Every finding on record at Hazard Health and Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to maintain and ensure recording of the reconciliation of controlled medication was occurring as required for 8 of 8 medication carts.The findings include: Review of the facility policy titled, Controlled Medication Storage effective date June 2024, revealed, at shift change, a physical inventory of all controlled medications was to be conducted by two licensed nurses or a licensed nurse and a medication aide. Further review revealed the inventory was to be documented on the (facility's) controlled medication accountability record. Review of the facility's, Routine Narcotic Count Record forms for January and February 2026 revealed numerous missing staff signatures across all eight medication carts indicating medication reconciliation had not consistently been documented as completed during shift change. Review of the forms revealed: the 100 Back Hall cart: had 24 missing signatures (Feb); the 100 Front Hall cart had five missing signatures for February: the 200 Front Hall cart had seven missing signatures for February and 16 missing signatures for January; and the 200 Back Hall cart had 18 missing signatures for February and 53 missing signatures for January. Continued review of the forms revealed: the 300 Back Hall two missing signatures for February, and seven missing signatures January; the 300 Front hall cart had 13 missing signatures for January; the 400 locked unit medication cart had 27 missing signatures for February and 39 missing signatures for January; and the 400 Hallway cart had 32 missing signatures for February, and 42 missing signatures for January. During interview on 02/25/2026 at 10:25 PM, Registered Nurse (RN) 11 stated on hand-off of the medication carts at shift change, two licensed staff were to reconcile the narcotics counts and both sign the counts to indicate they were correct. RN 11 stated the staff did perform the counts upon hand-off of the carts; however, were failing to sign off on the narcotics count sheet. The RN further stated it was important to sign the narcotic sheets to help protect themselves and the residents from misappropriation of narcotic medications. During interview on 02/25/2026 at 4:17 PM, the Director of Nursing (DON) stated two licensed nurses were to sign off on the narcotics sheet upon hand-off of the medication cart at shift change. She said, I have preached and preached to the staff to sign the narcotics count sheets as required. The DON stated not signing off on the narcotic count sheet at hand-off of the cart could cause significant issues if medications were missing. She further stated she had not provided education on the policy for medications and narcotic counts in at least six months or longer. Additionally, she stated the Clinical Coordinators should have been checking the signatures prior to turning the narcotic sheets in to medical records, and she had also failed to check the signatures herself in a while. During interview on 02/26/2026 at 11:50 AM, with RN 12, one of the Clinical Coordinators, stated she was supposed to be checking the narcotic count sheets to see if they had been signed off by two licensed staff as required. She further stated not signing the narcotic count sheets when handing off the cart could lead to issues if the counts were incorrect. During interview on 02/26/2026 at 4:15 PM, the Administrator stated her expectation was for two staff to count narcotics, and both sign the narcotic count sheet attesting that the counts were correct. She stated that was important in order to accurately track narcotics. The Administrator stated she should have been providing oversight to ensure the narcotic counts were being performed and documented as required.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 41 sampled residents (Resident (R)4, R77, R28, R42 and R50).The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. Per review, the EBP were to be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. Further review revealed high contact care activities included assisting with and providing hands on care. Review of the facility's policy titled, Infection Control dated 03/10/2024, revealed all nebulizer tubing was to be in a sealed bag when not in use. Further review revealed it was okay to take the tubing out of the bag to be used; however, it should be in a bag when not in use. 1. Observation on 02/23/2026 at 3:12 PM, revealed Certified Nursing Assistant (CNA) 2 failed to don (put on) Personal Protective Equipment (PPE) prior to providing care for R77 who was on Enhanced Barrier Precautions (EBP). Additionally, observation revealed CNA 2 failed to wash or sanitize her hands upon exiting R77's room after providing care. Observation on 02/23/2026 at 3:42 PM, revealed a sign on the door to R77'a room that stated, enhanced barrier precautions. Further observation revealed there was a gown and gloves located on the inside of the door. During interview on 02/24/2026 at 9:22 AM, CNA 2 stated if PPE was not donned appropriately for EBP it placed the resident, other residents and staff at risk for spread of infection. The CNA reported all residents on EBP should not be touched by staff unless staff were wearing gloves and a disposable gown. She said she always tried to don appropriate PPE prior to entering R77's room and knew she should wash or sanitize her hands upon exiting the resident's room. CNA 2 further stated, I must have been in a hurry. I would never put any of my residents at risk for getting an infection or bacteria. 2. Observation of R28's room on 02/23/2026 at 11:36 AM, revealed a nebulizer machine with tubing touching the floor. Per observation, the nebulizer machine was not in use and the nebulizer kit was lying on the ground and not in use or stored in a bag. 3. Observation of R42's room on 02/24/2026 at 11:58 AM, revealed a hand sanitizer machine not working located outside the resident's room. Further observation revealed CNA 4 entering R42's room without washing or sanitizing her hands. 4. Observation of R4's wound care on 02/24/2026 at 1:52 PM, revealed Registered Nurse (RN) 4 changed gloves after touching the inside of R19's wound; however, failed to wash her hands before donning new gloves. 5. Observation of R50's room on 02/24/2026 at 12:12PM, revealed a hand sanitizer machine located outside the resident's room that was not working. Additionally, observation revealed a yellow liquid around the toilet lid, some of which was dried and some was still wet. During interview on 02/24/2026 at 3:12 PM, RN 1 stated all staff had been educated on the facility's infection control policies and an EBP sign on the door indicated that resident was on EBP. RN 1 said all staff were to be aware they were to don the appropriate PPE before providing any type of care for residents on EBP. She reported she monitored staff as she was going down the halls and if staff were identified as not wearing appropriate PPE, she would immediately educate them. RN 1 further stated the Infection Preventionist (IP) completed daily rounds to monitor for infection control measures as well. During interview on 02/24/2026 at 1:46 PM, the IP stated she expected nursing staff to follow the facility's policies regarding PPE and EBP. She said if she saw any staff not following proper infection control procedures, she immediately provided them education on what they were doing wrong, and what corrective actions were needed. The IP reported following infection control policies and procedures for a resident on EBP was important to prevent other residents or staff from being exposed to infection. She explained it was important to use good hand hygiene after providing resident care, and upon exiting a resident's room. The IP said she tried to make daily rounds and educate staff regarding infection control procedures as needed. She further stated per facility policy, all nebulizer tubing was to be stored in a bag at the resident's bedside when not in use. During interview on 02/24/2026 at 2:32 PM, the Administrator stated general hand washing was number one, and donning PPE as indicated was expected of all staff. She said she left it to the clinical management staff to make rounds to ensure there were no infection control concerns. The Administrator explained the facility policy was that all nebulizer tubing was to be stored in a bag, and that was her expectation. She further stated she expected all staff to follow the facility's infection control policies.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping services to ensure a clean and sanitary environment for 5 of 41 sampled residents, (Resident (R)3, R36, R51, R100, R181). The findings include: Review of the facility policy titled, Resident Rights, undated, revealed the residents had a right to a safe, clean, comfortable and homelike environment. 1. Observation on 02/24/2026 at 11:48AM, of R36's room, revealed a cracked tile on the floor next to the baseboard on the wall. Further observation revealed the toilet paper holder in the bathroom was broken, and had a sharp edge. 2. Observation on 02/24/2026 at 11:58 AM, of R51's room, revealed a black stain around the toilet. In interview with R51, at the time of observation, the resident stated That stain has been there ever since I have been here. I don't like it, but I never complain. I've tried to clean it up but they won't let me. 3. Observation on 02/24/2026 at 12:18 PM, of R100's room, revealed a broken toilet paper holder with a sharp edge. 4. Observation on 02/24/2026 at 12:26 PM, of R181's room, revealed a broken toilet paper holder with a sharp edge. 5. Observation on 02/24/2026 at 12:34 PM, on the 200 hallway, revealed a broken wall bumper with a sharp edge. 6. Observation on 02/24/2026 at 12:42 PM, on the 300 hallway, revealed a broken wall bumper in the hallway and one next to the dining room. 7. Observation on 02/24/2026 at 12:58 PM, of R3's bathroom, revealed two bedpans stored lying on top of a black bag. Continued observation revealed one bedpan was not covered and had a yellow liquid in it. 8. Observation on 02/24/2026 at 1:08 PM, of the 200 hall men's shower room, revealed hair, nail clippings, and a brown substance underneath the shower mat on the shower bed. 9. Observation on 02/24/2026 at 1:19 PM, of the 300 hall men's shower room, revealed hair, nail clippings, and a dry white non-odorous substance underneath the shower mat on the shower bed. Per request of the State Survey Agency (SSA) Surveyor, the Director of Nursing (DON) came into the shower room and was shown the underneath of the shower mat. In interview at the time of the observation, the DON stated, That is filthy and I will take care of it now. In interview on 02/25/2026 at 11:42AM, the Maintenance Director stated they expected staff to notify maintenance of any issues needing to be fixed. He said there was a facility form staff could fill out and we will get it taken care of. The Maintenance Director reported there were no current active work orders and he had not been made aware of anything needing to be fixed at that time. He stated, As of right now, I don't know of anything that would need fixed. We try to do a walk through of the facility at least on a weekly basis to check for issues that may need to be fixed and nobody has reported it to us. In an additional interview on 02/25/2026 at 1:14 PM, the DON stated all residents deserved to have a clean and sanitary environment that made them feel comfortable. She said, We all love these residents here. If there is something that needs to be repaired or just something a resident wants, we encourage them to let us know so that we can help to get it taken care of. The DON stated there should not be any broken tiles or broken wall bumpers in the facility. She further stated if there were such issues maintenance should be checking into it. During interview with the Housekeeping Manager on 02/25/2026 at 1:12 PM, she stated, Each resident room will get a deep clean a few times a week. She reported she instructed her staff to report anything needing to be fixed or repaired to her or to maintenance so the issue could be fixed/repaired. The Housekeeping Manager said, They all know we are supposed to report anything that needs repaired, to maintenance. That is my expectation of all my staff in housekeeping. This is also the expectation of the DON and Administrator. In interview on 02/25/2026 at 1:49 PM, the Administrator stated, We are big on resident satisfaction here. If something needs to be fixed, we will fix it. Residents deserve to have a homelike environment. It is my expectation that maintenance will repair anything in the facility that needs to be fixed. The Administrator further stated the facility had a maintenance form that could be filled out by any staff member in the facility and maintenance would prioritize those and fix the problem.

Based on interview, record review, and review of facility policies, the facility failed to ensure residents had the right to privacy in their use of electronic social [NAME] communication for 1 of 41 residents (Resident (R)151). The findings include: Review of the facility's, Resident Rights packet (provided by the Kentucky State Long-Term Care Ombudsman Program to the facility), copyright 2022, revealed residents had a right to privacy and confidentiality including the right to privacy in using electronic communications. Review of R151's admission Record Sheet revealed the facility admitted the resident on 06/09/2021, with diagnoses which included diabetes, cerebral infarction, major depressive disorder, hemiplegia and hemiparesis, and anxiety. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed R151 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition Review of the Social Service Note for R151, dated 02/09/2026 as a late entry for 01/20/2026, documented by the Social Services Director (SSD), revealed per administration's request, she (SSD) encouraged R151 to consider removing a personal social media post. Further review revealed R151 pulled (took down) the social media post up on her phone and the SSD assisted the resident in deleting the post. During interview, on 02/25/2026 at 3:48 PM, the SSD stated she had been asked by the Administrator and Regional Nurse to speak to R151 regarding a social media most she made regarding concerns about a fall the resident sustained in the facility. She said she did not really look at it (the post); however, had spoken to R151 regarding the facility's concerns with the post. The SSD reported she was unsure what the Administrator's concerns had been about the post, except for appearances since people know where she lives. She stated R151 showed her the post and said she wanted to delete it if it was causing problems and asked the her (SSD) to show her how to delete it. Additionally, she further stated R151 held her phone the entire time while she (the SSD) assisted her (the resident) in deleting the post. During interview, on 02/25/2026 at 4:10 PM, R151 stated she had made a social media post of herself after a fall in January 2026. She said the SSD, along with other staff, asked her to remove the post, and she told them she did not know how to delete a post; R151 stated the SSD deleted the post for her. She reported the post was only of her own face and did not show any other residents or the name of the facility in the post. R151 further stated she had felt pressured to delete the post by several staff members coming into her room and asking her to do so During interview, on 02/25/2026 at 4:20 PM, the Director of Nursing (DON) stated she had been in R151's room when the SSD discussed a social media post with the resident. She said however, she could not recall what was stated to R151 or what the post was concerning. The DON told the State Survey Agency (SSA) Surveyor to talk with the Administrator as that was who asked the SSD to take down the post. She further stated, if it's not a big deal, I don't put a lot of thought into it. During interview, on 02/26/2026 at 11:40 AM, the Administrator stated she had discussed R151's social media post with the SSD because the resident posted some concerns regarding the care she was receiving (at the facility) on the post. She reported she did not instruct the SSD to have R151 remove the post, just to address the concerns on it regarding the resident's care. The Administrator further stated she could not recall how she was made aware of the social media post in the first place, and R151 had not shared the post with her directly. She further stated she had not saved a copy of the post and could not remember exactly what it stated.

Based on observation, interview, record review, and review of facility policies, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident to include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs and describe the services to be furnished to attain or maintain a resident's highest practicable physical, mental, and psychosocial well-being for 3 of 41 sampled residents, (Resident (R)90, R138 and R24). The findings include:: Review of the facility's, Care Plan Policy and Protocol revised in 09/2024, revealed the facility was to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs as identified in a comprehensive assessment. Further policy review revealed the comprehensive care plan in the Electronic Health Record (EHR) shall be periodically reviewed and revised by the interdisciplinary team after each assessment and on an as-needed basis. Review of the facility's, Protocol for Completing Trauma Assessment, developed in 07/2019, revealed it was the facility's process to complete the assessment on admission, and to develop the care plan based on the screening. Continued review revealed if the initial screening was negative (for trauma), but later, there were indicators of past trauma, the resident was to be re-evaluated and referred to psychiatric services at that time, after consultation with the resident's physician. Further review of the Protocol revealed the Trauma Assessment Form was to be completed on the admission and Annual or Significant Change Minimum Data Set (MDS) Assessment. Review of the facility's job description for the MDS Coordinator, revised 09/25/2024, revealed the position was responsible for oversight of the residents' baseline care plans and coordination of the completed comprehensive care plan according to regulatory requirements. Per review, the MDS Coordinator was also responsible for coordinating the input of the interdisciplinary team (IDT) members toward accurate and timely completion of MDS assessments and care plans. Further review revealed the job description described the Licensed Practical Nurse (LPN) MDS Nurse as a secondary position, and the Registered Nurse (RN) MDS position as responsible for the oversight of the (MDS) position. (1) Review of the Face Sheet for R138 revealed the facility originally admitted the resident on 11/21/2024, with diagnoses that included Post Traumatic Stress Disorder (PTSD), Schizoaffective Disorder, Bipolar, Generalized Anxiety Disorder, and Major Depressive Disorder. Review of the facility's Trauma Informed Care Screening, performed on the resident's admission and dated 11/21/2024, revealed R138 was negative for a history of PTSD. Review of the Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 01/28/2026, revealed the facility assessed R138 to have a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. Review of the Comprehensive Care Plan (CCP) for R138 revealed an entry dated 05/30/2025, which noted R138 used psychotropic medications and had multiple mental health diagnoses, including PTSD. Further review of the CCP revealed however, no indication of what the PTSD pertained to or what interventions were to be in place to mitigate the potential for further psychosocial trauma. Review of a clinical note documented by Psychiatric (Psych) Nurse Practitioner (NP) 1, dated 03/06/2025, regarding R138, a diagnosis of PTSD was listed in the note, with childhood sexual abuse identified as the cause of the PTSD. During an interview on 02/24/2026 at 2:12 PM with R138, she confirmed she had a diagnosis of PTSD, which was related to childhood abuse. R138 denied having any specific triggers and did not feel that having male caregivers caused her increased anxiety. During an interview on 02/25/2026 at 2:38 PM, the Social Services Director (SSD) stated she was aware R138 had a diagnosis of PTSD, but she was not sure what the cause was for the diagnosis. She said she thought it might have to do with a family issue at home, as an adult, but stated she would have to ask R138, and she had not previously done that. The SSD reported there had been no further investigation by her regarding R138's PTSD diagnosis or triggers. She further stated the risk of failure to prevent triggers might cause R138 to be retraumatized and could be harmful to the resident's mental health. (2) Observation on 02/23/2026 at 2:45 PM, revealed R90 lying on the bed, with eyes closed, and a sitter at the side of his bed. Further observation revealed a fall mat located on the floor to the left of the bed, with the right side of the bed against the wall. Review of the Face Sheet for R90 revealed the facility admitted the resident on 11/28/2025, with primary diagnoses including: encephalopathy, generalized anxiety, depression, essential tremor, sleep apnea, and hypertension. Continued record review revealed a diagnosis of PTSD had been added on 02/19/2026. Review of the admission MDS Assessment, with an ARD of 12/05/2025, revealed the facility assessed R90 to have a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Further MDS review revealed the facility also assessed R90 to have diagnoses of Anxiety and Depression. In interview on 02/24/2026 at 4:00 PM, R90's family Guardian stated she was the resident's niece, and became his Guardian around 2023. She said R90 had witnessed the death of his father and brother by gunshot and then lost two more siblings due to drowning within less than 10 years. The Guardian reported R90 did not talk much about those deaths; however, on occasion, he said he wished he had gotten to know them better. She explained that after COVID-19, he lost any desire to do anything, and she noticed his overall health had declined. The Guardian stated she was unaware of any specific triggers related to R90's PTSD. She further stated she thought she recalled speaking to someone during R90's admission about his PTSD but could not recall who she talked to. The Guardian additionally said if the PTSD had been discussed with R90, he likely had not understood due to some hearing difficulties he had in crowded areas. In interview on 02/25/2026 at 3:04 PM, Certified Nursing Assistant (CNA) 10 stated the floor staff were made aware of how to care for residents based on the residents' care plan. He said floor staff had the care plan information readily available on the Kardex, which was kept on the unit, in a three-ring binder. After reviewing the Kardex for R90 and R138, CNA 10 stated however, he was unable to identify triggers for PTSD for those residents. He reported he had not been made aware of specific triggers for either R90 or R138, but felt that information would be helpful when providing care for those residents to prevent causing them unnecessary distress. The CNA further stated he was aware of only one resident who was care planned for special care, and that was R111, who was not to have male caregivers and also had a diagnosis of PTSD. During interview on 02/24/2026 at 1:54 PM, Registered Nurse (RN) 8, the Unit Manager (UM), stated a Kardex was a document kept on the floor for staff to use for the resident's latest care plan interventions and orders. She said the Kardex was used as it could have information added to or items removed, since a pencil was used. RN 8/UM stated it was part of her job to ensure what was on the Kardex aligned with the residents' orders and care plans. She reported that those changes were addressed in the facility's morning clinical meetings throughout the week. RN 8/UM explained the official computerized care plan was updated by the MDS Nurse at that time. She stated she was aware R138 and R90 both had a diagnosis of PTSD, but was not aware what either resident's PTSD diagnosis pertained to or what might be triggers for them. She further stated she would like to know that information so those situations could be avoided as they had the potential to create unnecessary distress for the residents. During interview on 02/25/2026 at 3:50 PM, RN/MDS Nurse 2 stated MDS performed the Trauma Informed Care Assessment on residents. She said that the assessment was to be done upon admission and annually thereafter. RN/MDS 2 reported that the interviews for that assessment were done one-on-one, at the resident's bedside, along with the depression assessment and the BIMS assessment. She explained she was not familiar with either resident; however, she did know R138 had a diagnosis of PTSD. RN/MDS 2 said she was not sure why or what triggers might need to be avoided for R138. She stated she had not read the full clinical psych note, and that information had not previously been brought to her attention. RN/MDS 2 explained not knowing what triggers a resident might have for a PTSD diagnosis had the potential to create unnecessary distress for that resident. She further stated as an RN/MDS Nurse it was her responsibility to review and sign off on any work done by the LPN/MDS Nurse, specifically LPN/MDS 2. During interview on 02/26/2026 at 9:45 AM, RN/MDS Nurse 1 stated the Trauma Informed Care Assessment was done on admission, and the Care Plan was entered into the EHR by the MDS nurse. She said if necessary, updates to the care plan could be added to the Kardex at the UM's direction, and then MDS would add those updates to the resident's Care Plan the next workday. RN/MDS Nurse 1 reported she was aware of the PTSD diagnoses for R138 and R90 but did not know what the diagnoses were related to for those residents. She stated she was not aware of specific triggers for either resident; however, she did understand how the potential for unnecessary distress to the residents could occur without that information. RN/MDS Nurse 1 further stated it was the RN/MDS Nurse's responsibility to review and sign off on work performed by the LPN/MDS Nurse, specifically LPN/MDS 1. During interview on 02/26/2026 at 10:12 AM, LPN/MDS Nurse 1, stated she had been trained for the MDS role for three days and then was precepted by RN/MDS Nurse 1. She said she was only familiar with R90 and knew he had a history of PTSD, but she was not aware of what triggers he might have. LPN/MDS Nurse 1 reported R90's Guardian had been interviewed during the first care plan meeting and did not mention any previous traumatic experiences. She stated it was important to know what specific triggers any resident with a diagnosis of PTSD might have, so those situations could be avoided. After review of the residents' care plans, she said staff would not be aware of what, if any, triggers to avoid for residents with PTSD. LPN/MDS Nurse 1 further stated that, as a result, the residents could suffer increased anxiety or unnecessary distress. During interview on 02/24/2026 at 3:45 PM, the Primary Nurse Practitioner (NP) stated she was aware of the PTSD diagnosis for both R90 and R138. She said she knew the history of both residents; however, was unaware of specific triggers for either resident. The Primary NP reported knowing what, if any, triggers were associated with a PTSD diagnosis would be beneficial in providing the best care for those residents. She stated, in regards to R138 specifically, that resident had previously been treated by her current Psych NP 2 and she had requested Psych NP 2 work with the resident again. The Primary NP further stated R138 had briefly been seen by Psych NP 1 during the interim, but returned to the care of Psych NP 2 a couple of weeks ago. She additionally said the records from Psych NP 1 were available in the EHR for review. During interview on 02/24/2026 at 3:55 PM, Psych NP 2 stated she was aware of R138's PTSD diagnosis, and what it pertained to. She said new medications had been initiated for R138; however, the resident had not been using the medications long enough to evaluate their effectiveness. Psych NP 2 stated she was aware of efforts to incorporate talk therapy as well. She further stated knowing PTSD triggers would be beneficial in assessing appropriate care needs of the residents. During interview on 02/25/2026 at 2:53 PM, the Director of Nursing (DON) stated the initial care plans were done upon admission by the MDS Nurses. She said unless a resident's admission was after hours, then the floor nurse would do a baseline care plan, and MDS would review that care plan on the next working day. The DON reported she was aware R138 and R90 both had a diagnosis of PTSD, but she was not sure the reasons why. She explained the UM would be the first to review new clinical notes and address any new orders or new diagnoses, and then that information would be discussed in the morning clinical meetings. The DON verbalized understanding of what PTSD was, and stated it was important to avoid any potential triggers so a resident with that diagnosis did not suffer any additional psychosocial harm. She stated she understood the concern with the missing PTSD part of both residents' care plans she reviewed. The DON further stated she was not aware if that information had been obtained and was unable to explain why the missing information had not been previously caught. During interview on 02/25/2026 at 3:29 PM, the Administrator stated she was not clinical, but she was able to verbalize what PTSD stood for, Post-Traumatic Stress Disorder, which meant the resident had suffered from an event or situation that caused physical or mental trauma. She said it was important to avoid situations that might cause the residents to be re-traumatized. The Administrator stated the nurses should have access to what triggers the resident might have or some type of information regarding the PTSD diagnosis. She further stated not having that information could cause failing health, increased anxiety, depression, or regression for residents with a PTSD diagnosis. She was unable to verbalize why that information had not been included in the residents' care plans reviewed. (3) Review of R24's admission Record revealed the facility admitted the resident on 12/16/2024, with diagnoses which included polyneuropathy, essential tremors, osteoarthritis, and major depressive disorder. Review of R24's Quarterly MDS Assessment, dated 06/20/2025, revealed the facility assessed the resident to have a BIMS score of three out of 15, indicating severe cognitive impairment. Continued review revealed the facility assessed R24 to have diagnoses which included, muscle weakness, difficulty in walking, and lack of coordination. Further MDS review revealed the facility assessed R24 to not have had any falls since admission or for the prior assessment. Review of R24's Quarterly MDS Assessment, dated 09/19/2025, revealed the facility again assessed the resident to have a BIMS score of three out of 15, indicating severe cognitive impairment. Per MDS review, the facility assessed R24 to have had two or more falls with no injury and one fall with major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) since the prior MDS Assessment (on 06/20/2025). Review of R24's Care Plan, initiated 01/27/2026, revealed the facility noted the resident was at high risk for falls due to need for activities of daily living (ADL) assistance, medication use, age, and co-morbidities. Continued review revealed the facility developed interventions for non-skid footwear, to check placement of that footwear during rounds and reapply as needed; and provide wheelchair/walker as needed. Further review of the care plan revealed however, no date noted for when those interventions were implemented. Additional review revealed the only intervention dated was an intervention for scheduled toileting which was noted as resolved on 11/20/2025. Review of the facility's Fall Investigations for R24 revealed the resident sustained a fall on 08/18/2025, and the facility implemented an intervention for non-skid footwear for R24. Per continued review of the Fall Investigations, R24 experienced another fall on 08/26/2025, and the facility implemented an intervention to give the resident a rolling walker. Further review of the Fall Investigations revealed R24 again fell on [DATE], while ambulating without a walker and wearing sandals which slipped off her foot, and sustained a dislocated shoulder. In addition, review of the Fall Investigations revealed R24 sustained another fall on 11/11/2025, while wearing one shoe with the root cause analysis noted as improper footwear. Review of the Fall Investigations also revealed R24 experienced another fall on 11/17/2025, when the facility assessed R24 to have failed to use her walker. During interview, on 02/25/2025 at 3:25 PM, the LPN/MDS Nurse stated she was responsible for ensuring residents' care plan interventions were transferred to their comprehensive care plan. She further stated the care plan was important for letting staff know how to care for residents. During interview, on 02/26/2025 at 10:10 AM, the RN/MDS Nurse stated she was responsible for making sure R24's care plans were updated with appropriate interventions. She said the Unit Coordinator investigated residents' falls and ensured an appropriate intervention was implemented after each fall. The RN/MDS Nurse explained she placed the Unit Coordinator's intervention onto the residents' comprehensive care plan. She stated R24 already had comprehensive care plan interventions in place for non-skid footwear and a rolling walker when she fell on [DATE], 11/11/2025, and 11/17/2025; however, staff were not following the resident's interventions appropriately. Additionally, she stated the Unit Coordinator was responsible for monitoring the effectiveness of new fall care plan interventions.

Based on interview, record review, and review of facility documentation and policy, the facility failed to revise the comprehensive person-centered care plan for 1 of 41 sampled residents, (Resident (R)24) The findings include: Review of the facility's policy, Care Plan Policy and Protocol, revised 09/2024, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables. Further review revealed the comprehensive care plan was to be periodically reviewed and revised by the interdisciplinary team (IDT) after each assessment and on an as needed basis. Review of the facility's job description for the, Minimum Data Set (MDS) Coordinator, revised 09/25/2024, revealed the position was responsible for the coordination of the completed comprehensive care plan according to regulatory requirements. Review of the admission Record for R24 revealed the facility admitted her on 12/16/2024, with diagnoses that included polyneuropathy, osteoarthritis, and essential tremors. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/20/2025, revealed the facility assessed R24 as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Further MDS review revealed the facility also assessed R24 to have diagnoses of muscle weakness, difficulty in walking, and lack of coordination, and to have had no falls since the admission or prior assessment. Review of the Quarterly MDS Assessment, dated 09/19/2025, revealed the facility assessed R24's BIMS score to continue to be three out of 15, indicating severe cognitive impairment. Continued MDS review revealed the facility assessed R24 to have had 2 or more falls with no injury and 1 fall with major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) since the prior assessment (on 06/20/2025). Review of the Care Plan, initiated 01/27/2026, revealed the facility noted R24 was at high risk for falls due to age, co-morbidities, and need for assistance with activities of daily living (ADL). Per care plan review the interventions included non-skid footwear; however, there was no date for when that intervention was implemented. Review of the facility's Fall Investigations for R24 revealed the resident sustained a fall on 08/18/2025 and the facility implemented an intervention for non-skid footwear for the resident. However, continued review of the Fall Investigations revealed R24 experienced a fall on 10/31/2025, while ambulating with improper footwear (sandals) which slipped off her foot, and not the facility's intervention for ensuring the resident had on the non-skid footwear. During interview, on 02/26/2025 at 10:10 AM, the Registered Nurse (RN)/MDS Nurse stated she was responsible for making sure R24's care plans were updated with appropriate interventions. She said the Unit Coordinator investigated residents' falls and ensured an appropriate intervention was implemented after each fall. The RN/MDS Nurse stated she then placed the Unit Coordinator's intervention onto the comprehensive care plan. She further stated R24 had a comprehensive care plan intervention in place for non-skid footwear when she fell on [DATE] and the resident's comprehensive care plan was not revised with a new intervention. RN/MDS Nurse additionally said the Interdisciplinary Team (IDT) met every Friday to discuss every fall that had occurred during that week.

Based on observation and interview, the facility failed to ensure that two corridors were equipped with firmly secure handrails on each side of the hallway which has the potential to affect all ambulatory residents in the facility. Failure to have handrails could affect residents' ability to safely ambulate down the hallways. Findings include: Observation on 10/29/24 at 4:20 PM revealed no handrail on the north front corridor wall in a 12 foot section. The wall was across the hall from the outpatient physical therapy room. Observation on 10/29/24 at 4:20 PM revealed no handrail on the south front corridor wall near the outpatient therapy room measuring six feet. The wall was next to the outpatient physical therapy room. Observation on 10/29/24 at 4:20 PM revealed no handrail on the south front corridor measuring 15 feet near the front door. Observation on 10/29/24 at 4:25 PM revealed no handrail on the east wall 10 feet to the fire doors. Observation on 10/29/24 at 4:25 PM revealed no handrail five feet on the west wall from a second outpatient room door to the smoke doors leading to the 100 unit. Observation on 10/29/24 at 4:25 PM revealed no handrail on the wall at the administrator office measuring 17 feet to the smoke doors leading to the 200 unit. Observation on 10/29/24 at 4:25 PM revealed no handrail on the wall at the ice cream room to the smoke doors measuring eight feet. Interview with the Administrator on 10/29/24 at 4:30 PM verified the lack of handrails on the noted corridor walls above.

Based on observation, interview, record review, document review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to minimize the risk of food borne illness to all 151 residents residing in the facility and who received meals from the kitchen. Specifically, the water temperature in three out of four handwashing sinks in the kitchen was not hot; sanitizer solutions were too strong; microwave ovens were soiled; individual cartons of shakes were not labeled with expiration dates, and the refrigerator/freezers on the units were not monitored and/or were not functioning properly. Findings include: Review of the facility's undated policy titled, Unit Kitchenette Policy provided by the facility revealed, Foods will be stored on the units in a manner that comply with safe food handling practices .Food and nutrition services or other designated staff should maintain clean food storage areas . Refrigerated foods will be stored below 41 degrees . Freezers must keep frozen foods solid and maintain a temperature of 0 degrees or below. Refrigerator & freezer temps [temperatures] will be monitored daily by the nutrition services staff shift food and nutrition aid . No employee items are to be in the resident's refrigerator or freezers at any time. Review of the facility's undated policy titled, Sanitation of Dishes/Manual Washing provided by the facility revealed, Quaternary Ammonium Compound Solutions - Concentration as indicated by manufacturer . Review of the label of Quat-Clean sanitizer revealed, To sanitize immobile items .prepare a fresh solution .The product is an effective sanitizer when diluted in water up to 250 PPM [parts per million] . 1. During the initial kitchen inspection on [DATE] at 10:34 AM, the following concerns were observed: a. The water temperature in the hand washing sink, located across from the steam table, was operated by pressure (pressing against a lever with one's leg). There was no way to adjust the water temperature. The water was turned on and ran for 30 seconds; the temperature was cool. There were three other handwashing sinks in the kitchen that operated in the same manner. b. The microwave oven interior was observed and it was caked with accumulated food/beverage splatters. 2. During a subsequent kitchen observation with the Dietary Manager (DM) on [DATE] at 10:30 AM, the following concerns were observed: a. The water temperature in the hand washing sink, located across from the steam table was turned on and ran for 30 seconds. The water temperature was measured by the DM after 30 seconds and it was 77 degrees Fahrenheit (F), cool to touch. b. The water temperature in the hand washing sink, located by the reach-in refrigerator, was turned on and ran for 30 seconds. The water temperature was measured by the DM, and it was 85 degrees F, it was cool to touch. c. The water temperature in the hand washing sink, located in the dish room area, was turned on and ran for 30 seconds. The water temperature was measured by the DM, and it was 64 degrees F, cold to touch. The DM verified none of the water temperatures in these three handwashing sinks were as hot as they should be for adequate handwashing. The DM stated on [DATE] at 10:38 AM that he had noticed previously that the water temperature in the hand washing sink across from the steam table was not always warm. d. The concentration of the wiping rag sanitizer solution in the dish room was checked by the DM using a quaternary ammonia test strip. The concentration was observed and confirmed by the DM as 500 parts per million (PPM). The DM stated on [DATE] at 10:39 AM that the solution should be mixed to a concentration between ,d+[DATE] PPM. The DM checked the concentration of another bucket of wiping rag solution located by the tilt skillet, and it read 500 PPM. The DM stated the dietary staff did not document checking the concentration of the wiping rag sanitizer solutions. The DM went to the dispenser and mixed a new bucket of solution, and it also read 500 PPM. The DM confirmed the solutions were too strong and could leave a chemical residue on the surfaces that were cleaned. e. The microwave oven interior was observed, and it was caked with accumulated food/beverage splatters, in the same condition as noted on [DATE]. The DM stated on [DATE] at 10:41 AM that it was filthy. 3. On [DATE] from 10:36 AM - 11:08 AM the kitchenettes on the resident units were inspected with the DM. None of the refrigerator/freezer logs in the five kitchenettes (100 unit, 200 unit, 300 unit, 400 unit, 440 secure unit) included documentation of the freezer temperatures. The DM verified the logs documented only refrigerator temperatures. In addition, the following concerns are noted in the kitchenettes: a. The kitchenette in the 400 Unit had a refrigerator/freezer. There were two thermometers in the refrigerator; one read 43 degrees F and the other 44 degrees F, verified by the DM, who stated the refrigerator was not cold enough and stated the goal was for temperatures to be 41 degrees F or below. There was a variety of snacks in the refrigerator such as sandwiches, yogurts, and assorted beverages. The DM stated dietary staff was responsible for cleaning and monitoring the refrigerators/freezers and microwaves in the kitchenettes. b. The kitchenette in the 200 Unit had a refrigerator/freezer. The interior of the refrigerator had a large sticky area (food/beverage residue); the DM stated the refrigerator needed to be cleaned. A thermometer in the refrigerator read 44 degrees F. There were four cartons of unlabeled, individually packaged four ounce Ready Care shakes. The label on the shakes indicated the shakes expired 14 days after being pulled out of the freezer. The DM stated it was unknown what date the shakes had been pulled out of the freezer. c. The kitchenette in the 300-unit had a refrigerator/freezer. A thermometer in the refrigerator read 52 degrees F. The DM measured the temperature of one of the Ready Care shakes and it was 54.8 degrees F. There were sandwiches yogurts, cream cheese, shakes and other beverages in the refrigerator. There were two undated cartons of Ready Care shakes in the refrigerator. The DM measured the temperature of the freezer, and it was 20 degrees F. The DM stated it should be zero degrees or below. There were popsicles and individual portions of ice cream that were soft to touch. The DM stated they should be frozen solid and indicated he would throw away the contents of the refrigerator and freezer. 3. During an interview on [DATE] at 11:50 AM, the Registered Dietitian (RD) stated the dietary staff should monitor the refrigerator and freezer temperatures on the units every day. The RD stated the sanitizer solution should be mixed to a concentration of 150 - 200 PPM and verified if the concentrator was higher, it was too strong. The RD stated that all individual cartons of health shakes in the unit refrigerators should be labeled so staff would know when to discard them, which was no later than three days after they arrived on the unit. The RD turned on the water at the handwashing sink near the disposal and tested the temperature with her hand. The RD stated the water was cold. During an interview on [DATE] at 5:11 PM, the Maintenance Director stated the maintenance staff checked water temperatures throughout the facility on a weekly basis, which included water temperatures in the kitchen. The Maintenance Director stated the water temperature for the handwashing sinks should be between 100 - 110 degrees F. and temperatures had not been a problem when he checked the hand washing sinks previously. The Maintenance Director stated it could take ,d+[DATE] seconds for the water to circulate and come up to temperature. The Maintenance Director stated he learned today that the refrigerator/freezer on the 300 unit was not working properly The Maintenance Director stated the dietary staff were responsible for cleaning and defrosting the refrigerator/freezers on the units and should notify him if the refrigerator/freezers were not working properly. During a follow up interview on [DATE] at 5:33 PM, the Maintenance Director brought the surveyor his water temperature logs and stated maintenance had been checking the water temperature for the dishwasher in the kitchen. The Maintenance Director stated he had been mistaken earlier in that maintenance staff had not been checking water temperatures in the hand washing sinks. Review of the logs from [DATE] - [DATE] verified the water temperatures of the handwashing sinks in the kitchen had not been monitored.

Based on observation, record review, interview and facility document review, the facility was to follow Enhanced Barrier Precautions (EBP) when performing direct care to one of 36 residents (Resident (R)108) and failed to update infection control policies annually. This failure has the potential to spread infection to residents, staff are administering direct care to. Findings included: 1. Review of R108's Electronic Medical Record (EMR) undated Face Sheet located under the Profile tab, indicated R108 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, dysphagia, and adult failure to thrive. Review of R108's quarterly Minimum Data Set (MDS) located in R108's EMR under the MDS tab, with an Assessment Reference Date (ARD) of 08/19/24, revealed R108's cognition was severely impaired, and the resident had short and long term memory issues. R108 is also coded as having a gastrostomy (A surgical procedure that creates an opening in the abdominal wall into the stomach to provide nutritional support.) Review of R108's Physician Orders located in R108's EMR under the Orders tab, revealed orders dated 02/05/24 for Glucerna 1.5 @ 45 cc/hr. [cubic centimeter/hour] continuous per pump. There was also a physician's order dated 04/03/24 which stated, Enhanced Barrier Precautions every shift. Observation on 10/28/24 at 12:21 PM, Certified Nursing Assistant (CNA)5 and CNA6 were performing R108's incontinence care. CNA 5 and CNA6 wore gloves but did not wear gowns while providing this care. During an interview on 10/28/24 at 12:41 PM, when asked CNA6 if R108 was in EBP, CNA6 replied, I don't think so. When asked what Personal Protective Equipment (PPE) you would use if a resident was in EBP, CNA6 stated that she was unsure what PPE to wear. When asked which residents should be in EBP, CNA6 stated, Maybe a resident with a tube feeding. CNA6 was asked what EBP was. CNA6 replied, You gown up to protect the residents from your germs. During an interview on 10/28/24 at 12:49 PM, Registered Nurse (RN)5 was asked what EBP was and how would you know if a resident was in EBP. RN5 stated, Anyone in EBP has an orange dot besides the resident's door. Residents are in EBP, they have a wound, tube, or a history of CRE (Carbapenem-resistant Enterobacterales, a group of bacteria that are resistant to antibiotics and can cause serious infections). RN5 was asked if R108 was in EBP. RN5 stated, Yes and that staff are to wear gown and gloves with any type of direct care. During an interview on 10/28/24 at 1:06 PM, CNA5 was asked if R108 was in EBP. CNA5 stated, Yes, she is. When asked if CNA5 wore gown and gloves when performing R108's incontinence care. CNA stated, It slipped my mind. When asked how do you know when a resident is in EBP, CNA5 stated there will be an orange sticker on the outside of the door. When asked what PPE was to be worn when a resident was in EBP, and direct care is being delivered. CNA5 replied, You should wear gown and gloves when the resident is in EBP. During an interview on 10/29/24 at 6:00 PM, the Infection Preventionist (IP) nurse was asked what PPE should be worn for EBP. The IP stated that gown and gloves are to be worn for direct resident care when a resident is in EBP. The IP nurse stated, When performing direct care such as bathing, changing residents, and performing dressing changes to wounds. The IP nurse confirmed R108 was in EBP due to having a feeding tube. During an interview on 10/31/24 at 5:15 PM, the Director of Nursing (DON) confirmed that any staff providing direct care to a resident in EBP are to wear gowns and gloves. During an interview on 10/31/24 at 5:30 PM, the Administrator stated, Staff are to wear gowns and gloves when performing any kind of direct care with residents that have a feeding tube, wounds, or catheters. The CNAs should have been wearing gloves and gowns when performing peri care and changing this resident's brief. Review of the facility's policy titled, Enhanced Barrier Precautions dated 03/24 stated, . EBP includes the use of a gown and gloves during high-contact resident care activities, including dressing, bathing or showering, performing transfers, changing linens, providing hygiene, changing a resident's brief or assisting them with toileting, direct care of an indwelling medical device, such as a central line, urinary catheter, feeding tube, or tracheostomy, and when performing wound care on any skin opening that requires a dressing . 2. Review of the facility's infection control policies revealed the policy titled Infection Prevention & Control Program did not have a date of the last review of this policy. Review of the facility policy titled Antibiotic Stewardship Program was dated Dev. 09/17 . During an interview on 10/31/24 at 6:15 PM, the DON stated, I honestly didn't know they had to be reviewed annually. During an interview on 10/31/24 at 6:15 PM, the IP stated, We talk about this in QA [Quality Assurance], but I don't know about how they are reviewed annually. During an interview on 10/31/24 at 6:35 PM, the Administrator stated she was looking for when the infection control policies were last updated and felt these were last updated during the facility assessment that was completed this year. On 10/31/24 at 7:20 PM, the Administrator returned to the surveyor and provided a copy of the 2024 Facility Assessment Page 20 which stated, .Part 6-Infection Control Program Evaluation (Infection Risk Assessment) 6.2 Staff are trained in basic infection control principles on hire and annually. A more thorough training is based on their position. Audits are conducted randomly such as hand hygiene, glove use, peri care, etc. This identifies areas and individuals that may need further education. Infection Risk Assessment is completed annually . The facility was unable to provide documentation other than the dates on the infection control policies that were provided earlier in the survey prior to the exit conference.

46592 Based on record review, interview, and facility policy review, the facility failed to provide written hospital transfer notices for four of six residents (Resident (R) 9, 14, 35, and R58) reviewed for hospitalization out of a total sample of 36 and failed to inform the Ombudsman of the hospital transfers. The failure had the potential to cause residents to not fully understand the purpose of the hospital transfer and the Ombudsman to not be aware of resident transfers to the hospital from the facility. Findings include: Review of the facility's undated policy titled, Transfer and Discharge Rights provided by the Administrator revealed, ensure that the resident's right to refuse a transfer or discharge from the facility is not violated. The only written notice indicated in the policy was related to permanent discharge of the facility. There is no reference for the written notice for transfer when residents are transferred to the hospital. 1. Review of R14's Health Status note dated 07/30/24 and located under the Prog Notes tab of the electronic medical record (EMR) revealed R 14 was transferred to the hospital for a possible pulmonary event. Review of R14's Progress Notes and Misc [miscellaneous] tabs in the EMR revealed no documentation R14 or her representative were provided with written notice of R14's hospital transfer. 2. Review of R35's Health Status note dated 03/31/24 and located under the Prog Notes tab of the EMR revealed R35 had been transferred to the hospital for a having a temperature, feeling weak and nauseated throughout the night. Review of R35's Progress Notes and Misc tabs in the EMR revealed no documentation R35 or his representative were provided with written notice of R35's hospital transfer. 3. Review of R58's Health Status note dated 08/11/24 and located under the Prog Notes tab of the EMR revealed R58 had been transferred to the hospital for a having chest pain and bilateral arm pain. Review of R58's Progress Notes and Misc tabs in the EMR revealed no documentation R58 or his representative were provided with written notice of R58's hospital transfer. 4. Review of R9's undated Face Sheet located in the EMR under the Profile tab revealed R9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R9's Nurses Notes, dated 09/11/24, located in the resident's EMR under the Progress Note tab revealed .res [resident] lying in bed .diaphoretic, respirations labored, grunting noise, res [resident] states abd [abdominal] pain . new orders received to send to .ED [emergency department] [sic] . R9 was admitted to an acute care hospital for septic shock, acute kidney injury with tachycardia. In an interview on 10/30/24 at 10:50 AM, Accounts Receivable (AR) stated there is not a transfer notice given in writing to the residents or representatives when a hospital transfer occurs but stated the transport personnel get a transfer form. The AR stated she calls the Ombudsman when a hospital transfer takes place, but stated she was unable to provide documentation of the call. In an interview on 10/31/24 at 5:30 PM the Director of Nursing (DON) stated a transfer form is filled out per resident and given to the transport personnel. She stated the forms indicated pertinent medical information but was not a form stating why the resident was being transferred. When asked if the resident or representative received the notice, the DON stated they did not. The DON also stated she believed AR informed the Ombudsman of hospital transfers, but was unaware it was done by phone with no documented proof. During an interview on 10/31/24 at 5:30 PM, the Administrator was notified of the above documented findings regarding the notifications to the ombudsman. The Administrator stated, I know [AR's name] does that.

Based on interviews, record review, and policy review the facility failed to ensure that one resident (Resident (R) R119) out of a total sample of 36 residents, was protected from abuse, when R148 slapped R119 on the cheek of her face. Findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy revised 07/2024 stated, Our facility does not condone or tolerate resident abuse, this includes .physical abuse .under any circumstances by anyone, including staff members, other residents .Physical abuse includes hitting, slapping, pinching and kicking . Review of R119's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab revealed that she was admitted to the facility on [DATE] with a primary diagnosis of chronic lymphocytic leukemia. Review of R119's Quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 08/07/24 included a Brief Interview for Mental Status (BIMS) score of seven out of 15 indicating she had severe cognitive impairment. Review of R148's undated Admission Record located in the EMR under the Resident tab revealed that she was admitted to the facility on [DATE] with a primary diagnosis of dementia and remained in the facility during the survey observations. Review of R148's Admission MDS located in the EMR under the MDS tab with an ARD of-08/19/24 included a BIMS score of three out of 15 indicating she had severe cognitive impairment. Review of R148's Care Plan located in the EMR under the Care Plan tab and revised on 10/29/24 included altered moods and behaviors including agitation, anxiety, physical and verbal combativeness. She had been noted to hit, punch, pinch, kick, and scream at staff. Due to aggressive and impulsive behaviors, R148 had been assigned one-to-one supervision since 08/31/24. Review of the facility reported incident investigation dated 10/08/24 revealed R148 and R119 both resided on the secure unit at the facility. Licensed Practical Nurse (LPN2) interviewed R119 who reported she hadn't bothered anyone, was minding her own business when R148 slapped her. A physical assessment was performed and noted no visible injuries. Certified Nurse Assistant (CNA10) witnessed the incident reporting that she was assigned one-to-one monitoring for R148. CNA10 reported that she .was trying to put R119 back in her chair when R148 slapped her on her lower left cheek. CNA11 stated, CNA10 was making sure R119 didn't fall out of her chair and R148 slapped R119. The summary of interviews with staff responsible for oversight and supervision of the residents stated, Both residents reside in the secured unit on 400 hall .Staff that were interviewed stated that R148 requires a one on one sitter and has a lot of behaviors and has to be monitored continuously. She gets agitated easily and is combative. The conclusion of the facility's investigation stated We have concluded the investigation. At this time, we can verify that R148 did slap R119, with no injuries noted. R119 stated she is fine and had no concerns with R148 at this time. During an interview on 10/29/24 at 10:15 AM, R119 stated she did not recall being slapped by another resident. When asked if she knew R148, she stated, Oh yes, she's hateful. When R119 was asked if she was afraid of anyone at the facility, she said no. During an interview on 10/29/24 at 10:27AM, CNA10 reported she was R148's one-to-one monitor the day that she made contact with R119. CNA10 reported she was trying to help R119 back to her seat and all of a sudden R148 open handed slapped R119 on her cheek. R119 had mild redness on her cheek. R148 had been on one-to-one monitoring since one week after her admission. During an interview on 10/30/24 at 12:13PM, LPN2 stated on the day of the incident, staff were trying to assist R119 to sit and R148 reached out and slapped R119. R148 had not been reported to have made physical contact with any other residents but had tried. LPN2 stated that when she interviewed R119 after the incident, she stated she was fine but didn't see it coming and denied being fearful of any residents or staff. When LPN2 interviewed R148 she did not recall anything about the incident. During an interview on 10/31/24 at 11:18 AM, the Administrator stated that at the time of the incident, R148 had a sitter who witnessed R148 getting up and about to stumble. The sitter went to assist and stabilize R148, who then went behind the sitter and came around and smacked R119's face. Staff report to her frequently that R148 had outbursts and became agitated. R 148 gets easily agitated when staff try to assist her.

Based on record review, interview, and facility policy review, the facility failed to provide written information regarding the facility's bed-hold daily pricing for three of six residents (Resident (R)14, 35, and R58) reviewed for hospitalization out of a total sample of 36. The failure had the potential to cause confusion for residents planning on returning to the facility. Findings include: Review of the undated facility policy titled, Policy: Bed Hold and provided by the Administrator revealed, at the time of transfer of a resident for hospitalization or therapeutic leave, the facility will provide the resident and/or resident representative a written notice which specifies the duration of the bed hold or if no bed hold days available. The policy did not indicate a daily price for each respective resident's bed hold would be provided on written notice to the residents. 1. Review of R14's Health Status note dated 07/30/24 and located under the Prog Notes tab of the electronic medical record (EMR) revealed she had been transferred to the hospital for a possible pulmonary event. Review of R14's Progress Notes and Misc [miscellaneous] tabs in the EMR revealed no documentation R14 or her representative were provided with written notice of the facility's bed-hold policy including daily pricing when transferred to the hospital. 2. Review of R35's Health Status note dated 03/31/24 and located under the Prog Notes tab of the EMR revealed he had been transferred to the hospital for a having a temperature, feeling weak and nauseated throughout the night. Review of R35's Progress Notes and Misc tabs in the EMR revealed no documentation R35 or his representative were provided with written notice of the facility's bed-hold policy including daily pricing when transferred to the hospital. 3. Review of R58's Health Status note dated 08/11/24 and located under the Prog Notes tab of the EMR revealed he had been transferred to the hospital for a having chest pain and bilateral arm pain. Review of R58's Progress Notes and Misc tabs in the EMR revealed no documentation R58 or his representative were provided with written notice of the facility's bed-hold policy including daily pricing when transferred to the hospital. Interview on 10/30/24 at 10:50 AM, Accounts Receivable (AR) stated the form the facility used explained timeframes and insurance obligations, but there is not a cost per day for the bed-hold on the given form. In an interview on 10/31/24 at 5:30 PM the Director of Nursing (DON) confirmed that the bed hold form did not contain daily pricing for the holds.

Based on observation, interview, record review, and policy review, the facility failed to ensure that one out of two residents (Resident (R)147) reviewed for activities of daily living (ADLs) received services to help her maintain her ability to ambulate (walk) after the discontinuation of physical therapy (PT). This created the potential for R147 to decline in her ability to ambulate which could impact her goal of discharge to the community. Findings include: Review of the facility's undated Protocol for Restorative Nursing Program revealed the purpose, Assist residents in maintaining abilities and functions as possible with limits of disease/diagnosis, etc . When it has been determined that a resident may benefit from the Restorative Nursing Program, the nurse/clinical coordinator will implement the restorative nursing program . A Restorative Nursing Care plan will also be initiated for the specific plan to be done . Review of the undated Admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R147 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke caused by a blocked or narrowed blood vessel in the brain), hemiplegia (complete or severe loss of strength that results in paralysis on one side of the body), and difficulty in walking. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/24 in the EMR under the MDS tab revealed R147 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R147 was impaired in range of motion (ROM) on one side to the upper and lower extremity. R147 was dependent on staff for transfers and going from sitting to lying, from lying to sitting, and coming to a standing position from sitting. R147 did not attempt walking. Review of the PT Evaluation & Plan of Care dated 07/28/24 -08/26/24 and provided by the facility revealed a goal, Patient will safely ambulate on level surfaces 50 feet using Hemi-Walker with CGA (care giver assistance) with reduced risk for falls in order to increase independence with all functional ambulation. Review of the PT Discharge Summary dated 10/18/24 and provided by the facility revealed R147 received services from 07/28/24 - 10/18/24. R147 met the goal of ambulating 50 feet using a Hemi-Walker with moderate assistance. Discharge recommendations include, Recommend 2 staff to assist with ambulation with Hemi-Walker 30 feet. Review of the Therapy to Nursing Daily Communication dated 10/18/24 and provided by the facility revealed a recommendation from the PT to nursing for ambulating R147 with staff using a Hemi-Walker following R147's discharge from therapy. Review of R147's Care Plan dated 10/25/24 in the EMR under the Care Plan tab revealed R147 had the, Potential for self-care deficit. Resident requires extensive to total assistance with ADLs . The goal was, The resident will continue to have needs anticipated and met by staff . Interventions included in pertinent part, Ambulate with assistance to allow as much freedom as possible. During an interview on 10/28/24 at 11:27 AM, R147 stated she was admitted to the facility after having a stroke and prior to that had lived at home independently. R147 stated it was her goal to discharge back to the community, but she had to be more independent in ADLs. R147 stated she needed to continue walking so she could go home. R147 stated she was discharged from PT on 10/18/24 and was supposed to receive restorative nursing and walk with staff as part of the program. R147 stated she had not walked since PT was discontinued and no one had spoken to her about restorative or about walking with her. During a subsequent interview on 10/31/24 at 3:51 PM, R147 stated staff had not offered to walk her since 10/18/24 and no one had come and talked to her about going onto the restorative program or about Certified Nurse Aides (CNAs) or restorative nurse aides (RNAs) walking with her. R147 stated it was very important to her to continue walking. Observations during the survey revealed R147 ambulated in a wheelchair: On 10/28/24 at 11:27 AM, R147 was sitting in a wheelchair in her room. On 10/29/24 at 3:54 PM, R147 was sitting in her wheelchair in the hallway. On 10/31/24 at 10:00 AM, R147 was sitting in her wheelchair near the dining room. On 10/31/24 at 10:34 AM, R147 was sitting in her wheelchair in the hallway. On 10/31/24 at 1:49 PM, R147 was sitting in her wheelchair in the dining room in an activity. During an interview on 10/30/24 at 1:28 PM, PT stated R147 had improved significantly in her ability to ambulate while receiving physical therapy. The PT stated she walked up to 50 feet upon being discharged from therapy on 10/18/24. The PT stated he had referred R147 to nursing staff for ambulation. The PT stated he documented his recommendation for services after discharge from PT on the Therapy to Nursing Daily Communication dated 10/18/24 and provided it to nursing staff. The PT stated the nursing staff determined who would go onto the restorative program and developed the program using the information therapy provided. The PT stated he did not know if R147 was on restorative currently. During an interview on 10/30/24 at 1:55 PM, CNA7 stated R147 was able to stand but it was hard for her to walk. CNA7 stated she did not ambulate with R147. CNA7 stated therapy staff would walk with R147, not the CNAs. During an interview on 10/30/24 at 2:06 PM, MDS Coordinator (MDSC)2 stated therapy staff gave the MDS Coordinators the Therapy to Nursing Daily Communication forms when residents were being discharged from therapy and there were recommendations for nursing services such as restorative. MDSC2 stated the MDS Coordinators met with the Unit Supervisors and talked about which residents would most benefit from restorative services. MDSC stated not all residents with recommendations could go on restorative because there were limitations to how many residents could be picked up and added to the restorative nursing program. MDSC stated there were two restorative aids working each day which allowed for five residents from each unit (four units and a total census of 151 residents) to receive restorative services at any given time. The MDSC stated CNAs could walk residents if the residents wanted to walk if they were not receiving restorative services. MDSC2 stated the MDS Coordinators and unit managers had not discussed R147 going on restorative services yet. During an interview on 10/31/24 at 10:33 AM, Licensed Practical Nurse (LPN)1, who was also the Unit Supervisor for R147's unit, stated R147 was recently discharged from therapy, and she would be in the next batch of residents who could go onto restorative when someone else was discharged (creating an opening). LPN1 stated therapy identified R147 as being a good candidate for restorative and presented nursing with recommendations. LPN1 stated the facility did not always have enough slots to put all residents on restorative who might be eligible or who might benefit, but eventually eligible residents would be added to the program as other residents came off the program. LPN1 stated R147 talked to her on 10/28/24 or on 10/29/24 that she wanted to go on restorative. LPN1 stated R147 wanted to discharge home and restorative was part of the plan to promote discharge. During an interview on 10/31/24 at 12:53 PM, RNA1 stated in August 2024 the facility started up the restorative nursing program again. She was not sure hold long the facility had not had the program. RNA1 verified there were four RNAs. RNA1 stated if the MDS Coordinators felt a resident was at risk of losing Range of Motion (ROM) then they referred them to the restorative program. RNA1 stated, when therapy discharged a resident from therapy services, they sent the recommendation to the MDS Coordinators, who then approved/denied the recommendation. If it was approved, the MDS Coordinator let the RNAs know when the resident was to start restorative and for how long. RNA1 stated tasks usually included ROM, transfers, and walking. During an interview on 10/31/24 at 5:26 PM, the Director of Nursing (DON) stated the restorative program was new, having been implemented a couple of months ago. The DON stated the facility had hired four CNAs to be Restorative Aides. The DON stated therapy provided education to nursing staff regarding their recommendations when residents were discontinued from therapy. The DON stated the RNAs could not manage more than 14 residents each per day. The DON stated that whichever resident was doing their best on restorative would be discharged after about a month and a half so other residents could be added. The DON stated they could not put everyone on restorative who might benefit because they did not want to overload the RNAs. The DON stated residents received restorative services three times a week for a minimum of 15 minutes. The DON stated R147 was determined to get back to the community and verified implementing a restorative program could benefit her.

Based on observation, record review and interview, the facility failed to ensure that it provided an ongoing program to support residents in their choice of activities, both facility sponsored and group activities for one resident (Resident (R)49) of 36 sampled residents. Findings include: Review of R49's electronic medical record (EMR)with an admitted [DATE] from the profile tab listed a diagnosis of Pick's Disease, Parkinson's Disease with dyskinesia, unspecified joint contractures, aphasia, generalized anxiety disorder, major depression, neurocognitive disorder with Lewy Bodies, Alzheimer's Disease, unspecified quadriplegia, contracture of the right hand. R49's Care Plan from EMR under the Care Plan tab dated 08/29/24 revealed a goal for activities indicating the resident will be involved with activities as possible with stable moods and behaviors. The care plan listed preferred activities such as television, music, and sensory stimulation. Observation of R49 on the following dates and time reveal the resident in her bed or wheelchair in front of a television that was turned off in her bedroom and not involved in any activities: 10/28/24 at 10:50 AM, R49 was in bed with no television and no activity 10/29/24 at 9:31 AM, R49 was in bed, no activities, no television 10/29/24 at 10:45 AM, R49 was in bed, no activities, and no television 10/29/24 at 2:05 PM, R49 was in bed, no activities, no television 10/30/24 at 9:30 AM, R49 in her wheelchair in bedroom, no television, no activities 10/30/24 at 10:50 AM, R49 in wheelchair in bedroom, no television, and no activities 10/31/24 at 10:10 AM, R49 in wheelchair in bedroom, no television, and no activities Review of the EMR significant change Minimum Data Set (MDS) with an assessment reference date (ARD) a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated the resident's cognition was severely impaired. Review of the Activity Assessment in the EMR under MDS tab dated 07/11/24 revealed that R49 had no response for all activity preferences. Review revealed written activity logs of May 2024 through October of 2024 revealed 170 days logged of television watching, 11 days/time frames of sensory stimulation and two days of special singings all of which are initialed by the Activity Director (AD). Interview with Certified Nurse Aide (CNA) 3 and CNA4 on 10/30/24 at 10:50 AM revealed they could not find R49's television remote to turn the television on so she could watch. CNA3 stated she was not sure how long the television had not worked. Interview with the AD on 10/30/24 at 10:55 AM, the AD stated that I put her in her room to watch television. We have tried sensory stimulation and music and reading, but do not get much of a response. Interview with the Administrator on 10/30/24 at 11:40 AM, the Administrator stated that she was not aware R49's television was not working.

Based on observation, interview, record review, and policy review, the facility failed to ensure that one out of three residents (Resident (R)147) reviewed for range of motion (ROM) received services to prevent further declines in ROM after the discontinuation of therapy. Physical therapy (PT) and occupational therapy (OT) recommended R147 to wear right foot and hand splints, and that staff provide ROM exercises. The failure to implement these interventions created the potential for R147 to decline in ROM which could impact her goal of discharge to the community. Findings include: Review of the facility's undated policy titled, Protocol for Restorative Nursing Program revealed, Assist residents in maintaining abilities and functions as possible with limits of disease/diagnosis, etc . When it has been determined that a resident may benefit from the Restorative Nursing Program, the nurse/clinical coordinator will implement the restorative nursing program . A Restorative Nursing Care plan will also be initiated for the specific plan to be done . Review of the undated Admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R147 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke caused by a blocked or narrowed blood vessel in the brain), hemiplegia (complete or severe loss of strength that results in paralysis on one side of the body), and difficulty in walking. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/24 in the EMR under the MDS tab revealed R147 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R147 was impaired in ROM on one side to the upper and lower extremity. Review of the PT Evaluation & Plan of Care dated 07/28/24 -08/26/24 and provided by the facility revealed the reason for the referral was, Pt [patient] reports she was previously living at home alone and was indep [independent] with all mobility without any devices. Pt has declined to required DEP [dependent] x 2 [with two staff] assist for bed mob [mobility] and 2 person assist for transfers and is unable to amb [ambulate] at this time . Current orthotic device = foot drop splint. Thereabout (resting foot splint); Splint/Orthotic recommendations: PRN [as needed] in bed. Location of contracture R [right] ankle .Potential treatment approaches of therapeutic exercises, and orthotic management and training. Goals included, Pt [patient] to be fitted with resting foot splint target 8/10/24. Review of the PT Discharge Summary dated 10/18/24 and provided by the facility revealed R147 received services from 07/28/24 - 10/18/24. R147's response to treatment documented, functional abilities have progressed as a result of skilled interventions. Patient has improved functional transfers, improved wheelchair mobility, improved bed mobility, and improved gait distance . Review of the Therapy to Nursing Daily Communication dated 10/18/24 and provided by the facility revealed a recommendation from the PT to nursing for active and passive ROM, application of the resting foot splint PRN [as needed] in bed, and application of right knee brace when using the Hemi-Walker. Review of the OT Evaluation & Plan of Care dated 07/27/24 - 08/25/24 and provided by the facility revealed R147 was referred for OT due to functional decline with ADLs/self-care tasks and functional mobility with a goal of enhancing R147's quality of life by improving her ability to return to prior level of living. R147's right upper extremity ROM (including the shoulder, elbow, and wrist ) was impaired. Review of the OT Discharge Summary dated 09/19/24 and provided by the facility revealed discharge recommendations included, OT recommends PROM [passive range of motion] for patient's RUE [right upper extremity] for all major joints through all planes of motion daily. OT recommends the use of R [right] resting hand splint daily. Pt tolerated wear of splint without signs of skin breakdown and/or pain/discomfort. Review of the Therapy to Nursing Daily Communication dated 09/19/24 and provided by the facility revealed OT recommended PROM for all major joints through all planes . Right resting hand splint applied daily. Review of R147's Care Plan dated 10/25/24 in the EMR under the Care Plan tab revealed R147 had the, Potential for self-care deficit. Resident requires extensive to total assistance with ADLs . The goal was, The resident will continue to have needs anticipated and met by staff . Interventions included in pertinent part, Therapy/restorative nursing as ordered . Review of R147's Care Plan dated 10/25/24 in the EMR under the Care Plan tab revealed, . Potential for altered skin integrity . Resident requires assist with her ADLs and continues to work with PT . require a resting right foot and a resting right hand splint . Interventions included, Resting hand splint to Right hand QS [every shift] . Resting splint to right foot daily as tolerated. R147's limitations in ROM were not documented on the care plan. The provision of ROM exercises was not documented on the Care Plan. The Care Plan did not identify a problem with R147 refusing application of her splints. Review of the Tasks for September 2024 and October 2024 (through 10/30/24), provided by the facility revealed Certified Nurse Aides (CNAs) documented daily every shift, Monitor - Right multipodus boot to right foot as tolerated q shift .Right resting hand splint to right had as tolerated q [every] shift. There was no task regarding the provision of ROM exercises. During an interview on 10/28/24 at 11:27 AM, R147 stated she was admitted to the facility after having a stroke and prior to that had lived at home independently. R147 stated it was her goal to discharge back to the community, but she had to be more independent in ADLs. R147 stated she needed to continue with exercises on her impaired right side so she could go home. R147 showed the surveyor her right hand that was curled into a fist and stated she could not open her hand. R147 stated she was discharged from OT first and then from PT on 10/18/24 and was supposed to receive restorative nursing after that. R147 stated she had a right knee brace, a right ankle brace, and a right-hand brace. R147 verified staff did not perform ROM exercises with her. During a subsequent interview on 10/31/24 at 3:51 PM, R147 stated staff had not applied her splints at all this week. She stated staff used to help her put them on but lately she had not been wearing them. Observations during the survey (10/28/24 at 11:27 AM; on 10/29/24 at 3:54 PM, on 10/31/24 at 10:00 AM, 10:34 AM, 1:49 PM, and 3:51 PM) when the resident was in her wheelchair revealed R147 was not wearing splints. During an interview on 10/30/24 at 1:28 PM, PT stated he documented his recommendation for services after discharge from PT on the Therapy to Nursing Daily Communication dated 10/18/24 and provided it to nursing staff. The PT stated the nursing staff determine who would go onto the restorative program and develop the program using the information therapy provided. The PT stated he did not know if R147 was on restorative currently. He stated his recommendations included R147 wearing a right foot splint as needed to prevent foot drop that was to be worn when she was in bed and the knee brace was to be worn when staff walked R147. During an interview on 10/30/24 at 1:35 PM, OT stated the OT recommendations for R147 after coming off therapy was for her to wear her resting hand splint daily as tolerated. The OT verified the nursing staff was responsible to help her do this. The OT verified the recommendations also included ROM exercises be done with the resident. During an interview on 10/30/24 at 1:55 PM, CNA7 stated staff assisted R147 to wear splints on her right hand and foot as she could tolerate. CNA7 stated R147 had worn the splints previously but was not wearing the splints very often now. CNA7 denied providing ROM exercises to the resident. During an interview on 10/30/24 at 2:06 PM, MDS Coordinator (MDSC)2 stated therapy staff gave the MDS Coordinators the Therapy to Nursing Daily Communication forms when residents were being discharged from therapy and there were recommendations for nursing services such as restorative. MDSC2 stated the MDS Coordinators met with the Unit Supervisors and talked about which residents would most benefit from restorative services. MDSC stated not all residents with recommendations could go on restorative because there were limitations to how many residents could be picked up and added to the restorative nursing program. MDSC2 stated there were two restorative aids working each day which allowed for five residents from each unit (four units and a total census of 151 residents) to receive restorative services at any given time. The MDSC2 stated CNAs could walk residents if the residents wanted to walk if they were not receiving restorative services. MDSC2 stated the MDS Coordinators and unit managers had not discussed R147 going on restorative services yet. During an interview on 10/31/24 at 10:33 AM, Licensed Practical Nurse (LPN)1, who was also the Unit Supervisor for R147's unit, stated R147 was recently discharged from therapy, and she would be in the next batch of residents who could go onto restorative when someone else was discharged (creating an opening). LPN1 stated therapy identified R147 as being a good candidate for restorative and presented nursing with recommendations. LPN1 stated the facility did not always have enough slots to put all residents on restorative who might be eligible or who might benefit, but eventually eligible residents would be added to the program as other residents came off the program. LPN1 stated R147 talked to her on 10/28/24 or on 10/29/24 and notified her she wanted to go on restorative. LPN1 stated R147 wanted to discharge home and restorative was part of the plan to promote discharge. During an interview on 10/31/24 at 12:53 PM, Restorative Nurse Aide (RNA)1 stated in August 2024 the facility started up the restorative nursing program again. RNA1 verified there were four RNAs. RNA1 stated if the MDS nurses felt a resident was at risk of losing ROM then they referred them to the restorative program. RNA1 stated, when therapy discharged a resident from therapy services, they sent the recommendation to the MDS nurse, then the MDS nurse approved/denied the recommendation. If it was approved, the MDS nurse let the RNAs know when the resident was to start restorative and for how long. RNA1 stated tasks usually included ROM, transfers, and walking. During an interview on 10/31/24 at 5:26 PM, the Director of Nursing (DON) stated the restorative program was new, having been implemented a couple of months ago. The DON stated the facility had hired four CNAs to be RNA. The DON stated therapy provided education to nursing staff regarding their recommendations when residents were discontinued from therapy. The DON stated the RNA could not manage more than 14 residents each per day. The DON stated that whichever resident was doing their best on restorative, the resident would be discharged after about a month and a half so other residents could be added. The DON stated they could not put everyone on restorative who might benefit because they did not want to overload the RNAs. The DON stated residents received restorative services three times a week for a minimum of 15 minutes. The DON verified R147 was not currently receiving restorative services.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of the nebulizer mouthpiece when not in use for one of 36 residents in the survey sample (Resident (R)133). This deficient practice increases the risk of infection for a resident requiring nebulizer therapy. Findings include: Review of R133's Electronic Medical Record (EMR) undated Face Sheet located under the Profile tab, indicated R133 was admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure with hypoxia. Review of R133's quarterly Minimum Data Set (MDS) located in R133's EMR under the MDS tab with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R133 was moderately cognitively impaired. Review of R133's Physician Orders located in R133's EMR under the Orders tab, revealed orders dated 08/04/24 Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligram) one inhalation by mouth twice a day. During an observation on 10/28/24 at 12:37 PM, R133's nebulizer mouthpiece was propped up on the nebulizer machine and was not covered in a plastic bag. During an interview on 10/28/24 at 12:49 PM, Registered Nurse (RN) 5 was asked how the nebulizer mouthpieces were to be stored when not in use by the resident. RN5 stated, They are placed in a plastic bag. During an observation and interview on 10/30/24 at 11:22 AM, R133's nebulizer mouthpiece was propped up on the nebulizer machine and not covered with a plastic bag. Licensed Practical Nurse (LPN) 1 went into the resident's room and was asked how the nebulizer mouthpiece was to be stored when not in use. LPN1 replied, The mouthpiece is supposed to be stored in the nebulizer compartment and the cover to the machine is to be closed. Then it is to have a bag over the entire machine. During an interview on 10/31/24 at 4:30 PM, the Director of Nursing (DON) was notified of R133's nebulizer mouthpiece was left exposed and not covered when it was not in use. The DON stated, They are supposed to be in a plastic bag when not in use. During an interview on 10/31/24 at 5:00 PM, the Infection Preventionist (IP) nurse was notified of the observations of R133's nebulizer mouthpiece being uncovered when not in use. The IP nurse stated, It is to be stored in a plastic bag. The IP nurse was asked for the policy concerning the storage of the nebulizer mouthpiece. The IP nurse replied, We don't have a policy. On 10/31/24 at 5:30 PM, the Administrator was notified of R133's nebulizer mouthpiece observed to be propped up by the nebulizer machine and it was not covered by a plastic bag.

Based on observation, interview, record review, policy review, and review of the admission packet, the facility failed to ensure two out of five residents (Resident (R)78 and R131) reviewed for unnecessary medications with dementia diagnoses had medication regimens free of unnecessary psychotropic medications. Failures included lack of adequate indication and identification of behaviors warranting the use of antipsychotic medications; duplicate therapy, lack of explaining risks versus benefits prior to the initiation of the medications, and a lack of qualitative and quantitative monitoring of behaviors and side effects. This created the potential for overmedication. Findings include: Review of the facility's Admission Agreement provided by the facility revealed, Too many residents, however, particularly those living with dementia, are being given off-label antipsychotic drugs to control their behavior . These drugs can have serious, life-threatening side effects for older people. Antipsychotic drugs are NOT a treatment for dementia or Alzheimer's disease, they are only appropriate for patients with specific mental disorder diagnoses such as schizophrenia . Antipsychotic drugs, when given to older adults with dementia, can be unsafe . they often come with a black box warning about their dangerous, life-threatening risks. A black box warning is the most serious warning by the US Food and Drug Administration. Review of the facility's policy titled, Medication Monitoring and Management dated June 2024 provided by the facility revealed, The facility employs a system to assure that medication usage is evaluated on an ongoing basis . the medication order is evaluated for the following: 1) The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacture's specification for use .The prescriber documents the clinical rationale in the resident's record for using a medication outside these stated guidelines . Facility staff monitor the resident for possible medication-related adverse drug reactions/consequences, including mental status and level of consciousness . When a resident receives medication from the same class or with similar therapeutic effects (duplicate therapy), the clinical rationale and benefit are documented in the resident's record. Review of the facility's undated policy titled, Protocol for Review & Reduction of Psychoactive Medications provided by the facility revealed, Residents that are prescribed psychotropic medications will be evaluated quarterly during the RAI [Resident Assessment Instrument] process and as indicated to ensure that residents are being observed for adverse effects of the medications . 1. Review of the undated Admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R78 was admitted to the facility on [DATE] with diagnoses including dementia, panic disorder, depression, and anxiety disorder. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 in the EMR under the MDS tab revealed R78 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The MDS indicated R78 felt down, depressed, or hopeless seven to 11 days of the assessment period. R78 exhibited no behaviors during the assessment period. R78 received antipsychotic, antianxiety, and antidepressant medications. Review of the quarterly MDS with an ARD of 08/30/24 in the EMR under the MDS tab revealed R78 continued to be moderately impaired in cognition with a BIMS score of 10 out of 15. The MDS indicated that R78 felt down, depressed, or hopeless seven to 11 days of the assess period. R78 exhibited no behavior during the assessment period. R78 received antipsychotic, antianxiety, and antidepressant medications. Review of the History & Physical dated 05/06/24 in the EMR under the Documents tab revealed that R78 had been living at home prior to being hospitalized with nausea, vomiting, diarrhea, and hyponatremia (low sodium). R78 was taking the following medications at home: quetiapine (Seroquel) an antipsychotic 100 milligrams (mg) twice daily (bid) for mood, lorazepam (Ativan) an antianxiety medication, 1 mg at bedtime (q hs) as needed (prn) for anxiety, lorazepam .5 mg bid PRN for anxiety, and Trazadone an antidepressant 100 mg q hs. Review of Orders tab dated 10/29/24 in the EMR under the Clinical tab revealed current physician orders for medications including: -Ativan (lorazepam) tablet 1 milligram (mg), three times a day (tid) for anxiety disorder. Started on 09/05/24. Prior to this date, R78 had been prescribed Ativan 1 mg Q HS PRN and Ativan .5 mg bid prn. -Seroquel tablet 100 mg), one tablet by mouth bid for anxiety disorder, dementia with mood disturbance. This was the same dose R78 was admitted on . Review of the Care Plan dated 09/03/24 in the EMR under the Care Plan tab revealed a focus area of Psych Meds, the resident receives psychotropic medication as ordered. The goal was The resident will be free of adverse reactions r/t [related to] psychotropic medication use through the review date. The specific medications being administered (antianxiety, antipsychotic and antidepressant) were not identified. The interventions included in pertinent part: -Evaluate quarterly and prn for possible dose reductions or discontinuation of psychotropic medication and consult with the MD [Medical Doctor] prn . -Observe for any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS Extrapyramidal Symptoms)(shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person, etc. -Observe moods and behaviors q shift -Pharmacist to review medications monthly and prn making suggestions to the MD as indicated. The Care Plan did not identify which side effects were associated with which medications. Review of the Behavior Monitoring and Interventions Report from 05/01/24 to 10/29/24, completed by the certified nurse aides (CNAs) revealed there were 47 possible behaviors listed from which the CNAs could document the behavior (or a lack of any behaviors) that occurred and 13 interventions with outcome that could be documented. Documentation indicated R78 exhibited no behaviors over the course of this five-month period. There were no specific behaviors identified for use of Seroquel. Review of the Psychiatric Nurse Practitioner's Progress Note dated 06/25/24 and the one dated 09/04/24 in the EMR under the Documents tab revealed the NP completed a behavior health evaluation and follow up on these dates. R78's affect/mood was, appropriate, anxious. R78's attitude was cooperative. R78 experienced no delusions or hallucinations and had mildly impaired cognitive function. Diagnoses included anxiety disorder, panic disorder, and dementia with mood disorder. Treatment for anxiety disorder was to continue administration of Quetiapine at 100 mg daily. The Progress Note dated 09/04/24 addressing panic disorder documented an increase of lorazepam to 1 mg, tid due to symptoms being inadequately controlled. The EMR (Medication and Treatment Administration Records, progress notes etc.) were reviewed to determine if monitoring for side effects/adverse reactions was documented. There was no documentation of ongoing monitoring for adverse reactions. There was no evaluation for tardive dyskinesia (movement disorder that can be caused by antipsychotic medication use) considering R78's antipsychotic medication use. Review of the quarterly Psychotropic Drug Monitoring Form dated 08/30/24 in the EMR under the Assessment tab revealed R78 received psychotropic medication for behaviors of agitation and irritability. The form did not indicate which specific psychotropic medications or type (antipsychotic, antianxiety, or antidepressant) of medications or the respective doses or changes in doses R78 was administered. There was no qualitative assessment of behaviors related to the psychotropic medication use. Under the heading of Adverse Reactions, a box for None apparent was checked. Under the heading of Evaluation a box for Appears controlled was checked. There was no information related to assessment for a gradual dose reductions. Review of the Pharmacist's Note to Attending Physician/Prescriber dated 07/18/24 and provided by the facility revealed, The resident receives Seroquel 100 mg po (by mouth) BID (05/25/24) for anxiety w [with]/panic disorder and dementia. The FDA [Food and Drug Administration] issued a black box warning for antipsychotics which states: elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death, found that these medications were of limited value for elders with dementia, and as a result many feel that these medications are overprescribed . Would you consider using the lowest dose for the shortest time possible and gradually reducing dose in order to discontinue once symptoms subside (please taper prior to discontinuing)? The provider's response dated 07/29/24 was checking the box that read, Disagree: An attempted dose reduction would likely impair the resident function or cause psychiatric instability. Review of the Pharmacist's Note to Attending Physician/Prescriber dated 10/16/24 and provided by the facility revealed, The resident receives Seroquel 100 mg po BID (05/24/24) for anxiety w/panic disorder and dementia. Would you consider the resident a candidate for a gradual dose reduction for the medication above? The provider's response dated 10/30/24 was checking the following boxes that read, Disagree: An attempted dose reduction would likely impair the resident function or cause psychiatric instability and Disagree: Benefits of medication sue at present dosage outweigh risk for current regimen. During an observation on 10/28/24 at 11:16 AM, R78 was lying in bed with her pajamas on with the TV on. When interviewing her, R78 stated she did not feel well, but had no specific complaints. Additional observations revealed R78 stayed in bed as follows: On 10/28/24 at 4:11 PM, R78 was lying in bed under the covers with the door open with her eyes closed. On 10/29/24 at 4:51 PM, R78 was lying in bed with blanket over her with the TV on. On 10/30/24 at 05:49 PM, R78 was lying in bed under the covers and was awake; her meal was on the overbed table. On 10/31/24 at 9:37 AM, 10/31 AM and 1:48 PM, R78 was lying in bed under the covers with the lights off and door open with her eyes closed. During an interview on 10/30/24 at 2:02 PM, CNA7 stated R78 liked to stay in bed. CNA7 stated R78 was anxious or nervous but did not exhibit any behaviors. During an interview on 10/30/24 at 2:27 PM, MDSC2 stated the MDSC Coordinator completed the quarterly Psychotropic Drug Monitoring Forms. MDSC2 stated she looked at diagnoses for antipsychotic medication use and R78's diagnosis for Seroquel was, not appropriate. MDSC2 verified the specific psychotropic medications, doses, changes in doses, and changes in behaviors, were not documented on the quarterly review form. MDSC2 stated the facility tried not to use antipsychotic medications unless a resident hallucinated or delusions or something similar; however, the physician might order them (antipsychotic medications). MDSC2 stated residents were monitored for adverse reactions to medications when a new medication was started or with a dose increase. MDSC2 stated the staff used a paper form that got uploaded into the EMR. MDSC2 reviewed the EMR looking for the paper form associated with the increase in lorazepam on 09/05/24; however, she verified there was no paper form. During an interview on 10/30/24 03:16 PM, the Social Service Director (SSD) stated R78 was very anxious and was nervous at baseline. The SSD stated R78 did not want to be a bother to anyone. The SSD stated R78 did not exhibit any other behaviors (besides anxiety). During an interview on 10/31/24 at 10:43 AM, Licensed Practical Nurse (LPN) 1 stated she did not know what specific behavior R78 was being administered Seroquel. LPN1 stated she did not know where documentation for monitoring for potential adverse reactions was located. LPN1 stated R78 did not have an approved diagnosis for use of the Seroquel and that there was a Black Box warning for use of Seroquel showing the medication was contraindicated with dementia. During an interview on 10/31/24 at 3:37 PM, the Director of Nursing (DON) stated behavior monitoring was completed each shift by the CNAs under tasks. The DON stated nurses charted physical behaviors in the progress notes. The DON stated there was no specific monitoring or assessment completed for antipsychotic medications for potential symptoms of tardive dyskinesia. The DON verified potential side effects were to be monitored on a paper form for new psychotropic medications and when medications were increased for a period of seven days. The DON stated the quarterly Psychotropic Drug Monitoring Form did not identify which medications or the doses the resident was prescribed. The DON stated R78 did not have an appropriate diagnosis to support administration of Seroquel. The DON stated R78 stayed in her room often but came out occasionally. The DON stated R78 had a history of anxiety and had calmed down since she was admitted to the facility. During an interview on 10/31/24 at 4:32 PM, the Pharmacist stated he made a recommendation related to Seroquel for R78 in July 2024. The Pharmacist stated R78 was prescribed Seroquel 100 mg a day for anxiety disorder and dementia. The Pharmacist stated he made a recommendation to decrease and eventually discontinue the medication due to there being a Black Box warning of increased risk of death and the medication showing limited value for a diagnosis of dementia. The Pharmacist stated he made a second recommendation to do a gradual dose reduction of Seroquel in October 2024. He stated the Physician had declined both recommendations. 2. Review of R131's undated Admission Record in the EMR under the Profile tab revealed R131 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, unspecified mood, and depression. Review of the History & Physical dated 08/23/24 in the EMR under the Documents tab revealed R131 was assessed in a medical center after exhibiting altered mental status at home and was diagnosed with metabolic encephalopathy (brain dysfunction caused by an underlying condition). The only psychotropic medication R131 had been administered at home was Trazadone (antidepressant) 50 mg daily. Under the heading of Metabolic encephalopathy, R131 was documented as, Altered mental status may be secondary to dementia changes. Start the patient on Aricept (dementia medication) and Seroquel (antipsychotic). Continue Trazadone. IV [intravenous] Ativan (antianxiety medication) for agitation. Review of the admission MDS with an ARD of 08/30/24 in the EMR under the MDS tab revealed R131 was severely impaired in cognition with a BIMS: score of four out of 15. He had no mood indicators and under behaviors, R131 exhibited verbal behaviors towards others and other behavioral symptoms not directed at others occurring one to three days during the assessment period and wandering behaviors one to three days during the assessment period. R131 received antipsychotic, antianxiety, and antidepressant medications. Review of Orders tab dated 10/29/24 in the EMR under the Clinical tab revealed current physician orders for psychotropic medications including: Buspirone HCl (antianxiety medication) oral tablet 10 mg, one tablet by mouth three times a day for generalized anxiety disorder started on 09/08/24. Vistaril (hydroxyzine), an antihistamine, oral capsule 25 mg, one capsule by mouth once a day for anxiety started on 9/23/24. Klonopin (antianxiety/benzodiazepine medication) tablet .5 mg, one tablet twice a day for anxiety started on 10/08/24. Risperdal (antipsychotic medication) 0.5 mg tablet twice a day for unspecified dementia, unspecified severity with other behavioral disturbance ordered on 09/25/24. Prior to this date, R131 was prescribed Seroquel from his admission on 08/25/24; it was discontinued on 09/25/24, the same date that Risperdal was initiated. Review of the Care Plan dated 09/04/24 in the EMR under the Care Plan tab revealed a focus area of, The resident receives psychotropic medication as ordered. The specific medications being administered (antianxiety, antipsychotic and antidepressant) were not identified. The goal was, The resident will be free of adverse reactions r/t [related to] psychotropic medication use through the review date. Interventions included in pertinent part: Administer medication as ordered . Evaluate quarterly and prn for possible dose reductions or discontinuation of psychotropic medication and consult with the MD prn . Observe for any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person, etc. The Care Plan did not identify which side effects were associated with which medications. Review of the quarterly Psychotropic Drug Monitoring Form dated 09/03/24 in the EMR under the Assessment tab revealed R131 received psychotropic medication for a behavior of agitation. The form did not indicate which specific psychotropic medications or type (antipsychotic, antianxiety, or antidepressant) of medications or the respective doses or changes in doses R131 was administered. There was no qualitative assessment of behaviors related to the psychotropic medication use. Under the heading of Adverse Reactions, a box for None apparent was checked. Under the heading of Evaluation a box for No change noted was checked. There was no information related to assessment for a gradual dose reductions. Review of the Psychiatric Nurse Practitioner's Progress Note dated 09/04/24 in the EMR under the Documents tab revealed, He is currently being treated with Aricept (donepezil) for dementia, Seroquel (quetiapine) for mood stabilization and sleep, Buspar (buspirone) for anxiety, Trazodone for insomnia, and Vistaril (hydroxyzine) for anxiety. The patient reports that he is doing great since moving into the facility .He has been adjusting well to his new surrounding and expresses no significant issues with anxiety or emotional distress . The staff corroborate that the patient has been adapting well to his new environment and have observed no behavioral concerns or cognitive issues during his stay. Review of the Psychiatric Nurse Practitioner's Progress Note dated 09/25/24 in the EMR under the Documents tab revealed the R131's affect/mood was appropriate, his attitude was cooperative, his insight and judgement were impaired. R131 exhibited no delusions or hallucinations. Treatment for generalized anxiety order included stopping Quetiapine, continuing buspirone, and starting Klonopin .5 mg, one tablet bid as needed. For treatment of dementia, Risperidone .5 mg, one tablet bid was started. The progress note indicated, Over the past few weeks, the patient has been experiencing behavioral disturbance that include increased agitation, irritability, and episodes of screaming and yelling. He has become so distressed that he has started to hit himself during moments of extreme frustration . The patient has become religiously preoccupied, often obsessing about religious themes, and expressing strong beliefs that Halloween decorations are evil . There was no documentation on the form of the Resident's Representative (RR) being contacted about the addition of Risperidone, the new antipsychotic medication, on this date. During an interview on 10/31/24 at 10:13 AM, Registered Nurse (RN)4 reviewed R131's EMR and stated there were no nursing or provider notes showing R13's RR was contacted about the initiation of Risperidone on 09/25/24. RN4 stated when a medication was changed or added the nurses completed paper drug monitoring forms for seven days that were scanned into the EMR. RN4 reviewed R131's EMR and stated she did not see any monitoring forms for the psych medication changes for R131. During an interview on 10/29/24 at 9:01 AM, Family Member (F)131 stated the facility had notified her of some of the psychotropic medications the resident was taking; however, denied the facility had discussed the risks versus benefits of the medications with her. F131 stated she was aware R131 was taking Klonopin; however, was unsure when some of the other psychotropic medications were mentioned. F131 stated R131 was much more active at home and walked around a lot. F131 stated R131 was not walking much anymore. F131 stated, He has more trouble walking, getting up, and feeding himself. Observations revealed R131 was sleeping or staring off at various times of the day during the survey: On 10/29/24 at 4:22 PM, R131 was sitting on the couch in the day room with his eyes open, fixed, and staring off in front of him. On 10/30/24 at 11:03 AM and at 3:25 PM, R131 was lying on the couch in the day room with his eyes closed. On 10/31/24 at 9:39 AM R131 was sitting at the counter in the day room where he ate meals with his head down and eyes closed. During an interview on 10/20/24 at 4:07 PM, CNA8 stated R131 could be agitated in the afternoons. CNA8 stated R131 sat out in the day room during the day and napped or talked with residents. CNA8 stated R131 seemed to be adjusting to being in the facility. CNA8 stated she did not have problems providing care to R131. During an interview on 10/30/24 at 3:00 PM, the SSD stated R131 got agitated at times and started hollering. The SSD stated she did not know much about him, and no one had come to her and reported specific concerns. During an interview on 10/30/24 at 2:32 PM, MDSC2 stated R131 screamed, cried, played in his feces, and stated he wanted to go home, and exhibited sundowning. MDSC2 stated R131 was a preacher, and they tried activities such as gospel music, turning religious channels on TV, and had given him sermon books, but the interventions lasted a short while or did not work. MDSC2 reviewed R131's EMR and stated both the regular NP and psych NP had ordered psychotropic medications for R131 and there had been a lot of medication changes. MDSC2 stated the facility did not have a formal system/tool used for monitoring potential adverse reactions to the psych medications. During an interview on 10/31/24 at 3:52 PM the DON stated she was aware the facility was high in psychotropic medication use. The DON stated the facility had done some gradual dose reductions but most of them were unsuccessful and the residents had to go back onto the medications. The DON verified there was no system/form used for monitoring potential side effects. The DON stated the MDS reviewed psychotropic medications quarterly. The DON verified the quarterly form did not address specific medications, discontinuing medications, adding new medications or changes in the doses. During an interview on 10/31/24 at 4:47 PM, the Pharmacist stated he had requested a gradual dose reduction of R131's Seroquel and this had been completed. The Pharmacist stated he was not aware that the provider discontinued one antipsychotic (Seroquel) and ordered another (Risperdal) on the same day. The Pharmacist stated he reviewed medication regimens for duplicative therapy and verified R131 received three different medications to treat anxiety. The Pharmacist stated he would make a recommendation about this within the first six months after admission, adding the resident was new to the facility.

Based on observation, staff interview, record review and facility policy review, the facility failed to secure medications in a locked medication cart when left unattended on one of four units (300 Hallway). Resident (R)80's insulin was left on top of the medication cart and was left unattended in the hallway where visitors were present. This failure had the potential for an unauthorized person to take this insulin causing harm to themselves or others. Findings included: Review of R80's Electronic Medical Record (EMR) undated Face Sheet located under the Profile tab, indicated R80 was admitted to the facility on [DATE] with diagnosis of type two diabetes mellitus. Review of R80's admission Minimum Data Set (MDS) located in R80's EMR under the MDS tab, with an Assessment Reference Date (ARD) of 07/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 11 of 15 which indicated R80 was moderately cognitively impaired. Review of R80's Physician Orders located in R80's EMR under the Orders tab, revealed orders dated 08/29/24 for Basaglar KwikPen Subcutaneous Solution Pen injector 100 unit/ml (milliliter) Inject 58 units subcutaneously two times a day related to type 2 diabetes mellitus. Observation on 10/30/24 at 5:54 PM on the 300 hallway, Registered Nurse (RN)3 left the medication cart beside the door of room [ROOM NUMBER] and walked around the corner. The medication cart was observed to be left unlocked and R80's Kwikpen insulin syringe was on top of the cart. Two adult visitors and two children were observed to be approximately seven feet diagonally across the hallway at the doorway of room [ROOM NUMBER]. On 10/30/24 at 5:56PM, Licensed Practical Nurse (LPN)1 confirmed the medication cart was unlocked and that R80's KwikPen insulin syringe was on top of the cart. During an interview on 10/30/24 at 6:00 PM, LPN1 stated, The nurse should never leave the medication cart unlocked and walk away. During an interview on 10/30/24 at 6:05 PM, RN3 stated, I walked away and didn't think to lock the cart. When asked if RN3 could visualize the medication cart when she left the, RN3 confirmed that she could not visualize the medication cart. During an interview on 10/30/24 at 6:10 PM, the Director of Nursing (DON) was notified of RN3 leaving the medication cart unlocked and unattended and that R80's KwikPen insulin pen was on top of the cart. The DON confirmed the medication cart was to be locked when left unattended by the nurse. During an interview on 10/30/24 at 6:14 PM, the Administrator confirmed the medication carts are to be locked when left unattended by the nurse. Review of the facility policy titled Medication Storage in the Facility dated June 2024 stated, . Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access .

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure each resident each resident was free from abuse for one (1) of nine (9) sampled residents, (Resident #4). Review of the facility's investigation and interview revealed Resident #4 experienced verbal abuse from an employee of the facility on 03/10/2022. Review revealed Nurse Aide (NA) #15 stated that if Resident #4 hit her one (1) more time the NA would go to jail because she was going to lay hands on the resident. The findings include: Review of the facility's policy titled, Abuse, Neglect and Misappropriation and Exploitation, revised 11/2017, revealed the facility did not condone or tolerate resident abuse under any circumstances by anyone. Continued review of the policy revealed verbal abuse was defined as any oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Further review revealed mental abuse was defined as including humiliation, harassment, threats of punishment or deprivation. Review of Resident #4's medical record revealed the facility admitted the resident on 03/25/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #4 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not cognitively intact and had been unable to complete the interview. Further review revealed the facility assessed Resident #4 to have no behavioral symptoms, as incontinent of bowel and bladder, and as totally dependent on staff for all his/her care needs. Review of the facility's self- reported Initial Report, incident form dated 03/10/2022, completed by DON revealed an allegation of physical abuse had been reported. Continued review revealed during Resident #4's am (morning) bath the resident tried to hit and pinch NA #14 and NA #15 (who had been working the 7:00 PM to 7:00 AM shift). Further review revealed NA #15 slapped at Resident #4's hands, with NA #14 unable to determine if NA #15 made contact with the resident. Review of the facility's Investigation Summary documentation, noted as completed on 03/10/2022 and signed by the Administrator on 03/15/2022, revealed the facility initiated the investigation as soon as report of the incident was made. Per review, NA #14 had reported the incident to Licensed Practical Nurse (LPN) #6 near the end of their shift. Continued review of the facility's Investigation Summary revealed Resident #4 had severe cognitive impairments, and therefore, the nurse completed a head-to-toe assessment of Resident #4 with no injuries or issues observed or noted. Review revealed the staff present when NA #15 came out of Resident #4's room reported NA #15 stated if he/she puts his/her hands on me again, I'm going to put my hands back on him/her and go to jail. Review revealed staff also reported NA #15 appeared agitated; however, left left the floor and clocked out. Review of NA #14's written statement revealed it corroborated what she reported to LPN #6 on 03/10/2022. In addition, review revealed alert and oriented residents were interviewed with no reports of abusive actions from NA #15 noted. Review further revealed noninterviewable residents had head to toe skin assessments completed by nurses with no unidentified injuries noted. Additional review revealed the DON spoke with NA trainee #15 on the phone with NA #15 denying all allegations. Per review of the Investigation Summary, the facility terminated NA #15's employment via a telephone (phone) call on 03/10/2022 and was not allowed entrance back into facility. Review further revealed no documented evidence the facility substantiated abuse against NA #15. Review of the facility's personnel file for NA #15's revealed a date of hire of 02/10/2022. Per review, NA #15 received abuse training on 02/10/2022, during the employee's orientation. Continued review revealed the facility validated NA #15 was not listed on the State's Abuse Registry or the Adult Care Giver Misconduct Registry on 02/08/2022. Telephonic interview was attempted with NA #15 times three (3) on 05/30/2022 at 10:15 AM, 06/02/2022 at 6:55 PM, and 06/03/2022 at 5:00 PM; however all attempts were unsuccessful. Telephonic interview was attempted with NA #14 times three (3) attempts on 05/30/2022 at 10:00 AM, 06/02/2022 at 1:04 PM, and, 06/03/2022 at 5:25 PM; however, all attempts were unsuccessful. Interview with State Registered Nurse Aide (SRNA) #5 on 06/02/2022 at 4:50 PM, revealed she had been coming on shift the morning of 03/10/2022, when NA #15 was in hallway just outside of Resident #4's room. Per interview, SRNA #5 overheard NA #15 state, I have had my butt whipped, and the next time Resident #4 puts hands on me I am going to put my hands back on him/her. Continued interview revealed she told NA #15 she could not do that to the resident, and would go to jail if she did so. SRNA revealed NA #15 then left the facility, and SRNA #5 went with NA #14 immediately to LPN #6 to report the incident. SRNA #5 revealed NA #14 was no longer an employee of the facility either. Further interview revealed SRNA #5 reported checking on Resident #4 and had noted no issues. Interview with LPN #6 on 06/02/2022 at 3:30 PM, revealed in the early morning of the day of the incident, LPN #5 and NA #14 came into her office and reported while NA #14 had been assisting NA #15 in providing Resident #4's bath, NA #15 had swatted at the resident's hands as he/she had been trying to hit and grab at both NA's. NA#14 revealed she did not actually see or hear NA #15 make physical contact with Resident #4. LPN #6 stated she was also informed that NA#15 had stated I have already had my butt whipped and if he/she (Resident #4) did that again I will lay hands on him/her. Further interview revealed LPN #6 immediately went to the floor to remove NA #15 from her duties; however, the NA had already left the building. Interview with the DON on 06/02/2022 at 2:30 PM, revealed she initiated the facility's investigation immediately after it was reported to her. Per the DON, head to toe assessments were performed of all residents NA #15 had provided care for during her shift with no issues noted. Further interview revealed the DON had contacted NA #15 by phone during the investigation and the NA denied all allegations. Further interview revealed the DON was involved in the facility's education/inservices regarding abuse training and reporting. The DON further revealed her oversight of the education was completed by performing walking rounds, and speaking with residents. Interview with the Administrator on 06/03/2022 at 5:32 PM, revealed she completed the facility's investigative summary after the investigation was completed. Per interview, the Administrator and DON shared the role of the facility's Abuse Coordinator. Continued interview revealed as a result of the facility's investigation, NA #15 was terminated via phone contact, and no actual physical abuse was substantiated. The Administrator further revealed oversight for abuse was provided by speaking with the residents, and through walking rounds completed by administrative staff. In addition, she stated discussion of abuse related concerns was completed in the facility's Interdisciplinary meetings.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to provide appropriate interventions for residents with a diagnosed mental health disorder, to attain their highest practicable psychosocial wellbeing for one (1) of nine (9) sampled residents, Resident #2. Resident #2 had a traumatic history of having been raped when he/she was young, and had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #2's mental health well-being. The findings include: Review of the facility's Care Plan Policy and Protocol revised 09/2017, revealed the facility was to develop a comprehensive care plan for each resident which included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the facility's comprehensive assessment. Continued review revealed each resident's care plan should be periodically reviewed and revised by the facility's Interdisciplinary Team (IDT) after each resident's assessment and on an as needed basis. Review of the facility's Social Worker (SW) job description revealed the SW was responsible for assessment of the facility's residents' psycho-social problems and needs. Continued review revealed the SW was also responsible for the supervision and implementation of the facility's Residents Bill of Rights. Review of the facility's investigation report dated 04/05/2022, revealed the Nursing Secretary had been in her office when she observed Resident #1 roll his/her wheelchair towards Resident #2 with his/her lips puckered in a kissing manner and asked Resident #2, Do you want some of this?. Per review, Resident #2 stated No, I don't. Further review revealed the residents were separated and taken to their rooms. In addition, review further revealed Resident #1's Physician was contacted for a medication review, and the resident was scheduled to see the Psychiatric (Psych) Nurse Practitioner. Review of Resident #2's medical record revealed the facility admitted the resident on 01/23/2014, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed no documentation related to any reported incidents between Resident #2 and Resident #1, such as on 04/05/2022. Further review revealed no documented evidence of the facility's Social Worker to note any follow-up with Resident #2 after the 04/05/2022 incident. Review of Resident #2's Significant Change Minimum Data Set (MDS) Assessment, dated 04/13/2022 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated moderate cognitive impairment. Review of Resident #2's comprehensive care plan revealed a focus initiated on 03/19/2022, which noted the potential for altered moods and behaviors with a goal for Resident #2 to have stable moods and behaviors. Further review revealed however, no documented evidence the facility had updated or made any modifications to Resident #2's care plan following the 04/05/2022 incident. Observation and interview with Resident #2 on 06/02/2022 at 4:10 PM, revealed the resident sitting up on the side of his/her bed. Interview revealed Resident #2 was aware of his/her surroundings. Resident #2 revealed the resident was very uncomfortable around Resident #1 due to his/her unwanted verbal interaction and physical touching. Resident #2 stated on multiple occasions, Resident #1, said things to him/her like, Do you still love me doll?, and touched his/her clothing or tapped him/her on the arm, which startled Resident #2. Continued interview revealed Resident #1 had never hurt Resident #2 physically; however had his/her feelings. Per interview, Resident #1 had came into Resident #2's room one (1) time wanting to talk, but Resident #2 had not wanted to talk to the resident, and told Resident #1 that and he/she left the room. Resident #2 further revealed he/she had been raped by a family member when he/she was younger, and that was why Resident #1 made him/her uncomfortable Interview with the Nursing Secretary on 06/03/2022 at 11:55 AM, revealed on 04/05/2022, the day of the incident involving Resident #1 and Resident #2, she observed Resident #1 asking Resident #2 if he/she wanted a kiss and Resident #2 had replied No, I don't. Per interview, the Nursing Secretary went out of her office and saw Resident #1 had been talking to Resident #2. The Nursing Secretary stated she kept the residents separated and had the SW come out of her office which was across the hall to assist her. Further interview revealed the SW took Resident #1 back to his/her room and the Nursing Secretary took Resident #2 back to her/his room. The Nursing Secretary further revealed the incident had been immediately reported to the Administrator. Interview with the SW on 06/03/2022 at 1:20 PM, revealed on the morning of 04/05/2022, the day of the incident involving Resident #2 and Resident #1, she had been in her office and overheard a co-worker telling Resident #1 that he/she could not talk to another resident like that. Per interview, Resident #1 and Resident #2 were separated and sent back to their rooms away from each other. The SW stated she assisted Resident #1 back to his/her room and spoke with the resident about not talking with other residents in the manner he/she had just done. Further interview revealed Resident #1 was care planned for staff to provide redirection tactics. However, the SW reported not being sure as to when Resident #1 had been moved following that incident. Continued interview revealed the SW also spoke with Resident #2 on 04/05/2022, following the incident. Per the SW, during her interview with Resident #2 she had noted no issues and Resident #2 stated he/she was not afraid of Resident #1. Interview revealed therefore, the SW had felt there was nothing that needed to be added or changed on Resident #2's care plan. The SW revealed she was constantly going through the building and speaking with residents about how they were doing, which included Resident #2. She stated however, she could not possibly document every conversation she had with all the residents she talked to. Further interview revealed the SW was aware of Resident #2's extensive traumatic history, but as she frequently spoke with Resident #2 she knew the resident was not afraid of Resident #1. The SW further revealed Resident #2 told her That's just how Resident #1 was, and the SW stated she had not noted any psychosocial harm in Resident #2 when she spoke with him/her after the incident. Interview with the Director of Nursing (DON) on 06/02/2022 at 2:30 PM, revealed she was made aware of any incidents with residents and completed or assisted in completion of the facility's investigations. She stated when she was made aware of the incidents involving Resident #1 and Resident #3, and had Resident #1 moved to a different wing of the facility, and Resident #1 also currently resided on a different wing away from Resident #2. The DON stated oversight of any abuse in the facility was provided through walking rounds and resident visits. Further interview revealed she personally had told residents to contact her with any concerns they might have, and she stated she provided abuse education to staff constantly. The DON further revealed any information regarding incidents involving residents was discussed in the facility's morning IDT meetings. Interview with the Administrator on 06/03/3033 at 5:32 PM, revealed she lead the facility's morning Interdisciplinary Team ( IDT) meetings and incidents involving residents were discussed in those meetings. The Administrator revealed she expected staff to ensure documentation in each resident's chart regarding follow up for any incidents related to possible abuse/harm of the resident. Continued interview revealed the Administrator's expectations included staff updating residents' care plans to reflect any changes necessary after an incident, and with any additional interventions put in place. The Administrator further revealed she expected residents' Kardexes to be updated/revised to reflect keeping residents separated who might have a conflict with one another. Per interview, the facility's Quality Assurance (QA) audits were performed quarterly and more frequently as needed as oversight of the facility's processes. Interview revealed Resident #1 had been moved to a room on another hall in the facility; however, Resident #1 and Resident #2 were both mobile and able to move about the facility when up in their wheelchairs. The Administrator stated Resident #1 had been moved from his/her previous unit on 03/27/2022. Further interview revealed staff were monitoring and providing oversight of the residents when they were in group activities such as church, and/or games.

Based on observation, interview, record review, and review of the facility's care plan policy, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a Comprehensive Care Plan for altered moods and behaviors with a history of physical and verbal aggression toward staff. In addition, Resident #1 had interventions for staff to provide diversional activities as needed. Further review of the care plan revealed the resident had altered communication with interventions for staff to allow Resident #1 adequate time to respond to requests and to not rush Resident #1 to ensure understanding. On 10/20/17 at approximately 11:00 PM, while Resident #1 was agitated and refusing medication, LPN #2 forcefully opened Resident #1's mouth to administer medication, took away the resident's baby doll, and stated to Resident #1, You are not getting this back for two weeks. In addition, LPN #2 stated to Resident #1, I'm not going to put up with this. In addition, there was no evidence the staff provided Resident #1 with diversional activities when he/she became agitated as directed per the comprehensive care plan and no evidence that the resident was allowed the opportunity to communicate his/her wants as directed by the care plan. The facility's failure to ensure that staff provided care in accordance with the plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/09/17 and determined to exist on 10/20/17 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223 - J, F225 - J, and F226 - J) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282 - J). Substandard Quality of Care was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 11/09/17. An acceptable Allegation of Compliance was received on 11/17/17, which alleged removal of the Immediate Jeopardy on 11/17/17. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/17/17, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Care Plan Policy and Protocol, revised November 2016, revealed the Kardex would be utilized as a guide for Nurse Aides to provide resident care on a daily basis. In addition, the policy stated the care plan would reflect person-centered care preferences. Record review revealed the facility admitted Resident #1 on 09/06/17 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #1 to have severe cognitive impairment with a Brief Interview for Mental Status score of 99 indicating Resident #1 was not interviewable. Review of a Comprehensive Care Plan dated 09/15/17 revealed the facility assessed Resident #1 to have alterations in mood and behaviors and a history of physical and verbal aggression. Additional review of the Comprehensive Care Plan revealed Resident #1 had an intervention for staff to provide diversional activities as needed. Further review of the Comprehensive Care Plan revealed the facility assessed Resident #1 to have alterations in cognition/decision-making/communication related to the [DIAGNOSES REDACTED]. Additional review of the Comprehensive Care Plan revealed Resident #1 had interventions for staff to allow Resident #1 adequate time to respond to requests, to not rush the resident, and to request clarification from the resident to ensure understanding. Review of a facility Investigative Summary, dated 10/20/17, revealed while Resident #1 was agitated and refusing medication, LPN #2 attempted to get Resident #1 to take his/her medications. Further review revealed LPN #2 spoke to Resident #1 in a loud voice, put her hands on Resident #1's jaw, and put the prepared medications in Resident #1's mouth. Further review revealed Resident #1 spat the medication out, was agitated and aggressive, and was striking out at the staff. In addition, Resident #1 had a doll and was swinging the doll at staff. Further review of the investigation revealed LPN #2 removed the doll from Resident #1. Review of Resident #1's medical record revealed no documented evidence that the staff provided care to Resident #1 as directed per his/her comprehensive care plan. The facility also failed to provide the diversional activities when Resident #1 was agitated. In addition, there was no evidence the staff allowed Resident #1 adequate time to respond to the request to take his/her medications. Interview with SRNA #1 on 11/08/17 at 3:36 PM and on 11/20/17 at 3:05 PM, revealed on 10/20/17 at approximately 11:00 PM, he observed LPN #1 attempting to administer medications to Resident #1. SRNA #1 stated Resident #1 was agitated and was refusing to take the medications. Further interview revealed SRNA #1 stated LPN #2 intervened and took the medication from LPN #1. SRNA #1 stated LPN #2 approached Resident #1 with the medication and Resident #1 stated, I don't want to take my medication. SRNA #1 stated LPN #2 placed her left hand around Resident #1's jaws, forced Resident #1's mouth open, and put the medication in Resident #1's mouth. Additional interview with SRNA #1 revealed he called the on-call administrative staff member, the Staff Development Coordinator, LPN #3, and reported the abuse. Additional interview with SRNA #1 revealed he had been trained by the facility regarding abuse and had been instructed that if he observed abuse occurring he was supposed to get the victim away from the abuser and make sure they did not abuse anybody else. SRNA #1 stated, I should have intervened immediately and removed the resident from the abusive situation. In addition, SRNA #1 stated, I guess I was in shock, I just couldn't believe what I was seeing. Continued interview with SRNA #1 revealed each resident has a Kardex at the nurses' station. Interview with LPN #1 on 11/08/17 at 4:35 PM revealed on 10/20/17 at approximately 11:00 PM, she was attempting to get Resident #1 to take his/her medications. Further interview revealed LPN #2 took the medications from her hand, approached Resident #1, and stated to the resident, You can't live here if you don't take your medications. Further interview with LPN #1 revealed she observed LPN #2 grab Resident #1 around his/her jaw, force his/her mouth open, and put the medications in the resident's mouth. LPN #1 stated Resident #1 spat the medication out. In addition, LPN #1 stated LPN #2 shook her finger at Resident #1 and stated, I'm not going to put up with this. LPN #1 stated LPN #2 was obviously angry at Resident #1. Additional interview with LPN #1 stated she did not intervene. LPN #1 stated she was afraid to physically get involved because Resident #1 was being aggressive, and she was afraid someone would get hurt. LPN #1 stated LPN #2 attempted to administer the medications to Resident #1 at least twice. She stated that at some point during the incident LPN #2 took Resident #1's baby doll and said to the resident, You are not getting this back for two weeks. Further interviews were attempted with LPN #1, but the LPN did not comment regarding following the resident's care plan. Interview with the Director of Nursing (DON) on 11/09/17 at 10:12 AM and on 11/20/17 at 2:25 PM, revealed she was on vacation at the time of the incident. Continued interview with the DON revealed all staff were expected to follow each resident's care plan. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1) Resident #1 was assessed by the Nurse Coordinator on 10/21/17 with no injuries noted. The resident's physician and representative were notified of the incident on 10/21/17. 2) Licensed Practical Nurse (LPN) #2 was terminated from employment at the facility. 3) Staff who witnessed the alleged abuse were counseled by the Director of Nursing (DON) regarding prompt intervention during incidents to protect residents. 4) All staff were interviewed on 11/09/17, by the DON, the Clinical Coordinators, the Staff Development Coordinator (SDC), and the Minimum Data Set (MDS) Coordinators to determine if other incidents had occurred that required notification to appropriate state agencies. 5) On 11/09/17 and 11/10/17, all interviewable residents were interviewed by the Clinical Coordinators, the SDC, and the Social Worker to determine if they had any concerns with abuse or if any incidents of abuse had occurred. Notification was made to appropriate state agencies if indicated. 6) On 11/09/17 and 11/10/17, residents that were not interviewable had skin assessments completed to insure any suspicious injuries were assessed. Nursing staff that work with the residents were interviewed and the residents' medical records, including skin assessments, Social Services Notes and Nurses' Notes were reviewed for any signs of unreported injuries or changes in mood/behaviors. 7) A Department Head meeting was conducted on 11/10/17 to review the information detailed in the Immediate Jeopardy notification and develop a plan for abatement of the Immediate Jeopardy. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, and the SDC. 8) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, and the Corporate Consultant began observation of residents that had been assessed to exhibit behaviors to ensure appropriate individualized interventions were in place and being implemented as directed by the resident's plan of care. 9) The Administrator met with the Medical Director on 11/11/17, and informed the Medical Director of the Immediate Jeopardy. 10) On 11/10/17, the Corporate Consultant began reviewing all allegations of abuse and neglect from 10/20/17 till the present to ensure policy and procedures were being followed, including immediate staff intervention when indicated, immediate removal of an alleged perpetrator from the facility pending investigation, and a thorough completion of the investigation with necessary corrective action being taken as indicated. 11) On 11/09/17, the Administrator, the DON, and the SDC were educated by the Corporate Consultant related to conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that have had care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. 12) On 11/10/17, the Abuse Policy & Procedure was revised by the Administrator and Corporate Consultant to include immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Staff training was then provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. 13) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. A post test is required to be taken by each staff member after the education to ensure understanding and retention of the education. The training will continue until all employees have been educated prior to their next scheduled shift. Staff will not be permitted to work until they have received the education. A master list of all employees is being reviewed and maintained by the business office staff with reports given to the Administrator and DON to ensure all staff can be contacted and educated prior to their next scheduled shift. The post test will continue to be administered to ten (10) staff members from random units and shifts on a daily basis for two weeks, and then 10 staff members weekly for one month. The post tests will be administered by the DON, the Clinical Coordinators, the SDC, and the Corporate Consultant. The Administrator or the DON will report the results of the post testing to the Quality Assurance Committee. 14) On 11/14/17, education was initiated with all nurses and nurse aides related to providing care to residents with challenging behaviors and the development and utilization of interventions to address the challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. The education will continue until all licensed and unlicensed nursing staff have been trained. The business office staff are maintaining a list of all employees that have completed the training to ensure all staff are trained prior to providing resident care. The Clinical Coordinators will continue to conduct resident observations and care plan reviews for eight residents, two from each unit daily for one week and then eight per week for one month to ensure appropriate interventions are being utilized for residents that are exhibiting behaviors. These observations will include all shifts at random. Results will be provided by the Clinical Coordinators to the Administrator and the DON, who will review the findings and address any concerns promptly with the involved staff. The DON will report the results of the observations to the Quality Assurance Committee which will determine the need for further education/follow-up. 15) A Department Head meeting was conducted on 11/10/17 to review the Immediate Jeopardy. On 11/11/17, the Medical Director was notified of the plan for abatement of the Immediate Jeopardy. 16) Corporate Consultant staff will review abuse allegations to ensure the revised Abuse Policy & Procedure is being followed. The review will consist of ensuring the alleged perpetrator was removed from the facility immediately, any witnesses to the alleged abuse acted promptly to ensure resident safety, the investigation was thorough and a conclusion was determined, and that appropriate corrective action had been taken. The Administrator or DON will report the findings to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) A Quality Assurance meeting was conducted on 11/16/17 to review the status of staff education, monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, the SDC, consultant staff, and the Medical Director. 18) Quality assurance meetings will be held at least weekly until substantial compliance is achieved, and then monthly for one quarter. **The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of the medical record for Resident #1 revealed the resident was assessed for signs and symptoms of abuse on 10/21/17. The physician and resident representative were notified of the incident. 2) Review of the personnel file for LPN #2 revealed the employee was terminated from the facility on 11/10/17. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed LPN #2 was terminated on 11/10/17. 3) Review of counseling forms dated 11/13/17 and 11/14/17 revealed all employees who were involved in the incident were counseled by the DON. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed all employees involved in the incident were counseled. Interviews with SRNA #1 on 11/20/17 at 3:05 PM, and SRNA #3 on 11/21/17 at 9:10 AM, revealed they were counseled regarding the incident by the DON. 4) Review of staff interviews dated 11/09/17 revealed the DON, the Clinical Coordinators, the SDC, or the MDS Coordinator interviewed all staff to determine if any other incidents of abuse had occurred that had not been identified and to ensure that required notification had been made to state agencies. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been interviewed and were not aware of any incidents of abuse that had not been reported. 5) Review of a resident census revealed all interviewable residents were interviewed related to any concerns with abuse on 11/09/17 and 11/10/17. Interviews conducted on 11/20/17 at 1:30 PM with Resident #10, at 1:00 PM with Resident #11, and at 12:55 PM with Resident #12, revealed the residents had no concerns with abuse or mistreatment by facility staff. 6) Review of the facility census dated 11/09/17 and 11/10/17 revealed non-interviewable residents had skin assessments completed, and their clinical records were reviewed to identify any incidents of abuse that had not been identified. Interviews on 11/21/17 with the Clinical Coordinator at 9:55 AM and the MDS Coordinator at 10:10 AM reveled all non-interviewable residents had skin assessments completed and their records were reviewed for any concerns related to abuse. 7) Review of an attendance roster revealed a Department Head meeting was conducted on 11/09/17 to review the Immediate Jeopardy and a plan was developed to abate the Immediate Jeopardy. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they met on 11/09/17 to develop a plan for the abatement of Immediate Jeopardy. 8) Review of resident observation documentation dated 11/10/17 through 11/20/17 revealed observations had been conducted daily on eight residents assessed to exhibit behaviors, to ensure appropriate individualized interventions were in place and being implemented as indicated. Interviews with the Corporate Consultant, the Administrator, the DON, and the Clinical Coordinators on 11/21/17 from 9:55 AM to 2:20 PM revealed they had completed daily observations of at least eight residents with behaviors to ensure the residents' care plans were being implemented appropriately. 9) Review of Quality Assurance meeting minutes dated 11/11/17 revealed the Immediate Jeopardy and abatement plan were discussed with the Medical Director. Interview with the Administrator on 11/21/17 at 1:50 PM revealed she had met with the Medical Director on 11/11/17 and discussed the Immediate Jeopardy and abatement plan. 10) Review of facility investigations from 11/05/17 through 11/14/17 revealed the Corporate Consultant had reviewed the investigations. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed she had reviewed all incidents to ensure the facility's abuse policy and procedures had been followed. 11) Review of education dated 11/09/17 revealed the Corporate Consultant had trained the Administrator, the DON, and the SDC on conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that had received care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. Interviews on 11/21/17 from 12:55 PM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, and the SDC revealed they had received the education by the Corporate Consultant on 11/09/17. 12) Review of the facility's abuse policy and procedure revealed it was revised on 11/10/17 and included immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Review of staff education dated 11/10/17 revealed training was provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, the SDC, and the Housekeeping Supervisor revealed they had all received the training on the facility's abuse policy and procedure. 13) Review of education sign-in sheets dated 11/10/17 revealed the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. Review of post tests revealed they had been completed by all staff who had received the education. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been educated on the facility's abuse policy/procedure and had completed a post test. 14) Review of facility education dated 11/14/17 revealed nurses and nurse aides were trained related to providing care to residents with challenging behaviors and implementing interventions to address challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. Interviews conducted with nurses and SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been trained on providing care to residents with challenging behaviors and ensuring the residents' care plans were being followed. 15) Review of Department Head meeting minutes dated 11/10/17 revealed a meeting was held to review the Immediate Jeopardy. Review of meeting minutes revealed the Medical Director was notified of the plan for abatement of the Immediate Jeopardy on 11/11/17. 16) Review of abuse allegations revealed the Corporate Consultant had reviewed all abuse allegations to ensure the revised Abuse Policy & Procedure had been followed. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed they had completed the reviews of abuse allegations to ensure the facility's abuse policy and procedures had been followed. Interview with the Administrator and DON on 11/21/17 at 1:40 PM and 1:50 PM, revealed they would report the findings of the abuse allegation reviews to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) Review of Quality Assurance meeting minutes dated 11/16/17 revealed that the education provided to facility staff, the monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal had been discussed in the meeting. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they had all attended the Quality Assurance meeting conducted on 11/16/17. 18) Interview with the Administrator and the DON on 11/21/17 at 1:40 PM and 1:50 PM revealed the Quality Assurance meetings will be held weekly until substantial compliance is achieved, and then monthly for one quarter.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure written policies and procedures were established to ensure the protection of residents and failed to ensure staff were trained regarding dementia management related to abuse for one (1) of three (3) sampled residents (Resident #1). On 10/20/17 at approximately 11:00 PM Resident #1 was agitated and refusing his/her medication. Licensed Practical Nurse (LPN) #2 forcefully opened Resident #1's mouth to administer the medication. She took the resident's baby doll and stated to Resident #1, You are not getting this back for two weeks. In addition, LPN #2 stated to Resident #1, I'm not going to put up with this. The altercation was witnessed by other staff members. One of the witnesses, State Registered Nurse Aide (SRNA) #1, contacted an on-call administrative staff member and reported the abuse. The administrative staff member called the facility and spoke with LPN #2 and directed her to leave the facility. However, the facility failed to ensure that the alleged perpetrator left the facility and that residents were protected from further potential abuse. Subsequently, LPN #2 continued to provide care for residents for approximately three hours and twenty minutes after the allegation of abuse. Furthermore, review of the employee file for LPN #2 revealed no evidence that LPN #2 received dementia management training for resident abuse prevention. The facility's failure to ensure written policies and procedures were established to ensure the protection of residents and failure to ensure staff were trained regarding dementia management related to abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/09/17 and determined to exist on 10/20/17 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223 - J, F225 - J, and F226 - J) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282 - J). Substandard Quality of Care was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 11/09/17. An acceptable Allegation of Compliance was received on 11/17/17, which alleged removal of the Immediate Jeopardy on 11/17/17. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/17/17, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Abuse Policy, last revised November 2016, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Further review of the policy revealed employees accused of resident abuse would be removed from work. However, the policy did not address how the facility would ensure residents were protected from further potential abuse by ensuring that the accused employee left the facility and had no further contact with residents. Review of a facility Investigative Summary, dated 10/20/17, revealed Resident #1 was agitated and refusing medication. LPN #2 attempted to get Resident #1 to take his/her medications. Further review revealed LPN #2 spoke to Resident #1 in a loud voice, put her hands on Resident #1's jaw, and put the prepared medications in Resident #1's mouth. Further review revealed Resident #1 spat the medication out and was agitated and aggressive, striking out at the staff. In addition, Resident #1 had a doll, swinging the doll at staff. Continued review of the investigation revealed LPN #2 removed the doll from Resident #1. The Summary further revealed the incident was reported by SRNA #1 to LPN #3 on 10/20/17. Interview with SRNA #1 on 11/08/17 at 3:36 PM revealed on 10/20/17 at approximately 11:00 PM, he observed LPN #1 attempting to administer medications to Resident #1. SRNA #1 stated Resident #1 was agitated and refusing to take his/her medications. Further interview revealed SRNA #1 stated LPN #2 intervened and took the medication from LPN #1. The SRNA stated LPN #2 approached Resident #1 with the medication and Resident #1 stated, I don't want to take my medication. SRNA #1 stated LPN #2 placed her left hand around Resident #1's jaws, forced Resident #1's mouth open, and put the medication in the resident's mouth. Additional interview with SRNA #1 revealed he called the on-call administrative staff member, who was the Staff Development Coordinator, LPN #3, and reported the abuse. Continued interview with SRNA #1 revealed after he called the on-call administrative staff member he left to go home. Interview with LPN #1 on 11/08/17 at 4:35 PM revealed on 10/20/17 at approximately 11:00 PM, she was attempting to get Resident #1 to take his/her medications. She stated LPN #2 took the medications from her hand, approached Resident #1, and stated to the resident, You can't live here if you don't take your medications. LPN #1 stated she observed LPN #2 grab Resident #1 around his/her jaw, force the resident's mouth open, and put the medications in his/her mouth. LPN #1 stated Resident #1 spat the medication out. In addition, LPN #1 stated LPN #2 shook her finger at Resident #1 and stated, I'm not going to put up with this. LPN #1 stated LPN #2 was obviously angry at Resident #1. However, LPN #1 stated she did not intervene. She stated LPN #2 attempted to administer the medications to Resident #1 at least twice. Further interview with LPN #1 revealed at some point during the incident LPN #2 took Resident #1's baby doll and said to the resident, You are not getting this back for two weeks. Continued interview with LPN #1 revealed she was not aware that LPN #3 had instructed LPN #2 to leave the building. Additional interview with LPN #1 revealed she did not tell LPN #2 to leave the building. LPN #1 stated, I didn't think it was my place to tell someone to go home. Interview with LPN #2 on 11/09/17 at 1:18 PM revealed on 10/20/17 at approximately 11:00 PM, she observed LPN #1 attempting to administer medications to Resident #1. She stated Resident #1 was agitated and refusing the medication. LPN #2 stated, I know (Resident #1) can be mean. LPN #2 stated she was afraid that if Resident #1 did not get his/her medications, we would be in for a long night. LPN #2 stated Resident #1 had slapped some of the SRNAs with his/her baby doll and had slung his/her vanilla shake at her which had gone all over her shirt. Further interview with LPN #2 revealed Resident #1 was flinging his/her arms around and LPN #2 told SRNA #3 to hold his/her hands down. LPN #2 stated while SRNA #3 was holding Resident #1's hands she grabbed his/her jaw and put the medication in the resident's mouth. Additional interview with LPN #2 revealed Resident #1 spat the medication out. LPN #2 stated she raised her voice and stated to Resident #1, Stop doing that! Ongoing interview with LPN #2 revealed the on-call administrative staff member, LPN #3, called the nurses' station and spoke with her on the phone. LPN #2 stated she was told by LPN #3 to get her meds passed, count her narcotic medications, and when she got finished with that she could go home. In addition, LPN #2 stated that LPN #3 told her she could go to the other units in the facility and see if she could get one of the other nurses to help her get medications passed. Continued interview with LPN #2 revealed after she spoke with LPN #3 she continued passing medications, and conducted a dressing change for a resident. LPN #2 stated she was in the facility approximately three to four hours and continued to provide care to residents after she spoke with LPN #3. Review of a facility Time Card Report revealed LPN #2 began her shift on 10/20/17 at 7:14 PM. Additional review of the Time Card Report revealed LPN #2 remained in the facility and did not end her shift until 2:21 AM on 10/21/17. Review of the personnel record of LPN #2 revealed she began work at the facility on 08/07/17. Further review of the personnel record revealed LPN #2 had been trained on the facility abuse policy on 08/07/17. There was no evidence in the personnel record that LPN #2 had received training on caring for residents with dementia. Interview with the Staff Development Coordinator (SDC), LPN #3, on 11/08/17 at 3:00 PM and 7:36 PM, on 11/09/17 at 10:12 AM, and 11/20/17 at 2:50 PM, revealed she was the on-call administrative staff on 10/20/17. LPN #3 stated SRNA #1 notified her at approximately 11:00 PM of an allegation of abuse by LPN #2 toward Resident #1. LPN #3 stated after speaking with SRNA #1, she phoned the facility and spoke with LPN #2. Continued interview with LPN #3 revealed she instructed LPN #2 to count her narcotic medication and leave the facility. LPN #3 stated she came into the facility at approximately 1:00-1:30 AM and noted that LPN #2 was still in the facility. LPN #3 stated when she arrived at the facility, she immediately removed LPN #2 from duty, but prior to the incident on 10/20/17, the facility did not have a system in place to ensure residents were protected and alleged perpetrators removed from duty. Further interview with LPN #3 revealed that all staff received annual Dementia Management training and the last training was in December 2016, prior to the employment of LPN #2. Therefore LPN #2 had not received Dementia Management training. Interview with the Director of Nursing (DON) on 11/09/17 at 10:12 AM revealed she was on vacation at the time of the incident. Further interview with the DON revealed she expected the staff to have intervened and ensured the residents were protected from further potential abuse by ensuring LPN #2 had left the facility and had no further contact with residents. Interview with the Administrator on 11/08/17 at 8:20 PM revealed she became aware that LPN #2 remained in the building after the allegation of abuse the morning after the abuse had occurred. The Administrator stated that the facility was calling people and trying to get somebody to come in to work. She stated, What were we supposed to do, pull somebody out of thin air? The Administrator stated that prior to this incident, the policy did not address the steps the on-call administrative staff were to take to ensure residents were protected and that staff accused of abuse were removed from direct care. She stated she was not aware that all staff had not received dementia care training. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1) Resident #1 was assessed by the Nurse Coordinator on 10/21/17 with no injuries noted. The resident's physician and representative were notified of the incident on 10/21/17. 2) Licensed Practical Nurse (LPN) #2 was terminated from employment at the facility. 3) Staff who witnessed the alleged abuse were counseled by the Director of Nursing (DON) regarding prompt intervention during incidents to protect residents. 4) All staff were interviewed on 11/09/17, by the DON, the Clinical Coordinators, the Staff Development Coordinator (SDC), and the Minimum Data Set (MDS) Coordinators to determine if other incidents had occurred that required notification to appropriate state agencies. 5) On 11/09/17 and 11/10/17, all interviewable residents were interviewed by the Clinical Coordinators, the SDC, and the Social Worker to determine if they had any concerns with abuse or if any incidents of abuse had occurred. Notification was made to appropriate state agencies if indicated. 6) On 11/09/17 and 11/10/17, residents that were not interviewable had skin assessments completed to insure any suspicious injuries were assessed. Nursing staff that work with the residents were interviewed and the residents' medical records, including skin assessments, Social Services Notes and Nurses' Notes were reviewed for any signs of unreported injuries or changes in mood/behaviors. 7) A Department Head meeting was conducted on 11/10/17 to review the information detailed in the Immediate Jeopardy notification and develop a plan for abatement of the Immediate Jeopardy. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, and the SDC. 8) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, and the Corporate Consultant began observation of residents that had been assessed to exhibit behaviors to ensure appropriate individualized interventions were in place and being implemented as directed by the resident's plan of care. 9) The Administrator met with the Medical Director on 11/11/17, and informed the Medical Director of the Immediate Jeopardy. 10) On 11/10/17, the Corporate Consultant began reviewing all allegations of abuse and neglect from 10/20/17 till the present to ensure policy and procedures were being followed, including immediate staff intervention when indicated, immediate removal of an alleged perpetrator from the facility pending investigation, and a thorough completion of the investigation with necessary corrective action being taken as indicated. 11) On 11/09/17, the Administrator, the DON, and the SDC were educated by the Corporate Consultant related to conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that have had care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. 12) On 11/10/17, the Abuse Policy & Procedure was revised by the Administrator and Corporate Consultant to include immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Staff training was then provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. 13) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. A post test is required to be taken by each staff member after the education to ensure understanding and retention of the education. The training will continue until all employees have been educated prior to their next scheduled shift. Staff will not be permitted to work until they have received the education. A master list of all employees is being reviewed and maintained by the business office staff with reports given to the Administrator and DON to ensure all staff can be contacted and educated prior to their next scheduled shift. The post test will continue to be administered to ten (10) staff members from random units and shifts on a daily basis for two weeks, and then 10 staff members weekly for one month. The post tests will be administered by the DON, the Clinical Coordinators, the SDC, and the Corporate Consultant. The Administrator or the DON will report the results of the post testing to the Quality Assurance Committee. 14) On 11/14/17, education was initiated with all nurses and nurse aides related to providing care to residents with challenging behaviors and the development and utilization of interventions to address the challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. The education will continue until all licensed and unlicensed nursing staff have been trained. The business office staff are maintaining a list of all employees that have completed the training to ensure all staff are trained prior to providing resident care. The Clinical Coordinators will continue to conduct resident observations and care plan reviews for eight residents, two from each unit daily for one week and then eight per week for one month to ensure appropriate interventions are being utilized for residents that are exhibiting behaviors. These observations will include all shifts at random. Results will be provided by the Clinical Coordinators to the Administrator and the DON, who will review the findings and address any concerns promptly with the involved staff. The DON will report the results of the observations to the Quality Assurance Committee which will determine the need for further education/follow-up. 15) A Department Head meeting was conducted on 11/10/17 to review the Immediate Jeopardy. On 11/11/17, the Medical Director was notified of the plan for abatement of the Immediate Jeopardy. 16) Corporate Consultant staff will review abuse allegations to ensure the revised Abuse Policy & Procedure is being followed. The review will consist of ensuring the alleged perpetrator was removed from the facility immediately, any witnesses to the alleged abuse acted promptly to ensure resident safety, the investigation was thorough and a conclusion was determined, and that appropriate corrective action had been taken. The Administrator or DON will report the findings to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) A Quality Assurance meeting was conducted on 11/16/17 to review the status of staff education, monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, the SDC, consultant staff, and the Medical Director. 18) Quality assurance meetings will be held at least weekly until substantial compliance is achieved, and then monthly for one quarter. **The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of the medical record for Resident #1 revealed the resident was assessed for signs and symptoms of abuse on 10/21/17. The physician and resident representative were notified of the incident. 2) Review of the personnel file for LPN #2 revealed the employee was terminated from the facility on 11/10/17. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed LPN #2 was terminated on 11/10/17. 3) Review of counseling forms dated 11/13/17 and 11/14/17 revealed all employees who were involved in the incident were counseled by the DON. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed all employees involved in the incident were counseled. Interviews with SRNA #1 on 11/20/17 at 3:05 PM, and SRNA #3 on 11/21/17 at 9:10 AM, revealed they were counseled regarding the incident by the DON. 4) Review of staff interviews dated 11/09/17 revealed the DON, the Clinical Coordinators, the SDC, or the MDS Coordinator interviewed all staff to determine if any other incidents of abuse had occurred that had not been identified and to ensure that required notification had been made to state agencies. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been interviewed and were not aware of any incidents of abuse that had not been reported. 5) Review of a resident census revealed all interviewable residents were interviewed related to any concerns with abuse on 11/09/17 and 11/10/17. Interviews conducted on 11/20/17 at 1:30 PM with Resident #10, at 1:00 PM with Resident #11, and at 12:55 PM with Resident #12, revealed the residents had no concerns with abuse or mistreatment by facility staff. 6) Review of the facility census dated 11/09/17 and 11/10/17 revealed non-interviewable residents had skin assessments completed, and their clinical records were reviewed to identify any incidents of abuse that had not been identified. Interviews on 11/21/17 with the Clinical Coordinator at 9:55 AM and the MDS Coordinator at 10:10 AM reveled all non-interviewable residents had skin assessments completed and their records were reviewed for any concerns related to abuse. 7) Review of an attendance roster revealed a Department Head meeting was conducted on 11/09/17 to review the Immediate Jeopardy and a plan was developed to abate the Immediate Jeopardy. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they met on 11/09/17 to develop a plan for the abatement of Immediate Jeopardy. 8) Review of resident observation documentation dated 11/10/17 through 11/20/17 revealed observations had been conducted daily on eight residents assessed to exhibit behaviors, to ensure appropriate individualized interventions were in place and being implemented as indicated. Interviews with the Corporate Consultant, the Administrator, the DON, and the Clinical Coordinators on 11/21/17 from 9:55 AM to 2:20 PM revealed they had completed daily observations of at least eight residents with behaviors to ensure the residents' care plans were being implemented appropriately. 9) Review of Quality Assurance meeting minutes dated 11/11/17 revealed the Immediate Jeopardy and abatement plan were discussed with the Medical Director. Interview with the Administrator on 11/21/17 at 1:50 PM revealed she had met with the Medical Director on 11/11/17 and discussed the Immediate Jeopardy and abatement plan. 10) Review of facility investigations from 11/05/17 through 11/14/17 revealed the Corporate Consultant had reviewed the investigations. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed she had reviewed all incidents to ensure the facility's abuse policy and procedures had been followed. 11) Review of education dated 11/09/17 revealed the Corporate Consultant had trained the Administrator, the DON, and the SDC on conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that had received care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. Interviews on 11/21/17 from 12:55 PM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, and the SDC revealed they had received the education by the Corporate Consultant on 11/09/17. 12) Review of the facility's abuse policy and procedure revealed it was revised on 11/10/17 and included immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Review of staff education dated 11/10/17 revealed training was provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, the SDC, and the Housekeeping Supervisor revealed they had all received the training on the facility's abuse policy and procedure. 13) Review of education sign-in sheets dated 11/10/17 revealed the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. Review of post tests revealed they had been completed by all staff who had received the education. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been educated on the facility's abuse policy/procedure and had completed a post test. 14) Review of facility education dated 11/14/17 revealed nurses and nurse aides were trained related to providing care to residents with challenging behaviors and implementing interventions to address challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. Interviews conducted with nurses and SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been trained on providing care to residents with challenging behaviors and ensuring the residents' care plans were being followed. 15) Review of Department Head meeting minutes dated 11/10/17 revealed a meeting was held to review the Immediate Jeopardy. Review of meeting minutes revealed the Medical Director was notified of the plan for abatement of the Immediate Jeopardy on 11/11/17. 16) Review of abuse allegations revealed the Corporate Consultant had reviewed all abuse allegations to ensure the revised Abuse Policy & Procedure had been followed. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed they had completed the reviews of abuse allegations to ensure the facility's abuse policy and procedures had been followed. Interview with the Administrator and DON on 11/21/17 at 1:40 PM and 1:50 PM, revealed they would report the findings of the abuse allegation reviews to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) Review of Quality Assurance meeting minutes dated 11/16/17 revealed that the education provided to facility staff, the monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal had been discussed in the meeting. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they had all attended the Quality Assurance meeting conducted on 11/16/17. 18) Interview with the Administrator and the DON on 11/21/17 at 1:40 PM and 1:50 PM revealed the Quality Assurance meetings will be held weekly until substantial compliance is achieved, and then monthly for one quarter.

Based on interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated and failed to protect residents from further potential abuse after an allegation of abuse was made for one (1) of three (3) sampled residents (Resident #1). On 10/20/17 at approximately 11:00 PM, while Resident #1 was agitated and refusing medication, Licensed Practical Nurse (LPN) #2 forcefully opened Resident #1's mouth to administer medication, took away the resident's baby doll, and stated to Resident #1, You are not getting this back for two weeks. In addition, LPN #2 stated to Resident #1, I'm not going to put up with this. One of the witnesses, State Registered Nurse Aide (SRNA) #1, contacted an on-call, administrative staff member and reported the abuse. However, the on-call administrative staff failed to take action to protect residents from further abuse by failing to ensure the alleged perpetrator was immediately removed from providing resident care. The alleged perpetrator continued to provide care to residents for approximately two (2) hours and twenty-one (21) minutes. Furthermore, the facility failed to have evidence that a thorough investigation was conducted in order for the facility to make an appropriate determination and failed to ensure corrective action was implemented. The facility's failure to ensure that all alleged violations of abuse were thoroughly investigated and failure to protect residents from further potential abuse after an allegation of abuse was made has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/09/17 and determined to exist on 10/20/17 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223 - J, F225 - J, and F226 - J) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282 - J). Substandard Quality of Care was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 11/09/17. An acceptable Allegation of Compliance was received on 11/17/17, which alleged removal of the Immediate Jeopardy on 11/17/17. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/17/17, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Abuse Policy, last revised November 2016, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. The policy stated that when an allegation of abuse was reported, the employee would be immediately removed from duty until the investigation was completed. Further review of the policy revealed when an incident or suspected incident of resident abuse was reported the facility would appoint a representative to investigate the incident and a thorough investigation would be completed. The policy further stated that administrative staff would be in-serviced on the administrative role in investigating, preventing, and reporting abuse/neglect. The policy did not explain that role or how it was to be done. Review of a facility Investigative Summary, dated 10/20/17, revealed while Resident #1 was agitated and refusing medication, LPN #2 attempted to get Resident #1 to take his/her medications. Further review revealed LPN #2 spoke to Resident #1 in a loud voice, put her hands on Resident #1's jaw, and put the prepared medications in Resident #1's mouth. Further review revealed Resident #1 spat the medication out, was agitated and aggressive, and was striking out at the staff. In addition, Resident #1 had a doll and was swinging the doll at staff. Further review of the investigation revealed LPN #2 took the doll from Resident #1. Continued review of the Investigative Summary revealed the facility interviewed the staff that witnessed the incident and assessed Resident #1 for injuries. In addition, the facility suspended LPN #2. However, there was no evidence the facility conducted a thorough investigation, made an appropriate determination, and took necessary corrective action to ensure residents were protected after the allegation of abuse was reported. Record review revealed the facility admitted Resident #1 on 09/06/17 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #1 to have severe cognitive impairment with a Brief Interview for Mental Status score of 99 indicating Resident #1 was not interviewable. Interview with SRNA #1 on 11/08/17 at 3:36 PM revealed on 10/20/17 at approximately 11:00 PM, he observed LPN #1 attempting to administer medications to Resident #1. SRNA #1 stated Resident #1 was agitated and was refusing to take the medications. Further interview with SRNA #1 revealed LPN #2 intervened and took the medication from LPN #1. SRNA #1 stated LPN #2 approached Resident #1 with the medication and Resident #1 stated, I don't want to take my medication. SRNA #1 stated LPN #2 placed her left hand around Resident #1's jaws, forced Resident #1's mouth open, and put the medication in Resident #1's mouth. Additional interview with SRNA #1 revealed he called the on-call administrative staff member, the Staff Development Coordinator, LPN #3, and reported the abuse. SRNA #1 stated he was trained to separate the victim from the abuser when abuse was observed. SRNA #1 further stated that he should have intervened for Resident #1 but stated, I guess I was in shock, I just couldn't believe what I was seeing. SRNA #1 stated that after he reported the abuse to LPN #3, he left to go home because his shift was over. Interview with SRNA #3 on 11/09/17 at 8:21 PM revealed at approximately 11:00 PM, she observed LPN #2 attempting to give medications to Resident #1. SRNA #3 stated Resident #1 was agitated and was refusing to take his/her medications. SRNA #3 stated LPN #2 became angry, placed her hand around Resident #1's jaw, and forced the resident's mouth open. Further interview with SRNA #3 revealed LPN #2 then placed the medications in Resident #1's mouth. SRNA #3 stated Resident #1 spat the medication out. SRNA #3 revealed Resident #1 was attempting to hit the staff with his/her baby doll. SRNA #3 stated LPN #2 jerked the baby doll out of Resident #1's hands and instructed her to hold down Resident #1's arms. SRNA #3 stated she did hold Resident #1's hands in a soothing way to try to calm the resident down. SRNA #3 stated while she was holding Resident #1's hands, LPN #2 grabbed Resident #1's jaws a second time and attempted to administer the rest of Resident #1's medication. SRNA #3 stated the resident spat the medication out onto the floor. Further interview with SRNA #3 revealed LPN #2 got hateful with Resident #1 and told Resident #1 that he/she would get the doll back when he/she started acting right. Further interview with SRNA #3 revealed she was trained that if she witnessed abuse she was to move the resident to safety and immediately report the incident. SRNA #3 stated, We were all on egg shells working with (LPN #2); we were all in shock, and just couldn't believe what we were seeing. Interview with LPN #1 on 11/08/17 at 4:35 PM revealed on 10/20/17 at approximately 11:00 PM, she was attempting to get Resident #1 to take his/her medications. She stated LPN #2 took the medications from her hand, approached Resident #1, and stated to the resident, You can't live here if you don't take your medications. Further interview with LPN #1 revealed she observed LPN #2 grab Resident #1 around his/her jaw, force his/her mouth open, and put the medications in the resident's mouth. LPN #1 stated Resident #1 spat the medication out. In addition, LPN #1 stated LPN #2 shook her finger at Resident #1 and stated, I'm not going to put up with this. LPN #1 stated LPN #2 was obviously angry at Resident #1. She stated LPN #2 attempted to administer the medications to Resident #1 at least twice. Further interview revealed at some point during the incident LPN #2 took Resident #1's baby doll and said to the resident, You are not getting this back for two weeks. LPN #1 stated that she was afraid to intervene in the situation due to the level of Resident #1's agitation. She stated she was afraid that someone would get hurt. Continued interview with LPN #1 revealed she did not know where LPN #2 went immediately after the incident. LPN #1 stated, I did not tell her to go home; it's not my place to tell someone to leave. Interview with LPN #2 on 11/09/17 at 1:18 PM revealed on 10/20/17 at approximately 11:00 PM, she observed LPN #1 attempting to administer medications to Resident #1. LPN #2 stated Resident #1 was agitated and was refusing the medication. LPN #2 stated that she knew Resident #1 could be mean. LPN #1 stated that she was afraid that if Resident #1 did not get his/her medications, they would be in for a long night. LPN #2 stated Resident #1 had slapped some of the SRNAs with his/her baby doll and had slung his/her vanilla shake at her which had gone all over her shirt. Further interview with LPN #2 revealed Resident #1 was flinging his/her arms around. LPN #2 stated she told SRNA #3 to hold the resident's hands down. She stated while SRNA #3 was holding Resident #1's hands she placed her hands on the resident's jaw and put the medication in the resident's mouth. Additional interview with LPN #2 revealed Resident #1 spat the medication out. LPN #2 stated she raised her voice and stated to Resident #1, Stop doing that! Continued interview with LPN #2 revealed the on-call administrative staff member, LPN #3, called the nurses' station and spoke with her on the phone. LPN #2 stated she was told by LPN #3 to finish medication administration, count the narcotic medications, and then go home. LPN #2 stated that LPN #3 told her to go to another unit of the facility to see if another nurse could help get the medications passed. She stated she did obtain the assistance of one of the nurses on another unit; however, the other nurse only stayed for a few minutes and had to return to her own unit. Continued interview with LPN #2 revealed after she spoke with LPN #3 she continued passing medications and conducted a dressing change for a resident. LPN #2 stated she was in the facility approximately three to four hours and continued to provide care to residents after she spoke with LPN #3. Interview with the Staff Development Coordinator (SDC), LPN #3, on 11/08/17 at 3:00 PM and 7:36 PM, on 11/09/17 at 10:12 AM, and on 11/20/17 at 2:50 PM revealed she was the on-call administrative staff on 10/20/17. LPN #3 stated she was notified at approximately 11:00 PM by SRNA #1 of the allegation of abuse involving LPN #2 and Resident #1. LPN #3 stated after speaking with SRNA #1 she phoned the facility and spoke with LPN #2. Continued interview with LPN #3 revealed she instructed LPN #2 to count her narcotic medication and to leave the facility. She stated she came to the facility at approximately 1:00-1:30 AM and at that time, she became aware that LPN #2 was still in the facility. LPN #3 stated when she arrived at the facility, she immediately removed LPN #2 from duty. Further interview revealed that prior to the incident on 10/20/17, the facility did not have a system in place to ensure residents were protected and alleged perpetrators removed from duty. Interview with the Administrator on 11/09/17 at 8:56 PM, and on 11/21/17 at 1:15 PM revealed she was made aware of the allegation of abuse and at the time of the initial report she was asleep. She stated she went back to sleep after the report and began the investigation into the incident the next morning. She stated that was when she became aware that LPN #2 continued to provide care to other residents after the allegation of abuse was made. The Administrator stated that after an investigation was completed, she completed a summary of the investigation, but she did not make a determination as to whether abuse occurred. The Administrator stated that during the investigation she did not interview other residents or determine if any other residents had been affected by the abuse. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1) Resident #1 was assessed by the Nurse Coordinator on 10/21/17 with no injuries noted. The resident's physician and representative were notified of the incident on 10/21/17. 2) Licensed Practical Nurse (LPN) #2 was terminated from employment at the facility. 3) Staff who witnessed the alleged abuse were counseled by the Director of Nursing (DON) regarding prompt intervention during incidents to protect residents. 4) All staff were interviewed on 11/09/17, by the DON, the Clinical Coordinators, the Staff Development Coordinator (SDC), and the Minimum Data Set (MDS) Coordinators to determine if other incidents had occurred that required notification to appropriate state agencies. 5) On 11/09/17 and 11/10/17, all interviewable residents were interviewed by the Clinical Coordinators, the SDC, and the Social Worker to determine if they had any concerns with abuse or if any incidents of abuse had occurred. Notification was made to appropriate state agencies if indicated. 6) On 11/09/17 and 11/10/17, residents that were not interviewable had skin assessments completed to insure any suspicious injuries were assessed. Nursing staff that work with the residents were interviewed and the residents' medical records, including skin assessments, Social Services Notes and Nurses' Notes were reviewed for any signs of unreported injuries or changes in mood/behaviors. 7) A Department Head meeting was conducted on 11/10/17 to review the information detailed in the Immediate Jeopardy notification and develop a plan for abatement of the Immediate Jeopardy. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, and the SDC. 8) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, and the Corporate Consultant began observation of residents that had been assessed to exhibit behaviors to ensure appropriate individualized interventions were in place and being implemented as directed by the resident's plan of care. 9) The Administrator met with the Medical Director on 11/11/17, and informed the Medical Director of the Immediate Jeopardy. 10) On 11/10/17, the Corporate Consultant began reviewing all allegations of abuse and neglect from 10/20/17 till the present to ensure policy and procedures were being followed, including immediate staff intervention when indicated, immediate removal of an alleged perpetrator from the facility pending investigation, and a thorough completion of the investigation with necessary corrective action being taken as indicated. 11) On 11/09/17, the Administrator, the DON, and the SDC were educated by the Corporate Consultant related to conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that have had care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. 12) On 11/10/17, the Abuse Policy & Procedure was revised by the Administrator and Corporate Consultant to include immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Staff training was then provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. 13) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. A post test is required to be taken by each staff member after the education to ensure understanding and retention of the education. The training will continue until all employees have been educated prior to their next scheduled shift. Staff will not be permitted to work until they have received the education. A master list of all employees is being reviewed and maintained by the business office staff with reports given to the Administrator and DON to ensure all staff can be contacted and educated prior to their next scheduled shift. The post test will continue to be administered to ten (10) staff members from random units and shifts on a daily basis for two weeks, and then 10 staff members weekly for one month. The post tests will be administered by the DON, the Clinical Coordinators, the SDC, and the Corporate Consultant. The Administrator or the DON will report the results of the post testing to the Quality Assurance Committee. 14) On 11/14/17, education was initiated with all nurses and nurse aides related to providing care to residents with challenging behaviors and the development and utilization of interventions to address the challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. The education will continue until all licensed and unlicensed nursing staff have been trained. The business office staff are maintaining a list of all employees that have completed the training to ensure all staff are trained prior to providing resident care. The Clinical Coordinators will continue to conduct resident observations and care plan reviews for eight residents, two from each unit daily for one week and then eight per week for one month to ensure appropriate interventions are being utilized for residents that are exhibiting behaviors. These observations will include all shifts at random. Results will be provided by the Clinical Coordinators to the Administrator and the DON, who will review the findings and address any concerns promptly with the involved staff. The DON will report the results of the observations to the Quality Assurance Committee which will determine the need for further education/follow-up. 15) A Department Head meeting was conducted on 11/10/17 to review the Immediate Jeopardy. On 11/11/17, the Medical Director was notified of the plan for abatement of the Immediate Jeopardy. 16) Corporate Consultant staff will review abuse allegations to ensure the revised Abuse Policy & Procedure is being followed. The review will consist of ensuring the alleged perpetrator was removed from the facility immediately, any witnesses to the alleged abuse acted promptly to ensure resident safety, the investigation was thorough and a conclusion was determined, and that appropriate corrective action had been taken. The Administrator or DON will report the findings to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) A Quality Assurance meeting was conducted on 11/16/17 to review the status of staff education, monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, the SDC, consultant staff, and the Medical Director. 18) Quality assurance meetings will be held at least weekly until substantial compliance is achieved, and then monthly for one quarter. **The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of the medical record for Resident #1 revealed the resident was assessed for signs and symptoms of abuse on 10/21/17. The physician and resident representative were notified of the incident. 2) Review of the personnel file for LPN #2 revealed the employee was terminated from the facility on 11/10/17. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed LPN #2 was terminated on 11/10/17. 3) Review of counseling forms dated 11/13/17 and 11/14/17 revealed all employees who were involved in the incident were counseled by the DON. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed all employees involved in the incident were counseled. Interviews with SRNA #1 on 11/20/17 at 3:05 PM, and SRNA #3 on 11/21/17 at 9:10 AM, revealed they were counseled regarding the incident by the DON. 4) Review of staff interviews dated 11/09/17 revealed the DON, the Clinical Coordinators, the SDC, or the MDS Coordinator interviewed all staff to determine if any other incidents of abuse had occurred that had not been identified and to ensure that required notification had been made to state agencies. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been interviewed and were not aware of any incidents of abuse that had not been reported. 5) Review of a resident census revealed all interviewable residents were interviewed related to any concerns with abuse on 11/09/17 and 11/10/17. Interviews conducted on 11/20/17 at 1:30 PM with Resident #10, at 1:00 PM with Resident #11, and at 12:55 PM with Resident #12, revealed the residents had no concerns with abuse or mistreatment by facility staff. 6) Review of the facility census dated 11/09/17 and 11/10/17 revealed non-interviewable residents had skin assessments completed, and their clinical records were reviewed to identify any incidents of abuse that had not been identified. Interviews on 11/21/17 with the Clinical Coordinator at 9:55 AM and the MDS Coordinator at 10:10 AM reveled all non-interviewable residents had skin assessments completed and their records were reviewed for any concerns related to abuse. 7) Review of an attendance roster revealed a Department Head meeting was conducted on 11/09/17 to review the Immediate Jeopardy and a plan was developed to abate the Immediate Jeopardy. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they met on 11/09/17 to develop a plan for the abatement of Immediate Jeopardy. 8) Review of resident observation documentation dated 11/10/17 through 11/20/17 revealed observations had been conducted daily on eight residents assessed to exhibit behaviors, to ensure appropriate individualized interventions were in place and being implemented as indicated. Interviews with the Corporate Consultant, the Administrator, the DON, and the Clinical Coordinators on 11/21/17 from 9:55 AM to 2:20 PM revealed they had completed daily observations of at least eight residents with behaviors to ensure the residents' care plans were being implemented appropriately. 9) Review of Quality Assurance meeting minutes dated 11/11/17 revealed the Immediate Jeopardy and abatement plan were discussed with the Medical Director. Interview with the Administrator on 11/21/17 at 1:50 PM revealed she had met with the Medical Director on 11/11/17 and discussed the Immediate Jeopardy and abatement plan. 10) Review of facility investigations from 11/05/17 through 11/14/17 revealed the Corporate Consultant had reviewed the investigations. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed she had reviewed all incidents to ensure the facility's abuse policy and procedures had been followed. 11) Review of education dated 11/09/17 revealed the Corporate Consultant had trained the Administrator, the DON, and the SDC on conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that had received care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. Interviews on 11/21/17 from 12:55 PM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, and the SDC revealed they had received the education by the Corporate Consultant on 11/09/17. 12) Review of the facility's abuse policy and procedure revealed it was revised on 11/10/17 and included immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Review of staff education dated 11/10/17 revealed training was provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, the SDC, and the Housekeeping Supervisor revealed they had all received the training on the facility's abuse policy and procedure. 13) Review of education sign-in sheets dated 11/10/17 revealed the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. Review of post tests revealed they had been completed by all staff who had received the education. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been educated on the facility's abuse policy/procedure and had completed a post test. 14) Review of facility education dated 11/14/17 revealed nurses and nurse aides were trained related to providing care to residents with challenging behaviors and implementing interventions to address challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. Interviews conducted with nurses and SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been trained on providing care to residents with challenging behaviors and ensuring the residents' care plans were being followed. 15) Review of Department Head meeting minutes dated 11/10/17 revealed a meeting was held to review the Immediate Jeopardy. Review of meeting minutes revealed the Medical Director was notified of the plan for abatement of the Immediate Jeopardy on 11/11/17. 16) Review of abuse allegations revealed the Corporate Consultant had reviewed all abuse allegations to ensure the revised Abuse Policy & Procedure had been followed. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed they had completed the reviews of abuse allegations to ensure the facility's abuse policy and procedures had been followed. Interview with the Administrator and DON on 11/21/17 at 1:40 PM and 1:50 PM, revealed they would report the findings of the abuse allegation reviews to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) Review of Quality Assurance meeting minutes dated 11/16/17 revealed that the education provided to facility staff, the monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal had been discussed in the meeting. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they had all attended the Quality Assurance meeting conducted on 11/16/17. 18) Interview with the Administrator and the DON on 11/21/17 at 1:40 PM and 1:50 PM revealed the Quality Assurance meetings will be held weekly until substantial compliance is achieved, and then monthly for one quarter.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #1) from abuse. On 10/20/17 at approximately 11:00 PM, while Resident #1 was agitated and refusing medication, Licensed Practical Nurse (LPN) #2 forcefully opened Resident #1's mouth and forced medication into the resident's mouth. LPN #2 also took the resident's baby doll, and told the resident that he/she could have the doll when he/she started acting right. In addition, LPN #2 raised her voice, shook her finger at Resident #1 and stated, I'm not going to put up with this. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/09/17 and determined to exist on 10/20/17 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223 - J, F225 - J, and F226 - J) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282 - J). Substandard Quality of Care was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 11/09/17. An acceptable Allegation of Compliance was received on 11/17/17, which alleged removal of the Immediate Jeopardy on 11/17/17. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 11/17/17, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F223, F225, and F226) and 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Abuse Policy, last revised November 2016, revealed the facility would not condone abuse and defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Review of a facility Investigative Summary, dated 10/20/17, revealed while Resident #1 was agitated and refusing medication, LPN #2 overheard and saw that Resident #1 was not taking his/her medications. The summary stated that LPN #2 took the medications from LPN #1 and attempted to get the resident to take the medication. Further review revealed LPN #2 spoke to Resident #1 in a loud voice, put her hands on Resident #1's jaw, and put the prepared medications in Resident #1's mouth. Further review revealed Resident #1 spit the medication out, was agitated and aggressive, and was striking out at the staff. In addition, Resident #1 had a doll and was swinging the doll at staff. Further review of the Summary revealed LPN #2 removed the doll from Resident #1. The Investigative Summary did not include findings related to the allegation of abuse or determine if the resident had been abused. Record review revealed the facility admitted Resident #1 on 09/06/17 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #1 to have severe cognitive impairment with a Brief Interview for Mental Status score of 99 indicating Resident #1 was not interviewable. Review of a Nurse's Note dated 10/20/17 at 11:20 PM, revealed Resident #1 was agitated, attempting to choke staff, and was hitting staff with a baby doll. Additional review revealed PRN (as needed) medications were given to the resident at that time. Interview with State Registered Nurse Aide (SRNA) #1 on 11/08/17 at 3:36 PM revealed on 10/20/17 at approximately 11:00 PM, he observed LPN #1 attempting to administer medications to Resident #1. SRNA #1 stated Resident #1 was agitated and refusing to take the medications. Further interview revealed SRNA #1 stated LPN #2 intervened and took the medication from LPN #1. SRNA #1 stated LPN #2 approached Resident #1 with the medication and Resident #1 stated that he/she did not want to take the medication. SRNA #1 stated LPN #2 placed her left hand around Resident #1's jaws, forced Resident #1's mouth open, and put the medication in Resident #1's mouth. Additional interview with SRNA #1 revealed he called the on-call administrative staff member. SRNA #1 further stated that he had been trained (at the facility) regarding abuse and had been instructed that if he observed abuse occurring he was supposed to get the victim away from the abuser and make sure they did not abuse anybody else. SRNA #1 stated, I should have intervened immediately and removed the resident from the abusive situation. SRNA #1 stated, I guess I was in shock, I just couldn't believe what I was seeing. Interview with SRNA #3 on 11/09/17 at 8:21 PM revealed at approximately 11:00 PM on 10/20/17, she observed LPN #2 attempting to give medications to Resident #1. SRNA #3 stated Resident #1 was agitated and was refusing to take his/her medications. She stated LPN #2 became angry, placed her hand around Resident #1's jaw, and forced the resident's mouth open. Further interview with SRNA #3 revealed LPN #2 then placed the medications in Resident #1's mouth. SRNA #3 stated Resident #1 spit the medication back out. SRNA #3 revealed Resident #1 was attempting to hit the staff with his/her baby doll. She stated LPN #2 jerked the baby doll out of Resident #1's hands and instructed her to hold down Resident #1's arms. SRNA #3 stated she did not hold Resident #1's arms down; however, she did hold Resident #1's hands in a soothing way to try to calm the resident. SRNA #3 stated while she was holding Resident #1's hands, LPN #2 grabbed Resident #1's jaws a second time and attempted to administer the rest of the resident's medication. SRNA #3 stated the resident spat the medication out onto the floor. Further interview with SRNA #3 revealed LPN #2 got hateful with Resident #1 and told the resident that he/she would get the doll back when he/she started acting right. In addition, SRNA #3 stated no one moved Resident #1 away from LPN #2 when the LPN was confronting/arguing with the resident. SRNA #3 stated she had been trained that if she witnessed abuse she was to remove the resident to safety and immediately report the incident. Interview with LPN #1 on 11/08/17 at 4:35 PM revealed on 10/20/17 at approximately 11:00 PM, she was attempting to get Resident #1 to take his/her medications. Further interview revealed LPN #2 took the medications from her hand, approached Resident #1, and stated to the resident, You can't live here if you don't take your medications. Further interview with LPN #1 revealed she observed LPN #2 grab Resident #1 around his/her jaw, force his/her mouth open, and put the medications in the resident's mouth. LPN #1 stated Resident #1 spat the medication out. In addition, LPN #1 stated LPN #2 shook her finger at Resident #1 and stated, I'm not going to put up with this. LPN #1 stated LPN #2 was obviously angry at Resident #1. Additional interview with LPN #1 revealed she did not intervene. LPN #1 stated she was afraid to physically get involved because Resident #1 was being aggressive, and stated she was afraid someone would get hurt. LPN #1 stated LPN #2 attempted to administer the medications to Resident #1 at least twice. Further interview revealed at some point during the incident, LPN #2 took Resident #1's baby doll and said to the resident, You are not getting this back for two weeks. Additional interview with LPN #1 revealed after the incident occurred, Resident #1 continued to be so upset that she had to administer his/her as needed antianxiety medication to get the resident to calm down. Interview with LPN #2 on 11/09/17 at 1:18 PM revealed on 10/20/17 at approximately 11:00 PM, she observed LPN #1 attempting to administer medications to Resident #1. LPN #2 stated Resident #1 was agitated and was refusing the medication. LPN #2 stated that she knew Resident #1 could be mean. LPN #2 stated that she was afraid that if Resident #1 did not get his/her medications the staff would be in for a long night. LPN #2 stated Resident #1 had slapped some of the SRNAs with his/her baby doll and had slung his/her vanilla shake at her which had gone all over her shirt. Further interview with LPN #2 revealed Resident #1 was flinging his/her arms around and stated she told SRNA #3 to hold the resident's hands down. LPN #2 stated while SRNA #3 was holding Resident #1's hands, she placed her hands on the resident's jaw and put the medication in the resident's mouth. Additional interview with LPN #2 revealed Resident #1 spat the medication out. LPN #2 stated she raised her voice and stated to Resident #1, Stop doing that! Interview with the Staff Development Coordinator (SDC), LPN #3, on 11/09/17 at 10:12 AM, revealed she was responsible for educating staff members regarding abuse and neglect. LPN #3 stated all staff were instructed to intervene and move a resident to safety if they witnessed abuse occurring. LPN #3 further stated that she was the administrator on call at the time of the incident on 10/20/17. She stated that after the incident was reported to her, she called the facility and instructed LPN #2 to finish her narcotic count and leave the facility. LPN #3 stated she came to the facility later to conduct the investigation and found that LPN #2 was still in the building providing care. She stated that she had her to leave immediately after she found her still at the facility. Review of a facility Time Card Report revealed LPN #2 began her shift on 10/20/17 at 7:14 PM. Additional review of the Time Card Report revealed LPN #2 remained in the facility and did not end her shift until 2:21 AM on 10/21/17. Interview with the Director of Nursing (DON) on 11/09/17 at 10:12 AM revealed she was on vacation at the time of the incident. Further interview with the DON revealed she expected that the staff would have intervened and removed Resident #1 from the situation. Interview with the Administrator on 11/09/17 at 8:56 PM, and on 11/21/17 at 1:15 PM, revealed she was made aware of the allegation of abuse and at the time of the initial report she was asleep. She stated she went back to sleep after the report and began the investigation into the incident the next morning. She stated that was when she became aware that LPN #2 continued to provide care to other residents after the allegation of abuse was made. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1) Resident #1 was assessed by the Nurse Coordinator on 10/21/17 with no injuries noted. The resident's physician and representative were notified of the incident on 10/21/17. 2) Licensed Practical Nurse (LPN) #2 was terminated from employment at the facility. 3) Staff who witnessed the alleged abuse were counseled by the Director of Nursing (DON) regarding prompt intervention during incidents to protect residents. 4) All staff were interviewed on 11/09/17, by the DON, the Clinical Coordinators, the Staff Development Coordinator (SDC), and the Minimum Data Set (MDS) Coordinators to determine if other incidents had occurred that required notification to appropriate state agencies. 5) On 11/09/17 and 11/10/17, all interviewable residents were interviewed by the Clinical Coordinators, the SDC, and the Social Worker to determine if they had any concerns with abuse or if any incidents of abuse had occurred. Notification was made to appropriate state agencies if indicated. 6) On 11/09/17 and 11/10/17, residents that were not interviewable had skin assessments completed to insure any suspicious injuries were assessed. Nursing staff that work with the residents were interviewed and the residents' medical records, including skin assessments, Social Services Notes and Nurses' Notes were reviewed for any signs of unreported injuries or changes in mood/behaviors. 7) A Department Head meeting was conducted on 11/10/17 to review the information detailed in the Immediate Jeopardy notification and develop a plan for abatement of the Immediate Jeopardy. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, and the SDC. 8) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, and the Corporate Consultant began observation of residents that had been assessed to exhibit behaviors to ensure appropriate individualized interventions were in place and being implemented as directed by the resident's plan of care. 9) The Administrator met with the Medical Director on 11/11/17, and informed the Medical Director of the Immediate Jeopardy. 10) On 11/10/17, the Corporate Consultant began reviewing all allegations of abuse and neglect from 10/20/17 till the present to ensure policy and procedures were being followed, including immediate staff intervention when indicated, immediate removal of an alleged perpetrator from the facility pending investigation, and a thorough completion of the investigation with necessary corrective action being taken as indicated. 11) On 11/09/17, the Administrator, the DON, and the SDC were educated by the Corporate Consultant related to conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that have had care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. 12) On 11/10/17, the Abuse Policy & Procedure was revised by the Administrator and Corporate Consultant to include immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Staff training was then provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. 13) On 11/10/17, the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. A post test is required to be taken by each staff member after the education to ensure understanding and retention of the education. The training will continue until all employees have been educated prior to their next scheduled shift. Staff will not be permitted to work until they have received the education. A master list of all employees is being reviewed and maintained by the business office staff with reports given to the Administrator and DON to ensure all staff can be contacted and educated prior to their next scheduled shift. The post test will continue to be administered to ten (10) staff members from random units and shifts on a daily basis for two weeks, and then 10 staff members weekly for one month. The post tests will be administered by the DON, the Clinical Coordinators, the SDC, and the Corporate Consultant. The Administrator or the DON will report the results of the post testing to the Quality Assurance Committee. 14) On 11/14/17, education was initiated with all nurses and nurse aides related to providing care to residents with challenging behaviors and the development and utilization of interventions to address the challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. The education will continue until all licensed and unlicensed nursing staff have been trained. The business office staff are maintaining a list of all employees that have completed the training to ensure all staff are trained prior to providing resident care. The Clinical Coordinators will continue to conduct resident observations and care plan reviews for eight residents, two from each unit daily for one week and then eight per week for one month to ensure appropriate interventions are being utilized for residents that are exhibiting behaviors. These observations will include all shifts at random. Results will be provided by the Clinical Coordinators to the Administrator and the DON, who will review the findings and address any concerns promptly with the involved staff. The DON will report the results of the observations to the Quality Assurance Committee which will determine the need for further education/follow-up. 15) A Department Head meeting was conducted on 11/10/17 to review the Immediate Jeopardy. On 11/11/17, the Medical Director was notified of the plan for abatement of the Immediate Jeopardy. 16) Corporate Consultant staff will review abuse allegations to ensure the revised Abuse Policy & Procedure is being followed. The review will consist of ensuring the alleged perpetrator was removed from the facility immediately, any witnesses to the alleged abuse acted promptly to ensure resident safety, the investigation was thorough and a conclusion was determined, and that appropriate corrective action had been taken. The Administrator or DON will report the findings to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) A Quality Assurance meeting was conducted on 11/16/17 to review the status of staff education, monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal. Those in attendance included the Administrator, the DON, the Clinical Coordinators, the MDS Coordinators, the SDC, consultant staff, and the Medical Director. 18) Quality assurance meetings will be held at least weekly until substantial compliance is achieved, and then monthly for one quarter. **The State Survey Agency validated the correction actions taken by the facility as follows: 1) Review of the medical record for Resident #1 revealed the resident was assessed for signs and symptoms of abuse on 10/21/17. The physician and resident representative were notified of the incident. 2) Review of the personnel file for LPN #2 revealed the employee was terminated from the facility on 11/10/17. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed LPN #2 was terminated on 11/10/17. 3) Review of counseling forms dated 11/13/17 and 11/14/17 revealed all employees who were involved in the incident were counseled by the DON. Interviews with the DON and the Administrator on 11/21/17 at 1:40 PM and 1:50 PM revealed all employees involved in the incident were counseled. Interviews with SRNA #1 on 11/20/17 at 3:05 PM, and SRNA #3 on 11/21/17 at 9:10 AM, revealed they were counseled regarding the incident by the DON. 4) Review of staff interviews dated 11/09/17 revealed the DON, the Clinical Coordinators, the SDC, or the MDS Coordinator interviewed all staff to determine if any other incidents of abuse had occurred that had not been identified and to ensure that required notification had been made to state agencies. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been interviewed and were not aware of any incidents of abuse that had not been reported. 5) Review of a resident census revealed all interviewable residents were interviewed related to any concerns with abuse on 11/09/17 and 11/10/17. Interviews conducted on 11/20/17 at 1:30 PM with Resident #10, at 1:00 PM with Resident #11, and at 12:55 PM with Resident #12, revealed the residents had no concerns with abuse or mistreatment by facility staff. 6) Review of the facility census dated 11/09/17 and 11/10/17 revealed non-interviewable residents had skin assessments completed, and their clinical records were reviewed to identify any incidents of abuse that had not been identified. Interviews on 11/21/17 with the Clinical Coordinator at 9:55 AM and the MDS Coordinator at 10:10 AM reveled all non-interviewable residents had skin assessments completed and their records were reviewed for any concerns related to abuse. 7) Review of an attendance roster revealed a Department Head meeting was conducted on 11/09/17 to review the Immediate Jeopardy and a plan was developed to abate the Immediate Jeopardy. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they met on 11/09/17 to develop a plan for the abatement of Immediate Jeopardy. 8) Review of resident observation documentation dated 11/10/17 through 11/20/17 revealed observations had been conducted daily on eight residents assessed to exhibit behaviors, to ensure appropriate individualized interventions were in place and being implemented as indicated. Interviews with the Corporate Consultant, the Administrator, the DON, and the Clinical Coordinators on 11/21/17 from 9:55 AM to 2:20 PM revealed they had completed daily observations of at least eight residents with behaviors to ensure the residents' care plans were being implemented appropriately. 9) Review of Quality Assurance meeting minutes dated 11/11/17 revealed the Immediate Jeopardy and abatement plan were discussed with the Medical Director. Interview with the Administrator on 11/21/17 at 1:50 PM revealed she had met with the Medical Director on 11/11/17 and discussed the Immediate Jeopardy and abatement plan. 10) Review of facility investigations from 11/05/17 through 11/14/17 revealed the Corporate Consultant had reviewed the investigations. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed she had reviewed all incidents to ensure the facility's abuse policy and procedures had been followed. 11) Review of education dated 11/09/17 revealed the Corporate Consultant had trained the Administrator, the DON, and the SDC on conducting thorough investigations, ensuring immediate removal of an alleged perpetrator from the facility, interviewing staff that had worked with the alleged perpetrator, interviewing residents that had received care provided by the alleged perpetrator, documenting the conclusion of the investigation, and taking appropriate corrective action if necessary. Interviews on 11/21/17 from 12:55 PM to 2:20 PM with the Corporate Consultant, the Administrator, the DON, and the SDC revealed they had received the education by the Corporate Consultant on 11/09/17. 12) Review of the facility's abuse policy and procedure revealed it was revised on 11/10/17 and included immediate staff intervention to ensure resident safety and immediate removal of an alleged perpetrator from the facility. Review of staff education dated 11/10/17 revealed training was provided to the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager related to the revised Abuse Policy & Procedure. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, the SDC, and the Housekeeping Supervisor revealed they had all received the training on the facility's abuse policy and procedure. 13) Review of education sign-in sheets dated 11/10/17 revealed the DON, the Clinical Coordinators, the SDC, the MDS Coordinators, the Housekeeping Supervisor, and the Dietary Manager initiated mandatory education for all staff on the revised Abuse Policy & Procedure. Review of post tests revealed they had been completed by all staff who had received the education. Interviews conducted with three nurses and three SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been educated on the facility's abuse policy/procedure and had completed a post test. 14) Review of facility education dated 11/14/17 revealed nurses and nurse aides were trained related to providing care to residents with challenging behaviors and implementing interventions to address challenging behaviors. This education was conducted by the Administrator, the DON, the Clinical Coordinators, and the SDC. Interviews conducted with nurses and SRNAs on 11/21/17 from 9:30 AM to 10:15 AM revealed the staff had been trained on providing care to residents with challenging behaviors and ensuring the residents' care plans were being followed. 15) Review of Department Head meeting minutes dated 11/10/17 revealed a meeting was held to review the Immediate Jeopardy. Review of meeting minutes revealed the Medical Director was notified of the plan for abatement of the Immediate Jeopardy on 11/11/17. 16) Review of abuse allegations revealed the Corporate Consultant had reviewed all abuse allegations to ensure the revised Abuse Policy & Procedure had been followed. Interview with the Corporate Consultant on 11/21/17 at 2:20 PM revealed they had completed the reviews of abuse allegations to ensure the facility's abuse policy and procedures had been followed. Interview with the Administrator and DON on 11/21/17 at 1:40 PM and 1:50 PM, revealed they would report the findings of the abuse allegation reviews to the Quality Assurance Committee weekly for one month and then monthly for one quarter. 17) Review of Quality Assurance meeting minutes dated 11/16/17 revealed that the education provided to facility staff, the monitoring and audit results, and the progression of the plan for Immediate Jeopardy removal had been discussed in the meeting. Interviews on 11/21/17 from 9:55 AM to 2:20 PM with the DON, the Clinical Coordinator, the MDS Coordinator, and the SDC revealed they had all attended the Quality Assurance meeting conducted on 11/16/17. 18) Interview with the Administrator and the DON on 11/21/17 at 1:40 PM and 1:50 PM revealed the Quality Assurance meetings will be held weekly until substantial compliance is achieved, and then monthly for one quarter.