36 PM, by Registered Nurse (RN) #2 revealed Resident continues on Hospice care due to gangrenous arterial wounds to right foot and leg. All wounds are black with exposed tendons noted to the underside of the right leg. Fifth toe on his/her right foot is now black as well. Wounds do cause him/her a significant amount of pain with dressing changes and pain medication is given prior to dressing changes and as needed throughout the day. Foul odor noted to the wound. Dressings are being changed every other day. Review of a Departmental Note, dated [DATE] at 12:42 PM, by RN #1 revealed Arterial wounds to the right foot continue to decline. Necrotic tissue noted to the right heel, back of right leg and around right fifth toe. Wounds to the right leg continue with foul smelling drainage. Dressing changes are every other day. Review of a Departmental Note, dated [DATE] at 9:06 AM, by RN #1 revealed Resident continues with severe arterial wounds to the right foot and leg. Entire right foot and leg are noted to be necrotic with foul odor. Dressing changes to all wounds done as ordered. Resident is medicated with [MEDICATION NAME] (pain killer) prior to dressing changes for pain management. There was no documented evidence the resident refused treatments. Review of a Departmental Note, dated [DATE] at 7:25 PM (Late entry for 4:15 PM), by Licensed Practical Nurse (LPN) #2 revealed the Physician was notified of what appears to be maggots within an open area of the wound to Resident #1's medial right foot/ankle. The Physician ordered a one (1) time dose of [MEDICATION NAME], at the current dosage, to be given after the resident received a shower to remove the maggots. Further record review revealed a new order was received on [DATE] for the bilateral lower extremities to clean his/her foot with [MEDICATION NAME] and let dry. Apply Carboflex to wound areas and wrap with Kerlix. Secure with tape. Review of the (MONTH) TAR revealed no documented evidence this treatment was completed on the 30th. Review of the (MONTH) TAR revealed the treatment was completed on the 2nd; however, not on the 1st or 3rd. There was no documented evidence regarding as to why the dressings were not changed. Review of a Departmental Note, dated [DATE] at 8:34 AM, revealed Resident #1 expired at approximately 5:20 AM. Interview with Resident #1's daughter, on [DATE] at 9:30 AM, revealed she was not informed about the resident refusing dressing changes. She stated she had not observed the dressing while visiting, as there was always a towel laying over the wounds with his/her feet exposed. She revealed when she visited, two (2) days before, she was notified about the maggots, and the resident's legs were covered with a towel. She revealed there were flies on the towel, and the flies were attempting to go underneath the towel. Interview with LPN #1, on [DATE] at 11:35 AM, revealed she was the primary nurse through the week for Resident #1 because she worked that unit Monday through Friday. She stated Resident #1 would refuse dressing changes, and he/she would scream and curse for her to get out of the room. She revealed he/she would allow her to complete the dressing change at times, but then would refuse two (2) days in a row, indicating the dressing went five (5) to six (6) days without being changed. She stated it was the resident's right to refuse, and she was not the type of nurse to go against the resident's rights. No documentation was noted that the nurse attempted to educate the resident on the need for the dressing changes, or to offer pain medication or an anti-anxiety medication. Interview with LPN #2, on [DATE] at 12:00 PM, revealed she did the dressing change with the Weekend House Supervisor, and the dressing and the bed were saturated with foul drainage. She revealed when the dressing was cut off, approximately eight (8) maggots fell on to the bed covering, and then other maggots continued to fall from the wound. She stated at that time, the resident was taken to the shower to clean out the wound, and the resident was never told he/she had maggots in the wound, but had bugs. There was no evidence of documentation related to the resident's response. Interview with RN #1/Weekend Supervisor, on [DATE] at 12:00 PM, revealed, on [DATE], she assisted LPN #2 with Resident #1's dressing change and upon removal of the dressing, approximately eight (8) maggots fell out onto the bed cover. She stated, with manipulation of the wound, maggots fell out which had tunneled into the necrotic tissue. She revealed she had started working at the facility in (MONTH) (YEAR), and the resident only had some discoloration on the right lower extremity. She stated the wound progressed very fast, becoming black, open, and necrotic up the right calf. She revealed the resident refused treatment because of the pain, but by using the right approach, calm, baby, and pamper a little, have all supplies laid out and ready to go, and also pre-medicate thirty (30) minutes prior to the dressing change, he/she would always allow the dressing to be changed, but not every nurse used that approach. She stated she came in on the weekend and would find the dressing had not been changed for a few days, and at one (1) time the wound was only getting changed three (3) times a week, so it could have easily gone six (6) days without being changed. She revealed the day the maggots were found, the dressing was very saturated with foul drainage. She revealed, as a supervisor, she had educated LPN #1 on the need to change the dressing as ordered, but only verbally, she had not documented anything, and did not document that the Director of Nursing (DON) was made aware. Interview with RN #2/Weekday Supervisor, on [DATE] at 1:00 PM, revealed Resident #1 refused his/her dressing changes at times, but she was always able to change the dressing, if not on the first attempt, on the second attempt. She stated, if she was there, the dressing would always be changed. She further revealed she had approached LPN #1 frequently about the need for the dressing changes, but she did not document the conversations with LPN #1, or that the DON was made aware. Interview with Certified Nurse Aide (CNA) #1, on [DATE] at 11:20 AM, revealed she worked on Resident #1's hall (200 hall). She stated the wound smelled very bad and the smell would go into the hallway. She stated she never saw LPN #1 go into the resident's room to change the dressing, or ask her to assist with the dressing change, but would always assist LPN #2 with the dressing change on the weekend. She stated LPN #2 would be upset and frequently made the statement that she knew the dressing had not been changed. Interview with CNA #2, on [DATE] at 12:40 PM, who also worked Resident #1's hall, revealed it took two (2) people to change Resident #1's dressing and LPN #1 had asked her to help change Resident #1's dressing only two to three (,[DATE]) times. She stated the smell from the wound was awful and the wound would be covered with a saturated towel, so she would change the towel. She stated you could tell when the dressing had not been changed for a while because of the amount of saturation and odor. Interview with the DON, on [DATE] at 12:00 PM, revealed she was not made aware of the frequency of refusals, or the follow-up approaches made. She stated, in hindsight, things should have been done differently related to the proper approach to use when a resident refused care. She stated she expected staff to make multiple attempts to provide treatments if a resident refused, as well as to make the Unit Manager aware. Interview with the Administrator, on [DATE] at 12:15 PM, revealed she expected the staff to follow the physician's orders [REDACTED].

Based on interview and record review, it was determined the facility failed to ensure the clinical record was maintained in accordance with professional standards and practices that are complete and accurately documented for one (1) of four (4) sampled residents (Resident #1). Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed there were seven (7) scheduled days the dressing did not get changed. Review of the (MONTH) (YEAR) TAR revealed four (4) scheduled days the dressing did not get changed. Review of the (MONTH) (YEAR) TAR revealed two (2) scheduled days the dressing did not get changed; however, there was no documented evidence regarding the reason for the omission of the dressing change nor Physician, Guardian or Hospice notification. Additionally, there was no evidence other attempts or interventions were used at the time of refusal. Further review of the TARs revealed the dressings were changed only every other day, at times, and the resident would go from three (3) to six (6) days without a dressing change. The findings include: Interview with the Director of Nursing (DON), on [DATE] at 9:00 PM, revealed the facility did not have a policy related to documentation. Closed record review revealed the facility readmitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Review of a Departmental Note, dated [DATE] at 12:08 AM, revealed the Hospice Registered Nurse (RN) was at the facility at approximately 10:00 PM on [DATE] with orders to admit Resident #1 to Hospice due to [DIAGNOSES REDACTED]. Further review of a Departmental Note revealed to obtain daily vital signs and call Hospice for any change in condition or in the event of the resident's death. Review of a Departmental Note revealed, on [DATE] at 11:51 AM, Licensed Practical Nurse (LPN) #1 documented Resident continues to refuse dressing changes, meals, and takes off oxygen at times. Resident is known to have periods of confusion and tearfulness. Review of a Departmental Note by LPN #1 revealed, on [DATE] at 12:37 PM, Resident refused to have dressings changed times two (2). Review of a Departmental Note revealed, on [DATE] at 1:17 PM, LPN #1 documented Resident's wound assessment will be attempted tomorrow as resident refused assessment and dressing changes today. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to cleanse the right heel with normal saline, mix [MEDICATION NAME] (antibiotic) with [MEDICATION NAME] (numbing agent) and safe gel; apply to the wound bed and wrap with [MEDICATION NAME] every two (2) days starting on [DATE], order discontinued on [DATE]. Review of the TARs revealed when staff completed the treatment and dressing change, they put a check and initialed for that day, or would put a N and initialed, indicating the dressing was not changed. Further review of the TARs revealed the dressing was changed in (MONTH) (YEAR) a total of nine (9) times, and was not changed at all from [DATE] through [DATE], and changed a total of fourteen (14) times in (MONTH) (YEAR), and only one (1) time in (MONTH) (YEAR), prior to the resident's death on (MONTH) 4, (YEAR). Further review of the TARs and the Departmental Notes for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed no evidence of documentation regarding the reason for the omission of the dressing change, or Physician, Guardian or Hospice notification, or if other attempts or interventions were used at the time of refusal. Review of a Departmental Note, dated [DATE] at 8:34 AM, revealed Resident #1 expired at approximately 5:20 AM. Interview with LPN #1, on [DATE] at 11:35 AM, revealed she was the primary nurse through the week for Resident #1 because she worked that unit Monday through Friday. She stated Resident #1 would refuse dressing changes, and he/she would scream and curse for her to get out of the room. She revealed he/she would allow her to complete the dressing change at times, but then would refuse two (2) days in a row, indicating the dressing went five (5) to six (6) days without being changed. She stated it was the resident's right to refuse, and she was not the type of nurse to go against the resident's rights. Further interview, on [DATE] at 12:40 PM, when asked about documentation and attempted education of the importance for the resident's dressing changes, as well as proper notification related to the dressing changes, she stated I think it is time for me to leave now and take a lunch break. Interview with LPN #2, on [DATE] at 12:00 PM, revealed she did the dressing change with the Weekend House Supervisor, and the dressing and the bed were saturated with foul drainage. She revealed when the dressing was cut off, approximately eight (8) maggots fell on to the bed covering, and then other maggots continued to fall from the wound. She stated at that time, the resident was taken to the shower to clean out the wound, and the resident was never told he/she had maggots in the wound, but had bugs. There was no evidence of documentation related to the resident's response. Interview with RN #1/Weekend Supervisor, on [DATE] at 12:00 PM, revealed, as a supervisor, she had educated LPN #1 on the need to change the dressing as ordered, but only verbally, she had not documented anything, and did not document that the DON was made aware. Interview with RN #2/Weekday Supervisor, on [DATE] at 1:00 PM, revealed she had approached LPN #1 frequently about the need for the dressing changes, but she did not document the conversations with LPN #1, or that the DON was made aware. Interview with the DON, on [DATE] at 12:00 PM, revealed in hind sight, we now notice the documentation was not thorough enough to tell the whole story, and we will be educating on proper documentation. She stated when an N is used for the omission of the treatment, then the reason(s) why should be documented, along with resident education or other interventions used, and proper notification.

Based on interview, record review, and review of the facility's Abuse Policy it was determined the facility failed to ensure four (4) of eleven (11) sampled residents (Resident #2, Resident #3, Resident #4 and Resident #5) were free of mental and sexual abuse. The facility failed to identify and care plan the vulnerabilities of Residents #2, #3, #4 and #5, such as decreased cognition, impaired mobility, decreased safety awareness, behaviors of disrobing, need for a guardian, and/or visual deficits which placed them at risk for abuse. In addition, staff observed Resident #1 kissing and holding hands with Resident #3 in what the facility described as a consensual relationship. However, the facility failed to assess the residents to determine if the residents were able to provide consent; and, failed to notify Resident #3's guardian and physician, to ensure the safety of Resident #3. On [DATE], Resident #1 was observed by staff in the dining room with Resident #2's shirt lifted; he/she was kissing Resident #2's breast. Resident #1 was placed on one on one (1:1) checks then transferred to a hospital behavioral unit. The facility readmitted Resident #1 on [DATE] and placed him/her on thirty (30) minute checks (monitoring). The resident was found in the back North Hall with Resident #2, unsupervised. Staff could not determine how long the residents had been in the back hall. However, staff failed to report Resident #1 was found with Resident #2 until the Dietary Manager reported during the morning meeting the next day. Interviews with staff revealed that prior to the [DATE] incident, Resident #1 had been observed peeping into Resident #3's, #4's, and #5's rooms while the residents were in a state of undress. However, the facility failed to initiate or revise the residents' care plans to reflect measures to be taken to prevent recurrence and, failed to correct situations in which abuse/neglect were more likely to occur. In addition, the facility failed to provide education to staff to address Resident #1's behaviors of voyeurism (Peeping Tom) and his/her sexual tendencies to prevent reoccurrence. In addition, the facility failed to document the incidents in Resident #1's, #2's, #3's, #4's and #5's medical record to ensure continuity of care for the residents, and to ensure staff were knowledgeable of the resident's past history in order to protect other residents from potential sexual abuse. The facility's failure to ensure residents were free from sexual abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Policy, last updated (MONTH) (YEAR), revealed Abuse means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, reasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault, non-consensual sexual contact of any type with a resident/patient. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Training: each team member shall receive annual training on the requirements of the Center's policies and procedures regarding alleged violations and requirements of state and federal law. Training shall include appropriate interventions to deal with aggressive and/or catastrophic reactions of resident/patients and caregiver stress. Prevention: team members are required to report incidents of suspected abuse, neglect, exploitation or misappropriation of resident/patient property without fear of reprisal. The Administrator/Director of Nursing shall identify, intervene, and correct situations in which abuse, neglect, exploitation or misappropriation of resident/patient property are more likely to occur. All other staff is required to report such potential situations to the Administrator/Director of Nursing as soon as identified. Reporting of suspected alleged violations is required of every team member. Reporting: all alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance to state law. Immediately means as soon as possible. Protection: if circumstances require it, Administrator/Director of Nursing (DON) or designee shall remove a resident/patient suspected of being the subject of an alleged violation to an environment where the resident/patient's safety can be protected. If the suspected perpetrator is another resident/patient, the Administrator/Director of Nursing or designee shall separate the resident/patients so they do not have access to each other until the circumstances of the alleged incident can be determined. Where the circumstances of the alleged violation warrant, the DON shall initiate a physical and mental assessment of the resident/patient and document the findings. Factual information only shall be documented. The DON or appropriate clinician shall also notify the attending physician regarding alleged violation and findings and document the contact. The DON or appropriate clinician shall also notify the resident/patient's representative regarding the alleged violation and assessment findings and reassure the resident/patients representative that an investigation has been initiated and appropriate action will be taken. This contact will be documented. Investigation: anytime there is an allegation of neglect, abuse, or exploitation or misappropriation, the Center must report the alleged violation to the Administrator/DON, the Chief Compliance Officer, and other officials, and also initiate an immediate investigation and prevent further potential abuse, neglect, exploitation or misappropriation. Based on the investigation findings, the Center will implement corrective actions to prevent recurrence. The investigation shall include interviews of team members, visitors, resident/patient, volunteers and vendors who may have knowledge of the alleged incident. Factual information only should be documented. Written statements from involved parties should not be requested as all information will be documented on the investigation form and kept in a secure administrative file. The medical record should be reviewed to determine the resident/patient's past history and condition and its relevance to the alleged violation. Corrective Action: the Center shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident/patient or other resident/patients that may be affected. The DON in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include inservice or other measures as appropriate, these steps should be documented. Documentation: documentation in the medical record shall be make where necessary for continuity of care for the resident/patient. Review of the paraphrased Resident Rights provided by the facility, not dated revealed the patient/resident has a right to prompt efforts by the Center to resolve concerns, including those with the respect to the behavior of other patients/residents. The Patient/Resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. 1. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of (12) twelve which indicated the resident was interviewable. Further review of the MDS assessment revealed no physical or verbal behaviors directed toward others and no other behavioral symptoms not directed toward others. Review of a Brief Interview of Mental Status (BIMS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a a BIMS score of (14) which indicated the resident was interviewable. Further review revealed the resident had no behaviors. Review of Resident #1's [DATE], Comprehensive Care Plan for My Behavior Focus related to [DIAGNOSES REDACTED]. However, the care plan did not address any interventions specific to peeping or kissing/grasping of other residents; of having a consensual relationship with another resident; or, of the time frame of the incidents. In addition, the care plan did not address measures to be taken to prevent recurrence, per the facility policy. Observation on [DATE] at 3:46 PM, and interview on [DATE] at 5:42 PM, revealed Resident #1 stated he/she had not been visiting anyone and had no girlfriend/boyfriend. The resident denied any incident of kissing on anyone. Resident #1 stated he/she was not interested in anyone and was not in a relationship. Record review revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE] revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Review of Resident #2's Comprehensive Care Plans dated [DATE] and Certified Nursing Assistant (CNA) Care Guide Information Sheet dated [DATE], revealed the care plans did not address Resident #2 being a victim of sexually inappropriate behaviors or of being the victim of a Peeping Tom (voyeurism) to prevent recurrence, and correct situations in which abuse/neglect were more likely to occur, per facility policy. Review of the facility provided initial report dated [DATE], revealed on [DATE] at 1:45 PM, the Activities Director observed Resident #1 in the dining room with Resident #2. Resident #1 lifted Resident #2's shirt and placed Resident #2's breast in his/her mouth. Interview with the Activities Director on [DATE] at 2:40 PM; and, on [DATE] at 12:49 PM, revealed on [DATE] she observed Resident #1 and #2 in the dining room. The Activities Director stated she had observed Resident #1 lift Resident #2's shirt and was kissing the resident's breast. Review of Resident #1's Department Notes (Nurse's Notes) dated [DATE] at 4:11 PM, revealed Resident #1 was sent to a hospital behavioral health unit for sexually inappropriate behaviors. However, further review of the record revealed no specifics of the incident were documented to ensure staff were able to review the medical record to determine the resident/patient's past history and condition and its relevance to any alleged violations. Further review of the Notes revealed on [DATE] at 5:25 PM, Resident #1 returned from the hospital at 3:30 PM in a wheelchair. Review of the Thirty (30) Minute Check forms revealed Resident #1 was placed on 30 minute checks upon return from the behavioral hospital. Review of Resident #2's documents revealed Resident #2 was to be monitored for seventy-two (72) hours every shift following the sexual abuse allegation. However, review of the [DATE]-[DATE] Department Notes revealed only four (4) notes for for the nine (9) shifts. Interview on [DATE] at 10:31 AM and on [DATE] at 5:06 PM, with the Administrator revealed there was no policy for 72 hour charting but she would write what the facility expected staff to do for 72 hour charting. Review of a document provided by the facility on [DATE] at 5:37 PM on the 72 hour process revealed as situation warrants, we apply charting for 72 hours based on necessity and nursing judgement. For example, mood and behavior with every shift. Interview with Director of Nursing (DON) on [DATE] at 2:57 PM revealed Resident #1 and Resident #2 were being monitored after the sexual abuse allegation, which consisted of seventy-two (72) hour charting being completed every shift (three shifts in a 24 hour period routinely). The DON stated the nurses were responsible for completing the 72 hour charting and monitoring. When asked who was responsible for ensuring the 72 hour charting was completed by nurses, the DON stated the Unit Manager ensured the every shift 72 hour charting was completed and should report to her if it was not being completed. She stated when a resident was identified as having predatory behaviors, staff monitor and redirects the resident to ensure residents were safe and the behavior was reported to the her (DON) or the Administrator. Interview with Administrator on [DATE] at 2:46 PM and [DATE] at 5:25 PM revealed psychosocial needs were to be charted every shift for (72) hours. Interview (Post Survey) on [DATE] at 2:30 PM, revealed they do behavior tracking to ensure no adverse behaviors were identified and if behaviors were identified it was reported to the DON or Administrator for review. The behavior is then reviewed by the IDT team in the morning meeting and then interventions put in place to ensure resident safety. However, review of Resident #1, #3, #4 and #5's care plans revealed there were no interventions put in place to address Resident #1 behaviors of peeping into their rooms while they were in state of undress; Resident #3 related to kissing and hugging with Resident #1 and if assessed to determine if capable of giving consent; and Resident #4 and #5 related to disrobing behaviors. Further interview with the Administrator revealed if changes were made, they were discussed in the start up, then they updated them in the IDT meeting with the MDS Coordinator taking responsibility for updating/revising the care plan. On [DATE], the State Survey Agency notified the facility of an allegation of sexual abuse involving Resident #2 that allegedly occurred on [DATE]. Resident #1 was still on thirty (30) minute checks, when this allegation occurred. However, review of the thirty (30) minute checks, dated [DATE], revealed no documented evidence that the checks from 6:00 PM-8:00 PM for Resident #1 were completed. Review of the thirty (30) minute checks, dated [DATE] at 9:30 AM, revealed Resident #1 was redirected from Resident #2's room. Review of Resident #1's Department Note, dated [DATE], written by Registered Nurse (RN) #1 revealed Resident #1 had behaviors and was redirected from the West Hall (3) three times (Resident #3 resides on this hall); and, was redirected away from other residents rooms on the North Hall (Residents #2 and #5 reside on this hall). However, there were no specifics of the behaviors to ensure continuity of care for the residents and to ensure staff were able to review the medical record to determine the resident's past history and condition and its relevance to future alleged violations. Interview with RN #1 on [DATE] at 1:59 PM, revealed she could not recall the details of the [DATE] incident that she had documented Resident #1 was exhibiting behaviors Interviews with Certified Nursing Assistant (CNA) #9 on [DATE] at 3:32 PM, the Dietary Cook on [DATE] at 5:13 PM, and the Dietary Manager (DM) on [DATE] at 3:39 PM, revealed Resident #1 was discovered alone with Resident #2 in the back North Hall unsupervised, this was during the time the resident was on thirty (30) minute checks (date unknown, but after the resident's returned from the hospital). The DM stated she did not inform anyone of this until the next day during the morning meeting of Administrative/Departmental Staff. She stated she was aware the resident was on thirty (30) minute checks. She stated she was aware of the facility's abuse policy for reporting immediately, but she did not say anything to anyone that night because there was nothing happening as Resident #1 was sitting in his w/c with Resident #2 standing up and they were not even close enough to reach out and touch. However, staff could not determine or were not aware of how long the residents had been down the hall. Further interview with the Dietary Cook, and the Dietary Manager revealed there was no way to know how long the resident been down the hall. CNA #9 stated she had been looking for Resident #1 because she was doing the thirty (30) minute checks and could not find him/her. Interview with CNA #1 on [DATE] at 2:58 PM, revealed after Resident #1 had come back to the facility from behavioral health on [DATE], she had witnessed Resident #1 down the hallway speaking with Resident #2 while he/she was on (30) thirty minute checks. Interview with CNA #8 on [DATE] at 9:54 AM revealed she had been informed by CNA #9 that the interaction between Resident #1 and Resident #2 was a concern on the North Hall as the residents were supposed to be watched and not be alone together. She stated everyone was aware that this was a blind spot in the hall that could not be seen from the nursing station. Interview with CNA #14 on [DATE] at 11:47 AM, revealed Resident #1 would stop outside Resident #2's room and look into the room. CNA #14 stated she had to tell the resident to keep going. 3. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE] revealed the facility assessed Resident #3's cognition as moderately impaired with a BIMS' score of eleven (11) which indicated the resident was interviewable. Review of Resident #3's Comprehensive Care Plan dated [DATE], [DATE], and [DATE], revealed the care plan did not address Resident #3 having a consensual relationship with Resident #1 and further review of the record revealed there was no assessment to determine if Resident #3 was capable of a consensual relationship with Resident #1 to ensure the safety of the resident. Interview with Resident # 3's Responsible Party (RP) on [DATE] at 5:04 PM, revealed she had just been informed of a relationship between Resident #3 and #1 approximately (2) two weeks ago and of a friendship which included holding hands and kissing this week. The RP stated she was Resident #3's guardian for safety because the resident has . Dementia, forgets, is disabled mentally. Resident #3's RP stated she assumed the facility had rules and she would want to know if something occurred. Interview with Resident #3 on [DATE] at 2:30 PM revealed no one had kissed or touched him/her, and he/she did not have a boyfriend/girlfriend. The resident stated he/she would probably slap them if someone kissed him/her. Interview with LPN #3 on [DATE] at 12:13 PM, revealed Resident #3 was disoriented, confused and only knew his/her name, even though the facility stated the resident was in a consensual relationship with Resident #1 which included kissing and holding hands. Further interview revealed Resident #1 was going into Resident #3's room. 4. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #4's cognition as moderately impaired with a BIMS' score of eleven (11) which indicated the resident was interviewable. Review of Resident #4's Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Guide Information Sheet, dated [DATE] revealed the care plans did not address Resident #4 undressing/disrobing or of being the victim of a Peeping Tom. Nor did it reflect measures to be taken to prevent recurrence, where appropriate; and correct situations in which abuse/neglect were more likely to occur. Observations on [DATE] at approximately 9:05 AM, and on [DATE] at 9:30 AM, revealed Resident #4 had both legs off the bed and his/her brief half off, and the privacy curtain was not pulled. Further observation of the resident and attempted interview with the resident revealed he/she was difficult to communicate with and was anxious, crying, and his/her legs were flailing. 5. Record review revealed the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE] revealed the facility coded 2 for the BIMS' score which indicated the resident was moderately impaired. Review of Resident #5's Comprehensive Care Plan and CNA Care Guide Information Sheet dated [DATE], revealed the care plan did not address Resident #4's behaviors of undressing/disrobing or of being the victim of a Peeping Tom to reflect measures to be taken to prevent recurrence, where appropriate; and correct situations in which abuse/neglect are more likely to occur. Interview/communication with Resident #5 was conducted through squeezing of the hand (1) one time for yes, and two times for no. On [DATE] at 10:15 AM and at 5:00 PM revealed Resident #5 squeezed the hand one time for yes to the following questions: Has a resident in a wheelchair bothered you while here, has he/she come into your room? Has that resident touched you? Additionally, Resident #5 revealed through squeezing of the hand that he/she was afraid and that he/she was able to understand. Interview on [DATE] at 12:23 PM with the Speech Language Pathologist revealed she works with Resident #5, but she did not utilize the hand squeeze method. She stated she used the point at yes or no method. Interviews on [DATE] at 2:37 PM with CNA #8, on [DATE] at 2:58 PM with CNA #1, on [DATE] at 3:32 PM with CNA #9, on [DATE] at 3:48 PM with CNA #10 and [DATE] at 11:47 AM with CNA #14 revealed Resident #1 would look into Residents #3's room while in a stage of undress. In addition, interviews on [DATE] at 12:21 PM with Registered Nurse (RN) #2, on [DATE] at 4:24 PM with CNA #2, on [DATE] at 11:33 AM with CNA #13, and on [DATE] at 5:02 PM with CNA #12 revealed they had observed Resident #1 and #3 kissing and holding hands. However, further review of Resident #3's record revealed there was no documented evidence of an assessment to determine if Resident #3 was able to be in a consensual relationship. In addition, review of Resident #1's and #3's Comprehensive Care Plan revealed there were no interventions to address a consensual relationship between Resident #1 and #3 and no evidence Resident #3's Responsible Party or Physician had been informed. Interview with Resident #3's Responsible Party (RP) on [DATE] at 5:04 PM, revealed she was informed approximately (2) two weeks ago that Resident #3 was having a friendship. She stated she was informed this week that they were holding hands and kissing. The RP stated she was made guardian for Resident #3's safety and assumed the facility had rules. She stated Resident #3 had dementia, forgets, disabled mentally. The Responsible Party stated if something occurred she would want to know about it. Interview with CNA #14 on [DATE] at 11:47 AM, revealed Resident #1 had went into Resident #3's room while she was passing trays. CNA #14 stated Resident #1 was eating in the room with Resident #3 and she heard Resident #3 tell Resident #1 to get out of the room, but the door was open. Interview with LPN #7 on [DATE] at 2:47 PM revealed she did not feel that Resident #3 was capable of a consensual relationship. She stated she had heard about Resident #1 going into Resident #3's room. Interview with the Administrator on [DATE] at 2:35 PM, revealed Resident #1 and Resident #3 both had BIMS scores that indicated they were interviewable. She stated the scores were above eight (8) and the residents were cognitively intact. She stated the residents were in agreement to eating lunch together as they were friends and, There was nothing sexual about it, there is no sexual interaction, they were friends. Interview (Post Survey) on [DATE] at 2:30 PM, revealed she was not aware Resident #1 and #3 had been observed kissing and holding hands. Interview with CNA #8 on [DATE] at 5:08 PM revealed Resident #1 was seen in Resident #4's room looking at Resident #4 before the sexually inappropriate incident on [DATE]. CNA #8 stated Resident #4 had a brain condition and strips off (his/her) clothes. Interview (Post Survey) on [DATE] at 3:18 PM, revealed when she found Resident #1 looking in at Resident #4 she asked the resident to move to his/her room or nursing station and reported it to the DON. She stated they helped Resident #4 dress and pulled the curtain. Interview with CNA #14 on [DATE] at 11:47 AM, revealed that Resident #1 would try to peep in on female residents that undressed themselves. She stated Resident #1 was very aware of what he/she was doing. Interview with CNA #9 on [DATE] at 4:45 PM, revealed she had observed Resident #1 peeping into Resident #4's room. Interview with LPN #6 on [DATE] at 10:36 AM, revealed Resident #5 would take his/her clothes off . Further interview revealed that other staff had observed Resident #1 looking in on Resident #5 while he/she was in a state of undress. Interview with Certified Nursing Aide (CNA) #1 on [DATE] at 2:58 PM, revealed after Resident #1 had come back to the facility from behavioral health on [DATE] she had witnessed the resident with his/her back to the nursing station looking in on Resident #5. She stated the resident would look around then look back in on Resident #5 and they would have to redirect him/her. CNA #1 stated she told the nurse what Resident #1 was doing. She stated Resident #4 was known to undress as well. The CNA stated she had come out of the break room and discovered Resident #1 peeping in on Resident #2 and Resident #5. She stated the resident would give hugs to Resident #3. CNA #1 stated she had informed Resident #1 that he/she was to have no contact with the other residents (Residents #2,#3, #4, and #5) but Resident #1 acted like it went over his/her head. CNA #1 stated she did not inform anyone of the incident. Interview with Resident #5's Roommate (Unsampled Resident A) on [DATE] at 10:10 AM, revealed he/she tries to close the door when (Resident #5) is changing because (the resident) does not know to close the door and sometimes (a resident) in a wheelchair stands at the door. Interview on [DATE] at 2:37 PM, with CNA #8 revealed Resident #1 had been been redirected from Resident #2's room several times and other female residents' rooms several times. She stated Resident#1 would go over to Resident #2 in the dining room and when told that he/she should not be there, he/she would say he/she did not know. CNA #8 stated Resident #1 had been redirected several times on nights around ,[DATE] AM, as he/she wanders. She stated the resident wanders and tells them he/she is going to get a soda, but would go down to the break room on the North Hall and look back to see if someone was looking. CNA #8 stated staff had seen Resident #1 looking in Resident #4's room and Resident #3's room. She stated Resident #4 had behaviors of disrobing and Resident #3 was not in his/her right mind; and, had lost his/her spouse and was grieving. She stated Resident #1 was seen being overly affectionate to Resident #3 by holding hands and kissing. CNA #8 stated she felt it was not right because the resident had sundowners (Resident #3) and would become confused as the day went on; plus the resident's spouse had died recently. She stated the Administration was aware of the residents holding hands and being overly affectionate. She stated Administration would say Resident #3 had a high BIMS' score and could make decisions. Interviews on [DATE] at 10:37 AM with the Dietary Manager (DM); [DATE] at 12:38 PM with Business Office Manager (BOM); [DATE] at 12:49 with Activities Director (AD); on [DATE] at 1:24 PM with Social Services Director (SSD); and, [DATE] at 11:04 AM with the Minimum Data Set Coordinator (MDSC) revealed they had discussed Resident #1's behavior of peeping in on residents in stages of undress. She stated this was discussed prior to the [DATE] incident in the morning meeting. However, review of Residents #1,#3, #4, and #5's care plans revealed there were no interventions put in place to reflect measures to be taken to prevent recurrence, and to correct situations in which abuse/neglect were more likely to occur. Interview with the Director of Clinical Education on [DATE] at 4:00 PM and [DATE] at 12:43 PM, revealed she was unable to provide a copy of the [DATE] inservice on abuse that was provided. She stated she had not started an inservice related to the sexual abuse allegation reported to the facility by the State Survey Agency on [DATE]. Interviews on [DATE] at 12:29 PM with Health Information Manager Coordinator (HIMS), on [DATE] at 11:38 with RN #2, on [DATE] at 11:56 AM with LPN #2, on [DATE] at 9:26 AM with CNA #11, on [DATE] at 11:20 AM with CNA #12, on [DATE] at 11:33 AM with CNA #13, on [DATE] at 12:48 PM with Certified Medication Technician(CMT) #1 revealed they had not received any abuse and neglect training inservices related to voyeurism, Peeping Toms or residents with sexual tendencies. Interview with the Director of Nursing (DON) on [DATE] at 2:57 PM, revealed she had not been informed of Resident #1 looking in on other residents while they were undressing because she was out due to medical concerns during that time. She also stated Resident #1 was placed on thirty (30) minute checks when he/she returned from the behavior hospital and she expected the staff to immediately notify her of any incidents involving Resident #1 and Resident #2. However, there was no revision to Resident #1's care plan to address notifying the DON of any incidents involving Resident #1 and #2, as staff should per the facility's policy. The policy stated the DON in conjunction with other clinicians shall initiate or revise a care plan to reflect the measures to be taken to prevent recurrence. Interview with the Medical Director on [DATE] at 7:30 AM, revealed she expect

Based on observation, interview, record review, and review of the facility's Abuse Policy, it was determined the facility failed to implement its Abuse Policy for four (4) of eleven (11) sampled residents (Residents #2, #3, #4 and #5). The facility was aware that Resident #1 was peeping in at Residents #3, #4, and #5 when they were undressed. The facility was also aware that Resident #1 was also known to kiss and hold hands with Resident #3. However, the facility failed to provide training to staff to ensure they were aware of how to care for a resident who had sexual tendencies and exhibited behaviors of voyeurism (aka Peeping Tom). On 03/16/18, Resident #1 was found to have pulled Resident #2's shirt up in the dining room and was kissing on Resident #2's breast. However, the facility was unable to provide documented evidence staff were trained on abuse/neglect after this incident. Resident #1 was sent to a behavioral hospital on [DATE] and returned on 04/02/18. After the resident returned, he/she was placed on thirty (30) minute checks. However, upon Resident #1's return, he/she was found by staff, which included supervisory staff, alone with Resident #2 on the back hall. Even though staff was aware the resident was on thirty minute checks, they failed to report this incident immediately to the Administrator. In addition. staff failed to monitor Resident #1 during the thirty minute checks on 04/14/18 from 6:00 PM-8:00 PM. The facility's failure to ensure staff were trained on abuse and neglect related to Resident #1's sexually inappropriate behaviors and voyeurism, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/11/18 and determined to exist on 03/16/18. The facility was notified of the Immediate Jeopardy on 05/11/18. An acceptable Allegation of Compliance (AoC) was received on 05/22/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/18/18. The Scope and Severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Policy, last updated (MONTH) (YEAR), revealed Reporting: all alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law. Protection: if the suspected perpetrator is another resident/patient, the Administrator/Director of Nursing or designee shall separate the residents/patients so they do not have access to each other till the circumstances of the alleged incident can be determined, and the resident's representative shall be notified of the alleged violations, assessment findings, investigation initiation, and appropriate actions taken and this shall be documented. Training: shall include appropriate interventions to deal with aggressive and/or catastrophic reaction of residents/patients. Further review of the policy revealed the Director of Nursing (DON) in conjunction with other clinicians shall initiate or revise a care plan to reflect the resident/patient's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps shall be taken to prevent recurrence of the incident. This may include inservice or other measures as appropriate, these steps should be documented. Documentation: documentation in the medical record shall be made where necessary for continuity of care for the resident/patient. Interviews on 05/05/18 at 2:37 PM with Certified Nurse Aide (CNA) #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10; and, on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #4's and Resident #5's room while they were in a state of undress. In addition, interviews on 05/05/18 at 2:37 PM with CNA #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #3's room while the resident was in a stage of undress. Review of the facility provided initial report dated 03/16/18, and interview with the Activities Director on 05/04/18 at 12:49 PM revealed on 03/16/18 at 1:45 PM, she observed Resident #1 and Resident #2 in the dining room. She stated Resident #1 lifted Resident #2's shirt and was kissing on Resident #2's breast. Further interview revealed Resident #1 was transferred to a behavioral hospital on [DATE] and returned to the facility on [DATE]; and, was placed on thirty (30 ) minute checks. Interviews on 05/09/18 with the Dietary Manager at 10:37 AM, the Business Office Manager at 12:38 PM, the Activities Director at 12:49 PM, the Social Services Director at 1:24 PM; and the Minimum Data Set (MDS) Coordinator at 11:04 AM revealed Resident #1 had been discovered/observed peeping in on Resident #4 and Resident #5 (who had known behaviors of disrobing), while they were in their room in stages of undress. She stated this had been discussed in the morning meeting prior to the 03/16/18 incident. According to the facility's policy,Training: shall include appropriate interventions to deal with aggressive and/or catastrophic reaction of residents/patients. The Policy stated actions could include inservice or other measures as appropriate, these steps should be documented. However, the facility was unable to provide when training had been provided to staff related to voyeurism. Review of the resident's care plans revealed no interventions were put in place to ensure the safety of Resident #4 and #5 per facility policy. Interview with the Director of Clinical Education (DCE) on 05/10/18 at 4:00 PM and on 05/11/18 at 12:43 PM, revealed she had inserviced staff related to the sexual inappropriate behavior by Resident #1 towards Resident #2 on 03/16/18. However, the facility failed to follow its policy, as she was unable to provide documented evidence the staff had received the inservice. Review of the 30 minute monitoring checks revealed Resident #1 was placed on 30 minute checks on 04/02/18, after returning from the behavioral hospital and then placed on 15 minute checks from 04/10/18 through 04/11/18 related to behaviors. However, the sheet did not specify what behaviors were addressed. In addition, further review revealed Resident #1 was on thirty minute checks on 04/14/18; however, the facility failed to complete (30) minute checks from 6:00 PM till 8:00 PM for Resident #1 and failed to protect other residents, per facility policy. Interviews with Certified Nursing Assistant (CNA) #9 on 05/07/18 at 3:32 PM, the Dietary Cook on 05/09/18 at 5:13 PM, and the Dietary Manager on 05/10/18 at 3:39 PM revealed Resident #1 was discovered alone with Resident #2 in the back North Hall, unsupervised in an area that was out of view of the nursing station. This occurred while the resident was on (30) thirty minute checks. Interviews with staff revealed they were unable to determine how long the residents had been down the hall. They stated they did not know what date this incident happened, but it was in the evening after 6:30 PM. The staff stated they did not report this incident immediately, per facility policy to the Administrator/DON. The Dietary Manager, who is part of the management team, reported the incident the next day in the morning meeting. She stated she was aware of the facility's policy to report suspected abuse immediately; however, she did not report the incident immediately because the residents were not within reach of each other and she did not think anything had happened. Interviews on 05/06/18 at 6:31 AM with LPN #6, on 05/07/18 at 1:59 PM with RN #1, on 05/08/18 at 9:26 AM with CNA #11, at 11:20 AM with CNA #12, at 11:33 AM with CNA #13, at 12:48 PM with Certified Medication Technician(CMT) #1; at 8:56 AM with Housekeeping #1, on 05/11/18 at 12:29 PM with the Health Information Manager Coordinator (HIMC); at 11:38 with RN #2, and at 11:56 AM with LPN #2, revealed they did not receive any training on voyeurism, or residents with sexual tendencies. According to the facility's policy, staff should receive inservice and it should be documented. Interview with Acting DON on 05/16/18 at 4:31 PM revealed the facility had started the abuse and neglect training yesterday and the only thing new was the definition of Peeping(NAME)and voyeurism. Interview with the Director of Nursing (the DON when the 03/16/18 incident occurred) on 05/11/18 at 2:57 PM, revealed she was not sure their abuse and neglect training covered residents with sexual tendencies, voyeurism and Peeping Toms. She stated no training was provided when staff had identified Resident #1 was peeping in residents' rooms while the residents were disrobing. She stated she was not aware of Resident #1's behaviors because she was in and out of the morning meetings but she thought the facility's abuse/neglect training had sufficient information to cover Resident #1's behaviors even though it did not specifically address residents peeping into other resident rooms while in a state of undress. Interview with Administrator on 05/11/18 at 5:15 PM; and, on 05/16/18 at 5:25 PM, revealed she did not think the staff needed to report to her that Resident #1 was found with Resident #2 on the back North Hall unsupervised, while on (30) thirty minute checks. Interview (Post Survey) with the Administrator on 06/12/18 at 2:30 PM, revealed she was aware of the policy and the policy was being followed because there was no engagement between the two (2) residents and there was a team member in sight so there was no need to report the incident. She stated that any behaviors or moods that were identified were reviewed in the morning meetings and interventions were put in place to ensure resident safety. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Prior to 05/03/18, Resident #1 was on thirty (30) minute observational checks upon readmission from the hospital on [DATE]. 2. Resident #1 was seen by his/her Primary Care Physician on 05/11/18 and had changes to his/her medical treatment plan which included [MEDICATION NAME] ([MEDICATION NAME]) 200 milligrams (mg) twice a day, on 05/15/18. 3. Resident #1 was seen by Medoptions (medication management) on 05/14/18 for medication management with no new orders (NNO). Resident #1 was seen by Medoptions (Psychologist) on 05/15/18 for medication management with no recommendations. 4. Resident #1's care plan (CP) was revised on 05/16/18 by the Regional Director of Operations--to address amorous (sexual) behaviors with interventions to protect other residents. 5. Resident #1 was placed on 1:1 with team members starting 05/03/18 through 05/24/18, and is ongoing. 6. Resident #2 was immediately separated from Resident #1 on 03/16/18 and assessed for injury with no injury noted. 7. Resident #1 was placed on 1:1 supervision with a Center team member on 03/16/18, immediately after the incident prior to being sent out to hospital for further evaluation. 8. Both Resident #1 and Resident #2 had notification to their MD and representative of the incident that occurred on 03/16/18. This was completed by the Administrator on 03/16/18. 9. Resident #2 had revision to the care plan on 05/15/18. This was completed by the Regional Director of Clinical Operations for psychosocial needs. 10. Resident #2 was seen by Medoptions on 05/15/18. Medoptions provides the Center with psychiatric services for physiological therapy. There were no adverse findings. 11. Resident #3 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings. 12. Resident #3's CP was revised on 05/15/18 by the Regional Director of Clinical Operations for psychosocial needs related to his/her past friendship with Resident #1 and psychosocial needs r/t the incident with Resident #1 peeping into his/her room. 13. Documentation was added to the medical record notifying Resident #3's representative of the friendship which included kissing and hand holding that had occurred with Resident #1. 14. Documentation was added to the medical record notifying Resident #3's MD of the friendship which included kissing and hand holding that had occurred with Resident #1. 15. Resident #4 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in his/her room. 16. Resident #4's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #4 removes his/her clothing items, this was completed by the Regional Director of Clinical Operations. Revisions were also made for the psychosocial needs related to the incident with Resident #1 looking into the resident's room. 17. Resident #5 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in on him/her. 18. Resident #5's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #5 removes his/her clothing. This was completed by the Regional Director of Clinical Operations. The psychosocial needs related to Resident #1 looking into his/her room were also addressed. 19. Initiated further investigation on 05/03/18, to identify any other potential affected residents which was concluded on 05/15/18. The investigation consisted of interviews with interviewable residents (BIMS of 8 and up), skin inspections on non-interviewable residents (BIMS of 7 or lower) for injury of unknown source, 72 hour mood and behavior monitoring for non-interviewable residents (BIMS of 7 or less), and Center team member interviews. All interviewable residents with BIMS of 8 and up were interviewed from 05/03/18-05/04/18, inquiring if they had ever been sexually abused by another resident or team member in the Center; if they had ever witnessed sexual abuse of another resident by a resident or team member; and if they had, whom did they report this to? This was completed by the Administrator, BOM, SSD, or DM. These interviews did not reveal any findings. The Center re-interviewed all interviewable residents with BIMS of 8 and up from 05/03/18--05/04/18 (previous time frame of interviews of all interviewable residents with BIMS of 8 and up) inquiring if they knew what sexual abuse was and if they ever witnessed any resident intentionally looking in on other residents of the opposite sex. These interviews commenced on 05/15/18 and were completed on 05/15/18 by the Director of Clinical Education. These interviews did not review any findings. 20. Skin inspections were conducted on all non-interviewable residents (BIMS of 7 or less) checking for any injury. These were completed on 05/03/18 through 05/17/18 by direct care nurses, all of whom were Licensed Practical Nurses (LPN). There with no undocumented injuries or injuries of unknown origin identified with this review. 21. Certified Nursing Assistants (CNAs), LPNs, and Registered Nurses (RN) conducted 72 hour mood and behavior observations on all non-interviewable. residents with BIMS of 7 or less. These observations monitored for any adverse effects from 05/11/18 through 05/14/18. These were completed on each 12 hour shift in the Center. 22. On 05/14/18, the Clinical Interdisciplinary Team (IDT) which included the Administrator, DON, Activity Director, SSD, MDS Coordinator, Health Information Management Coordinator (HIMC), DM and Director of Rehabilitation met to review the 72-hour mood and behavior observations. No newly identified changes to the mood and behavior was identified during this review, for residents already identified with behaviors. However, three (3) residents' care plans were revised on 05/14/18, based upon this review to capture newly identified mood and behaviors. 23. Interviews with Team Members were conducted inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 besides the incident on 03/16/18. These interviews were conducted on 05/03/18 through 05/04/18 by the Administrator, Maintenance Director, Dietary Manager (DM), Director of Rehabilitation (DoR) and Director of Clinical Education (DCE) inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 other than the incident on 03/16/18. No new altercations were identified. 24. Additional interviews of Team Members, (who were interviewed on 05/04/18 through 05/16/18) were conducted after the State Survey Agency (SSA) brought to the Center's attention, an allegation of a past relationship between Resident #1 and Resident #3. These interviews inquired if they had ever witnessed Resident #1 and Resident #3 being sexually inappropriate with each other. Team member interviews were conducted by the Administrator, Maintenance Supervisor, Dietary Manager, Director of Rehab and Director of Clinical Education. 25. Further Team Members interviews were completed to inquire if they had ever witnessed any resident intentionally looking into residents' rooms of the opposite sex and what did they do about it. These interviews were commenced on 05/15/18 and completed on 05/17/18. These interviews were conducted by the Administrator, DON, Maintenance Director, Dietary Manager, Director of Rehab and Director of Clinical Education. 26. All residents' records, including the most recent history and physical (H&P) and/or most recent Psychiatric Visit Consult Notes were reviewed for a history of sexual tendencies or looking into rooms of residents of the opposite sex to ensure the care plans addressed this behavior and included interventions to protect other residents. Any resident with a history of sexually acting out behavior or looking into rooms of residents of the opposite sex, who did not have a care plan addressing inappropriate sexual behavior had one developed during this review. This review found three (3) residents with a history of sexual tendencies and two (2) had existing care plans in place to address the behaviors and (1) one resident (Resident #1) had his/her care plan revised. This revision to Resident #1's care plan was revised on 05/16/18 and was completed by Regional Director of Clinical Operations. The record reviews were completed by the Regional Director of Clinical Operations, DON, and the Director of Clinical Education. 27. The Administrator and DON were given 1:1 education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies. This inservice was presented by the Regional Director of Clinical Operations. This was completed on 05/15/18. 28. All other Department Leaders which included the SSD, DCE, MDS Coordinator, Health Information Management Coordinator (HIMC), Dietary Services Manager (DM), Housekeeping Manager, Maintenance Director, Activities Director, Business Officer Manager, DoR, and HR/Payroll Manager were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy. The training also included identifying residents with sexual tendencies. This was presented by the Administrator, DON, or Regional Director of Clinical Operations and completed on 05/15/18. 29. All other Center Team Members were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. Education commenced on 05/15/18 and was completed on 05/16/18. Education was completed by the Administrator, Maintenance Director, Director of Rehab, DCE, Regional Director of Clinical Operations or the DON. A post-test was given to determine understanding and competency of the education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. 30. Educational material regarding abuse and identification of sexual tendencies and peeping as a form of voyeurism; including a post-test to determine understanding and competency, have been included in the Center's orientation materials to be completed with future new hires and will be given by the Director of Clinical Education (DCE) or a designated clinical leadership nurse prior to providing direct care to residents. 31. Educational material regarding the potential psychosocial effect of sexual trauma was developed by the Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided this education to the Center's clinical leadership team which consisted of the DON, Social Service Director (SSD) and DCE on 05/15/18. Education which included post-test to determine understanding and competency with all other nursing team members (LPNs & RNs) and nursing assistants commenced on 05/15/18 and was completed by 05/16/18. The education and post-test were presented by the DCE. 32. Educational material regarding potential psychosocial effect of sexual trauma with a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed with future nursing team member (CNA's, LPN's, RN's) hires and will be completed by the DCE or a designated clinical leadership nurse prior to providing direct care to residents. 33. All Center licensed nurses have been educated on accuracy of documenting abuse investigations in the medical record on 05/15/18 through 05/16/18 dates. A post-test was given after education was completed to determine understanding and competency. This education and post-test were developed by the Regional Director of Nursing Management Services, who is an RN. The Regional Director of Clinical Operations provided education on accuracy of documenting abuse investigations in the medical record to the Center's clinical leadership team which consist of the DON and DCE, on 05/15/18. A post-test to determine understanding and competency. 34. Education materials regarding accuracy of documenting abuse investigation in the medical record with a post-test to determine understanding and competency, will be included in the Center's orientation to be completed with future new licensed nurse (LPN and RN) hires. This education will be presented by the DCE or designated clinical leadership nurse prior to the new hires providing direct care to residents. 35. Educational material regarding updating residents' care plans, when a resident displays sexual tendencies or when there is a potential psychosocial need was developed by Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided the education to the Center's Clinical leadership team which consist of the DON and DCE on 05/15/18. Education included post-test to determine understanding and competency. All other licensed team members in the Center (LPN's & RN's) were educated regarding updating residents' care plans when a resident displays sexual tendencies or when there is a potential psychosocial need. The education commenced on 05/15/18 and was completed on 05/16/18; and was presented by the DCE or DON. 36. Educational material regarding updating the resident's CP when a resident displays sexual tendency or when there is a potential psychosocial need occurs and a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed by the DCE or designated clinical leadership nurse prior to providing direct care to residents. 37. Any resident in future allegations of abuse will have their medical record reviewed within the clinical start up process by the IDT for accuracy of the medical record documentation and for follow-up. The purpose of the clinical start up meeting is a daily qualitative review of documentation and delivery of care to assure actions are in place to deliver and drive quality outcomes. Items that are reviewed in the clinical start up process include residents with change of condition, falls or incidents, new physician orders, new admissions and discharges. The IDT meets daily Monday-Friday for clinical start-up meeting. On the weekends and holidays, the RN in the Center completes the clinical start-up meeting minutes and reviews any findings with the Center's Managers on Duty (MOD). Members of the MOD include the Administrator, SSD, MDS Coordinator, HIMC, Dietary Service Manager, Activities Director, Maintenance Director and BOM. In addition, to the above which is reviewed in clinical start-up, residents who have new or changes to psychosocial needs including dignity and privacy needs will also be reviewed as part of the clinical start up process, by the IDT to ensure the CP accurately reflects these needs. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will also be reviewed within the clinical start-up process, by the IDT to ensure a care plan is in place with interventions for the protection of other residents. The Clinical Startup IDT consist of: the Administrator, DON, MDS Coordinator, DCE, SSD, Director of Rehab, HIMC, The IDT will ensure that the medical record accurately reflects the resident and includes follow-up of any instances of abuse. 38. Any resident requiring 1:1 supervision in the Center will have an IDT review prior to removal or the weaning of 1:1 supervision. The IDT Team completing the review will be the Administrator, DON, Assistant Directors of Nursing (ADNS), and SSD. 39. On 05/14/18, an impromptu QAPI (Quality Assurance and Performance Improvement) meeting was held. Members consisted of the Administrator, DON, Regional Director of Clinical Operations, and Medical Director. These members reviewed the actions, education and audits taken by the Center effective 05/14/18. 40. The findings of the audits and actions taken after 05/14/18, will be reviewed at the monthly QAPI meeting by the QAPI Team. The QAPI Team consists of the Medical Director, Administrator, DNS, and at least three (3) other department leaders - which include the SSD, DCE, MDS Coordinator, HIMC, Dietary Service Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, BOM, or Director of Rehab. 41. The Administrator, DNS, SSD, DCE will conduct a total of ten (10) team members' interviews per week for eight (8) weeks--then five (5) team member interviews per week for eight (8) weeks. Interviews will include specific questions regarding the Center's abuse policy and dealing with residents with sexual tendencies to ensure continued and thorough understanding of the policy. Interviews will be conducted with the Team Member Abuse QAPI Questionnaire--with any incorrect answers immediately addressed through one on one education provided by the auditor and an immediate QAPI meeting. All findings will be reviewed with the Center's QAPI team who will determine a schedule for continued monitoring after the initial sixteen (16) weeks. 42. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will be reviewed within the CSU Process by the IDT to ensure a care plan is in place with interventions for the protection of other residents. In addition, residents who have new or changes to their psychosocial needs including dignity and privacy needs will also be reviewed as part of the CSU process by the IDT, to ensure the care plan accurately reflects these needs. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will also be reviewed with the CSU Process, by the IDT, to ensure a care plan is in place with interventions for the protection of other residents. The IDT meets daily Monday-Friday for clinical start up meetings and on the weekend and holidays, the RN in the Center completes the Clinical Start Up Meeting minutes and reviews any finding with the Center's Manager on Duty (MOD). Members of the MOD include: Administrator, SSD, MDS Coordinator, HIMC, Dietary Service Manager, Activities Director, Maintenance Director, and BOM on the weekend and holidays. The purpose of the Clinical start up (CSU) meeting is a daily qualitative review of documentation and delivery of care to assure actions are in place to deliver and drive quality outcomes. Items reviewed in the CSU process include: residents with change of conditions, falls or incidents, new physician orders, new admissions and discharges. Contents of the minutes will be reviewed five (5) times a week for twelve (12) weeks and then weekly, and will be reviewed with the Center's QAPI team, who will determine the schedule for continued monitoring. Any finding prior to the monthly QAPI meeting will be addressed in an immediate QAPI meeting. 43. The DON or DCE will review the Clinical Start Up (CSU) Meeting Abuse Allegation Documentation/Psychosocial Needs or Sexual Behaviors Minutes for identification of sexual tendency behaviors including peeping, care plan development for newly identified sexual tendencies, or CP revision for worsening sexual tendencies to ensure compliance with behavior identification and care planning. In addition, they will review for identification of residents with new psychosocial needs, care plan development for newly identified psychosocial needs or CP revision for changes in psychosocial need to ensure compliance with identification of residents with new or change to their psychosocial needs and CP. They will also review for accuracy of the medical record in instances of abuse to ensure documentation is present within the medical record and follow up documentation is completed. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview on 05/07/18 at 2:35 PM with CNA #8 revealed Resident #1 had been placed on thirty (30) minute checks upon return from behavioral health on 04/02/18. Review of (30) thirty minute checks from 04/02/18-05/03/18 revealed Resident #1 was on (30) thirty-minute monitoring. 2. Review of 05/11/18 physician progress notes [REDACTED].#1. Review of Physician order [REDACTED]. 3. Review of Medoptions, Medication Management Assessment, dated 05/14/18, completed by the Nurse Practitioner (NP) revealed follow-up (F/U) of mood and medications: [REDACTED]. Review of the Meditelecare Visit Log dated 05/14/18, revealed: Facility caseload; Resident #1 visit type medication management (MM). Review of Medoptions Therapy Assessment with the Psychologist dated 05/15/18, revealed diagnosis, symptoms, behavioral disturbances, pertinent medical history, Axis III, session content, patient concerns, follow-up therapy, and interventions. 4. Resident #1's CP was revised to include history of peeping in on female residents' rooms. It was noted that on 03/16/18 placed my mouth on a female resident's breast, also had a friendship with a female resident in the Center that included kissing and holding hands (revised on 05/16/18). 5. Observation revealed 1:1 monitoring on 05/22/18 through 05/24/18 of Resident #1. Interviews on 05/23/18 at 9:05 AM, with CNA #10 revealed she was providing 1:1 monitoring of Resident #1 for the day. Interview on 05/23/18 at 11:26 with CNA #8 revealed Resident #1 had been on 1:1 monitoring and Resident #2 had been on thirty (30) minute monitoring checks. Interview on 05/23/18 at 11:49 AM with CNA#14 revealed Resident #1 was on 1:1 monitoring checks and Resident #2 on thirty (30) minute monitoring checks. Interview on 05/23/18 at 1:00 PM with HR/Payroll revealed Resident #1 was on 1:1 monitoring checks and on 05/23/18 a

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to review and revise the care plan for five (5) of eleven (11) sampled residents related to sexually inappropriate behaviors (Residents #1, #2, #3, #4, and #5). Resident #1 was discovered peeping in on Resident #3, Resident #4 and Resident #5 in stages of undress prior to 03/16/18. However, the facility failed to revise the care plans of the residents to address Resident #1 peeping in on them; and failed to revise Resident #4's and 5's care plans to address their behaviors of disrobing. The facility was also aware Resident #1 was kissing and holding hands with Resident #3 prior to 03/16/18. However, the facility failed to revise their care plans to identify if this behavior was consensual or not. On 03/16/18, Resident #1 was found in the dining room with Resident #3's shirt lifted up and he/she was kissing on Resident #2's breast. However, review of Resident #1's and #2's care plans revealed Resident #2's care plan did not address the resident being a victim of sexually inappropriate behaviors. Resident #1's care plan did not address his/her behavior towards Resident #2 and did not include interventions to protect residents in the facility. The facility's failure to revise the care plan for residents related to sexually inappropriate behaviors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/11/18 and determined to exist on 03/16/18. The facility was notified of the Immediate Jeopardy on 05/11/18 . An acceptable Allegation of Compliance (AoC) was received on 05/22/18 . The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/18/18. The Scope and Severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview on 05/15/18 at 9:20 AM, with the Acting Director of Nursing (DON) revealed the facility did not have a care plan policy. She stated the facility follows the Resident Assessment Instrument (RAI) Manual when developing care plans. Review of the facility's stated policy related to care plans, the CMS (Centers for Medicare and Medicaid) RAI version 3.0 Manual pages 4-8--4-1, dated (MONTH) (YEAR), revealed the comprehensive care plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. The care plan must be reviewed and revised periodically and the services provided or arranged must be consistent with each resident's written plan of care. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving. The care plan is driven by identified resident issues and/or conditions and also by a resident's unique characteristics, strength, needs; and is based on a thorough assessment, effective clinical decision making and is compatible with current standards of clinical practice. 1. Record review revealed the facility admitted Resident #1 (alleged perpetrator) on 03/30/17, with [DIAGNOSES REDACTED]., Acquired absence of right Leg below Knee, and Difficulty in Walking. Review of Quarterly Minimum Data Set (MDS) assessment, dated 01/15/18, revealed Resident #1's cognition was intact with a Brief Interview of Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Further review revealed the resident was assessed as needing supervision with activities of daily living (ADLs) and had no behaviors. However, review of the BIMS' interview dated 04/16/18, revealed a summary score of (14) fourteen indicating the resident was cognitively intact and interviewable. Review of Resident #1's Comprehensive Care Plan dated 04/02/18 revealed the resident had a history of [REDACTED]. Interviews on 05/07/18 at 2:37 PM with Certified Nurse Aide (CNA) #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #3's, #4's and Resident #5's room while he/she was in a state of undress. However, review of Resident #1's Comprehensive Care Plan dated 04/02/18 revealed the care plan did not address the specifics of the resident peeping in on other residents while they were in a state of undress and no specific interventions to address this behavior. Review of the facility's initial report dated 03/16/18, and interview with the Activities Director on 05/04/18 at 12:49 PM, revealed on 03/16/18 at 1:45 PM, the Activities Director observed Resident #1 and Resident #2 in the dining room. Resident #1 had lifted Resident #2's shirt and was kissing on Resident #2's breast. However, further review of Resident #1's Comprehensive Care Plan dated 03/16/18, revealed there was no care plan that addressed Resident #1's specific behaviors towards Resident #2. Interviews on 05/08/18 at 12:21 PM with Registered Nurse (RN) #2, on 05/06/18 at 4:24 PM with CNA #2, on 05/08/18 at 11:33 with CNA #13, and on 05/08/18 at 5:02 PM with CNA #12 revealed they had observed Resident #1 and #3 kissing and holding hands. However, further review of Resident #1's care plan revealed there were no revisions to his/her care plan to address if this was a consensual relationship or not. 2. Record review revealed the facility admitted Resident #4 on 09/29/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 04/24/18, revealed the facility assessed Resident #4's cognition as moderately impaired with a BIMS' score of eleven (11) which indicated the resident was interviewable. Interviews with the MDS Coordinator on 05/10/18 at 11:04 AM, CNA #18 on 05/10/18 at 2:13 PM, and LPN #7 on 05/16/18 at 2:47 PM revealed Resident #4 had behaviors of disrobing. Interviews on 05/07/18 at 2:37 PM with CNA #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10, on 05/08/18 at 11:47 AM with CNA #14, and on 05/08/18 at 5:02 PM with CNA #12 revealed knowledge that Resident #4 would disrobe or undress. In addition, interviews on 05/07/18 at 2:37 PM with Certified Nurse Aide (CNA) #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #4's room while he/she was in a state of undress. However, review of Resident #4's Comprehensive Care Plans, dated 05/09/18, revealed the care plan did not address the resident's behaviors of disrobing and Resident #1 peeping in on him/her while in a state of undress. 3. Record review revealed the facility admitted Resident #5 on 03/06/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 03/13/18 revealed the facility assessed and coded 2 for the BIMS score which indicated the resident was moderately impaired. Interviews with the MDS Coordinator on 05/10/18 at 11:04 AM, CNA #18 on 05/10/18 at 2:13 PM, LPN #7 on 05/16/18 at 2:47 PM, CNA #8 on 05/07/18 at 2:37 PM, CNA #1 on 05/07/18 at 2:58 PM, CNA #9 on 05/07/18 at 3:32 PM, CNA #10 on 05/07/18 at 3:48 PM, CNA #14 on 05/08/18 at 11:47 AM, and with CNA #12 on 05/08/18 at 5:02 PM revealed knowledge that Resident #5 would disrobe or undress. In addition, interviews on 05/07/18 at 2:37 PM with CNA #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #5's room while he/she was in a state of undress. However, review of Resident 5's Comprehensive Care Plan, dated 03/06/18, revealed the care plan did not address the resident's behaviors of disrobing and Resident #1 peeping in on him/her while in a state of undress. Interviews on 05/09/18 with the Dietary Manager at 10:37 AM. the Business Office Manager at 12:38 PM, the Activities Director at 12:49 PM, the Social Services Director at 1:24 PM, and, the Minimum Data Set (MDS) Coordinator on 05/10/18 at 11:04 AM; revealed Resident #1's behavior of peeping in on Residents #4 and #5 while they were in periods of undress was discussed in the morning meeting prior to 03/16/18. They stated they did not recall if Resident #1's care plan was revised related to peeping in on residents while they were not dressed, or if Resident #4's and #5's care plans were revised related to their disrobing behaviors and Resident #1 peeping in at them. 2. Record review revealed the facility admitted Resident #2 on 01/08/16 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 01/23/18 revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable; and, was assessed as requiring extensive assist with bed mobility, transfers, dressing and toileting and requiring supervision with walking, locomotion and eating. Review of Resident #2's Comprehensive Care Plans dated 01/08/16, 03/14/16, and 07/25/17 with a goal and target date of 07/24/18; and, the Certified Nursing Assistant (CNA) Care Guide Information Sheet dated 05/09/18, revealed the care plan did not address Resident #2 being a victim of sexually inappropriate behaviors due to Resident #1 lifting up his/her shirt and kissing on Resident #2's breast on 03/16/18. 3. Record review revealed the facility admitted Resident #3 on 04/24/15, with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 01/02/18 revealed the facility assessed Resident #3's cognition as moderately impaired with a BIMS' score of eleven (11) which indicated the resident was interviewable. Interviews on 05/05/18 at 2:37 PM with CNA #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10, and on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Residents #3's room while the resident was in a stage of undress. In addition, interviews on 05/08/18 at 12:21 PM with Registered Nurse (RN) #2, on 05/06/18 at 4:24 PM with CNA #2, on 05/08/18 at 11:33 AM with CNA #13, and on 05/08/18 at 5:02 PM with CNA #12 revealed they had observed Resident #1 and #3 kissing and holding hands. However, review of Resident #3's Comprehensive Care Plan dated 08/18/17, with a goal/target date of 04/18/18, revealed there was no care plan with interventions to address Resident #3 having a consensual relationship (holding hands and kissing) with Resident #1, or of Resident #1 peeping in on Resident #3 while undressing. Interviews on 05/15/18 with LPN #4 at 12:19 PM, LPN #6 at 10:36 AM, and LPN #1 at 4:51 PM revealed care plans should be revised when staff identified that a resident had behaviors of disrobing, was a victim of a peeping toms/sexually inappropriate behaviors, having sexually inappropriate behaviors, and were having a consensual relationship with another resident. They were unable to provide an explanation as to why this was not completed. Interviews on 05/09/18 with the Dietary Manager at 10:37 AM, the Business Office Manager at 12:38 PM, the Activities Director at 12:49 PM, and the Social Services Director at 1:24 PM revealed Resident #1's peeping at residents when they were undressed was discussed in the morning meeting prior to the 03/16/18 sexually inappropriate behavior of Resident #1 against Resident #2. Further interview revealed they did not recall placing any new interventions in place. Interview (Post Survey) with the MDS Coordinator, on 06/12/18 at 4:33 PM, revealed she was responsible for updating the Comprehensive Care Plan and she should have updated Resident #1's, #3's, #4's and #5's care plans related to the resident's behaviors after it was discussed in morning meeting but she failed to do so. She was unable to provide an explanation as to why the care plan was not updated. Interviews with Residents #1, #3, #4, and #5's Physician on 05/16/18 at 2:33 PM and with the Medical Director/Physician of Resident #2 on 05/21/18 at 7:30 AM revealed they would expect behaviors such as residents having a consensual relationship, inappropriate sexual behavior, voyeurism/peeping tom, being a victim of sexual inappropriate behavior, or behaviors of undressing to be care planned. Further interview (Post Survey) with the Medical Director on 06/12/18 at 3:22 PM. revealed she was not notified of Resident #1's, #3's, #4's and #5's behaviors prior to the 03/16/18 incident and she should have been informed. She stated she did not attend the morning meetings and she meets with the Administrator and DON on Wednesdays to discuss all the residents in the facility but was not made aware of the behaviors. Interview with the Acting (New) Director of Nursing (DON) as of 05/13/18, on 05/16/18 at 4:31 PM revealed she would have expected something on the care plan related to the sexually inappropriate behavior of Resident #1, Resident #2 being a victim of sexually inappropriate behaviors, and if there were specifics they should be documented. She stated if the residents kissed or there was a more intimate relationship between Resident #1 and Resident #3 it should be care planned. Additionally, the Acting DON stated that Resident #4's and Resident #5's undressing behaviors should have been care planned. Interview on 05/16/18 at 3:51 PM with the Director of Clinical Education revealed she did expect Resident #2 to have interventions related to him/her being a victim of sexually inappropriate behaviors. She stated the MDS Coordinator was responsible for revising the care plans. Additionally, the DCE stated she would expect Resident #4 and Resident #5 to be care planned related to them undressing and being victims of a Peeping Toms. She stated if she read Resident #1's care plan she would not see the resident had behaviors of looking in on residents while they were undressing or the incident when the resident kissed a resident's breast. Interview on 05/16/18 at 5:25 PM with the Administrator revealed the MDS Coordinator was ultimately responsible for updating the care plans. She stated that exposing and undressing should be care planned for residents, but the nurses coming on shift would know of Resident #1's sexually inappropriate behavior by shift reports. Further interview (Post Survey) with the Administrator on 06/12/18 at 2:30 PM, revealed the facility's process is for the Interdisciplinary Team to review the Departmental Notes and Physician order [REDACTED]. She was unable to provide an explanation as to how she was monitoring to ensure the care plans were updated. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Prior to 05/03/18, Resident #1 was on thirty (30) minute observational checks upon readmission from the hospital on [DATE]. 2. Resident #1 was seen by his/her Primary Care Physician on 05/11/18 and had changes to his/her medical treatment plan which included [MEDICATION NAME] ([MEDICATION NAME]) 200 milligrams (mg) twice a day, on 05/15/18. 3. Resident #1 was seen by Medoptions (medication management) on 05/14/18 for medication management with no new orders (NNO). Resident #1 was seen by Medoptions (Psychologist) on 05/15/18 for medication management with no recommendations. 4. Resident #1's care plan (CP) was revised on 05/16/18 by the Regional Director of Operations--to address amorous (sexual) behaviors with interventions to protect other residents. 5. Resident #1 was placed on 1:1 with team members starting 05/03/18 through 05/24/18, and is ongoing. 6. Resident #2 was immediately separated from Resident #1 on 03/16/18 and assessed for injury with no injury noted. 7. Resident #1 was placed on 1:1 supervision with a Center team member on 03/16/18, immediately after the incident prior to being sent out to hospital for further evaluation. 8. Both Resident #1 and Resident #2 had notification to their MD and representative of the incident that occurred on 03/16/18. This was completed by the Administrator on 03/16/18. 9. Resident #2 had revision to the care plan on 05/15/18. This was completed by the Regional Director of Clinical Operations for psychosocial needs. 10. Resident #2 was seen by Medoptions on 05/15/18. Medoptions provides the Center with psychiatric services for physiological therapy. There were no adverse findings. 11. Resident #3 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings. 12. Resident #3's CP was revised on 05/15/18 by the Regional Director of Clinical Operations for psychosocial needs related to his/her past friendship with Resident #1 and psychosocial needs r/t the incident with Resident #1 peeping into his/her room. 13. Documentation was added to the medical record notifying Resident #3's representative of the friendship which included kissing and hand holding that had occurred with Resident #1. 14. Documentation was added to the medical record notifying Resident #3's MD of the friendship which included kissing and hand holding that had occurred with Resident #1. 15. Resident #4 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in his/her room. 16. Resident #4's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #4 removes his/her clothing items, this was completed by the Regional Director of Clinical Operations. Revisions were also made for the psychosocial needs related to the incident with Resident #1 looking into the resident's room. 17. Resident #5 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in on him/her. 18. Resident #5's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #5 removes his/her clothing. This was completed by the Regional Director of Clinical Operations. The psychosocial needs related to Resident #1 looking into his/her room were also addressed. 19. Initiated further investigation on 05/03/18, to identify any other potential affected residents which was concluded on 05/15/18. The investigation consisted of interviews with interviewable residents (BIMS of 8 and up), skin inspections on non-interviewable residents (BIMS of 7 or lower) for injury of unknown source, 72 hour mood and behavior monitoring for non-interviewable residents (BIMS of 7 or less), and Center team member interviews. All interviewable residents with BIMS of 8 and up were interviewed from 05/03/18-05/04/18, inquiring if they had ever been sexually abused by another resident or team member in the Center; if they had ever witnessed sexual abuse of another resident by a resident or team member; and if they had, whom did they report this to? This was completed by the Administrator, BOM, SSD, or DM. These interviews did not reveal any findings. The Center re-interviewed all interviewable residents with BIMS of 8 and up from 05/03/18--05/04/18 (previous time frame of interviews of all interviewable residents with BIMS of 8 and up) inquiring if they knew what sexual abuse was and if they ever witnessed any resident intentionally looking in on other residents of the opposite sex. These interviews commenced on 05/15/18 and were completed on 05/15/18 by the Director of Clinical Education. These interviews did not review any findings. 20. Skin inspections were conducted on all non-interviewable residents (BIMS of 7 or less) checking for any injury. These were completed on 05/03/18 through 05/17/18 by direct care nurses, all of whom were Licensed Practical Nurses (LPN). There with no undocumented injuries or injuries of unknown origin identified with this review. 21. Certified Nursing Assistants (CNAs), LPNs, and Registered Nurses (RN) conducted 72 hour mood and behavior observations on all non-interviewable. residents with BIMS of 7 or less. These observations monitored for any adverse effects from 05/11/18 through 05/14/18. These were completed on each 12 hour shift in the Center. 22. On 05/14/18, the Clinical Interdisciplinary Team (IDT) which included the Administrator, DON, Activity Director, SSD, MDS Coordinator, Health Information Management Coordinator (HIMC), DM and Director of Rehabilitation met to review the 72-hour mood and behavior observations. No newly identified changes to the mood and behavior was identified during this review, for residents already identified with behaviors. However, three (3) residents' care plans were revised on 05/14/18, based upon this review to capture newly identified mood and behaviors. 23. Interviews with Team Members were conducted inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 besides the incident on 03/16/18. These interviews were conducted on 05/03/18 through 05/04/18 by the Administrator, Maintenance Director, Dietary Manager (DM), Director of Rehabilitation (DoR) and Director of Clinical Education (DCE) inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 other than the incident on 03/16/18. No new altercations were identified. 24. Additional interviews of Team Members, (who were interviewed on 05/04/18 through 05/16/18) were conducted after the State Survey Agency (SSA) brought to the Center's attention, an allegation of a past relationship between Resident #1 and Resident #3. These interviews inquired if they had ever witnessed Resident #1 and Resident #3 being sexually inappropriate with each other. Team member interviews were conducted by the Administrator, Maintenance Supervisor, Dietary Manager, Director of Rehab and Director of Clinical Education. 25. Further Team Members interviews were completed to inquire if they had ever witnessed any resident intentionally looking into residents' rooms of the opposite sex and what did they do about it. These interviews were commenced on 05/15/18 and completed on 05/17/18. These interviews were conducted by the Administrator, DON, Maintenance Director, Dietary Manager, Director of Rehab and Director of Clinical Education. 26. All residents' records, including the most recent history and physical (H&P) and/or most recent Psychiatric Visit Consult Notes were reviewed for a history of sexual tendencies or looking into rooms of residents of the opposite sex to ensure the care plans addressed this behavior and included interventions to protect other residents. Any resident with a history of sexually acting out behavior or looking into rooms of residents of the opposite sex, who did not have a care plan addressing inappropriate sexual behavior had one developed during this review. This review found three (3) residents with a history of sexual tendencies and two (2) had existing care plans in place to address the behaviors and (1) one resident (Resident #1) had his/her care plan revised. This revision to Resident #1's care plan was revised on 05/16/18 and was completed by Regional Director of Clinical Operations. The record reviews were completed by the Regional Director of Clinical Operations, DON, and the Director of Clinical Education. 27. The Administrator and DON were given 1:1 education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies. This inservice was presented by the Regional Director of Clinical Operations. This was completed on 05/15/18. 28. All other Department Leaders which included the SSD, DCE, MDS Coordinator, Health Information Management Coordinator (HIMC), Dietary Services Manager (DM), Housekeeping Manager, Maintenance Director, Activities Director, Business Officer Manager, DoR, and HR/Payroll Manager were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy. The training also included identifying residents with sexual tendencies. This was presented by the Administrator, DON, or Regional Director of Clinical Operations and completed on 05/15/18. 29. All other Center Team Members were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. Education commenced on 05/15/18 and was completed on 05/16/18. Education was completed by the Administrator, Maintenance Director, Director of Rehab, DCE, Regional Director of Clinical Operations or the DON. A post-test was given to determine understanding and competency of the education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. 30. Educational material regarding abuse and identification of sexual tendencies and peeping as a form of voyeurism; including a post-test to determine understanding and competency, have been included in the Center's orientation materials to be completed with future new hires and will be given by the Director of Clinical Education (DCE) or a designated clinical leadership nurse prior to providing direct care to residents. 31. Educational material regarding the potential psychosocial effect of sexual trauma was developed by the Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided this education to the Center's clinical leadership team which consisted of the DON, Social Service Director (SSD) and DCE on 05/15/18. Education which included post-test to determine understanding and competency with all other nursing team members (LPNs & RNs) and nursing assistants commenced on 05/15/18 and was completed by 05/16/18. The education and post-test were presented by the DCE. 32. Educational material regarding potential psychosocial effect of sexual trauma with a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed with future nursing team member (CNA's, LPN's, RN's) hires and will be completed by the DCE or a designated clinical leadership nurse prior to providing direct care to residents. 33. All Center licensed nurses have been educated on accuracy of documenting abuse investigations in the medical record on 05/15/18 through 05/16/18 dates. A post-test was given after education was completed to determine understanding and competency. This education and post-test were developed by the Regional Director of Nursing Management Services, who is an RN. The Regional Director of Clinical Operations provided education on accuracy of documenting abuse investigations in the medical record to the Center's clinical leadership team which consist of the DON and DCE, on 05/15/18. A post-test to determine understanding and competency. 34. Education materials regarding accuracy of documenting abuse investigation in the medical record with a post-test to determine understanding and competency, will be included in the Center's orientation to be completed with future new licensed nurse (LPN and RN) hires. This education will be presented by the DCE or designated clinical leadership nurse prior to the new hires providing direct care to residents. 35. Educational material regarding updating residents' care plans, when a resident displays sexual tendencies or when there is a potential psychosocial need was developed by Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided the education to the Center's Clinical leadership team which consist of the DON and DCE on 05/15/18. Education included post-test to determine understanding and competency. All other licensed team members in the Center (LPN's & RN's) were educated regarding updating residents' care plans when a resident displays sexual tendencies or when there is a potential psychosocial need. The education commenced on 05/15/18 and was completed on 05/16/18; and was presented by the DCE or DON. 36. Educational material regarding updating the resident's CP when a resident displays sexual tendency or when there is a potential psychosocial need occurs and a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed by the DCE or designated clinical leadership nurse prior to providing direct care to residents. 37. Any resident in future allegations of abuse will have their medical record reviewed within the clinical start up process by the IDT for accuracy of the medical record documentation and for follow-up. The purpose of the clinical start up meeting is a daily qualitative review of documentation and delivery of care to assure actions are in place to deliver and drive quality outcomes. Items that are reviewed in the clinical start up process include residents with change of condition, falls or incidents, new physician orders, new admissions and discharges. The IDT meets daily Monday-Friday for clinical start-up meeting. On the weekends and holidays, the RN in the Center completes the clinical start-up meeting minutes and reviews any findings with the Center's Managers on Duty (MOD). Members of the MOD include the Administrator, SSD, MDS Coordinator, HIMC, Dietary Service Manager, Activities Director, Maintenance Director and BOM. In addition, to the above which is reviewed in clinical start-up, residents who have new or changes to psychosocial needs including dignity and privacy needs will also be reviewed as part of the clinical start up process, by the IDT to ensure the CP accurately reflects these needs. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will also be reviewed within the clinical start-up process, by the IDT to ensure a care plan is in place with interventions for the protection of other residents. The Clinical Startup IDT consist of: the Administrator, DON, MDS Coordinator, DCE, SSD, Director of Rehab, HIMC, The IDT will ensure that the medical record accurately reflects the resident and includes follow-up of any instances of abuse. 38. Any resident requiring 1:1 supervision in the Center will have an IDT review prior to removal or the weaning of 1:1 supervision. The IDT Team completing the review will be the Administrator, DON, Assistant Directors of Nursing (ADNS), and SSD. 39. On 05/14/18, an impromptu QAPI (Quality Assuranc

Based on interview, record review, and facility policy review, it was determined the facility failed to maintain a complete and accurately documented medical record for five (5) of eleven (11) sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). Resident #1 was identified to have been peeping in Residents #3, #4, and #5's rooms while they were in stages of undress. The facility was also aware that Resident #1 was kissing and hugging Resident #2. However, reviews of Residents #1, #2, #3, #4 and #5's medical records revealed there was no documentation describing these incidents in the Departmental Notes (Nurse's Notes) or, on the care plan to ensure staff would be aware of what behaviors and/or what had happened to each of these residents so they could ensure the residents were protected and the required care was provided. In addition, Administration was aware Resident #1 and #3 had a relationship and were hugging and kissing; and Resident #1 was going into Resident #3's room; however, there was no documentation of an assessment to identify if the residents were capable of giving consent and no documentation of the incidents in the resident's records. On 03/16/18, Resident #1 was found with Resident #2's shirt pulled up; and Resident #1 was kissing Resident #2's breast. Resident #2 was to have psychosocial assessments conducted for nine (9) shifts (over 72 hours) after the sexual inappropriate behavior on 03/16/18. However, the facility failed to document four (4) of the nine (9) psychosocial assessments. Resident #1 was sent to a behavioral hospital on [DATE] and returned on 04/02/18 and placed on thirty minute checks. However, staff failed to document the thirty minutes checks for two (2) hours to ensure residents were protected. The facility's failure to maintain a complete and accurately documented record has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/11/18 and determined to exist on 03/16/18. The facility was notified of the Immediate Jeopardy on 05/11/18. An acceptable Allegation of Compliance (AoC) was received on 05/22/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 05/18/18. The Scope and Severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policies provided by the facility and entitled 30.2.2.1-Documentation to Support Skilled Care Determinations issued 01/14/14, revealed claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine whether skilled involvement is required in order for the services in question to be furnished safely and effectively. The services are reasonable and necessary for the treatment of [REDACTED].e., are consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice. The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals; and performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage. Therefore, the patient's medical record must document as appropriate: the history and physical exam pertinent to the patients' care, (including the response or changes in behavior to previously administered skilled services) The documentation in the patients' medical record must be accurate, and avoid vague or subjective descriptions of the patient's care that would not be sufficient to indicate the need for skilled care. In addition, review of the facility's policy titled, Abuse Policy, last updated (MONTH) (YEAR), revealed the medical record should be reviewed to determine the resident/patient's past history and condition and its relevance to the alleged violation. 1. Record review revealed the facility admitted Resident #1 on 03/30/17 with [DIAGNOSES REDACTED]. Review of Resident #1's (30) thirty-minute monitoring sheets revealed on 04/10/18, Resident #1 was placed on (15) fifteen minute checks related to behaviors, but it did not specify or describe the behaviors. On 04/14/18, there were no (30) minute checks recorded from 6:00 PM till 8:00 PM for Resident #1 concerning his/her whereabouts in the facility and/or if there were any behaviors. Interview on 05/16/18 at 3:51 PM, with Director of Clinical Education revealed she expected behavior monitoring sheet to be completed on residents who were on thirty minute checks. She stated the monitoring sheets on 04/14/18 should have been filled out and the date and time should be documented on the monitoring sheets. The DCE stated she would expect the documentation to be there if it was relevant to the care of a resident, and would expect the behaviors to be defined related to the monitoring sheets. Review of a Department Note on 04/15/18 at 3:52 PM, revealed (Resident #1) with noted behaviors this AM; redirected away from (female/male) residents' room on North Hall (NH). However, the Note did not specify what the specific or describe the behavior. 2. Record review revealed the facility admitted Resident #2 on 01/08/16 with [DIAGNOSES REDACTED]. Review of the facility provided initial report dated 03/16/18, and interview with the Activities Director on 05/04/18 at 12:49 PM revealed on 03/16/18 at 1:45 PM, the Activities Director observed Resident #1 and Resident #2 in the dining room. Resident #1 was observed kissing on Resident #2's breast after lifting the resident's shirt. However, review of the Resident #1's and Resident #2's medical record including, care plans, progress notes, physician orders, electronic medical administration record (eMAR), electronic treatment administration record (eTAR), and behavior monitoring sheets revealed no documented evidence of this incident. Interview on 05/11/18 at 2:57 PM with the former Director of Nursing (DON) #1 revealed she did not remember any psychosocial needs of any other resident other than Resident #1 and Resident #2 being monitored during the sexual abuse allegation, which consisted of (72) hour charting being done every shift (has three shift in a 24 hour period). Review of Resident #2's documents revealed Resident #2 was to be monitored for seventy-two (72) hours every shift following the sexual abuse allegation. However, review of Department Notes dated 03/16/18 through 03/19/18 revealed only four (4) Notes for the nine (9) shifts. Interview on 05/11/18 at 2:46 PM and 5:15 PM and on 05/16/18 at 5:25 PM, with the Administrator revealed residents' psychosocial needs were to be charted every shift for (72) hours. He stated anything identified in the psychosocial monitoring charted by the nurses was gone over in morning meeting and was by the Interdisciplinary team. Interviews with Certified Nursing Assistant (CNA) #9 on 05/07/18 at 3:32 PM, the Dietary Cook on 05/09/18 at 5:13 PM, and the Dietary Manager on 05/10/18 at 3:39 PM revealed Resident #1 was discovered alone with Resident #2 in the back North hall unsupervised, while on (30) thirty minute checks. They stated they did not know what date this incident happened, but it was in the evening after 6:30 PM. Further review of the (MONTH) (YEAR) through (MONTH) 3, (YEAR) Departmental Notes, care plans or behavior monitoring sheets revealed no documentation of Resident #1 being found in Resident #2's presence while on supervised (30) thirty minute checks out of visualization of staff. 3. Record review revealed the facility admitted Resident #3 on 04/24/15, with [DIAGNOSES REDACTED]. Interviews on 05/05/18 at 2:37 PM with CNA #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Residents #3's room while in a stage of undress. In addition, interviews on 05/08/18 at 12:21 PM with Registered Nurse (RN) #2, on 05/06/18 at 4:24 PM with CNA #2, on 05/08/18 at 11:33 with CNA #13, and on 05/08/18 at 5:02 PM with CNA #12 revealed they had observed Resident #1 and #3 kissing and holding hands. However, review of Resident #1's and 3's Department Notes and Comprehensive Care Plans revealed there was no documentation of these behaviors and no documentation the residents were assessed to determine if the residents were capable of giving consent. In addition the care plan did not address if the residents were in a concensual relationship or not. In addition, review of Resident #3's Progress Notes revealed no documentation Resident #3's responsible party or physician was informed of Resident #1 and Resident #3's relationship. 4. Record review revealed the facility admitted Resident #4 on 09/29/17 with [DIAGNOSES REDACTED]. Staff interviews revealed Resident #1 was looking in on Resident #4 while in a state of undress. 5. Record review revealed the facility admitted Resident #5 on 03/16/18 with [DIAGNOSES REDACTED]. Interviews on 05/05/18 at 2:37 PM with Certified Nurse Aide (CNA) #8, on 05/07/18 at 2:58 PM with CNA #1, on 05/07/18 at 3:32 PM with CNA #9, on 05/07/18 at 3:48 PM with CNA #10 and on 05/08/18 at 11:47 AM with CNA #14 revealed Resident #1 would look into Resident #4 and Resident #5's room while they were in a state of undress. However, review of Resident #1's, #4's and #5's Department Notes and Comprehensive Care Plans revealed there was no documentation of these behaviors. In addition, review of Resident #3's, #4's, and #5's Department Notes revealed there was no documented evidence the resident's were being monitored for psychosocial needs every shift for 72 hours after the incidents occurred. Interview on 05/08/18 at 12:21 PM with Registered Nurse (RN) #2 (Unit Manager) revealed the Department Heads reviewed notes for the past (24) twenty-four hours and Progress Notes in the morning meeting. She stated there should have been documentation in Resident #2's chart so the resident could have been monitored more closely for emotional or physical issues related to being a victim of sexually inappropriate behaviors. RN #2 stated if she was a new nurse on the floor he/she would want to be aware. Interview with CNA #8 on 05/16/18 at 9:54 AM, revealed they were told to watch how they documented because it would come back and bite (them) in the butt. CNA #8 stated the medical record should accurately reflect the resident and, for the safety of the residents it should be detailed so staff could identify patterns. She further stated, You cannot identify if (Resident) #1 was having the same behaviors. She stated staff could not do basic care without knowing the history of the resident. CNA #8 stated the staff only had what was documented about sexual tendencies and they needed to know because if staff was new and don't know Resident #1 was a sexual predator then the residents were at risk for being abused. Interview on 05/16/18 at 2:47 PM with LPN #7 stated staff should be made aware of the behaviors, situations and circumstances in order to provide appropriate care to the residents. LPN #7 stated the monitoring sheets should have been completely filled out on 04/14/18 from 6:00 PM- 8:00 PM, because there was no way to tell what the resident was doing, if it wasn't documented. Interview on 05/15/18 at 3:38 PM with the Acting DON revealed the monitoring sheets should have been completely filled out to include specific behaviors. Interview on 05/16/18 at 2:33 PM with Physician #1 revealed undressing/consensual relationships/sexual tendencies/peeping tom or voyeurism/victims of sexually inappropriate behaviors should be documented. Interview with Director of Nursing (DON) on 05/11/18 at 2:57 PM revealed the nurses were responsible for completing the 72 hour charting and monitoring and the Unit Manager was responsible for ensuring the 72 hour charting was completed by nurses, Interview with Administrator on 05/11/18 at 2:46 PM and 05/16/18 at 5:25 PM revealed psychosocial needs should have been charted for Resident #2 every every shift for (72) hours. She stated her and the DON had been monitoring the 72 hour checks. She stated residents' behaviors should be charted so they can be reviewed by the IDT team in the morning meeting and the care plan can be updated with interventions put in place to ensure resident safety. In addition, staff should ensure documentation is completed when they are doing every thirty minute checks. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Prior to 05/03/18, Resident #1 was on thirty (30) minute observational checks upon readmission from the hospital on [DATE]. 2. Resident #1 was seen by his/her Primary Care Physician on 05/11/18 and had changes to his/her medical treatment plan which included [MEDICATION NAME] ([MEDICATION NAME]) 200 milligrams (mg) twice a day, on 05/15/18. 3. Resident #1 was seen by Medoptions (medication management) on 05/14/18 for medication management with no new orders (NNO). Resident #1 was seen by Medoptions (Psychologist) on 05/15/18 for medication management with no recommendations. 4. Resident #1's care plan (CP) was revised on 05/16/18 by the Regional Director of Operations--to address amorous (sexual) behaviors with interventions to protect other residents. 5. Resident #1 was placed on 1:1 with team members starting 05/03/18 through 05/24/18, and is ongoing. 6. Resident #2 was immediately separated from Resident #1 on 03/16/18 and assessed for injury with no injury noted. 7. Resident #1 was placed on 1:1 supervision with a Center team member on 03/16/18, immediately after the incident prior to being sent out to hospital for further evaluation. 8. Both Resident #1 and Resident #2 had notification to their MD and representative of the incident that occurred on 03/16/18. This was completed by the Administrator on 03/16/18. 9. Resident #2 had revision to the care plan on 05/15/18. This was completed by the Regional Director of Clinical Operations for psychosocial needs. 10. Resident #2 was seen by Medoptions on 05/15/18. Medoptions provides the Center with psychiatric services for physiological therapy. There were no adverse findings. 11. Resident #3 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings. 12. Resident #3's CP was revised on 05/15/18 by the Regional Director of Clinical Operations for psychosocial needs related to his/her past friendship with Resident #1 and psychosocial needs r/t the incident with Resident #1 peeping into his/her room. 13. Documentation was added to the medical record notifying Resident #3's representative of the friendship which included kissing and hand holding that had occurred with Resident #1. 14. Documentation was added to the medical record notifying Resident #3's MD of the friendship which included kissing and hand holding that had occurred with Resident #1. 15. Resident #4 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in his/her room. 16. Resident #4's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #4 removes his/her clothing items, this was completed by the Regional Director of Clinical Operations. Revisions were also made for the psychosocial needs related to the incident with Resident #1 looking into the resident's room. 17. Resident #5 was seen by Medoptions on 05/15/18 for psychosocial follow-up with no adverse findings related to Resident #1 looking in on him/her. 18. Resident #5's CP was revised on 05/15/18 to ensure his/her dignity and privacy when Resident #5 removes his/her clothing. This was completed by the Regional Director of Clinical Operations. The psychosocial needs related to Resident #1 looking into his/her room were also addressed. 19. Initiated further investigation on 05/03/18, to identify any other potential affected residents which was concluded on 05/15/18. The investigation consisted of interviews with interviewable residents (BIMS of 8 and up), skin inspections on non-interviewable residents (BIMS of 7 or lower) for injury of unknown source, 72 hour mood and behavior monitoring for non-interviewable residents (BIMS of 7 or less), and Center team member interviews. All interviewable residents with BIMS of 8 and up were interviewed from 05/03/18-05/04/18, inquiring if they had ever been sexually abused by another resident or team member in the Center; if they had ever witnessed sexual abuse of another resident by a resident or team member; and if they had, whom did they report this to? This was completed by the Administrator, BOM, SSD, or DM. These interviews did not reveal any findings. The Center re-interviewed all interviewable residents with BIMS of 8 and up from 05/03/18--05/04/18 (previous time frame of interviews of all interviewable residents with BIMS of 8 and up) inquiring if they knew what sexual abuse was and if they ever witnessed any resident intentionally looking in on other residents of the opposite sex. These interviews commenced on 05/15/18 and were completed on 05/15/18 by the Director of Clinical Education. These interviews did not review any findings. 20. Skin inspections were conducted on all non-interviewable residents (BIMS of 7 or less) checking for any injury. These were completed on 05/03/18 through 05/17/18 by direct care nurses, all of whom were Licensed Practical Nurses (LPN). There with no undocumented injuries or injuries of unknown origin identified with this review. 21. Certified Nursing Assistants (CNAs), LPNs, and Registered Nurses (RN) conducted 72 hour mood and behavior observations on all non-interviewable. residents with BIMS of 7 or less. These observations monitored for any adverse effects from 05/11/18 through 05/14/18. These were completed on each 12 hour shift in the Center. 22. On 05/14/18, the Clinical Interdisciplinary Team (IDT) which included the Administrator, DON, Activity Director, SSD, MDS Coordinator, Health Information Management Coordinator (HIMC), DM and Director of Rehabilitation met to review the 72-hour mood and behavior observations. No newly identified changes to the mood and behavior was identified during this review, for residents already identified with behaviors. However, three (3) residents' care plans were revised on 05/14/18, based upon this review to capture newly identified mood and behaviors. 23. Interviews with Team Members were conducted inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 besides the incident on 03/16/18. These interviews were conducted on 05/03/18 through 05/04/18 by the Administrator, Maintenance Director, Dietary Manager (DM), Director of Rehabilitation (DoR) and Director of Clinical Education (DCE) inquiring if they had ever witnessed any abuse occur between Resident #1 and Resident #2 other than the incident on 03/16/18. No new altercations were identified. 24. Additional interviews of Team Members, (who were interviewed on 05/04/18 through 05/16/18) were conducted after the State Survey Agency (SSA) brought to the Center's attention, an allegation of a past relationship between Resident #1 and Resident #3. These interviews inquired if they had ever witnessed Resident #1 and Resident #3 being sexually inappropriate with each other. Team member interviews were conducted by the Administrator, Maintenance Supervisor, Dietary Manager, Director of Rehab and Director of Clinical Education. 25. Further Team Members interviews were completed to inquire if they had ever witnessed any resident intentionally looking into residents' rooms of the opposite sex and what did they do about it. These interviews were commenced on 05/15/18 and completed on 05/17/18. These interviews were conducted by the Administrator, DON, Maintenance Director, Dietary Manager, Director of Rehab and Director of Clinical Education. 26. All residents' records, including the most recent history and physical (H&P) and/or most recent Psychiatric Visit Consult Notes were reviewed for a history of sexual tendencies or looking into rooms of residents of the opposite sex to ensure the care plans addressed this behavior and included interventions to protect other residents. Any resident with a history of sexually acting out behavior or looking into rooms of residents of the opposite sex, who did not have a care plan addressing inappropriate sexual behavior had one developed during this review. This review found three (3) residents with a history of sexual tendencies and two (2) had existing care plans in place to address the behaviors and (1) one resident (Resident #1) had his/her care plan revised. This revision to Resident #1's care plan was revised on 05/16/18 and was completed by Regional Director of Clinical Operations. The record reviews were completed by the Regional Director of Clinical Operations, DON, and the Director of Clinical Education. 27. The Administrator and DON were given 1:1 education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies. This inservice was presented by the Regional Director of Clinical Operations. This was completed on 05/15/18. 28. All other Department Leaders which included the SSD, DCE, MDS Coordinator, Health Information Management Coordinator (HIMC), Dietary Services Manager (DM), Housekeeping Manager, Maintenance Director, Activities Director, Business Officer Manager, DoR, and HR/Payroll Manager were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy. The training also included identifying residents with sexual tendencies. This was presented by the Administrator, DON, or Regional Director of Clinical Operations and completed on 05/15/18. 29. All other Center Team Members were given education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. Education commenced on 05/15/18 and was completed on 05/16/18. Education was completed by the Administrator, Maintenance Director, Director of Rehab, DCE, Regional Director of Clinical Operations or the DON. A post-test was given to determine understanding and competency of the education on abuse, preventing abuse and investigating abuse using the Diversicare Abuse Policy and on identifying residents with sexual tendencies and peeping as a form of voyeurism. 30. Educational material regarding abuse and identification of sexual tendencies and peeping as a form of voyeurism; including a post-test to determine understanding and competency, have been included in the Center's orientation materials to be completed with future new hires and will be given by the Director of Clinical Education (DCE) or a designated clinical leadership nurse prior to providing direct care to residents. 31. Educational material regarding the potential psychosocial effect of sexual trauma was developed by the Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided this education to the Center's clinical leadership team which consisted of the DON, Social Service Director (SSD) and DCE on 05/15/18. Education which included post-test to determine understanding and competency with all other nursing team members (LPNs & RNs) and nursing assistants commenced on 05/15/18 and was completed by 05/16/18. The education and post-test were presented by the DCE. 32. Educational material regarding potential psychosocial effect of sexual trauma with a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed with future nursing team member (CNA's, LPN's, RN's) hires and will be completed by the DCE or a designated clinical leadership nurse prior to providing direct care to residents. 33. All Center licensed nurses have been educated on accuracy of documenting abuse investigations in the medical record on 05/15/18 through 05/16/18 dates. A post-test was given after education was completed to determine understanding and competency. This education and post-test were developed by the Regional Director of Nursing Management Services, who is an RN. The Regional Director of Clinical Operations provided education on accuracy of documenting abuse investigations in the medical record to the Center's clinical leadership team which consist of the DON and DCE, on 05/15/18. A post-test to determine understanding and competency. 34. Education materials regarding accuracy of documenting abuse investigation in the medical record with a post-test to determine understanding and competency, will be included in the Center's orientation to be completed with future new licensed nurse (LPN and RN) hires. This education will be presented by the DCE or designated clinical leadership nurse prior to the new hires providing direct care to residents. 35. Educational material regarding updating residents' care plans, when a resident displays sexual tendencies or when there is a potential psychosocial need was developed by Regional Director of Clinical Operations (DCO), who is an RN. The Regional Director of Clinical Operations provided the education to the Center's Clinical leadership team which consist of the DON and DCE on 05/15/18. Education included post-test to determine understanding and competency. All other licensed team members in the Center (LPN's & RN's) were educated regarding updating residents' care plans when a resident displays sexual tendencies or when there is a potential psychosocial need. The education commenced on 05/15/18 and was completed on 05/16/18; and was presented by the DCE or DON. 36. Educational material regarding updating the resident's CP when a resident displays sexual tendency or when there is a potential psychosocial need occurs and a post-test to determine understanding and competency, has been included in the Center's orientation materials to be completed by the DCE or designated clinical leadership nurse prior to providing direct care to residents. 37. Any resident in future allegations of abuse will have their medical record reviewed within the clinical start up process by the IDT for accuracy of the medical record documentation and for follow-up. The purpose of the clinical start up meeting is a daily qualitative review of documentation and delivery of care to assure actions are in place to deliver and drive quality outcomes. Items that are reviewed in the clinical start up process include residents with change of condition, falls or incidents, new physician orders, new admissions and discharges. The IDT meets daily Monday-Friday for clinical start-up meeting. On the weekends and holidays, the RN in the Center completes the clinical start-up meeting minutes and reviews any findings with the Center's Managers on Duty (MOD). Members of the MOD include the Administrator, SSD, MDS Coordinator, HIMC, Dietary Service Manager, Activities Director, Maintenance Director and BOM. In addition, to the above which is reviewed in clinical start-up, residents who have new or changes to psychosocial needs including dignity and privacy needs will also be reviewed as part of the clinical start up process, by the IDT to ensure the CP accurately reflects these needs. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will also be reviewed within the clinical start-up process, by the IDT to ensure a care plan is in place with interventions for the protection of other residents. The Clinical Startup IDT consist of: the Administrator, DON, MDS Coordinator, DCE, SSD, Director of Rehab, HIMC, The IDT will ensure that the medical record accurately reflects the resident and includes follow-up of any instances of abuse. 38. Any resident requiring 1:1 supervision in the Center will have an IDT review prior to removal or the weaning of 1:1 supervision. The IDT Team completing the review will be the Administrator, DON, Assistant Directors of Nursing (ADNS), and SSD. 39. On 05/14/18, an impromptu QAPI (Quality Assurance and Performance Improvement) meeting was held. Members consisted of the Administrator, DON, Regional Director of Clinical Operations, and Medical Director. These members reviewed the actions, education and audits taken by the Center effective 05/14/18. 40. The findings of the audits and actions taken after 05/14/18, will be reviewed at the monthly QAPI meeting by the QAPI Team. The QAPI Team consists of the Medical Director, Administrator, DNS, and at least three (3) other department leaders - which include the SSD, DCE, MDS Coordinator, HIMC, Dietary Service Manager, Housekeeping Supervisor, Activities Director, Maintenance Director, BOM, or Director of Rehab. 41. The Administrator, DNS, SSD, DCE will conduct a total of ten (10) team members' interviews per week for eight (8) weeks--then five (5) team member interviews per week for eight (8) weeks. Interviews will include specific questions regarding the Center's abuse policy and dealing with residents with sexual tendencies to ensure continued and thorough understanding of the policy. Interviews will be conducted with the Team Member Abuse QAPI Questionnaire--with any incorrect answers immediately addressed through one on one education provided by the auditor and an immediate QAPI meeting. All findings will be reviewed with the Center's QAPI team who will determine a schedule for continued monitoring after the initial sixteen (16) weeks. 42. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will be reviewed within the CSU Process by the IDT to ensure a care plan is in place with interventions for the protection of other residents. In addition, residents who have new or changes to their psychosocial needs including dignity and privacy needs will also be reviewed as part of the CSU process by the IDT, to ensure the care plan accurately reflects these needs. Residents with newly identified or worsening sexual tendencies or peeping as a form of voyeurism will also be reviewed with the CSU Process, by the IDT, to ensure a care plan is in place with interventions for the protection of other residents. The IDT meets daily Monday-Friday for clinical start up meetings and on the weekend and holidays, the RN in the Center completes the Clinical Start Up Meeting minutes and reviews any finding with the Center's Manager on Duty (MOD). Members of t

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system in place to ensure two (2) of nine (9) sampled residents (Resident #1 and #5) were free from abuse by staff. Licensed Practical Nurse (LPN) #2 alleged LPN #1 physically and mentally abused Resident #5 on 11/04/14 by placing a hot pepper in Resident #5's mouth causing the resident's mouth to burn and the resident to cry out and repeatedly yell "hot". LPN #1 laughed at the resident and told staff repeatedly that it "was priceless". Kentucky Medication Assistant (KMA) #1, Certified Nurse Aide (CNA) #2 and CNA #3 all witnessed the alleged abuse but did not report it to the Administrator. LPN #1 told LPN #2 what she had done on 11/05/14; however, LPN #2 did not report it until 11/07/14 (Friday after hours) when she left a phone message on the Director of Nursing's (DON) voicemail which was not retrieved until 11/10/14 (Monday). On 10/18/14, CNA #1 witnessed LPN #3 tell Resident #1 that he/she was fat and staff was tired of getting him/her up with the sling lift. LPN #3 told the resident if he/she would take his/her medication and stop being so mean to the staff, he/she would not be in the shape he/she "was in". LPN #3 also told the resident she was not going to give the resident his/her pain pill because his/her finger nails were dirty and needed cleaning. CNA #1 immediately reported this alleged abuse to the former Administrator; however, there was no evidence the former Administrator investigated the allegation, suspended the alleged perpetrator and reported the alleged abuse to the appropriate State agencies. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/13/14 and determined to exist on 10/18/14. The facility was notified of the Immediate Jeopardy on 11/13/14. An acceptable Allegation of Compliance (AoC) was received on 11/19/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/20/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, "Policy Regarding Abuse", last updated 10/28/13, revealed the staff will protect the rights of patients to be free from verbal, sexual, mental abuse, corporal punishment, involuntary seclusion and misappropriations of property. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, other agency staff, family members, legal guardian, friends or other individuals. Review of the facility's policy titled, "Abuse Prevention", dated 09/23/08, revealed the facility will protect and promote the rights of individual patients to be free of abuse. Review of the facility's policy titled, "Policy Regarding Abuse", dated 10/28/13, revealed "if a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation. During the coarse of the investigation, the staff person accused of abuse will be suspended without pay. The allegation will be reported in accordance with state and federal regulations." 1. Record review revealed the facility admitted Resident #5 on 10/08/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/14, revealed the facility assessed Resident #5's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) which indicated the resident was not interviewable. Review of the physician's orders [REDACTED]. Review of the facility's 11/04/14 video/audio surveillance recording, on 11/14/14 at 10:00 AM, revealed LPN #1 sitting at the Nurses' Station when Resident #5 came up in a wheelchair. LPN #1 removed an item from a bag and placed it in Resident #5's mouth. Resident #5 began to scream and yell "hot". Further review of the video recording revealed LPN #1 laughed at the resident for several minutes and repeatedly stated "that was priceless". Further observation revealed KMA #1, who witnessed this incident, handed Resident #5 a cup of water and asked the resident to take a drink. In addition, CNA #2 and CNA #3 were sitting at the Nurses' Station and witnessed this incident; however, they did not intervene or report the incident. Interview with KMA #1, on 11/13/14 at 10:20 AM, revealed she observed LPN #1 place a hot pepper in Resident #5's mouth on the afternoon shift on 11/04/14. She stated the resident began to cry and yell "hot". KMA #1 stated she gave the resident a glass of water to help reduce the burning. Further interview with KMA #1 revealed Resident #5 was on a pureed diet. She stated the resident could have choked on the pepper. KMA #1 stated she did not report this incident because at the time she did not view the occurrence as abusive behavior toward the resident. Interview with CNA #3, on 11/13/14 at 10:36 AM, revealed that on 11/04/14, she observed LPN #1 give Resident #5 a hot pepper from a plastic bag. CNA #3 stated the resident had reached for the bag several times during the shift and she had told the resident he/she could not have one of the peppers. CNA #3 stated LPN #1 pulled the pepper from the bag, said "here" to the resident and placed the pepper in the resident's mouth. CNA #3 stated Resident #5 was on a pureed diet and should have never been given a hot pepper because he/she could have choked on it. She stated she did not report the incident because LPN #1 was her supervisor and she was in fear of retaliation. However, the facility's policy states, "Residents must not be subjected to abuse by anyone including but not limited to facility staff, ..." and "if a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation." Interview with CNA #2, on 11/13/14 at 2:40 PM, revealed she had witnessed LPN #1 give a hot pepper to Resident #5. CNA #2 stated while sitting at the Nurses' Station, LPN #1 tore a piece of a hot pepper off and gave it to Resident #5. CNA #2 stated the resident "flipped out" and, LPN #1 laughed at the resident's reaction and facial expressions. She stated she did not report the incident to the Administrator and gave no reason why she didn't report the incident. Phone interviews were attempted on 11/15/14 with LPN #2 at 9:00 AM and LPN #1 at 9:10 AM without success. Interview with the current Administrator, on 11/10/14 at 4:12 PM, revealed the DON retrieved a voicemail from her office phone from LPN #2 on the afternoon of 11/10/14, that was left on 11/07/14 after office hours. Further interview revealed the recording stated that LPN #1 had told her she had placed a hot pepper in Resident # 5's mouth on the evening of 11/04/14. The Administrator stated LPN #2 stated she thought about reporting the incident several times that week because she considered it to be abusive but got busy and forgot to do so. The incident was reported via telephone message after hours on 11/07/14 (Friday) and was not retrieved until the afternoon of 11/10/14 (Monday). The Administrator stated she confronted LPN #1 on 11/10/14 when the LPN arrived to work and the LPN "confessed" to placing the pepper in Resident #5's mouth but stated she was playing with the resident. The Administrator stated she terminated LPN #1 immediately as she considered this conduct to be resident abuse. Interview with the current Administrator, on 11/13/14 at 3:08 PM, revealed she expected staff to report any form of abuse immediately. 2. Record review revealed the facility admitted Resident #1 on 06/14/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 10/24/14, revealed the facility assessed Resident #1's Brief Interview of Mental Status (BIMS) score as fourteen (14) indicating the resident was interviewable. During the initial tour, on 11/06/14 at 12:50 AM, Resident #1 was observed crying. During an interview with the resident, he/she stated that he/she had been verbally abused by LPN #3 about two (2) weeks prior. He/She stated LPN #3 told him/her that she/she was fat and staff was tired of getting him/her up with the sling lift. Resident #1 continued to cry and stated LPN #3 told him/her if he/she would take his/her medication right and stop being so mean to the staff, he/she would not be in the shape he/she was in. Additionally, Resident #1 stated LPN #3 also told him/her that he/she was not getting a pain pill because his/her finger nails were dirty and needed cleaning. Resident #1 stated at the time he/she wanted to kill him/herself over what LPN #1 had said because of how bad it had made him/her feel. The resident stated he/she could not help that he/she required assistance. The resident stated CNA #1 had overheard the incident and had tried to console him/her. Interview with CNA #1, on 11/04/14 at 5:08 PM, revealed she had witnessed LPN #3 being "verbally abusive" toward Resident #1 on 10/18/14. CNA #1 stated LPN #3 told the resident "that's the reason you are sick and that's what's wrong with you now" and he/she "needed to stop being so mean". CNA #1 stated Resident #1 was crying and the resident stated "he/she did not like LPN #3 because she was so abusive." CNA #1 stated she immediately reported the incident to the former Administrator. CNA #1 stated that later, the former Administrator told her she had taken care of the problem that she had reported. CNA #1 stated she took this to mean the Administrator had investigated the allegation and had taken action. A phone interview was attempted with LPN #3, the alleged perpetrator, on 11/15/14 at 9:22 AM and again at 9:35 AM ; however, it was unsuccessful. Interview with the DON, on 11/07/14 at 10:20 AM, revealed she was aware something had happened on 10/18/14; however, the former Administrator refused to tell her what had happened. The DON stated she was never made aware of an allegation of abuse or any form of an investigation. She stated that on 10/28/14, the former Administrator fired LPN #3 and she asked the former Administrator why she had fired the LPN; but the former Administrator told her that she did not have to give the employee a reason. The DON stated she expected any form of abuse to be reported to her and an investigation was to be completed immediately. Upon request of documented evidence of an investigation, the facility did not present any evidence that the allegation had been investigated, LPN #3 had been suspended, per facility policy, and/or the alleged abuse had been reported to the appropriate state agency. LPN #3 was allowed to continue to work until the time of termination of 10/28/14 according to the former Administrator's interview. Interview with the former Administrator, on 11/06/14 at 11:15 AM, revealed while she was the Administrator of the facility, CNA #1 had reported LPN #3 had verbally abused Resident #1 and she did not think anything had been done about it. The former Administrator failed to report, investigate and suspend the alleged perpetrator and she did not provide a reason why this was not done. Interview with the current Administrator, on 11/10/14 at 4:12 PM, revealed she was not employed at the facility at the time of the allegation on 10/18/14. Interview with the Medical Director, on 11/13/14 at 11:04 AM, revealed he had not been made aware of the allegations made on 10/18/14 or 11/04/14 until a Quality Assurance meeting on 11/12/14. He stated the incident on 11/04/14 was a serious concern and he felt this was an obvious case of physical/mental abuse toward the resident. Additionally, he stated the incident on 10/18/14 was very unprofessional and he was very concerned because this was an obvious case of verbal/mental abuse toward this resident. He stated he had seen Resident #1 on 11/11/14 and he/she was of sound mind and felt his/her complaint was legitimate. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The two (2) alleged perpetrators (LPN #1 and LPN #3) were suspended immediately and after completion of the facility's investigation the two alleged perpetrators were terminated. 2. On 11/12/14, the Abuse Log was reviewed by the DON and Administrator. All residents with allegation of abuse in the past thirty (30) days had their abuse investigation file re-assessed for completeness of the following: Immediate reporting of allegation to Administrator, physician and family/responsible party; immediate resident assessment; twenty-four (24) hour notification of allegation to appropriate state agency, when indicated; documentation of investigation including but not limited to; resident statement, witness (staff and family) statements, assessment of precipitating events, risks and conclusion; and five (5) day follow-up provided to State Agency, when indicated. On 11/14/14, any gaps identified from above were followed-up on by the Administrator to ensure care plans and kardexes were updated. No issues were identified. 3. On 11/13/14, all personnel files were audited by the Business Office Manager for completion of current license, abuse registry check, and criminal background verifications. Staff with incomplete personnel files will not be allowed to work until their files are brought current. No problems were identified. 4. On 11/07/14-11/11/14, the Social Service Director and/or RNs, interviewed all cognitively intact residents (BIMS score greater than eight {8}) for any history of potential allegations of abuse. Any allegations of abuse were logged, investigations were completed and appropriate notifications were made. No problems were identified. 5. On 11/07/14-11/11/14 Licensed Nurse Staff conducted body audits of all non-cognitive residents (BIMS less than nine {9}) to identify any bruises, skin tears, etc, for potential abuse. Any indications of abuse were logged, investigations were completed and appropriate notifications were made. No concerns identified. 6. On 11/10/14-11/14/14, all staff was provided in-service education by the DON and the Ombudsman on abuse prohibition and reporting policies. The education will be provided annually thereafter and as indicated by the DON, Ombudsman, and/or Administrator. All staff will complete this education prior to being allowed to continue to work. 7. All new hires will be provided in-service education on abuse prohibition and reporting policies during their general facility orientation by the Orientation Coordinator and/or Department Supervisor. 8. All new hires will have their personnel records reviewed by the Business Office Manager and/or Administrator for completeness of verification and background checks, prior to their first day of work. 9. On 11/14/14, the Social Services Director provided the Resident Council members education on abuse prohibition and reporting to the resident council. This education will be provided quarterly thereafter. 10. The Administrator and/or DON will be responsible for ensuring completeness of the resident abuse files and maintaining the Abuse Log. 11. On 11/12/14, abuse prohibition and reporting information was posted in common areas within the facility. 12. The Administrator and/or DON will be responsible for verifying, during the morning meetings, that any new allegations of abuse were reported immediately. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. 13. The Administrator and/or DON will review the abuse files weekly for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. **The State Survey Agency validated on 11/19/14 the corrective action taken by the facility as follows: 1. Interview with the current Administrator, on 11/20/14 at 10:30 AM, revealed LPN #1 and LPN #3 were terminated on 11/10/14 as soon as she was made aware. 2. Review of the Abuse Log, dated 11/12/14, revealed all residents with allegations of abuse in the past thirty (30) days had their abuse investigation file reassessed for completeness. No concerns were identified. 3. Review of the Business Office Manager's log, dated 11/13/14, revealed all staff's personnel records were reviewed to ensure the abuse registry check, criminal background checks, and current license verifications were conducted. No concerns identified. 4. Review of interviews conducted on 11/07/14-11/11/14 with residents with a BIMS of nine (9) or greater revealed no new problems identified. Interview with Resident #1 on 11/20/14 at 9:45 AM, revealed he/she had no additional concerns and the staff had been very nice to him/her. 5. Review of thirty-six (36) body audits for residents with a BIMS score of eight (8) or less revealed there were no new concerns identified. 6. Review of inservice record, dated 11/14/14, revealed all staff was inserviced on abuse prohibition and reporting policies. Interviews on 11/20/14 with day shift CNA #7 at 9:15 AM, day shift Restorative Aide at 9:22 AM, day shift Housekeeping Aid at 9:26 AM, day shift Certified Occupational Therapy Assistant (COTA) at 9:40 AM, Housekeeping Supervisor (all shifts) at 9:46 AM, 2nd shift LPN #4 at 10:32 AM, evening shift CNA # 4 at 10:48 AM, 2nd shift CNA #5 at 10:48 AM, 3rd shift CNA #6 at 10:55 AM, day shift Business Office Manager at 12:59 AM, Maintenance Director (all shifts) at 2:00 PM, Dietary Manager (all shifts) at 2:12 PM, day shift Administrative Assistant at 2:16 PM, revealed they had received an in-service on 11/14/14 related to abuse and reporting. 7. Review of new hire orientation training for a new hire (CNA) revealed she was educated on abuse prohibition and reporting policies. 8. Review of three (3) Personnel Record, revealed new (CNA) background checks and abuse registry checks were completed. 9. Review of the SSD's education, dated 11/14/14, revealed Resident Council members were educated on abuse prohibition and reporting to the resident council. 10. Interview with the current Administrator, on 11/20/14 at 2:30 PM, revealed she assumed the responsibility of ensuring the resident abuse files and maintaining the abuse log. She stated the log was reviewed daily. 11. Observation throughout the facility revealed abuse prohibition and reporting information was posted at the West Hall lobby, front entrance, therapy entrance, and break room. 12. Interview with Administrator, on 11/20/14 at 2:30 PM, revealed she has verified during morning meetings that new allegations of abuse were reported immediately and the findings reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months. 13. Interviews with the Administrator, on 11/20/14 at 2:30 PM, revealed she or the DON will review the abuse files for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months and the findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure staff reported observed incidents of abuse immediately for two (2) of nine (9) sampled residents (Residents #1 and #5). Licensed Practical Nurse (LPN) #1 was alleged to have abused and mistreated Residents #5 on 11/04/14 by placing a hot pepper in the resident's mouth. The resident cried out "hot" repeatedly and LPN #1 laughed at the resident's reaction. Kentucky Medication Assistant (KMA) #1, Certified Nurse Aide (CNA) #2 and CNA #3 witnessed the alleged abuse but did not report it to the Administrator. LPN #1 told LPN #2 what she had done on 11/05/14; however, LPN #2 did not report it until 11/07/14 (Friday after hours) when she left a phone message on the Director of Nurse's (DON) voicemail which was not retrieved until 11/10/14 (Monday). (Refer to F223) Additionally, LPN #3 was alleged to have abused and mistreated Resident #1 on 10/18/14 by calling the resident fat, telling the resident he/she was mean and refusing to administer the resident's pain medication. CNA #1 observed the alleged abuse and reported the alleged abuse to the former Administrator immediately; however, there was no evidence the former Administrator suspended the alleged perpetrator and investigated and reported the alleged abuse to the appropriate State agencies, as per facility policy. (Refer to F223) The facility's failure to ensure staff reported and investigated alleged abuse immediately has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/13/14 and determined to exist on 10/18/14. The facility was notified of the Immediate Jeopardy on 11/13/14. An acceptable Allegation of Compliance (AoC) was received on 11/19/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/20/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Abuse Prevention Employee's Responsibility", updated 08/18/99, revealed "... if abuse is suspected, than any allegation of abuse is to be reported immediately to the Administrator, Director of Nursing (DON), Charge Nurse or Immediate Supervisor. In the absence of the Administrator when the allegation occurs, he/she should be contacted immediately and the investigation should begin immediately." Review of the facility's policy titled, "Policy Regarding Abuse", dated 10/28/13, revealed "... if a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation. During the coarse of the investigation, the staff person accused of abuse will be suspended without pay. The allegation will be reported in accordance with state and federal regulations." Review of an addendum to the facility's policy titled, "Abuse Prevention", updated 09/24/14, revealed staff must speak to the Administrator or DON and leaving a voice mail message does not meet the definition of contacting either the Administrator or DON. Failure to follow the abuse prevention policy and procedure may result in immediate job termination. 1. Interviews with KMA #1, CNA #2, CNA #3 and the current Administrator and review of a surveillance video, dated 11/04/14, revealed LPN #1 abused Resident #5 on 11/04/14 by placing a hot pepper in the resident's mouth. When the resident repeatedly cried out "hot", LPN #1 laughed at the resident. KMA #1, CNA #2 and CNA #3, witnessed the incident but failed to report the incident to the Administrator. On 11/05/14, LPN #1 told LPN #2 what she had done to Resident #5. However, LPN #2 failed to report the allegation until 11/07/14 (Friday after hours) when she left a message on the Director of Nursing's (DON) voicemail which was not retrieved until 11/10/14 (Friday). Interview with the current Administrator, on 11/10/14 at 4:12 PM, revealed the DON received a voicemail from LPN #2 stating LPN #1 had told her she had placed a hot pepper in Resident #5's mouth on the evening of 11/04/14. The Administrator stated the incident was reported via phone message to the DON's office after business hours on 11/07/14 (Friday) and was not retrieved until the afternoon of 11/10/14 (Monday). The Administrator revealed LPN #2 stated she thought about reporting the incident several times that week but failed to do so. Further interview with the Administrator revealed she confronted LPN #1 on 11/10/14 when she arrived to work and LPN #1 admitted she had placed a pepper in the resident's mouth and laughed at him/her. The Administrator stated LPN #1 was terminated immediately on 11/10/14 and she considered LPN #1's actions to be resident abuse. LPN worked from the day of the incident 11/04/14, until 11/10/14 when she was terminated, as staff failed to report the incident timely. Per facility policy, "... if abuse is suspected, than any allegation of abuse is to be reported immediately to the Administrator, Director of Nursing (DON), Charge Nurse..." The addendum to the policy stated "... and leaving a voice mail message does not meet the definition of contacting either the Administrator or DON." Interview with KMA #1, on 11/13/14 at 10:20 AM, revealed she observed LPN #1 place a hot pepper in the mouth of Resident #5 on the afternoon shift of 11/04/14. KMA stated she had received training during orientation and annually on abuse. However, she stated she initially did not see this as abuse, but later felt she should have reported this to the Administrator. Interview with CNA #3, on 11/13/14 at 10:36 AM, revealed she observed LPN #3 give Resident #5 a hot pepper from a plastic bag. She stated she did not report the incident because LPN #3 was her supervisor and she was afraid LPN #3 would retaliate. Interview with CNA #2, on 11/13/14 at 2:40 PM, revealed she had witnessed LPN #3 give a hot pepper to Resident #5. CNA #2 stated LPN #3 placing the pepper in the resident's mouth was wrong. She revealed she was aware of how to report alleged abuse but failed to do so. A phone interview was attempted with LPN #2 on 11/15/14 at 9:00 AM and was unsuccessful. 2. Interviews with Resident #1 and CNA #1 revealed LPN #3 verbally abused Resident #1 on 10/18/14. CNA #1 stated she reported the alleged abuse immediately to the former Administrator. However, the former Administrator failed to suspend the allege perpetrator and investigate and report the alleged abuse to appropriate State Agencies. Per the facility's policy, "... if a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation. During the coarse of the investigation, the staff person accused of abuse will be suspended without pay." Interview with the former Administrator, on 11/06/14 at 11:15 AM, revealed while she was the Administrator of the facility. The Administrator stated CNA #1 had reported LPN #3 had verbally abused Resident #1; however, she did not think anything had been done about the allegation. She gave no reason as to why she never investigated it as the Administrator and was fired on 10/29/14. Interview with Director of Nursing (DON), on 11/04/14 at 10:20 AM, revealed she was aware something had happened in 10/18/14; however, the former Administrator refused to tell her what it was and she was not aware it involved an allegation of abuse. She stated she expected that any form of abuse of a resident should have been brought to her attention and a formal investigation should have been conducted. The DON stated she asked the former Administrator why she terminated LPN #3 on 10/28/14 and she was told she did not have to give a reason. Interview with the current Administrator, on 11/13/14 at 3:08 PM, revealed she expected any form of abuse to be verbally reported immediately. She stated voicemail or electronic reporting was not acceptable. The current Administrator stated her expectations were that staff should report allegations of abuse to her or her designee immediately; the alleged abuser suspended immediately; and, the Administrator should report the allegation to the State Agency. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The two (2) alleged perpetrators (LPN #1 and LPN #3) were suspended immediately and after completion of the facility's investigation the two alleged perpetrators were terminated. 2. On 11/12/14, the Abuse Log was reviewed by the DON and Administrator. All residents with allegation of abuse in the past thirty (30) days had their abuse investigation file re-assessed for completeness of the following: Immediate reporting of allegation to Administrator, physician and family/responsible party; immediate resident assessment; twenty-four (24) hour notification of allegation to appropriate state agency, when indicated; documentation of investigation including but not limited to; resident statement, witness (staff and family) statements, assessment of precipitating events, risks and conclusion; and five (5) day follow-up provided to State Agency, when indicated. On 11/14/14, any gaps identified from above were followed-up on by the Administrator to ensure care plans and kardexes were updated. No issues were identified. 3. On 11/13/14, all personnel files were audited by the Business Office Manager for completion of current license, abuse registry check, and criminal background verifications. Staff with incomplete personnel files will not be allowed to work until their files are brought current. No problems were identified. 4. On 11/07/14-11/11/14, the Social Service Director and/or RNs, interviewed all cognitively intact residents (BIMS score greater than eight {8}) for any history of potential allegations of abuse. Any allegations of abuse were logged, investigations were completed and appropriate notifications were made. No problems were identified. 5. On 11/07/14-11/11/14 Licensed Nurse Staff conducted body audits of all non-cognitive residents (BIMS less than nine {9}) to identify any bruises, skin tears, etc, for potential abuse. Any indications of abuse were logged, investigations were completed and appropriate notifications were made. No concerns identified. 6. On 11/10/14-11/14/14, all staff was provided in-service education by the DON and the Ombudsman on abuse prohibition and reporting policies. The education will be provided annually thereafter and as indicated by the DON, Ombudsman, and/or Administrator. All staff will complete this education prior to being allowed to continue to work. 7. All new hires will be provided in-service education on abuse prohibition and reporting policies during their general facility orientation by the Orientation Coordinator and/or Department Supervisor. 8. All new hires will have their personnel records reviewed by the Business Office Manager and/or Administrator for completeness of verification and background checks, prior to their first day of work. 9. On 11/14/14, the Social Services Director provided the Resident Council members education on abuse prohibition and reporting to the resident council. This education will be provided quarterly thereafter. 10. The Administrator and/or DON will be responsible for ensuring completeness of the resident abuse files and maintaining the Abuse Log. 11. On 11/12/14, abuse prohibition and reporting information was posted in common areas within the facility. 12. The Administrator and/or DON will be responsible for verifying, during the morning meetings, that any new allegations of abuse were reported immediately. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. 13. The Administrator and/or DON will review the abuse files weekly for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. **The State Survey Agency validated on 11/19/14 the corrective action taken by the facility as follows: 1. Interview with the current Administrator, on 11/20/14 at 10:30 AM, revealed LPN #1 and LPN #3 were terminated on 11/10/14 as soon as she was made aware. 2. Review of the Abuse Log, dated 11/12/14, revealed all residents with allegations of abuse in the past thirty (30) days had their abuse investigation file reassessed for completeness. No concerns were identified. 3. Review of the Business Office Manager's log, dated 11/13/14, revealed all staff's personnel records were reviewed to ensure the abuse registry check, criminal background checks, and current license verifications were conducted. No concerns identified. 4. Review of interviews conducted on 11/07/14-11/11/14 with residents with a BIMS of nine (9) or greater revealed no new problems identified. Interview with Resident #1 on 11/20/14 at 9:45 AM, revealed he/she had no additional concerns and the staff had been very nice to him/her. 5. Review of thirty-six (36) body audits for residents with a BIMS score of eight (8) or less revealed there were no new concerns identified. 6. Review of inservice record, dated 11/14/14, revealed all staff was inserviced on abuse prohibition and reporting policies. Interviews on 11/20/14 with day shift CNA #7 at 9:15 AM, day shift Restorative Aide at 9:22 AM, day shift Housekeeping Aid at 9:26 AM, day shift Certified Occupational Therapy Assistant (COTA) at 9:40 AM, Housekeeping Supervisor (all shifts) at 9:46 AM, 2nd shift LPN #4 at 10:32 AM, evening shift CNA # 4 at 10:48 AM, 2nd shift CNA #5 at 10:48 AM, 3rd shift CNA #6 at 10:55 AM, day shift Business Office Manager at 12:59 AM, Maintenance Director (all shifts) at 2:00 PM, Dietary Manager (all shifts) at 2:12 PM, day shift Administrative Assistant at 2:16 PM, revealed they had received an in-service on 11/14/14 related to abuse and reporting. 7. Review of new hire orientation training for a new hire (CNA) revealed she was educated on abuse prohibition and reporting policies. 8. Review of three (3) Personnel Record, revealed new (CNA) background checks and abuse registry checks were completed. 9. Review of the SSD's education, dated 11/14/14, revealed Resident Council members were educated on abuse prohibition and reporting to the resident council. 10. Interview with the current Administrator, on 11/20/14 at 2:30 PM, revealed she assumed the responsibility of ensuring the resident abuse files and maintaining the abuse log. She stated the log was reviewed daily. 11. Observation throughout the facility revealed abuse prohibition and reporting information was posted at the West Hall lobby, front entrance, therapy entrance, and break room. 12. Interview with Administrator, on 11/20/14 at 2:30 PM, revealed she has verified during morning meetings that new allegations of abuse were reported immediately and the findings reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months. 13. Interviews with the Administrator, on 11/20/14 at 2:30 PM, revealed she or the DON will review the abuse files for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months and the findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure the implementation of the facility's Abuse policy and procedures for two (2) of nine (9) sampled residents (Residents #1 and #5). Licensed Practical Nurse (LPN) #1 was alleged to have physically and mentally abused and mistreated Residents #5. Kentucky Medication Assistant (KMA) #1, Certified Nurse Aide (CNA) #2 and CNA #3 witnessed the alleged abuse but did not report it to the Administrator per facility policy and procedure. LPN #1 told LPN #2 what she had done on 11/05/14; however, LPN #2 did not report the incident until 11/07/14 (Friday after hours) when she left a phone message on the Director of Nursing's (DON) voicemail which was not retrieved until 11/10/14 (Monday). LPN #2 failed to follow the facility's policy and report the allegation verbally to the Administrator or Director of Nursing (DON) immediately. (Refer to F223 and F225) In addition, LPN #3 was alleged to have verbally abused and mistreated Residents #1. CNA #1 observed the alleged abuse and reported it to the former Administrator immediately; however, the former Administrator failed to suspend the alleged perpetrator and investigate and report the alleged abuse to the appropriate State Agencies, per the facility's policy and procedures. (Refer to F223 and F225) The facility's failure to ensure staff followed the facility's policy and procedure for abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/13/14 and determined to exist on 10/18/14. The facility was notified of the Immediate Jeopardy on 11/13/14. An acceptable Allegation of Compliance (AoC) was received on 11/19/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/20/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Abuse Prevention Employee's Responsibility", updated 08/18/99, revealed "... if abuse is suspected, than any allegation of abuse is to be reported immediately to the Administrator, Director of Nursing (DON), Charge Nurse or Immediate Supervisor. In the absence of the Administrator when the allegation occurs, he/she should be contacted immediately and the investigation should begin immediately." Review of the facility's policy titled, "Policy Regarding Abuse", dated 10/28/13, revealed if a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation. During the coarse of the investigation, the staff person accused of abuse will be suspended without pay. The allegation will be reported in accordance with state and federal regulations. Review of an addendum to the facility's policy titled, "Abuse Prevention", updated 09/24/14, revealed staff must speak to the Administrator or DON and leaving a voice mail message did not meet the definition of contacting either the Administrator or DON. Failure to follow the abuse prevention policy and procedure may result in immediate job termination. Interviews with KMA #1, CNA #2, CNA #3 and the current Administrator and review of a facility surveillance video, dated 11/10/14, revealed LPN #1 physically and mentally abused Resident #5 on 11/04/14 by placing a hot pepper in the resident's mouth and when the resident cried out "hot" repeatedly, the LPN laughed at the resident's reaction. Kentucky Medication Aide (KMA) # 1, CNA #2 and CNA #3 witnessed the incident but the staff did not follow the facility's policy and procedure for reporting abuse immediately to the Administrator, Director of Nursing (DON), Charge Nurse or Immediate Supervisor. Interview with KMA #1, on 11/13/14 at 10:20 AM, revealed initially she did not see the incident that she had witnessed, involving LPN #1, as abuse. She stated later she felt she should have followed the facility's policy and reported it to the Administrator but she did not follow through with reporting. Interview with CNA #3, on 11/13/14 at 10:36 AM, revealed she knew the facility's policy was to report alleged abuse immediately but she did not report the alleged abuse by LPN #1 because she feared retaliation by LPN #1 because LPN #1 was her supervisor. Interview with CNA #2, on 11/13/14 at 2:40 PM, revealed she did not report the alleged abuse by LPN #1 that she had witnessed per the facility's policy but she was aware of how to report an allegation of abuse. CNA #2 stated she did not report the abuse because LPN #1 was her supervisor and she was afraid she would loose her job. An unsuccessful phone interview was attempted with LPN #2 on 11/15/14 at 9:00 AM. Interview with the DON, on 11/07/14 at 10:20 AM, revealed she expected staff to report any allegation of alleged abuse to her per the facility's policy and not to leave a voicemail on her phone. Interview with the Administrator, on 11/13/14 at 3:08 PM, revealed she expected any form of abuse to have been reported immediately in person per policy. Interview with the Medical Director, on 11/13/14 at 11:04 AM, revealed he had not been made aware of either allegation on 10/18/14 or 11/04/14 until a Quality Assurance meeting on 11/12/14. He stated that the incidents were of serious concern. He further stated he felt the incidents were abuse and should have been reported immediately, per the facility policy. 2. Interviews with CNA #1, the DON and the former Administrator, revealed LPN #3 verbally abused Resident #1 on 10/18/14. CNA #1 witnessed the alleged abuse and immediately reported the incident to the Administrator; however, the Administrator failed to suspend the alleged perpetrator and investigate and report the allegation to the appropriate State agencies per the facility's policy and procedure. The DON stated the former Administrator refused to inform her of the allegation. The former Administrator stated she was aware the allegation had happened, but she did not do anything about it. Per the facility's policy, "... if abuse is suspected, than any allegation of abuse is to be reported immediately to the Administrator, Director of Nursing (DON), Charge Nurse or Immediate Supervisor. In the absence of the Administrator when the allegation occurs, he/she should be contacted immediately and the investigation should begin immediately." Interview with the DON, on 11/07/14 at 10:20 AM, revealed she was aware there was something that had happened on 10/18/14; however, the former Administrator refused to tell her what it involved. She stated she was never aware of an allegation of abuse or any form of investigation. Interview with current Administrator on 11/13/14 at 4:14 PM, revealed when an allegation of abuse was received the alleged perpetrator should be suspended, an investigation should be conducted and the allegation should be reported to the appropriate State Agencies, as per the facility's policy and procedures. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The two (2) alleged perpetrators (LPN #1 and LPN #3) were suspended immediately and after completion of the facility's investigation the two alleged perpetrators were terminated. 2. On 11/12/14, the Abuse Log was reviewed by the DON and Administrator. All residents with allegation of abuse in the past thirty (30) days had their abuse investigation file re-assessed for completeness of the following: Immediate reporting of allegation to Administrator, physician and family/responsible party; immediate resident assessment; twenty-four (24) hour notification of allegation to appropriate state agency, when indicated; documentation of investigation including but not limited to; resident statement, witness (staff and family) statements, assessment of precipitating events, risks and conclusion; and five (5) day follow-up provided to State Agency, when indicated. On 11/14/14, any gaps identified from above were followed-up on by the Administrator to ensure care plans and kardexes were updated. No issues were identified. 3. On 11/13/14, all personnel files were audited by the Business Office Manager for completion of current license, abuse registry check, and criminal background verifications. Staff with incomplete personnel files will not be allowed to work until their files are brought current. No problems were identified. 4. On 11/07/14-11/11/14, the Social Service Director and/or RNs, interviewed all cognitively intact residents (BIMS score greater than eight {8}) for any history of potential allegations of abuse. Any allegations of abuse were logged, investigations were completed and appropriate notifications were made. No problems were identified. 5. On 11/07/14-11/11/14 Licensed Nurse Staff conducted body audits of all non-cognitive residents (BIMS less than nine {9}) to identify any bruises, skin tears, etc, for potential abuse. Any indications of abuse were logged, investigations were completed and appropriate notifications were made. No concerns identified. 6. On 11/10/14-11/14/14, all staff was provided in-service education by the DON and the Ombudsman on abuse prohibition and reporting policies. The education will be provided annually thereafter and as indicated by the DON, Ombudsman, and/or Administrator. All staff will complete this education prior to being allowed to continue to work. 7. All new hires will be provided in-service education on abuse prohibition and reporting policies during their general facility orientation by the Orientation Coordinator and/or Department Supervisor. 8. All new hires will have their personnel records reviewed by the Business Office Manager and/or Administrator for completeness of verification and background checks, prior to their first day of work. 9. On 11/14/14, the Social Services Director provided the Resident Council members education on abuse prohibition and reporting to the resident council. This education will be provided quarterly thereafter. 10. The Administrator and/or DON will be responsible for ensuring completeness of the resident abuse files and maintaining the Abuse Log. 11. On 11/12/14, abuse prohibition and reporting information was posted in common areas within the facility. 12. The Administrator and/or DON will be responsible for verifying, during the morning meetings, that any new allegations of abuse were reported immediately. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. 13. The Administrator and/or DON will review the abuse files weekly for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months. The findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up on areas identified every month for three (3) months. **The State Survey Agency validated on 11/19/14 the corrective action taken by the facility as follows: 1. Interview with the current Administrator, on 11/20/14 at 10:30 AM, revealed LPN #1 and LPN #3 were terminated on 11/10/14 as soon as she was made aware. 2. Review of the Abuse Log, dated 11/12/14, revealed all residents with allegations of abuse in the past thirty (30) days had their abuse investigation file reassessed for completeness. No concerns were identified. 3. Review of the Business Office Manager's log, dated 11/13/14, revealed all staff's personnel records were reviewed to ensure the abuse registry check, criminal background checks, and current license verifications were conducted. No concerns identified. 4. Review of interviews conducted on 11/07/14-11/11/14 with residents with a BIMS of nine (9) or greater revealed no new problems identified. Interview with Resident #1 on 11/20/14 at 9:45 AM, revealed he/she had no additional concerns and the staff had been very nice to him/her. 5. Review of thirty-six (36) body audits for residents with a BIMS score of eight (8) or less revealed there were no new concerns identified. 6. Review of inservice record, dated 11/14/14, revealed all staff was inserviced on abuse prohibition and reporting policies. Interviews on 11/20/14 with day shift CNA #7 at 9:15 AM, day shift Restorative Aide at 9:22 AM, day shift Housekeeping Aid at 9:26 AM, day shift Certified Occupational Therapy Assistant (COTA) at 9:40 AM, Housekeeping Supervisor (all shifts) at 9:46 AM, 2nd shift LPN #4 at 10:32 AM, evening shift CNA # 4 at 10:48 AM, 2nd shift CNA #5 at 10:48 AM, 3rd shift CNA #6 at 10:55 AM, day shift Business Office Manager at 12:59 AM, Maintenance Director (all shifts) at 2:00 PM, Dietary Manager (all shifts) at 2:12 PM, day shift Administrative Assistant at 2:16 PM, revealed they had received an in-service on 11/14/14 related to abuse and reporting. 7. Review of new hire orientation training for a new hire (CNA) revealed she was educated on abuse prohibition and reporting policies. 8. Review of three (3) Personnel Record, revealed new (CNA) background checks and abuse registry checks were completed. 9. Review of the SSD's education, dated 11/14/14, revealed Resident Council members were educated on abuse prohibition and reporting to the resident council. 10. Interview with the current Administrator, on 11/20/14 at 2:30 PM, revealed she assumed the responsibility of ensuring the resident abuse files and maintaining the abuse log. She stated the log was reviewed daily. 11. Observation throughout the facility revealed abuse prohibition and reporting information was posted at the West Hall lobby, front entrance, therapy entrance, and break room. 12. Interview with Administrator, on 11/20/14 at 2:30 PM, revealed she has verified during morning meetings that new allegations of abuse were reported immediately and the findings reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months. 13. Interviews with the Administrator, on 11/20/14 at 2:30 PM, revealed she or the DON will review the abuse files for timeliness in reporting, thorough investigations and appropriate resolution weekly for four (4) weeks, every other week for one (1) month, then monthly for three (3) months and the findings will be reported during the monthly Quality Assurance (QA) meeting for follow-up every month for three (3) months.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure services provided or arranged by the facility were provided by qualified persons in accordance with the written plan of care for one (1) of nine (9) sampled residents (Resident #5). The facility failed to ensure Resident #5's care plan interventions for a pureed diet and to supervise, cue and assist with decision making were implemented. Licensed Practical Nurse (LPN) #1 was alleged to have physically and mentally abused Resident #5. The resident was care planned for supervision, cueing, and assistance with decision making and a pureed diet; however, it was determined LPN #1's abusive behaviors towards the resident failed to ensure those needs were met in accordance with the care plan. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/13/14 and determined to exist on 10/18/14. The facility was notified of the Immediate Jeopardy on 11/13/14. An acceptable Allegation of Compliance (AoC) was received on 11/19/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/20/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, "Comprehensive Care Plan", not dated, revealed the facility was to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Record review revealed the facility readmitted Resident #5 on 10/08/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/14, revealed the facility assessed Resident #5's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) indicating the resident was not interviewable. Review of the physician's orders [REDACTED].#5 had a physician's orders [REDACTED]. Review of the Comprehensive Care Plan, initiated 01/30/14, revealed Resident #5 was at risk for choking and was on a pureed diet. Review of a Comprehensive Care Plan, dated 03/29/14, revealed the facility had assessed the resident to have impaired cognitive and physical deficits with interventions to supervise, cue and assist with decision making. Interview with Kentucky Medication Aide (KMA) #1, on 11/13/14 at 10:20 AM, revealed she observed LPN #1 place a hot pepper (a pepper that was not pureed) in Resident #5's mouth on the afternoon shift of 11/04/14. The resident began to cry and yell "hot". KMA #1 stated the resident was cognitively impaired, unable to make decisions and depended on staff to be responsible for his/her safety at all times. KMA #1 stated the resident was also on a pureed diet and was at risk for choking. Interview with Certified Nurse Aide (CNA) #3, on 11/13/14 at 10:36 AM, revealed she observed LPN #1 give Resident #5 a hot pepper from a plastic bag. CNA #3 stated Resident #5 was on a pureed diet and should have never been given a hot pepper. CNA #3 revealed the resident could have choked on the pepper. Interview with CNA #2, on 11/13/14 at 2:40 PM, revealed the resident was unable to make a conscious choice and staff was responsible for the resident's safety and well-being. Interview with Dietary Manager, on 11/12/14 at 4:31 PM, revealed Resident # 5 was ordered a pureed diet. She revealed a pureed diet would be the consistency of baby food and nothing whole. She stated the resident receiving anything whole could cause choking and possible aspiration. Interview with the Director of Nursing (DON), on 11/07/14 at 10:20 AM, revealed she expected each resident to have a Comprehensive Care Plan and the care plans should be followed at all times for each resident. Interview with the Administrator, on 11/13/14 at 3:08 PM, revealed she expected staff to always follow the care plan for each resident. Interview with the Medical Director, on 11/13/14 at 11:04 AM, revealed he expected each resident to have a care plan and the staff should follow them per policy. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The two (2) perpetrators (LPN #1 and LPN #3) were suspended immediately and after completion of the facility's investigation the two perpetrators were terminated. 2. On 11/14/14, Resident #5 and Resident #1 were assessed by the Registered Nurse (RN) MDS Coordinators and RN Supervisor for changes in their psychosocial condition with their care plans and kardexes updated. 3. On 11/15/14 and 11/16/14, residents with mental health and/or dementia [DIAGNOSES REDACTED]. Thirty-nine (39) were assessed out a census of fifty-one (51). 4. On 11/14/14-11/16/14, State Registered Nurse Aides (SRNA), KMAs LPNs and RNs were provided in-service education by the Administrator, RN Supervisor and/or Social Service Director, on the following topics: Understanding the psychosocial needs of residents; documenting and reporting changes in the psychosocial needs of residents; and, implementation of resident psychosocial care plans and Activities of Daily Living records. SRNAs, KMAs, LPNs, and RNs will not be allowed to return to work until they have completed the above training. All education has been completed 5. The above education will be provided by the Orientation Coordinator and/or Department Supervisor to SRNAs, KMAs, LPNs, and RNs new hires and/or any staff during their orientation process and prior to providing direct care. 6. All new resident admissions will have a psychosocial assessment completed by the Social Services Director or Admission Nurse, within seventy-two (72) hours of admission to the facility and an initial psychosocial care plan and kardex developed as indicated. 7. All residents that exhibit changes in their psychosocial condition will be reassessed by the DON and/or Social Services Director within seventy-two (72) hours. The resident's care plan and kardex will be updated and the physician will be notified of the changes. 8. The Social Service Director, Administrator, and/or DON will interview direct care staff for understanding of residents with psychosocial needs and appropriate implementation of the resident care plans. This will be conducted on all three (3) shifts weekly times four (4) weeks, every other week times one (1) month, then monthly for three (3) months. Results of the interviews will be reviewed by the Quality Assurance (QA) committee to ensure appropriateness of interview frequency. 9. The Interdisciplinary Team will meet and review the appropriateness and effectiveness of interventions for residents with psychosocial care plans weekly times four (4) weeks, every other week times one (1) month, then monthly for three (3) months. Findings will be brought to the QA Committee by the DON and/or Social Services Director monthly for additional follow-up of areas identified. 10. The DON and/or Administrator will review all SRNA, KMA, LPN and RN new hires' information to ensure psychosocial training has been conducted as indicated above, prior to the new hire providing direct care to residents. Findings will be brought to the QA Committee by the DON and/or Social Services Director monthly for additional follow-up of areas identified. **The State Survey Agency validated on 11/19/14, the corrective action taken by the facility on as follows: 1. Interview with the current Administrator, on 11/20/14 at 10:30 AM, revealed LPN #1 and LPN #3 were terminated on 11/10/14 as soon as she was made aware of the allegations. 2. Interview with the current Administrator, on 11/20/14 at 2:30 PM, revealed Resident #1 and #5 were assessed and care planned and kardexes updated if required. Review of the assessments, care plans and kardexes for Resident #1 and #5 revealed no concerns. 3. Review of the Psychosocial Assessments for residents with a mental health and/or dementia diagnosis, dated 11/15/14-11/16/14 revealed the residents were reassessed for changes in psychosocial conditions and care plans/kardexes were updated. Thirty- nine (39) of fifty- one (51) residents were assessed with [REDACTED]. 4. Review of the Employee Sign in Sheets revealed 100% of all staff was reeducated on 11/14/14-11/16/14 related to the abuse policy, understanding the psychosocial needs of the residents, documenting and reporting changes in psychosocial needs of residents, and implementation of residents' psychosocial care plans and ADL records. Posts test were completed same day as the in-service date. Interviews on 11/20/14 with CNA #7 at 9:15 AM, a Restorative Aide at 9:22 AM, a Housekeeping Aid at 9:26 AM, a Certified Occupational Therapy Assistant (COTA) at 9:40 AM, the Housekeeping Supervisor at 9:46 AM, LPN #4 at 10:32 AM, CNA # 4 at 10:48 AM, CNA #5 at 10:48 AM, CNA #6 at 10:55 AM, the Business Office Manager at 12:59 AM, the Maintenance Director at 2:00 PM, the Dietary Manager at 2:12 PM, and the Administrative Assistant at 2:16 PM, revealed they were inserviced on 11/14/14 on abuse reporting and assessing residents for change, understanding the psychosocial needs of the residents, documenting and reporting of changes in psychosocial needs and implementation of the care plans. 5. Review of new hire orientation training for a new hire (CNA) revealed psychosocial education was provided. 6. Interview with the current Administrator, on 11/20/14 at 11:15 AM, revealed the facility had not had any new admits since 11/10/14. 7. Interview with the current Administrator, on 11/20/14 at 2:30 PM, revealed all residents that exhibit changes in their psychosocial condition will be reassessed by the DON and/or Social Services Director within seventy-two (72) hours. The resident's care plan and kardex will be updated and the physician will be notified of the changes. Interview with the DON on 11/20/14 at 2:52 PM, revealed she was aware the residents were to be assessed for signs of psychosocial changes within 72 hours of the time the change was identified. 8. The Social Services Director, Administrator, and /or DON are conducting ongoing interviews with direct care staff regarding understanding of residents with psychosocial needs and appropriate implementation of residents care plans. A review of the monitoring sheet revealed interviews were conducted on 11/19/14 and 11/20/14 with direct care staff regarding their understanding of residents with psychosocial needs and appropriate implementation of residents care plans. The monitoring sheet was blocked out for future weeks for all three shifts. Interview on 11/20/14 at 2:30 PM with the current Administrator revealed she was ensuring the direct care staff was fully aware of the importance of monitoring the residents for psychosocial changes and that this should be reported to their supervisor immediately. 9. Review of Interdisciplinary Team (IDT) meeting held on 11/18/14 (usually meets on Tuesday) revealed revisions were made to the residents' care plans as needed related to monitoring of appropriateness and effectiveness of interventions for residents with psychosocial problems. 10. A review of the new hire (CNA) personnel record, revealed the Administrator educated the CNA on psychosocial training.

Based on interview, record review, review of the Administrator's Position Description, and review of the facility's policy/procedure, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being for residents residing in the facility. On 10/18/14, Certified Nursing Assistant (CNA) #1 reported to the former Administrator that LPN #3 verbally abused and mistreated Residents #1; however, the former Administrator failed to suspend the alleged perpetrator and investigate and report the alleged abuse to the appropriate State Agencies, per the facility's policy and procedures. The facility's failure to ensure the Administrator administered the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/13/14 and determined to exist on 10/18/14. The facility was notified of the Immediate Jeopardy on 11/13/14. An acceptable Allegation of Compliance (AoC) was received on 11/19/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/20/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of policy titled "Policy Regarding Abuse", last updated 10/28/13, revealed any suspected abuse of a resident is to be reported immediately to the administrator which will conduct an investigation of the alleged abuse. "... If a staff member is suspected of abuse then appropriate action will be taken to protect the residents during the investigation. During the coarse of the investigation, the staff person accused of abuse will be suspended without pay. The allegation will be reported in accordance with state and federal regulations." Review of the facility's policy titled, "Abuse Prevention", dated 09/23/08, revealed the facility will protect and promote the rights of individual patients to be free of abuse. Review of the "Comprehensive Job Description" for the Administrator, revised 11/01/13, revealed the position of the Administrator is to oversee the day-to-day operations of the facility. The Administrator must know and understand the federal and state regulations and must implement and continuously update changes as they occur. Interview with the former Administrator, on 11/06/14 at 11:15 AM, revealed while she was the Administrator of the facility, CNA #1 had reported to her that LPN #3 had verbally abused Resident #1. During further interview with the Administrator, she stated she did not think anything had been done about the allegation. The former Administrator failed to report, investigate and suspend the alleged perpetrator and she did not provide a reason why this was not done. However, the facility's policy states , "... suspected abuse of a resident is to be reported immediately to the administrator who will conduct an investigation of the alleged abuse." Interview with the DON, on 11/07/14 at 10:20 AM, revealed she was aware something had happened on 10/18/14 (the day LPN #3 was alleged to have abused Resident #1); however, the former Administrator refused to tell her what had happened. The DON stated she was never made aware of an allegation of abuse or any form of an investigation. Upon request of documented evidence of an investigation, the facility did not present any evidence that the allegation had been investigated, LPN #3 had been suspended, per facility policy, and/or the alleged abuse had been reported to the appropriate state agency. Interview with the former Administrator revealed LPN #3 was allowed to continue to work until she was terminated on 10/28/14. Interview with the facility's Owner, on 12/08/14 at 4:10 PM (post survey interview), revealed the former Administrator had been in her position for twenty-seven (27) years. He stated the former Administrator was a licensed Long Term Administrator and he was confident that she was knowledgeable of the State and Federal regulatory requirements on investigating and reporting abuse. Further interview revealed he expected her to have followed the regulations. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 11/12/14, the Abuse Log was reviewed by the DON and the current Administrator. All residents with allegation of abuse in the past thirty (30) days had their abuse investigation file re-assessed for completeness of the following: Immediate reporting of allegation to Administrator, physician and family/responsible party; immediate resident assessment; twenty-four (24) hour notification of allegation to appropriate state agency, when indicated; documentation of investigation including but not limited to; resident statement, witness (staff and family) statements, assessment of precipitating events, risks and conclusion; and five (5) day follow-up provided to State Agency, when indicated. On 11/14/14, any gaps identified from above were followed-up on by the Administrator to ensure care plans and kardexes were updated. No issues were identified. 2. On 11/13/14, all personnel files were audited by the Business Office Manager for completion of current license, abuse registry check, and criminal background verifications. Staff with incomplete personnel files will not be allowed to work until their files are brought current. No problems were identified. 3. On 11/07/14-11/11/14, the Social Service Director and/or RNs, interviewed all cognitively intact residents (BIMS score greater than eight {8}) for any history of potential allegations of abuse. Any allegations of abuse were logged, investigations were completed and appropriate notifications were made. No problems were identified. 4. On 11/07/14-11/11/14 Licensed Nurse Staff conducted body audits of all non-cognitive residents (BIMS less than nine {9}) to identify any bruises, skin tears, etc, for potential abuse. Any indications of abuse were logged, investigations were completed and appropriate notifications were made. No concerns identified. 5. On 11/10/14-11/14/14, all staff was provided in-service education by the DON and the Ombudsman on abuse prohibition and reporting policies. The education will be provided annually thereafter and as indicated by the DON, Ombudsman, and/or Administrator. All staff will complete this education prior to being allowed to continue to work. 6. All new hires will be provided in-service education on abuse prohibition and reporting policies during their general facility orientation by the Orientation Coordinator and/or Department Supervisor. 7. All new hires will have their personnel records reviewed by the Business Office Manager and/or Administrator for completeness of verification and background checks, prior to their first day of work. 8. On 11/14/14, the Social Services Director provided the Resident Council members education on abuse prohibition and reporting to the resident council. This education will be provided quarterly thereafter. 9. The facility Owner and the Ombudsman educated the current Administrator on the actions that should be taken when there is an allegation of abuse/neglect. The Administrator or designated staff will do the following: A. If the resident identifies the perpetrator, he/she will suspend the perpetrator immediately and he/she will be removed from the facility pending the investigation. B. The resident (if interviewable) will provide a statement of the allegation. C. If the allegation is physical in nature, he/she will ensure a skin assessment of the resident(s) has been conducted to identify any signs of physical or psychosocial injury. D. The resident(s) family/ responsible party and physician is to be notified immediately. E. Within twenty-four (24) hours, he/she will notify the appropriate authorities (Office of Inspector General, Adult Protective Services/Centralized Intake, Ombudsman and Law Enforcement (if required.). F. He/She will review any precipitating events or risks that have have contributed to the allegation which will be reported to the Leadership Team during morning meeting. G. A conclusion will be reached within five (5) days and appropriate action will be taken based on the findings of the investigation which will be reported to the Office of Inspector General, Adult Protective Services, Ombudsman and resident(s) physician. H. All evidence of the above actions will be documented in the abuse log and the administrator will review the abuse log for appropriate completion and follow up as required. **The State Survey Agency validated on 12/08/14, the corrective action taken by the facility on as follows: 1. Review of the Abuse Log, dated 11/12/14, revealed all residents with allegations of abuse in the past thirty (30) days had their abuse investigation file reassessed for completeness. No concerns were identified. 2. Review of the Business Office Manager's log, dated 11/13/14, revealed all staff's personnel records were reviewed to ensure the abuse registry check, criminal background checks, and current license verifications were conducted. No concerns identified. 3. Review of interviews conducted on 11/07/14-11/11/14 with residents with a BIMS of nine (9) or greater revealed no new problems identified. Interview with Resident #1 on 11/20/14 at 9:45 AM, revealed he/she had no additional concerns and the staff had been very nice to him/her. 4. Review of thirty-six (36) body audits for residents with a BIMS score of eight (8) or less revealed there were no new concerns identified. 5. Review of inservice record, dated 11/14/14, revealed all staff was inserviced on abuse prohibition and reporting policies. Interviews on 11/20/14 with day shift CNA #7 at 9:15 AM, day shift Restorative Aide at 9:22 AM, day shift Housekeeping Aid at 9:26 AM, day shift Certified Occupational Therapy Assistant (COTA) at 9:40 AM, Housekeeping Supervisor (all shifts) at 9:46 AM, 2nd shift LPN #4 at 10:32 AM, evening shift CNA # 4 at 10:48 AM, 2nd shift CNA #5 at 10:48 AM, 3rd shift CNA #6 at 10:55 AM, day shift Business Office Manager at 12:59 AM, Maintenance Director (all shifts) at 2:00 PM, Dietary Manager (all shifts) at 2:12 PM, day shift Administrative Assistant at 2:16 PM, revealed they had received an in-service on 11/14/14 related to abuse and reporting. 6. Review of new hire orientation training for a new hire (CNA) revealed she was educated on abuse prohibition and reporting policies. 7. Review of three (3) Personnel Record, revealed new (CNA) background checks and abuse registry checks were completed. 8. Review of the SSD's education, dated 11/14/14, revealed Resident Council members were educated on abuse prohibition and reporting to the resident council. 9. A Post Survey interview with the current Administrator, on 12/08/14 at 3:38 PM, revealed on 11/06/14 she assumed the position of facility Administrator. She stated she was trained by the facility owner on 11/06/14 and by the Ombudsman on 10/14/14 related to abuse prohibition and the facility's policies on report abuse. She revealed if there was an allegation of abuse, she or her designee would: identify the alleged perpetrator and suspend immediately and remove from the facility pending the investigation. She stated the resident (if interviewable) would provide a statement of the allegation. She revealed if the allegation is physical in nature, she would ensure a skin assessment of the resident(s) has been conducted to identify any signs of physical or psychosocial injury and the resident(s) family/ responsible party and physician would be notified immediately. She stated within twenty-four (24) hours, she would notify the appropriate authorities (Office of Inspector General, Adult Protective Services/Centralized Intake, Ombudsman and Law Enforcement (if required.) She would review and assess any precipitating events or risks that may have contributed to the allegation and report to the Leadership Team during morning meeting. A conclusion will be reached within five (5) days and appropriate action taken based on the findings of the investigation which would be reported to the Office of Inspector General, Adult Protective Services, Ombudsman and resident(s) physician. She stated all evidence of the above actions will be documented in the abuse log and she would review the abuse log for appropriate completion and follow up as required.