Every finding on record at Grant Healthcare and Rehabilitation

Based on observation, interview, and review of the facility's policy, the facility failed to prepare and serve food in a safe manner. Observations on 09/09/2025 during lunch tray line preparation staff failed to utilize proper hand hygiene. The findings include:Review of the facility's policy titled Hand Hygiene dated 06/09/2025, revealed for all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene technique when using soap and water to dry thoroughly with a single-use towel and use clean towel to turn off the faucet. The use of gloves does not replace hand hygiene.Observation during initial tour of kitchen on 09/09/2025 at 11:06 AM revealed hand hyenine signage located above the hand sink near the tray line and proper glove use signage above the hand sink between the production area and the dish room. A review of the signage in the kitchen located above the hand sink in the production area, not dated, revealed it stated all employees must wash their hands before returning to work and explained the steps for proper handwashing. Proper hand washing: 1. Wet hands up to the elbow with hot water. 2. Apply soap. 3. Rub hands together for 20 seconds. 4. Clean under fingernails, 5. Rinse thoroughly under running water. 6. Dry hands with paper towel or an electric hand dryer. A review of the signage in the kitchen posted above the hand sink in the production area between the dish room not dated, titled proper glove use 1. Wear gloves to help prevent contaminating foods with bare hands 2. Change gloves frequently-especially when switching between tasks or after four hours of continuous use. 3. Wash hands between glove changes. Observation on 09/09/2025 at 12:30 PM revealed cook 1 walked from the production area to the hand sink turned on the faucet, washed her hands and turned off the faucet handles with her bare hands. She then used the paper towel to dry her hands and returned to serve the lunch tray line. Observation on 09/09/2025 at 12:41 PM revealed dietary worker 1 took off her gloves, turn on the faucet, washed her hands and then with the tips of her fingers turn off the faucets. She then used the paper towel to dry her hands. She returned to the production area behind the tray line. In an interview with the Dietary Manager on 09/11/2025 at 7:40 AM she stated staff should sing happy birthday twice when washing their hands. They should use the paper towel to turn off the faucet. She stated proper handwashing prevents the potential for infection and bacteria. In an interview with Director of Nursing (DON)Infection Preventionist (IP) on 09/12/2025 at 9:20 PM, she stated her expectations would be for dietary staff to use proper hand hygiene techniques. In an interview with the Administrator on 09/12/2025 at 9:34 AM, he stated his expectation was for staff to use proper hand hygiene techniques and turn off the faucet with a paper towel.

Based on observation, interview, record review, and review of the facility's policies, 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 and control the development and transmission of communicable diseases and to implement interventions to protect the residents. The facility failed to follow their policy related to ensuring the ice machines and water fountain were properly cleaned. Additionally, the facility failed to ensure Resident (R) 9's catheter was properly secured, and the catheter bag remained off the floor to help prevent infection. The findings include: Review of the facility policy titled Infection Prevention and Control Program dated 02/02/2025 revealed the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. Added review revealed standard precautions taken included environmental cleaning and disinfection according to facility policy. Further review revealed all staff have responsibility for cleanliness of the facility and are to report problems to appropriate department when outside their scope of practice. Continued review revealed all reusable equipment requiring special cleaning, disinfection shall be cleaned in accordance with current procedures. Review of ice machine manufacturer's instructions given by the facility, revealed the ice machine should be cleaned and descaled every 6 months or more often if the Time to Clean light comes on or if there is visible buildup. Added review revealed weekly maintenance included to empty and sanitize ice storage bin, clean door gaskets and frame, and to clean external surfaces with mild detergent or stainless-steel cleaner. Further review revealed monthly maintenance included cleaning and sanitizing the ice storage bin. 1. Observation of the ice machine on the 200 Hall on 09/10/2025 at 3:35 PM, revealed large amounts of dust and cobwebs collected underneath machine on the floor and on each side of the machine. Continued observation revealed large collection of dust and cobwebs on the walls on each side and back walls behind machine. Added observation revealed the supply lines leading from the wall into the machine had large amounts of cobwebs and dust. Further observation revealed black substance located on the front corners of the ice collection bin. During this observation the Maintenance Director scrapped black substance with his thumb nail from left corner. 2. Observation of Heritage Hall ice machine at 3:40 PM on 09/10/2025 revealed black substance located on rim of ice storage bin and inside ice dispenser. Added observation revealed underneath the machine with flashlight, revealed a large buildup of cobwebs and dust on the bottom of the ice machine, underneath the ice machine on the floor, and on lines leading to ice machine. Further observation revealed large buildup of dust and cobwebs on walls of each side and back wall of machine.During review of the manufactures maintenance instructions for the ice machines with the Maintenance Director (MD) on 09/12/2025 at 9:25 AM, he stated he had never seen those maintenance instructions before and was not following the recommendations but was doing the weekly maintenance and would provide that log; however, the log was not provided prior to exit on 09/12/2025. 3. Observation of the drinking fountain on 09/10/2025 at 1:30 and on 09/12/2025 at 9:26 AM, revealed the water fountain was functioning with water coming out spout when activated by panel button. Further observation revealed a buildup of a black substance on the drinking spout and drain of the drinking fountain. During the observation with the MD, he scraped it off with his thumb nail and said it could be mold. He further stated he did not think the water fountain worked. During an interview with the facility Maintenance Director (MD) on 09/11/2025 at 9:43AM, he stated he had worked at the facility for about 9 years, and he was responsible for taking care of repairs to the building and the upkeep of equipment. When asked how often the filter is changed on drinking fountain, he stated he was not sure adding he thought it doesn't have one. Continued interview with the MD on 09/12/2025 at 9:25 AM, he stated in the 9 years he had been here, he had never done anything to the drinking fountain on the memory care unit. When asked what his concern would be if not cleaned properly, he stated the water could be contaminated and could make people sick. Request was made at this time for manufactures instructions for water fountain; however, one was not provided by end of survey on 09/12/2025. During an interview on 09/12/2025 at 9:56 AM with the Environmental Services Director when asked how often the drinking fountain was cleaned on memory care unit, he stated he thought the drinking fountain on memory care unit was not even working. When asked if his department cleaned it, he again stated, he did not think it was working but would look at it and clean it if needed. During an interview with the Director of Nursing (DON) at 10:10 AM on 09/12/2025, she stated she was also the facility's Infection Preventionist (IP) nurse. She stated her duties as IP nurse include monitoring infections in building and assuring staff was following infection control procedures. She stated the black substances on the ice machines and water fountain and the buildup of dirt and dust on the ice machines were concerning to her because there could be a chance of cross contamination and bacteria buildup. She further stated when staff used bath basins to fill the coolers with ice, they should be thrown away to prevent infections. She stated her concern with the functioning water fountain on the memory care unit would be bacteria could be spread between residents. She added another concern would be residents who were on thickened liquids could be drinking from the fountain which could lead to aspiration pneumonia (lung infection caused by inhaling objects or substances in lungs instead of swallowing). During an interview with facility Administrator on 09/12/2025 at 11:30 AM he stated he provided oversite of the facility to include making sure staff received education. He stated equipment should be in working order and cleaned properly for the residents' safety. He stated he expected the ice machines and water fountain to be cleaned and maintained for infection control purposes, but he was unable to provide logs or documentation of a cleaning schedule for drinking fountain or ice machines. In continued interview, he stated when asked why a bath basin was sitting on top of 200 Hall ice machine, he stated that was what staff use to fill up coolers with ice but should be discarding and get a new one each time. e. In continued interview with the Administrator, he stated the memory care unit should not have a drinking fountain. When asked why, he stated there may be residents getting water that should not have thin liquids, and it posed a risk of cross contamination. He added it was his understanding the memory care unit drinking fountain was turned off. 4. Review of the facility's policy titled Indwelling Catheter Use and Removal dated 06/13/2025, revealed the catheter should be anchored to the resident's leg to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of R9's Resident Face Sheet revealed the facility readmitted R9 to the facility on [DATE] with diagnoses to include Obstructive Reflux Uropathy. Review of R9's Physician's Orders, dated 06/08/2022 revealed an order for a urinary catheter and catheter care to be performed twice daily. Continued review revealed change foley for blockage, leakage, or signs, symptoms of infection. Observation on 09/09/2025 at 1:34 AM, revealed R9 was in bed with his eyes closed, laying on his left side and catheter tubing appeared to have a white cloudy appearance. Observation on 09/10/2025 at 10:06 AM revealed R9's catheter bag was lying on the floor by the right side of the bed. Observation on 09/10/2025 at 2:28 PM revealed R9's catheter bag was lying on the floor between the right side of the bed and the residents' wheelchair. Observation on 09/10/2025 at 10:06 AM revealed R9 was in bed, with the catheter bag laying on the floor. Observation on 09/10/2025 at 2:28 PM revealed R9's catheter bag was on the floor to the left side of the bed. The resident's wheelchair was positioned close to the catheter tubing and the tubing was not secured to the resident. Observation on 09/11/2025 at 9:53 AM revealed R9 was in the hallway outside of his room, dressed sitting in his wheelchair. The catheter bag was not hanging from the wheelchair, R9 was holding the catheter bag under his shirt. In an interview with R9 on 09/11/2025 at 9:53 AM, he stated he was waiting in line to go outside to smoke. In an interview with State Registered Nurse Aide (SRNA) 3 on 09/11/2025 at 2:30 PM she stated the catheter bag should be hooked on the side of bed with the flap or dignity bag on the outside of the bed. In an interview with Licensed Practical Nurse (LPN) 1on 09/12/2025 at 9:11 AM, she stated it was an infection issue if the catheter bag was laying on the floor and catheter tubing should always be secured to the resident's leg. In an interview with Director of Nursing (DON)/Infection Preventionist (IP) on 09/12/2025 at 9:16 AM, she stated it would be an infection control concern if the catheter bag was laying on the floor, and the catheter tubing was not secured to the resident's leg. In an interview with Administrator on 09/12/2025 at 9:20 AM, he stated his expectations were for the catheter bags to be properly hung on the bed or under the resident's wheelchair.

Based on observation, interview, review of the facility's policies, review of the manufacturer's directions for use for the Assure Prism Multi-Blood Glucose Monitoring System, and review of the instructions for Clorox Healthcare Bleach Germicidal Wipes, the facility failed to follow standard infection procedures for cleaning and handling 1 of 8 glucometers. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, dated 01/02/2020, revealed the purpose of the policy was to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility's policy titled, Blood Glucose Monitoring, dated 01/02/2020, revealed the purpose of the policy was for the facility to perform blood glucose monitoring to diabetic residents as per physician's orders. The policy outlined the procedure for obtaining a resident's blood glucose level. As part of the procedure for obtaining the blood glucose level, the policy stated the glucometer was to be cleaned and disinfected per manufacturer's instructions. Review of the Assure Prism Multi-Blood Glucose Monitoring System's User Instruction Manual revealed the glucometer should be cleaned and disinfected after use on each resident and might only be used for testing multiple residents when Standard Precautions and the manufacturer's disinfection procedures were followed. Further review revealed the only cleaning and disinfecting solution that had been validated for use with this glucometer was Clorox Healthcare Bleach Germicidal Wipes. Review of the cleaning and disinfecting instructions for Clorox Healthcare Bleach Germicidal Wipes container revealed for cleaning and disinfection the contact time was three (3) minutes. Observation on 10/23/2024 at 8:35 AM revealed Registered Nurse (RN) 1 placed the cleaned glucometer onto the surface of the medication cart labeled Cart 400-408, without a barrier underneath. Further observation revealed RN1 touched the glucometer without wearing gloves. In an interview with RN1 on 10/23/2024 at 8:35 AM, he stated he only placed cleaned glucometers on barriers when he set them on surfaces inside a resident's room. He also stated he did not wear gloves to touch the glucometer unless he was performing a blood glucose test, handling a used glucometer, or cleaning the glucometer. In an interview with Licensed Practical Nurse (LPN) 5 on 10/23/2024 at 8:58 AM, she stated glucometers were to be cleaned between residents. She stated they were to be cleaned/disinfected with Clorox Wipes. She stated after wiping the glucometer, she wrapped it in the Clorox wipe and placed it in a clean cup. LPN5 stated the time needed to kill microbes was three minutes. After the glucometer dried, she stated she placed it on a barrier (a paper towel) on top of her medicine cart. In an interview with the Director of Nursing (DON) on 10/24/2024 at 4:24 PM, she stated her expectation was that nursing staff would clean the glucometer after use, in between each resident. The DON stated the procedure for cleaning and disinfecting the glucometers was the glucometer was cleaned by wiping it with the Clorox Healthcare Bleach Germicidal Wipes and then disinfected by wrapping it in the wipe to keep it wet for the three minutes needed to kill microbes. She stated the wrapped glucometer was placed in a clean plastic cup. She stated, once cleaned and disinfected, the glucometer should be placed on a barrier. In an interview with the Administrator on 10/25/2024 at 8:20 AM, he stated glucometers should be cleaned after use/between each resident. He stated he expected nursing staff to clean and disinfect the glucometers with the wipes provided by the facility. He stated, once the glucometer was cleaned/disinfected, it should be placed on a barrier.

Based on observation, interview, review of the website https://www.fda.gov/media/74866/download, review of Medication Refrigerator Temperature Guidelines: What You Should Know, and review of the facility's policies, the facility failed to label and store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication refrigerators observed. A multi-use vial of Tuberculin Purified Protein Derivative (PPD) was found in a plastic bag in the door of the refrigerator and was opened and not dated in the Medication Room on Heritage Hall. The findings include: Review of the facility's policy titled, Medication Storage, revised 08/01/2024, revealed it was the policy of the facility to ensure all medications housed on the premises would be stored in accordance with the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the facility's policy titled, Medication Administration, revised 02/20/2024, revealed the nurse must identify the expiration date. Per the policy, if the medication was expired, the nurse manager should be notified. Review of website https://www.fda.gov/media/74866/download, under Storage for Tuberculin Purified Protein Derivative stated a vial of tubersol which has been entered and in use for 30 days should be discarded. It also stated PPD should be stored in a refrigerator at a temperature between 35 to 46 degrees Fahrenheit. Review of the American Biotech Supply document Medication Refrigerator Temperature Guidelines: What You Should Know, undated, revealed medications should be stored in the center of the refrigerator, away from the bottoms and sides. It stated to never store medications in door shelves or bins as these areas were prone to larger fluctuations in temperature. Observation on 10/22/2024 at 11:00 AM, revealed one opened and undated multiuse vial of PPD (used in a tuberculin skin test to diagnose tuberculosis) was found in door of the refrigerator on the Heritage Hall medication room. During an interview with an agency nurse, Licensed Practical Nurse (LPN) 7 on 10/24/2024 at 8:39 AM, she stated when opening a multi-use vial of medication, it was to be dated. LPN7 stated she was not aware of not storing medications in the door of the refrigerator. She stated she received all her education through her agency. During an interview with LPN5 on 10/24/2024 at 8:43 AM, she stated she knew to date multi-dose medications when opening for the first time. She stated she knew not to store medications in the refrigerator door. She stated all her education and competencies were done through the agency portal. During an interview with Registered Nurse (RN) 3 on 10/24/2024 at 9:20 AM, she stated any medication should be dated when opened. She stated, if a medication was found opened and undated, it should be discarded and replaced with a new one. She stated no medication should be kept in the door of the refrigerator due to not being stored at the proper temperature. During an interview with LPN1 on 10/24/2024 at 9:49 AM, she stated any medication should be dated when opened. She stated, if opened and not dated, the medication should be discarded and replaced with a new one. She stated this was done because if the medication was outdated, it might not work the same. LPN1 stated no medication should ever be placed in the door of the refrigerator. During an interview with the Director of Nursing (DON) on 10/24/2024 at 8:52 AM, she stated she expected nurses to date medications when they opened them. She stated no medications should be stored in the door of the refrigerator. During an interview with the Administrator on 10/25/2024 at 9:38 AM, he stated it was his expectation for staff to follow policies and procedures that were in place related to medication storage and administration. He stated staff had to date the medication when opened for the first time so staff knew when the medication should be discarded. He stated it was important to ensure the residents were not receiving expired medications.

Based on interview, record review, and review of the facility's policy, the facility failed to keep residents free from abuse for 1 of 25 sampled residents (Resident (R) 341). On [DATE], R341 was physically restrained by Certified Nursing Assistant (CNA) 6 and Licensed Practical Nurse (LPN) 6 while they were providing care which resulted in bruising of both of the resident's forearms. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, revised date [DATE], revealed, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy also stated, 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and C. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriaton of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI program. Review of R341's Facesheet revealed the facility admitted the resident on [DATE] with diagnoses of Alzheimer's disease, dementia, mood disturbance, and cerebral infarction without residual deficits. Further review revealed R341 expired on [DATE]. Review of R341's quarterly Minimum Data Set (MDS) assessment with an Assesment Reference Date (ARD) of [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating the resident had severe cognitive impairment. Further review revealed R341 was dependent for toileting hygiene. Review of R341's Care Plan revealed R341 was care planned for behavioral symptoms related to a history of resisting/refusing the care regime with the intervention/approach of to respect the resident's right to make decisions, dated [DATE]; provide a calm environment and demeanor, and if the resident resisted care, try to do the task later without forcing her, dated [DATE]; and if the resident refused care, try at a later time, possibly with a different staff member, dated [DATE]. Review of R341's ,d+[DATE] Medication Administration Record (MAR) revealed she had an order for aspirin 81 milligrams (mg) daily. Review of CNA6's Witness Statement, dated [DATE], revealed during rounds on [DATE], CNA6 entered R341's room and told her CNA6 was going to change her. R341 refused, pulled the covers up, and would not allow CNA6 to change her. Per the statement, CNA6 left the room and reported to LPN6 that R341 was refusing to be changed. Per the statement, CNA6 stated LPN6 told her she would help her change R341 when she was finished with her medication administration. Per the statement, CNA6 stated once LPN6 was finished, they both went into R341's room to change her, and the resident still refused to be changed. Per the statement, CNA6 stated LPN6 had to hold R341's hands against R341's chest because she was trying to hit them. Per the statement, once CNA6 changed the resident, they were rolling her back over, and CNA6 reported she was then holding R341's hands, and R341 was squeezing CNA6's hands. Per the statement, CNA6 was asked if at any point did R341 state they were hurting her. CNA6 stated yes. Review of R341's Wound Management Note, dated [DATE] at 6:34 PM, revealed the left lower arm bruise measured 12 centimeters (cm) long by 6.5 cm wide, and the color was black. The right lower arm bruise measured 18 cm (length) X 9.5 cm (width) and was black in color. Review of R341's Progress Notes on [DATE] at 9:05 PM revealed the resident was noted with discolorations to her bilateral upper extremities (BUE); the resident took aspirin daily; the Medical Director was aware of the bruising; a message was left for R341's representative to call the facility; and new orders were received to observe the resident every shift. Review of R341's Progress Notes on [DATE] at 1:23 AM revealed there was no change in the bruising on her arms; sleeves were in place; the resident denied pain or distress; and no open areas or infection were noted. Further review revealed on [DATE] at 2:17 PM geri-sleeves (placed on the arms to prevent skin injury) were in place. Review of R341's Progress Notes on [DATE] at 2:28 AM revealed the resident continued to have bruising to her BUE but denied pain and geri-sleeves were in place. The note stated on [DATE] at 10:04 AM the BUE bruising remained, and the resident would be followed by the Wound Nurse Practitioner (NP) on rounds. Per the note, R341's representative was now aware. Further review revealed on [DATE] at 2:43 PM the resident continued with bruising to her BUE, and geri-sleeves were in place. Review of R341's Progress Notes on [DATE] at 2:17 AM revealed the resident continued with bruising to her BUE but denied pain, and geri-sleeves were in place. Further review on [DATE] at 8:53 PM revealed both arms were looking better, and the bruising was getting lighter. Review of R341's Progress Notes on [DATE] at 6:53 AM and 10:03 AM revealed the bruises remained on her BUE, and the geri-sleeves were in place. Review of R341's Progress Notes on [DATE] at 2:45 AM revealed the resident denied pain; at 2:45 AM and 11:56 AM the note stated the resident continued with bruising to her BUE, and the geri-sleeves were in place. Review of R341's Progress Notes on [DATE] at 2:03 AM and [DATE] at 2:57 AM revealed the resident continued with bruising to her BUE, and the geri-sleeves were in place. Review of R341's Progress Notes on [DATE] at 11:13 AM revealed the resident refused a skin assessment and a shower and/or bed bath at this time. Per the note, the resident had no complaints of pain/discomfort. Review of R341's Progress Notes on [DATE] at 6:40 PM revealed the resident was seen by the Wound NP on rounds and documented the discoloration to the resident's BUE were healed, and the Medical Director was aware. Unsuccessful attempts were made to contact R341's representative on [DATE] at 4:04 PM. Immediately after this, a text message was sent, with no response received. During an interview with CNA6 on [DATE] at 6:00 PM, she stated she was familiar with R341 because she had just returned to work from maternity leave when the incident happened. She stated R341 had fragile skin and needed to be cleaned frequently. She stated when she entered R341's room to clean her up, R341 was not acting like she normally did, and the resident was being mean and combative. She stated she went out of room to get assistance from another staff member to help her. She stated she asked LPN6 for help, and LPN told her the LPN would help after she administered medications. CNA6 stated when she and LPN6 entered the room to clean R341, LPN6 was holding R341's arms to keep her from hitting. She stated, once they turned R341 over to get the dirty things out from under her, LPN6 instructed her to hold the resident's arms. She stated she followed instructions and held the resident's hands, but she did not feel like she held them tightly enough to cause bruising. She stated the whole time the resident was yelling that they were hurting her. She stated she did not know the bruises were there until the next day when she overheard staff talking about it. She stated when she entered R341's room the resident pointed CNA6 out, held up her arms, and said, You did this to me. CNA6 stated she was on her way to talk to the Director of Nursing (DON), when she was called into the office and suspended. She stated she was suspended for one week, and then the facility called her and terminated her over the phone. During an interview with Registered Nurse (RN) 3 on [DATE] at 9:20 AM, she stated she had no concerns related to care provided by CNA6 and did not recall the agency nurse involved. During an interview with LPN1 on [DATE] at 9:49 AM, she stated she was working the day the bruises were discovered on R341. LPN1 stated R341 complained that someone grabbed her arm. LPN1 stated she never had any issues/concerns with the care provided to residents by CNA6. She stated she did not remember LPN6. During an interview with the Activities Director (AD) on [DATE] at 12:30 PM, she stated she was a CNA at the time of the incident. She stated she entered the resident's room after coming on shift on [DATE]. She stated R341raised her arms and said, Look what they did to me. The AD stated R341 had bruises on both forearms that covered most of the surface area. The AD stated she had worked the previous day, and the bruises were not there. She stated she never had any concerns regarding care provided by CNA6 prior to this event. However, she stated CNA6 had no reaction when the resident showed her the bruises, and CNA6 never apologized to the resident. She stated CNA6 reported to her that she had to get a little aggressive and hold the resident's arms so she could perform care. During an interview with LPN6 on [DATE] at 1:05 PM, she stated she was an agency nurse at the time of the incident. She stated she worked at the facility via the agency for six to eight months. She stated she remembered the resident and the incident. She stated the incident was why she quit picking up shifts at the facility. She stated the resident was confused on the day of the incident and did not want to be cleaned. However, she stated the resident had a pressure ulcer to her bottom and needed to be cleaned. LPN6 stated she had always been able to redirect R341, and she was able this day as well. However, she stated midway through cleaning R341, the resident became angry, combative, and began to throw her arms around. She stated the resident hit her and CNA6, who was helping. LPN6 stated she had to protect herself and had to hold the resident's hands. However, LPN6 stated she did not feel she held the resident tight enough to cause bruising. She also stated, if CNA6 felt like she was causing harm to the resident, she would have expected the CNA to tell her. During an interview with the DON on [DATE] at 8:52 AM, she stated she never had any concerns with CNA6 providing care to residents. She stated she expected any abuse to be reported immediately. She also stated residents had the right to refuse care. During an interview with the Administrator on [DATE] at 9:38 AM, he stated he was also the abuse coordinator. He stated he attempted to reached out to both perpetrators and was unsuccessful with reaching LPN6 but was able to reach CNA6. He stated he had a conversation and took a statement from CNA6. He stated LPN6 was an agency nurse who never returned his call. He stated he did not believe CNA6 intended to harm to resident, but she was ultimately terminated. He stated LPN6 was placed on a do not return list. He stated the incident was reported to the Ombudsmen, state agency, and Adult Protective Services (APS). He stated LPN6 was reported to her agency. He stated CNA6 was previously employed at an assisted living facility before she came to the facility. He stated, once here, she had some issues with services related to changing/cleaning residents that was addressed but did not exhibit behaviors related to any abuse toward residents. He stated LPN6 did not exhibit any behaviors prior to the incident. He stated his expectation was that no one in the facility was abused. He stated if staff saw abuse, he expected staff to stop it, keep residents safe, and report it immediately. The Administrator stated this was important because, I care about the resident, and they should not be in an environment where there is a possibility they could be abused.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from abuse for one (1) of thirteen (13) sampled residents, Resident #7. On 06/02/2021 at approximately 8:19 AM, Resident #2 reached out and grabbed Resident #7, who was walking past, in his/her private area over the top of his/her clothing. The findings include: Review of the facility's policy titled, Abuse Prohibition, last reviewed 04/09/2021, revealed the facility defined abuse as the willful infliction of injury and defined willful as the abuser acted deliberately, not that harm or injury was intended. In addition, the policy defined sexual abuse as non-consensual sexual contact of any type with a resident. Review of a Long Term Care Facility Self-Reported Incident Form, final report, dated 06/07/2021, revealed on 06/02/2021, Resident #2 was in the hallway in his/her wheelchair when Resident #7 walked past. Resident #2 reached out and grabbed Resident #7 in his/her private area, over his/her clothing and brief, witnessed by SRNA #7 who immediately separated them and Resident #2 was placed on one-to-one (1:1) supervision. The report goes on to reveal Resident #7 continued to walk away from Resident #2, apparently unaffected by the event. The report goes on to reveal Resident #2 laughed and stated he/she was just playing when asked why he/she did that. Review of Resident #2's medical record revealed the resident was admitted to the facility, on 12/03/2019, and was readmitted to the facility, on 05/20/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #2, in a Quarterly Minimum Data Set (MDS) Assessment, dated 05/21/2021, as scoring nine (9) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of Resident #2's Comprehensive Care Plan revealed a care plan for sexually inappropriate behavior, with behaviors identified consisting of attempting to grope staff and making sexually inappropriate comments to staff. Continued review of Resident #2's care plan revealed no mention of sexually inappropriate behaviors or statements directed at other residents, until the care plan revision on 06/07/2021 following this incident. Review of Resident #7's medical record revealed Resident #7 was admitted to the facility, on 07/13/2020, and was readmitted to the facility, on 05/11/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #7, in a Significant Change MDS, dated [DATE], as scoring two (2) out of a possible fifteen (15) on the BIMS, indicating severe cognitive impairment. Review of Resident #7's Skin Check, dated 06/02/2021, revealed no new areas identified in this assessment, which was conducted following the incident. Interview with Resident #2, on 06/08/2021 at 3:17 PM, revealed he/she was unable to get up as he/she was paralyzed. When asked if staff assisted him/her up, the resident shared they did assist him/her to the wheelchair when he/she wanted up. In addition, Resident #2 did not respond when asked about the incident on 06/02/2021. Observation and interview with Resident #7, on 06/08/2021 at 3:20 PM, revealed he/she was wandering in the hallway of the facility holding a yellow flower. The State Survey Agency Surveyor commented the flower was pretty and asked the resident how he/she was doing, to which he/she responded twenty-nine dollars today. The resident then continued ambulating down the hall. Interview with State Registered Nurse Aide (SRNA) #3, on 06/08/2021 at 11:43 AM, revealed staff had just gotten Resident #2 up, on 06/02/2021, and he/she was ambulating down the hall in his/her wheelchair when the incident occurred. She stated Resident #7 was coming up the hall, and when Resident #2 saw Resident #7, he/she put his/her arm out and cupped Resident #7's groin area as they tried to walk past. SRNA #3 stated Resident #7 swatted his/her hands at Resident #2's arm, not making contact, with Resident #2 holding onto Resident #7's groin area, until SRNA #3 called out for Resident #2 to let go. SRNA #3 stated Resident #7 continued ambulating down the hall as if nothing had happened, and the SRNA alerted the nurse. Interview with Licensed Practical Nurse (LPN) #1, on 06/08/2021 at 12:18 PM, revealed SRNA #3 reported to her that Resident #2 had groped Resident #7 in his/her private area on 06/02/2021. She stated Resident #2 was immediately placed on one-to-one (1:1) supervision when up, and fifteen (15) minute checks while in bed, as Resident #2 was unable to independently transfer to his/her wheelchair. She stated there were no changes to Resident #7's mood or behaviors, and she educated Resident #2 that his/her behavior was inappropriate. Per interview, she stated Resident #2 told her that he/she was just playing. She said Resident #2 was not often up but had been getting up recently for therapy, and went back to bed immediately after. She stated Resident #2 did not like to be up and told people he/she was paralyzed, although he/she was not, and had been using that as an excuse to not get up and to receive more staff care. In addition, she stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Registered Nurse (RN) #1, on 06/09/2021 at 9:09 AM, revealed Resident #2 was constantly trying to grab female staff in their private areas. She said she was informed, on 06/02/2021, that Resident #2 had grabbed Resident #7's private area, and staff had him/her return to his/her room after the incident. Further, she stated staff had already alerted the Administrator and the Director of Nursing (DON). RN #1 stated she assessed Resident #7 and found no physical evidence from the incident. Interview with the DON, on 06/09/2021 at 4:47 PM, revealed her expectation was abuse should not occur, but sometimes things occurred that could not be predicted. She stated if abuse did happen, it was her expectation the facility followed its policy, protecting residents from the abuse, suspending immediately any staff accused of abuse, and conducting assessments and interviews as part of a comprehensive investigation, as well as making necessary notifications, including to the state agency. Further, the DON stated, prior to this incident, there had been no history of Resident #2 attempting any type of inappropriate contact with other residents. Interview with the Administrator, on 06/09/2021 at 3:08 PM, revealed staff had promptly reported to him, when Resident #2 touched Resident #7, and stopped Resident #2 before anything else could occur. He stated police were called, and he went back with the officer to speak with Resident #2. The Administrator stated the officer became frustrated with Resident #2, as Resident #2 did not respond to his questions. The Administrator stated the facility followed its protocol to try to keep other residents safe. Per interview, he said he expected residents to be protected from abuse, and if it occurred, he expected it to be reported to him right away, anytime day or night.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to maintain an accurate medical record by failing to document two (2) missed [MEDICAL TREATMENT] appointments for Resident #1. This effected one (1) of three (3) sampled residents who receive [MEDICAL TREATMENT] at an outside clinic. The findings include: Review of the facility's Refusal of Treatment policy (#OPS214) revised 03/01/18 revealed in the event that a facility resident chooses to exercise their right to refuse a physician ordered treatment, staff will document discussions with the patient, physician and other involved persons in the medical record. Facility staff are to document what the resident is refusing, assess the reasons for the refusal, advise the resident of the consequences of refusal and offer alternative treatments. Interview on 03/05/21 at 10:45 AM with Resident #1's niece revealed Resident #1 received [MEDICAL TREATMENT] (HD) on Mondays, Wednesdays, and Fridays at a local HD clinic. She stated Resident #1 had missed two consecutive Friday HD clinic appointments on 02/19/21 and 02/26/21 by not arriving to the scheduled appointments. The niece said Resident #1 had no cognitive deficits and was able to make his/her own medical decisions. She further stated Resident #1 had a history of [REDACTED]. Record review of Resident #1's medical record revealed the Primary Care Physician (PCP) ordered HD at the local [MEDICAL TREATMENT] clinic on Monday, Wednesday and Friday. Record review of the facility's Daily Assignment record revealed Licensed Practical Nurse (LPN) # 1 was assigned to Resident #1 on 02/19/21 and LPN #2 was assigned to Resident #1 on 02/26/21. Both LPN #1 and LPN #2 were responsible for preparing Resident #1 for HD on their assigned shifts. Review of Resident #1's medical record revealed no documented evidence entries were made on 02/19/21 or 02/26/21 describing that Resident #1 had missed the scheduled HD appointments. Further review of the medical record revealed no documentation entries were made describing attempts to Resident #1 to reconsider and attend the HD appointments, notification of the physician, notification of the HD clinic or notification of Resident #1's family. Interview 03/08/21 at 1:15 PM with Resident #1 revealed he/she agreed to have HD three (3) times a week at an outside HD facility. Resident #1 stated for a couple of Friday's in a row, I got frustrated and did not go to my [MEDICAL TREATMENT] appointments. Resident #1 stated he/she informed both LPN's that he/she had chosen to wait and attend the next scheduled appointment on Monday. Resident #1 also reported a prior history of choosing not attend scheduled HD appointments. Interview 03/08/21 at 10:45 AM with LPN #1 revealed she was assigned to Resident #1 on 02/19/21 and was responsible for getting the resident prepared for the scheduled HD appointment. During the interview, LPN #1 stated she was not aware Resident #1 did not leave for his/her scheduled HD appointment on 02/19/21 therefore, she did not document in Resident #1's medical record the resident hed refused to go to the HD appointment. LPN #1 stated she was not informed until several days later that Resident #1 had refused to go the HD appointment. Telephone interview conducted on 03/08/21 at 11:00, with LPN #2 revealed she was assigned to Resident #1 on 02/26/21 and was responsible for getting him/her prepared for his scheduled HD appointment. During the interview, LPN #2 stated that she was aware Resident #1 was refusing to go to his scheduled HD appointment that morning. The LPN revealed she did not document in Resident #1's medical record that the resident was refusing to go to the appointment. Interview conducted on 03/08/21 at 11:30 AM, with Unit Manager (UM) #3 revealed when a resident refused to go to a scheduled HD appointment, the nurse on duty at the time of the refusal was responsible for documenting the refusal in the medical record. The assigned nurse was also responsible for documenting that they notified the physician, the [MEDICAL TREATMENT] clinic and the resident's responsible party if a resident was not able to make their own medical decisions. Interview conducted on 03/08/21 at 2:45 PM with the Chief Nursing Executive (CNE), revealed the assigned nurse should document in the medical record every time a [MEDICAL TREATMENT] resident refuses to go to his/her appointment. Our agency nurses are employed by a different company, which is owned by our corporation. Interview on 03/08/21 at 3:10 PM with the facility Staff Educator revealed before any Agency nurse was assigned to resident care, they were shown a training manual that instructed them on specific facility policies, including required documentation in the medical record for each resident. Interview on 03/08/21 at 3:45 PM with the Administrator revealed that it was his expectation that the medical records were accurate and completer. He stated nurses were to record in the medical record when a [MEDICAL TREATMENT] resident refused to go to their appointment.

Based on record review, interview, and review of the facility's policy, it was determined the facility failed to ensure the primary care physician was notified when Resident #1 missed two (2) [MEDICAL TREATMENT] appointments. This effected one (1) of three (3) residents reviewed for [MEDICAL TREATMENT]. The findings include: Review of the facility's Refusal of Treatment policy (#OPS214) revised 03/01/18 revealed in the event that a facility resident chooses to exercise their right to refuse a physician ordered treatment, staff will notify the physician of the refusal of treatment. Review of the facility's Physician/Advanced Practice Provider (APP) Notification policy (#NSG115), revised 11/01/19 revealed that upon identification of a patient who has a change in condition or abnormal labs, a licensed nurse will perform appropriate clinical observations, and collect pertinent patient information and report to the physician/advanced practice provider (APP). A telephone interview was conducted on 03/05/21 at 10:45 AM with Resident #1's niece. During the interview, the niece stated Resident #1 received [MEDICAL TREATMENT] (HD) on Mondays, Wednesdays and Fridays at a local HD clinic. Resident #1 had missed two consecutive Friday HD clinic appointments on 02/19/21 and 02/26/21 by not arriving to the scheduled appointments. The niece said Resident #1 had no cognitive deficits and was able to make his/her own medical decisions. Per the interview, Resident #1 had a history of [REDACTED]. A telephone interview was conducted on 03/08/21 at 2:15 PM with the Clinic Manager of the local HD clinic, where Resident #1 received [MEDICAL TREATMENT] treatments. The Clinic Manger reported the HD clinic did not have a record of anyone contacting the clinic on 02/19/21 or 02/26/21, informing them Resident #1 was not going to come to the scheduled appointment. The Clinic Manager reported it was not unusual for Resident #1 to miss scheduled appointments by refusing to come to them. Record review of the facility's Daily Assignment record revealed Licensed Practical Nurse (LPN) # 1 was assigned to Resident #1 on 02/19/21 and LPN #2 was assigned to Resident #1 on 02/26/21. Both LPN #1 and LPN #2 were responsible for preparing Resident #1 for HD on their assigned shifts. Record review of Resident #1's medical record revealed the Primary Care Physician (PCP) ordered HD at the local [MEDICAL TREATMENT] clinic on Monday, Wednesday and Friday. Review of nursing documentation revealed no documented evidence Resident #1's PCP was made aware of the missed HD appointments on 02/19/21 or 02/26/21. Interview 03/08/21 at 1:15 PM with Resident, #1 revealed the resident did agreed to have HD three (3) times a week when he/she admitted by the facility. Resident #1 stated for a couple of Friday's in a row, I got frustrated and did not go to my [MEDICAL TREATMENT] appointments. The resident stated LPN #1 and LPN #2 were instructed not to schedule a make-up HD appointment over the weekend. Resident #1 informed both the LPNs he/she had chosen to wait and attend the next scheduled appointment on Monday. Resident #1 also reported a prior history of choosing not attend the scheduled HD appointments. Interview 03/08/21 at 10:45 AM with LPN, #1 revealed the LPN was assigned to Resident #1 on 02/19/21 and was responsible for getting Resident #1 prepared for the scheduled HD appointment. During the interview, LPN #1 stated she was not aware Resident #1 did not leave for his scheduled HD appointment on 02/19/21. No one ever came and told me he was refusing to go. LPN #1 stated she did not notify Resident #1's PCP that the he/she was refusing to go to the HD appointment. LPN #1 stated she was not informed until several days later that Resident #1 had refused to go the HD appointment. Telephone interview conducted on 03/08/21 at 11:00 with LPN #2 revealed the LPN was assigned to Resident #1 on 02/26/21 and was responsible for getting him/her prepared for the scheduled HD appointment. During the interview, LPN #2 stated that she was aware Resident #1 was refusing to go to the scheduled HD appointment that morning. LPN #2 stated she did not notify Resident #1's PCP that the he/she was refusing to go to the scheduled HD appointment. Instead of calling and notifying the PCP, LPN #2 passed the information onto the relief nurse for Resident #1. Interview conducted on 03/08/21 at 11:30 AM with Unit Manager (UM) #3, revealed she was the Unit Manager of the unit Resident #1 resided on. During the interview UM #3 stated when a resident refused to go to a scheduled HD appointment, the nurse on duty at the time of the refusal was responsible for notifying the PCP. The assigned nurse was also responsible for documenting in the medical record that they notified the physician, the [MEDICAL TREATMENT] clinic and the resident's responsible party if a resident was not able to make their own medical decisions. Interview conducted on 03/08/21 at 11:50 AM with Medical Doctor (MD) #4 revealed he was Resident #1's primary care physician. During the interview, MD #4 stated he was not notified on the mornings of 02/19/21 and 02/26/21 that Resident #1 had refused to go to the scheduled HD appointments. MD #4 reported Resident #4 had been challenging to medically manage because of the Resident's end stage [MEDICAL CONDITION] and frequent refusal to go to scheduled HD appointments. He further stated he would expect to be notified by the facility that the resident refused HD. Interview conducted on 03/08/21 at 2:45 PM with the Chief Nursing Executive (CNE), revealed the assigned nurse should notify the resident's PCP every time a [MEDICAL TREATMENT] resident refused to go to an appointment. She stated Agency nurses were employed by a different company, which was owned by the same corporation. When agency nurses came to the facility, the Education Nurse provided facility specific competency instructions to them. Agency nurses are paired with a staff nurse for orientation. All agency nurses were to be educated on facility policy. The staffing agency educated agency nurses on physician notification policies before they were assigned to the facility. Interview on 03/08/21 at 3:10 PM with the facility Staff Educator revealed before any agency nurses was assigned to resident care, they were shown a training manual that instructed them on specific facility policies. Agency staff were instructed to ask a member of management if they were unclear about any of the policies. Interview on 03/08/21 at 3:45 PM with the Administrator revealed it was the expectation of the Administrator that Agency Nurses were to notify the physician when a resident who received HD at an outside clinic refused to go to their appointment. The Administrator also stated it was the expectation of the Administrator that Agency nurses be educated on company policies by the staffing agency prior to being assigned to the facility.

Based on interview, record review, review of Kentucky Revised Statute (KRS) Chapter 209.030, and review of the facility's policy, it was determined the facility failed to ensure an allegation of abuse was reported immediately, but not later than two (2) hours after the allegation was made for one (1) of six (6) sampled residents (Resident #1). On 11/26/2020 at approximately 12:00 PM, State Registered Nurse Aide (SRNA) #4 alleged witnessing SRNA #12 at the Providence Nurses Station being verbally abusive to Resident #1. SRNA #4 escorted Resident #1 to his/her room for safety, then reported the alleged verbal abuse to Unit Manager Heritage. However, the facility failed to implement its written abuse policy related to reporting the alleged violation to state agencies. Although the allegation was witnessed by SRNA #4 and reported to Unit Manager Heritage, Unit Manager Heritage did not report it to the Center Executive Director (CED). The allegation was not reported to the CED until four (4) days later, on 11/30/2020, by SRNA #4. The findings include: Review of KRS Chapter 209.030, revealed an oral or written report was to be made immediately to state agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of the facility's policy, Abuse Prohibition, revision date 07/01/2019, revealed allegations were to be reported by witnessing staff to their supervisor immediately to ensure resident safety. The policy stated the supervisor was responsible for reporting allegations to the CED or designee and other officials in accordance with state law, and the employee alleged to have committed the abuse to be removed from duty immediately pending investigation. Per policy review, allegations involving abuse, to include verbal abuse, were to be reported by the CED or designee no later than two (2) hours after the allegation was made. Review of the Long Term Care Facility-Self Reported Incident Form Initial Report, sent to the Office of Inspector General (OIG), on 11/30/2020 by the Interim Executive Director (IED), revealed an allegation of verbal abuse that occurred on 11/26/2020 was reported by SRNA #4 on 11/30/2020. SRNA #4 witnessed SRNA #12 being verbally inappropriate with Resident #1. Further review revealed SRNA #12 had been placed on administrative leave, on 11/30/2020. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility, on 09/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with SRNA #4, on 01/26/2021 at 2:03 PM, revealed she was working on the Providence Unit when she witnessed Resident #1 in his/her wheelchair at the Providence Nurses Station. She stated she heard SRNA #12 call Resident #1 a [OBSCENITY] ing dumbass. She revealed Resident #1 had told SRNA #12 he/she had used the employee restroom and had come to the nurses station to let staff know he/she was done using the restroom. SRNA #4 stated she took Resident #1 back to his/her room, as she was not comfortable leaving Resident #1 at the nurses station. Per interview, she stated she then reported what she witnessed to Unit Manager Heritage. In addition, SRNA #4 stated, when she was working on 11/30/2020, she noticed SRNA #12 working on the same hall as Resident #1, so, at that time, she reported the incident to the Interim Executive Director (IED). She revealed the IED had her report everything that had happened. She revealed staff escorted SRNA #12 out of the facility that day. Interview with the Unit Manager Heritage, on 01/27/2021 at 9:11 AM, revealed she was informed by SRNA #4 of an allegation of verbal abuse on 11/26/2020. She revealed she spoke with both Resident #1, the alleged victim, and SRNA #12, the alleged perpetrator, with both denying any allegation of abuse. Unit Manager Heritage stated, since the incident, she had learned she should have contacted the CED and CNE when the allegation was reported to her. Telephone interview with the former Interim Executive Director (IED), on 01/28/2021 at 10:56 AM, revealed she was at the facility for a few weeks helping out and had several reportable incidents during her time at the facility. She was unable to recall the specific incident in question or if there was a discrepancy regarding timeliness of reporting. She stated when incidents were reported to her, she reported them within two (2) hours to state agencies. Per interview, the IED stated she expected staff to report incidents to the CED when they occurred. Telephone interview with the Assistant Director of Nursing (ADON), on 01/28/2021 at 11:03 AM, revealed she was unable to recall the allegation in question. When information was shared with her, she stated the incident should have been reported on 11/26/2020 to the CED, as the CED needed to know about situations when they occurred. Interview with the Center Nurse Executive (CNE), on 01/28/2021 at 1:44 PM, revealed she was not working at the time of the incident. She stated the CED should be notified immediately of any allegations of abuse. The CNE stated she expected notifications, including to OIG, to be made within two (2) hours following an allegation of abuse. Interview with the CED, on 01/28/2021 at 1:51 PM, revealed he had been working at the facility for under a month and was not present at the time of the allegation. He revealed he expected staff to notify him immediately of any allegation of abuse to ensure resident safety. The CED stated, once he was made aware of an allegation, he would notify state agencies, including OIG, of the allegation.

Based on interview, record review, review of Kentucky Revised Statute (KRS) Chapter 209.030, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy was implemented related to reporting allegations of abuse and protection from abuse for one (1) of six (6) sampled residents (Resident #1). On 11/26/2020 at approximately 12:00 PM, State Registered Nurse Aide (SRNA) #4 alleged witnessing SRNA #12 at the Providence Nurses Station being verbally abusive to Resident #1. SRNA #4 escorted Resident #1 to his/her room for safety, and then she reported the alleged verbal abuse to Unit Manager Heritage. However, the facility failed to implement its written abuse policy related to reporting the alleged violation to state agencies and protecting the resident throughout the investigation because SRNA #12 worked, on 11/29/2020 and 11/30/2020, on the same unit where Resident #1 resided. Although the allegation was witnessed by SRNA #4 and reported to Unit Manager Heritage, the manager did not report it to the Center Executive Director (CED). The allegation was not reported to the CED until four (4) days later, on 11/30/2020, by SRNA #4. The findings include: Review of the facility's policy, Abuse Prohibition, revision date 07/01/2019, revealed allegations were to be reported by witnessing staff to their supervisor immediately to ensure resident safety. The policy stated the supervisor was responsible for reporting allegations to the CED or designee and other officials in accordance with state law, and the employee alleged to have committed the abuse was to be removed from duty immediately, pending investigation. Per policy review, allegations involving abuse, to include verbal abuse, were to be reported by the CED or designee to state agencies no later than two (2) hours after the allegation was made. Review of KRS Chapter 209.030, revealed an oral or written report was to be made immediately to state agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of the Long Term Care Facility-Self Reported Incident Form Initial Report, sent to the Office of Inspector General (OIG), on 11/30/2020, by the Interim Executive Director (IED), revealed an allegation of verbal abuse that occurred, on 11/26/2020, and was reported by SRNA #4, on 11/30/2020. SRNA #4 witnessed SRNA #12 being verbally inappropriate with Resident #1. Further review revealed SRNA #12 had been placed on administrative leave, but not until 11/30/2020, four (4) days after the alleged verbal abuse occurred. Review of the facility's staffing schedules for 11/26/2020, 11/29/2020, and 11/30/2020 revealed SRNA #12 was assigned to the Providence Unit, for the 7:00 AM to 3:00 PM shift, on 11/26/2020, 11/29/2020, and 11/30/2020. Additional review revealed SRNA #4 was assigned to the Providence Unit, for the 7:00 AM to 3:00 PM shift, on 11/26/2020. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility, on 09/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #1 resided on the Providence Unit. Interview with SRNA #4, on 01/26/2021 at 2:03 PM, revealed she was working on the Providence Unit, on 11/26/2020, when she witnessed Resident #1 in his/her wheelchair at the Providence Nurses Station, at approximately 12:00 PM. She stated she heard SRNA #12 call Resident #1 a [OBSCENITY] ing dumbass. She revealed Resident #1 had told SRNA #12 he/she had used the employee restroom and had come to the nurses station to let staff know he/she was done using the restroom. SRNA #4 stated she took Resident #1 back to his/her room, as she was not comfortable leaving Resident #1 at the nurses station. Per interview, she stated she then reported what she witnessed to Unit Manager Heritage. She stated she did not see SRNA #12 the rest of the day. In addition, SRNA #4 stated, when she was working on 11/30/2020, she noticed SRNA #12 working on the same hall as Resident #1, so, at that time, she reported the incident to the Interim Executive Director (IED). She revealed the IED had her report everything that had happened. She revealed staff escorted SRNA #12 out of the facility that day. Interview with the Unit Manager Heritage, on 01/27/2021 at 9:11 AM, revealed she was informed by SRNA #4 of an allegation of verbal abuse on 11/26/2020. She revealed she spoke with both Resident #1, the alleged victim, and SRNA #12, the alleged perpetrator, with both denying any allegation of abuse. Unit Manager Heritage stated, since the incident, she had learned she should have contacted the CED and CNE when the allegation was reported to her. Interview with the Director of Social Services (DSS), on 01/27/2021 at 1:48 PM, revealed she remembered an allegation of verbal abuse involving Resident #1 and had interviewed Resident #1 several times following the allegation, and he/she had no recollection of anyone saying anything derogatory to him/her. The DSS revealed the facility reported the incident, and inservices were conducted on professionalism and abuse. Interview with SRNA #11, on 01/27/2021 at 3:45 PM, revealed she was at the Providence Nurses Station, on 11/26/2020, and remembered Resident #1 being upset at SRNA #12 because she was telling him/her the employee bathroom was off limits. She stated Resident #1 was loud and fussed with SRNA #12, and SRNA #12 told the resident to quiet down. She stated Resident #1 rolled away from the nurses station, and she overheard SRNA #12 state under her breath stupid. She stated SRNA #12 did not say what was alleged by SRNA #4 to the resident, did not cuss at the resident, and had been trying to get Resident #1 to calm down as he/she had been screaming at her. SRNA #11 stated the incident occurred a few days prior to staff being asked to give statements regarding the incident. Telephone interview with the former Interim Executive Director (IED), on 01/28/2021 at 10:56 AM, revealed she was at the facility for a few weeks helping out and had several reportable incidents during her time at the facility. She was unable to recall the specific incident in question or if there was a discrepancy regarding timeliness of reporting. She stated when incidents were reported to her, she reported them within two (2) hours to state agencies. She stated her expectation was staff reported incidents to the CED when they occurred. Telephone interview with the Assistant Director of Nursing (ADON), on 01/28/2021 at 11:03 AM, revealed she was unable to recall the allegation in question. When information was shared with her, she stated the incident should have been reported, on 11/26/2020, to the CED, as the CED needed to know about situations when they occurred. Interview with the Center Nurse Executive (CNE), on 01/28/2021 at 1:44 PM, revealed she was not working at the time of the incident. She revealed her expectation was staff protect residents from abuse, and the CED should be notified immediately of any allegations of abuse. She revealed another expectation was employees alleged to have abused residents should be immediately suspended to protect residents, and notifications, including to OIG, should be made within two (2) hours following allegations of abuse. Interview with the Center Executive Director (CED), on 01/28/2021 at 1:51 PM, revealed he had been working at the facility for under a month and was not present at the time of the allegation. He revealed his expectation was the CED be notified immediately of any allegation of abuse to ensure resident safety. He revealed, once he was made aware of an allegation, he began an investigation and notified the OIG of the allegation. In addition, he stated any employee alleged to have abused a resident would be immediately suspended.

Based on interview, record review and review of facility Policy, it was determined the facility failed to ensure residents are free from abuse for two (2) of five (5) sampled residents (Resident #2, Resident #4) On 01/28/2020, staff observed Resident #1 in the dining room kissing Resident #2 and touching Resident #2's peri area over his/her clothing. On 02/10/2020, Resident #3 threw a hard football shaped stress ball at Resident #4, resulting in bruising to Resident #4's left cheek and area around the left eye. The findings include: Review of the facility OPS300 Abuse Prohibition Policy, revised 07/01/19, revealed the Genesis HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of residents. Per Policy, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. 1. Review of the Long Term Care Facility-Self Reported (Five Day) Incident Form and Investigation dated 01/30/2020, completed by the Center Executive Director (CED), revealed State Registered Nurse Aide (SRNA) #1 witnessed the event at approximately 4:20 PM on 01/28/2020, as she was walking past the dining room. SRNA #1 observed Resident #1 kissing Resident #2 and touching his/her peri area outside of his/her clothing. Further, SRNA #1 and Licensed Practical Nurse (LPN) #1 immediately separated the residents and placed Resident #1 on one-on-one (1:1) supervision. A skin assessment was conducted for Resident #2 with no new areas noted. Continued review of the facility Investigation, revealed local law enforcement was notified and interviewed Resident #1. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/14/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, initiated 05/20/19, revealed the resident exhibited or had the potential to demonstrate verbal behaviors related to ineffective coping skills and poor anger management. Further review revealed the resident cursed and yelled at nurses, refused showers, was combative, and on 12/19/19 was noted sticking his/her hands down the front of his/her pants and then trying to rub it on the SRNA's face. The goal stated the resident would have fewer verbal outburst. There were several interventions including: if resident tries to rub his/her hands in staff's faces, stand back and tell him/her to stop as that was inappropriate; evaluate medications; explain all care and the reason for performing the care, and if resistive, postpone care and allow time for resident to regain composure. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/23/2020, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating no cognitive impairment. Further review revealed no behaviors noted during the look back period. Resident #1's Comprehensive Care Plan was revised (undated) after the incident with Resident #2, to state the resident was at risk for emotional distress related to recent resident to resident encounter with kissing, groping with Resident #1 the initiator. The goal stated the resident would have no signs and symptoms of unrelieved emotional distress. Interventions initiated 02/03/2020 included fifteen (15) minute checks, notify Physician as needed, observe for emotional distress, psyche consult and Social Services visits as needed. Review of Resident #1's physician's orders [REDACTED]. On 02/11/2020, [MEDICATION NAME] was increased to 20 mg per day. Review of the Brief Cognitive Assessment Tool (BCAT) Report, dated 02/06/2020, completed as a result of the 01/28/2020 incident, revealed Resident #1 had poor recall, scoring a total of sixteen (16) out of fifty (50). Interview with Resident #1, on 02/13/2020 at 4:00 PM, revealed he/she had no memory of any incident in the dining room involving himself/herself and another resident. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/28/15 with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan, initiated 07/31/19, revealed a behavioral care plan for being intrusive of other people's space and difficult to redirect. The goal stated the resident would demonstrate a decrease in physical behaviors. Interventions included diverting resident attention, removing resident from the environment as needed, and offering resident beverages or snacks. Resident #2's Comprehensive Care Plan was revised (undated) after the incident involving Resident #1 to state the resident was at risk for emotional distress related to Resident #2 being the recipient of a recent resident to resident encounter of kissing and groping. The goal stated the resident would have no signs and symptoms of unrelieved emotional distress. Interventions included notify Physician as needed; observe resident for emotional distress and reassure as needed; and social services visit. Review of skin assessments conducted on 01/22/2020 and 01/29/2020, revealed no changes in assessments, and no new areas indicated. Review of the Annual MDS Assessment, dated 02/03/2020, revealed the facility assessed Resident #2 as having a BIMS score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review revealed no behaviors noted during the look back period. Resident #2 was observed on 02/13/2020 at 4:30 PM, out in his/her wheelchair, up and down the hallways when not near the nursing station or in the dining room. The resident was not interviewable. Interview with SRNA #1, on 02/13/2020 at 1:02 PM, revealed she was walking past the dining room on 01/28/2020, prior to the evening meal, when she observed Resident #1 sitting in front of Resident #2. She stated she was unable to see what was going on when she walked past, so she backed up and saw Resident #1 attempting to kiss Resident #2. She further stated she turned and called out for LPN #1, and by the time the two (2) of them got into the dining room to separate Resident #1 and Resident #2, Resident #1 had his/her hand over Resident #2's peri area, touching his/her privates over the clothing. Per interview, Resident #1 was moved to a table by himself/herself, and Resident #2 was taken to the nurse's station. She stated Resident #2 had a grin on his/her face, and did not act like the incident had bothered him/her in any way. Interview with LPN #1, on 02/13/2020 at 1:17 PM, revealed she was on the 200 hallway conducting medication pass when SRNA #1 asked her for assistance. She stated when she got to the dining room, she observed Resident #1 touching Resident #2 on his/her private area on top of his/her clothing. She further stated she did not observe Resident #1 attempting to kiss Resident #2. Per interview, Resident #2 did not appear to be in any distress. LPN #1 stated Resident #2 was taken to the nurse's station, and Resident #1 was placed on one-on-one (1:1) supervision. Further interview revealed she had observed Resident #2 since the incident, and had not observed any changes in his/her behavior. Per interview, Resident #1 stayed in his/her room a lot, and she had never heard of or observed any kind of sexual behaviors towards residents prior to or after the incident on 01/28/2020. Interview with the Director of Social Services (DSS), on 02/13/2020 at 1:28 PM, revealed she followed up with both Resident #1 and Resident #2 during the week following the 01/28/2020 incident, with neither having knowledge of the event or exhibiting any changes in behaviors or routine. She stated local law enforcement came out and interviewed Resident #1, although no charges were pressed. Per interview, it was her expectation residents were free from any type of sexual abuse. Interview with SRNA #2 on 02/13/2020 at 1:50 PM revealed Resident #1 had exhibited inappropriate behaviors towards staff, although not towards residents. She stated she had only worked with Resident #1 once following the incident, and had observed no changes to his/her routines or behaviors, aside from more sexual comments towards staff providing care. She further stated she hadn't noticed any changes in Resident #2's behaviors following the incident. Interview with SRNA #3, on 02/13/2020 at 2:00 PM, revealed Resident #1 spent eighty (80) percent of his/her time in bed during the day, and as a result of inappropriate sexual comments towards staff, there was to be two (2) staff members providing care. She stated she had heard about the situation involving Resident #1 and Resident #2, but was not present when it occurred. She further stated she was unaware of Resident #1 being inappropriate with other residents until this incident. Interview with the Speech Therapist, on 02/13/2020 at 2:33 PM, revealed she conducted a BCAT test with Resident #1 on 02/06/2020 as a result of his/her statements of not recalling anything about the incident on 01/28/2020. She stated the BCAT assessment was more intensive than the BIMS, and a lot of the time in working with residents, the BIMS would indicate a resident was competent and would not be accurate. She further stated the BCAT covered different areas, with residents having to remember details after a much longer time, and included some functional reasoning, a clock test, and abstract reasoning. Per interview, Resident #1 did well on orientation and immediate memory, but shut down on problem solving executive function, and reasoning skills. She stated Resident #1 scored a sixteen (16) on the BCAT, with anything less than twenty-four (24) considered severe cognitive impairment range. She further stated this had impacted his/her ability to participate in speech therapy in the past. Interview with the Center Nurse Executive (CNE), on 02/13/2020 at 4:27 PM, revealed she was called by nursing staff on 01/28/2020 and received report on the incident. She stated appropriate parties were contacted, including the Physician, Power of Attorney or Guardians, and local law enforcement. She further stated she was present when law enforcement read Resident #1 his/her rights, and interviewed the resident. Per interview, Resident #1 denied the allegations, and appeared to have no recollection of events. Additional interview revealed Resident #1's [MEDICATION NAME] medication was increased on 01/10/2020, and following the incident, the Nurse Practitioner discontinued the [MEDICATION NAME] and started him/her on [MEDICATION NAME] 10 mg, noting that the [MEDICATION NAME] increase could have caused [MEDICAL CONDITION]. The CNE stated Resident #2 had no recollection of the event. Continued interview revealed it was her expectation residents that were unable to consent to sexual contact should be protected by staff from unwanted contact. Further, it was her expectation residents were free from sexual abuse. Interview with the Center Executive Director (CED) on 02/13/2020 at 5:07 PM, revealed after the incident involving Resident #1 and Resident #2, Resident #1 was placed on one-on-one (1:1) supervision until he/she could be seen by the Physician on 01/30/2020, at which time medication changes were made. She stated one-on-one (1:1) supervision was continued through the weekend and was changed to fifteen (15) minute checks on 02/03/2020. Per interview, the Director of Social Services had also been following up with both Resident #1 and Resident #2. Per interview, the family of Resident #1 was mortified by his/her behaviors. 3. Review of the Long Term Care Facility-Self Reported (Five Day) Incident Form and Investigation, dated 02/12/2020, completed by the CED, revealed on 02/10/2020 at 3:40 PM, Resident #3 threw a football-shaped stress ball at Resident #4, striking Resident #4 in the cheek and causing a raised area. Both residents shared a room and were in their respective beds at the time of the incident. When questioned, Resident #3 stated he/she threw the ball at Resident #4 as he/she was tired of the smell. Residents were separated following the incident, with Resident #3 requesting to change rooms, which staff were able to accommodate. Resident #4 was treated with an ice pack. Local law enforcement were contacted and conducted an interview with Resident #3, who acknowledged he/she should not have thrown the ball. Resident #4 declined to press charges. Continued review of the Investigation revealed lab work was completed for Resident #3, with no irregularities noted. Resident #4's left cheekbone developed a raised area of blue to purple bruising extending from the left cheekbone to the inner canthus of the left eye. Review of Resident #3's clinical record revealed the facility admitted the resident on 06/19/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/24/19, revealed the facility assessed Resident #3 as having a BIMS of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Further review revealed no behaviors noted during the look back period. Review of Resident #3's Comprehensive Care Plan, revised 01/03/2020, revealed a behavioral care plan revealing the resident had a history of [REDACTED]. The goal stated the resident would not exhibit disruptive behaviors. Interventions included allowing resident times to vent feelings, and observing for and managing unmet needs; approach in a calm and friendly manner; and reassure when resident was being repetitive. Review of the Comprehensive Care Plan, (undated), revised after the altercation with Resident #4, revealed the resident was at risk of emotional distress due to resident to resident altercation with a goal that the resident would have no signs/symptoms of emotional distress. Interventions included allow resident to express feelings; observe for emotional distress; provide emotional support; room change on 02/10/2020; and SSD visits as needed. Interview with Resident #3, on 02/13/2020 at 10:00 AM, revealed difficulty communicating, due to slurred speech. Resident #3 was able to provide simple responses, and for more complex communication was able to type on an electronic communication board. When asked about the incident on 02/10/2020, the resident stated he/she threw the ball at Resident #4 as Resident #4 Stunk and wouldn't do anything about it. Resident #3 stated he/she was trying to get Resident #4 to leave by throwing the ball. When questioned about what precipitated the event, Resident #3 stated he/she Just got tired of it. When asked if Resident #3 had told anyone about his/her concerns regarding Resident #4, he/she initially stated no, then stated he/she had, but could not remember who he/she had spoken to or anything more related to communicating his/her concerns to staff. 4. Review of Resident #4's clinical record revealed the facility admitted the resident on 02/25/19 with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan initiated 03/31/19, revealed the resident exhibits or had the potential to demonstrate verbal behaviors related to frontal lobe and executive function deficit and ineffective coping skills with a goal that the resident would not exhibit verbal outbursts directed towards others. Interventions included evaluate medications; observe for pain; evaluate need for Psyche/Behavioral consult; and observe for signs and symptoms that may contribute to verbal behaviors. Review of the Quarterly MDS Assessment, dated 11/27/19, revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Further review revealed no behaviors noted during the look back period. Review of Resident #4's Comprehensive Care Plan, undated, revised following the 02/10/2020 incident, revealed a care plan for emotional distress, stating the resident was at risk for complications and emotional stress related to resident to resident altercation with a goal stating the resident would be free from signs and symptoms of emotional distress. Interventions included allow resident to express feelings; observe for emotional distress; and provide emotional support and SSD visits. Continued review of Resident #4's clinical record revealed a skin assessment dated [DATE], with no skin breakdown noted, and a skin assessment dated [DATE], noting a 1.0 centimeter (cm) abrasion to the left cheek. Observation of Resident #4, on 02/13/20 at 1:02 PM, revealed bruising from the left cheekbone up around the nose and eye, with bruising dark purple around the nose and eye and dark blue to the cheek. Interview with Resident #4, on 02/13/2020 at 1:02 PM, revealed on 02/10/2020, prior to the incident, he/she had pulled the curtain back a little so he/she wouldn't be bothered by Resident #3's television, and a moment later saw Resident #3 reaching for his/her grab bar to pull the curtain back. Per interview, Resident #4 told Resident #3 not to bother, and pulled the curtain back, and the next thing he knew Resident #3 threw a stress ball as hard as he/she could, hitting him/her just below the left eye. Resident #4 stated the bruising was about twice as big yesterday, but the swelling had gone down with ice packs. Resident #4 further stated he/she wasn't sure why Resident #3 threw the stress ball at him/her, but stated he/she felt Resident #3 was a potential danger to any roommates, and Resident #3 needed some serious mental help. Resident #4 stated he/she felt safe since Resident #3's room change. Interview with SRNA #1, on 02/13/2020 at 1:02 PM, revealed Resident #3 had a temper, and would sometimes sweep things off of his/her overbed table into the floor. SRNA #1 further stated Resident #3 had never attempted to hurt anyone in the four (4) years she had worked with him/her, and had never complained to her about Resident #4. She described Resident #4 as a nice person that didn't complain about anything. Interview with LPN #1, on 02/13/2020 at 1:17 PM, revealed Resident #3 spent his/her time in bed and was more of an evening person. She stated she was unaware of any behaviors. Regarding Resident #4, LPN #1 described him/her as pretty independent and nice. She stated she was unaware of any complaints by one resident against the other prior to the 02/10/2020 incident. Interview with the DSS, on 02/13/2020 at 1:28 PM, revealed the stress ball Resident #3 threw at Resident #4 was about six (6) inches long and football shaped with tapered ends, although hard like a baseball and difficult to squeeze. She stated she had sent it home with Resident #3's father after the incident. She further stated she came down to the room a few minutes after the incident happened, and spoke with both residents. Further, based on her interviews, she believed Resident #3 became upset over Resident #4 pulling the privacy curtain down, as Resident #3 liked to watch his/her television and also liked to be able to see out into the hall. She stated Resident #3 informed her he/she threw the ball because Resident #4 was too stinky and he/she couldn't stand it any longer. Per interview, Resident #3 wanted to change rooms, and they were able to accommodate the room change. She further stated local law enforcement came and interviewed both residents, with Resident #4 opting not to press charges, and Resident #3 sticking to his/her account of throwing the stress ball due to the odor. The DSS stated she did not observe any odor when she was in the room with Resident #4. She concluded that neither resident had expressed any concerns following the incident, and both seemed happier with the room changes. Interview with the CNE, on 02/13/2020 at 4:27 PM, revealed she was on the Phone with the medical director when she heard Resident #3 yelling. She could not make out what was being said, but recognized Resident #3's voice. She further stated all nearby staff, including her, instantly bolted towards the resident's room. Per interview, by the time she got to the resident's room, the Unit Manager, the Social Worker, Resident #4's son and another nurse were already in the room. Further interview revealed Resident #3 admitted to throwing the stress ball, and said he/she did it because Resident #4 stinks. Resident #4 stated Resident #3 threw the stress ball as he/she got angry with Resident #4 for moving the privacy curtain. Additional interview revealed the Nurse Practitioner came in the next day and examined Resident #4, and Resident #3 was scheduled to be seen by the Psychiatrist. The CNE stated prior to the incident she spoke with both residents often, and if there was a concern she would think they would have expressed their concern prior to resorting to violence. Per interview, it was her expectation residents were free from any abuse. Interview with the CED on 02/13/2020 at 5:07 PM revealed she had been alerted by the unit manager that Resident #3 threw a stress ball and injured Resident #4. She revealed when she entered the room, both residents were calm. Per interview, following the incident, neither resident was left alone until after Resident #3 had changed rooms. She stated there had been no prior history of violence from Resident #3, and Resident #4 did not want to press charges. Per interview, it was her expectation that every resident be free from any type of abuse.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure residents are free from abuse for one (1) of four (4) sampled residents (Resident #1). On 10/24/19, Resident #1 sustained scratches and skin tears to his/her face and skin tears and a scratch to his/her left arm during a resident-to-resident altercation with Resident #2. The findings include: Review of the facility Policy titled, OPS300 Abuse Prohibition , revised 07/01/19, revealed the Genesis HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of residents. Per Policy, abuse was defined as the willful infliction of injury, irrespective of any mental or physical condition. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/12/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/10/19, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Further, the facility assessed the resident as having a mood score of six (6), indicating moderate depression; and also assessed the resident as having no behaviors during the look back period. Continued review of the MDS Assessment revealed the facility assessed the resident as requiring extensive assist for transfers and locomotion on/off the Unit and requiring total assistance of staff for other Activities of Daily Living. Review of Resident #1's Comprehensive Care Plan, initiated 07/12/17, revealed a focus of behaviors; unaware of personal boundary spaces of others, and bumps wheelchair into things. The goal stated the resident would be able to be redirected. Interventions included musical activities, picture books/magazines, may eat meals in lounge to reduce over-stimulation as needed, and place on fifteen (15) minute checks when over-stimulated or repeatedly bumping into things until he/she calms down. Review of the Skin Assessment, dated 10/24/19, revealed the resident sustained [REDACTED]. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 05/02/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/06/19 revealed the facility assessed the resident as having a BI[CONDITION] score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Further, the facility assessed the resident as having a mood score of (9) indicating moderate depression. Continued review revealed the facility assessed Resident #2 as having no behaviors during the look back period. Review of Resident #2's Comprehensive Care Plan, initiated 11/19/18, revealed the resident had the potential to exhibit physical behaviors due to a history of swinging at staff members, refusing care, and resident to resident altercations. The goal stated the resident would have a decrease in behaviors. There were several interventions including provide redirection as needed, allow for time for expression of feelings, and social services to provide support. New interventions added 10/24/19 included stop sign to the resident's doorway. Review of the Long Term Care Facility-Self Reported Incident Form (Five Day) and Investigation dated 10/30/19, completed by the Administrator, revealed a State Registered Nurse Aide (SRNA) witnessed Resident #1 exiting Resident #2's room and noticed blood on Resident #1's left arm and face on 10/24/19. Resident #2 informed the SRNA that he/she punched Resident #1 in the face because Resident #1 wandered into his/her room. Per the Investigation, the alleged alleged perpetrator (Resident #2), was directed to the conference room for an interview, and did admit to hitting Resident #1 because he/she was pilfering through his/her belongings. Further, during the interview, Resident #2 drew his/her fist back to hit the Unit Manager as she tried to assist him/her by freeing his/her wheelchair from a chair leg. Continued review of facility investigation revealed local law enforcement was notified and upon arriving at the facility, interviewed Resident #2. Per the Investigation, Resident #2 admitted to the police officer he/she hit Resident #1 and would do again if he/she continued to come into his/her room and go through his/her things. Further review of the facility's investigation, revealed Resident #2 was immediately placed on one on one (1:1) supervision for two (2) shifts, and then placed on every fifteen (15) minute checks until 10/28/19. Per the Investigation, residents with a BI[CONDITION] score of eight (8) or above were interviewed related to abuse with no concerns noted. A stop sign was placed on Resident #2's doorway in an effort to deter Resident #1 from entering Resident #2's room. Per the Investigation, Resident #2 verbalized satisfaction and stated the stop sign seemed to be working. Interview was attempted with Resident #1 on 11/20/19 at 11:10 AM; however, the resident was unable to answer questions related to cognitive status. Interview with Resident #2, on 11/20/19, at 11:18 AM, revealed he/she did not remember having any type of physical altercation with Resident #1 related to the resident being in his/her room. Continued interview revealed the stop sign staff put across the doorway to deter people from coming into the room uninvited had helped. Interview with the 300 Hall Unit Manager (UM), on 11/20/19, at 8:47 AM, revealed she was working the day of the incident, on 11/24/19. Per interview, the SRNAs notified her of Resident #1 being bloody when coming out of Resident #2's room. She stated she cleaned Resident #1's wounds, assessed the resident for further injury, and reported the incident to management. She stated Resident #1's injuries included scratches and skin tears to his/her face and left arm. Per interview, the Physician was notified with treatment orders received. Continued interview revealed Resident #2 had drawn back a fist as if to hit her during the interview process. Further interview revealed she felt Resident #2's interaction with Resident #1 would be defined as abuse, based on the verbage of facility policy. Interview with SRNA #2, on 11/20/19, at 11:17 AM, revealed on 10/24/19, she witnessed Resident #1 exiting Resident #2's room and he/she was bloody on his/her face and arm. Further interview revealed she directed Resident #1 to the Unit Manager to be assessed for injury. Interview with SRNA #1, on 11/20/19 at 11:02 AM, revealed SRNA #2 had summoned her to help with Resident #1, who was bleeding. Continued interview revealed when she saw Resident #1 bleeding, she asked Resident #2 what happened and he/she admitted to hitting Resident #1. Further interview revealed she felt Resident #2's interaction with Resident #1 was abuse, based on the facility's abuse policy. Interview with the Social Services Director, on 11/20/19, at 3:21 PM, revealed she had followed up with both Resident #1 and Resident #2, almost on a daily basis, for about a week after the incident on 11/24/19. She stated there were no further concerns noted with the residents. Interview with the Director of Nursing (DON), on 11/20/19, at 4:39 PM, revealed she was working the day of the incident. She stated she was informed of the resident altercation between Resident #1 and Resident #2 immediately by the Unit Manager. Per interview, Resident #2 was immediately put on one on one (1:1) monitoring and taken to the conference room, a less stimulating environment for interview. The DON stated, during the interview process Resident #2 admitted he/she did indeed strike Resident #1 for being in his/her room, pilfering in his/her things. She further stated Resident #2 attempted to strike the Unit Manager during the interview process. Further interview revealed Resident #2 did wilfully strike Resident #1, and she felt a recent change in Resident #2's medications exacerbated his/her behaviors that day. She stated there had been no previous altercations between Resident #1 and Resident #2 prior to this altercation. Per interview, it was an incident of abuse, since Resident #2 willfully injured Resident #1. Continued interview revealed Resident #2 was placed on one on one (1:1) monitoring and then every fifteen (15) minutes checks for close monitoring for several days after the incident and also a stop sign was placed on his/her door in an attempt to keep other residents from entering his/her room. She stated the facility tried to obtain a psychiatric hospital admit; however, they were unsuccessful. She stated there had been no further altercations between residents. Interview with the Administrator, on 11/20/19, at 5:13 PM, revealed based on the facility abuse policy verbage, Resident #2's actions towards Resident #1 was wilful and constituted abuse. She stated physical, medical and pharmacological factors could influence behaviors at times and Resident #2 had recent medication changes that may have influenced his/her behavior before the altercation. Further interview revealed it was her expectation the residents would remain safe, free from abuse.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 07/30/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:07 PM, a total of twenty-seven (27) minutes prior to food being served from tray line. In addition, observation on 07/31/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:00 PM, a total of twenty (20) minutes, prior to food being served from tray line. Furthermore, observation of a test tray on 07/31/19 at 1:01 PM, revealed milk and juice temperatures were measured at fifty-two (52) degrees Fahrenheit (F), and tuna fish on the test tray was measured at sixty (60) degrees F, indicating cold foods did not hold temperature. The findings include: Review of the facility Food: Preparation Policy, revised (YEAR), revealed the Dining Services Directors/Cook(s) will be responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than forty-one (41) degrees Fahrenheit and/or less than one hundred thirty-five (135) degrees Fahrenheit, or per state regulation. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. 1. Observation on 07/30/19 at 11:40 AM, revealed food items were placed on the steam table, and temperatures were obtained. Further observation revealed food on the steam table was uncovered from 11:40 AM until 12:07 PM, a total of twenty-seven (27) minutes. At 12:07 PM, the food trays started being served off the tray line. Observation on 07/31/19 at 11:40 AM, revealed food on the steam table was uncovered from 11:40 AM until 12:00 PM, a total of twenty (20) minutes. At 12:00 PM, the food trays started being served off the tray line. 2. Observation of temperatures obtained from a test tray on 07/31/19 at 1:01 PM, revealed the milk and juice temperatures on the test tray were measured at fifty-two (52) degrees Fahrenheit (F); and the temperature of the tuna fish on the test tray was measured at sixty (60) degrees F, indicating the cold foods did not hold temperatures. Interview with the Director of Dinning Services, on 08/01/19 at 2:29 PM, revealed he was not sure why the food on the steam table went uncovered as it was normal practice to cover food items to maintain the heat and temperature of the food and in accordance with professional standards for food safety. Further interview revealed he acknowledged milk and juice should have been below forty-one (41) degrees on the test tray, indicating the cold liquids were not holding temperature. He stated it was important temperatures were maintained as per regulation to ensure food safety and prevent bacteria growth. He further stated hot foods should remain hot and cold foods should remain cold, and the temperatures observed from the test tray on 07/31/19 for the cold foods were not acceptable. Interview with the Administrator, on 08/01/19 at 6:00 PM, revealed it was her expectation for foods to be served in in accordance with professional standards and at safe temperatures in order to maintain food safety for residents.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the Resident or the Resident Representative related to the Bed-hold Policy at the time of transfer for one (1) of eighteen (18) sampled residents (Resident #39). The facility obtained a Provider's Order to transfer Resident #39 to an acute care facility for evaluation following a change in condition on 05/18/19; however, there was no documented evidence the facility provided the Resident or the Resident's Representative written information related to the facility's Bed-hold Policy related to this transfer. The findings include: Review of the facility's Policy titled, Bed Hold Notice dated 12/14/18, revealed prior to a resident's transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and resident representative, the Bed Hold Policy Notice and Authorization Form. Additionally, the resident copy will be given directly to the resident prior to transfer and this will be noted in the medical record. Continued review revealed the resident representative's copy will be delivered electronically via email/secure fax or a hard copy via mail if the representative was not present at the time of the transfer. The notice must be delivered to the resident/representative in order to satisfy federal regulation. Per policy, the Bed Hold Notice of Policy and Authorization Form was a four (4) carbon copy form. The original copy is to be sent to the Business Office, canary copy to be given to the resident, pink copy to be given to the resident representative, and goldenrod copy to be sent to medical records. Further, the Business Office will follow up with the resident or resident representative Review of Resident #39's closed medical record revealed the facility admitted the resident on 02/17/15, with [DIAGNOSES REDACTED]. Review of Resident #39's physician's orders [REDACTED]. Review of Resident #39's medical record revealed a Nursing Home to Hospital Transfer Form, dated 05/18/19, which revealed the resident was short of breath and required oxygen at two (2) liters per nasal cannula. Additionally, the resident had decreased platelet count, hemoglobin, and hematocrit. Continued review revealed the Emergency Contact and Hospital were notified of the resident's transfer and clinical status. Review of the Discharge Return Anticipated Minimum Data Set (MDS), dated [DATE], revealed the Discharge was unplanned and the facility assessed the resident as having continuous disorganized thinking. However, further review of Resident #39's medical record revealed there was no documented evidence the resident or the resident's representative received a Bed-hold Notice related to the transfer on 05/18/19. Interview with the Director of Nursing (DON), on 08/01/19 at 4:41 PM, revealed it was the resident's right to be informed of the Bed Hold Policy when transferred out of the facility. Additionally, she stated it was her expectation the facility Bed Hold Policy be followed with each transfer. Further, the staff conducting the transfer out of the facility were responsible to ensure the Bed Hold Policy was initiated at the time of transfer. Interview with the Director of Social Services, on 08/01/19 at 5:00 PM, revealed she provided the facility Bed Hold Policy with thirty (30) day discharge notices to residents and/or resident representatives. She stated she did not provide Bed Hold forms with transfer/discharge for acute unplanned hospital transfers. Continued interview revealed she was not aware of a facility process related to providing Bed Hold forms for transfer/discharge related to acute unplanned transfers. However, she stated residents and/or resident representatives should be made aware of the Bed Hold Policy to ensure awareness of the financial responsibilities. Interview with the Business Office Manager, on 08/01/19 at 5:20 PM, revealed she received a copy of the Bed Hold Notice of Policy and Authorization, from nursing staff when a resident was transferred out of the facility to another healthcare facility. Per interview, she reviewed the Bed Hold Notice of Policy and Authorization Form and determined if a resident and/or resident representative required follow up information from her. Additional interview revealed the copy of the Bed Hold Notice of Policy and Authorization Form from the nursing staff notified her of when a resident was transferred out of the facility. However, further interview revealed she was not aware of any process in place to provide written notification of transfer to the resident and/or resident representative for hospital transfers, other than nursing staff giving residents a copy of the Bed Hold Notice of Policy and Authorization Form. Further, she was not aware that acute hospital transfers required written notification of the Bed Hold Policy. Interview with the Administrator, on 08/01/19 at 6:30 PM, revealed she expected facility staff to be knowledgeable of the Bed Hold Policy and to ensure this Policy was followed. Additional interview revealed she expected nursing staff to verbally notify the resident and/or the resident representative, at the time of transfer followed by written notification. Continued interview revealed Resident #39 and his/her representative should have received the Bed Hold Policy in writing related to the 05/18/19 transfer to the hospital. Further, she was not aware of the facility's current process for notification related to Bed Hold, forms, who was responsible, or if there was an audit process to ensure the facility policy was being implemented. However, she stated it was important residents and/or resident representatives were made aware of the Bed Hold and the financial responsibility, to ensure they were fully informed.

Based on interview, record review, and review of the facility Policies, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of eighteen (18) residents (Resident #63). Resident #63 was assessed by the facility to be a Fall Risk, per the Admission Assessment, dated 06/10/19. The facility implemented a tab alarm to the resident's wheelchair as a fall intervention, on 06/19/19 after a fall accident/incident. However, there was no documented evidence in the medical record of an assessment for the tab alarm as a least restrictive device or no documented evidence of the reasons why this device would be appropriate/effective for this resident to prevent further falls prior to implementation of the device on 06/19/19, status [REDACTED]. In addition, Resident #63 sustained a fall on 06/27/19 and the Root Cause Analysis was identified as excess fluid removed during [MEDICAL TREATMENT]. Per the Falls Investigation dated 06/27/19, the facility was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. However, there was no documented evidence this intervention was being implemented in order to reduce the risk for further fall accident/incidents of the same nature and minimize the risk for injury. (Refer to F-656 and F-657) The findings include: Review of the facility's Accidents/Incident Policy, reviewed 05/02/18, revealed all accidents/incidents which occur will be reviewed and investigated by staff to define causative/contributing factors and institute preventative measures to avoid further occurrence. Additionally, accidents are defined as unexpected or unintentional incidents, which may result in injury or illness to a resident. Further, incidents are defined as any occurrence not consistent with routine operations that pose a threat to safety or security. Review of the facility's Fall Management Policy, reviewed 03/01/16, revealed residents would be assessed for falls risk as part of a nursing assessment process. Additionally, those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury and the actually occurrence of falls. Further, after a fall accident/incident the Care Plan would be updated to reflect new interventions. Review of Resident #63's Electronic Medical Record (EMR) revealed the facility admitted the resident on 06/10/19, with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 06/10/19, revealed Resident #63 was a Fall Risk related to impaired cognition, impaired mobility, medications, and comorbidities related to diagnoses. Interview with the DON, on 08/01/19 at 10:02 AM, revealed the facility did not have a separate Fall Risk Assessment which would generate a score based on a scale of severity for Fall Risk. Review of the Comprehensive Care Plan (CCP), initiated on 06/10/19, revealed Resident #63 was at risk for falls related to impaired mobility, difficulty walking, Renal Osteodystropy, Diabetes, End Stage [MEDICAL CONDITION] with [MEDICAL TREATMENT], medication use, and Vision Loss in the Right eye. The goal stated the resident would have no falls with injury. The interventions included, but were not limited to: provide verbal cues initiated; place call light within reach; maintain a clutter free environment; and encourage activities. All interventions were initiated 06/10/19. Review of Resident #63's Admission Minimum Data Set (MDS) Assessment, dated 06/17/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIM) score of four (04) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review of the Assessment revealed the facility assessed the resident as Independent with all functional status including transfers, ambulation in room and corridor and locomotion. Additionally, the resident's balance during transitions was steady. Per the MDS Assessment, the facility was unable to determine fall history prior to admission. Review of the Fall Investigation, dated 06/19/19 at 5:15 PM, revealed Resident #63 experienced a witnessed fall accident/incident in the dining room at the sink. The resident independently transferred from his/her wheelchair and ambulated a short distance to the sink, lost his/her balance and fell to the floor before staff could assist him/her. Per the Investigation, the resident obtained a skin tear to the left elbow. Additionally, the facility determined the Root Cause Analysis (RCA) of the fall event was poor safety awareness, [MEDICAL CONDITION] and recent change in condition related to Blood Pressure (BP) and medication changes. The long-term intervention to prevent falls of the same nature was to implement a tab alarm to the wheelchair. Review of Resident #63's physician's orders [REDACTED]. Further review of the Falls CCP, revealed a new intervention for tab alarm to wheelchair was initiated 06/19/19. However, the CCP was not developed to include interventions for ongoing monitoring for effectiveness and modifying as necessary regarding the tab alarm to the wheelchair on 06/19/19. (Refer to 656) In addition, review of the medical record from 06/10/19 till 08/01/19 revealed no documented evidence of an Assessment related to the tab alarm to ensure this was the least restrictive device or and/or no documented evidence of the reasons why this device would be appropriate/effective for this resident prior to implementation of the device on 06/19/19, status [REDACTED]. Review of the Fall Investigation, dated 06/27/19 at 1:20 PM, revealed Resident #63 experienced an unwitnessed fall event while sitting at the nurse's station in the wheelchair. Per the Investigation, the resident fell out of the wheelchair and onto the floor, hitting his/her head on the floor with loss of consciousness and [MEDICAL CONDITION] activity [MEDICATION NAME] thirty (30) seconds. Per the Investigation, the resident complained of right shoulder pain and was sent to the emergency room for further evaluation and treatment. Additionally, the facility determined the RCA of the fall event was excess fluid taken off the resident during [MEDICAL TREATMENT]. The long term intervention to prevent falls of the same nature was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. However, there was no documented evidence in the medical record the intervention to communicate with the [MEDICAL TREATMENT] clinic related to fluid volume exchange, was implemented based on the RCA after the fall on 06/27/19 or that the CCP was developed to include the intervention status [REDACTED]. Interview with Resident #63, on 07/30/19 at 9:44 AM, revealed he/she was oriented to name, and place (the facility); however was uncertain of the time/date. Per interview, the resident had sustained a couple of falls in the past. However, he/she could not recall the specifics of the fall or interventions the facility had implemented to prevent further falls. Interview with the Director of Nursing (DON), on 08/01/19 at 4:41 PM, revealed she expected the least restrictive interventions to be implemented to prevent further fall accidents/incidents before the implementation of alarms to ensure freedom of movement, quality of life and safety. Per interview, the facility did not have a Policy specific to Least Restrictive Devices or Alarms. However, she stated the effectiveness and necessary modification was discussed each morning in the Clinical meeting, Monday through Friday, with the department heads, including Nursing, Administration and Therapy. Per the DON, she could not share the documentation with the State Inspector related to the daily review of Least Restrictive Devices and Alarms because it was an internal tool that was not part of the medical record. However, she stated there was no documented evidence of an assessment related to Resident #63's tab alarm since admission, which was the responsibility of the Interdisciplinary Team. Per interview, there should have a documented evaluation to ensure the tab alarm was the least restrictive device or documentation related to the need for the alarm as opposed to other least restrictive measures before the implementation of the tab alarm for Resident #63 on 06/19/19. Further interview with the DON, revealed after Resident #63 experienced the fall on 06/27/19, the identified RCA was excess fluid taken off the resident during [MEDICAL TREATMENT]. Per interview, to prevent recurrence the facility was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. However, she stated she could find no documented evidence this intervention was being implemented in order to reduce the risk for further fall accident/incidents of the same nature and minimize the risk for injury. Interview with the Administrator, on 08/01/19 at 6:30 PM, revealed she expected the IDT to implement the least restrictive device or least restrictive measures after a fall and only progress after there was reasonable rationale why the next level was necessary. Additionally, she stated she expected the facility to assess for the need for an alarm prior to implementing that intervention after a fall. Per interview, evaluation of alarms prior to placement was necessary and this assessment should be part of the EMR. Per interview, when an assessment of alarms was completed and the alarm was justified that would be when an alarm would be implemented as an appropriate intervention after a fall. Further interview with the Administrator, revealed after Resident #63 sustained the fall on 06/27/19, the RCA was identified and to prevent recurrence the facility was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. Per interview, this intervention should have been implemented in an attempt to prevent further falls.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to develop and implement the Comprehensive Care Plan (CCP) to address the resident's needs for one (1) of eighteen (18) sampled residents (Residents # 63). Resident #63 sustained a fall on 06/19/19, and the facility implemented a tab alarm to the resident's wheelchair as a fall prevention intervention. However, there was no documented evidence the CCP was developed and implemented with an intervention for ongoing re-assessment of the effectiveness of the tab alarm device with necessary modification as necessary. In addition, Resident #63 sustained a fall on 06/27/19. Per the Investigation, the facility determined the Root Cause Analysis (RCA) of the fall event was excess fluid removed during [MEDICAL TREATMENT]. However, there was no documented evidence the CCP was developed and implemented related to the intervention based on the Root Cause Analysis (RCA) to communicate with the [MEDICAL TREATMENT] clinic related to fluid volume exchange. The findings include: Review of the facility's Person-Centered Care Plan Policy, reviewed 06/12/19, revealed the CCP would include instructions needed to provide effective and person-centered care that meets professional standards of quality of care. Further, the CCP's purpose was to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being by eliminating triggers that may cause re-traumatization of the resident and to promote positive communication between the interdisciplinary team and optimal clinical outcomes. Review of Resident #63's Electronic Medical Record (EMR), revealed the facility admitted the resident on 06/10/19, with [DIAGNOSES REDACTED]. Review of the CCP, initiated 06/10/19, revealed the resident was at Risk for Falls related to impaired mobility, difficulty walking, Diabetes, End Stage [MEDICAL CONDITION] with [MEDICAL TREATMENT], medication use, and vision loss in the right eye. The goal stated the resident would have no falls with injury. The interventions included, but were not limited to: provide verbal cues initiated 06/10/19; place call light within reach initiated 06/10/19; maintain a clutter free environment initiated 06/10/19; and encourage activities initiated 06/10/19. Review of Resident #63's Admission Minimum Data Set (MDS) Assessment, dated 06/17/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of four (04) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review of the MDS Assessment, revealed the facility assessed the resident as Independent with all functional status including transfers, ambulation and locomotion; and as having steady balance during transitions. Per the MDS Assessment, the facility was unable to determine fall history prior to admission. Review of the Fall Investigation, dated 06/19/19 at 5:15 PM, revealed the resident experienced a witnessed fall accident/incident in the dining room at the sink. Resident #63 independently transferred from his/her wheelchair and ambulated a short distance to the sink, lost his/her balance and fell to the floor before staff could assist him/her. Per the investigation, the facility determined the Root Cause Analysis (RCA) of the fall event was poor safety awareness, [MEDICAL CONDITION] and recent changes in, condition related to Blood Pressure and medication changes. Further review of the Investigation, revealed the long-term intervention to prevent falls of the same nature was to implement a tab alarm to the wheelchair. Review of Resident #63's physician's orders [REDACTED]. Further review of the CCP, initiated 06/10/19 status [REDACTED]. However, the CCP was not developed to include ongoing re-assessment of the effectiveness of the tab alarm device with necessary modification as necessary. Interview with the MDS Coordinator, on 08/01/19 at 5:15 PM, revealed the CCP guides resident care and was used by the entire team to provide person centered care to meet the resident's needs. Further interview revealed Resident #63's CCP should have been developed to include interventions for ongoing monitoring of the wheelchair tab alarm for effectiveness and to ensure safety related to usage of the device. Interview with the Director of Nursing (DON), on 08/01/19 at 4:41 PM, revealed the CCP should include ongoing reassessment of the effectiveness of the least restrictive devices (including alarms) and necessary modification, which was the responsibility of the Interdisciplinary Team (IDT). Per interview, this was to ensure safety and to reduce the risk for further fall accident/incidents of the same nature. Further, Resident #63's CCP should have been developed and implemented to provide ongoing assessment of the least restrictive device (alarm) and modification as necessary. Interview with the Administrator, on 08/01/19 at 6:30 PM, revealed she expected the CCP to be developed and implemented per the facility policies. Additionally, the CCP should include ongoing assessment of the least restrictive devices and alarms and modification as necessary to meet the resident's care needs. Review of Resident #63's Fall Investigation, dated 06/27/19 at 1:20 PM, revealed the resident experienced an unwitnessed fall event while sitting at the nurse's station in the wheelchair. Per the Investigation, the resident fell out of the wheelchair and onto the floor, hitting his/her head on the floor with loss of consciousness and [MEDICAL CONDITION] activity which lasted thirty (30) seconds. According to the Investigation, the resident complained of right shoulder pain and was sent to the emergency room for further evaluation and treatment. Per the Investigation, the facility determined the RCA of the fall event was excess fluid removed during [MEDICAL TREATMENT]. In addition, the Investigation revealed the long term intervention to prevent falls of the same nature was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. However, there was no documented evidence the CCP was developed or implemented with the intervention to communicate with the [MEDICAL TREATMENT] clinic related to fluid volume exchange, based on the RCA status [REDACTED]. Interview with the MDS Coordinator, on 08/01/19 at 5:15 PM, revealed the CCP guided resident care and was used by the entire team to provide personal centered care to meet the resident's needs. Additionally, after a resident sustains a fall, the CCP should be developed and implemented with an intervention based on the RCA to prevent further falls of the same nature. Further interview with the DON, revealed after Resident #63 experienced the fall on 06/27/19, the identified RCA was excess fluid taken off the resident during [MEDICAL TREATMENT]. Per interview, to prevent recurrence the facility was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. However, she stated she could find no documented evidence the CCP was developed with an intervention to include communication and collaboration with the [MEDICAL TREATMENT] Clinic, nor could she find documented evidence this intervention was being implemented. Additionally, she stated she expected the CCP to be developed and implemented related to interventions based on the RCA after a resident sustained [REDACTED]. Additional interview with the Administrator, revealed after Resident #63 sustained the fall on 06/27/19, the RCA was identified and to prevent recurrence the facility was to communicate with [MEDICAL TREATMENT] related to modification of fluid volume exchange during [MEDICAL TREATMENT] visits. Per interview, the CCP should have been developed related to this intervention in order for the intervention to be implemented in an attempt to prevent further falls.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have evidence that all alleged violations of abuse are thoroughly investigated. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). Staff interviews revealed on 04/22/19, Resident #81 was involved in a resident-to-resident verbal altercation with Resident #31 that escalated resulting in Resident #81 grabbing a butter knife from the table and threatening to stab Resident #31. However, there was no documented evidence of an investigation related to this incident. The findings include: Review of the facility's OPS300 Abuse Prohibition Policies and Procedures, dated 06/01/96 and revised 07/01/19, revealed, Only an investigation can rule out abuse, neglect, or mistreatment. An investigation should be initiated within twenty-four (24) hours of an allegation of an allegation of abuse or neglect which should include clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation should be thoroughly documented to include witness interviews. The Center Executive Director (CED) (Administrator) or designee will take all necessary corrective action depending on the results of the investigation. The findings of all completed investigations should be reported within five (5) working days to the Department of Health using the state on-line reporting system or state-approved forms. All phases of the reporting process will be kept confidential. At monthly Quality Assurance and Performance (QAPI) meetings, the facility will review all allegations of abuse that were reported to the state in order to analyze occurrences to determine what changes are needed; prevent further occurrences; identify situations which have a potential for risk; and determine what preventive measures will be implemented by staff. Review of Resident #31's medical record revealed the facility admitted the resident on 03/16/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/13/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. During an interview with Resident #31, on 07/30/19 at 12:56 PM, he/she revealed Resident #81 pulled a knife on him/her a few months ago. Review of Resident #81's medical record revealed the facility admitted the resident on 04/08/19 with [DIAGNOSES REDACTED]. Review of Resident #81's Comprehensive Care Plan, dated 04/08/19, revealed the resident exhibited verbal behaviors which would exacerbate in the evening, and the resident became easily agitated. The goal stated the resident would not exhibit verbal outburst directed toward others. There were several interventions to include: offer cokes or sweets to re-direct the resident; if agitated, postpone care/activity; if over stimulated gently guide him/her to a quiet area; and notify Physician as needed. Review of Resident #81's Admission MDS Assessment, dated 04/15/19, revealed the facility assessed the resident as having a BIMS score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Additional review of the MDS Assessment, revealed the facility assessed the resident as having behavioral symptoms directed towards others one (1) to three (3) days during the look back period. Review of Resident #81's Progress Notes, dated 04/22/19 at 8:00 AM, completed by Licensed Practical Nurse (LPN) #2/Unit Manager (UM), revealed the nurse was called to the dining room due to Resident #81 fighting with another resident. Per the Notes, Resident #81 was yelling at the other resident and throwing food at him/her. Attempted to redirect Resident #81; however, he/she continued to yell at staff and another resident. Per the Notes, the nurse was able to calm both residents down and they returned to their tables. Additional review of Resident #81 Progress Notes, dated 04/22/19 at 8:10 AM, completed by LPN #2/UM, revealed the nurse was called back to the dining room, and the resident was yelling at the same resident again and getting close to his/her face. Resident #81 was stating he/she would kick his/her ass, and the other resident moved from the area. Additional review of Resident #81's Progress Notes, dated 04/22/19 at 8:28 AM, completed by LPN #2/Unit Manager, revealed Resident #81 was sitting at a table with another resident and was asked if he/she wanted some milk. Resident #81 started yelling and cursing at the resident. Resident #81 was redirected and moved to a different table. Review of Resident #81's Progress Notes, dated 04/22/19 at 8:43 AM, completed by LPN #2/UM, revealed the nurse was called to the dining room again related to Resident #81 cussing a resident and the other resident at the table returned comments. Per the Notes, Resident #81 then picked up a knife off the table and stated he/she would stab him/her. Staff member intervened and Resident #81 held the knife up to the staff member and stated he/she would stab her too. Other staff members were able to remove the knife, and assist Resident #81 out of the dining room, and back to his/her room. A call was placed to 911 to transport Resident #81 to the hospital. Resident #81 was yelling at staff and making movements like he/she would hit them with his/her walker. Staff members redirected Resident #81 down the hall with one on one (1:1) supervision. Police and transport arrived to transfer Resident #81 to the hospital for evaluation. A report was called to the hospital and a call was placed to Resident 81's son and a message was left notifying him of the incident. Interview with LPN #2/UM, on 7/31/19 at 4:15 PM revealed on 04/22/19, staff reported Resident #81 was sitting at the dining table with Resident #31 and when Resident #81 started yelling and cursing at Resident #31, staff moved Resident #81 to a different table. Continued interview revealed staff summoned LPN #2/UM to the dining area because Resident #81 and Resident #31 were feuding with each other and the feud was escalating. She stated when she arrived in the dining area, Resident #81 was very vocal, raising his/her voice, shouting. She further stated she settled Resident #81 down, and allowed him/her to remain in the dining area because the staff was there, and could monitor both residents. Additional interview with LPN #2/UM, revealed she came back to the dining area a second time by staff request to find Resident #81 yelling again. Per interview, she then re-located Resident #81 to the other side of the room and he/she appeared calm. She stated after this Resident #81 began shouting, and cursing again and staff summoned LPN #2/UM a third time to the dining area. Per interview, this time Resident #81 began yelling at staff, including LPN #2/UM, and also the facility Administrator who had entered the room. LPN #2/UM further stated Resident #81 became belligerent, argumentative, striking out, and was threatening LPN #2/UM and the facility Administrator, and would not calm down. Per interview, the facility notified the police, and the police transported Resident #81 to the local Hospital, and then on to a Behavioral Health facility, for further evaluation. Further interview with LPN #2/UM, revealed per her documentation in the Resident #81's medical, the resident did grab a butter knife and threaten to stab Resident #31. LPN #2/UM was questioned if the situation as she described met criteria as an abuse situation, as defined in her abuse training and outlined in the facility's Abuse Policy, she stated, Yeah, I guess. Interview with State Registered Nurse Aide (SRNA) #2 on 08/01/19 at 2:00 PM, revealed she witnessed the entire dining room incident on 04/22/19 with Resident #81. She stated during the first interaction, Resident #81 said something to Resident #31, but she could not hear their conversation. She further stated Resident #31 then voiced he/she was going to hit Resident #81 with his/her cane. Per interview, SRNA #2 took the cane and separated the two (2) residents, and both residents calmed down. Continued interview revealed a second interaction occurred when Resident #81 stated he/she was going to throw coffee on Resident #31. Per interview, SRNA #2 moved Resident #81 to another table and encouraged him/her to calm down and he/she appeared calm. Additional interview with SRNA #2, revealed a third dispute erupted when Resident #81 began talking aggressively to another resident, but she could not remember if the other resident was Resident #31. Per interview, this other resident asked Resident #81 not to talk like that, and Resident #81 then told the other resident he/she was going to stab him/her. SRNA #2 further stated Resident # 81 picked up the butter knife, and SRNA #2 jumped in between the other resident and Resident #81. SRNA #2 revealed a Physical Therapy Aide (PTA)/SRNA #3 came from across the hall and took the knife from Resident #81's hand. SRNA #2 further revealed LPN #2/UM came into the dining area along with the facility Administrator and the police were called. Per interview, after the police arrived, Resident #81 remained very belligerent, very combative and uncooperative even when the police officers placed him/her on the gurney and transported him/her out. SRNA #2 was questioned if what she witnessed was abuse, and she stated it was Verbal abuse and resident to resident altercations. Interview with PTA/SRNA #3, on 08/01/19 at 3:00 PM, revealed she was in a room across the hall from the dining room and heard a loud commotion coming from the dining room on 04/22/19. Per interview, she opened the door and SRNA #2 summoned her to come to the dining room. She stated upon entering the dining room, Resident #81 was facing SRNA #2 with a butter knife in his/her hand, and SRNA #2 was telling him/her to put the knife down. PTA/SRNA #3 further stated Resident #81 refused to put the knife down and he/she was loud, shouting, cursing, and threatening to stab SRNA #2 with the knife. Further, when Resident #81 rested his/her hand on the table, PTA/SRNA #3 managed to move to the side of him/her and retrieve the knife from his/her hand. Interview with the Director of Nursing (DON), on 08/01/19 at 11:40 AM, revealed she did not witness the incident with Resident #81, and other residents on 04/22/19, as she was not onsite on that date. She stated based on documentation in the nurse's notes, in black and white, yes, I would consider this a reportable abuse event. Further interview revealed after a resident to resident altercation staff should start the paper work to include an Incident Report, Change in Condition Note, skin assessment for residents involved, pain evaluation for residents involved, care plan updates, Physician and responsible party notification, and seventy-two (72) hour follow-up charting. Further interview revealed there was no documented evidence a thorough investigation occurred after the dining room incident involving Resident #81 on 04/22/19. The DON stated she failed to utilize the Policy as a guide for conducting the investigation and as a result there was no documented evidence of staff interviews, witness statements, resident interviews, or any interviews. In addition, she stated there was no documented evidence of comprehensive follow-up assessments and charting for the residents involved. Interview with the Administrator, on 08/01/19 at 2:30 PM, revealed she did recall the dining room incident on (MONTH) 22, 2019, involving Resident #81 brandishing a butter knife and threatening staff and residents. Per interview, she responded to a call regarding a disturbance in the dining room area and upon arriving in the area, Resident #81 was at the edge of the hallway outside the dining area and was very agitated, and not responding to conversations to de-escalate him/her. Further, the police were called and after police arrived Resident #81 remained agitated, and the resident was loaded on to a stretcher and transported to the hospital. Continued interview with the Administrator, revealed it was her expectation staff follow the facility Abuse Policy related to investigating any allegations of abuse. When the Administrator was questioned if the facility followed it's policy regarding investigating the incident on 04/22/19 involving Resident #81 and Resident #31 she stated, At the time I did, as I did not know about the resident-to-resident threat. Further interview revealed based on the account of the incident as written in Resident #81's Progress Notes, this would be an allegation of abuse. Additional interview with the Administrator, revealed per facility policy, if a resident was threatening another resident, the investigation process should be followed which would include initiating an investigation within twenty-four (24) hours of an allegation of abuse/abuse. Per interview, the investigation should include documentation of interviews from witnesses, and residents involved. She further stated, the facility would also provide the resident (victim) with a safe environment by identifying persons with whom he/she felt safe and and Social Services would need to monitor the resident's (victim) feelings concerning the incident. Per interview, the Administrator would take all necessary corrective action depending on the results of the investigation, and the findings of all completed investigations was to be reported to the Office of Inspector General (OIG) within five (5) working days. Additional interview with the Administrator, revealed the facility did not do a thorough investigation as outlined in the Abuse Policy related to the resident to resident altercation involving Resident #81 and Resident #31 as there was no documented evidence of staff interviews, interviews with residents involved, witness statements, witness statements or any interviews related to the incident. Per interview, there should have been a thorough investigation related to this altercation.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure all alleged violations involving abuse are reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and to State Agencies for two (2) of eighteen (18) sampled residents (Residents #81 and Resident #31). On 07/30/19 at 12:56 PM, Resident #31 reported during an interview with the State Agency (SA) Representative, Resident #81 pulled a knife on him/her a few months ago. Review of Resident #81 Progress Notes, dated 04/22/19, revealed Resident #81 cussed a resident and subsequently picked up a knife off the table and stated he/she would stab the other resident. Staff interviews verified the allegation; however, there was no documented evidence the facility reported the allegation to the Administrator and to State Agencies. The findings include: Review of the facility's Policy titled OPS300 Abuse Prohibition Policies and Procedures, revised 07/01/19, revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) (Administrator) or designee and other officials in accordance with state law. If the resident sustains serious bodily injury, the employee who forms the suspicion or witnesses the incident must report no later than two (2) hours after forming the suspicion. All reports of suspected abuse must also be reported to the resident's family and attending physician. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Administrator) or designee will report the allegations not later than two (2) hours after the allegation is made. Review of Resident #31's Clinical Record revealed the facility admitted the resident on 03/16/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/13/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #31 on 07/30/19 at 12:56 PM, revealed Resident #81 pulled a knife on him/her a few months ago. Review of Resident #81's Clinical Record revealed the facility admitted the resident on 04/08/19 with [DIAGNOSES REDACTED]. Review of Resident #81's Comprehensive Care Plan (CCP), dated 04/08/19, revealed the resident exhibited verbal behaviors which were exacerbated in the evening, and the resident became easily agitated. Per the CCP, the resident frequently thought he/she was in the army. The goal stated the resident would not exhibit verbal outburst directed toward others. There were several interventions including: offer cokes or sweets to re-direct the resident; if agitated, postpone care/activity; if over stimulated gently guide him/her to a quiet area; and notify Physician as needed. Review of Resident #81's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as having behavioral symptoms directed towards others one (1) to three (3) days during the look back period. Review of Resident #81's Clinical Record Progress Notes, dated 04/22/19 at 8:00 AM, completed by Licensed Practical Nurse (LPN) #2/Unit Manager (UM), revealed the nurse was called to the dining room related to Resident #81 fighting with another resident. Resident #81 was yelling at the other resident and throwing food at him/her. Attempted to redirect Resident #81, but he/she continued to yell at staff and another resident. Was able to calm both residents down and they returned to their tables. Further review of Resident #81 Progress Notes, dated 04/22/19 at 8:10 AM, completed by LPN #2/UM, revealed the nurse was called back to the dining room, and resident was yelling at same resident again and getting close to his/her face. Resident #81 was stating he/she would kick his/her ass. The other resident moved from the area. Additional review of Resident #81's Progress Notes, dated 04/22/19 at 8:28 AM, completed by LPN #2/Unit Manager, revealed Resident #81 was sitting at a table with another resident and was asked if he/she wanted some milk. Resident #81 started yelling and cursing at the resident. Resident #81 was redirected and moved to a different table. Review of Resident #81 Progress Notes, dated 04/22/19 at 8:43 AM, completed by LPN #2/UM, revealed the nurse was called to the dining room again related to Resident #81 cussing a resident and the other resident at the table returned comments. Resident #81 then picked up a knife off the table and stated he/she would stab him/her. Staff member intervened and Resident #81 held the knife up to the staff member and stated he/she would stab her too. Other staff members were able to remove the knife, and get Resident #81 out of the dining room, and back to his/her room. A call was placed to 911 to transport Resident #81 to the hospital. Resident #81 was yelling at staff and making movements like he/she would hit them with his/her walker. Staff members redirected Resident #81 down the hall with one on one (1:1) supervision. Police and transport arrived to transfer Resident #81 to the hospital for evaluation. A report was called to the hospital and a call was placed to Resident 81's son and a message was left notifying him of the incident. Interview with LPN #2/UM, on 7/31/19 at 4:15 PM revealed she reported any witnessed abuse or abuse allegations to her immediate supervisor, which in her case was the Director of Nursing (DON) and the DON would notify the Administrator of the allegations. Additional interview revealed on 04/22/19, staff reported Resident #81 was sitting at the dining table with Resident #31 and when Resident #81 started yelling and cursing at Resident #31, staff moved Resident #81 to a different table. Further interview revealed staff summoned LPN #2/UM to the dining area because Resident #81 and Resident #31 were feuding with each other and the feud was escalating. Per interview, when she arrived in the dining area, Resident #81 was very vocal, raising his/her voice, shouting. She stated she settled Resident #81 down, and allowed him/her to remain in the dining area because the staff was there, and could monitor both residents. Further interview with LPN #2/UM, revealed she came back to the dining area a second time by staff request to find Resident #81 yelling again. She stated she then re-located Resident #81 to the other side of the room and he/she appeared calm. She further stated after this Resident #81 began shouting, and cursing again and staff summoned LPN #2/UM a third time to the dining area. Per interview, this time Resident #81 began yelling at staff, including LPN #2/UM, and the facility Administrator who had entered the room. LPN #2/UM stated Resident #81 became belligerent, argumentative, striking out, and threatening LPN #2/UM and the facility Administrator, and would not calm down. Per interview, the facility called the police, and the police transported Resident #81 to the local Hospital, and then on to a Behavioral Health facility, for further evaluation. Additional interview with LPN #2/UM, revealed per her documentation in the Resident #81's medical, the resident did grab a butter knife and threaten to stab Resident #31. When LPN #2/UM was questioned if the situation as she described met criteria as a reportable abuse situation, as defined in her abuse training and outlined in the facility's Abuse Policy, she stated, Yeah, I guess. Per interview, although the Administrator arrived in the diningroom to assist related to Resident #81's behavior and ensured the police were called on 04/22/19, she was not sure if the Administrator was notified of Resident #81 grabbing a butter knife and threatening to stab Resident #31. Interview with State Registered Nurse Aide (SRNA) #2 on 08/01/19 at 2:00 PM, revealed she witnessed the entire dining room event on 04/22/19 with Resident #81. She stated during the first interaction, Resident #81 said something to Resident #31, but she could not hear the conversation. She further stated Resident #31 then stated he/she was going to hit Resident #81 with his/her cane. SRNA #2 stated she took the cane and separated the two (2) residents, and both residents calmed down. Further interview revealed a second interaction occurred when Resident #81 stated he/she was going to throw coffee on Resident #31. SRNA #2 stated she then moved Resident #81 to another table and encouraged him/her to calm down and he/she appeared calm. Continued interview with SRNA #2, revealed a third dispute erupted when Resident #81 began talking aggressively to another resident, but she could not remember if the other resident was Resident #31. Per interview, this other resident asked Resident #81 not to talk like that, and Resident #81 told the other resident he/she was going to stab him/her. SRNA #2 stated Resident # 81 picked up the butter knife, and SRNA #2 jumped in between the other resident and Resident #81. SRNA #2 stated a Physical Therapy Aide (PTA)/SRNA #3 came from across the hall and took the knife from Resident #81's hand. SRNA #2 further stated, LPN #2/UM came into the dining area after this, along with the facility Administrator and the police were called. Per interview, when the police arrived, Resident #81 remained very belligerent, very combative and uncooperative even when the police officers placed him/her on the gurney and transported him/her out. When SRNA #2 was questioned if what she witnessed was abuse, she stated it was Verbal abuse and resident to resident altercations. Interview with PTA/SRNA #3, on 08/01/19 at 3:00 PM, revealed she was in a room across the hall from the dining room when she heard a loud commotion coming from the dining room. She stated she opened the door and SRNA #2 summoned her to come to the dining room. Per interview, upon entering the dining room, Resident #81 was facing SRNA #2 with a butter knife in his/her hand, and SRNA #2 was telling him/her to put the knife down. PTA/SRNA #3 stated Resident #81 refused to put the knife down and he/she was loud, shouting, cursing, and threatening to stab SRNA #2 with the knife. Per interview, when Resident #81 rested his/her hand on the table, PTA/SRNA #3 managed to move to the side of him/her and retrieve the knife from his/her hand. Interview with the Assistant Director of Nursing (ADON)/Nurse Practice Educator (NPE) on 08/01/19 at 11:00 AM, revealed staff received abuse training and education upon hire. Per interview, she would oversaw this aspect of staff training and education. She stated abuse training took place annually, and whenever additional training was warranted, and covered types of abuse (physical, verbal, mental, seclusion), how to recognize abuse, who was report abuse (everybody), to whom (immediate supervisor) and the period (immediately). Further interview revealed a report of abuse to regulatory agencies must occur within two (2) hours. Further interview with the ADON/NPE, revealed she did not remember the resident-to-resident event that occurred (MONTH) 22 involving Resident #81. She stated she did not witness the event, nor did she remember the staff informing her of the event. Per interview, she was aware Resident #81 was sent out to the Behavioral Health facility, but she did not remember being told about the butter knife incident. She stated the only thing she knew about the incident was what was in the Nurse's Notes and based on that documentation, she considered the incident a resident-to-resident abuse situation which was reportable, per facility policy. Interview with the DON, on 08/01/19 at 11:40 AM, revealed she did not witness the incident with Resident #81, and other residents on 04/22/19, as she was out of the building at the time. Per the DON, based on documentation in the nurse's notes, in black and white, yes, I would consider this a reportable abuse event. Further interview revealed any allegation of abuse was to be reported immediately to the Administrator, Office of Inspector General (OIG), Adult Protective Services (APS), Ombudsman and if necessary, the police. Per interview, there was a two (2) hour time crunch to report allegations of abuse to State Agencies. Interview with the Administrator, on 08/01/19 at 2:30 PM, revealed she recalled the dining room incident on (MONTH) 22, 2019, involving Resident #81 brandishing a butter knife and threatening staff and residents. She stated she responded to a call regarding a disturbance in the dining room area and upon arriving in the area, Resident #81 was at the edge of the hallway outside the dining area and was very agitated, and not responding to conversations to de-escalate him/her. Per interview, the police were called and after police arrived Resident #81 remained agitated, and the resident was loaded on to a stretcher and transported to the hospital. Further interview with the Administrator, revealed per facility policy, if a resident was threatening an employee this was not reported to State Agencies. She stated other measures would be implemented such as Physician notification, police notified if necessary, or transferring the resident to the emergency room if needed. However, she stated if a resident threatened another resident, this would be an allegation of abuse and would need to be reported to State Agencies. The Administrator stated all staff received abuse training upon hire, annually, and intermittently based on facility needs, including the Administrator. Per interview, every employee was responsible for recognizing and reporting abuse. She stated the Administrator was responsible for reporting the event or allegation and follow-up to the OIG, APS, and District Ombudsman immediately or within two (2) hours. Additional interview with the Administrator, revealed it was her expectation staff follow the facility Abuse Policy related to reporting any allegations of abuse. When questioned if the facility followed it's policy regarding reporting the incident on 04/22/19 involving Resident #81 and Resident #31 to State Regulatory Agencies, she stated, At the time I did, as I did not know about the resident-to-resident threat. I would have reported that immediately. Further interview revealed based on the account of the incident as written in Resident #81's Progress Notes, this would be a reportable event.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to implement written policies related to reporting and investigating allegations of abuse. This affected two (2) of eighteen (18) sampled residents (Residents #81 and #31). There was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation after staff witnessed a resident-to-resident verbal altercation which lead to Resident #81 grabbing a butter knife and threatening to stab Resident #31 on 04/22/19. In addition, there was no documented evidence the facility implemented their written abuse polices related to reporting the alleged violation to State Agencies. (Refer to F-609 and F-610) The findings include: Review of the facility's Policy titled OPS300 Abuse Prohibition Policies and Procedures, revised 07/01/19, revealed anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) (Administrator) or designee and other officials in accordance with state law. If the resident sustains serious bodily injury, the employee who forms the suspicion or witnesses the incident must report no later than two (2) hours after forming the suspicion. All reports of suspected abuse must also be reported to the resident's family and attending physician. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Administrator) or designee will report the allegations not later than two (2) hours after the allegation is made. Further review of the Policy, revealed, Only an investigation can rule out abuse, neglect, or mistreatment. An investigation should be initiated within twenty-four (24) hours of an allegation of an allegation of abuse or neglect which should include clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation should be thoroughly documented to include witness interviews. The Center Executive Director (CED) (Administrator) or designee will take all necessary corrective action depending on the results of the investigation. The findings of all completed investigations should be reported within five (5) working days to the Department of Health using the state on-line reporting system or state-approved forms. All phases of the reporting process will be kept confidential. At monthly Quality Assurance and Performance (QAPI) meetings, the facility will review all allegations of abuse that were reported to the state in order to analyze occurrences to determine what changes are needed; prevent further occurrences; identify situations which have a potential for risk; and determine what preventive measures will be implemented by staff. Staff interviews revealed on 04/22/19, Resident #81 was involved in a resident-to-resident verbal altercation with Resident #31 that escalated resulting in Resident #81 grabbing a butter knife from the table and threatening to stab Resident #31. However, there was no documented evidence the facility notified the Administrator or State Agencies within two (2) hours of the allegation, nor was there documented evidence an investigation was completed related to the alleged violation. (Refer to F-609 and F-610) Interview with the Director of Nursing (DON), on 08/01/19 at 11:40 AM, revealed she did not witness the incident related to Resident #81, Resident #31 and other residents on 04/22/19, as she was not onsite at the time. Per the DON, based on documentation in the nurse's notes, in black and white, yes, I would consider this a reportable abuse event. She stated any allegation of abuse was to be reported immediately to the Administrator, Office of Inspector General (OIG), Adult Protective Services (APS), Ombudsman and if necessary, the police. She further stated there was a two (2) hour time crunch to report allegations of abuse to State Agencies. Further interview with the DON, revealed after a resident to resident altercation staff should start the paper work to include an Incident Report, Change in Condition Note, skin assessment for residents involved, pain evaluation for residents involved, care plan updates, Physician and responsible party notification, and also complete seventy-two (72) hour follow-up charting. However, she stated there was no documented evidence a thorough investigation occurred after the dining room incident involving Resident #81 and Resident #31 on 04/22/19. Per interview, she failed to implement the Policy for conducting the investigation and as a result there was no documented evidence of staff interviews, witness statements, resident interviews, or any interviews. Per interview, there was also no documented evidence of comprehensive follow-up assessments and charting for the residents involved. Interview with the Administrator, on 08/01/19 at 2:30 PM, revealed she recalled the dining room incident on (MONTH) 22, 2019, which involved Resident #81 brandishing a butter knife and threatening staff and residents. She further stated she responded to a call regarding a disturbance in the dining room area and upon arriving in the area, Resident #81 was at the edge of the hallway outside the dining area and was very agitated, and not responding to conversations to de-escalate him/her. Per interview, the police were notified and after police arrived Resident #81 remained agitated, and the resident was loaded on to a stretcher and transported to the hospital. Further interview with the Administrator, revealed she (Administrator) was responsible for reporting the event or allegation and follow-up to the Office of Inspector General (OIG), Adult Protective Services (APS), and District Ombudsman immediately or within two (2) hours. Additional interview with the Administrator, revealed it was her expectation the facility Abuse Policy be implemented related to reporting any allegations of abuse. Continued interview with the Administrator, revealed it was her expectation the Abuse Policy be implemented related to investigating any allegations of abuse. Additional interview with the Administrator, revealed per facility policy, if a resident was threatening another resident, the investigation process should be followed which would include initiating an investigation within twenty-four (24) hours of an allegation of abuse/abuse. Per interview, the investigation should include documentation of interviews from witnesses, and residents involved. She further stated, the facility would also provide the resident (victim) with a safe environment by identifying persons with whom he/she felt safe and and Social Services would need to monitor the resident's (victim) feelings concerning the incident. Per interview, the findings of all completed investigations was to be reported to Office of Inspector General (OIG) within five (5) working days. Further interview with the Administrator, revealed the facility did not implement it's policy regarding reporting and investigating the incident on 04/22/19 involving Resident #81 and Resident #31 to State Regulatory Agencies. She stated, she was unaware of Resident #81 threatening to stab Resident #31 or she would have reported that immediately. Additional interview with the Administrator, revealed the facility did not do a thorough investigation as outlined in the Abuse Policy related to the resident to resident altercation involving Resident #81 and Resident #31 as there was no documented evidence of staff interviews, interviews with residents involved, witness statements, witness statements or any interviews related to the incident.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to notify the Resident or the Resident's Representative of the transfer/discharge and the reasons for the transfer in writing, for two (2) of eighteen (18) sampled residents (Resident # 36 and Resident #39). Resident #36 was transferred to an acute care hospital, on 05/28/19 with return anticipated; however, there was no documented evidence Resident #36 or his/her Resident Representative received a written notice of transfer/discharge. Additionally, Resident #39 was transferred to an acute care hospital, on 05/18/19 with return anticipated; however, there was no documented evidence Resident #39 or his/her Resident Representative received a written notice of transfer/discharge. The findings include: Review of the facility Discharge and Transfer Policy, revised 02/01/19, revealed Transfer included movement of a patient to a bed outside of the certified Center. Additionally, the Center must immediately inform the patient/resident representative, when there was a decision to transfer the patient from the Center. Continued review of the Policy, revealed the patient and the resident representative must be notified in writing and in a language and manner, they understand. Further, for an unplanned, acute transfer to a hospital, the patient and/or resident representative will be notified verbally followed by written notification. 1. Review of Resident #36's closed medical record revealed the facility admitted the resident on 12/05/18, with [DIAGNOSES REDACTED]. Review of Resident #36's Progress Note, dated 05/26/19 at 3:23 AM, revealed the resident came to the nurse's station with complaints of not feeling well and having a headache. Per the Note, the resident's skin was warm, dry and pale in color, and the resident's blood pressure was 196/111 (normal is less than 120/80 for adults) and heart rate 94 (normal-60 to 100 beats per minute for adults). Further review of the Note, revealed the resident's right leg had increased [MEDICAL CONDITION]. Per the Note, the Medical Director was notified and new orders were received to send the resident to the emergency room for evaluation. Review of Resident #36's Nursing Home to Hospital Transfer Form, dated 05/26/19, revealed the resident had abnormal vital signs. Further, the resident's Emergency Contact and the hospital were notified of the resident's transfer and clinical status. Review of the subsequent Progress Note, dated 05/26/19 at 4:31 AM, revealed the resident was admitted to the hospital with [REDACTED]. Review of the Discharge Return Anticipated Minimum Data Set (MDS) Assessment, dated 05/28/19, revealed the Discharge was unplanned and the facility assessed the resident as having no signs or symptoms of [MEDICAL CONDITION] or acute onset of mental status changes. However, further review of Resident #36's medical record, revealed there was no documented evidence Resident #36 or his/her Resident Representative received a written notice of transfer/discharge. 2. Review of Resident #39's closed medical record revealed the facility admitted the resident on 02/17/15, with [DIAGNOSES REDACTED]. Review of Resident #39's Nursing Home to Hospital Transfer Form, dated 05/18/19, revealed the Resident was short of breath and required oxygen at two (2) liters per nasal cannula. Additionally, the resident had decreased platelet count, hemoglobin, and hematocrit. Continued review revealed the Emergency Contact and Hospital were notified of the resident's transfer and clinical status. Review of the Discharge Return Anticipated Minimum Data Set (MDS) Assessment, dated 05/18/19, revealed the Discharge was unplanned and the facility assessed the resident as having continuous disorganized thinking. However, further review of Resident #39's medical record, revealed there was no documented evidence Resident #39 or his/her Resident Representative received a written notice of transfer/discharge. Interview with the Director of Nursing, on 08/01/19 at 4:41 PM, revealed it was a resident's right to be informed of the reason for transfer out of the facility. Additionally, she stated it was her expectation the facility policy be followed related to Discharge and Transfer. However, she stated she was not aware if unplanned acute transfers required written notification related to transfer reasons, bed hold information or appeal rights. Further interview revealed the Social Worker was responsible for providing residents and/or resident representatives with written notification of transfer and/or discharge. Interview with the Director of Social Services, on 08/01/19 at 5:00 PM, revealed she provided the facility Bed Hold Policy with thirty (30) day Notices to residents and/or resident representatives. She stated she did not provide written Notice of Transfer/Discharge for acute unplanned hospital transfers. Continued interview revealed she was not aware of a facility process or policy related to providing or ensuring written Notice of Transfer/Discharge related to acute unplanned transfers. However, she stated residents and/or resident representatives should be made aware of the reason for transfer and of the resident's financial status and clinical status to ensure continuity of care. Interview with the Business Office Manager, on 08/01/19 at 5:20 PM, revealed she received a copy of the Bed Hold Notice of Policy and Authorization Form from nursing staff when a resident was transferred out of the facility for acute unplanned healthcare. Per interview, she reviewed the Bed Hold Notice of Policy and Authorization Form and determined if the resident and/or resident representative required follow up information. Continued interview revealed she relied on the copy of the Bed Hold Notice of Policy and Authorization Form (from nursing) to know when a resident had been transferred out of the facility. However, she stated she was not aware of any process in place to provide written Notification of Transfer/Discharge to the resident and/or resident representative for hospital transfers, other than nursing staff giving residents a copy of the Bed Hold Notice of Policy and Authorization Form. Further, she was not aware that acute hospital transfers required written notification to include the reason why a resident was sent to the hospital, or appeal rights. Interview with the Administrator, on 08/01/19 at 6:30 PM, revealed she expected facility staff to be aware of and follow the facility policy related to Discharge and Transfer. Additionally, she expected nursing staff to verbally notify the resident and/or the resident representative, at the time of transfer followed by written notification. Continued interview revealed the Transfer/Discharge Notice should include the reason for transfer, bed hold information, and information regarding appeal rights. Further, she was not aware of the facility's current process for notification related to transfer/discharge, forms, who was responsible, or of an audit process to maintain the facility policy. However, she stated it was important that residents and/or resident representatives were made aware of their appeal rights, the financial responsibility, and to be fully informed. She stated a written notice of discharge should have been provided to Resident #36 and Resident #39 and their Resident Representatives.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (1) of five (5) sampled residents (Resident #1). Interview and record review revealed the facility had assessed Resident #1 to need extensive physical assist of two (2) staff for transfers. On 03/18/15 Resident #1 experienced a fall, sometime between 7:00 PM and 8:00 PM, when Certified Nursing Assistant (CNA) #1, unassisted, lowered the resident to the floor after the resident's leg gave out during a transfer from the wheelchair to the bed. The resident was assessed to have no injury and was assisted back to bed. On 03/19/15 at 8:15 AM, Resident #1's left leg was observed to have an inward rotation and complaints of pain. The Physician was notified and orders received to send Resident #1 to the hospital emergency room (ER), where the resident was diagnosed with [REDACTED]. (Refer to F323) The findings include: Review of the facility's policy titled, "Accidents/Incidents", revised 05/15/14, revealed the facility would use the "Risk Management System (RMS)" to report, review and investigate all accidents/incidents which occurred, or allegedly occurred, on the facility's property and involved, or allegedly involved, for residents receiving services. The Policy revealed an accident was defined as any unexpected or unintentional incident which would result in injury or illness to a resident. Review of the Policy revealed a licensed nurse would utilize the RMS to report accidents/incidents and assist with completion of a timely investigation to determine the root cause. Per the Policy, the nurse would examine a resident involved in a accident/incident, and would notify the Physician or mid-level provider of the accident/incident, report the physical findings and extent of injuries, and obtain orders as indicated. The Policy revealed if a resident's injury was of an emergent nature, the resident would be transported to the hospital. Continued review revealed the incident/accident was to be documented in the resident's medical record to include all pertinent information, date, time, place, notifications, and initial and ongoing assessments. The Policy noted the incident/accident would be documented on the facility's "24 Hour Report", and the Director of Nursing (DON) or designee would close the event within five (5) days. Further review revealed the Administrator or designee would coordinate all the facility's investigations. Review of the facility's, "Fall Response Protocol" Policy, revised May 2013, revealed staff would evaluate and monitor a resident for seventy-two (72) hours after a fall. Per the Policy, after a resident's fall staff would evaluate the resident's level of consciousness, vital signs, airway, breathing, circulation, and summon help. Continued review revealed staff would also document and investigate the circumstances per a "change of condition note", Incident Report, Fall Investigation Form and RMS, if applicable. Review of Resident #1's medical record revealed the facility admitted the resident on 12/11/09, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/15, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status score of three (3), which indicated the resident was severely cognitively impaired. Continued review of the MDS Assessment revealed the facility assessed Resident #1 to require extensive physical assist of two (2) staff for transfers and bed mobility. Further review revealed the facility assessed Resident #1's balance during transitions when moving from a seated to standing position and for surface-to-surface transfers, such as transferring from the bed to the wheelchair, as "not steady, only able to stabilize with staff assistance". Review of Resident #1's Comprehensive Care Plan, revised 03/05/15, revealed the facility had care planned the resident for being at risk for falls; however, review of the interventions revealed no documented evidence of how much assistance he/she required with transfers. Continued review revealed the facility care planned Resident #1 for requiring assistance with Activities of Daily Living (ADLs) care due to history of falls, cognitive impairment, Parkinson's Disease, Anxiety and decreased mobility. Review of the ADL care plan revealed Resident #1 required assistance with most ADLs including the ability to transfer. The ADL care plan goal stated Resident #1's ADL care needs would be anticipated and met in order to maintain the highest practicable level of functioning and physical well-being. Review of the ADL care plan interventions revealed for staff to assist with the resident's ADLs as needed and adjust the level of care according to the individual needs. Review of the MDS Kardex, the CNAs care plan, dated March 2015, revealed Resident #1 was an extensive assist of two (2) staff with bed mobility and transfers. Review of the facility's RMS Incident Report, with a completion date of 03/31/15 at 10:03 AM, revealed Resident #1 experienced a fall on 03/18/15 at 7:30 PM. Review of the "injury" section of the Incident Report revealed "while being transferred from wheelchair to bed", Resident #1's legs gave out and staff lowered the resident to the floor. The Incident Report noted after the fall Resident #1 was able to move all extremities, denied any pain, was assisted to bed per two (2) staff, and the Physician and family notified. Review revealed the witnesses included CNA #1 and CNA #2. Further review of the Incident Report revealed under the "summary of investigation" section Resident #1 was "lowered to floor per CNA around 8:00 PM while being transferred to bed" with staff reporting the resident's "knees gave out". Continued review of the "summary of investigation" section revealed an assessment was performed of Resident #1 by the nurse after the fall, with the resident denying pain, able to move all extremities within "normal limits", and was assisted back to bed per three (3) staff members. Further review of the Incident Report revealed Resident #1 was sent to the hospital ER where the resident was diagnosed with [REDACTED]. Review of the facility's investigation statements, dated 03/19/15 at 4:10 PM, revealed CNA #1 reported she went into Resident #1's room on 03/18/15, to put the resident to bed. She wrote Resident #1 stood to get into bed, slumped down and stood back up and then slumped again. Per CNA #1's written statement, Resident #1 fell on his/her left side and his/her legs were laying "funny". She revealed Registered Nurse (RN) #1 asked Resident #1 if he/she was in pain and the resident said, his/her "back". Review of the written statement revealed RN #1 asked Licensed Practical Nurse (LPN) #1 to assess Resident #1 as well, and they both determined the resident was fine. CNA #1 noted Resident #1 did not complain of pain anymore that night, but CNA #1 observed the resident's leg did not appear to move correctly when he/she turned. Further review of CNA #1's written statement revealed she told RN #1 about Resident #1's leg, and the RN checked the resident around 11:00 PM, and the resident was fine. Interview with CNA #1, on 04/01/15 at 2:58 PM, revealed she worked with Resident #1 every day, and the resident was care planned to be a two (2) person assist, but could bear weight. Per interview, it helped to have two (2) people to assist when transferring Resident #1, and the resident's "care card" indicated he/she was a two (2) person assist. Continued interview with CNA #1 revealed on the night of 03/18/15, at approximately 8:00 PM, she was assisting Resident #1 back to his/her room, where she assisted the resident to transfer from his/her wheelchair to the bed. She stated Resident #1 appeared to be a little weak when standing up, and the resident stood and pivoted to the left, while CNA #1 pivoted to the right. Per interview, CNA #1 was standing in front of Resident #1 during the transfer, and the resident moved down and stood up again holding onto the CNA's arms. CNA #1 reported she asked Resident #1 if he/she was okay; however, the resident did not respond, and then slumped over and put all of his/her weight onto CNA #1 and leaned forward. Continued interview revealed CNA #1 eased Resident #1 to the floor to sit on his/her bottom. She stated she was on the other side of Resident #1 and believed she had a good hold on the resident when he/she went down onto the floor, which happened pretty quickly. Per CNA #1, Resident #1 landed on his/her bottom, and his/her left leg was turned inward facing his/her right knee. She reported the placement of the resident's leg "didn't look normal, it looked abnormal". CNA #1 stated she asked Resident #1 if the leg hurt, and the resident stated "no, my back, my back, my back". The CNA revealed this was how Resident #1 expressed pain, and she had someone get RN #1. She stated RN #1 and CNA #2 came to Resident #1's room, and the RN assessed the resident before they moved him/her off the floor onto the bed. Interview revealed CNA #1 heard Resident #1 continue to say, "my back"; however, after RN #1 assessed the resident, she said it was okay to move the resident to the bed. CNA #1 reported she and CNA #2 proceeded to put Resident #1 to bed, she did not see any bruising on the resident's leg, but was bothered by the way the resident's leg was turned. Per the CNA, RN #1 asked Resident #1 if he/she was okay and the resident continued to say, "my back". Interview revealed LPN #1 also came into Resident #1's room and assessed the resident with RN #1, and the resident was able to move his/her leg pretty well at that point. Further interview with CNA #1 revealed at 10:30 PM, she was doing her final rounds and Resident #1 needed to be changed, so she rolled the resident and his/her left leg moved along with her "lifelessly". She stated Resident #1's left leg was not bruised or had any swelling, but the leg did not have any resistance or no force at all when the resident was moved. Further interview with CNA #1 revealed when she moved the resident, there was also a slight popping which she told RN #1 about. In addition, she stated she told RN #1 Resident #1's knee was turned inward and it was facing toward the right knee, and the RN checked the resident by shaking his/her left foot. According to CNA #1, RN #1 asked Resident #1 if he/she was in pain, and the resident said,"no, no, no". CNA #1 further revealed she should have asked for assistance when transferring Resident #1 from the wheelchair to the bed, as the care plan indicated the resident was a two (2) person assist. Additionally, CNA #1 added, "If there was another CNA to assist, I'm sure the resident would not have fallen or hurt" himself/herself. Review of CNA #2's statement, dated 03/27/15 at 4:15 PM, revealed during a transfer from the "chair to bed" on 03/18/15, Resident #1 was lowered to the floor. CNA #2 noted she went to get RN #1 and the vitals machine. Review of the written statement revealed Resident #1 was seated on his/her bottom with his/her back against the bed. CNA #2 documented when Resident #1 was placed in the bed, his/her knees popped with movement. Per the written statement, RN #1 and LPN #1 assessed Resident #1, and reported the resident was fine. CNA #2 noted she did not return to Resident #1's room anymore that night. Interview with CNA #2, on 03/31/15 at 5:18 PM, revealed she did not normally care for Resident #1, normally CNA #1 was assigned to work the resident's hall. She reported on the night of the incident, 03/18/15, she was returning from break between 7:30 PM and 8:30 PM, and the bathroom's emergency light was on and CNA #1 was asking for RN #1. She stated she observed Resident #1 sitting on the floor with his/her back leaned up against the bed. Per interview, she and CNA #1 asked Resident #1 if he/she was hurting and the resident said, "yes", his/her leg was hurting. CNA #2 reported RN #1 assessed Resident #1's leg and she and CNA #1 both told the RN the resident complained of his/her leg hurting. She stated RN #1 moved both of Resident #1's legs around, and CNA #2 was pretty sure the resident continued to express being in pain. Per CNA #2, LPN #1 also came into Resident #1's room and assessed the resident by moving his/her legs as well, and asked the resident if he/she was okay, but the resident did not respond. CNA #2 reported Resident #1's vitals were taken and the resident's vital signs were normal. CNA #2 revealed she believed Resident #1 was care planned to be a two (2) person assist, and staff was aware the resident was two (2) person assist. According to CNA #2, CNA #1 told her Resident #1 would often assist her with transfers and could bear weight and she was trying to transfer Resident #1 on her own because the resident normally helped her. Additionally, CNA #2 stated she would not try to transfer a resident on her own because "it's just too risky". Review of CNA #3's written statement, dated 03/27/15 at 2:55 PM, revealed she went into Resident #1's room at 1:00 AM on 03/19/15, and the resident did not appear to be in any pain and he/she was not complaining of pain when being turned in bed. CNA #3 noted when she went back into Resident #1's room at 4:00 AM to check on the resident, he/she did not want her to touch his/her left leg. Review revealed Resident #1's left leg appeared to be turned inward. Continued review of CNA#3's written statement revealed she asked LPN #1 to look at Resident #1's leg and an x-ray was ordered for the resident. Interview with CNA #3, on 04/01/15 at 7:13 PM, revealed she worked the second and third shifts on the night Resident #1 fell . She stated CNA #1 did not tell her many details of Resident #1's fall, only that the resident had fallen, but seemed to be okay. Per interview, this was about 11:00 PM, and she was working on a different unit at the time. According to CNA #3, she did not see Resident #1 until around 1:00 AM to 1:30 AM. She reported Resident #1 did not seem to be in any pain at that time, and the resident was dry and didn't need changing. Continued interview with CNA #3 revealed she checked on Resident #1 again at 4:00 AM, and when she walked in the room, the resident's left leg was turned in so she immediately got RN #2. Per CNA #3, she thought Resident #1's leg was swollen, and knew there was something wrong when she saw the resident's leg. She stated Resident #1 did not say anything until RN #2 started to move his/her left leg when the resident said "it hurts". CNA #3 reported RN #2 had LPN #1 come and assess Resident #1 also, and when LPN #1 tried to move the resident's leg, the resident kept saying, "it hurts, it hurts". Further interview revealed LPN #1 then called the doctor who ordered an x-ray. She revealed RN #2 assisted her with changing Resident #1, and the resident grimaced while they were changing him/her. Review of LPN #1's investigation statement, dated 03/19/15 with no time documented, revealed she was called to Resident #1's room and the resident was observed in his/her bed without any sign of pain. The statement revealed she reported she was told by the staff present Resident #1 was being transferred to bed by two (2) CNAs, and the resident's leg had went out from under him/her so, they lowered the resident to the floor. Per the statement, as Resident #1 was assisted to bed and had no sign of any pain or discomfort she left the room. LPN #1's statement revealed she was called back to Resident #1's room around 4:40 AM, to check the resident regarding reported pain, and the LPN documented a slight inward rotation of the left foot and the knee looked displaced. Continued review of the statement revealed when LPN #1 was assessing Resident #1, the resident did not complain of pain when his/her leg was moved. The statement noted LPN #1 reported staff told her Resident #1 complained of pain when they were turning the resident and reported the resident did not complain of pain during the night. Further review of the statement revealed LPN #1 received an order to obtain an x-ray of Resident #1's knee and hip. Interview with LPN #1, on 04/01/15 at 11:28 PM, revealed on the day of the incident, 03/18/15, she was working as a nursing assistant on the floor on second shift, at the time the incident occurred. LPN #1 reported she was called to the resident's room by RN #1 who asked her "to check something for her". She stated when she entered Resident #1's room, the resident was already in bed and CNA#1 and CNA #2 were in the room with the resident. Continued interview revealed LPN #1 was not sure she was told Resident #1 had experienced a fall but she was told the resident's knees buckled. Per interview, she talked to Resident #1, but the resident did not say anything, and she did not ask the resident if he/she was in pain because the resident was already in bed. The LPN revealed she was not even sure why she was called to Resident #1's room that night, as RN #1 was the resident's nurse and handled "everything else. Review of RN #1's investigation statement, dated 03/19/15 at 12:30 PM, and on 03/27/15 at 3:00 PM, revealed Resident #1 was sitting on the floor beside his/her bed when she entered the room on 03/18/15. The statement revealed RN #1 was told by CNA #1, she had lowered Resident #1 to the floor, and LPN #1 and LPN #3 also came into the resident's room to check on the resident. She documented the resident did not complain of pain at the time, and had no noted deformities and was able to move everything. Per the RN #1's later statement, Resident #1 was transferred from the wheelchair to his/her bed, on 03/18/15 at 8:00 PM, by two (2) staff, and was eased to the floor by the staff landing on his/her buttocks. The statement revealed RN #1 assessed Resident #1, the resident had no complaints of pain and was assisted to bed by two (2) staff who elevated both of the resident's legs on a pillow. RN #1 documented she asked Resident #1 at 8:20 PM that night if he/she was hurting and the resident complained of his/her back hurting. Per the statement, at 10:00 PM and through the rest of the evening RN #1 continued to observe Resident #1 for discomfort, without any changes. Further review of the statements revealed at 11:00 PM on 03/18/15, a CNA (not mentioned by name) made rounds changed Resident #1's brief and reported while turning the resident, there was no resistance. RN #1 documented she had the evening manager and night manager assess Resident #1 before she left work at the facility, and when she spoke to them they had found no apparent problems. Interview with RN #1, on 04/01/15 at 6:42 PM, revealed CNA #2 called her to Resident #1's room on 03/18/15, reporting the resident had fallen. Per interview, when she entered Resident #1's room, the resident was seated on the floor and was calling out "my back, my back". She stated she was told by CNA #1 and CNA #2 Resident #1's legs gave out during a transfer and the resident was eased to the floor. RN #1 reported she assessed Resident #1 took vital signs, then CNA #1 and CNA #2 assisted the resident onto the bed. According to RN #1, she took Resident #1's vital signs and the resident was monitored for seventy-two (72) hours. However, record review revealed no documented evidence this monitoring was completed. Continued interview revealed she asked LPN #1 to assess Resident #1 also, and LPN #1 thought the resident was "fine" as well. RN #1 stated she continued to take vital signs on Resident #1 that night. However record review revealed no documented evidence Resident #1's vital signs were taken except the set obtained after the resident's initial fall. Continued interview with RN #1 later that night, CNA #1 asked her to look at Resident #1's left leg because she thought the leg was lying differently. Per interview, she told CNA #1 the resident's leg "always" looked that way due to his/her Arthritis. RN #1 stated she contacted the resident's Physician to inform him of Resident #1's fall; however, did not inform him the resident had an injury as her assessment had revealed no injury. She stated she completed the RMS Incident Form, but the current one was incorrect as her findings suggested the resident was without injury and no fracture was indicated. Further interview with RN #1 revealed she was not aware Resident #1 was transferred by an assist of one (1) that night, but sometimes the resident could be a one (1) person assist because he/she could bear weight. She stated however, she believed Resident #1 was care planned to be a two (2) person assist, but was not certain of that. Continued interview with LPN #1, on 04/01/15 at 11:28 PM, revealed switched from a nursing assistant role to Supervisor on third shift the night of the incident. She stated she was called to Resident #1's room around 4:00 AM that morning, 03/19/15 by RN #2, who told her the resident was complaining of his/her leg. Per LPN #1, she "checked" Resident #1's leg, and noticed the knee, "not so much the foot" was turned and "looked deformed". LPN #1 stated she thought it was Arthritis, but the resident was saying, "oh my leg, my leg", when the left leg was moved when she did range of motion (ROM) on his/her legs. According to LPN #1, RN #2 and CNA #3 told her Resident #1 complained of pain every time they turned him/her. LPN #1 revealed at around 1:00 AM, she called Resident #1's Physician and "got an order for [REDACTED]. However, she stated when she returned to Resident #1's room the resident was asleep, so she arranged to have the x-ray "first thing in the morning". Further interview with LPN #1 revealed if she had known Resident #1 had fallen "earlier", she would have checked the resident out a little more, and inquired how the fall occurred, how far had the resident fallen, and how he/she landed after the fall. LPN #1 stated if she had known it was a fall, vital signs would have been checked four (4) times every half hour, then four (4) times every hour, then every four (4) hours for twenty-four (24) hours. Review of RN #2's statement, dated 03/19/15 at 4:15 PM, revealed Resident #1 was lowered to the floor by CNA #1. The statement revealed CNA #1 went and got the resident's nurse, RN #1, and the night shift Supervisor, LPN #1, to assess Resident #1 at around 7:00 PM to 7:30 PM on 03/18/15. RN #1 noted she heard RN #1 report "they" assessed Resident #1, and helped put the resident to bed. Per the statement, RN #2 did not hear anything else that night until CNA #3 got her out of another resident's room to come assess Resident #1. According to the statement, RN #2 entered Resident #1's room around 4:00 AM to 4:30 AM, and observed the resident's left leg was inverted and he/she was complaining of pain. Further review of the statement revealed RN #2 noted Resident #1 could not say what was hurting, the resident just kept saying, "don't touch" when the leg was moved. The statement revealed RN #2 got LPN #1 to come assess Resident #1 as well, and LPN #1 then obtained orders to get an x-ray. Interview with RN #2, on 04/02/15 at 3:29 PM, revealed she was working as a CNA during the night shift when the incident occurred. RN #2 revealed she recalled hearing CNA #1 stating she lowered Resident #1 to the floor, and RN #1 and LPN #1 talked about the resident's fall during third shift report. Per interview, she did not hear anything else about Resident #1 until about 4:00 AM, on 03/19/15, when CNA #3 called her into the resident's room. She reported when she entered Resident #1's room, the resident's leg looked inverted, and she then went to get LPN #1, who was the acting Supervisor to assess the resident also. Per RN #2, LPN #1 advised her and CNA #3 not to touch Resident #1 until she obtained an x-ray. RN #2 reported she recalled Resident #1 saying, "don't touch, don't touch". Continued interview revealed RN #2 interpreted that as an indication Resident #1 was in pain, and due to the condition of the resident's leg, she would have made the judgement call to call an ambulance. She stated Resident #1's Physician was notified and LPN #1 was advised to get an x-ray for the resident. RN #2 revealed she asked LPN #1 if she needed any assistance and LPN #1 reported she was fine. Per RN #2, LPN #1 "was the nurse for the whole building that night". RN #2 stated Resident #1 was a two (2) person assist and therefore the resident should never be transferred by one (1) person as it was not safe. Interview with LPN #2, on 04/01/15 at 12:32 PM, revealed she normally worked first shift, and when she reported to work the morning of 03/19/15 at around 7:00 AM, she was told in shift report, Resident #1 had fallen and complained of pain in the middle of the night and a mobile x-ray had been ordered. LPN #2 stated she went to see Resident #1 after the morning report and the resident was awake and lying on his/her bed. Per interview, Resident #1 was holding his/her left leg and repeating,"my hip, my hip, my hip". LPN #2 revealed she assessed Resident #1's left hip and noticed the thigh area was swollen, and the leg was rotated inward. According to LPN #2, she asked Resident #1 if he/she was hurting and the resident stated, "my hip". Continued interview revealed LPN #2 immediately thought Resident #1 had a fractured hip and alerted RN #3, the Unit Manager. LPN #2 reported she was instructed to call the resident's Physician, which she did and informed the Physician of Resident #1's fall and he/she was complaining of pain. She stated she also told the Physician Resident #1's leg was rotated inward and it appeared to be fractured. LPN #2 revealed in looking at Resident #1's leg, it could not have been mistaken as Arthritis. Per LPN #2, "I just knew it wasn't right". Further interview with LPN #2 revealed when a resident experienced a witnessed fall, vital signs would be taken on the resident before moving the resident, no other vital signs would be taken after that. However, the facility's policy stated staff would evaluate and monitor a resident for seventy-two (72) hours after a fall. LPN #2 stated Resident #1 should not have been assisted with only one (1) staff person, for the resident's safety, as well as, staff. Interview with RN #3, on 04/02/15 at 10:45 AM, revealed she arrived to work on 03/19/15 at 8:00 AM, and LPN #2 reported to her Resident #1 was in pain, stating, "my hip, my hip". Per interview, she asked LPN #2 if x-rays were ordered and was told an order was received around 5:00 AM. She stated after assessing Resident #1's leg, she thought the knee might have been dislocated, and asked LPN #2 to notify the Physician to have the resident sent to the hospital. RN #3 revealed it was the facility's policy in the event of a fall which was witnessed, the assessment of the resident would "stop" with the initial vital signs. However, the facility's policy stated staff would evaluate and monitor a resident for seventy-two (72) hours after a fall. Continued interview revealed Resident #1 should never have been transferred by one (1) person for the resident's and staff's safety. Interview, on 04/01/15 at 10:30 AM, with the hospital ER RN revealed when Resident #1 arrived at the ER he/she was non-verbal and pale. Continued interview revealed Resident #1 "grimaced" in pain every time he/she was moved. Per the ER RN, Resident #1 had an "s-shaped" left femur fracture which was "rock hard". She stated the fracture appeared to be an "older fracture" which had been "sitting for a while, at least a couple of hours". Further interview revealed if the fracture had been "fresh", the muscle would still spasm. According to the ER RN, "you would not have needed to be in the medical profession" to have know Resident #1 had fractured his/her leg, as there was an "obvious deformity". Interview with the Assistant Director of Nursing (ADON), acting for the Director of Nursing (DON), on 04/02/15 at 4:02 PM, revealed on 03/18/15, she was notified of Resident #1's fall, but was not notified of the resident's change of condition at 4:00 AM. She stated she should have been notified, as she was the on call person, and the facility's process was for staff to phone the on call person. Per interview, in the event of a fall, a resident would be assessed from head to toe, staff would check for ROM, and ensure there were no deformities anywhere. The ADON revealed if the fall was a unwitnessed, then neurological (neuro) checks would have been completed; however, if the fall was witnessed and the resident hadn't hit his/her head this would not be done. However, the facility's policy stated staff would evaluate and monitor a resident for seventy-two (72) hours after a fall and the policy did not differentiate between a witnessed fall or an unwitnessed fall. Continued interview as Resident #1's fall was witnessed, vital signs should have been taken on every shift; however, the ADON reported there was no documented evidence this was done. She stated when Resident #1 complained of pain, it was her expectation staff would have found out where the pain was coming from. Further interview revealed since there were two (2) aides in Resident #1's room after the fall, it was assumed the resident was assisted by staff of two (2); however, later discovered the resident had been assisted by only one (1). The ADON revealed the resident should not have been assisted by only one (1) staff member. Interview with the Administrator, on 04/02/15 at 4:45 PM, revealed there was an investigation regarding the incident involving Resident #1, and he was under the impression the resident was transferred from the wheelchair to the bed by two (2) staff. He stated he did not know Resident #1's care plan was not followed for two (2) staff to assist because he did not have that information. Per interview, he would have expected his staff to follow the facility's policy regarding incident/accidents and the fall protocol, in which the resident's vital signs would have been assessed.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents Comprehensive Care Plans were implemented for one (1) of five (5) sampled residents (Resident #1). Resident #1 was care planned to have assistance with ADL's, which included transfers, and the "care card" (Kardex) utilized by the facility's Certified Nursing Assistants (CNAs) revealed the resident required two (2) person extensive physical assist with transfers. However, on 03/18/15, between 7:00 and 8:00 PM, Resident #1 experienced a fall as a result of being transferred with assistance of only one (1) staff, CNA #1. Additionally, Resident #1 was care planned for pain with interventions which included to administer medications as ordered and observe for nonverbal signs and symptoms (s/s) of pain. After Resident #1 experienced the fall on 03/18/15, sometime between 7:00 and 8:00 PM, the resident complained of pain by verbalizing, "my back, my back", and continued to complain of pain. On 03/19/15 at 4:52 AM, Resident #1 was noted to complain of pain to the left hip and knee area, and at 8:15 AM, the resident was stating, "my hip, my hip, my hip", with the left leg noted to be rotated inward and swollen around the knee and upper thigh area. However, there was no documented evidence staff had administered Resident #1's as necessary (PRN) pain medications for relief of the resident's pain, as per the care plan. Resident #1 was sent to the hospital emergency room (ER) where he/she was given [MEDICATION NAME] (a narcotic pain reliever) for pain and diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled, "Care Plans", with a revision date of 01/02/14, revealed the comprehensive, individualized care plan would be developed by the interdisciplinary team (IDT) for each resident. Review revealed the care plan would include measurable objectives and goals as identified by the assessment process. The Policy revealed the purpose of the care plan was to provide necessary care and services to attain or maintain the patient's highest practicable physical, mental, and psychosocial well being. 1. Record review revealed the facility admitted Resident #1 on 12/11/09, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/15, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status score of three (3), which indicated he/she was severely cognitively impaired. Continued review of the MDS revealed the facility assessed Resident #1 to require extensive physical assist of two (2) staff for transfers and bed mobility. Review of Resident #1's Comprehensive Care Plan, revised 03/05/15, revealed the facility care planned the resident for requiring assistance with activities of daily living (ADLs) which included for transfers. Continued review revealed the goal was for staff to anticipate and meet Resident #1 ADL care needs in order to maintain the highest practicable level of functioning and physical well-being. Further review revealed interventions which included staff to assist Resident #1 with ADLs as needed and adjust the level of care as needed. Review of the MDS Kardex, (CNAs care plan), dated March 2015, revealed Resident #1 was an extensive assist of two (2) staff with transfers. Review of the facility's Risk Management System (RMS) Incident Report, completed on 03/31/15 at 10:03 AM, revealed Resident #1 had fallen on 03/18/15 at 7:30 PM, when being transferred from wheel chair to bed and was lowered to the floor. Per the Incident Report, Resident #1 denied pain and was assisted to bed per two (2) staff. The Incident Report revealed CNA #1 and CNA #2 were witnesses of the fall. Review of the corrective action section of the Incident Report revealed Resident #1 was assessed by a nurse with no signs or symptoms (s/s) of pain or discomfort, x-rays were ordered at 5:00 AM and canceled due to the resident being sent to the ER at 8:15 AM. Further review revealed the hospital called the facility to report Resident #1 had a left femur fracture. Interview, on 04/01/15 at 2:58 PM, with CNA #1 revealed she cared for Resident #1 regularly, and stated the resident was care planned to be a two (2) person assist, but could bear weight. Per interview, it helped to have two (2) people to assist when transferring Resident #1. Continued interview revealed on the night of 03/18/15, at approximately 8:00 PM, she was attempting to transfer Resident #1 by herself from the wheelchair to the bed, when the resident slumped over onto her and leaned forward. CNA #1 stated she eased Resident #1 to a sitting position on the floor. She reported Resident #1's left leg was turned inward facing his/her right knee, and "didn't look normal" CNA #1 further revealed she should have asked for assistance when transferring Resident #1, as the care plan noted he/she was a two (2) person assist and she should have followed it. CNA #1 stated "If there was another CNA to assist, I'm sure the resident would not have fallen or hurt" himself/herself. Interview, on 03/31/15 at 5:18 PM, with CNA #2, revealed it was known among staff Resident #1 was a two (2) person assist, and the resident was care planned to be a two (2) person assist. Per interview, CNA #1 told her Resident #1 could bear weight and often assisted her with transfers. She stated CNA #1 told her she was trying to transfer Resident #1 on her own because the resident normally helped her. Continued interview revealed however, if a resident was care planned to be an assist of two (2) staff, then staff should seek assistance from another aide before transferring the resident. Additionally, CNA #1 reported she would not try to transfer a resident on her own because "it's just too risky". Further interview revealed it was important to follow residents' care plans to ensure the resident's or staff were not hurt. The CNA stated Resident #1's care plan should have been followed by CNA #1. Interview, on 04/02/15 at 7:58 AM, with CNA #5, revealed Resident #1 was care planned for a two (2) person assist and should not be transferred with an assist of one (1). She stated Resident #1 could not bear weight, and it would be difficult to transfer the resident by yourself. Per CNA #5, "if a resident was a fall risk, then bad things could happen to them" if the care plan was not followed. She stated staff should follow the care plan like it was their bible. Interview, on 04/01/15 at 12:32 PM with Licensed Practical Nurse (LPN) #2 and at 6:42 PM with Registered Nurse (RN) #1, and on 04/02/15 at 10:45 AM with RN #3 and at 3:29 PM with RN #2, revealed they all stated Resident #1 was a two (2) person assist with transfers. RN #1 and RN #3 revealed Resident #1's Comprehensive Care Plan noted to assist Resident #1 with ADLs as needed and adjust care to his/her individual needs. Per RN #1 and RN #3, the CNA's "care cards" (Kardex) noted the assistance residents required, and RN #1 stated Resident #1's "care card" indicated the resident was an assist of two (2) staff for transfers. Per RN #1, Resident #1 was sometimes a one (1) person assist because he/she could bear weight; however, it was important the care plan was followed by staff. Interview with the Minimum Data Set (MDS) Coordinator and the Clinical Reimbursement Coordinator (CRC), on 04/02/15 at 2:07 PM, revealed the Comprehensive Care Plan was a tool used to guide and direct the care for the residents. When reviewing Resident #1's Care Plan, they reported the intervention related to transfers was not specific as to the number of staff required to complete the transfer; however, the Kardex, (CNAs care plan), specified Resident #1 required extensive assist of two (2) staff persons to transfer the resident. The MDS and CRC stated the nursing staff and CNAs should be referring to the care plan and Kardex to direct the care of the resident. Additionally, they both stated Resident #1's care plan should have been followed. Interview with the Assistant Director of Nursing (ADON), acting for the Director of Nursing (DON), and the Administrator, on 04/02/15 at 4:45 PM, revealed Resident #1 was care planned to be a two (2) person assist and should not have been assisted by one (1) staff member. Both the Administrator and the ADON stated it was their expectation, the Care Plan would be followed by staff. 2. Continued review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have moderate pain during the last five (5) days, which made it hard to sleep at night. Continued review of Resident #1's Comprehensive Care Plan, revised 03/05/15, revealed the facility care planned the resident as at risk for alterations in comfort with a goal for the resident not to exhibit nonverbal indicators of pain. Further review of the care plan revealed the interventions included to administer medications as ordered and to observe for nonverbal signs and symptoms (s/s) of pain. Review of the March 2015 physician's orders [REDACTED].#1 also had as necessary (PRN) [MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME] ordered every six (6) hours PRN for pain. Review of the March 2015 Medication Administration Record [REDACTED]. Review of the computerized Nurse's Notes dated 03/18/15 at 9:30 PM, noted by RN #1 revealed Resident #1 had an "accident/incident fall" in the past seventy-two (72) hours, which was witnessed during a transfer. Continued review of the Note revealed Resident #1 was not demonstrating symptoms of pain. Interview, on 04/01/15 at 6:42 PM, with RN #1 revealed Resident #1 expressed his/her back was hurting by stating, "my back, my back". However, RN #1 stated she did not give Resident #1 pain medication, as she didn't know if the resident was truly expressing pain. RN #1 revealed unless a resident asked her for a pain medication, she would not give the resident anything for pain. Continued interview with RN #1 revealed she was not familiar with Resident #1's care plan and often got her information from shift report. Review of the 03/19/15 at 4:52 AM, Nurse's Note documented by LPN #1 revealed Resident #1 complained of pain to the left hip and knee when moved, with an inward rotation of the leg. Review of Nurse's Notes dated 03/19/15 at 4:56 AM, documented by LPN #1 revealed it was a follow-up note from the "accident/incident/fall" Resident #1 had experienced in the past seventy-two (72) hours. The Note revealed Resident #1 now complained of pain to hip and knee area on the left side noted an inward rotation to leg. Per the Note, an order was received to get a "stat" (as soon as possible) x-ray. However, there was no documented evidence Resident #1's PRN pain medication was administered for the resident's pain, as per the care plan. Interview with LPN #1, on 04/01/15 at 11:28 PM, revealed if she determined the resident was in pain she would check for PRN pain medication orders, and administer the PRN. However, even though LPN #1 documented Resident #1 complained of pain, LPN #1 failed to administer the resident's PRN pain medication, per the resident's plan of care. Review of the "Late Entry" Nurse's Note dated 03/19/15 at 8:00 AM, documented by RN #3 revealed Resident #1's left leg was swollen at the thigh and the knee was disfigured, and LPN #2 was told to send the resident "out", to the hospital. Interview, on 04/02/15 at 10:45 AM, with RN #3 revealed she was told by RN #2, Resident #1 expressed he/she was in pain by stating, "my hip, my hip". RN #3 reported she did not give the resident anything for pain because the resident did not express to her that he/she was in pain. Continued interview with RN #3 revealed she would have given Resident #1 something for pain had she heard the resident say he/she was in pain; however the resident did not say anything when she went to the resident's room. RN #3 revealed the resident was care planned for pain; however, revealed the "paper" was the last thing she looked at, adding the interventions were something they already did. Additionally, RN #3 stated the care plan should have been followed. RN #3 reported that the potential for psychological harm to the resident when the pain went untreated would be, "If left untreated, it would be internalized or emotional to the resident and the resident could shut down". Review of LPN #2's Nurse's Note dated 03/19/15 at 8:15 AM, revealed Resident #1's left leg was rotated inward and swollen around knee and upper thigh area. Further review revealed Resident #1 was stating, "my hip, my hip, my hip". The Note revealed the Physician was called and an order received to send Resident #1 to the ER. However, there was no documented evidence Resident #1's PRN pain medication was administered for pain, as per the care plan. Interview, on 04/01/15 at 12:32 PM, with LPN #2 revealed when she checked on Resident #1 the morning of 03/19/15 between 7:00 AM and 7:30 PM, the resident was touching his/her left hip repeating, "my hip, my hip, my hip". LPN #2 reported she knew Resident #1 was in pain by the way he/she was grabbing his/her hip. Continued interview with LPN #2 revealed she did not give Resident #1 his/her PRN pain medications because she was more concerned about sending the resident out. Interview with the ADON, acting for the DON, on 04/02/15 at 4:02 PM, revealed it would be her expectation that staff would follow Resident #1's care plan regarding pain. She reported staff, on each shift, should be asking the resident, "Are you in Pain?". The ADON reported it would have been her expectation that staff would have provided the resident his/her PRN pain medications when he/she expressed he/she was in pain. Interview with the ADON and the Administrator, on 04/02/15 at 4:45 PM, revealed Resident #1 was care planned for PRN pain medication and it should have been administered. Per the Administrator and the ADON, it was their expectation the care plan would be followed by staff.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure monitoring residents for pain for one (1) of five (5) sampled residents (Resident #1). Resident #1 experienced a fall on 03/18/15, sometime between 7:00 and 8:00 PM, and the resident complained of pain to staff by verbalizing, "my back, my back". Resident #1 continued to complain of pain every time he/she was turned. Resident #1 had physician's orders [REDACTED]. However, there was no documented evidence Resident #1 received PRN pain medication. On 03/19/15 at 8:00 AM, Resident #1's left leg was noted to be swollen at the thigh and knee and "disfigured". At 8:15 AM, Resident #1 was saying, "my hip, my hip, my hip", the Physician was notified and an order received to transport the resident to the hospital emergency room (ER). Resident #1 was grimacing in pain on arrival to the ER, and his/her heart rate would elevate every time the left leg was touched. [MEDICATION NAME] (a narcotic pain reliever) was ordered for the pain and administered in the ER. Resident #1 was diagnosed with [REDACTED]. (Refer to F282) The findings include: Review of the facility's policy titled, "Pain Management", revised 01/02/14, revealed residents would be evaluated for pain on admission/re-admission, quarterly, with a change in condition or change in pain status. Per the Policy, the purpose was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain. Review revealed "as a minimum of daily" residents would be evaluated for the presence of pain by inquiry or by observation for signs of pain. If a resident experienced a change in their pain status, the nurse was to complete a "Pain Screening and Evaluation Tool". In addition, the Policy revealed facility staff would report any observation or communication of residents' pain to the nurse responsible for the resident. Medical record review revealed the facility admitted Resident #1 on 12/11/09, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/12/15, revealed the facility assessed Resident #1 as severely cognitively impaired, and to have moderate occasional pain in the past five (5) days which made it hard to sleep at night. Review of Resident #1's Comprehensive Care Plan, revised 03/05/15, revealed the facility care planned the resident as being at risk for alterations in comfort, with a goal for the resident not to exhibit non-verbal indicators of pain through the "next review". Review of the care plan revealed interventions which included "administer medications as ordered", encourage the resident to communicate presence of pain and observe for non verbal signs and symptoms (s/s) of pain. Review of the March 2015 physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the facility's Risk Management System (RMS) Incident Report, with a completion date of 03/31/15 at 10:03 AM, revealed Resident #1 had experienced a fall during a transfer and was lowered to the floor on 03/18/15 at 7:30 PM. The Incident Report revealed at the time of the fall Resident #1 denied pain and was assisted to bed. Continued review revealed the corrective action section included the following information: Resident #1 was "placed in bed, per staff, assessment completed per nurse, no s/s of pain or discomfort, x-rays ordered at 5:00 AM stat (immediately), then canceled due to resident being sent to the ER at 8:15 AM". Further review of the corrective action section revealed the hospital called the facility to report Resident #1 had a left femur fracture. Review of Resident #1's Nurse's Note dated 03/18/15 at 9:30 PM, documented by Registered Nurse (RN) #1 revealed the Note was a "change in condition" Note which stated Resident #1 had experienced "a(n) accident/incident/fall" in the past seventy-two (72) hours, which was witnessed during a resident room transfer. Interview with Certified Nursing Assistant (CNA) #1, on 04/01/15 at 2:58 PM, revealed after the fall on 03/18/15, Resident #1 expressed his/her back was hurting. Per interview, Resident #1 often expressed pain by stating, "my back", but mainly staff would observe his/her facial expression since the resident did not talk very much. Further interview revealed she did not see RN #1 give Resident #1 anything for pain after the fall, but she believed something should have been given. Interview with CNA #2, on 03/31/15 at 5:18 PM, revealed she recalled Resident #1 expressing being in pain, and stated, "yes" his/her leg was hurting when asked if she was in pain. Continued interview with CNA #2 revealed she and CNA #1 told RN #1, Resident #1 expressed being in pain, and RN #1 moved both of the resident's legs around with the resident continuing to complain of pain. However, CNA #2 stated she wasn't sure if RN #1 gave Resident #1 anything for pain or not. Per CNA #2, she was told by CNA #1, Resident #1 appeared to be in a lot of pain when she went in to change the resident, but CNA #2 stated she did not seen the resident the rest of that night. Interview with RN #1, on 04/01/15 at 6:42 PM, revealed after the fall on 03/18/15, Resident #1 expressed his/her back was hurting by stating, "my back, my back". She stated however, she did not give Resident #1 any type of pain medication because she did not know if the resident was truly expressing pain. She stated Resident #1 would be able to tell her if he/she wanted a pain medication by stating, "yes", when asked if he/she was hurting. Per interview, Resident #1 was nonverbal, and for a non-verbal resident staff would watch for a grimace or for some kind of facial expression. Continued interview revealed Resident #1 did not show any of these signs after the fall. She stated unless a resident asked her for a pain medication, she would not give the resident anything for pain. Further interview revealed taking vital signs could indicate if a resident was in pain, and she stated Resident #1's vital signs were taken after the fall but not taken throughout her shift on 03/18/15. However, record review revealed no documented evidence the resident's vitals were taken after his/her initial fall. Review of the 03/19/15 Nurse's Note timed 4:52 AM, documented by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was complaining of pain in the left hip and knee when moved, inward rotation of the leg was noted, the Physician was notified with orders received for mobile x-rays, and the mobile x-ray company was notified. Review of Nurse's Note dated 03/19/15 at 4:56 AM, revealed LPN #1 documented a "change in condition follow-up note" related to the "accident/incident/fall" Resident #1 had experienced in the past seventy-two (72) hours. Continued review of the Note revealed "status of condition: deteriorated" regarding Resident #1, as the resident was now complaining of pain to the left hip and knee, with an inward rotation of the leg noted, orders received for x-ray. However, record review revealed no documented evidence Resident #1 was administered his/her PRN pain medication. Interview with CNA #3, on 04/01/15 at 7:13 PM, revealed she reported to LPN #1 the resident's leg was swollen, and when LPN #1 moved Resident #1's leg, he/she kept saying, "it hurts, it hurts". CNA #3 stated Resident #1 grimaced when they changed him/her. Per interview, it was obvious Resident #1 was in pain that night after he/she experienced the fall. Interview with LPN #1, on 04/01/15 at 11:28 PM, revealed she assessed nonverbal residents for pain by looking at a resident's body movement, and observing the way a resident was acting. Per LPN #1, around 4:00 AM that morning, 03/19/15, she "checked" Resident #1's leg, and the resident was saying, "oh my leg, my leg", when the left leg was moved when she did range of motion (ROM) on his/her legs. She stated if she determined the resident was in pain she would check for PRN pain medication orders, and administer the PRN. Further interview revealed if the PRN was not effective she would notify the Physician for any additional orders or recommendations. Further interview revealed nonverbal residents should have their vital signs checked to assist in the pain assessment. LPN #1 revealed she could not recall if she had checked Resident #1's vital signs after the fall on 03/18/15. Further review of the Nurse's Notes revealed a "Late Entry" Note dated 03/19/15 at 8:00 AM, documented by RN #3. Review of the Note revealed RN #3 was called Resident #1's room where she observed the resident "lying in bed, quiet" with no "crying out in pain". Continued review of the Note revealed RN #3 noted Resident #1's left leg was "swollen at the thigh and knee and disfigured". RN #3 documented she told LPN #2 to send Resident #1 "out". Interview with RN #3, on 04/02/15 at 10:45 AM, revealed she was told by RN #2 Resident #1 expressed he/she was in pain by stating, "my hip, my hip". RN #3 stated she did not give Resident #1 anything for pain however, because the resident did not express to her he/she was in pain. Continued interview revealed she would have given Resident #1 something for pain had she heard the resident say he/she was in pain. However, she stated Resident #1 did not say anything when she went to the resident's room. Interview with RN #2, on 04/02/15 at 3:29 PM, revealed when she entered Resident #1's room at approximately 4:00 AM on 03/19/15, the resident stated, "don't touch, don't touch". She stated she believed Resident #1 was in pain at that time and she would have given the resident something for pain had she been the his/her nurse. Continued interview revealed with any resident's fall, the nurse should conduct a pain assessment of the resident. Review of LPN #2's Nurse's Note dated 03/19/15 at 8:15 AM, revealed Resident #1's left leg was rotated inward and swollen around knee and upper thigh area. LPN #2 noted Resident #1 was stating, "my hip, my hip, my hip". Per the Note, LPN #2 called the Physician and received an order to send Resident #1 to the ER for x-ray, ambulance personnel arrived and transported the resident out of the facility to the hospital ER. However, record review revealed no documented evidence Resident #1 was administered his/her PRN pain medication after LPN #2 heard the resident stating, "my hip, my hip, my hip". Interview with LPN #2, on 04/01/15 at 12:32 PM, revealed Resident #1 could not always express his/her needs, and it was important to recognize nonverbal cues for pain. LPN #2 stated when she checked on Resident #1, on 03/19/15 between 7:00 AM and 7:30 PM, the resident was touching his/her left hip repeating, "my hip, my hip, my hip". She reported she thought Resident #1's hip was fractured and contacted the resident's Physician. LPN #2 stated she knew Resident #1 was in pain by the way he/she was grabbing his/her hip, there was no question about it. Further interview revealed she did not give Resident #1 his/her PRN pain medications however, because she was more concerned with sending the resident out to the ER. Review of the hospital ER record revealed Resident #1 was diagnosed with [REDACTED]. Review of the ER RN's Nurse's Note dated 03/19/15 at 8:58 AM, revealed Resident #1 had not been medicated with pain medications prior to the ER admission after the ER RN had reviewed the resident's MAR indicated [REDACTED]"so was unable to express pain". Review revealed Resident #1's vital signs were stable; however, the resident's heart rate elevated when his/her left leg was "touched or messed with". Further review revealed [MEDICATION NAME] four (4) mg was administered upon arrival to the ER. Interview, on 04/01/15 at 10:30 AM, with the ER RN, who had cared for Resident #1 in theER on [DATE], revealed when the resident arrived at the ER, he/she was observed to be nonverbal and pale. Per interview, Resident #1 grimaced in pain every time the ER staff would move him/her. Per the ER RN, Resident #1 was given [MEDICATION NAME] for pain and started to relax. She stated when Resident #1 arrived at the ER, she noticed when going through the resident's MAR indicated [REDACTED]. The ER RN revealed with the type of femur fracture Resident #1 had, no one should have to ask the resident if he/she was in pain, they should have known. According to the ER RN, Resident #1 had PRN medications which should have been given to the resident. Further interview with the ER RN revealed there was a potential for psychological harm to Resident #1. She stated it would , "be horrible to a person's psychological well-being" to lay in pain after being picked up from a fall and just left until morning, it would be "torture". Further interview revealed the time Resident #1 had to wait for relief from his/her pain was "unacceptable". Review of Resident #1's March 2015 Medication Administration Record [REDACTED]. Continued review revealed for the monitoring Resident #1 for pain order stated to ask Resident #1 "are you free of pain or hurting". Per the monitoring for pain order, it was noted "if no, indicate response through chart code: PI every shift", with no code noted if the answer was "yes". However, review of the pain monitoring order revealed nurses had documented a "Y" for each shift from 03/06/15 through 03/18/15, even though review of the MAR "chart codes/follow-up codes" revealed no evidence of a code for a "Y". Further interview with RN #2, on 04/02/15 at 3:29 PM, revealed in reviewing Resident #1's MAR, RN #2 stated since the resident reported or gave a sign he/she was "in pain", the MAR indicated [REDACTED]"progress notes". Continued interview revealed the "Y" in the MAR indicated [REDACTED]"Are you free from pain?". However, RN #2 was unable to explain why there was a "Y" documented on second and third shift on 03/18/15, if Resident #1 had expressed being in pain. Further interview revealed if "the resident would be in continuous pain, it would be devastating to the resident". Further interview with RN #1, on 04/01/15 at 6:42 PM revealed even though Resident #1 had an order to monitor the resident every shift for pain, RN #1 expressed she had never filled out the MAR indicated [REDACTED]. She revealed she was not familiar with what the "Y's" on the form meant, and stated she did not know she was supposed to monitor Resident #1 for pain by asking the resident every shift, "Are you free of pain or hurting?" as indicated on the MAR. Per RN #1, she did not often ask Resident #1 if he/she was in pain, unless the resident appeared to be restless. According to RN #1, she would document a resident's pain in a "progress note" and would not document unless a resident expressed he/she was in pain. She stated if someone were left in pain without relief that would be, "pretty bad". Interview with CNA#5, on 04/02/15 at 7:58 AM, revealed Resident #1 did not communicate and staff would have to ask the resident if he/she was in pain. Per interview, staff would observe Resident #1's "body language" to determine if the resident was in pain. CNA #5 stated Resident #1 was not able to ask for pain medication and could not state, "I am in pain". Interview with the Social Worker (SW), on 04/02/15 at 2:42 PM, revealed Resident #1 was nonverbal and often repeated words. She reported she had seen Resident #1 express pain in the past by "grimacing", and when this occurred she got a nurse to assist the resident. Interview with the MDS Coordinator and the Clinical Reimbursement Coordinator (CRC), on 04/02/15 at 2:07 PM, revealed when a resident experienced a fall, it would be documented in the "change of condition" computer file. They reported the "pain assessment" would be part of one (1) of the assessments completed after a resident's fall. Continued interview revealed staff should be completing Resident #1's MAR indicated [REDACTED]?" as indicated. Per interview, if Resident #1 had a PRN pain medication, then the pain medication should have been given based on the resident's pain. Interview with the Assistant Director of Nursing (ADON), acting for the Director of Nursing (DON), on 04/02/15 at 4:02 PM, revealed it was her expectation staff on each shift, should have be asking Resident #1, "Are you in Pain or Hurting" and indicate this assessment on the MAR. The ADON stated that if Resident #1 reported he/she was in pain the MAR indicated [REDACTED]. Continued interview revealed the "Y" in the MAR indicated [REDACTED]"Are you free from pain?". Further interview revealed the ADON expected staff would have provided Resident #1 his/her PRN pain medications when he/she expressed being in pain. Interview with the facility's Medical Director, on 04/01/15 at 4:52 PM, revealed it was his expectation the facility staff would provide residents with PRN pain medications if the resident was hurting. Interview with the Administrator, on 04/02/15 at 4:45 PM, revealed it was his expectation staff would have administered Resident #1 his/her PRN pain medications when he/she expressed being in pain.

Based on interview, record review, and review of the facility's policy and Incident Report it was determined the facility failed to have an effective system to ensure the residents' environment remained as free of accident hazards as possible. The facility failed to have procedures in place to ensure all lab specimens were stored in a safe secure area to prevent resident access for one (1) of three (3) sampled residents (Resident #1). (Refer to F281) On 10/19/13 at approximately 9:00 AM, Resident #1, who was sitting in a wheelchair in front of the Heritage Unit nursing station, was observed by a nurse to have a lab specimen tube of blood with the stopper removed, holding the tube to his/her mouth. Resident #1 had a red substance in his/her mouth; on his/her face and hands; on the blanket covering Resident #1's upper leg area; and, on the floor beside his/her wheelchair. A second lab specimen tube of blood was lying on the floor near Resident #1's wheelchair, and the biohazard specimen bag was lying on the blanket covering the resident's upper leg area. Resident #1 was assessed and laboratory tests were obtained for both Resident #1 and the resident from whom the specimen was drawn. Based on the results of the assessment and tests no negative impact on Resident #1 had been identified. The facility's failure to ensure the residents' environment remained as free of accident hazards as possible was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 10/30/13, and was determined to exist on 10/19/13. The facility was notified of the Immediate Jeopardy on 10/30/13. An acceptable credible Allegation of Compliance (AOC) was received on 11/01/13, which alleged removal of the Immediate Jeopardy on 10/22/13, prior to the initiation of the abbreviated survey. The State Survey Agency determined the deficient practice was corrected related to environmental hazards on 10/22/13 as alleged in the AOC, therefore, it was determined to be Past Immediate Jeopardy. In addition, based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for three (3) of three (3) sampled residents (Residents #1, #2, and #3). Resident #1 experienced a fall on 09/04/13 which resulted in complaints of pain and the resident being transported to the hospital for evaluation. The facility failed to ensure the personal tab alarm and chair alarm were in place at the time of the fall. Resident #2 experienced a fall on 10/24/13 and the facility failed to ensure revisions to the care plan. Resident #3 experienced falls on 06/26/13 and 09/09/13; however, the care plan was not revised to include additional interventions to prevent further falls. (Refer to F280 and F282) Therefore, it was determined the facility had continued non-compliance at 42 CFR 483.25 in regards to falls at a Scope and Severity (S/S) of a "E" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic change. The findings include: Review of the facility's policy titled "Collection and Transportation of Specimens" dated 02/15/01, with a revision date of 10/01/13, revealed the policy contained a process for obtaining blood specimens and ensuring placement in a biohazard specimen bag. However, the policy failed to address where specimens should be stored for lab pick-up. Review of an Incident Report dated 10/19/13, timed 9:30 AM, revealed Resident #1 was found sitting in a wheelchair in front of the nursing station. Resident #1 was noted to have a "lab vial" in his/her hand with the "cap" to the "lab vial" laying on the resident's "lap". Continued review of the Incident Report revealed Resident #1 had a "red colored residue" noted to his/her "face around mouth and on blanket and floor". A "lab bag" was "on the floor" in front of Resident #1. Further review of the Incident Report revealed a "head to toe assessment" was completed by staff with "no open areas noted". Resident #1 was transported to his/her room and "mouth care" was completed by staff. Record review revealed the facility admitted Resident #1 on 06/11/11, and readmitted the resident on 09/08/13, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 05/14/13, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of two (2) which indicated severe cognitive impairment. Review of a Nurse's Note dated 10/19/13 and timed 5:30 PM, revealed at "around 9:30 AM" that morning Resident #1 was noted to be sitting in front of the nurse's station. The Nurse's Note stated "red-colored residue" was observed on Resident #1's face around the mouth area, on the blanket in his/her lap, and on the floor. Continued review of the Note revealed oral and denture care was provided and a head to toe skin assessment was performed. Further review of the Note revealed Resident #1's responsible party was notified of this information. Interview, on 10/29/13 at 1:15 PM, with Resident #1's daughter, who was the resident's Power of Attorney (POA), revealed on 10/19/13, at approximately 10:00 AM she received a call from a facility staff person to tell her Resident #1 had been sitting in front of the nurse's station and had gotten a vial of blood off the desk. Resident #1's daughter indicated she was told Resident #1 opened the vial of blood and had the blood all over him/her; including in his/her mouth. Interview, on 10/30/13 at 10:40 AM, with Licensed Practical Nurse (LPN) #1 revealed she was the first employee to see Resident #1 with the tube of blood on 10/19/13. She stated Resident #1 had obtained the tube of blood from the nurse's desk at the nurse's station. LPN #1 indicated she did not recall seeing the tube of blood on the desk when she received report that morning. Further interview with LPN #1, on 10/31/13 at 10:10 AM, revealed lab specimens had always been placed on the nurse's station for lab to pick up. Interview, on 10/30/13 at approximately 1:55 PM, with State Registered Nursing Assistant (SRNA) #3 revealed she had followed a nurse from another unit to the nurse's station on Resident #1's unit on 10/19/13. She stated she observed Resident #1 sitting in his/her wheelchair by the nurse's station. SRNA #3 stated Resident #1 had blood on his/her clothes and blood was coming out of his/her mouth. According to SRNA #3, a nurse had a "vial" in her hand and asked SRNA #3 to get some mouthwash. SRNA #3 stated she thought Resident #1 had been "coughing up" blood, then realized what had happened. Interview, on 10/30/13 at 2:05 PM, with LPN #4, who was the facility supervisor on 10/19/13, revealed Resident #1 had a "vial" of blood in his/her hand and had blood on his/her face and mouth, on a blanket, and on the floor. LPN #4 indicated the facility process had "always been" to place lab specimens that did not require refrigeration on the nurse's desk, at the nurse's station, for lab to pick up. Interview, on 10/30/13 at 5:20 PM, with Registered Nurse (RN) #3 revealed she was the night shift nurse who had obtained the two (2) tubes of blood from another resident on another unit on 10/19/13. She stated that she had taken the two (2) tubes of blood to Resident #1's unit because the resident she had drawn the blood from also had a urine specimen to be picked up which was located in a refrigerator on the unit where Resident #1 resided. She indicated that way all the specimens would be in the same area for the lab pick up. According to RN #3, she handed the specimen bag with the two (2) tubes of blood in it to LPN #5 on Resident #1's unit. She stated there was never a specific place for staff to put lab specimens waiting for lab pick up. Interview, on 10/31/13 at 10:05 AM, with LPN #5 revealed RN #3 had brought blood specimen tubes to her on 10/19/13. LPN #5 stated she put the blood specimen tubes, RN #3 had brought to her, on the desk at the nurse's station. She stated staff had always placed lab specimens on the desk at the nurse's station for lab pickup. Interview, on 10/30/13 at 2:48 PM, with the Interim Director of Nursing (DON) revealed she received a call from facility staff at approximately 9:30 AM on 10/19/13. She stated staff notified her of the incident at that time. The Interim DON stated that she directed staff on what to do, and notified the Administrator of the incident on her way in to the facility. She further stated there was no system in place as to where to store lab specimens that did not require refrigeration until lab picked the specimens up. Interview, on 10/30/13 at 4:15 PM, with the Administrator revealed he was notified of the incident involving Resident #1 at approximately 9:00 AM on 10/19/13. He indicated he was informed by staff it had always been the process to store lab specimens on the desk at the nurse's station to await lab pickup. According to the Administrator, he had not been aware staff was using this process for lab specimens until the incident involving Resident #1. He reported the process had been changed since the incident. The Administrator stated he thought processes, for lab specimens awaiting pickup, had been developed by the former DON who left the facility in September 2013. The facility provided an acceptable credible Allegation of Compliance (AOC) on 11/01/13, that alleged removal of the IJ effective 10/22/13. Review of the AOC revealed the facility implemented the following: 1) On 10/19/13, Resident #1 was assessed head to toe with vital signs for any injuries. No injuries were noted. 2) On 10/19/13, incident report entered into the facility electronic system. 3) On 10/19/13 an entry was made to the Treatment Administration Record (TAR) of the exposed resident, Resident #1, to monitor for signs and symptoms (S/S) of infection each shift to include vital signs every shift time forty-eight (48) hours. 4) On 10/19/13 the Physician and family of each resident was notified. 5) On 10/19/13 lab work for the source resident was to be re-drawn to comply with the original lab orders for this resident. Lab work was obtained as ordered for both the source resident and Resident #1 after the incident to screen for Human Immunodeficiency Virus (HIV) and Hepatitis B & C. No abnormalities were noted on the initial lab work for each resident. The lab work was to be repeated in three (3) months as recommended by the Physician for further monitoring. 6) On 10/19/13 a complete audit of the facility areas that were accessible to residents (nursing station, medication carts, hallways, day rooms, resident rooms, dining rooms, shower rooms, and lobby) was performed to determine that no potentially hazardous items were present and if any other resident obtained any lab specimen or other potentially hazardous item. Any items identified were to be secured. No other concerns were identified after the audit. 7) On 10/19/13 the facility developed a protocol for the storage of lab specimens while waiting for lab pick up. The protocol was for placement of a bin in each medication room labeled "Lab Specimens" for all pending lab specimens to be stored in until lab pick up. 8) On 10/19/13 all nurses were educated by the Director of Nursing (DON) and Unit Managers on the new "Lab Specimen" storage location. Nurses were educated on supervision of residents and to monitor for potentially hazardous items in areas accessible to residents. All nurses were educated either in person or via telephone. All new hires will be educated on this protocol during orientation. The facility did not use agency staff. 9) On 10/21/13 education was provided by the DON, Unit Manager, and Administrator for all nursing assistants, therapy, activity, dietary, housekeeping, social services, and maintenance staff in regards to supervision of residents and, to monitor for potentially hazardous items in areas accessible to residents. 10) On 10/19/13 and "ongoing", the nursing supervisor was to complete a round of the facility daily for five (5) days to include a weekend day. The nursing supervisor would then complete rounds weekly for three (3) weeks including a weekend day to determine that no potentially hazardous items were accessible to residents, such as lab specimens. 11) On 10/19/13 and "ongoing", the nursing supervisor was to audit utilization of the lab specimen storage bin each morning for two (2) weeks including a weekend. Then the nursing supervisor was to audit utilization of the lab specimen storage bin weekly for four (4) weeks to include a weekend to determine that pending lab specimens were secure. 12) On 10/19/13 a message was left by the Administrator for the Medical Director to notify him of the incident. On 10/21/13 the Administrator discussed the incident in more detail with the Medical Director. 13) On 10/21/13 an "ad hoc" (which means for a particular purpose only) Performance Improvement (PI) meeting was held to review the AOC plan for further review and recommendation. 14) On 10/19/13, the Administrator was educated by the Manager of Clinical Operations, on the protocol for storage of lab specimens and the expectations of the Administrator as indicated by the regulations. 15) On 10/20/13, the lab was notified of the incident and of the new facility protocol for lab specimen storage. 16) On 10/19/13, the DON checked lab vials in the facility to determine that no defective lab vials were present. 17) On 10/21/13, the Administrator performed a check of lab vials to determine that no defective lab vials were present. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the resident record revealed that on 10/19/13, Resident #1 did have a head to toe assessment completed with vital signs. 2) Review of the facility's electronic system for Incident Reports revealed the Incident Report related to Resident #1 was entered on 10/19/13. 3) Review of Resident #1 Treatment Administration Record (TAR) revealed the resident was monitored every shift for forty-eight (48) hours for S/S of infection which included vital signs. 4) Record review for both the source resident and the exposed resident revealed that the Physician and family were notified of the incident on 10/19/13. 5) Record review of the source resident revealed that the labs were re-drawn to comply with the original lab order and for the new lab order on 10/19/13. Review of Resident #1's record revealed labs were drawn as ordered on [DATE]. Further record review for Resident #1 and the source resident revealed lab results were filed in both of the medical records for the labs drawn on 10/19/13 with negative results for both residents. 6) Review of the facility's investigation binder revealed that audits of the facility areas accessible to residents was completed on 10/19/13. 7) Review of the facility's investigation binder revealed it contained the protocol dated 10/19/13, that was developed for safe secure storage of lab specimens that did not require refrigeration. 8) Review of the facility's investigation binder revealed all nurses were educated to the new lab specimen storage protocol and expectations either in person or by telephone by 10/21/13 as evidenced by the sign-in sheets. Interviews on 11/01/13 at 2:25 PM, with Licensed Practical Nurse (LPN) #6; at 2:27 PM with LPN #7; at 2:30 PM with Registered Nurse (RN) #4; and at 3:10 PM with RN #2, revealed they had been educated and were aware of the new lab protocol. These interviews revealed the nurses had also been educated on supervision of residents and monitoring areas accessible to residents for hazardous items. 9) Review of the facility's investigation binder revealed that education on supervision of residents and to monitor the environment for potentially hazardous items was completed with all nursing assistants, therapy, activity, dietary, housekeeping, social services, and maintenance staff on 10/21/13 as evidenced by the sign-in sheets. Interviews on 11/01/13, at 2:35 PM with State Registered Nursing Assistant (SRNA) #6; at 2:45 PM with SRNA #1; at 3:10 PM with SRNA #3; and at 4:00 PM with SRNA #2 revealed they had all received the education on supervision of residents and monitoring areas accessible to residents for hazardous items. Interviews with other facility staff on 11/01/13, at 1:00 PM with an Activities personnel; at 3:30 PM with Housekeeper (HK) #2; at 3:35 AM with HK #1; at 3:00 PM with Cook #1; and at 3:15 PM with a Maintenance personnel, revealed they had all been inserviced on the supervision of residents and monitoring areas accessible to residents for hazardous items. 10) Review of the facility's investigation binder revealed the nursing supervisor performed rounds of the facility to determine that no potentially hazardous items were accessible to residents. Review of the forms revealed the rounds were initiated on 10/19/13 and they completed them daily for seven (7) days versus five (5) days; and, were being performed weekly for three (3) weeks. 11) Review of the facility's investigation binder revealed the nursing supervisor was auditing the utilization of the lab specimen storage bin each morning for two (2) weeks which was initiated on 10/20/13. 12) Review of the facility's investigation binder revealed the facility's Medical Director was notified of the incident involving Resident #1 and the AOC plan, by the Administrator via a phone message on 10/19/13. Further review revealed on 10/21/13, the Administrator covered the AOC plan in more detail with the Medical Director. 13) Review of the facility's investigation binder revealed the Administrator did hold an "ad hoc" PI meeting on 10/21/13, to discuss the incident and AOC plan. Review of the documentation revealed the DON, Social Services personnel, Minimum Data Set (MDS) personnel, and Unit Managers, were present in the meeting. Additionally review revealed two (2) Physicians and the Medical Director participated in the PI meeting via phone. Interview with the DON confirmed a PI meeting was held on 10/21/13 with discussion of the incident and AOC plan. 14) Review of the facility's investigation binder and interview revealed on 10/19/13, the Administrator was educated by the Manager of Clinical Operations, on the protocol for storage of lab specimens and the expectations of the regulations in regards to the Administrator. 15) Review of the facility's investigation binder revealed Med Lab, the lab utilized by the facility, was notified on 10/20/13, of the facility's new protocol for lab specimen storage of specimens that did not require refrigeration. 16) Review of the facility's investigation binder and interview revealed on 10/19/13, the DON checked all lab vials and no defective vials were found. 17) Review of the facility's investigation binder and interview revealed that on 10/21/13, the Administrator checked all lab vials and no defective vials were found. Additionally, based on observation, interview, and record review it was determined the facility failed to implement interventions to prevent accidents and to monitor and modify interventions as necessary. Review of the facility's policy titled, "Accidents/Incidents" with an effective date of 01/08, revealed the "intent" of the policy was for the facility to identify each resident at risk for accidents and/or falls, "adequately" care plan these residents and implement procedures to prevent accidents. Interview with the Interim DON, on 10/31/13 at 5:40 PM, revealed the facility's process for reviewing and investigating falls was for the IDT team to review the Incident Reports to determine what was going on at the time of the falls, see if there were any medical issues that contributed to the falls, and look at environmental issues as indicated. Then interventions were developed and added to the care plan by the Unit Managers. She further stated Unit Managers were also responsible for adding the interventions to the SRNA care plans. She continued by saying the Fall Risk Assessments were reviewed by the Unit managers to ensure accuracy. 1. Review of Resident #1's record revealed an admission date of [DATE], and readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 05/04/13 revealed the facility assessed Resident #1 as being severely cognitively impaired. Further review of the MDS Assessment revealed the facility assessed Resident #1 to require extensive assist of one (1) staff person for all Activities of Daily Living (ADLs). Review of the Resident Fall Evaluation form revealed an assessment was completed on 05/16/13 and 05/22/13. Further review of the form revealed if a "yes" was answered this indicated a fall risk factor. Review of the assessments completed on 05/16/13 and 05/22/13 revealed a "yes" was answered seven (7) times on 05/16/13 and a "yes" was answered eight (8) times on the 05/22/13 evaluation, indicating Resident #1 was at risk for falls. Review of Resident #1's Comprehensive Care Plan dated 05/14/13, revealed a "risk for falls" care plan with interventions which included a chair alarm in chair, do not leave unattended while in wheelchair, Dycem (a product which prevents slippage) under the Chux (a protective pad) and wheelchair alarm. Review of the Nurse's Note dated 05/22/13 and timed 1:15 PM, revealed Resident #1 was "found" sitting on the floor in front of the chair with no injury noted. Review of the Incident Report, dated 05/22/13, revealed the resident was found in front of the chair on the floor. It further stated the resident appeared to have slipped from the chair and the chair alarm was in place. Further review of the care plan revealed it was revised on 05/22/13, following the fall, to include the use of a personal tab alarm when the resident was up in the recliner. Review of the Resident Fall Evaluation form with an assessment date of 08/01/13 revealed "yes" was answered six (6) times indicating Resident #1 had fall risk factors. Review of the Comprehensive Care Plan with a review date of 08/12/13, revealed the intervention of not to leave the resident unattended while in the wheelchair was discontinued. Additional review of a Nurse's Note dated 09/04/13 timed 10:40 AM, revealed Resident #1 was found on the floor, "yelling out with complaints of pain" in the lower back area; however, there was no documented evidence of an alarm being in place. Further review of the Note revealed Emergency personnel were contacted and transported Resident #1 to the hospital. Review of the Incident Report, dated 09/04/13 timed 10:40 AM, revealed Resident #1 had been found on the floor in "front of chair" with complaints of lower back pain. Continued review of the Incident Report revealed Resident #1 was transported to the hospital. Review of the hospital Radiology Report dated 09/04/13 timed 11:28 AM revealed no compression fracture was noted; however, "degenerative changes" were noted in Resident #1's lumbar region of the spine. Review of the Risk Management System (RMS) investigation form for the 09/04/13 fall revealed the resident self-propelled the wheelchair into his/her room and attempted to self-transfer to the recliner. It further indicated an alarm was to be used for Resident #1; however, further review of the form revealed no alarm was in place on the resident's wheel chair at the time of the resident's fall. Interview, on 11/04/13 at 11:40 AM, with Licensed Practical Nurse (LPN) #3 revealed he was the nurse assigned to Resident #1's care on 09/04/13 when the resident fell . LPN #3 stated Resident #1 was found lying in front of the recliner "like" he/she had tried to self-transfer to the recliner from the wheel chair. He further stated Resident #1 did not have an alarm on his/her wheel chair as care planned to alert staff of attempts of self-transfer. In addition, he stated it was the nurse's responsibility to ensure the alarms were in place and working. Review of the resident's Treatment Administration Record (TAR) revealed LPN #3 had signed off Resident #1's alarm was in place on 09/04/13. However, review of the facility's investigation revealed the alarm was not in place. Interview, on 11/04/13 at 2:30 PM, with the Interim DON revealed State Registered Nursing Assistants (SRNAs) were to assure the alarms were in place each time Resident #1 was transferred. Additional interview with the Interim DON revealed nurses were to check alarms for placement and function every shift and nurses were responsible to ensure the care plan interventions were implemented and document this on the residents' TAR. 2. Review of Resident #2's record revealed an admission date of [DATE], and readmission date of [DATE], with [DIAGNOSES REDACTED]. Further record review revealed a Fall Risk Evaluation form with assessment dates of 02/28/13 and 03/09/13, with "yes" checked indicating the resident was at risk for falls. Review of the Comprehensive Care Plan with a print date of 04/15/13 revealed a plan of care for risk for falls with interventions which included: large reminder signs in the room to ask for help; non skid strips beside the bed on the floor; discourage use of shoes without backs; encourage resident to ask for assistance when getting out of bed; provide reacher to assist with picking things up; and have commonly used articles within easy reach. Review of Resident #2's Annual MDS Assessment, dated 05/07/13, revealed the facility assessed the resident as having a potential for falls. Further review revealed Brief Interview for Mental Status (BIMS) score of fifteen (15) out fifteen (15) indicating the resident was assessed as being cognitively intact. Review of the Care Area Assessment (CAA) Summary of the MDS for falls revealed Resident #2 was at risk due to balance problems; receiving antidepressant medication; and, the resident utilized a walker. Further review of the CAA Summary revealed Resident #2 required assist from staff for ambulation. Continued record review revealed Resident #2 had fallen six (6) times since 07/07/13 with the last fall occurring on 10/24/13. Record review revealed the falls occurred on 07/07/13, 07/22/13, 07/28/13, 09/04/13, 10/15/13 and on 10/24/13. Further review of the resident ' s record revealed no documented evidence the facility assessed the resident any further after three (3) documented falls in July of 2013, a documented fall on 09/04/13 and a documented fall on 10/15/13. Review of the Incident Report, date 07/07/13, revealed Resident #2 was found outside the facility on his/her knees. The resident stated he/she tripped over the walker. The resident had two (2) skin tears to the left arm. Review of the care plan revealed the facility added the interventions to monitor the resident's gait and encourage the use of a wheel chair as needed. In addition the intervention was added to encourage the resident to ask for help if needed. Review of the Incident Report, dated 07/22/13 revealed Resident #2 fell in the dining room while trying to get up from the chair resulting in skin tears to his/her arms. Further review of the Incident Report revealed no documented evidence of the type of shoes the resident was wearing; however, review of the care plan revealed an intervention was added which stated encourage resident to use proper footwear, shoes or gripper socks and not to wear slip on shoes. Review of the Incident Report dated 07/28/13 revealed staff heard the resident yell and heard a thump. The resident was found next to the bed with skin tears to the right elbow and left shin and a small bump on the back of the resident's head. Further review revealed the resident stated he/she was kneeling on the bed and fell backwards. Review of the care plan revealed an intervention was added to encourage the resident not to kneel on bed and to ask for assistance. Review of the Incident Report dated 09/04/13 revealed the resident was found sitting in the center of his/her room at 9:00 AM and stated she fell while taking her breakfast tray to the hallway. Review of the care plan revealed an added intervention which stated educate resident not to carry lunch tray down the hall. Review of the Incident Report dated 10/15/13 revealed the resident was found sitting in the floor of his/her room and the resident stated he/she slid off the bed and the resident was not wearing gripper socks. Further review of the Incident Report revealed no indication that non skid strips were in place on the floor beside the bed. Review of the Incident Report dated 10/24/13 timed 8:15 PM, revealed Resident #2 was in his/her room yelling "help". Review of the Incident Report revealed the nurse responded and found Resident #2 on the floor next to the bed. Continued review of the Incident Report revealed Resident #2 stated he/she was trying to get up and go to the bathroom and "fell down". Further review revealed Resident #2 was observed to have a skin tear to the right wrist area. Review of the care plan revealed no documented evidence the care plan was revised following this fall. Observation on 10/31/13 at 11:30 AM, of Resident #2's room revealed no evidence of large reminder signs in the room to remind the resident to ask for assistance for transfers. Observation did reveal a hand written sign on the resident's refrigerator door approximately five (5) inches by four (4) inches which stated "ask for assistance". Continued observation of Resident #2's room revealed no evidence of non-skid strips on the floor beside the bed. Review of the State Registered Nursing Assistant (SRNA) Care Plan from July 2013 to October 2013, revealed no documented evidence it had been updated to include for Resident #2 to have non-skid strips to the floor beside his/her bed. Additionally, there was no documented evidence that Resident #2 was to have large reminder signs in his/her room to request assistance for transfers. Interview, on 11/04/13 at 2:38 PM, with SRNA #14 revealed she was assigned to provide care for Resident #2 "sometimes". She stated she was not aware the resident was to have non-skid strips on the floor by the his/her bed. She further stated it would be "very helpful" if this information was on the SRNA care plan. According to SRNA #14, she moved around the facility's units "a lot" and things did change with residents' care. Interview, on 11/04/13 at 3:54 PM, with SRNA #12, who provided care for Resident #2, revealed to have non-skid strips to the floor by his/her bed. She reviewed the SRNA care plan and stated the information for Resident #2 to have non-skid strips by his/her bed was not on it. Interview with the Unit Manager/Registered Nurse (RN) #2, on 11/01/13 at 12:10 PM, revealed it was the nurses' responsibility to ensure the SRNA care plans were revised with current interventions and the nurses' responsibility to ensure all care plan interventions were in place and implement for each resident. She further stated Resident #2's care plan was not revised after the 10/24/13 fall and was not followed for fall interventions. 3. Review of Resident #3's record revealed the facility admitted the resident on 12/28/11, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated 12/28/11 revealed a falls risk care plan with interventions which included re-educate resident as need on proper foot wear as needed, non-slip footwear, remind resident to use call light prior to ambulating or transferring, and have commonly used articles within easy reach. Review of the Nurse's Notes revealed Resident #3 experienced falls on 05/23/13, 06/26/13 and 09/09/13. Continued review of Resident #3's record revealed no documented evidence of the completion of Fall Risk Assessments after the resident had documented falls on 05/23/13 and 06/26/13. Review of the Incident Reported dated 05/23/13 at 7:00 AM revealed Resident #3 fell when walking to the bathroom. Review of this Incident Report revealed Resident #3 was noted to have no shoes on at the time of the fall, even though the care plan intervention was to ensure the resident had non-slip

Based on interview, record review and review of the facility's residents' rights information, it was determined the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of their individuality for one (1) of seventeen (17) sampled residents (Resident #3). Resident #3 stated the staff did not answer the call light in a timely manner resulting in an incontinent episode, which made him/her feel "terrible". The findings include: Review of the facility's "Resident Rights and Information for Residents Living in Kentucky", undated, revealed that every resident should be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs. Interview with Administrator, on 07/25/13 at 3:17 PM, revealed that facility did not have a separate dignity policy. Review of Resident #3's medical record revealed the facility admitted the resident on 07/08/10 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) Assessment, dated 05/24/13, revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident had no cognitive impairment. Further review of the MDS revealed the facility assessed the resident as being incontinent of urine and as requiring extensive assistance with toileting. Individual interview with Resident #3, on 07/25/13 at 11:10 AM, revealed staff did not answer his/her call light in a timely manner which caused him/her to void or defecate on himself/herself. Resident #3 revealed he/she has had to wait up to two (2) hours before his/her call light was answered. Resident #3 also revealed the accidents made him/her feel "terrible". Interview with Certified Nursing Assistant (CNA) #4, on 07/25/13 at 12:15 PM, revealed it was expected of the staff to answer all call lights as soon as possible. Interview with the Unit Manager (UM), on 07/25/13 at 2:30 PM, revealed call lights would be answered as quickly as possible. She further revealed it was the responsibility of the staff to check each resident with a history of incontinence every two (2) to three (3) hours for toileting or changing. Interview with the Assistant Director of Nursing (ADON), on 07/25/13 at 3:05 PM, revealed staff was to answer call lights as soon as possible and further revealed a resident should not have to wait more that two (2) or three (3) minutes before their call light was answered. Interview with Administrator, on 07/25/13 at 3:17 PM, it was his expectation of the staff to answer all call lights within a reasonable amount of time and further stated that a wait time of two (2) hours was not acceptable.