Every finding on record at Henson Park Health & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents received food portions consistent with planned serving sizes by failing to use the required scoop size when serving mashed potatoes and by using tongs rather than a standardized portioning utensil to serve roast beef. This deficient practice had the potential to result in all residents who receive meals from the dietary department to receive inconsistent portions and inadequate nutritional intake.The findings include: Review of the facility policy titled Policy #ADM-136 - Portion Control, undated, revealed all meals shall be portioned according to standardized recipes and menu requirements to ensure consistent quality and nutritional accuracy. The policy further stated portion utensils and scales were to be used for all serving lines, cooks were to follow recipe yield and portion guides exactly, the trayline was to be monitored daily by the Manager or Lead [NAME] for consistency, and over- or under-portioning was to be corrected immediately. Review of the facility policy titled Policy #ADM-029 - Trayline Operations, undated, revealed the trayline shall operate in an organized and efficient manner to ensure accuracy, safety, and resident satisfaction. The policy further stated trayline set-up must include proper utensils and that line servers were responsible for verifying each tray item matched the resident's ticket. Observation, on 08/03/2026 at 4:30 PM, revealed a Disher Sizes reference chart was posted on a cabinet in the dietary department adjacent to the trayline. The chart identified standardized disher sizes and corresponding portion volumes for use during meal service. Review of the trayline on 08/03/2026 at 4:42 PM, in conjunction with interview of the Dietary Manager, revealed the regular dinner menu listed a three-ounce serving of roast beef with gravy, a four-ounce serving of roasted red potato wedges, a four-ounce serving of cauliflower au gratin, a four-ounce serving of fruit cocktail, a four-ounce serving of milk, and an alternate entree of a four-ounce serving of lemon pepper pangasius. The Dietary Manager stated the facility had substituted four ounces of mashed potatoes for the four-ounce serving of roasted red potato wedges, four ounces of mixed vegetables for the four-ounce serving of cauliflower au gratin, and chicken noodle soup for the alternate four-ounce serving of lemon pepper pangasius Observation, on 08/03/2026 at 4:45 PM, revealed [NAME] 1 served mashed potatoes using a green-handled No. 12 disher, which dispensed approximately 2.875 fluid ounces, rather than the required four-ounce serving. Observation further revealed [NAME] 1 used tongs to portion the prescribed three-ounce serving of roast beef rather than a standardized portioning utensil. During an interview, on 08/03/2026 at 4:49 PM, the Dietary Manager stated not using the correct sized serving utensils was a concern because we are underserving food. During an interview, on 08/05/2026 at 2:56 PM, with [NAME] 1 she stated staff were trained to use standardized portion sizes and relied on the facility's spreadsheet and menu book to determine the correct scoop or utensil for each menu item. [NAME] 1 stated tongs were used to portion the roast beef because it made the meat easier to separate and more presentable, she acknowledged a standardized scoop should have been used, and stated, That was on me. [NAME] 1 further stated the incorrect green-handled scoop was used for the mashed potatoes because [NAME] 1 believed it was the correct size. [NAME] 1 stated it was important to follow the menus serving sizes to ensure residents were given correct portions and to ensure they are getting all of the nutrients they need. [NAME] 1 stated it was the responsibility of both the cook and the Dietary Manager to monitor portion sizes during trayline and ensure the correct serving utensils were used. During an interview, on 08/05/2026 at 1:27 PM, the Dietary Manager (DM) stated it was her responsibility to ensure the correct portion scoops were used during trayline and cooks were responsible for knowing the required serving sizes and using the appropriate portion utensils. The Dietary Manager stated staff were not trained to estimate serving sizes and that a scoop designated for meats should have been used to portion the roast beef rather than tongs. The Dietary Manager further stated the green-handled scoop used to serve the mashed potatoes stuck out because it was not a scoop typically used for that menu item. The Dietary Manager acknowledged noticing the incorrect scoop was being used and admitted the issue should have been corrected when it was observed. The Dietary Manager further stated proper portion sizes were important to ensure residents received the nutrition they needed and that residents requiring additional nutrition, including those who were underweight or had wounds, depended on receiving the prescribed portions. During an interview, on 08/06/2026 at 11:30 AM, the Registered Dietitian (RD) stated serving sizes were determined by facility policies, standardized recipes, production sheets, and menu requirements. The RD stated dietary staff were expected to use the standardized scoop sizes identified on the production sheet and that foods should be pre-portioned before trayline rather than estimated or portioned with tongs. The Registered Dietitian stated serving foods in portions smaller than those identified on the production sheet could increase residents' nutritional risk, particularly for residents with poor intake, those who were underweight, or those requiring additional nutrition for wound healing. The Registered Dietitian further stated portion control was a high priority to ensure residents received the planned calories, protein, and nutrients, and that inaccurate portion sizes could affect calorie counts, nutritional assessments, and evaluation of residents' nutritional status. The Registered Dietitian stated menu substitutions should be nutritionally equivalent, approved by the Dietary Manager or Registered Dietitian, and documented prior to implementation. The Registered Dietitian further stated that when menus changed, staff were still expected to use the correct portion sizes, obtain approval for substitutions, follow standardized recipes, and communicate menu changes to residents. During an interview, on 08/06/2026 at 2:51 PM, the Administrator stated dietary staff were expected to serve meals as written on the approved menu, use the correct serving utensils, and provide the prescribed portion sizes to residents. She stated menu substitutions were reviewed by the Registered Dietitian and compliance with physician-ordered diets, serving sizes, and standardized recipes was verified through routine monitoring and audits. The Administrator acknowledged failure to follow prescribed portion sizes could negatively affect residents' health, weight, and overall nutritional status.

Based on observation and interview, the facility failed to maintain clean and sanitary conditions in the facility's kitchen; failed to ensure proper setup of the three-compartment sink; and failed to not have personal items in the food handling area. This had the potential to affect all residents who received nutrition from the kitchen.Findings included: An initial tour of the kitchen was done on 07/15/2025 beginning at 9:20 AM with the Intern Dietary Manager (IDM) and revealed the following:-The floors of the walk-in refrigerator located inside the kitchen were sticky with a black substance on the floor. The IDM agreed the floors were dirty.-Debris and a black substance were visible on the kitchen floor between the dish station and the wall. The IDM agreed the floor was dirty.-Debris and a black substance were visible on the floor between the coffee station and the wall.-Personal sunglasses were observed on the second shelf of the cart that held the coffee, creamer, and sugar.-The tube light above the stove was observed covered with dust, and the light fixture had spots of rust.-The entire kitchen ceiling was observed with spots where paint was peeling off the tiles and some areas of the tiles had separated from the ceiling, leaving visible holes in the ceiling. The IDM agreed the kitchen ceiling did not look clean.-The IDM tested the sanitizer concentration of the three-compartment sink using a test strip. The strip showed orange, which indicated there was no sanitizing solution being dispensed from the dispenser. The IDM stated sometimes the Maintenance Director came to the kitchen to jiggle the hose and then the dispenser would work again. A concurrent interview was held on 07/15/2025 at 9:20 AM with Dietary Aide (DA) #2, DA #3, and the IDM. DA #3 stated they did not know how to check the sanitizer level for the three-compartment sink. The IDM stated there was another DA who usually worked the three-compartment sink and did the sanitizer testing, but the IDM did not know who did the testing when that DA was off work. The IDM said the kitchen was deep cleaned weekly, which included the baseboards, walls, stainless steel items, the wheels on the carts, and everything that needed to be cleaned. During an interview on 07/17/2025 at 1:47 PM with the IDM and the Administrator (ADM), the IDM stated their expectation was that the kitchen be kept clean with no personal items in the kitchen. The ADM said their expectation was that the kitchen be cleaned daily and remain clean

Based on observation, interview, and facility document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 45 resident rooms had a homelike environment. Specifically, room [ROOM NUMBER] was observed with ceiling tiles bulging downward and with brown stains.Findings included: An observation on 07/16/2025 at 8:38 AM revealed ceiling tiles in room [ROOM NUMBER] were bulging downward, and other ceiling tiles were noted with brown stains. An observation on 07/17/2025 at 10:55 AM revealed ceiling tiles in room [ROOM NUMBER] were bulging downward, and other ceiling tiles were noted with brown stains. An additional ceiling tile in the bathroom of room [ROOM NUMBER] was also noted with brown stains. A facility document titled, Work Order #856, dated 04/29/2025, revealed staff reported that room [ROOM NUMBER] had one tile by the bathroom door that needed to be popped back up and one tile near the window had cracks. The Work Order indicated the Maintenance Director updated the status of the Work Order to completed on 05/20/2025, with Comments that reflected, fixed. During a concurrent observation and interview with Licensed Practical Nurse (LPN) #1 on 07/17/2025 at 10:55 AM, ceiling tiles above the foot of the resident bed in room [ROOM NUMBER] were observed with brown stains and were bulging downward. Upon entrance to the resident's bathroom, one ceiling tile was observed with brown stains. LPN #1 stated she had not seen the bulging ceiling tiles or brown stains previously. LPN #1 stated that when there were issues with resident rooms, the information was input into The Equipment Lifecycle Systems (TELS), and maintenance was then responsible for fixing the concern. She stated staff were trained and expected to place any information regarding maintenance issues into the maintenance system. During an interview on 07/17/2025 at 11:17 AM, the Maintenance Director stated the facility used the TELS system to track any preventative or corrective maintenance for the building. He stated anyone was able to access the system to document concerns or issues, and once a work order was entered, he received an alert. The Maintenance Director stated he trained staff and expected them to be able to input a work order. He stated the facility did not have a written policy addressing the TELS system. During an interview on 07/17/2025 at 3:06 PM, the Assistant Director of Nursing (ADON) stated staff were trained and expected to ensure everything in a resident's room worked. The ADON stated that daily, staff should ensure there were no hazards in residents' rooms when they made rounds. She stated staff were trained to report any identified issues using the TELS system. During an interview on 07/17/2025 at 3:25 PM, the Administrator stated she expected things to be in good working order, including ceiling tiles. She said staff were trained and expected to put in work orders if there were any concerns or issues with a resident's room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure supplemental oxygen tubing was dated when changed and the physician-prescribed supplemental oxygen flow rate was followed for 1 (Resident #1) of 2 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled, Oxygen Administration, revealed, 5. Turn on the oxygen at the number of liters / [per] minute as ordered by the physician/practitioner. 6. Place appropriate oxygen device on the resident (i.e., [id est, that is] mask, nasal cannula and/or nasal catheter). 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered. An admission Record indicated the facility admitted Resident #1 on 05/28/2025. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), chronic pulmonary edema, and obstructive sleep apnea. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had shortness of breath or trouble breathing when lying flat and used supplemental oxygen during the assessment period. Resident #1's Care Plan Report included a focus area, initiated on 05/29/2025, that indicated the resident was at risk for respiratory complications secondary to COPD, pulmonary edema, obstructive sleep apnea, a history of smoking, dysphagia (difficulty swallowing), coronary artery disease, and a history of cerebrovascular accident. An intervention dated 05/29/2025 directed staff to administer supplemental oxygen as ordered. Resident #1's July 2025 Treatment Administration Record (TAR) revealed transcription of an order started on 05/28/2025 for supplemental oxygen at 2 liters per minute by way of nasal cannula, continuously. The July 2025 TAR revealed no orders for or documentation of changing or dating the resident's supplemental oxygen tubing. An observation on 07/15/2025 at 1:00 PM revealed Resident #1was receiving supplemental oxygen at a flow rate of 3 liters per minute. The resident's supplemental oxygen tubing was observed without a date to indicate when the tubing was last changed. An observation on 07/16/2025 at 11:26 AM revealed Resident #1was receiving supplemental oxygen at a flow rate of 3 liters per minute. The resident's supplemental oxygen tubing was observed without a date to indicate when the tubing was last changed. During an interview on 07/17/2025 at 10:45 AM, Licensed Practical Nurse (LPN) #1 stated the night shift nurses were responsible for changing out the supplemental oxygen tubing and for labeling the tubing. Per LPN #1, the nurses obtained the correct oxygen flow rate from the physician's orders. LPN #1 stated she checked the oxygen flow rate for residents every shift but had not checked the flow rates as of the time of the interview. LPN #1 stated staff were trained and expected to ensure the residents' oxygen flow rates were correct and to label the supplemental oxygen tubing when it was changed. During an interview on 07/17/2025 at 3:11 PM, the Assistant Director of Nursing (ADON) stated the night shift nurses were responsible for changing out the residents' supplemental oxygen tubing. The ADON stated staff were expected to date and initial the tubing when it was changed. The ADON stated staff were trained and were expected to follow physician's orders to maintain oxygen equipment. During an interview on 07/17/2025 at 3:19 PM, the Administrator stated staff were trained and were expected to follow physician's orders.

Based on observation and interview, it was determined the facility failed to follow professional standards for proper sanitation practices and maintaining equipment to prevent cross contamination. Observation on 06/10/2024 revealed an ice scoop stored uncovered by an ice machine in the kitchen which is used to provide ice to all residents. Additionally, observations on 06/11/2024, revealed dietary staff towel drying plate covers which were then used to cover the residents lunch meal. The findings include: Review of the 2017 United States Food and Drug Administration Food Code Section 4-903.11 (B)(1) Equipment, Utensils, Linens, and Single-Service and Single-Use Articles revealed Clean Equipment and Utensils shall be stored in a self-draining positron that allows air drying. Further review of the food code revealed ice scoops may be stored handles up in an ice bin except for an ice machine. Observation during initial kitchen tour on 06/10/2024 at 3:20 PM revealed an ice scooper stored in an uncovered bin by the ice machine which was used for all residents. Observation during lunch time meal service on 06/11/2024 at 11:40 AM revealed Dietary Aide 1 drying plate covers with a dry towel and not allowing them to air dry. Further observation revealed the dietary aide had already dried approximately 5-6 plate covers before the surveyor entered the kitchen, and dried an additional 3-4 more before the Dietary Director asked her to stop towel drying them, leaving the rest to drip dry on the cart. During an interview with Dietary Aide 1 on 06/11/24 at 12:10 PM, she stated she had just started in the kitchen a couple of weeks ago. Dietary Aide 1 stated no one had ever told her that she was not to towel dry the plate covers and that they were to air dry. During a brief interview with the Dietary Director on 06/10/2024 at 3:30 PM, he stated the ice machine was used for all residents and the ice scoop was stored separately from the ice. He stated he was not aware that the storage container for the ice scoop needed to be covered and he would take care of it. In an additional interview with the Dietary Director on 06/11/2024 at 11:45 AM, he stated staff were drying them the plate covers, because they felt pressed for time as they had gotten behind today. He further stated that he would remind staff to allow them to air dry and not wipe them dry. During an interview with the Administrator on 06/12/2024 at 1:20 PM, she stated she expected the dietary staff to provide clean and sanitary conditions in which to prepare nutritious food for residents.

Based on observation, interview, facility policy review and facility job descriptions review, it was determined the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for four of 46 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The findings include: Review of facility's policy titled Homelike Environment Guidance, revised 06/20/2024, revealed it was the policy of the facility to ensure the environment provided for residents was safe, sanitary, functional, and comfortable. Continued review of the facility policy revealed as part of daily guardian angel rounds, as well as, whenever it was noticed, institutional odors will be addressed and eliminated. Additionally, all room contents to include clothes, furniture, devices, linens, bedspreads, privacy curtains, window coverings, wall hangings, wallpaper, and floors should be clean and in good repair. Review of facility's housekeeping job description, undated, revealed the housekeeper was responsible for cleaning resident rooms and other interior and exterior facility areas and assisting in maintaining a clean and attractive environment for the residents. Continued review of the housekeeping's job description revealed it was the housekeeper's job duties to clean and straighten resident rooms, offices, and common areas, which included vacuuming, wiping, moping, and polishing. Additionally, it was the duty of the housekeeper to ensure resident's rooms are safe, comfortable, and maintained in an attractive manner. Review of facility's Maintenance Director job description, undated, revealed the Maintenance Director was responsible to ensure the facility was well-maintained in a safe and comfortable manner. Continued review of the facility's maintenance job description revealed it was the job duty to make daily rounds to assure that appropriate maintenance procedures are being rendered to meet the needs of the facility. 1. Observation of room [ROOM NUMBER], on 06/09/2024 at 2:23 PM, on 06/10/2024 at 9:12 AM, and on 06/11/2024 at 3:46 PM, revealed three missing floor tiles underneath the B side bed. During an interview with Registered Nurse (RN) 2 on 06/09/2024 at 3:10 PM, she stated C hallway (where room [ROOM NUMBER] was located) had recently been closed for repairs but she had not noticed the three missing tiles. RN2 stated she was not sure what happened as the missing tiles were stacked under the bed, but she would let the Maintenance Director know about the missing tiles. RN2 stated the risk could be a fall from either the staff or the resident if the bed was moved around the room. RN2 stated the resident residing in room [ROOM NUMBER] had no recent falls. During an interview with the Maintenance Director, on 06/12/2024 at 10:00 AM, he initially stated he did not have a current work order for room [ROOM NUMBER]'s missing floor tiles, but later stated he did have a work order dated 06/02/2024 for the missing tiles in the floor. The Maintenance Director stated the missing tiles was from the moving of the bed back into the room after C hallway opened back up. During an interview with the Assistant Director of Nursing (ADON) on 06/12/2024 at 1:16 PM, she stated she was not aware of the flooring issue in room [ROOM NUMBER] until today but the Maintenance Director was getting tiles to replace/repair the missing tiles in the room. 2. Observation of room [ROOM NUMBER] and 25's connecting bathroom, on 06/09/2024 at 2:30 PM and on 06/10/2024 at 11:23 AM, revealed strong urine odor present with sticky flooring around the toilet. Interview with Certified Nurse Aide (CNA) 1 on 06/09/2024 at 2:55 PM, he stated he had been in the shared bathroom of rooms [ROOM NUMBERS] and sprayed the bathroom floor around the commode with a cleaner, but the bathroom still smelled of urine. CNA1 stated he had told housekeeping and they were going to come back and clean it again. 3. Observation of room [ROOM NUMBER], on 06/09/2024 at 4:00 PM, on 06/10/2024 at 1:30 PM, and on 06/11/2024 at 9:10 AM, revealed strong urine odors present in room [ROOM NUMBER] and a yellowish-brown discoloration on the floor that was sticky, and the bathroom had an elevated toilet seat with a brown substance on the surface. Continued observation of room [ROOM NUMBER], on 06/12/2024 at 9:20 AM, revealed the strong urine odors and dark yellowish stains were still present on the floor. Interview with Licensed Practical Nurse (LPN) 1 on 06/09/2024 at 2:45 PM, she stated she could smell the strong urine odor and stated the housekeeper had been in rooms [ROOM NUMBER] cleaning earlier in the day. LPN1 stated room [ROOM NUMBER] would continue to have a strong smell of urine even after cleaning of the room. During an interview with Certified Nurse Aide (CNA) 1 on 06/09/2024 at 2:55 PM, he stated room [ROOM NUMBER] always had a strong odor of urine even after housekeeping cleaned the room. CNA1 stated one of the residents was blind and would sometimes urinate on the floor, which could be a reason for the strong urine smell in the room. During a second interview with CNA1, on 06/11/2024 at 12:05 PM, he stated not aware of staff reporting the strong urine odor in room [ROOM NUMBER] but would ensure the unit manager was made aware. He further stated he had not noticed room [ROOM NUMBER]'s bathroom being soiled but had not assisted the resident to the bathroom that morning. Additionally, he stated if he was aware that the bathroom was soiled, he would take care of it unless it was something more time consuming then housekeeping would be notified. During an interview with Housekeeper 1, on 06/12/2024 at 8:58 AM, she stated she was familiar with and the strong urine odors in the room [ROOM NUMBER]. She stated she had completed deep cleanings on a regular basis including pulling the bed from the wall and ensuring the floor was cleaned and sanitized underneath. She stated no matter what cleaning process was used the tiles were still covered with dark yellow urine stains which she believed would need to be replaced to resolve the issue. She stated the odor had gotten stronger over time. She stated housekeeping had checked the room regularly to ensure there was no urine on the floor and to address the odors. She further stated that if CNAs had observed urine on the floor or bed they would notify housekeeping. Housekeeper 1 stated she loved the residents and wanted to ensure they were treated with respect and dignity because this had been their home. She stated if the soiled tiles had not been addressed the strong urine odors would not be resolved. She stated that residents could experience possible skin breakdown if the bed was soiled. Additionally, she stated residents could experience sadness or anxiety because of an unacceptable home environment. During an interview with Housekeeping Supervisor (HS), on 06/12/2024 at 9:25 AM, she stated she had worked in the facility for a total of [AGE] years. She stated she was aware of the strong urine odors in room [ROOM NUMBER] and had made multiple attempts to resolve the issue. She stated staff had used several cleaning techniques and processes including different chemicals, vinegar, degreasers and scrubbing with a buffer, but nothing had worked to eliminate the odors. The HS stated the next step was to remove the soiled tiles, ensure the floor was cleaned underneath, and have new flooring installed. Per the HS, she was already in the process of correcting the issue when it was reported by CNA1. She further stated she wanted to provide a clean and homelike environment for all residents. She stated her expectations were that housekeepers cleaned the resident rooms daily with more attention given to rooms with odor concerns and to report issues that were not resolved. Additionally, she stated residents could experience negative consequences both emotionally and/or physically due to an unpleasant environment and other incontinent concerns. During an interview with the Maintenance Director, on 06/12/2024 at 10:00 AM, he stated that maintenance staff would repair the issues in the facility if they were skilled to do so otherwise it would be outsourced. He stated certain concerns would be repaired right away if were a potential and immediate danger for residents, otherwise the other facility concerns would be entered into the Technology to Streamline Building Management (TELS) program so they would be addressed as soon as possible. He stated he was made aware this week of room [ROOM NUMBER] and would be addressing the floor tile in that room in an attempt to resolve the odors. He further stated maintenance staff made rounds in the facility on a regular basis to check for any environmental concerns, but staff could also report any concerns to the maintenance department for repairs. During an interview with the Assistant Director of Nursing (ADON) on 06/12/2024 at 1:16 PM, she stated she felt the facility had a homelike environment. The ADON stated she was aware of the strong urine odor and the staff was working to resolve the issue. The ADON stated she would not expect strong urine odors to have a homelike feel to it. The ADON stated she was part of the guardian angel rounds, which are done daily in the facility. The ADON stated in those rounds, the staff would look for cleanliness and for any issues which needed repairs. Per the ADON, the guardian angel forms were brought to the stand-up meeting for discussion on how to fix the issue. The ADON stated on weekends the manager on duty would make rounds and fill out the guardian angel rounds form. Per the ADON, the problems (odors, missing floor tiles) had not been documented on guardian angel rounds. The ADON stated she was aware of the sticky floors, and it was a product issue. She stated the housekeepers would be using hot water with the current product until the new product arrived at the facility. The ADON stated the nursing staff knew to report any cleaning issues or repair issues needed in the facility. In an interview with Family Member (FM) 2, on 06/12/2024 at 1:51 PM, she stated she had observed the strong urine odors in room [ROOM NUMBER] and was concerned. FM2 stated she expected the facility to address the concern. During an interview with the Director of Nursing (DON) on 06/12/2024 at 2:29 PM, she stated daily cleaning of the facility was completed by housekeeping and she had no issues with the cleaning of the facility. The DON stated she made rounds daily as part of the guardian angel rounds and was not aware of the missing tiles or strong urine odors in the facility. The DON stated she expected the facility staff to look at what was on the guardian angel forms, which included things like dirty dishes, floor being dirty, curtains dirty, rooms with odors, or even missing floor tiles, and write it down on the form provided for those rounds. The DON stated the guardian angel forms are brought and discussed in morning meeting and both nursing stations have a binder where to put any housekeeping or maintenance issues. Per the DON, she had not been made aware of problems with odors and missing tile on guardian angel rounds. The DON stated all staff was aware of how to contact either housekeeping or maintenance with issues. The DON further stated she expected staff to be looking in the residents' rooms on rounds for any issues and to report those issues immediately to the appropriate staff to be resolved. During an interview with the Administrator on 06/12/2024 at 3:27 PM, she stated she became aware during the survey of the sticky floors, the missing floor tiles, and the strong urine odors in the facility and the facility was currently working on resolving these issues. The Administrator stated the sticky floors was due to the housekeeper's cleaning product and she had discussed the issue with the HS, and they were going to start using hot water with the product until the other product arrived which had been ordered. The Administrator stated some of the managers had guardian angel rounds and those rounds were tailored around what was currently going on in the facility. The Administrator stated the staff doing the guardian angel rounds would interview the residents (if able) to see how they were being treated and to observe for any environmental issues. The Administrator stated she expected the managers and the floor staff making rounds to look for call lights working, privacy curtains being clean and pulled during care, any odors in the rooms, and any missing floor tiles or ceiling tiles. The Administrator stated those rounds were written down on forms and were discussed in morning meetings. The Administrator stated those issues were again discussed in the daily stand down meeting to ensure the issues had been resolved. However, she stated the problems (sticky floors, missing tile, odors) had not been identified during the guardian angel rounds. The Administrator stated it was her expectation the facility was clean, safe, and odor free for the residents and the staff.

Based on interview and record review, it was determined the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for four days (03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024) out of 104 days from 03/01/2024 through 06/12/2024. The findings include: During an interview with the Administrator on 06/12/2024 at 3:27 PM, she stated the facility did not have a staffing policy. Additionally, the Administrator stated the facility did not have an RN staffing waiver. Review of the facility's daily schedules dated 03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024, revealed the facility did not have a Registered Nurse (RN) scheduled to work on these dates. Review of the facility's timecards for all nursing staff, dated 03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024, revealed the facility did not have an RN working on those dates. During an interview with Certified Nursing Assistant (CNA) 1 on 06/11/2024 at 10:27 AM, he stated he was picking up more shifts in the facility due to either call ins or just short on staff. CNA1 stated he had noticed the facility used Kentucky Medication Aide's (KMA) instead of nurses most of the days he was in the facility. During an interview with LPN1 on 06/12/2024 at 12:51 PM, she stated there had been a few occasions in the facility where they had no RN coverage over the past couple of months. LPN1 stated the facility had to use a staffing agency to get enough help in the facility. LPN1 stated nurse management was not always willing to come in and help when the facility had call ins for shifts, especially on the weekends. During an interview with the Scheduler, who was also a KMA, on 06/12/2024 at 2:14 PM, she stated she had been the Scheduler since February 2024, and she was not aware of the RN rule until today. The Scheduler stated the Director of Nursing (DON) had told her about this rule today. The Scheduler stated the facility had gone to set schedules which rotated workdays each week and she stated the facility had a lot of staff to quit over it. The Scheduler reviewed the daily schedules for the past 4 months and stated there appeared to be 4 days with no RN coverage. The Scheduler stated the facility had agency staff to cover holes (lack of staff) in the schedule, but stated someone had to cover the shifts if agency was not available. The Scheduler stated her and the nurse managers had to work to cover holes in the schedule. During an interview with the Assistant Director of Nursing (ADON) on 06/12/2024 at 1:16 PM, she stated the facility usually staffed two RNs on night shift or at least 1 RN and 1 LPN, but stated one RN on night shift was currently on medical leave. The ADON stated the facility usually staffed on dayshift 1 nurse (either LPN or RN) with 1 KMA on both A/C hallway and B hallway with 3 CNAs on each side. The ADON stated on night shift there was usually 2 CNAs on each side, but the census had been low lately. The ADON stated she was not aware of a time when the facility was not staffed in this manner. The ADON stated there were 6 nurses who rotated call for the weekends, and she had to come in to cover call ins for the facility. During an interview with the Director of Nursing (DON) on 06/12/2024 at 2:29 PM, she stated she did not see RN coverage for the dates of 03/27/2024, 04/24/2024, 05/27/2024, and 06/10/2024 on the daily schedule. The DON stated the facility did not have a nursing waiver. The DON stated the Scheduler worked on the schedule and both the Scheduler and the ADON called the staffing agencies whenever coverage was needed. The DON stated the schedule was posted two weeks in advance and it was discussed what the holes or needed staff were for each day. The DON stated the holes had to be filled and if agency could not cover it and the floor staff could not cover it, then she expected the nurse managers to cover the shifts. The DON stated, depending on what the hole in the schedule was for, either nurse, KMA, or CNA, then the Scheduler covered the hole first, then the Unit Manager (UM), the ADON, and then herself. The DON stated she was an RN and could always assist if something happened in the facility. The DON stated she was aware of the regulation for RN coverage, but stated it was hard to find RNs to work in long term care facilities. The DON stated she was not aware of any adverse effects from the four days of no RN coverage. The DON stated she expected to have enough staff to take care of the residents but would not give a number for what enough staff would be to take care of the residents in the facility. During an interview with the Administrator on 06/12/2024 at 3:27 PM, she stated she reviewed staffing daily, and she was aware of the no RN coverage, but she had done various things to get more RNs for the facility. The Administrator stated she had put out sign on bonuses, yard signs out for staffing, and had ads running for RN coverage, but did not have much luck with getting RNs hired at the facility. The Administrator stated the facility did not have a staffing waiver and the facility utilized staffing agencies to cover any holes in the schedule. The Administrator stated nursing management took care of call ins, but it usually took all hands-on deck to get the schedule holes filled up. The Administrator stated she expected her nurse managers to cover if a call in or hole in the schedule could not be filled with regular staff or with agency staff. The Administrator stated she expected to have enough staff to cover the shifts but would not give a number for how much was enough staff to take care of the residents in the facility.

Based on observation, interviews, and facility policy review it was determined the facility failed to implement procedures that address and monitor the safe storage and handling of medications for one of three medication storage refrigerators. Observation of the medication storage refrigerator on the A Hall on 06/11/2024 at 10:00 AM revealed the refrigerator was unplugged and the temperature inside the refrigerator registered at 62 degrees Fahrenheit (F). The findings include: Review of facility policy titled, Medication Storage in the Facility, revised 11/21/2022, revealed medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy stated medications shall be stored at temperatures between 36 degrees F and 46 degrees F. On 06/11/2024 at 10:00 AM, a review of the Medication Storage Refrigerator temperature log located on the A Hall revealed it was last checked on 06/10/2024 at 9:00 PM and registered at 38 degrees F. During an observation of the Medication Storage Refrigerator on A Hall on 06/11/2024 at 10:00 AM, the refrigerator was noted to be unplugged and the temperature was registered at 62 degrees F inside the refrigerator. During an in an interview with the Housekeeping Director on 06/11/24 at 11:22 AM, she stated they sweep and mop the medication rooms. She also stated the refrigerators up front in the nurses station is where they kept snacks for residents, and housekeeping is responsible for keeping them clean and defrosted, and that they just got assigned the task of defrosting the medication refrigerators recently. She stated she defrosted the two refrigerators on B Hall this morning, and the night shift nurse did the one on A Hall. She stated the Director of Nursing (DON), told her that she didn't have to do those on the A Hall because the nurse had already done those but did not state which nurse did them. She stated the process to defrost the refrigerators is to ask the nurse to remove the medications first, then she defrosts the fridge. She stated after that occurs she lets the nurse know when she is done and the nurse comes back and puts the medications back in. She stated she nor her staff touch any of the medications that are stored in refrigerator. She stated she documents the task in a file on her computer. During an in an interview with Licensed Practical Nurse (LPN) 4 on 06/11/2024 at 10:00 AM, she stated she was unsure of how the refrigerator became unplugged and that she thought it was because housekeeping mopped the room last night. She stated they shouldn't be unplugging things without notifying nursing staff first. She stated she did not use anything out of the refrigerator this morning and that if she had it could pose potential harm to residents. Per LPN4, 62 degrees F was not acceptable medication refrigerator temperature. She stated they will have to waste the medications and get a replacement from pharmacy. During an interview with LPN3 on 06/12/2024 at 4:10 PM, she stated she contacted the facility's pharmacy on 06/11/2024 at 10:00 AM regarding the medications that were being stored in the refrigerator on A Hall at the direction of the Director of Nursing (DON). She stated the pharmacy advised her that all the medications stored in the A Hall refrigerator were good except the Procrit and TB Serum, and she discarded those medications and reordered them at this time. During an interview with the Director of Nursing (DON) on 06/11/2024 at 3:25 PM, she stated that she had asked housekeeping to defrost the refrigerators on B Hall and the night nurse to do the ones on A Hall. She stated they are putting in a process to correct the error by doing audits and having nursing staff sign yes or no if the refrigerator is plugged in. She stated it is ultimately the nurse's responsibility to ensure the medication refrigerator is at the proper storage temperature. She stated she had one of the nurses call the pharmacy and they went over all the medications that were in the fridge and all of them were good except the Procrit and TB Serum. She stated those medications have been reordered and will be in tomorrow. During an interview with the Administrator on 06/12/2024 at 1:20 PM, she stated that she had been made aware of the error and that the Director of Nursing was handling the refrigerator medication storage issue. She stated she expects her nursing staff to follow storage guidelines as a prudent nurse would do. She further stated that the nursing administration was working together to put a plan in place to ensure proper storage so that this does not occur again.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an infection 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 one of 35 sampled residents (R) R8. The findings include: Review of the facility's policy, titled Infection Prevention and Control Guideline, revised 02/25/2022, revealed it was the policy of the facility to ensure a comprehensive system was in place which prevents, identifies, investigates reports, records and controls infections and prevent the development and transmission of communicable disease processes for residents/care providers, staff, visitors, and others within the facility to include those providing contractual services in an effort to provide a safe, sanitary, and comfortable environment. Continue review of the facility policy revealed the facility would determine the most effective practices to reduce infection rates as well as identifying ways to integrate these practices into the everyday workday to create a culture of safety as related to infection control. Additionally, newly hired staff would be educated on infection prevention conducted by the infection preventionist on topic to include but not limited to hand hygiene, blood borne pathogens, personal protective equipment (PPE), and sharps handling. Review of the facility's policy, titled Syringe and Needle Disposal, dated March 2023, revealed used syringes and needles are disposed of safely in conformance with applicable laws and safety regulations. Continued review of the policy revealed immediately after use, syringes and needles are placed into sharps containers. Observation of medication pass with Licensed Practical Nurse (LPN) 6 on 06/11/2024 at 8:12 AM revealed LPN6 was preparing to administer R8's Insulin, Detemir and Insulin Aspart, in two separate syringes. Continued observation revealed after LPN6 administered the injectable insulin to the resident, the LPN laid down both syringes on R8's bed without first covering the needles. Review of R8's admission record revealed R8 was admitted to the facility on [DATE] with admitting diagnoses of acute and chronic respiratory failure with hypoxia, unspecified congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizophrenia, obstructive sleep apnea, and anxiety disorder. Review of R8's physician's orders, dated June 2024, revealed R8 had an order for Insulin Detemir 100 unit/milliliter inject 80 units subcutaneously two times a day. Continued review of the physician's orders revealed R8 had an order for Insulin Aspart 100 unit/milliliter inject 80 units subcutaneously four times a day and to hold if blood sugar was less than 70. Review of R8's medication administration record (MAR), dated June 2024, revealed R8 had a blood sugar of 369 on 06/11/2024 at 11:30 AM and both insulin's were to be given per physician's orders. Review of R8's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) dated 03/13/2024, revealed R8 had a Brief Interview for Mental Status (BIMS) of 7 out of 15, which indicated severe cognitive impairment. Review of R8's comprehensive care plan (CCP), dated 10/25/2022, revealed R8 was at risk to have an alteration in carbohydrate metabolism related to the diagnosis of type 2 diabetes mellitus with a goal for R8 to be free from complications through the next review date. Continued review of the CCP revealed R8 had interventions to give medications as ordered, obtain labs as ordered, obtain blood sugar as ordered, and to observe for signs and symptoms of hypoglycemia or hyperglycemia and report abnormal findings to the physician as needed. Review of Licensed Practical Nurse (LPN) 6's employee file revealed LPN6 was hired in May 2024 and had received education in orientation for infection control, safe sharps handling, and medication administration and had made 100% passing score on all posttests. An interview with LPN6 on 06/11/2024 at 8:24 AM, revealed she knew she was supposed to push the safety needle up after usage, but she was nervous and forgot to do it. LPN6 stated she had been working at the facility for about a month, but she had been a nurse for almost 7 years and knew better. LPN6 stated the risk for not disposing of needles immediately after usage could be a needlestick for either the resident or the staff member who was handling the sharps, which could spread infection such as bloodborne pathogens. During an interview with the Director of Nursing (DON) on 06/11/2024 at 8:42 AM, she stated LPN6 had training in orientation on medication administration, sharps disposal, and infection control. The DON stated LPN6 had training on the floor with another nurse on proper medication administration, which included injections and safely disposing of sharps after usage. The DON stated it was her expectation for all sharps to be disposed of immediately after being used to prevent infection control issues. The DON stated the risk for not disposing of needles immediately after usage could be the spread of infection via needlestick. During an interview with the Assistant Director of Nursing (ADON) on 06/12/2024 at 1:16 PM, she stated she would not expect needles to be placed on a bed uncovered. The ADON stated she and the DON re-educated LPN6 about glucose monitoring, proper insulin administration, and syringe/needle disposal. The ADON stated LPN6 was being placed back in orientation for another week. During an interview with the DON on 06/12/2024 at 2:29 PM, she stated she expected her nurses to always follow the needle safety policy. The DON stated when nurses complete an injection, the needle and the syringe should immediately be disposed of properly in a sharp's container. The DON stated a syringe, or a needle should never be put anywhere other than a sharps container. The DON stated LPN6 had been re-educated by the DON, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting had been done, and a performance improvement plan (PIP) had been initiated. The DON stated she would review LPN6's performance in a week and would go from there. During an interview with the Administrator on 06/12/2024 at 3:27 PM, she stated the facility did an Ad Hoc Quality Assurance (QA) meeting over the syringe issue with LPN6. The Administrator stated she expected all staff to follow the infection control policy and she expected the nurses to dispose of syringes and needles properly by immediately placing the used syringe or needle in a sharps container and not lay the items down on the bed. The Administrator stated LPN6 was re-educated by the DON and put back in orientation for another week. The Administrator stated the DON would review LPN6's progress and would continue to work with the PIP which had been started on LPN6. The Administrator stated the risk of not disposing of sharps immediately would be the spread of infection.

Based on observation, interview, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to provide or arrange for services or care that adhered to accepted standards of practice for three (3) of twenty-three (23) sampled residents (Residents #59, #14, and #58). The residents' nurse and/or Kentucky Medication Aide (KMA) dispensed the medications from the blister pack into their (nurse/KMA) ungloved hand and then into the medicine cup. The findings include: Review of the facility's policy, Policy and Procedure, Medication Administration, undated, outlined timeframes for medication administration. However, there was no information on medication distribution. Review of the facility's policy, Medication Administration Competency, dated 06/2011, revealed it provided instruction on dispensing of medication from blister packs into medication cup. However, it did not instruct staff on how to handle the medication and avoid using the bare hand. Review of the facility's document, Landmark-Clinical Standard and Guideline: Medication Administration Policy Guideline, dated 05/17/2021, revealed it failed to cover dispensing of tablet medication and proper procedure for the nurse or Kentucky Medication Aide (KMA). Review of the facility's document, Landmark Medication Administration Test revealed it covered the standard practice of dispensing medication from a blister pack into the medication cup, bypassing contact with hands. 1. Observation on 01/10/2024 at 8:20 AM of Licensed Practical Nurse (LPN) #3 in B Hall standing at medication cart #2, revealed the LPN dispensed a tablet from the blister pack then into her ungloved hand. From that point, LPN #3 dropped the tablet into a clear plastic medication cup on top of the medication cart. Following the same practice for four (4) more medications, LPN #3 proceeded to dispense a capsule from a blister pack onto the top of the medication cart. She then proceeded to grasp the capsule with both ungloved hands and empty the contents into a clear plastic bag containing the other medications to be crushed. After crushing the medications, they were mixed with pudding and given to Resident #14 sitting in the hallway. In an interview with LPN #3 on 01/10/2024 at 9:43 AM, LPN #3 stated, Please tell me if I am doing anything wrong. I want to know if there is something I need to improve on. When asked if the LPN knew dispensing of medication from the blister pack to an ungloved hand and then to the medicine cup was not current practice, LPN #3 asked, What am I supposed to do? and Should I use gloves? The State Survey Agency (SSA) Surveyor responded that LPN #3 needed to follow the facility's policy for medication administration and consult with the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about appropriate medication distribution. 2. Observation on 01/10/2024 at 8:19 AM of Registered Nurse (RN) #3 on the A Hall at medication cart #1 revealed the RN was dispensing multiple pills from a blister pack into h/her ungloved hand. RN #3 then placed all of the medication into a clear plastic medication cup for Resident #58. 3. Observation on 01/11/2024 at 9:15 AM of KMA #3 working on B Hall at medication cart #1 revealed KMA #3 took a card of blister pack medication, dispensed the medication into his/her ungloved hand, then placed the medication into the clear plastic medication cup. After dispensing three (3) additional medications using the same process, KMA #3 entered Resident #59's room and administered the medication. In an interview with KMA #3 on 01/11/2024 at 9:26 AM in B Hall, when asked if the KMA could explain the process for getting medication from the cards to the medication cup. KMA #3 replied, you pull the card with the medication and put it into the cup. When asked if the medication should touch ungloved hands, KMA #3 replied, I guess not. I thought it was okay to touch the medication once your hands are clean. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 01/11/2024 at 10:20 AM, they stated they expected nursing staff to practice according to professional standards. They stated the facility had a management meeting later that day and developed a training and competency skills test to be performed by each KMA or nurse before returning to work on the floor. The DON stated, That is not appropriate practice for a nurse to have medication come in contact with a bare hand. The DON stated the new education and competency provided understanding of the importance with medication administration and tested the nurses' understanding of non-contact with hands. In an interview with the Administrator on 01/11/2024 at 10:45 AM, the Administrator stated that her expectation was that all nursing staff would practice using accepted standards. She stated after she met with her team and discussed deficient practice identified, she would investigate the employees responsible for the deficient practice. She stated, I will meet with the DON to ensure all nurses or KMAs are re-educated, tested , and perform a return demonstration before they are allowed to return to resident care.

Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were implemented related to abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835) at the highest scope and severity of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12, Free from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Abuse Prevention Program, dated 10/22/2022, revealed it was the facility's policy that staff members, who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident, and the findings of the examination must be recorded in a separate incident report. Per the policy, to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Review of Resident #9's Admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Alzheimer's Disease, history of falling, and dementia with mood disturbance and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow on dementia. Per the report, statements were written and signed by Licensed Practical Nurse (LPN) #13, CNA #33, and CNA #35. Review of the facility's Five (5) day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment on Resident #9, and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. Per the report, all residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed, and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment), and no areas of concern were identified. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of CNA #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with topics discussed as follows: medication administration; proper progress notes and documentation; use of the chart audit tool; all residents at risk for elopement and the review of all elopement drills; the need for twenty-four/seven (24/7) front door monitoring; resident care plans; and use of the Continuous Quality Improvement (CQI) tool. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON, the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said to Resident #9, I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy on abuse and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. In further interview with CNA #33, on 10/17/2023 at 5:21 PM, she stated the DON told her she was going to call the Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 told her I have to send CNA #35 home and I'm nervous. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She continued to state she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34, on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She continued to state CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9 and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She continued to state CNA #35 told CNA #34 sit in that chair and don't let him/her get up or touch anything. She stated LPN #13 came into the room and talked with the resident, then CNA #35 came back into the room and she left, leaving LPN #13 and CNA #35 in Resident #9's room. CNA #34 further stated no one asked her to write out a statement related to the incident stating, I've been waiting for someone to ask me about the incident, and no one's asked me. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023, she was caring for a resident about two (2) doors down the hall from Resident #9's room around 2:00 AM when she heard crying coming from Resident #9's room, a high pitched sound. She stated Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her, I need to report abuse. She further stated she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. LPN #13 stated CNA #33 told her CNA #35 said to Resident #9, It's time for bed, and used vulgar words to address Resident #9. Additionally, she stated she told CNA #33 to call the DON, then the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9 and she told CNA #35 she had to go home and she watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse, now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and she was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should have probably been removed from the facility earlier than she was. In an interview with Police Officer #1, on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated staff informed him that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. He further stated he did not attend the QAPI meeting held on 10/13/2023 either in person or by telephone. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33 who reported CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She states she called and notified Administrator #2, then called and talked to a nurse and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room, but from the time the incident occurred until CNA #35, was sent home was approximately ten to fifteen (10-15) minutes. The DON stated she was aware the police came to the building but was not sure what they did. Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023, since it was an allegation and had not been thoroughly investigated at that time. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the policy titled Abuse and Neglect Reporting Policy, but would reach out to the Regional Nurse Consultant to see if another policy was in effect. He later presented the State Survey Agency with a policy titled Abuse Prevention Program. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) about an abuse allegation and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and to complete a head to toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8) (which indicated cognitive impairment), and interview any residents with a BIMS score of eight (8) or higher. He further stated the police should be contacted, if needed. During continued interview with the Administrator, on 10/18/2023 at 10:18 AM, he stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. The Administrator stated he did not need to list everyone he interviewed in his report and that the conclusion (located on the facility's 5-day investigation report) stated, based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. He stated he discussed the incident in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. He further stated he discussed it with the department heads and the Medical Director. However, CNA #34, the staff the resident reported the physical and verbal abuse to, stated in interview, she had not been interviewed related to the incident. Additionally, interview with the Medical Director revealed he was unaware of the incident and did not attend the QAPI meeting held on 10/13/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going forward. In an interview with the facility's Scheduler on 10/21/2023 at 2:39 PM, she stated she did not attend the meeting in which the abuse allegation which involv [TRUNCATED]

Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. The facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. The facility's failure to ensure residents were protected from abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs, and situations such as inappropriate language and insensitive handling. Continued review revealed the policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that were necessary to attain and maintain physical, mental and psychosocial well-being. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Physical abuse included hitting, slapping, pinching, kicking, etc. and controlling behavior through corporal punishment. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident and the findings of the examination must be recorded in a separate incident report. Continued review of the facility's policy, titled, Abuse Prevention Program, dated 10/22/2022, revealed when an alleged case of abuse or neglect was reported, the Administrator, or person in charge of the facility, would notify the following person or agencies immediately per Kentucky Revised Statute, Chapter 209: Kentucky Cabinet for Health and Family Services, Office of the Inspector General, Division of Long Term Care (LTC), Law Enforcement Officials as per the Policy on Reporting Reasonable Suspicions of a crime in LTC facility, Section 1150B of the Social Security Act. Policy Number 2.11a., the resident representative and the physician. Additionally, review of the policy revealed to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Additional review of the Abuse Prevention Program policy, dated 10/22/2022, revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services department monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of Resident #9's Admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Muscle Weakness, Alzheimer's Disease, and Dementia with Mood Disturbance and Anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Comprehensive Care Plan, dated 03/02/2022, revealed the facility determined the resident to be at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease with interventions that included: on 03/02/2022 for Wander Guard (an electronic bracelet on the resident's ankle that caused the door alarm to sound if the resident went through the door) per order, to check Wander Guard function/placement as ordered, complete Elopement/Wander Assessment as indicated, redirect wandering as needed, and staff to provide one-to-one (1:1) supervision as needed. Review of the facility's initial report, dated 10/12/2023, revealed CNA #33 heard a scream, went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of Certified Nursing Assistant (CNA) #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report form, dated 10/12/2023 by Officer #1 of the local police department, CNA #35 was charged with Assault and Wanton Abuse. Review of the facility's five (5) day final report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the Director of Nursing (DON). Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. All residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment) and no areas of concern were identified. Per the report, the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. The State Survey Agency (SSA) Surveyor attempted to contact CNA #35 by phone three (3) times, but CNA #35 did not return the calls. These attempts occurred on 10/17/2023 at 3:32 PM and 8:55 PM and on 10/18/2023 at 11:02 AM. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 (who was sitting 1:1 with Resident #9) stand up and use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified Licensed Practical Nurse (LPN) #13, who stated she was unaware of the facility policy. She stated LPN #13 asked her to call the Director of Nursing (DON). She further stated she went to the front lobby area bathroom and called the DON using her cellphone. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 said, I have to send CNA #35 home and I'm nervous. On 10/17/2023 at 5:21 PM, CNA #33 further stated she did not want to be close to CNA #35 when CNA #35 was told to go home because CNA #35 could get ugly quickly. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with Certified Nursing Assistant (CNA) #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room, and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9. She stated she went with CNA #35 to report to Licensed Practical Nurse (LPN) #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break. She stated when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. Additionally, she stated CNA #35 seemed aggravated. She stated LPN #13 came into the room and talked with the resident. She stated CNA #35 came back into the room and CNA #34 left, leaving LPN #13 and CNA #35 in Resident #9's room. She further stated she believed the staff did a good job protecting Resident #9 and reporting timely to administration. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023 around 2:00 AM, she was caring for a resident about two (2) doors down the hall from Resident #9's room. She stated she heard crying coming from Resident #9's room and a high pitched sound, and Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her I need to report abuse. LPN #13 stated CNA #33 told her she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. She stated CNA #33 told her CNA #35 said to Resident #9 it's time for bed and used vulgar words to address Resident #9. In a continued interview with LPN #13, on 10/17/2023 at 7:55 PM, she stated she told CNA #33 to call the DON. She stated the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9, and she told CNA #35 she had to go home and watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse; now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something and was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Officer #1 on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated he was told by staff that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Director of Nursing (DON) on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33. She stated CNA #33 told her CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She stated she called and notified the Administrator #2. She stated she then called and talked to a nurse, and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room. However, she stated from the time the incident occurred until CNA #35 was sent home was approximately ten to fifteen (10-15) minutes. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). She stated she was aware the police came to the building but was not sure what they did. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the Abuse and Neglect Reporting Policy. He stated he would reach out to the Regional Nurse Consultant to see if another policy was in effect. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) with abuse allegations and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and do a head-to-toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8), which indicated cognitive impairment. He stated he also told staff to interview any residents with a BIMS score of eight (8) or higher and to call the police if needed. Further interview, on 10/18/2023 at 10:18 AM, with the Administrator, he stated the Social Services Director (SSD) did follow up assessments for psychosocial harm. He stated these assessments should have been done throughout the shift during which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. He stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. He stated he did not need to list everyone he interviewed in his report and that the conclusion said based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as

Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident, I'm not dealing with your ass tonight. CNA #33 stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. However, the facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse allegation from 10/12/2023 was not discussed. The Administrator's and DON's failure to ensure residents were immediately protected from abuse in a timely manner; failure to thoroughly investigate an abuse incident; and failure to involve the Quality Assurance and Performance Improvement (QAPI) Committee in addressing the abuse incident in a timely manner has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's job description for Administrator, undated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. Further review revealed the Administrator's Essential Job Functions included: job knowledge and administrative duties, interpersonal skills, safety/infection control, and resident care/dignity. Per the job description, the Administrator's responsibilities also included: communicating and observing the Corporate Compliance Program effectively; working with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments; monitoring each department's activities, communicating policies, evaluating performance, providing feedback and assistance, coaching and discipline as needed; ensuring consultants and other support resources were appropriately utilized and a high level of inter-departmental teamwork was maintained; and maintaining a working knowledge and ensuring compliance with all governmental regulations and company Quality Assurance Standards. Continued review revealed the Administrator's responsibilities included: he/she was aware of Resident Abuse Reporting Law, ensured understanding of, and compliance with, all rules regarding residents' rights, possessed strong knowledge regarding state, federal and local regulations as they pertain to long term care, and successfully completed facility conducted orientation, mandatory training, and in-service programs. Review of the facility's job description for the Director of Nursing, undated, revealed the DON, under the supervision of the Administrator, had the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, and, in the absence of the Administrator, the DON assumed responsibility for the facility. Further review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week and was delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures. Continued review revealed the DON's Essential Job Functions included: job knowledge/duties, administrative duties, nursing systems, nursing documentation, interpersonal skills, safety, infection control, and resident care/dignity. Per the job description, the DON's responsibilities included: acting appropriately under the direction of the Administrator, acting as an active member of the Interdisciplinary Team (IDT); communicating and observing the Corporate Compliance Program effectively and complying with the Code of Conduct when performing work functions; supervising, evaluating, counseling and disciplining inter-departmental personnel; participating in coordination of resident services through departmental and appropriate staff committee meetings (such as Quarterly Quality Assurance and Assessment and Resident Care policy and procedure meeting); planning staff development programs that would enhance staff knowledge of quality resident care; reviewing all accidents and incidents daily and developing an appropriate plan to prevent future accidents and incidents; conducting periodic reviews of documentation for inconsistencies on each unit; was aware of, and adhered to the Resident's [NAME] of Rights and Confidentiality of Resident Information; was aware of Resident Abuse Reporting Law and ensured all staff understanding/compliance; recognizing, removing, and/or reporting potential hazards; and ensuring nursing personnel complied with residents' personal and property rights. Additionally, the DON must possess strong knowledge of state, federal, and local regulations as they pertained to long term care. Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed it was the policy of the facility for staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs and situations such as inappropriate language and insensitive handling. Additionally, review of the policy revealed the facility stated to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Record review revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services Department to monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of the facility's policy titled Quality Assurance and Performance Improvement, dated 11/2017, revealed it was the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life. Further review revealed the QA (Quality Assurance) Committee should be interdisciplinary and consist, at a minimum, of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, at least one (1) of which must be the Administrator, Owner, a board member or other individual in a leadership role, and the Infection Control and Prevention Officer. Additionally, adverse events would be monitored in accordance with established procedures for the type of adverse event with the data related to adverse events used to develop activities to prevent them. Per the policy, the governing body and/or executive leadership was responsible and accountable for the QAPI program. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow. Per the report, statements were written and signed by LPN #13, CNA #33, and CNA #35. However, CNA #34, who witnessed some of the incident, was not listed. Review of the facility's Five (5) Day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities we noted. Resident #9 stated I just had to go to the bathroom. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her/his usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with several topics discussed. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON. the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, which caused the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and asked CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because he/she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9, and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. When asked if she made a statement to anyone from the facility, she stated, No, I've been waiting for someone to ask me about the incident; no one's asked me for a statement. In an interview with LPN #13 on 10/17/2023 at 7:55 PM she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and was not sure what the policy was specifically. She stated CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Police Officer #1 on 10/17/2023 at 9:08 PM he stated the police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated, based on his report, CNA #35 would be arrested and charged with Assault and Wanton Abuse. In an interview with the Social Services Director (SSD) on 10/18/2023 at 10:58 AM, she stated she was aware of the abuse allegation on 10/12/2023 when she arrived to the facility for her regularly scheduled work day (time punch on 10/12/2023 revealed she clocked in at 9:03 AM). She further stated she talked with the resident's son during the morning of 10/12/2023, and he was okay with the situation. However, there was no documented evidence to support her conversation with the son or that she talked with the resident. She stated she did not do a psychosocial assessment on Resident #9. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated, after hearing about the abuse allegation concerning Resident #9, she called CNA #35 and told her to leave the building, but she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023 since it was an allegation and had not been thoroughly investigated at that time, and she was instructed by corporate to not discuss it on 10/13/2023. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated the SSD did follow up assessments for psychosocial harm, and these should have been done throughout the shift on which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. The Administrator stated he discussed the incident and abuse prevention in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. However, he stated CNA #34, a witness to some of the events with Resident #9 on 10/12/2023, was not interviewed. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7 [TRUNCATED]

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure the security and confidentiality of residents' medical records for two (2) of four (4) medication carts in the facility. Observation on [DATE] of Medication Cart #1 on the B Hall and on [DATE] of Medication Cart #2 on the B Hall revealed unattended computers were open with resident information displayed on the computer screen located on the cart. The findings include: Review of the facility's policy titled, Medical Records Health Insurance Portability and Accountability Act (HIPAA) Guideline, dated [DATE], revealed Personal Health Information (PHI) would be used and disclosed in accordance with the HIPAA Privacy Standards and other applicable laws. Further review revealed PHI included oral, written, or otherwise recorded information that was created or received by the facility and might relate to an individual's physical or mental health, payment, or health care services provided to an individual. Continued review revealed PHI might pertain to a health condition or payment in the past, present, or future, and the person who was the subject of the information might be alive or deceased . Additionally, PHI would be protected in any form, including, but not limited to, telephone conversations and voice mail, paper records, computers, transmissions over the Internet, dial-up lines, private networks, fax machines, electronic memory chips, magnetic tape, magnetic disk, and compact disc read-only memory (CD-ROM [a computer disc]). Review of the facility's policy titled Resident Rights, dated ,d+[DATE], revealed the resident had a right to personal privacy and confidentiality of his/her personal and medical records. Further review revealed the resident had the right to secure and confidential personal and medical records. Observation on [DATE] at 4:33 PM, revealed an open computer on the unattended B Hall Medication Cart #1 with multiple residents' medical records displayed, visible and accessible to staff walking down the hallway and residents sitting in the hallway. Further observation revealed Kentucky Medication Aide (KMA) #1 was standing outside a resident's room down the hallway from the medication cart. Observation on [DATE] at 8:42 AM, revealed an open computer on the unattended B Hall Medication Cart #2 with multiple residents' medical records displayed. Multiple residents were sitting in the hallway within sight of the computer screen. Further observation revealed Registered Nurse (RN) #3 in a resident's room near the medication cart. During an interview with KMA #1 on [DATE] at 4:35 PM, she stated she had been administering medications to residents when a resident threw his/her legs out of the bed. She stated she walked into the resident's room to check on him/her, leaving the computer open on the medication cart. KMA #1 stated the computer screen should have been locked because anyone walking down the hallway could have seen the residents' names and room numbers. She stated someone could have clicked the computer to open a new screen with additional resident information, such as a medication list. The KMA stated she had received education on making sure the screen was locked when stepping away from the medication cart because other people could use the computer to access residents' information. During an interview with Registered Nurse (RN) #3 on [DATE] at 8:45 AM, she stated the computer screen should have been closed because anyone walking by could have looked at the computer screen and seen residents' confidential information. She stated she normally kept it closed and had received education to lock the computer screen whenever she stepped away from the cart so no one could access residents' information. During an interview with the Director of Nursing (DON) on [DATE] at 2:15 PM, she stated staff had been educated to lock the computer screens when they stepped away from them to protect residents' confidential information. She further stated residents' information could be obtained from viewing the computer screen, which would be in violation of HIPAA laws. The DON stated it was her expectation that staff members closed computer screens any time they were not actively using them in order to safeguard residents' confidential medical records. During an interview with Administrator #2, on [DATE] at 10:18 AM, he stated it was his expectation that all staff would follow the policies and procedures of the facility and protect the residents' privacy and confidentiality.

Based on observation, interview, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to provide or arrange for services or care that adhered to accepted standards of practice for three (3) of twenty-three (23) sampled residents (Residents #59, #14, and #58). The residents' nurse and/or Kentucky Medication Aide (KMA) dispensed the medications from the blister pack into their (nurse/KMA) ungloved hand and then into the medicine cup. The findings include: Review of the facility's policy, Policy and Procedure, Medication Administration, undated, outlined timeframes for medication administration. However, there was no information on medication distribution. Review of the facility's policy, Medication Administration Competency, dated 06/2011, revealed it provided instruction on dispensing of medication from blister packs into medication cup. However, it did not instruct staff on how to handle the medication and avoid using the bare hand. Review of the facility's document, Landmark-Clinical Standard and Guideline: Medication Administration Policy Guideline, dated 05/17/2021, revealed it failed to cover dispensing of tablet medication and proper procedure for the nurse or Kentucky Medication Aide (KMA). Review of the facility's document, Landmark Medication Administration Test revealed it covered the standard practice of dispensing medication from a blister pack into the medication cup, bypassing contact with hands. 1. Observation on 01/10/2024 at 8:20 AM of Licensed Practical Nurse (LPN) #3 in B Hall standing at medication cart #2, revealed the LPN dispensed a tablet from the blister pack then into her ungloved hand. From that point, LPN #3 dropped the tablet into a clear plastic medication cup on top of the medication cart. Following the same practice for four (4) more medications, LPN #3 proceeded to dispense a capsule from a blister pack onto the top of the medication cart. She then proceeded to grasp the capsule with both ungloved hands and empty the contents into a clear plastic bag containing the other medications to be crushed. After crushing the medications, they were mixed with pudding and given to Resident #14 sitting in the hallway. In an interview with LPN #3 on 01/10/2024 at 9:43 AM, LPN #3 stated, Please tell me if I am doing anything wrong. I want to know if there is something I need to improve on. When asked if the LPN knew dispensing of medication from the blister pack to an ungloved hand and then to the medicine cup was not current practice, LPN #3 asked, What am I supposed to do? and Should I use gloves? The State Survey Agency (SSA) Surveyor responded that LPN #3 needed to follow the facility's policy for medication administration and consult with the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about appropriate medication distribution. 2. Observation on 01/10/2024 at 8:19 AM of Registered Nurse (RN) #3 on the A Hall at medication cart #1 revealed the RN was dispensing multiple pills from a blister pack into h/her ungloved hand. RN #3 then placed all of the medication into a clear plastic medication cup for Resident #58. 3. Observation on 01/11/2024 at 9:15 AM of KMA #3 working on B Hall at medication cart #1 revealed KMA #3 took a card of blister pack medication, dispensed the medication into his/her ungloved hand, then placed the medication into the clear plastic medication cup. After dispensing three (3) additional medications using the same process, KMA #3 entered Resident #59's room and administered the medication. In an interview with KMA #3 on 01/11/2024 at 9:26 AM in B Hall, when asked if the KMA could explain the process for getting medication from the cards to the medication cup. KMA #3 replied, you pull the card with the medication and put it into the cup. When asked if the medication should touch ungloved hands, KMA #3 replied, I guess not. I thought it was okay to touch the medication once your hands are clean. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 01/11/2024 at 10:20 AM, they stated they expected nursing staff to practice according to professional standards. They stated the facility had a management meeting later that day and developed a training and competency skills test to be performed by each KMA or nurse before returning to work on the floor. The DON stated, That is not appropriate practice for a nurse to have medication come in contact with a bare hand. The DON stated the new education and competency provided understanding of the importance with medication administration and tested the nurses' understanding of non-contact with hands. In an interview with the Administrator on 01/11/2024 at 10:45 AM, the Administrator stated that her expectation was that all nursing staff would practice using accepted standards. She stated after she met with her team and discussed deficient practice identified, she would investigate the employees responsible for the deficient practice. She stated, I will meet with the DON to ensure all nurses or KMAs are re-educated, tested , and perform a return demonstration before they are allowed to return to resident care.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored safely and securely for one (1) of three (3) treatment carts. Observation of the C Hall treatment cart on 10/16/2023 at 2:20 PM revealed various creams and ointments were accessible in the unsecured treatment cart. The findings include: Review of the facility's policy, titled Medication Storage in the Facility, revised on 11/21/2022, revealed medications and biologicals should be stored safely, securely, and properly following the manufacturer's or supplier's recommendations. Further review of the policy revealed the medication rooms, medication and treatment carts, and medication supplies should be locked or attended by a person with authorized access. Observation on 10/16/2023 at 2:20 PM of the C Hall Treatment Cart, revealed it was unlocked. Continued observation revealed various creams and ointments were noted in individual zip lock bags with residents' names on them in the unlocked treatment cart. These creams and ointments included: 1) four (4) tubes of Preparation H Ointment (used to treat hemorrhoids); six (6) tubes of Diclofenac Sodium Topical Gel 1% (anti-inflammatory used to treat arthritis pain); three (3) tubes of Ketoconazole Cream 2% (used to treat fungal skin infections); five (5) tubes of Biofreeze gel (used to treat muscle and joint pain); two (2) tubes of [NAME] and [NAME] Oil (used to treat skin wounds and bed sores); four (4) tubes of Venelex Wound Dressing Ointment; one (1) bottle of Johnson and Johnson Baby Shampoo; ten (10) tubes of Renew Dimethicone Skin Protectant (used to treat minor skin rashes); three (3) bottles of Betadine Antiseptic Spray; six (6) tubes of Equate Pain Relieving Cream Lidocaine 4%; and four (4) bottles of Nystatin Topical Powder (used to treat fungal skin infections). Review of the Safety Data Sheet (SDS) for Preparation H Ointment revealed it might cause an allergic skin reaction; and if ingested, rinse mouth immediately and drink plenty of water. Review of the SDS for Diclofenac Sodium Topical Gel 1% revealed it might cause serious eye irritation, drowsiness, dizziness. Further review revealed the Gel was suspected of damaging fertility or the unborn child, and might cause damage to organs through prolonged or repeated exposure; and if ingested, do not induce vomiting and seek medical attention immediately. Review of the SDS for Ketoconazole Cream 2% revealed it might cause mild skin irritations; and if ingested, do not induce vomiting and seek medical attention immediately. Review of the SDS for Biofreeze Gel revealed it was flammable, harmful if swallowed, and might cause eye irritation; and if ingested, do not induce vomiting and immediately call a poison control center or doctor. Review of the SDS for [NAME] and [NAME] Oil revealed it might cause skin irritation; and if ingested, seek medical attention immediately. Review of the SDS for Venelex Wound Dressing Ointment revealed it might cause skin and eye irritation, an allergic skin reaction, or cancer; and if ingested and symptoms occur, consult a doctor immediately. Review of the SDS for Johnson and Johnson Baby Shampoo revealed no hazard statements; but if ingested, do not induce vomiting and seek medical attention immediately. Review of the SDS for Betadine Antiseptic Spray revealed it might cause eye or skin irritation; and if ingested, wash mouth out with copious amounts of water and seek medical attention immediately. Review of the SDS for Equate Pain Relieving Cream Lidocaine four percent (4%) revealed it might cause irritation of the nose and throat and eye irritations; and if ingested, flush out mouth with water and consult a physician immediately. Review of the SDS for Nystatin Topical Powder revealed it might cause eye, skin, gastrointestinal, and/or respiratory tract irritation; and if ingested, flush out mouth with water and seek medical attention immediately. During an interview on 10/16/2023 at 2:56 PM with Licensed Practical Nurse (LPN) #8, who was in charge of the cart, she stated the treatment cart being unlocked was not good. When asked about what not good meant, LPN #8 stated if a dementia resident was to open the treatment cart and get any of the ointments or creams in the cart, then the resident could eat it. She stated if residents ate the medication, it could make them sick, and they could die or at the least have an allergic reaction. LPN #8 stated the treatment cart was supposed to be locked when the nurse was not working with it and had the cart in sight of the nurse. The LPN stated if a resident got into the treatment cart, then she would have to notify the Medical Director (MD), the DON, and the family. During an interview on 10/16/2023 at 3:10 PM with LPN #2, who was in charge of the treatment cart, she stated that medication and treatment carts were supposed to be locked when the nurse was not using them. She stated the carts were to be locked so residents could not get the ointments and creams and eat them. LPN #2 stated certain residents had diagnoses like dementia and might not understand what they were doing. She stated if a resident ingested these ointments and/or creams, it could cause an allergic reaction. During an interview on 10/18/2023 at 9:05 AM with the DON, she stated all medication and treatment carts were supposed to be locked except when nurses were using them. The DON stated it was her expectation that those carts were to be locked so residents could not get into them and get medications whether it was pills or creams. She further stated if a resident ingested some chemical somebody would be in trouble. The DON stated residents could potentially have adverse reactions such as nausea and vomiting and could have to be hospitalized . She also stated her expectation was nurses would call poison control, the MD, the family, and both herself and the Administrator if a resident had been harmed because a medication cart or treatment cart had been left unlocked by a nurse. During an interview on 10/20/2023 at 1:24 PM with Interim Administrator #3, she stated her expectation was for any cart to be locked, whether it was a medication cart or a treatment cart. Interim Administrator #3 stated if a resident got into an unlocked cart, it could be harmful if the resident ingested a substance found in the unlocked cart.

Based on observation, interview, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to provide or arrange for services or care that adhered to accepted standards of practice for three (3) of twenty-three (23) sampled residents (Residents #59, #14, and #58). The residents' nurse and/or Kentucky Medication Aide (KMA) dispensed the medications from the blister pack into their (nurse/KMA) ungloved hand and then into the medicine cup. The findings include: Review of the facility's policy, Policy and Procedure, Medication Administration, undated, outlined timeframes for medication administration. However, there was no information on medication distribution. Review of the facility's policy, Medication Administration Competency, dated 06/2011, revealed it provided instruction on dispensing of medication from blister packs into medication cup. However, it did not instruct staff on how to handle the medication and avoid using the bare hand. Review of the facility's document, Landmark-Clinical Standard and Guideline: Medication Administration Policy Guideline, dated 05/17/2021, revealed it failed to cover dispensing of tablet medication and proper procedure for the nurse or Kentucky Medication Aide (KMA). Review of the facility's document, Landmark Medication Administration Test revealed it covered the standard practice of dispensing medication from a blister pack into the medication cup, bypassing contact with hands. 1. Observation on 01/10/2024 at 8:20 AM of Licensed Practical Nurse (LPN) #3 in B Hall standing at medication cart #2, revealed the LPN dispensed a tablet from the blister pack then into her ungloved hand. From that point, LPN #3 dropped the tablet into a clear plastic medication cup on top of the medication cart. Following the same practice for four (4) more medications, LPN #3 proceeded to dispense a capsule from a blister pack onto the top of the medication cart. She then proceeded to grasp the capsule with both ungloved hands and empty the contents into a clear plastic bag containing the other medications to be crushed. After crushing the medications, they were mixed with pudding and given to Resident #14 sitting in the hallway. In an interview with LPN #3 on 01/10/2024 at 9:43 AM, LPN #3 stated, Please tell me if I am doing anything wrong. I want to know if there is something I need to improve on. When asked if the LPN knew dispensing of medication from the blister pack to an ungloved hand and then to the medicine cup was not current practice, LPN #3 asked, What am I supposed to do? and Should I use gloves? The State Survey Agency (SSA) Surveyor responded that LPN #3 needed to follow the facility's policy for medication administration and consult with the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about appropriate medication distribution. 2. Observation on 01/10/2024 at 8:19 AM of Registered Nurse (RN) #3 on the A Hall at medication cart #1 revealed the RN was dispensing multiple pills from a blister pack into h/her ungloved hand. RN #3 then placed all of the medication into a clear plastic medication cup for Resident #58. 3. Observation on 01/11/2024 at 9:15 AM of KMA #3 working on B Hall at medication cart #1 revealed KMA #3 took a card of blister pack medication, dispensed the medication into his/her ungloved hand, then placed the medication into the clear plastic medication cup. After dispensing three (3) additional medications using the same process, KMA #3 entered Resident #59's room and administered the medication. In an interview with KMA #3 on 01/11/2024 at 9:26 AM in B Hall, when asked if the KMA could explain the process for getting medication from the cards to the medication cup. KMA #3 replied, you pull the card with the medication and put it into the cup. When asked if the medication should touch ungloved hands, KMA #3 replied, I guess not. I thought it was okay to touch the medication once your hands are clean. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 01/11/2024 at 10:20 AM, they stated they expected nursing staff to practice according to professional standards. They stated the facility had a management meeting later that day and developed a training and competency skills test to be performed by each KMA or nurse before returning to work on the floor. The DON stated, That is not appropriate practice for a nurse to have medication come in contact with a bare hand. The DON stated the new education and competency provided understanding of the importance with medication administration and tested the nurses' understanding of non-contact with hands. In an interview with the Administrator on 01/11/2024 at 10:45 AM, the Administrator stated that her expectation was that all nursing staff would practice using accepted standards. She stated after she met with her team and discussed deficient practice identified, she would investigate the employees responsible for the deficient practice. She stated, I will meet with the DON to ensure all nurses or KMAs are re-educated, tested, and perform a return demonstration before they are allowed to return to resident care.

Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident, I'm not dealing with your ass tonight. CNA #33 stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. However, the facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse allegation from 10/12/2023 was not discussed. The Administrator's and DON's failure to ensure residents were immediately protected from abuse in a timely manner; failure to thoroughly investigate an abuse incident; and failure to involve the Quality Assurance and Performance Improvement (QAPI) Committee in addressing the abuse incident in a timely manner has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's job description for Administrator, undated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. Further review revealed the Administrator's Essential Job Functions included: job knowledge and administrative duties, interpersonal skills, safety/infection control, and resident care/dignity. Per the job description, the Administrator's responsibilities also included: communicating and observing the Corporate Compliance Program effectively; working with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments; monitoring each department's activities, communicating policies, evaluating performance, providing feedback and assistance, coaching and discipline as needed; ensuring consultants and other support resources were appropriately utilized and a high level of inter-departmental teamwork was maintained; and maintaining a working knowledge and ensuring compliance with all governmental regulations and company Quality Assurance Standards. Continued review revealed the Administrator's responsibilities included: he/she was aware of Resident Abuse Reporting Law, ensured understanding of, and compliance with, all rules regarding residents' rights, possessed strong knowledge regarding state, federal and local regulations as they pertain to long term care, and successfully completed facility conducted orientation, mandatory training, and in-service programs. Review of the facility's job description for the Director of Nursing, undated, revealed the DON, under the supervision of the Administrator, had the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, and, in the absence of the Administrator, the DON assumed responsibility for the facility. Further review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week and was delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures. Continued review revealed the DON's Essential Job Functions included: job knowledge/duties, administrative duties, nursing systems, nursing documentation, interpersonal skills, safety, infection control, and resident care/dignity. Per the job description, the DON's responsibilities included: acting appropriately under the direction of the Administrator, acting as an active member of the Interdisciplinary Team (IDT); communicating and observing the Corporate Compliance Program effectively and complying with the Code of Conduct when performing work functions; supervising, evaluating, counseling and disciplining inter-departmental personnel; participating in coordination of resident services through departmental and appropriate staff committee meetings (such as Quarterly Quality Assurance and Assessment and Resident Care policy and procedure meeting); planning staff development programs that would enhance staff knowledge of quality resident care; reviewing all accidents and incidents daily and developing an appropriate plan to prevent future accidents and incidents; conducting periodic reviews of documentation for inconsistencies on each unit; was aware of, and adhered to the Resident's [NAME] of Rights and Confidentiality of Resident Information; was aware of Resident Abuse Reporting Law and ensured all staff understanding/compliance; recognizing, removing, and/or reporting potential hazards; and ensuring nursing personnel complied with residents' personal and property rights. Additionally, the DON must possess strong knowledge of state, federal, and local regulations as they pertained to long term care. Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed it was the policy of the facility for staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs and situations such as inappropriate language and insensitive handling. Additionally, review of the policy revealed the facility stated to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Record review revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services Department to monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of the facility's policy titled Quality Assurance and Performance Improvement, dated 11/2017, revealed it was the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life. Further review revealed the QA (Quality Assurance) Committee should be interdisciplinary and consist, at a minimum, of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, at least one (1) of which must be the Administrator, Owner, a board member or other individual in a leadership role, and the Infection Control and Prevention Officer. Additionally, adverse events would be monitored in accordance with established procedures for the type of adverse event with the data related to adverse events used to develop activities to prevent them. Per the policy, the governing body and/or executive leadership was responsible and accountable for the QAPI program. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow. Per the report, statements were written and signed by LPN #13, CNA #33, and CNA #35. However, CNA #34, who witnessed some of the incident, was not listed. Review of the facility's Five (5) Day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities we noted. Resident #9 stated I just had to go to the bathroom. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her/his usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with several topics discussed. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON. the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, which caused the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and asked CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because he/she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9, and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. When asked if she made a statement to anyone from the facility, she stated, No, I've been waiting for someone to ask me about the incident; no one's asked me for a statement. In an interview with LPN #13 on 10/17/2023 at 7:55 PM she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and was not sure what the policy was specifically. She stated CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Police Officer #1 on 10/17/2023 at 9:08 PM he stated the police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated, based on his report, CNA #35 would be arrested and charged with Assault and Wanton Abuse. In an interview with the Social Services Director (SSD) on 10/18/2023 at 10:58 AM, she stated she was aware of the abuse allegation on 10/12/2023 when she arrived to the facility for her regularly scheduled work day (time punch on 10/12/2023 revealed she clocked in at 9:03 AM). She further stated she talked with the resident's son during the morning of 10/12/2023, and he was okay with the situation. However, there was no documented evidence to support her conversation with the son or that she talked with the resident. She stated she did not do a psychosocial assessment on Resident #9. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated, after hearing about the abuse allegation concerning Resident #9, she called CNA #35 and told her to leave the building, but she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023 since it was an allegation and had not been thoroughly investigated at that time, and she was instructed by corporate to not discuss it on 10/13/2023. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated the SSD did follow up assessments for psychosocial harm, and these should have been done throughout the shift on which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. The Administrator stated he discussed the incident and abuse prevention in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. However, he stated CNA #34, a witness to some of the events with Resident #9 on 10/12/2023, was not interviewed. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the In[TRUNCATED]

Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. On 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 witnessed CNA #35 push Resident #9 in the chest while yelling at the resident. There was no documented evidence CNA #35 was immediately removed from Resident #9's room or Resident #9 was placed in a safe location away from CNA #35. During an interview with CNA #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident, I'm not dealing with your ass tonight. CNA #33 stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. However, the facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse allegation from 10/12/2023 was not discussed. The Administrator's and DON's failure to ensure residents were immediately protected from abuse in a timely manner; failure to thoroughly investigate an abuse incident; and failure to involve the Quality Assurance and Performance Improvement (QAPI) Committee in addressing the abuse incident in a timely manner has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's job description for Administrator, undated, revealed the Administrator led and directed the overall operation of the facility in accordance with resident needs, federal and state government regulations, and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. Further review revealed the Administrator's Essential Job Functions included: job knowledge and administrative duties, interpersonal skills, safety/infection control, and resident care/dignity. Per the job description, the Administrator's responsibilities also included: communicating and observing the Corporate Compliance Program effectively; working with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments; monitoring each department's activities, communicating policies, evaluating performance, providing feedback and assistance, coaching and discipline as needed; ensuring consultants and other support resources were appropriately utilized and a high level of inter-departmental teamwork was maintained; and maintaining a working knowledge and ensuring compliance with all governmental regulations and company Quality Assurance Standards. Continued review revealed the Administrator's responsibilities included: he/she was aware of Resident Abuse Reporting Law, ensured understanding of, and compliance with, all rules regarding residents' rights, possessed strong knowledge regarding state, federal and local regulations as they pertain to long term care, and successfully completed facility conducted orientation, mandatory training, and in-service programs. Review of the facility's job description for the Director of Nursing, undated, revealed the DON, under the supervision of the Administrator, had the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, and, in the absence of the Administrator, the DON assumed responsibility for the facility. Further review revealed the DON was responsible for the overall management of resident care twenty-four (24) hours a day, seven (7) days a week and was delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures. Continued review revealed the DON's Essential Job Functions included: job knowledge/duties, administrative duties, nursing systems, nursing documentation, interpersonal skills, safety, infection control, and resident care/dignity. Per the job description, the DON's responsibilities included: acting appropriately under the direction of the Administrator, acting as an active member of the Interdisciplinary Team (IDT); communicating and observing the Corporate Compliance Program effectively and complying with the Code of Conduct when performing work functions; supervising, evaluating, counseling and disciplining inter-departmental personnel; participating in coordination of resident services through departmental and appropriate staff committee meetings (such as Quarterly Quality Assurance and Assessment and Resident Care policy and procedure meeting); planning staff development programs that would enhance staff knowledge of quality resident care; reviewing all accidents and incidents daily and developing an appropriate plan to prevent future accidents and incidents; conducting periodic reviews of documentation for inconsistencies on each unit; was aware of, and adhered to the Resident's [NAME] of Rights and Confidentiality of Resident Information; was aware of Resident Abuse Reporting Law and ensured all staff understanding/compliance; recognizing, removing, and/or reporting potential hazards; and ensuring nursing personnel complied with residents' personal and property rights. Additionally, the DON must possess strong knowledge of state, federal, and local regulations as they pertained to long term care. Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed it was the policy of the facility for staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs and situations such as inappropriate language and insensitive handling. Additionally, review of the policy revealed the facility stated to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Record review revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services Department to monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of the facility's policy titled Quality Assurance and Performance Improvement, dated 11/2017, revealed it was the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life. Further review revealed the QA (Quality Assurance) Committee should be interdisciplinary and consist, at a minimum, of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, at least one (1) of which must be the Administrator, Owner, a board member or other individual in a leadership role, and the Infection Control and Prevention Officer. Additionally, adverse events would be monitored in accordance with established procedures for the type of adverse event with the data related to adverse events used to develop activities to prevent them. Per the policy, the governing body and/or executive leadership was responsible and accountable for the QAPI program. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow. Per the report, statements were written and signed by LPN #13, CNA #33, and CNA #35. However, CNA #34, who witnessed some of the incident, was not listed. Review of the facility's Five (5) Day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities we noted. Resident #9 stated I just had to go to the bathroom. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her/his usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with several topics discussed. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON. the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, which caused the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and asked CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because he/she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9, and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. When asked if she made a statement to anyone from the facility, she stated, No, I've been waiting for someone to ask me about the incident; no one's asked me for a statement. In an interview with LPN #13 on 10/17/2023 at 7:55 PM she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and was not sure what the policy was specifically. She stated CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Police Officer #1 on 10/17/2023 at 9:08 PM he stated the police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated, based on his report, CNA #35 would be arrested and charged with Assault and Wanton Abuse. In an interview with the Social Services Director (SSD) on 10/18/2023 at 10:58 AM, she stated she was aware of the abuse allegation on 10/12/2023 when she arrived to the facility for her regularly scheduled work day (time punch on 10/12/2023 revealed she clocked in at 9:03 AM). She further stated she talked with the resident's son during the morning of 10/12/2023, and he was okay with the situation. However, there was no documented evidence to support her conversation with the son or that she talked with the resident. She stated she did not do a psychosocial assessment on Resident #9. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated, after hearing about the abuse allegation concerning Resident #9, she called CNA #35 and told her to leave the building, but she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023 since it was an allegation and had not been thoroughly investigated at that time, and she was instructed by corporate to not discuss it on 10/13/2023. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated the SSD did follow up assessments for psychosocial harm, and these should have been done throughout the shift on which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. The Administrator stated he discussed the incident and abuse prevention in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. However, he stated CNA #34, a witness to some of the events with Resident #9 on 10/12/2023, was not interviewed. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7 [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #10). On [DATE], the facility admitted Resident #10 and on [DATE], Registered Nurse (RN) #4 discovered Resident #10's admission orders had been transcribed incorrectly. Therefore, Resident #10 was administered the wrong medications from [DATE] to [DATE]. The facility's failure to have an effective system to ensure residents were free of significant medication errors is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR S483.45 (F760) Pharmacy Services at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.45 (F760) Pharmacy Services. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and IJ is ongoing. The findings include: Review of the facility's policy titled, Medication Errors dated ,d+[DATE], revealed medications were to be administered according to the Physician's orders and in accordance with accepted standards and principles which applied to professionals who provided services. Review of the facility's policy titled, Medication Transcription Guidelines dated [DATE], revealed all drug orders received via a transfer sheet were to be verified by the attending Physician and transcribed into the facility's electronic charting system, Point Click Care (PCC). Continued review revealed staff were to complete documentation; clarify orders, and transcribe the prescribed medication orders into PCC. Per review, transcription of newly prescribed medication orders, new order changes, and discontinued medications were to be completed in PCC, and the orders transcribed into PCC were to be electronically transmitted to the provider pharmacy to be filled. Review of the facility's contracted Pharmacy provider's policy, Resident Information (Admission/Change of Status), undated, revealed it was the Pharmacy's policy for the facility to provide complete and accurate information to the Pharmacy relative to admission/readmission and change in status prior to the Pharmacy dispensing medications. Review of the facility's policy titled, Quality Care Process dated [DATE], revealed a daily Continuous Quality Improvement (CQI) meeting was to include a medication administration audit to be run for missed and late medications. Per review, the medication administration audit to determine what had not been signed on the Electronic Medication Administration Record (EMAR). Further review revealed any medications not administered in the previous twenty-four (24) hours were to be looked at for codes as to why some had not taken medications and followed up as needed. The facility did not provide any policy for CQI prior to [DATE]. Review of the Pharmacy Services Agreement between the facility and contract Pharmacy provider, undated, revealed the Pharmacy agreed to provide prescriptions and over the counter medications, whether oral, intravenous (IV), topical, or otherwise, and pharmacy supplies to the facility as requested by the facility pursuant to the order of the resident's attending Physician. Further review revealed the contract Pharmacy agreed to provide the services in accordance with professional standards and all laws, rules, and regulations that applied or related to the performance of the services. Review of Resident #10's Admission Record/electronic medical record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses which included Chronic Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's previous facility's Discharge Summary dated [DATE], revealed the resident had been prescribed Budesonide-formoterol (inhaler used to treat asthma), Diltiazem (high blood pressure), Duo Neb (used to treat breathing conditions), Eliquis (a blood thinner), Gabapentin 600 mg twice a day (used to treat neurological pain), Hydralazine (used to treat high blood pressure), Januvia (used to treat diabetes), Losartan (used to treat high blood pressure), Primidone (used to treat seizures), Spiriva (used to treat breathing conditions), and Tramadol (used to treat pain) upon admission. Further review revealed however, the current facility failed to ensure those medications were transcribed onto Resident #10's current Medication Administration Record (MAR) to be administered to the resident. Review of the [DATE] MAR for Resident #10 revealed the following medications listed as having been administered: Seroquel one (1) tablet (no dosage) at bedtime (used to treat mental disorders); Xarelto twenty (20) mg (a blood thinner) at bedtime; Aspart Insulin two (2) units (used to treat diabetes) with meals and Detemir Insulin sixteen (16) units (used to treat diabetes) twice a day; and Gabapentin three hundred (300) mg (used to treat neurological pain) three times a day from [DATE] until [DATE]. (However, none of the medications listed were prescribed for Resident #10, except for the Gabapentin, which should have been 600 mg twice daily as prescribed). Review of the facility's documentation revealed the facility completed a medication error form; however, there was no documented evidence the facility investigated the medication error related to the resident not receiving his/her prescribed medications, to determine whose medication had been administered to Resident #10. Review of Resident #10's Progress Note dated [DATE], entered by RN #4, revealed the resident had uncontrolled pain, was diaphoretic (sweating heavily), short of breath, and had shaking hands. Continued review of the Note revealed Resident #10 should have been prescribed and have received Tramadol fifty (50) mg (a pain medication) daily and Tramadol fifty (50) mg twice daily as needed for pain, which had not been ordered for the resident upon admission. In interview on [DATE] at 2:50 PM, Registered Nurse (RN) #4 stated she spoke with Resident #10's family member who reported Resident #10 expressed to the family that he/she was in pain due to not having received his/her pain medications. Further review of Resident #10's EMR revealed the resident had been admitted to the hospital on [DATE] and readmitted to the facility on [DATE], with new orders to administer Invanz (antibiotic used to treat infection) daily on [DATE] and [DATE], and Daptomycin (antibiotic used to treat infection) daily from [DATE] until [DATE] for a Urinary Tract Infection (UTI). However, review of Resident #10's [DATE] MAR revealed no documented evidence the resident received the Invanz on [DATE], nor the Daptomycin on [DATE] and [DATE], as ordered to treat his/her infection. Review of Resident #10's Physician's Order sheet (completed by the Physician upon seeing the resident and scanned into the system, not entered into PCC) dated [DATE], and signed by the Medical Director (MD) revealed the resident had a urinalysis completed which had been highly suggestive of a UTI and was confirmed with a culture. Continued review revealed Resident #10 had been placed on treatment for the infection and had been slow to improve in terms of his/her symptoms. Continued review of Physician's Order sheet dated [DATE] and signed by the MD, revealed the resident had been hospitalized a week prior with metabolic encephalopathy that had been determined to be secondary to ESBL ([Extended Spectrum Beta-Lactamases] enzymes from bacteria which cause resistance to some antibiotics) UTI. Further review revealed the Physician's Plan had been to complete Resident #10's course of Invanz. Review of the Pharmacy Invoices revealed the Invanz had been delivered on [DATE] at 7:51 PM, and the Daptomycin had been delivered on [DATE] at 8:22 AM. Review of Resident #10's [DATE] MAR revealed the Invanz had been documented as not having been available on [DATE], and was not administered until [DATE]. Continued review revealed and there was no documented evidence the second dose of Invanz had been administered as ordered. Further review revealed Resident #10 did not receive the first dose of Daptomycin until [DATE], and the doses of Daptomycin were documented as having been unavailable on [DATE] and [DATE]. Review of Resident #10's Progress Note dated [DATE], entered by Registered Nurse (RN) #1, revealed the Daptomycin had been unavailable for administration from the Pharmacy. Review of Resident #10's Progress Note dated [DATE], entered by Licensed Practical Nurse (LPN) #2 revealed she had notified the Pharmacy and the Physician on [DATE] that the intravenous (IV) antibiotic medications had not been available to administer. Further review revealed LPN #2 had been unable to administer the Invanz on [DATE] because it had been unavailable from Pharmacy. Review of the Progress Note dated [DATE] entered by LPN #5 revealed the Daptomycin had not been available to administer. Continued review revealed however, no documented evidence on [DATE], the Physician was notified the Daptomycin remained unavailable for administration. Review of Resident #10's Progress Note dated [DATE], entered by LPN #1 revealed the resident had been found unresponsive and had been readmitted to the hospital. Review of Resident #10's hospital records revealed the resident had been admitted on [DATE]. Continued review revealed on [DATE], the resident had been diagnosed with staphylococcus epidermidis (a bacterial infection) and Acinetobacter (a bacterial infection) which he/she had developed since being discharged from the hospital on [DATE]. Further review revealed unfortunately, now Resident #10 had new and even more resistant bugs. In addition, review further revealed Resident #10 had an infection on [DATE] which had been sensitive to Daptomycin. Review of Resident #10's Palliative Care Hospital Note dated [DATE], revealed the resident had multiple multi-drug resistant organisms. Continued review revealed Resident #10 expired on [DATE] with the cause of death documented as refractory (hypotension and end-organ dysfunction) sepsis infection. The State Survey Agency (SSA) Surveyor attempted telephone interview on [DATE] at 8:00 AM and 3:18 PM, and on [DATE] at 12:15 PM; however, all attempts were unsuccessful. Messages were left for RN #6, who entered Resident #10's [DATE] orders, to return the SSA Surveyor's call, but no return call was received, and the nurse no longer worked at the facility. During an interview with Registered Nurse (RN) #4 on [DATE] at 2:50 PM, she stated she found Resident #10's medications had been entered incorrectly on [DATE], when the resident had his/her daughter called the facility to inquire about the resident's Tramadol for pain. She stated the orders did not sit right and since this had been a new resident for her, she looked at Resident #10's discharge medications and realized they did not match what the resident had been ordered in the facility's system. RN #4 stated she talked with Resident #10 and his/her family regarding the medications and was told the medications ordered on [DATE] were incorrect. In addition, she stated the facility had a triple check process in place to verify the Physician's orders. The RN stated the orders were to be verified by another nurse (either a nurse on a different hallway or the nurse coming on for the next shift); the clinical team/Unit Manager looked at the orders at the next day's Clinical Meeting; and the night shift nurse was supposed to have completed a twenty-four (24) hour chart check nightly. During an interview with RN #1 on [DATE] at 9:43 AM, she stated Resident #10 had a history of being hospitalized and she did not recall the resident's IV medication having been unavailable on [DATE]. She further stated if the medication had been unavailable, she should have notified the Pharmacy and the Physician and followed any further orders given to her by the Physician. During an interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:00 PM, she stated she did not recall Resident #10 not having IV medications on [DATE]; however, if a medication had not been available, she should have checked the Cubex (the facility's automated medication dispensing system medications). LPN #2 stated if the medication had been unavailable in the Cubex, she should have notified the Pharmacy and the Physician. She further stated she would then have followed any orders given to her by the Physician at that time. During an interview with RN #3 on [DATE] at 4:19 PM, she stated if a medication had been unavailable at the time it was scheduled to be administered, she would have looked in the Cubex. RN #3 stated if it had not been available in the Cubex, she would have called the Pharmacy to have it sent immediately to the facility, which usually took about four (4) hours. She further stated she would have notified the Physician of any medication having been unavailable at the time it was scheduled to be administered. During an interview with LPN #3 on [DATE] at 4:30 PM, she stated when a medication was unavailable, she checked the Cubex, and if not in the Cubex, she called the Pharmacy to see where the medication was. She stated she would notify the Physician to let him know so he could change the orders if needed. LPN #3 further stated delaying a resident's IV antibiotics related to a UTI could cause complications such as urinary frequency, confusion, painful urination, fever, and sepsis. During an interview with the Medical Director on [DATE] at 7:35 PM, he stated erroneous administration of Insulin and Xarelto had been pretty bad errors and a resident who received incorrect medications for two (2) days seemed like a lot and was unacceptable. He stated the resident erroneously receiving insulin could have became hypoglycemic, or receiving Xarelto in error could have been at an increased risk for bleeding. The Medical Director stated if a resident did not receive his/her medication as prescribed it could cause increased pain. He stated he could not recall if he had been notified on [DATE] and [DATE] of Resident #10's IV medications not having been available. The Medical Director stated however, it would have been his expectation to be notified whenever a medication was not available. He stated the delay of IV medication for one (1) day was not good, but the delay of two (2) days of the IV medications would have been really inexcusable. The Medical Director stated if he had been made aware of any medications which was not going to be available for multiple days, he would have looked at changing the order to another medication that would have been available. He further stated the delay in Resident #10 receiving his/her Invanz and Daptomycin could have contributed to the resident developing sepsis and eventually expiring on [DATE]. During an interview with the contract Pharmacy's Director of Clinical Services on [DATE] at 5:12 PM, she stated Resident #10's orders came into the Pharmacy after 2:00 PM on [DATE], so the medication should have been delivered on the afternoon of [DATE]. She stated the Pharmacy did not have any system in place to double check the orders placed in Point Click Care and, unless the medication had some abnormal dosage, the Pharmacy would have filled the medication as ordered by facility staff. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:42 PM, she stated she signed for the medications for Resident #10 on [DATE]; however, had not been responsible for the care of Resident #10 on that date. She stated she had not opened the bags the medications were in, but had accepted them at the facility door from the Pharmacy delivery driver and handed them to the nurse working on the floor at that time. The ADON stated it was her expectation for the nurses to communicate with each other to ensure medications were given as ordered. She stated any medication errors should have been caught in the morning clinical meeting and investigated, with the resident monitored for any abnormal side effects. The ADON stated all orders were reviewed in the morning clinical meeting and she was unsure why the incorrect medications for Resident #10 entered on [DATE], had not been caught prior to [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 3:19 PM, she stated it was her expectation if a medication was unavailable for the nurses to check the Cubex to see if it was there, and, if not, to call the Pharmacy and Physician to notify them of the medication being unavailable. She stated it was her expectation for the [DATE] Daptomycin to have been given by day shift once it arrived at the facility. The DON stated had it had been a failure in communication from night shift to day shift that the medication was unavailable and should have been given later in the day when Pharmacy delivered it. She further stated she was not working in the facility in 2022, and could not speak to the triple check process, as the facility did not have a triple check process in place currently. During an interview with the Administrator on [DATE] at 3:45 PM, she stated currently orders were reviewed in the morning clinical meetings for accuracy. The Administrator stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She stated the night shift nurse should have communicated to the day shift nurse on [DATE] that Resident #10's Daptomycin had not been delivered, and ensured an order had been written for a time change of administering the medication, so the day shift nurse would have been aware she needed to administer it.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents received adequate supervision to prevent accidents for three (3) of twenty-five (25) sampled residents (Residents #9, #15, and Resident #14). 1. On 08/31/2023 at approximately 7:00 PM, Resident #9 exhibited exit-seeking behaviors and was witnessed attempting to exit the facility by staff. Staff responded to the alarm and assisted Resident #9 back into the facility; however, failed to increase the resident's supervision. Subsequently, Resident #9 followed closely behind the Social Service Director (SSD) and exited the facility without staff's knowledge. 2. On 04/16/2022, Resident #15 sustained a fracture to his/her femur after the resident rolled off of his/her low air loss mattress while only one (1) staff provided his/her care. The resident was care planned to require the extensive assistance of two (2) staff for bed mobility. 3. The facility assessed Resident #14 to be a high risk for falls. Staff interviews revealed Resident #14 was impulsive, independent, and forgets to ask for assistance which would have required the resident to have increased supervision, to include one-on-one (1:1). On 07/05/2023, Resident #14 stood up and fell while out of staff's reach. Subsequently, the Mobile x-ray revealed the resident had an age-indeterminate nondisplaced humeral neck fracture. The facility's failure to have an effective system to ensure residents received adequate supervision and monitoring to prevent accidents has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 09/13/2023 and was determined to exist on 08/31/2023, in the area of 42 CFR S483.52 Free of Accident Hazards/Supervision/Devices (F689) at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.52 Free of Accident Hazards/Supervision/Devices The facility was notified of the Immediate Jeopardy (IJ) on 09/13/2023 and IJ is ongoing. (Refer to F656 and F657) The findings include: Review of the facility's policy titled, Policy and Procedure for Personal Safety Devices for Residents at Risk of Elopement, dated 08/12/2011, revealed it was the policy of the facility that all residents were provided adequate supervision to meet each resident's nursing and personal care needs. Continued review revealed all residents would be assessed for behaviors or conditions that put them at risk of elopement and all residents assessed to be at risk of elopement would be provided with a Personal Safety Device. Further review revealed a plan of care would be developed for all residents identified to be at risk of elopement and all personal safety devices and exit door alarms would be tested daily to assure each device and door alarm were functioning properly. Review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed residents at risk for elopement were to be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera, door alarms on facility exits, or a personal safety device that notified facility staff when the resident attempted to or had left the facility without supervision. Continued review revealed all personal safety devices, such as Wander Guard bracelets, were to have their location and function documented every shift, door alarms were to be tested and documented daily, video/camera systems were to be tested and addressed should the screen(s) appear to be malfunctioning or not recording and any concerns were to be immediately addressed if found. Further review revealed if a resident was discovered missing, the facility was to report to the State if the incident met reportable criteria. Further review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, undated, revealed a Quality Improvement Committee (QAPI) were to review the facility's systems and response to the elopement to determine whether there were any deficits that should have been addressed. Continued review revealed at the Ad-Hoc QAPI meeting, any Action Plan that was rolled out was to be reviewed and discussed. Additional review revealed should a resident attempt an elopement, a review of his/her individualized care plan was to be completed for any identified needed changes. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised 01/20/2023, revealed the guide emphasized a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognized supervision and guidance to the resident was an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed: 1). when a resident had been assessed either by the staff nurse or Psychosocial staff to have stable physical and psychosocial needs regular rounds would be maintained to ensure that all the resident's needs were met; 2). If the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident would require every thirty (30) minute, every fifteen (15) minute or 1:1 supervision; 3). staff assignments were to be based on the resident's needs as far as their acuity, their assessment results, and their person-centered care planning. 1.) Review of Resident #9's Admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Lack of Coordination, Anxiety Disorder, and Muscle Weakness. Additional diagnoses were Alzheimer's Disease, History of Falling, and Dementia with Mood Disturbance and Anxiety. Review of Resident #9's Quarterly Minimum Data (MDS) Set, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Comprehensive Care Plan, dated 03/02/2022 revealed the facility determined the resident to be at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease with interventions that included: on 03/02/2022 for Wander Guard (an electronic bracelet on the resident's ankle that caused the door alarm to sound if the resident went through the door) per order, to check Wander Guard function/placement as ordered, complete Elopement/Wander Assessment as indicated, redirect wandering as needed, and staff to provide one-to-one (1:1) as needed. However, there was no evidence Resident #9 received increased supervision, to include one-to-one (1:1) supervision after exhibiting exit-seeking behaviors on 08/31/2023 at 7:00 PM. Review of Resident #9's Elopement Assessments, dated 08/10/2023, revealed the facility assessed him/her to have an Elopement Score of sixteen (16), which indicated the resident was a high risk for elopement. Review of Resident #9's Progress Note, dated 08/31/2023 at 9:11 PM, signed by the Director of Nursing (DON), revealed the resident had increased wandering noted and was directed back to his/her unit. Further review revealed bedtime Activities of Daily Living (ADL) care was provided and the resident was placed on one-on-one (1:1). Review of a Work Performed description, completed by the company who serviced the facility's door alarms, dated 09/05/2023, revealed the facility's front door was serviced on 09/01/2023. Further review revealed the front door keypad and maglock was not re-engaging until thirty (30) seconds after the door closed, allowing a resident to tailgate outside of the facility. Observation of Resident #9, on 09/11/2023 at 2:55 PM, revealed the resident was up in his/her wheelchair in the front lobby area with other residents. Observation of Resident #9, on 09/12/2023 at 9:20 AM, revealed the resident in his/her room with no direct supervision. Observation of Resident #9, on 09/12/2023 at 6:15 PM, revealed the resident had a one-to-one (1:1) sitter. During an interview with Resident #12 on 09/12/2023 at 6:17 PM, he/she stated he/she was sitting in the front lobby on 08/31/2023 when he/she witnessed Resident #9 go out the lobby door into the foyer. Per the interview, the resident stated Resident #9 did not get out of the second door to exit the facility. He/she further stated that nurse LPN #4 brought Resident #9 back inside the lobby area. He/she stated the Social Service Director (SSD) was in the room near the nurses' station cleaning up boxes from a staff dinner and had taken her things outside while Resident #9 was sitting on a bench next to the lobby door. Resident #12 stated most staff watched to make sure the door locked, but when the SSD went outside with her final load, Resident #9 went out the door and onto the sidewalk before it completely closed. Resident #12 stated he/she yelled to inform staff that Resident #9 was outside. Resident #12 stated five (5) or six (6) staff members went outside to get Resident #9 and brought him/her back inside after about five (5) minutes. Resident #12 further stated LPN #4 brought her phone to him/her so that he/she could tell the Administrator how Resident #9 exited the facility. During an interview with Family Member #2 on 09/13/2023 at 2:58 PM, he stated he received a call from a staff member at the facility (name unknown) on 08/31/2023 at approximately 8:00 PM, stating someone went out the front door and Resident #9 followed behind them and was located on the sidewalk. He stated he was told during the call that Resident #9 would have increased supervision and he was under the impression someone would was providing one-on-one supervision to the resident. During an interview with Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated she responded to the front door alarm sounding on 08/31/2023 at approximately 7:00 PM and witnessed Resident #9 standing in the foyer area between the door from the front lobby and the outside door. She further stated the SSD was in the front lobby and she and the SSD brought the resident back into the lobby area where other residents were watching television. She continued to state she left Resident #9 in the front lobby and went back to her hall to pass medications. Further, she stated on 08/31/2023 at approximately 8:00 PM, she heard the front door alarm again and heard Resident #12 yell that Resident #9 went out the front door. LPN #4 stated she followed LPN #2 out of the facility's side door near the kitchen and found Resident #9 standing on the sidewalk outside the facility. The LPN stated she called for assistance to bring a wheelchair to assist the resident back inside. In a continued interview with Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated Resident #12 told her the SSD had just left and Resident #9 went out the door before it had completely shut. She further stated the resident was returned inside the building and she assisted the resident back to his/her hallway and placed the resident one-on-one (1:1) with staff while LPN #2 called the Administrator and explained what had happened. She stated she had Resident #12 talk with the Administrator on her cell phone. She additionally stated she received a phone call from the Director of Nursing (DON) about one to one and a half (1-1 1/2) hours later stating to leave the resident on one-on-one (1:1) supervision unless the resident was in bed sleeping, in which case he/she did not have to be one-to-one (1:1). The LPN stated the DON informed her that paperwork had been completed on the incident and advised her the incident was not reportable since staff always had eyes on the resident. Further review of the resident's record; however, revealed no documentation to support the facility investigated the incident. During an interview with LPN #2 on 09/18/2023 at 4:00 PM, she stated Resident #9 exited the facility on 08/31/2023 at approximately 8:00 PM. She further stated Resident #12 screamed out that Resident #9 had exited the facility and she saw the resident outside the front door. The LPN stated the front door locked down and she was unable to go out the front door, so she exited the side door by the kitchen, to retrieve Resident #9. LPN #2 stated the resident was found on the sidewalk outside the kitchen. She stated she notified the Administrator and had her on speaker phone so she could speak with Resident #12, who reported the resident's elopement. During an interview with a representative from the door alarm company on 09/12/2023 at 8:21 AM, he stated the facility's front door had been replaced on 07/25/2023 and his company's representative did not realize the door contact, which identified if the door was closed and immediately locked down, was taped shut and did not realize it was integrated into the keypad. He further stated the keypad never recognized the door as opened thus it would not lock the door for the required thirty (30) to sixty (60) seconds. He stated the keypad not locking the door down for up to a minute would allow someone to tailgate, or follow another person, out the door before the door locked. During an interview with the Social Services Director (SSD) on 09/12/2023 at 1:42 PM, she stated she saw Resident #9 sitting on a bench close to the front lobby door on 08/31/2023 and thought he/she got out the front lobby door into the foyer but did not go outside. She further stated she was unaware that Resident #9 had followed her out the door. During an interview with the Medical Director on 09/20/2023 at 7:35 PM, he stated it was his expectation that staff would have provided the necessary supervision to keep the resident safe. During an interview with the Director of Nursing (DON), on 09/13/2023 at 12:12 PM, she stated she was aware Resident #9 had gone into the foyer past the lobby door on 08/31/2023. She stated LPN #4 had called the Administrator and notified the Administrator the resident had exited the facility. Per the interview, the DON stated the Administrator then called her and told her LPN #4 called her and stated that while the resident had exited the facility, the LPN had her eyes on the resident. The DON stated she called LPN #4 and told her to put Resident #9 1:1 and he/she stayed 1:1 for a day or two (2). The DON, however, was unable to provide documentation to support the resident received 1:1 supervision on 08/31/2023. She continued to state she specifically asked LPN #4 if the resident had gotten outside, and LPN #4 stated no. She additionally stated she charted a progress note regarding the resident had increased wandering in Resident #9's chart after speaking with LPN #4 but did not come into the facility herself at that time. She stated she did not complete an investigation into the elopement as the Administrator notified her the resident had not been outside the building. The DON stated the potential for harm, of a resident who exited the facility without staff supervision, would have been the potential of falling or getting hit by a car while outside the building. During an interview with the Administrator on 09/13/2023 at 12:24 PM, she stated she was not aware Resident #9 had gotten out the lobby door on 08/31/2023. The Administrator stated she heard the SSD and a nurse or housekeeper discussing the resident needed to be redirected. She continued to state she was unsure why Resident #9 was placed on 1:1 on 08/31/2023. The Administrator stated she was aware the DON had received a call from staff stating Resident #9 had increased agitation on 08/31/2023 and stated that was probably the reasoning behind placing the resident on 1:1 supervision. She further stated the potential risk of harm, should a resident exit the building without staff supervision would be a risk of falls or accidents. Interview with Resident #12 on 09/12/2023 at 6:17 PM; LPN #2 on 09/18/2023 at 4:00 PM; LPN #4 on 09/12/2023 at 5:41 PM; and the DON on 09/13/2023 at 12:12 PM, however, revealed they had discussed concerns of Resident #9 exiting the facility with the Administrator. Review of the facility's policy titled, Incidents/Accidents/Falls, last revised 01/30/2022, revealed it was the policy of the facility to ensure any incident, including accidents related to falls was reported to the nurse in charge and after the resident had been assessed, and deemed to be safe, a Risk Management report was to be entered. The facility was to ensure the incident and/or accident was reported and investigated. The facility was to have a system to track and trend and discuss through the Quality Assurance Performance Improvement (QAPI) program. Such information was to be used to implement corrective action to include training to prevent reoccurrences when possible. Further review revealed any unwitnessed fall required neuro (neurological) checks to be started and continued per policy. Further review of the facility's policy titled, Incidents/Accidents/Falls, last revised 01/30/2022, revealed the progress note related to the event was to include a description of the occurrence to include the time and place, physical and mental status of the resident, time of Physician notification and the Physician response, any new orders, and the time of notification to the responsible part to include unsuccessful attempts. Per review, a completed incident/accident report was to be reviewed by the Director of Nursing (DON) and the Interdisciplinary Team (IDT) during the next meeting. Continued review revealed the Administrator was to be advised of the situation. The policy review revealed documentation of the resident's physical and mental status was to be completed each shift (every eight {8} hours minimally) over the next seventy-two (72) hours and the information was to be communicated from shift to shift until the resident's condition improved. Review further revealed the incidents/accidents/falls policy further revealed all falls required a site investigation to include determining the root cause. 2.) Closed record review of Resident #15's face sheet revealed the facility admitted the resident on 02/13/2020 with diagnoses related to history of Falls, Dementia, Alzheimer's, Osteoporosis without current pathological fractures, and Contracture to his/her right knee. Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident required the physical assistance of two (2) staff for bed mobility, transfers, toileting, dressing, and for personal hygiene. Review of Resident #15's person-centered Comprehensive Care Plan (CCP), related to Activities of Daily Living (ADLs), initiated on 03/30/2021, revealed the resident was care planned to require two (2) staff for bed mobility, to turn and reposition, for bathing and showers, dressing, personal hygiene, and toileting. Review of a Progress Note, dated 04/16/2022 at 10:58 PM, revealed the resident appeared to be in no pain or discomfort, and the resident rested in bed with his/her eyes closed. Review of a Progress Note completed by Registered Nurse (RN) #5, on 04/17/2022 at 12:50 AM, revealed the resident rested in bed with eyes closed, no signs and/or symptoms of pain or discomfort due to recent fall, no apparent injuries. Review of a progress note completed by LPN #3 on 04/17/2022 at 2:03 PM, the resident was noted to be resting in bed, no complaints of pain or decreased range of motion noted, no new injuries noted to post fall. Review of a Nursing Progress Note, completed by Registered Nurse (RN) #1, on 04/18/2022 at 2:56 AM, she noted the resident was resting quietly in bed, no sign or symptoms of pain or discomfort, range of motion appeared within normal limits, no apparent injuries. Review of a progress note completed by LPN #2 on 04/18/2022 at 5:45 PM, revealed the resident was lying in bed with eyes closed, resting quietly, no signs or symptoms of pain or discomfort noted, bed in lower position and call light within reach. Review of a Change in Condition (CIC) completed on 04/22/2022 by LPN #12 noted while an aide provided a shower for the resident on 04/22/2022 the resident began to cry in pain and it was noted his/her right hip was red and swollen. Review of an Interdisciplinary Team (IDT) Note dated 04/28/2022, revealed, that during care on 04/16/2022 the resident got too close to the edge of the bed and fell out. It was noted the resident was immediately assessed and placed back in bed. The MD and representative were notified, and no new orders were given. Review of the IDT Note on 04/28/2022, it was noted the resident was sent out to the Emergency Department (ED) on 04/22/2022 and was admitted to the hospital with a fractured right femur. The IDT team noted it was related to the fall that happened on 04/16/2022. However, the facility failed to ensure the resident's fall that occurred on 04/16/2022 was thoroughly investigated to include determining the Root Cause of the resident's fall, as per the facility's policy. Further review of the IDT Note revealed the resident returned to the facility on [DATE]. In an interview with Certified Nursing Assistant (CNA) #22, on 09/28/2023 at 1:51 PM, she stated she worked at the facility for over six (6) years. She stated she knew Resident #15 well and believed she was working on 04/16/2022 when the resident was hurt. She stated she heard the aide scream out and the nurse went into the resident's room, but she could not identify the staff member involved. She stated she believed the aide was an agency staff. CNA #22 stated the low air loss mattresses were very tricky and could be slippery. She stated when she was assigned a resident who had a low air loss mattress, she would not change the resident without assistance. She stated accidents could happen. She also stated it was her personal preference because she just felt it was safer for the resident. CNA #22 stated Resident #15 used to get out of bed daily but at some point, that stopped. She said the resident's legs were contracted badly and it was very painful for the resident to be out of bed which made it very difficult to provide peri care. In an interview with Licensed Practical Nurse (LPN) #3, on 09/25/2023 at 11:45 AM, she stated she could not recall the specific incident with Resident #15, however, she did recall Resident #15 was a two (2) person assist for all ADL care. She stated Resident #15 did not have the ability to roll and she said she could not see how the resident rolled out of bed on his/her own. She stated Resident #15 had a low air loss mattress, which required a two (2) person assist, as the mattress was too unstable, and the resident could fall out of bed. LPN #3 stated the resident enjoyed being up from his/her bed and noticed a change in the resident's condition after his/her fall on 04/16/2022. According to LPN #3, she should have followed the resident more closely as the resident was in his/her bed more than normal. In an interview with the current Assistant Director of Nursing (ADON), on 09/29/2023 at 11:03 AM, she stated she worked on 04/16/2022 when an aide provided peri care, by herself, on the resident and the resident rolled out of bed. She stated she was not assigned to that floor and could not remember the details. She said any resident who had a low air loss mattress really needed to have two (2) staff assist for any bed mobility, peri care, personal hygiene and transfer back into the bed. She stated that was for the resident's safety. In an interview with the Director of Nursing (DON), on 09/29/2023 at 1:20 PM, she stated she was unfamiliar with Resident #15. However, stated it would have been her expectation that the resident's care plan would have been followed, to have two (2) people assist with resident while providing care. In an interview with the Administrator, on 09/29/2023 at 1:30 PM, she stated her expectation would have been for the resident's care plan to have been followed. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised 01/20/2023, revealed the guide emphasized a proactive intervention promoting enhanced physical and psychosocial well-being. Per the policy review, the facility recognized supervision and guidance to the resident as an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed, 1). when a resident had been assessed either by the staff nurse or Psychosocial staff to have stable physical and psychosocial needs regular rounds would be maintained to ensure that all the resident's needs were met; 2). If the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident would require 30-minute, 15-minute or 1:1 supervision; 3). staff assignments would be based on the resident's needs as far as their acuity, assessment results, and person-centered care planning. 3.) Review of Resident #14's Admission Record revealed the facility admitted the resident on 10/19/2022 with diagnoses including Alzheimer's Disease; Coronary Artery Disease; Wandering; Difficulty Walking; Hypertension; and Dementia. Review of Resident #14's Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident to have had a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating the resident was severely impaired cognitively. Continued review revealed Resident #14 required extensive assistance of two (2) persons for transfers. Review of Resident #14's Comprehensive Care Plan revealed the resident had a focus of being high risk for falls as evidenced by potential contributing diagnoses of Alzheimer's and Atrial Fibrillation, initiated 10/25/2022 with a goal to reduce fall risk and injury through the next review. Interventions included: to ambulate when attempting to get out of his/her wheelchair with staff assistance and gait belt as tolerated; bed in lowest position as tolerated when not providing care; ensure resident was positioned in the center of the bed upon rounding; dycem to his/her wheelchair; encourage resident to go to the dining room for breakfast; encourage to lay down after last medication pass in the evening as tolerated; ensure trash can was at bedside when in bed; adjustments to anti-roll backs as needed (added 07/03/2023); staff to offer toileting with rounds; and up in wheelchair when restless as tolerated. Further review of Resident #14's care plan revealed no documented evidence to support the resident had been care planned for his/her impulsive behaviors which required increased supervision to his/her prevent falls. Review of Resident #14's Fall Risk assessments dated 07/01/2023 revealed the facility assessed the resident to be a high risk for falls. Review of the Mobile x-ray Report for Resident #14, dated 07/05/2023, revealed significant findings of his/her right shoulder arthritis and an age-indeterminate nondisplaced humeral neck fracture. Observation on 09/11/2023 at 2:15 PM revealed the resident was seated in his/her wheelchair with an overbed table in front of the resident. Continued observation revealed the resident had a magazine and a cup of water. Observation on 09/13/2023 at 1:22 PM revealed the resident was seated in a wheelchair near the nurse's station and was eating ice cream. During an interview on 09/26/2023 at 5:06 PM with Kentucky Medication Aide (KMA) #1, stated she had started the medication pass for the evening shift when she heard another resident say, Hey, he/she [Resident #14] is getting up. The KMA #1 stated she looked down the hallway and observed Resident #14 rising from the wheelchair while holding to the handrail, and immediately fell in front of the wheelchair. KMA #1 stated she yelled for the KMA #2, who was at the medication cart and had her back to Resident #14. KMA #1 stated KMA#2 turned around, and when she did, Resident #14 was sitting on the floor. KMA #1 stated all the staff knew to watch Resident #14 and if he/she was awake to bring him/her into the hallway for closer supervision because he/she frequently would attempt to stand unassisted. During an interview on 09/25/2023 at 4:30 PM, with Licensed Practical Nurse (LPN) #3, she stated Resident #14 was impulsive and forgets to call for help. Further, LPN #3 stated when the resident was up in his/her wheelchair, the staff kept the resident engaged with magazines, food, and drink. LPN #3 stated Resident #14 needed to be in sight of staff for more supervision when he/she was awake due to being a high fall risk. During an interview on 09/29/2023 at 3:10 PM, the Medical Director stated Resident #14 had numerous falls due to his/her dementia was non-ambulatory, utilized a wheelchair for mobility, and required assistance for transfers. The Medical Director stated he/she transferred without assistance, and was very stubborn and independent-minded, thinking he/she could still walk. The Medical Director stated Resident #14 was hard to control and the staff kept a close watch on the resident. The Medical Director stated he would expect the facility staff to follow the resident's care plan and provide supervision as ordered. During an interview with the Director of Nursing (DON) on 09/26/2023 at 03:11 PM, she stated she would have expected to see a complete and thorough documentation of the event to help with the investigation. Per the interview, the investigation started with the nurse and the residents needed a person-centered care plan that spoke to the resident's needs and risks. The DON stated Resident #14's care plan did not address his/her impulsive behavior or the need for increased supervision. During an interview on 09/26/2023 at 3:27 PM, with the Administrator, she stated Resident #14 should have had a behavior care plan. Further, she stated the resident's care plan did not address supervision for Resident #14 and added it was her expectation that the resident would be placed on 1:1 supervision due to his/her behaviors. The Administrator stated the facility failed to follow its policy related to providing increased supervision for Resident #14 to prevent his/her falls. 47852 34249

Based on interview, record review and facility policy review, it was determined the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that met each resident's physical, mental, and psychosocial needs for two (2) of twenty-five (25) sampled residents (Resident #4 and Resident #10). 1). On [DATE] at approximately 8:30 AM, the facility's Certified Nursing Assistants (CNAs) reported to Licensed Practical Nurse (LPN) #2 and LPN #3 that Resident #4 exhibited signs and symptoms of a stroke. The LPNs; however, failed to assess the resident immediately when staff reported to them the resident had a change in his/her condition. Subsequently, when LPN #2 arrived to Resident #4's room, approximately one-hour and a half (1 ,d+[DATE]) after staff notified the LPN of the resident's condition, the resident was found unresponsive. The resident was transferred to the Emergency Department (ED) with admitting diagnosis to include Middle Cerebral Artery (MCA) stroke. The resident expired on [DATE]. 2). The facility readmitted Resident #10 on [DATE] from the hospital with orders for Invanz and Daptomycin (Intravenous (IV) antibiotics) daily to treat his/her bacterial infections. However, record review revealed the resident missed one (1) scheduled dose of his/her Invanz Antibiotic and two (2) scheduled doses of his/her Daptomycin Antibiotic. This caused the resident to develop more severe bacterial infections, which the resident had developed since his/her discharge from the hospital. On [DATE], the resident was found unresponsive and was sent to the hospital with a diagnosis of Sepsis (an infection in the bloodstream). The resident expired on [DATE]. The facility's failure to have an effective system to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]; and on [DATE] and was determined to exist on [DATE], in the area of 42 CFR S483.25 Quality of Care (F684) at the highest S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.25 Quality of Care (F684) . The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and on [DATE] and IJ is ongoing (Refer to F657 and F760) The findings include: Review of the facility's policy titled, Change in Condition Notification, dated ,d+[DATE], revealed it was the policy of the facility to monitor residents for changes in their condition, to respond appropriately to those changes, and to notify the physician and responsible party/family member of changes. Further review of the policy revealed that in the event of a life-threatening change, the facility would initiate emergency care by calling 911 and provide appropriate emergency treatment until they arrive. Review of the facility's policy titled, Care Plan Review undated, revealed residents were to be assessed at least quarterly, and include visual and verbal assessment, obtaining information from the health record, as well as interviewing the nursing assistants prior to completing the Minimum Data Set Assessment and comprehensive person-centered care plan. Further review revealed staff were to evaluate the progress or lack thereof for each resident's goal and document the findings in measurable terms. 1). Review of Resident #4's Closed Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE] with diagnoses that included: Heart Failure, Atrial Fibrillation (AFib), Stroke, and Transient Ischemic Attack (TIA). Review of Resident #4's Admission Progress Note, dated [DATE], revealed the resident had a previous stroke two (2) years ago. Review of the Medical Director's (MD) Note, dated [DATE], revealed the resident had a stroke a few years ago and since then had difficulty taking care of himself/herself. Review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating the resident had severe cognitive impairment. Resident #4 was assessed to require extensive assistance of two (2) staff for bed mobility, transfers, dressing, and toileting. The resident was assessed to need one (1) person physical assistance for eating, personal hygiene, and walking on/off the unit. Review of Resident #4's Comprehensive Care Plan initiated on [DATE] and reviewed on [DATE], revealed no documented evidence the facility developed a focus area to monitor the resident for signs and symptoms of a stroke related to his/her history of a stroke. Review of Resident #4's Nursing Progress Note, entered by the current Assistant Director of Nursing (ADON), dated [DATE], revealed the resident complained of blurred vision and feeling scared, the Medical Director was present for regular rounds, assessed the resident and sent him/her to the Emergency Department (ED) for an evaluation. Review of Resident #4's Progress Note, dated [DATE] at 4:17 PM, revealed the resident returned to the facility and all vitals were noted to be at the resident's baseline. Review of Resident #4's Hospital Discharge Summary dated [DATE], revealed the resident was seen for a migraine headache. Review of Resident #4's Emergency Medical Services (EMS) Run Report dated [DATE], revealed 911 was called at 9:58 AM, the ambulance arrived at the facility at 10:03 AM, left the facility at 10:17 AM, and arrived at the hospital at 10:23 AM. Continued review revealed the resident was unresponsive, lying supine, responsive to painful stimuli, and breath sounds of twelve (12) breaths per minute (bpm). Review of Resident #4's Hospital Emergency Department (ED) Records dated [DATE], revealed the resident was seen in the ED on [DATE] and a Computerized Tomography (CT) Scan was completed, and a stroke was ruled out. On [DATE] another CT scan was conducted and showed a large left Middle Cerebral Artery (MCA) stroke. Further review of the ED records revealed the resident's prognosis was very poor and the family agreed he/she would be placed on palliative care. The resident expired on [DATE]. In an interview with Certified Nursing Assistant (CNA) #10, on [DATE] at 2:00 PM, she stated on [DATE], between the hours of 8:00 AM and 8:20 AM, during breakfast tray pass to the residents, CNA #15 asked her to check on Resident #4 because he/she did not look good. CNA #10 stated she immediately went to check on the resident and then asked LPN #2 to look at Resident #4 because the resident was not looking like himself/herself. CNA #10 stated she reported the resident's condition to LPN #2 who told her she was in the middle of medication pass and would get there. CNA #10 stated she went on with passing the rest of the breakfast trays before she followed up on Resident #4's status. Per the interview, she stated that since it was reported to the nurse, she did not know what else to do. In a continued interview with CNA #10, on [DATE] at 2:00 PM, she stated after she had completed passing out breakfast trays to the residents, she went back to check on Resident #4, with CNA #9, CNA #13, and CNA#15. She stated the resident did not look good. Further, she stated the resident's face was drooping to one side and she lifted the resident's arm which just flopped down. She said she immediately went to LPN #2 and stated, I think Resident #4 has had a stroke! CNA #10 said LPN #2 looked away from her computer, looked directly into her eyes, and then turned back and kept working from her computer while completing the medication pass. CNA #10 stated when she was getting ready to take her lunch, between the hours of 10:00 AM and 10:30 AM, LPN #2 was sending Resident #4 out to the Emergency Department (ED). Further, CNA #10 stated she saw LPN #2 at the nurse's station, freaking out, saying, Nobody reported anything to me. In an interview with Certified Nursing Assistant (CNA) #9, on [DATE] at 10:57 AM, she stated she did not feel things were addressed by nursing staff when concerns were brought to them. She stated the aides reported to Licensed Practical Nurse (LPN) #2 concerns that Resident #4 had a stroke on [DATE] and the nurse did not check on the resident until hours later. CNA #9 stated Resident #4 did not eat that morning, could not lift his/her arms, and felt those were symptoms of a stroke. In an additional interview with CNA #9, on [DATE] at 1:43 PM, she stated on [DATE] she was not assigned to care for Resident #4. She stated she only saw the resident that morning when she delivered breakfast to the resident. The CNA stated Resident #4 was normally a very independent person, would engage when engaged with, and would answer questions, but on [DATE], the resident's behavior was much different. She stated the resident was out of it, adding, his/her eyes were rolled back, and the resident was not talking. She stated CNA #10 told LPN #2 that the resident did not look right, that the resident's face was drooping, and the resident could not lift his/her arms. CNA #9 stated LPN #2 did not check on the resident's condition immediately. During further interview, with Certified Nursing Assistant (CNA) #9, on [DATE] at 1:43 PM, she stated she and CNAs #10, #13, and #15 went back to check on Resident #4, after passing out breakfast trays, and Licensed Practical Nurse (LPN) #2 still had not assessed the resident. CNA #9 stated she then went over to the B-Hall and asked LPN #3 if she would check on the resident's condition. Per the interview, CNA #9 stated she informed LPN #3 that the resident was not acting like himself/herself, and CNA #10 had reported these concerns to LPN #2, but the LPN still had not responded to check on the resident's condition. CNA #9 stated LPN#3 told her she did not want to step on any toes and that if the nurse on A-Hall asked for help she would get involved. In an interview with CNA #15, on [DATE] at 2:10 PM, she stated on [DATE], during breakfast tray pass, she noticed Resident #4 did not look right and asked CNA #10 to look at the resident. CNA #15 stated Resident #4 usually talked with them but this day he/she was not talking. The CNA stated she told LPN #2 that something was not right with Resident #4 and LPN #2 said, the resident was probably faking because he/she does that sometimes. CNA #15 said CNA #10 also reported to LPN #2 that she was concerned Resident #4 had a stroke. Per the interview, LPN #2; however, did not go check on the resident. CNA #15 stated she also reported to LPN #3 about the concern with Resident #4, but LPN #3; however, also failed to check on the resident's change in condition. CNA #15 stated about two (2) hours had passed before LPN #2 checked on Resident #4. Further, she stated she should have called someone else when she identified LPN #2 did not help Resident #4 and should have gone above the two (2) nurses to report her concerns. In an interview with LPN #2, on [DATE] at 2:40 PM, she stated on [DATE], when she got to Resident #4, the resident was not responsive and the resident was curled up in a little ball. LPN #2 stated she could not recall what CNAs worked on [DATE], but she believed LPN #1 was called to the room to assist with Resident #4. LPN #2 stated, that during the morning report at shift change, Registered Nurse (RN) #1 told her Resident #4 was not talking to us and the resident showed out yesterday and demanded to go to the hospital. LPN #2 stated the resident was sent out to the ED on [DATE] and when the resident returned from the hospital, staff were expected to complete seventy-two (72) hour charting of the resident's vitals. Per the interview, LPN #2 stated she had not completed vitals on the resident during her shift until she entered the resident's room for medication pass at approximately 10:00 AM and found the resident unresponsive. In a continued interview on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #2 stated she did not see Resident #4 until she got to the resident's room to administer the resident's medications, which she believed was just before 10:00 AM. LPN #2 stated she had twenty-five (25) residents, and she laid eyes on them, but they cannot all be assessed at the same time. She said Resident #4 was usually quiet and did not engage, so that was not a new behavior for the resident. LPN #2 stated she was not informed of a change in the condition of Resident #4, prior to getting to the resident's room to administer the medications. However, interviews with CNA #9, CNA #10, and CNA #15, all stated they reported Resident #4's change in condition to LPN #2. Further, the CNAs stated LPN #2 failed to respond immediately to assess the resident's condition. In an interview with LPN #1, on [DATE] at 8:40 PM, she stated she did not recall the situation with Resident #4 on [DATE]. She, however, stated that if an aide reported concerns to her about a resident not looking right she would have locked up her medication cart and immediately checked on the resident. She stated she would not wait until she reached the resident during her medication pass. Further, the LPN stated a nurse could not determine what was wrong with a resident until the resident was assessed. LPN #1 stated that an unresponsive resident would have needed to be sent to the hospital for an evaluation. In an interview with LPN #3, on [DATE] at 11:29 AM, she stated she normally worked on the B-Hall. She stated if an aide had reported a resident was not acting right she would immediately go and assess the resident, get vital signs (VS) to compare to the resident's baseline VS, look for signs and symptoms of pain, and ask the resident if he/she was in pain. LPN #3 further stated if management was not on-site, she would contact the Medical Director for directions. LPN #3 stated she heard staff talking about Resident #4 and that he/she was attention seeking when he/she was sent out to the ED on [DATE]. In a continued interview with LPN #3, on [DATE] at 11:29 AM, she stated the morning Resident #4 was sent out for stroke-like symptoms, CNA #9 and CNA #10 came and asked her to look at Resident #4. She stated the aides told her they reported to LPN #2 at least twice their concerns related to Resident #4 and LPN #2 had not assessed or checked on the resident. LPN #3 stated she told the aides if the nurse on duty came and asked for assistance, she would have gone and assessed the resident. Further, she stated she had previously been fussed at for overstepping, as she was told by the previous Director of Nursing (DON) that she could not tell another nurse what to do and it was her job to run the B-Hall. LPN #3 stated she should have gone to assess the resident, and she should have gone above LPN #1 and LPN #2's head by calling the manager on-call. In an interview with the current Assistant Director of Nursing (ADON), on [DATE] at 9:35 AM, she stated if a CNA noted a change in a resident's condition, it should immediately be reported to a nurse and a Stop and Watch should be completed. She stated a Stop and Watch was something they used to notify nursing and management of any concerns with a resident. However, the process stopped under the previous Administration. The ADON stated she was involved in sending Resident #4 to the ED on [DATE]. She stated the Medical Director was present and assessed the resident before sending him/her out to the ED. She stated the Medical Director believed the resident to have had a migraine headache. The ADON stated when the resident returned from the ED, he/she should have been monitored for 72 hours with charting and noting the resident's condition, to determine if the resident's condition stayed the same or changed. She further stated symptoms of a stroke were facial drooping, unreactive pupils, and a weak grip. She stated when assessing a resident for a stroke, the timing was important because some reversal medications only worked for a certain amount of time. She said if any staff identified a change in the resident's condition, a nurse should be notified, and the resident should be checked immediately. In an interview with the Medical Director, on [DATE] at 2:33 PM, he stated he could not recall Resident #4 being sent out to the hospital on [DATE] for a migraine headache. He stated if staff found a resident unresponsive, or had any symptoms related to a stroke, it should be addressed within ten (10) minutes, and he would expect that the nurse would take immediate action. He further stated the nurse's involvement when dealing with a possible stroke should be aggressive and a time delay could result in an unchangeable condition or even death. In an interview with the Director of Nursing (DON), on [DATE] at 3:35 PM, she stated if a CNA found a resident outside of their baseline, she expected a nurse to be notified immediately when the change was noticed. The DON stated if the resident was unresponsive, the nurse should notify the Medical Director and send the resident out to the ED immediately. The DON stated all staff were informed they should contact her with any concerns. The DON stated it was her expectation that staff would respond immediately to concerns related to a resident's change in condition, especially in the case of a possible stroke which could result in death. In an interview with the Administrator on [DATE] at 3:48 PM, she stated if a resident was found not to be acting like himself/herself staff should immediately notify the nurse on duty. She stated she expected the nurse to immediately assess the resident and based on that assessment determine if a change in condition was warranted. The Administrator stated the facility should utilize the Stop and Watch sheets again, in which the aides would complete if they had any concerns about a resident. Further, the Administrator stated in a situation when the resident was unresponsive or had a change in mental status, the aide should have completed the Stop and Watch form after the incident. The Administrator stated she did not understand why staff had not reported these concerns to her. She stated if the staff did not feel as though the nurse on duty responded appropriately, they should have called the DON. The Administrator stated all changes in condition should have been reported to her in real-time as they occurred. 2). Closed record review of Resident #10's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident had an alteration in elimination and Urinary Tract Infection (UTI) with a history of Extended-spectrum beta-lactamases (ESBL) (an enzyme or chemical which caused some antibiotics not to work for treating bacterial infections and made certain antibiotics required) and incontinence. Interventions included monitoring for and reporting signs and symptoms of UTI, fever, and changes in output/intake, and medications as ordered. Review of Resident #10's Physician's Orders, dated [DATE], revealed Resident #10 had a urinalysis completed which was highly suggestive of a UTI and confirmed with a culture. The resident was placed on treatment and was slow to improve in terms of his/her symptoms. Review of the Physician's Orders, dated [DATE], revealed the resident had been hospitalized a week prior with metabolic encephalopathy that was determined to be secondary to ESBL UTI. Continued review revealed the Physician's Plan was to complete the resident's course of Invanz (an antibiotic used to treat severe infections). Review of Resident #10's Hospital Discharge Summary, dated [DATE], revealed the resident had been admitted to the hospital on [DATE] and readmitted to the facility on [DATE] with new orders to administer Invanz daily, for two (2) days, on [DATE] and [DATE] and Daptomycin (an antibiotic used to treat bacterial infections that has entered the bloodstream) daily from [DATE] until [DATE] for the resident's Urinary Tract Infection (UTI). Review of Resident #10's Pharmacy Invoices revealed the Invanz had been delivered on [DATE] at 7:51 PM and the Daptomycin had been delivered on [DATE] at 8:22 AM. Review of the resident's [DATE] Medication Administration Record (MAR) revealed the resident was not administered his/her Invanz on [DATE], missing one (1) scheduled dose of his/her medication to treat his/her severe infection. Continued review of the August MAR revealed the resident was not administered his/her Daptomycin on [DATE] and [DATE], which allowed the resident to miss two (2) scheduled doses of his/her medications to treat his/her bacterial infection that had entered his/her bloodstream. Review of Resident #10's Progress Note,dated [DATE], entered by Registered Nurse (RN) #1, revealed the Daptomycin was unavailable from the pharmacy. Further review revealed Licensed Practical Nurse (LPN) #2 notified the pharmacy and the physician on [DATE] the IV medications were not available. Continued review of the progress note revealed LPN #2 did not administer the Invanz on [DATE] because it was unavailable from the pharmacy. However, a review of the Pharmacy Invoice, dated [DATE], revealed the medication was delivered at 7:51 PM. Review of Resident #10's Progress Note,dated [DATE] at 6:58 AM, by LPN #5, revealed the Daptomycin was unavailable. However, there was no documentation to support the physician was notified of the medication being unavailable on [DATE] at 6:58 AM and no documentation to support the resident's medication was administered after the pharmacy delivered the medication at 8:22 AM. Review of Resident #10's Progress Note, dated [DATE] by LPN #1, revealed the resident was found unresponsive and had to be readmitted to the hospital. Review of Resident #10's Hospital record revealed on [DATE], the hospital admitted the resident. Further review revealed, on [DATE], the resident was diagnosed with Staphylococcus epidermidis and Acinetobacter (bacterial infections) which he/she had developed since being discharged from the hospital on [DATE], and unfortunately, now he/she had new and even more resistant bugs. Continued review of the hospital record revealed the resident had an infection on [DATE] which was sensitive to the Daptomycin. Further review revealed Resident #10 expired on [DATE] with the cause of death being refractory (hypotension and end-organ dysfunction) sepsis (an infection in the bloodstream). During an interview with Registered Nurse (RN) #1, on [DATE] at 9:43 AM, she stated Resident #10 had a history of being hospitalized and she did not recall the resident's IV medication being unavailable on [DATE]. She further stated if the medication was unavailable, she would have notified the pharmacy and the physician and followed any orders given to her by the physician. During an interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 4:00 PM, she stated she did not recall Resident #10 not having IV medications on [DATE] but if a medication was not available, she should have checked the Cubex (the facility's back up and emergency medication storage system), and if unavailable in the Cubex, she would have notified the pharmacy and physician. She further stated she would have followed any orders given by the physician at that time. During an interview with Registered Nurse (RN) #3, on [DATE] at 4:19 PM, she stated if a medication was not available at the time it was scheduled to be administered, she would look in the Cubex, and if it was not in the Cubex, then she would call the pharmacy to have it sent stat (immediately) to the facility, which she stated usually took about four (4) hours. She further stated she would notify the physician of any medication being unavailable at the time it was scheduled to be administered. During an interview with LPN #3, on [DATE] at 4:30 PM, she stated when a medication was unavailable, she would call the pharmacy to see where it was after checking to see if it was in the Cubex, then notify the physician to let him know so he could change the orders if needed. She stated delaying a resident's IV antibiotics related to a UTI could cause complications such as urinary frequency, confusion, painful urination, fever, and sepsis. During an interview with the Medical Director (MD), on [DATE] at 7:35 PM, he stated he could not recall if he was notified on [DATE] and [DATE] of Resident #10's IV medications being unavailable, but it was his expectation to be notified whenever a medication was not available. He further stated the delay of IV medication for one (1) day was not good but the delay of two (2) days was really inexcusable. He continued to state if he was aware of any medications that were not going to be made available for multiple days, he would look at changing the order to another medication that was available. Additionally, he stated the delay in the resident receiving the Invanz and Daptomycin could have contributed to the resident developing sepsis and eventually expiring on [DATE]. During an interview with the Pharmacy Director of Clinical Services, on [DATE] at 5:12 PM, she stated IV medications ordered by 2:00 PM would be delivered to the facility on the following morning. She stated Resident #10's orders came in after 2:00 PM on [DATE], so they should have been delivered on the afternoon of [DATE]. She further stated IV medications were sent out every two (2) days for the length of the prescription. The Pharmacy Director of Clinical Services further stated she was unsure why the facility did not receive both medications on [DATE]. During an interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:42 PM, she stated she signed for the medications for Resident #10 on [DATE] but was not responsible for the care of the resident on that date. She further stated she did not open the bags the medications were in but did accept them at the door from the pharmacy delivery driver and handed them to the nurse working on the floor at that time. She continued to state it was her expectation for the nurses to communicate with each other to ensure medications were given as ordered. During an interview with the Director of Nursing (DON), on [DATE] at 3:19 PM, she stated she had only been at the facility since [DATE] and was not aware of how many deliveries were made to the facility by pharmacy each day. She further stated it was her expectation if a medication was unavailable the nurses would check the Cubex to see if the medication was there, and, if not, call the pharmacy and physician to notify them the medication was unavailable. She continued to state it would have been her expectation that on [DATE], the day shift nurse should have given the resident his/her prescribed medication of Daptomycin, since it arrived after the 6:00 AM scheduled time but was available at 8:22 AM. Additionally, she stated this was a failure to communicate from the night shift to the day shift that the medication had been unavailable and should be given later in the day when the pharmacy delivered it. During an interview with the Administrator, on [DATE] at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated the nurses should have communicated to the day shift nurse on [DATE] that Resident #10's Daptomycin had not been delivered, and ensured an order was written for a time change for the medication, so the day shift nurse was aware she needed to administer it. She continued to state if the resident did not receive his/her medications for a UTI, he/she could have more discomfort, frequent urination, or increased confusion. 47852

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise each resident's Comprehensive Person Centered Care Plan for two (2) of twenty-five (25) sampled residents (Resident #10 and Resident #14). 1. On [DATE], the facility failed to revise Resident #10's Care Plan related to a new order to change the resident's code status to Do Not Resuscitate. Record review revealed the facility initiated a Comprehensive Care Plan on [DATE] for a Full Code Advanced Directive. Continued review revealed on [DATE], the resident's medical record included a signed and notarized Emergency Medical Services (EMS) Do Not Resuscitate (DNR) form. However, the facility failed to ensure the resident's Care Plan and Facesheet were revised to update the change in the resident's code status on [DATE]. Therefore, the facility transferred Resident #10 to the hospital on [DATE], as a Full Code. The resident was intubated and placed on a ventilator, which was against the resident's Advanced Directive wishes. 2. On [DATE] Resident #14 sustained a fall, and Mobile x-ray results on [DATE], revealed Resident #14 had an age-indeterminate nondisplaced humeral neck fracture. Review of Resident #14's care plan revealed no documented evidence the facility care planned the resident for his/her impulsive behavior which would have required increased supervision to prevent the resident from falling. The facility's failure to have an effective system to ensure each resident's care plan was reviewed and revised to reflect the resident's care and his/her needs has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR S482.21 Comprehensive Resident Centered Care Plan at the highest Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] and IJ is ongoing. (Refer to F578 and F689) The findings include: Review of the facility's policy titled, Care Plan Review, undated, revealed the facility was to update a resident's Comprehensive Care Plan at least Quarterly and with any changes in the resident's orders. Review of the facility's policy titled, Advance Directives Policy, dated [DATE], revealed the facility provided all residents the right to accept or refuse medical and surgical treatment, and, at the resident's option, formulate an Advanced Directive. Continued review revealed the facility was to establish mechanisms for documenting and communicating resident choices to the Interdisciplinary Team (IDT). Further review revealed if the resident or resident's legal representative executed one (1) or more Advanced Directives, the facility was to incorporate the resident's wishes into their care plan. In addition, review further revealed the resident's desires were to be re-evaluated as indicated to ensure the resident's or legal representative's choices were honored timely. Review of the facility's policy titled, Standard Staffing Supervision and Monitoring Guide, revised [DATE], revealed the facility recognized supervision and guidance to the resident as an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychosocial needs. Continued review revealed the following if the resident could not be guided, supervised, or redirected during regular intervals of rounds, the resident required every thirty (30) minutes, every fifteen (15) minutes or 1:1 supervision. Further review revealed staff assignments were to be based on the residents' needs as far as their acuity and their assessment results and their person-centered care planning. 1. Review of Resident #10's Admission Record/Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses which included: Chronic Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Anxiety, and Dementia. Review of Resident #10's Advanced Directives revealed the resident's code status, signed by the resident's spouse, dated [DATE], was Full Code. Review of Resident #10's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident had an Advanced Directive for a Full Code with interventions that included to honor the resident's choices and perform CPR. Review of Resident #10's Advanced Directives for an Emergency Medical Service (EMS) form, signed and notarized on [DATE], revealed the resident's code status changed to Do not Resuscitate (DNR); however, there was no documented evidence the facility sought to clarify the resident's code status with his/her family. A continued review; however, of Resident #10's care plan, initiated on [DATE], revealed no documented evidence the facility updated/revised Resident #10's Comprehensive Care Plan on [DATE], to change his/her code status to DNR. Review of Resident #10's hospital records revealed the hospital admitted the resident on [DATE]. Continued review of the emergency room (ER) Physician's Summary revealed ER staff thought Resident #10 was a Full Code as the resident's Face Sheet listed him/her as a Full Code, and an EMS DNR form was not presented at the time of the resident's transfer to the hospital. Further review revealed Resident #10 was intubated prior to the family's arrival at the hospital to clarify the resident's code status. During an interview with the Minimum Data Set (MDS) Nurse #1 on [DATE] at 3:20 PM, she stated she scanned the resident's EMS DNR form into the facility's Point Click Care (PCC) computerized system in [DATE]. She stated she inherited a stack of papers to scan in from the previous MDS person because the facility did not have a Medical Records Clerk. The MDS Nurse #1 stated she was not aware when the facility received a copy of the EMS DNR for Resident #10. She stated in general, if a copy of a DNR form was received an order for a DNR status should have been entered into PCC, his/her care plan revised, and the code status changed on the Face Sheet. She stated staff nurses could update residents' Comprehensive Care Plan interventions, and the care plans were updated daily by the MDS Nurses during morning clinical meeting. She further stated the MDS Nurses looked at the orders that had been entered and read the twenty-four (24) hour report book to ensure they were entering appropriate interventions into the residents' care plans. During an interview with the Medical Director on [DATE] at 7:35 PM, he stated it was his expectation the facility staff followed each resident's Comprehensive Care Plan. He further stated he expected residents' care plans to be updated as orders changed. The Medical Director stated the facility staff, including himself, should have spoken with the resident or his/her family/responsible party regarding the code status and followed the resident's wishes, including updating the care plan with that information. During an interview with the Director of Nursing (DON) on [DATE] at 3:19 PM, she stated she expected staff to update all residents' Comprehensive Care Plans as orders changed. She further stated the orders were reviewed daily in the morning Clinical meeting and the Care Plan should have been updated at that time. The DON further stated she expected staff to communicate with the resident and the resident's family and follow the doctor's orders, including revising the care plan as needed. During an interview with the Administrator on [DATE] at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated she expected staff to follow the facility's policies and revise the Care Plan as needed. The Administrator further stated that she was not present when Resident #10 was a resident and therefore, refused to speculate. 2. Review of Resident #14's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses of Alzheimer's Disease; Coronary Artery Disease; Wandering; Difficulty Walking; Hypertension; and Dementia. Review of Resident #14's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of six (6) out of fifteen (15), indicating severely impaired cognition. Continued review revealed the facility assessed Resident #14 to require extensive assistance of two (2) persons for transfers. Review of Resident #14's Comprehensive Care Plan initiated [DATE], revealed the facility developed a focus of being high risk for falls for the resident, as evidenced by potential contributing diagnoses of Alzheimer's Disease and Atrial Fibrillation. Continued review of the care plan revealed the high risk for falls focus had a goal to reduce fall risk and injury through the next review. Per review, the high risk for falls focus had interventions which included: ambulate the resident when attempting to get out of his/her wheelchair with staff assistance and gait belt as tolerated; bed in lowest position as tolerated when not providing care; and ensure the resident was positioned in the center of the bed upon rounding. Further review of the high risk for falls focus revealed additional interventions which included: Dycem to the resident's wheelchair; encourage the resident to go to the dining room for breakfast; encourage him/her to lay down after last medication pass in the evening as tolerated; ensure trash can was at bedside when in bed; and make adjustments to anti-roll backs as needed, added [DATE]. Review further revealed other interventions for: staff to offer toileting with rounds; and the resident up in wheelchair when restless as tolerated. In addition, review of Resident #14's care plan revealed no documented evidence the facility care planned for the resident's impulsive behavior, which would have required increased supervision to prevent the resident from falling. Observation on [DATE] at 2:15 PM, revealed Resident #14 seated in a wheelchair with an overbed table in front of him/her. Observation on [DATE] at 10:05 AM, revealed Resident #14 lying on his/her bed with eyes closed, with the bed in the lowest position and call light within reach. Observation on [DATE] at 9:48 AM, revealed Resident #14 seated in a wheelchair near a locked medication cart, rolling the wheelchair back and forth. Review of Resident #14's Fall Risk assessments dated [DATE], revealed the facility assessed the resident to be a high risk for falls. Review of Resident #14's Electronic Medical Record (EMR) revealed the resident sustained a fall on [DATE] at 7:35 PM, when staff observed the resident attempting to stand from the wheelchair by using a handrail. Per review, staff attempted to redirect Resident #14; however, the resident slid down to a sitting position on the floor. Further review revealed Resident #14 sustained injuries of abrasion to his/her right forearm and pain in the right shoulder, and a new order was received to obtain bilateral shoulder x-rays. In addition, review revealed a new care plan intervention was put in place for Resident #14 to be ambulated by staff when attempting to get out of the wheelchair. Review of Resident #14's Right Shoulder X-Ray dated [DATE] revealed an age-indeterminate (when a fracture cannot be dated with certainty) nondisplaced humeral neck (bone in the upper arm) fracture. During an interview on [DATE] at 4:30 PM, with Licensed Practical Nurse (LPN) #3 she stated Resident #14 was impulsive and forgot to call for help. LPN #3 stated when Resident #14 was up in his/her wheelchair, staff should keep the resident engaged with magazines, food, and drinks. The LPN further stated they were to follow Resident #14's care plan and currently the resident was not care planned for the increased supervision. During an interview on [DATE] at 5:06 PM, with Kentucky Medication Aide (KMA) #1 she stated she had started the medication pass for evening shift when she heard another resident say Hey he/she was getting up. KMA #1 stated she looked down the hallway and observed Resident #14 rising from the wheelchair while holding to the handrail, and saw the resident immediately fall to the floor in front of the wheelchair. She stated she yelled for KMA #2, who was at the medication cart and had her back to Resident #14, to turn around; however, by the time KMA #2 turned around, the resident was sitting on the floor. KMA #1 stated she could not recall if the wheelchair rolled back, and no other staff members were in the hallway at the time of the event. She stated the staff knew to check on Resident #14 frequently, due to the resident's attempts to get up unassisted. Further, the KMA stated the resident's care plan should have been updated to reflect the frequency and monitoring for Resident #14. During an interview with the Director of Nursing (DON), on [DATE] at 03:11 PM, she stated she needed more details about the event. She stated realistically a nurse would document what was not in place for a resident; however, she expected the process to start with the nurse identifying what was needed. The DON stated residents needed a care plan to match his/her specific situation. She stated Resident #14's care plan did not address his/her impulsive behavior. The DON stated she expected the resident's care plan to be more detailed with person-centered interventions. She further stated she would expect more supervision to be provided related to Resident #14's impulsive behavior. During an interview on [DATE] at 3:27 PM, with the Administrator, she stated Resident #14 should have had a behavior care plan in place with appropriate interventions. She stated the resident's care plan did not address supervision for him/her. She stated she would have expected Resident #14 to have had 1:1 supervision due to his/her behaviors and history of falls. The Administrator further stated the facility failed to follow its policy for supervision of Resident #14 and his/her care plan was incomplete. 47852

Based on interview, record review and facility policy review, it was determined the facility failed to ensure each resident's comprehensive care plan was developed and/or implemented for four (4) of twenty-five (25) sampled residents, (Residents #4, #9, #15, and #13). 1. Record review revealed Resident #4's care plan was not developed and/or implemented to ensure the resident was monitored related to his/her history of stroke and migraine headaches. 2. On 08/31/2023, at approximately 7:00 PM, Resident #9 attempted to exit the facility through the facility's front lobby door and was brought back inside the facility. However, facility staff did not implement Resident #9's care plan intervention for providing one-to-one (1:1) supervision as needed. Therefore, approximately an hour later, Resident #9 was able to exit the facility without staffs' knowledge. 3. Closed record review revealed Resident #15 sustained a femur fracture on 04/16/2022, after he/she rolled out of his/her low air loss mattress while only one (1) staff provided the resident's Activities of Daily Living (ADL) care. However, Resident #15 was care planned to require extensive assistance of two (2) staff for bed mobility, personal hygiene and turning and repositioning. 4. Record review revealed Resident #13's comprehensive care plan was not implemented to reduce the resident's behaviors which resulted in falls and staff using a gait belt as a restraint to prevent him/her from getting out of his/her chair. The facility's failure to have an effective system to ensure each resident's comprehensive care plan was developed and/or implemented has caused or is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on 09/13/2023 and was determined to exist on 08/31/2023; and on 09/26/2023 and was determined to exist on 07/08/2023, in the area of 42 CFR S482.21 Comprehensive Care Plans Develop and Implement (F656) at the highest Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 09/13/2023 and on 09/26/2023. IJ is ongoing. (Refer to F604, F684, and F689) The findings include: Review of the facility's policy titled, Care Plan Review undated, revealed residents were to be assessed at least quarterly, and include visual and verbal assessment, obtaining information from the health record, as well as interviewing the nursing assistants prior to completing the Minimum Data Set Assessment and comprehensive person-centered care plan. Further review revealed staff were to evaluate the progress or lack thereof for each resident's goal and document the findings in measurable terms. 1.) Review of Resident #4's Admission Record/electronic medical record (EMR) revealed the facility admitted the resident on 10/27/2022, with diagnoses to include: history of Transient Ischemic Attack (TIA) and Cerebral Infarction, Heart Disease, Dementia and Panic Disorder. Continued review revealed Resident #4's last admission was 02/27/2023. Per review, the Medical Director noted on 11/01/2022, that Resident #4 had a prior stroke about two (2) years before being admitted to the facility and had experienced a decline which prevented him/her from living alone. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), signifying severe cognitive impairment. Continued review revealed Resident #4 had been assessed to be absent of any upper and lower extremity impairments. Per MDS review, the facility assessed Resident #4 to require extensive assistance of two (2) staff for bed mobility, transfers, dressing and toileting. Further review of the MDS Assessment revealed Resident #4 had been assessed to require one (1) person physical assistance for eating, personal hygiene, and to ambulate using the walker. In addition, MDS review further revealed Resident #4 did not have any condition which was expected to limit his/her life expectancy in the next six (6) months. Review of Resident #4's Comprehensive Care Plan initiated on 02/28/2023 and reviewed on 06/27/2023, revealed no documented evidence the facility developed a focus area to monitor the resident for signs and symptoms of a stroke related to his/her history of a stroke, nor for migraine headaches. Review of Resident #4's Progress Note dated 07/07/2023, completed by the current Assistant Director of Nursing (ADON) revealed the Medical Director was present in the facility and assessed the resident related to complaints of blurred vision. Further review revealed the Medical Director ordered Resident #4 to be sent out to the Emergency Department (ED) for evaluation related to a possible migraine headache. In an interview with Certified Nursing Assistant (CNA) #14 on 09/18/2023 at 2:39 PM, she stated she rarely looked at residents' care plans. She stated she knew the residents and what care each of them required. CNA #14 stated any information she needed was received in report at the beginning of her shift. She stated the care plan was important because it told exactly what care each resident required, such as if the resident was to be transferred with a mechanical lift, or what type of diet the resident was on, or if the resident was a one (1) or two (2) persons assist. CNA #14 further stated not following the residents' care plan could cause a resident to get hurt or not receive the necessary care they required. In an interview with Licensed Practical Nurse (LPN) #2 on 09/18/2023 at 3:54 PM, she stated she did not believe CNAs had access to the Kardex and they often asked her how a resident was to be transferred. She stated the previous Director of Nursing (DON) told the nurses they could just tell the CNAs what needed to be done for residents, instead of the CNAs having to look at the residents' care plans. LPN #2 stated the facility's care plan policy stated the Registered Nurse (RN) was to initiate residents' care plans and any changes must be updated on their care plans. She stated if a resident sustained a fall, a new intervention for every fifteen (15) minute checks was initiated. She further stated it must be added to the resident's care plan. LPN #2 stated floor nurses should update residents' care plans, but the floor nurses already did everything., and there was not enough time. She stated there was a lot of miscommunications in the facility, and it made it hard to know what she was responsible for completing. The LPN stated she did not report the miscommunication as she did not feel comfortable reporting to management. LPN #2 stated she regularly provided care for Resident #4, and rarely looked at the care plans because she had worked at the facility for a long time and knew the care each resident needed. She stated any new information was to be provided at report during shift change. The LPN stated on 07/08/2023, at shift change, RN #1 informed her Resident #4 was not speaking to staff because the resident was mad and he/she showed out the night before. LPN #2 stated RN #1 called it showing out when Resident #4 asked to go to the Emergency Department (ED) on 07/07/2023, related to his/her blurred vision. She further stated it was important to use the residents' care plans to direct the residents' care and ensure they received the care they needed for quality of life. LPN #2 stated she should probably look at residents' care plans more; however, felt she just did not have the time to do so. In an interview with LPN #3 on 09/25/2023 at 11:45 AM, she stated staff were to look at the care plan every shift to ensure the residents' needs had not changed. LPN #3 stated she did not look at residents' care plans as often as she should; however, she counted on the pass down information from report for any information regarding changes in the residents. She stated the care plan showed staff how to care for the residents, what they ate, how often the resident was to be checked and changed, all the care for each resident. LPN #3 stated if the care plan did not include every area of care for the resident, it could be dangerous for the resident because care could be overlooked. LPN #3 further stated the care plan must be fully developed. She stated all concerns a resident had should be covered in their care plan, and when asked about Resident #4's history of stroke, she reported that should have been on the resident's care plan to ensure staff knew to observe him/her for signs and symptoms of a stroke. In an interview with MDS Coordinator #1 on 09/26/2023 at 9:14 AM, she stated she had been an Assistant MDS Nurse for twenty (20) years. She stated she attended the Interdisciplinary Team (IDT) meetings when the main MDS Coordinator was absent. MDS Coordinator #1 stated she was also responsible for scanning all documents into residents' EMR. She stated MDS #2 was the one who updated residents' care plans, and reviewed the orders, discharge summaries and twenty-four (24) hour notes. The MDS Coordinator stated the previous MDS Coordinator updated the residents' care plans in real time during the IDT meeting. She stated if the facility was aware Resident #4 had a history of strokes and/or migraine headaches those items should have been on the resident's care plan. Further interview with the MDS Coordinator #1, on 09/26/2023 at 9:14 AM, she stated the facility wanted migraine headaches to be addressed under the pain focus of the care plan because it would otherwise be an unspecified diagnosis and the facility did not want unspecified diagnoses on the resident's care plan. She reviewed Resident #4's care plan and stated the area for coronary artery disease (CAD) would cover the resident for monitoring for signs and symptoms of a stroke. However, she stated the symptoms of CAD would include breathing concerns, chest pain, and edema, whereas symptoms of a stroke would be identified as drooping face, slurred speech, and inability to use one (1) side of the body. MDS Coordinator #1 stated residents' care plans were important because it was the tool to provide better care for each resident, and the care plan could change often based on the resident's needs. She further stated staff should look at the residents' care plans prior to every shift. In addition, the MDS Coordinator #1 stated if the care plan was not developed and implemented the resident would not receive the care needed and the resident could be harmed. In an interview with MDS Coordinator #2 on 09/26/2023 at 10:56 AM, she stated she became the main MDS Coordinator in September 2023. She stated she was trained by the previous MDS Coordinator and received some training by the Corporate MDS person. MDS Coordinator #2 stated she attended morning meetings, read through the twenty-four (24) hour reports, and updated residents' care plans in real time during the meetings. She reviewed Resident #4's care plan and stated a history of TIAs was noted as a diagnosis; however, there had not been a focus area developed on the care plan for stroke monitoring or for migraine headaches for the resident. The MDS Coordinator stated the facility did not want any unspecified diagnoses used and that could be why migraine was not listed. She stated migraines would fall under the pain focus, and she was not sure if migraines could be listed under pain as something to watch for. MDS Coordinator #2 stated she would have to investigate that. In a continued interview with MDS Coordinator #2, on 09/26/2023 at 10:56 AM, she stated symptoms of a stroke and symptoms of CAD were different; however, the resident would still be monitored for the CAD and all changes would be reported, per the care plan. MDS Coordinator #2 stated when Resident #4 came to the facility as a new admission and was noted to have a history of stroke, a separate care plan focus should have been developed to monitor the resident for stroke symptoms. She further stated it would be important for staff to know Resident #4 had a history of a stroke, and ensure they watched for any signs of a new stroke. In an interview with the Director of Nursing (DON), on 09/29/2023 at 1:20 PM, she stated she expected residents' care plans to be developed and implemented based on the resident's admission records to include any hospital discharge summary. She stated even though care plans were not her strong suit, it was important to ensure residents' care plans covered every area of care the resident needed to make sure each resident got the best quality of care. The DON further stated she counted on the MDS Coordinators to ensure residents' care plans were developed and all staff were aware of the care plans to ensure the care plans were implemented. In an interview with the Administrator on 09/29/2023 at 1:30 PM, she stated residents' comprehensive care plans should address every care area and ensure each diagnosis had at least an area to monitor for changes especially if the resident still had those problems. The Administrator stated care plans were discussed in the morning meeting, during which they looked at Progress Notes, the 24-Hour Report, and Discharge Summaries. She stated residents' care plans were then updated in real-time. She stated the care plans should be developed with the admission history because that was the best way to ensure each resident got the best care. The Administrator stated if a focus area was not developed on the care plan, staff would not know to watch for changes in that particular area. She further stated it was a team effort to ensure care plans were developed properly. 2.) Review of Resident #9's Admission Record/EMR revealed the facility admitted the resident on 02/24/2022, with diagnoses which included Alzheimer's Disease, Dementia with Mood Disturbance, History of Falling, Lack of Coordination, Muscle Weakness, and Anxiety Disorder. Review of Resident #9's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Elopement Assessments, dated 02/25/2022 and 08/10/2023, revealed the facility assessed him/her to have an Elopement Score of sixteen (16), which indicated the resident was at high risk for elopement. Review of Resident #9's Comprehensive Care Plan dated 03/02/2022, revealed a focus for the resident being at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease, and with a goal that the resident would not leave the facility's grounds unattended. Continued review revealed interventions dated 03/02/2022, which included redirecting him/her as needed if he/she was wandering. Further review revealed an intervention for staff to provide 1:1 supervision as needed. However, review further revealed there was no documented evidence Resident #9's intervention for 1:1 supervision as needed was implemented on 08/31/2023 at 7:00 PM, after the resident exhibited exit seeking behaviors. Review of Resident #9's Progress Note dated 08/31/2023 at 9:11 PM, signed by the DON revealed the resident was noted to have increased wandering, and was directed back to the unit and his/her bedtime Activities of Daily Living (ADL) care was provided. Continued review revealed Resident #9 was placed on 1:1 supervision; however, there was no documented evidence as to why the 1:1 supervision was provided, and no documented evidence of the resident attempting to exit the facility. Per review of the Note, there was no documented evidence Resident #9's Comprehensive Care Plan intervention for 1:1 supervision had been implemented at 7:00 PM when the resident was exhibiting exit-seeking behaviors. Further review revealed the facility was unable to provide documentation of Resident #9 receiving the 1:1 supervision after exiting the building at 8:00 PM on 08/31/2023. In addition, review further revealed LPN #4 reported she placed Resident #9 on 1:1 supervision after returning the resident to the building; however, had not done so when she removed the resident from the foyer area earlier in the shift (as per the resident's care plan). Observation of Resident #9 on 09/11/2023 at 2:55 PM, revealed the resident was up in his/her wheelchair in the front lobby area with other residents. Observation of Resident #9 on 09/12/2023 at 9:20 AM, revealed the resident in his/her room with no direct supervision being provided. Observation of Resident #9 on 09/12/2023 at 6:15 PM, revealed the resident had a 1:1 sitter providing supervision. Observation of Resident #9 on 09/13/2023 at 3:55 PM, revealed the resident continued to have a 1:1 sitter providing supervision. During an interview with Resident #9's Family Member #2 on 09/13/2023 at 2:58 PM, he stated he received a call from a nurse on 08/31/2023 at approximately 8:00 PM, who told him someone went out the front door and Resident #9 went out the door behind that person and made it onto the sidewalk. He further stated he was told Resident #9 would have increased supervision and he was under the impression someone would be sitting with the resident at all times. During an interview with the Social Services Director (SSD) on 09/12/2023 at 1:42 PM, she stated she saw Resident #9 sitting on a bench close to the front lobby door on 08/31/2023, and thought he/she went out the front lobby door into the foyer but had not gone outside. She stated she was unaware Resident #9 had followed her out the facility door. The SSD further stated 1:1 supervision should have been provided for the resident as per his/her care plan. During an interview with Licensed Practical Nurse (LPN) #4 on 09/12/2023 at 5:41 PM, she stated she responded to the front door alarm sounding on 08/31/2023 at approximately 7:00 PM, and witnessed Resident #9 standing in the foyer area between the door from the front lobby and the outside door. She stated the SSD was in the front lobby and she and the SSD brought the resident back into the lobby area where other residents were watching television. LPN #4 stated she left Resident #9 in the front lobby, unsupervised and went back to her hall to pass medications. She stated on 08/31/2023 at approximately 8:00 PM, she heard the front door alarm sounding again and heard Resident #12 yell that Resident #9 had gone out the front door. LPN #4 stated she found Resident #9 standing on the sidewalk outside the facility and took the resident back inside and placed him/her on 1:1 supervision at that time. In further interview with the Licensed Practical Nurse (LPN) #4, on 09/12/2023 at 5:41 PM, she stated she received a phone call from the DON about an hour and a half later telling her to leave Resident #9 on 1:1 supervision unless the resident was in bed sleeping, in which case he/she did not have to be 1:1. LPN #4 stated the paperwork had been done, floor staff had been told by the administration they were not to update care plan interventions as that was performed by the MDS Nurses or the Administrative Clinical team. She stated that she did not revise Resident #9's Comprehensive Care Plan and thought the DON had revised it. The LPN stated she was unaware Resident #9 had been care planned for 1:1 supervision as needed when the resident attempted to exit the building at 7:00 PM. LPN #4 stated she did not look at residents' care plans every shift, and reported she relied on the previous shift nurse to relay any pertinent information to her. She stated Resident #9 was 1:1 supervision while up in the hallway after exiting the building at 8:00 PM; however, was not directly supervised after lying down on his/her bed that night. LPN #4 further stated the facility was unable to provide any evidence of Resident #9 receiving 1:1 supervision services on 08/31/2023. During an interview with MDS Coordinator #1 on 09/20/2023 at 3:20 PM, she stated the floor staff nurses could update residents' Comprehensive Care Plan interventions. She stated the care plans were also updated daily by the MDS Coordinators during morning clinical meetings. MDS Coordinator #1 stated the MDS Coordinators looked at the orders that had been entered and read the twenty-four (24) hour report book to ensure they were entering appropriate interventions to the residents' care plans. She further stated Resident #9 had an intervention in place for 1:1 supervision as needed, which should have been implemented if the resident attempted to exit seek on 08/31/2023 at 7:00 PM. During an interview with the Director of Nursing (DON) on 09/13/2023 at 12:12 PM, she stated she was aware Resident #9 had gone into the foyer past the lobby door on 08/31/2023, at which time the nurse should have implemented the Comprehensive Care Plan intervention for increased supervision. She stated she called LPN #4 and told her to put Resident #9 on 1:1 supervision and the resident stayed on 1:1 supervision for a day or two (2). The DON stated, however, that she was unable to provide any documentation of Resident #9 receiving 1:1 supervision on 08/31/2023 after he/she exited the facility. She stated the supervision for Resident #9 was placed as an order and no other documentation was completed. She stated she charted a progress note regarding Resident #9 having increased wandering in the resident's chart after speaking with LPN #4. The DON stated, however, she had not revised his/her care plan at that time because MDS updated the care plans at clinical morning meetings. She further stated the MDS Nurses updated Comprehensive Care Plans at the daily clinical meeting after reviewing the past twenty-four (24) hour shift reports and orders. During an interview with the Administrator on 09/13/2023 at 12:24 PM, she stated she was not aware Resident #9 had gotten out the lobby door on 08/31/2023, until the next day. She stated she heard the SSD and a nurse or housekeeper discussing that Resident #9 needed to be redirected. The Administrator stated she was unsure why Resident #9 was placed on 1:1 supervision on 08/31/2023; however, stated she was aware the DON had received a call from staff stating Resident #9 had increased agitation on 08/31/2023. Per the Administrator, all administrative staff said the resident did not elope and was placed on 1:1 for exit seeking. She stated that was probably why Resident #9 was placed on 1:1 supervision. The Administrator stated if Resident #9 was exit seeking at 7:00 PM, the resident should have had increased supervision at that time to prevent him/her from exiting the building at 8:00 PM. 3.) Review of Resident #15's Admission Record revealed the facility admitted the resident on 03/28/2022, with diagnoses to include Dementia, Hypertension, and Malnutrition. Review of Resident #15's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the facility assessed Resident #15 to require the physical assistance of two (2) staff for bed mobility, transfers, toileting, dressing, and for personal hygiene. Review of Resident #15's Comprehensive Care Plan revealed the facility care planned Resident #15 to require extensive assistance of two (2) staff for bed mobility, to turn and reposition, for bathing and showers, dressing, personal hygiene, and toileting. Review of a Change in Condition (CIC) completed on 04/22/2022, by LPN #12 revealed a CNA had been giving Resident #15 a shower on 04/22/2022 and the resident began to cry in pain and his/her right hip was red and swollen. Review of an Interdisciplinary Team (IDT) Note dated 04/28/2022, revealed during care on 04/16/2022 Resident #15 got too close to the edge of the bed and fell out. Per the review, it was noted Resident #15 was immediately assessed and placed back in bed. The Medical Director and resident's representative were notified, and no new orders were given. Continued review of the IDT Note revealed Resident #15 was sent to the Emergency Department (ED) on 04/22/2022 and was admitted to the hospital with a fractured right femur. Further review revealed the IDT noted the fracture was related to Resident #15's fall that happened on 04/16/2022. In addition, review of the IDT Note revealed Resident #15 returned to the facility on [DATE]. In interview on 09/28/2023 at 1:51 PM, CNA #22 stated she knew Resident #15 well and thought she was working on 04/16/2022, when the resident was hurt. CNA #22 stated she heard CNA #24 scream out. She stated the nurse went into the resident's room to assess Resident #15. CNA #22 stated the low air loss mattresses were very tricky and could be slippery. She stated when she provided care for a resident with a low air loss mattress she would not change the resident without the assistance of another staff person. CNA #22 stated Resident #15 used to be able to get out of bed every day; however, the resident's legs were badly contracted, and it was very painful for him/her to be out of bed, and that made it very difficult to provide his/her peri care. However, further record review revealed no documented evidence the facility implemented Resident #15's care plan on 04/16/2022, to ensure two (2) staff provided extensive assistance for the resident's bed mobility, turning and repositioning and personal hygiene. In an interview with the Kentucky Medication Assistant (KMA) #1 on 09/29/2023 at 10:25 AM, she stated that while providing care to a resident who had an air mattress, the aide should use two (2) staff because the bed was filled with air which made the bed unstable, the resident could fall out. KMA #1 additionally stated the use of the low-air loss mattress should have been care planned. In an interview with the current Assistant Director of Nursing (ADON), on 09/29/2023 at 11:03 AM, she stated she worked on 04/16/2022 when an aide provided peri care, by herself, on the resident and the resident rolled out of bed. She stated she was not assigned to the resident's floor and could not remember the details. She said any resident who had a low air loss mattress really needed to have two (2) staff assist with any bed mobility, peri care, personal hygiene and transfer back into the bed. She stated that was for the resident's safety. In an interview with the Director of Nursing (DON) on 09/29/2023 at 1:20 PM, she stated she was not familiar with Resident #15; however, it was her expectation that each resident's care plan was individualized to meet the resident's needs and she expected staff to ensure the care plan was implemented to meet those needs. In an interview with the Administrator on 09/29/2023 at 1:25 PM, she stated the use of an air mattress required an order from the Physician and should be care planned. She stated the air mattress should be checked each shift to ensure it was properly inflated. The Administrator stated the bed had an alarm that sounded if the bed was not at the correct setting, which alerted staff to respond and correct the settings. She stated all nursing staff should be able to adjust the beds, as required while providing care. The Administrator further stated she expected staff to follow the facility's policy to ensure each resident's care plan was updated and implemented to meet the resident's needs. Review of the facility's policy titled, Guidelines for Physical Restraints/Seclusion, last revised 05/17/2023, revealed physical restraints were only to be used as a last resort and only after every other alternative to a physical restraint (based on assessment) had been tried and failed that seemed to have the potential for being used successfully. Continued review revealed the policy noted a physical restraint was never to be used for staff convenience or for discipline. Further review revealed the care plan must reflect the use of the physical restraints to include medical condition as well as releasing at least every two (2) hours per shift. Review further revealed skin checks were to be completed during the use of restraints at the time of application and removal and by the nurse as indicated. 4.) Closed Record Review of Resident #13's medical record Face Sheet revealed the facility admitted the resident on 07/15/2023, with diagnoses of Dementia, Intracerebral Hemorrhage Intraventricular, and Altered Mental Status. Review of Resident #13's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of zero (0) out of fifteen (15) signifying the resident had severe cognitive impairment. Continued review revealed the facility assessed Resident #13 as requiring extensive assistance of two (2) staff for bed mobility, transfers, toileting, bathing, personal hygiene and one (1) person physical assistance for eating and locomotion. Further review revealed the facility also assessed Resident #13 as absent of behaviors, absent of upper and lower extremity impairments and was able to use a walker and/or a wheelchair for mobility. In addition, review further revealed the facility noted direct care staff believed Resident #13 could increase his/her independence and better his/her Activities of Daily Living (ADLs). Review of Resident #13's Comprehensive Care Plan initiated 07/20/2023, revealed the facility care planned the resident for mood and behaviors related to diagnoses of brief Psychotic Disorder, Depression, Anxiety, Altered Mental Status, Insomnia and Intracerebral Hemorrhage (prior to admission). Per review, it was noted Resident #13 received antidepressant medication therapy, and staff were to attempt diversional activities when the resident was agitated or restless. Review revealed staff were to observe and document all inappropriate behaviors and mood changes. In addition, review revealed staff were also to observe for and document any interventions used to discourage Resident #13's inappropriate behaviors. Continued review of Resident #13's Comprehensive Care Plan initiated 07/20/2023, revealed the facility care planned the resident to require extensive assistance of two (2) staff for all ADL care. Per review, the interventions included to: provide frequent periods of rest as indicated (08/09/2023); redirect as needed (08/09/2023); and use a gait belt for all assisted transfers (08/09/2023). Further care plan review revealed the facility assessed and care planned Resident #13 as a high fall risk with interventions which included: use of not skid socks at all times (07/19/2023); use of non skid pads on floor next to the bed (07/23/2023); use Dycem (non-slip, rubber-like plastic material used to stabilize surfaces) in the resident's wheelchair (07/28/2023); staff to assist the resident to bed when restless and as tolerated (07/30/2023); and staff were to anticipate and meet the resident's needs. Review of Resident #13's Progress Note dated 07/19/2023, entered by Licensed Practical Nurse (LPN) #1, revealed the resident had a private sitter at bedside with the family. Review of a Progress Note dated 07/20/2023, created by RN #1 revealed she documented Resident #13 had a private sitter at his/her bedside as well as family. Review further revealed RN #1 documented on 07/24/2023, Resident #13 had been found lying on the floor and had a quarter sized skin tear on the under part of the forearm. Further review of the 07/24/2023 Note, revealed RN #1 noted Resident #13 was assessed and placed back onto his/her bed. Review of a Progress Note, completed by current Assistant Director of Nursing (ADON) on 07/28/2023, revealed Resident #13 slid out of his/her chair and was on the floor on his/her back. Per review, the ADON noted an immediate intervention to move Resident #13 to the nurse's station for more supervision and the resident was placed on every fifteen (15) minute checks. Continued review revealed no documented evidence the interventions of keeping Resident #13 at the nurse's station for increased supervision and every fifteen (15) minute checks were added to his/her care plan. Review of Resident #13' [TRUNCATED]

Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were implemented related to abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835) at the highest scope and severity of a J. Substandard Quality of Care (SQC) was identified at 42 CFR §483.12, Free from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Abuse Prevention Program, dated 10/22/2022, revealed it was the facility's policy that staff members, who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident, and the findings of the examination must be recorded in a separate incident report. Per the policy, to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Review of Resident #9's admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Alzheimer's Disease, history of falling, and dementia with mood disturbance and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow on dementia. Per the report, statements were written and signed by Licensed Practical Nurse (LPN) #13, CNA #33, and CNA #35. Review of the facility's Five (5) day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment on Resident #9, and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. Per the report, all residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed, and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment), and no areas of concern were identified. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of CNA #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with topics discussed as follows: medication administration; proper progress notes and documentation; use of the chart audit tool; all residents at risk for elopement and the review of all elopement drills; the need for twenty-four/seven (24/7) front door monitoring; resident care plans; and use of the Continuous Quality Improvement (CQI) tool. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON, the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said to Resident #9, I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy on abuse and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. In further interview with CNA #33, on 10/17/2023 at 5:21 PM, she stated the DON told her she was going to call the Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 told her I have to send CNA #35 home and I'm nervous. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She continued to state she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34, on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She continued to state CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9 and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She continued to state CNA #35 told CNA #34 sit in that chair and don't let him/her get up or touch anything. She stated LPN #13 came into the room and talked with the resident, then CNA #35 came back into the room and she left, leaving LPN #13 and CNA #35 in Resident #9's room. CNA #34 further stated no one asked her to write out a statement related to the incident stating, I've been waiting for someone to ask me about the incident, and no one's asked me. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023, she was caring for a resident about two (2) doors down the hall from Resident #9's room around 2:00 AM when she heard crying coming from Resident #9's room, a high pitched sound. She stated Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her, I need to report abuse. She further stated she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. LPN #13 stated CNA #33 told her CNA #35 said to Resident #9, It's time for bed, and used vulgar words to address Resident #9. Additionally, she stated she told CNA #33 to call the DON, then the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9 and she told CNA #35 she had to go home and she watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse, now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and she was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should have probably been removed from the facility earlier than she was. In an interview with Police Officer #1, on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated staff informed him that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. He further stated he did not attend the QAPI meeting held on 10/13/2023 either in person or by telephone. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33 who reported CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She states she called and notified Administrator #2, then called and talked to a nurse and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room, but from the time the incident occurred until CNA #35, was sent home was approximately ten to fifteen (10-15) minutes. The DON stated she was aware the police came to the building but was not sure what they did. Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023, since it was an allegation and had not been thoroughly investigated at that time. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the policy titled Abuse and Neglect Reporting Policy, but would reach out to the Regional Nurse Consultant to see if another policy was in effect. He later presented the State Survey Agency with a policy titled Abuse Prevention Program. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) about an abuse allegation and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and to complete a head to toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8) (which indicated cognitive impairment), and interview any residents with a BIMS score of eight (8) or higher. He further stated the police should be contacted, if needed. During continued interview with the Administrator, on 10/18/2023 at 10:18 AM, he stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. The Administrator stated he did not need to list everyone he interviewed in his report and that the conclusion (located on the facility's 5-day investigation report) stated, based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. He stated he discussed the incident in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. He further stated he discussed it with the department heads and the Medical Director. However, CNA #34, the staff the resident reported the physical and verbal abuse to, stated in interview, she had not been interviewed related to the incident. Additionally, interview with the Medical Director revealed he was unaware of the incident and did not attend the QAPI meeting held on 10/13/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going f[TRUNCATED]

Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. She then witnessed CNA #35 push Resident #9 in the chest down into Resident #9's bed, and CNA #35 told Resident #9 to keep his/her ass in bed. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed Resident #9's abuse incident was not discussed at the meeting. The facility's failure to ensure its policies were implemented related to abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835) at the highest scope and severity of a J. Substandard Quality of Care (SQC) was identified at 42 CFR S483.12, Free from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Abuse Prevention Program, dated 10/22/2022, revealed it was the facility's policy that staff members, who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident, and the findings of the examination must be recorded in a separate incident report. Per the policy, to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Review of Resident #9's Admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Alzheimer's Disease, history of falling, and dementia with mood disturbance and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of the facility's Initial Report, dated 10/12/2023, revealed on 10/12/2023 at 1:53 AM, Certified Nursing Assistant (CNA) #33 heard a scream and went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Further review revealed CNA #35 was removed from the facility, and Resident #9's assessment showed no signs of injury. Continued review revealed the resident had a history of dementia with a care plan to follow on dementia. Per the report, statements were written and signed by Licensed Practical Nurse (LPN) #13, CNA #33, and CNA #35. Review of the facility's Five (5) day Final Report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the DON. Further review revealed the nurse immediately did a head to toe skin assessment on Resident #9, and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. Per the report, all residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed, and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment), and no areas of concern were identified. Continued review revealed the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of CNA #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Quality Assurance Performance Improvement (QAPI) Meeting Sign-In Sheet, dated 10/13/2023, revealed a QAPI meeting was held on 10/13/2023 with topics discussed as follows: medication administration; proper progress notes and documentation; use of the chart audit tool; all residents at risk for elopement and the review of all elopement drills; the need for twenty-four/seven (24/7) front door monitoring; resident care plans; and use of the Continuous Quality Improvement (CQI) tool. However, there was no documentation of a discussion about Resident #9's abuse incident. Further review revealed Corporate staff, the Administrator, the DON, the Social Services Director (SSD), and the Minimum Data Set (MDS) attended the meeting. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 stand up, use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said to Resident #9, I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified LPN #13, who stated she was unaware of the facility's policy on abuse and asked CNA #33 to call the DON, which she did. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. In further interview with CNA #33, on 10/17/2023 at 5:21 PM, she stated the DON told her she was going to call the Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 told her I have to send CNA #35 home and I'm nervous. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down because she was crying and agitated. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She continued to state she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with CNA #34, on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room and she went to another resident's room. She continued to state CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9 and she went with CNA #35 to report to LPN #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break and, when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She continued to state CNA #35 told CNA #34 sit in that chair and don't let him/her get up or touch anything. She stated LPN #13 came into the room and talked with the resident, then CNA #35 came back into the room and she left, leaving LPN #13 and CNA #35 in Resident #9's room. CNA #34 further stated no one asked her to write out a statement related to the incident stating, I've been waiting for someone to ask me about the incident, and no one's asked me. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023, she was caring for a resident about two (2) doors down the hall from Resident #9's room around 2:00 AM when she heard crying coming from Resident #9's room, a high pitched sound. She stated Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her, I need to report abuse. She further stated she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. LPN #13 stated CNA #33 told her CNA #35 said to Resident #9, It's time for bed, and used vulgar words to address Resident #9. Additionally, she stated she told CNA #33 to call the DON, then the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9 and she told CNA #35 she had to go home and she watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse, now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something, and she was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should have probably been removed from the facility earlier than she was. In an interview with Police Officer #1, on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated staff informed him that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9 at any time. He further stated he did not attend the QAPI meeting held on 10/13/2023 either in person or by telephone. In an interview with the DON on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33 who reported CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She states she called and notified Administrator #2, then called and talked to a nurse and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room, but from the time the incident occurred until CNA #35, was sent home was approximately ten to fifteen (10-15) minutes. The DON stated she was aware the police came to the building but was not sure what they did. Additionally, she stated the incident was not discussed in the QAPI meeting on 10/13/2023, since it was an allegation and had not been thoroughly investigated at that time. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the policy titled Abuse and Neglect Reporting Policy, but would reach out to the Regional Nurse Consultant to see if another policy was in effect. He later presented the State Survey Agency with a policy titled Abuse Prevention Program. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) about an abuse allegation and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and to complete a head to toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8) (which indicated cognitive impairment), and interview any residents with a BIMS score of eight (8) or higher. He further stated the police should be contacted, if needed. During continued interview with the Administrator, on 10/18/2023 at 10:18 AM, he stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. The Administrator stated he did not need to list everyone he interviewed in his report and that the conclusion (located on the facility's 5-day investigation report) stated, based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. He stated he discussed the incident in QAPI on 10/13/2023 in passing and that was why it was not listed on the QAPI minutes for 10/13/2023. He further stated he discussed it with the department heads and the Medical Director. However, CNA #34, the staff the resident reported the physical and verbal abuse to, stated in interview, she had not been interviewed related to the incident. Additionally, interview with the Medical Director revealed he was unaware of the incident and did not attend the QAPI meeting held on 10/13/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going forward. In an interview with the facility's Scheduler on 10/21/2023 at 2:39 PM, she stated she did not attend the meeting in which the abuse allegation which in [TRUNCATED]

The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was only identified as Quality Assurance (QA). The CNO stated that was a change in Phase 3 of the Federal Regulation roll out. She stated QAPI was added, and some of the policy was reorganized to make it easier to read. She stated the facility made the eight (8) different components more obvious. The CNO stated it was her expectation the facility would have an Ad-Hoc QAPI meeting within twenty-four (24) hours of any abuse allegation. 9. Review of the sign-in sheets for the Ad-Hoc meeting, dated 10/20/2023, revealed no evidence of a 10/19/2023 meeting, and attendees discussed the updated Abuse Policy and QAPI. Those noted as present were the Interim Administrator, DON, ADON, BOM, Activity Director, Dietary, Maintenance Assistant, LPN #6, LPN #7, HR, Housekeeping Director, Assisted Living Director (she helps at the facility sometimes), MDS Nurse #1 and MDS Nurse #2, Corporate MDS Coordinator, and SSD. Review of a zoom call sign-in sheet of a meeting that was conducted on 10/20/2023 at 1:00 PM revealed those present were the Lead by Chief Nursing Officer (CNO)/Governing Body, Present for call: Regional MDS Coordinator #1, Regional Travel DON, ADON, Maintenance Assistant, DON, BOM, Activity Director, Dietary Director, Interim Administrator, Maintenance Director, Housekeeping Director, Float (not Regional) MDS Nurse #3, and Regional MDS Nurse #2. Review of an email to the DON from the Medical Director, dated 10/20/2023 at 5:02 PM, revealed every policy and tag identified by the State Survey Agency (SSA) was discussed with the Administrator and nursing staff of the facility. The Medical Director noted he had been involved with the policies and procedures to correct processes going forward. In an interview with the facility's Scheduler on 10/21/2023 at 2:39 PM, she stated she did not attend the meeting in which the abuse allegation which involved Resident #9 was discussed. She stated the meeting was covered with her after the fact as she had a floor assignment. She stated they discussed the change of the abuse policy from QA to QAPI. She said a new question do you feel safe here was added to the list they completed during Guardian Angel rounds. The scheduler stated if there was an allegation of abuse, the resident was to be kept safe and removed from the situation, and then the incident was to be reported to management immediately. She said the most important part was to make sure the resident was safe. In an interview with the Activities Director on 10/21/2023 at 10:36 AM, she stated she recalled a meeting in which management discussed CNA #35 and the allegation she pushed Resident #9 and yelled at the resident. The Activities Director said there were discussions about the aide leaving the resident alone with the alleged perpetrator while she got help and did not get the resident out of danger. The Activities Director stated the aide should have called for someone to come and be with Resident #9 or she should have taken Resident #9 with her to get help. She stated on 10/20/2023 the CNO held a meeting, and they discussed the change from QA to QAPI on the abuse policy. She believed the policy remained the same except for those two (2) areas. In an interview with the Business Office Manager (BOM) on 10/21/2023 at 1:35 PM, she stated she was present at a meeting in which Resident #9 was discussed and what was done wrong, as the aide left the resident with the perpetrator. She stated the aide should have made sure the resident was safe first. She stated they talked about reporting abuse, and staff members needed to make sure it happened timely. The BOM stated they talked about education with the focus on resident safety. In an interview with the Human Resources (HR) Director on 10/21/2023 at 1:44 PM, she stated she was present in a meeting when Resident #9 and how to follow the abuse policy. She further stated the policy was changed to reflect QAPI instead of QA. In an interview with the Housekeeping Director on 10/21/2023 at 11:11 AM, she said the management team discussed what happened with Resident #9 and what could have been done to prevent the entire incident. She stated QA was changed to QAPI which was discussed in their meeting. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she stated she was present in a meeting in which Resident #9 was discussed. She stated the team discussed the allegation of abuse and that the aide left the resident alone with the alleged perpetrator while she went to get help. In an interview with Minimum Data Set (MDS) Coordinator #2 on 10/21/2023 at 2:09 PM, she stated the team discussed the abuse policy and about the change from QA to QAPI to match the federal regulations. She stated all department heads and the administrative team were present. She stated they discussed the abuse allegation related to Resident #9 and the importance of removing the resident to safety before anything else was done. MDS Coordinator #2 stated all abuse concerns had to be reported immediately to the supervisor and to the Abuse Coordinator, who had two (2) hours to report it to the required agencies. In an interview with LPN/UM #6 on 10/21/2023 at 10:58 AM, she stated she was aware the abuse policy had some updates mostly related to the wording of it. She stated management ensured all staff were educated about abuse and understood to make sure the resident was safe before getting help. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated the team met on 10/19/2023, and discussed the abuse policy, reporting procedures, making sure staff knew how to report, who to report to, and when to report any abuse concerns. She stated management reinforced resident safety and not to leave the resident alone with the perpetrator. She also stated the management team was present early on 10/21/2023 before shift change to make sure all staff members were educated before they started their shift on the floor. In an interview with the SSD on 10/21/2023 at 2:25 PM, she stated there was a meeting in which the administrative team and the department heads discussed the new tags related to the abuse allegation. She said they discussed the incident related to Resident #9. The SSD stated they discussed the report of abuse and what action was taken and what they would do from this point. The SSD stated the focus of the meeting was for staff members were to ensure the resident was safe before leaving the room to get help. In an interview with the Medical Director on 10/21/2023 at 5:22 PM, he stated the facility would implement the changes to ensure anytime there was an abuse allegation, a QAPI meeting would be held within one (1) day or that day. He also stated if the allegation was abuse, the person identified as the perpetrator would not be left alone with the resident. The Medical Director stated he would be involved with the Ad-Hoc QAPI meeting, and if he was not available, his Nurse Practitioner would be present. He further stated he was made aware of the changes to the policy to reflect QAPI instead of QA. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:53 PM, she stated she was present in a meeting in which Resident #9 was discussed and the abuse allegation. She said they talked about changes to the abuse policy, such as QA was changed to QAPI, and an immediate meeting would be held for all allegations of abuse. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated they held a meeting and discussed the concerns related to Resident #9. She said they discussed the allegation and the changes in the abuse policy. The DON stated the emphasis of the meeting was educating all the facility staff to ensure a resident was never left alone with an alleged perpetrator. The DON also noted the policy was changed to reflect QAPI instead of QA. In an interview with current Interim Administrator on 10/21/2023 at 11:33 AM, she stated she was called to start at the facility on 10/20/2023 in the morning. The Interim Administrator said the CNO informed her of Resident #9's abuse situation. She stated the facility management staff completed extensive education as well as follow up to ensure all staff understood how to deal with abuse allegations. The Interim Administrator stated the department heads conducted Guardian Rounds at the beginning of each day, and all concerns were addressed as a team. The Interim Administrator stated there were reminder signs posted all throughout the facility, even in the staff restrooms regarding abuse. She stated staff members were given quizzes about reportables and understanding they must report any concerns, even if they were not sure it was abuse. The Interim Administrator stated the department heads would continue to quiz staff. 10. In interviews with the Activities Director on 10/21/2023 at 10:36 AM, the LPN/UM #6 at 10:58 AM, the Business Office Manager (BOM) at 1:35 PM, Human Resource (HR) Director at 1:44 PM, and the MDS Coordinator #2 at 2:09 PM, they stated reeducation over the abuse policy was provided by the DON with the previous Interim Administrator present. They stated all staff took a post-test requiring a 100% passing score. In interviews with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:53 PM, and the DON at 3:45 PM, they stated abuse training was provided by the Regional Director of Operations (RDO) and were given a pretest and post-test. They stated there was a question on the quiz about ensuring the resident was safe and not to leave the resident with an alleged perpetrator when getting help or going to report it. The ADON and DON further stated they discussed signs and symptoms of abuse in residents with dementia and reporting requirements. 11. Review of the education sign-in sheets and quizzes, dated 10/20/2023, revealed all current staff had completed the education and achieved a passing score of 100 percent. In an interview with CNA #15 on 10/21/2023 at 9:58 AM; CNA #37 on 10/21/2023 at 10:05 AM; CNA #32 on 10/21/2023 at 10:08 AM; CNA #14 on 10/21/2023 at 10:15 AM; CNA #38 on 10/21/2023 at 10:20 AM; CNA #39 on 10/21/2023 at 10:41 AM; CNA #21 on 10/21/2023 at 3:12 PM; and CNA #46 on 10/21/2023 at 4:00 PM, all stated they were reeducated by the Regional Travel DON on abuse. Each CNA stated they covered the types of abuse, who to report to, what to do in an abuse situation, and when to report abuse. Each CNA stated they had to take a quiz after the education and score 100 percent to pass. Each aide explained if the quiz was not passed, reeducation was completed on the spot. All CNAs stated the focus of the reeducation was to ensure the resident was never left alone with the alleged perpetrator, and they got help by calling out for help or by hitting the call light. All aides were educated that abuse was to be reported immediately to management, and the Administrator was the Abuse Coordinator. In an interview with Housekeeping Aide (HKA) #4 on 10/21/2023 at 10:27 AM, she stated she had abuse training with the Regional Travel DON. She said the abuse training covered what to do with a resident in an abuse situation, the types of abuse, who to call, and when to call. HKA #4 stated she would contact the Administrator immediately to report an allegations of abuse. The HKA #4 stated if she witnessed any concerns of abuse, she would make sure the resident was safe before she reported it to management. HKA #4 stated she had to take a quiz on abuse and score 100 percent to pass. In an interview with Dietary Aide #1 on 10/21/2023 at 10:49 AM and Dietary Aide #2 on 10/21/2023 at 10:51 AM, they stated they received abuse training by the DON. They reported the abuse training included what to do if they suspected abuse, how long they had to report abuse, who to report to, and to make sure the resident involved in the situation was kept safe and not left alone with the alleged perpetrator. Dietary Aide #1 and #2 also stated they were to report any abuse concerns to the Administrator. In an interview with Dietary [NAME] #1 on 10/21/2023 at 10:46 AM and Dietary [NAME] #2 on 10/21/2023 at 10:53 AM, they stated they were educated by the DON prior to their shift today on the expectations when abuse concerns were identified. Both Dietary [NAME] #1 and #2 stated they had to take a posttest and score 100 percent to pass. They stated they were educated on what to report, when to report, and who to report to. They said they were told if they witnessed abuse the first thing they needed to do was ensure the resident was safe. The next thing they needed to do was report the allegation to management. Both Dietary Cooks identified the Administrator as the Abuse Coordinator. Both stated they were not to ever leave a resident with the alleged perpetrator while they got help. In an interview with LPN #11 on 10/21/2023 at 10:01 AM and LPN #14 on 10/21/2023 at 2:46 PM, they stated they had abuse training last night, and the training was completed by Regional Travel DON. LPN #11 stated training covered the types of abuse, the policy on abuse, what to do in an abuse situation, who to report the allegation to, and when to report the abuse situation. LPN #11 stated she would report allegations of abuse immediately to the Administrator. She also stated she took a posttest which required a passing score of 100 percent. LPN #11 stated when suspected abuse occurred, the first thing she needed to do was ensure the resident was safe and not to leave the resident with the alleged abuser. LPN #11 also stated she would report the allegation immediately to the Manager on Duty. In an interview with Speech Therapist #1 on 10/21/2023 at 2:10 PM, she stated she completed abuse education with many other staff on 10/20/2023. She said the training was completed by the facility DON and also corporate staff. Speech Therapist #1 stated they were educated on what needed to be reported, who it should be reported to, to make sure the resident was safe before going out to get help, and making sure the abuse was immediately reported. She also said they discussed QAPI. She said all staff were required to take and pass a quiz on abuse with a score of 100 percent. She stated those who did not score 100 percent were reeducated on the spot. She stated the Abuse Coordinator was the Administrator. In an interview with the Therapy Program Director (TPD) on 10/21/2023 at 1:48 PM, he stated he attended reeducation on abuse on 10/20/2023, and it was completed by the Regional Travel Nurse and the facility DON. He stated they discussed what abuse was, the types of abuse, when it had to be reported, and who it needed to be reported to. He stated they discussed making sure the resident involved was made safe and not left in the room with the alleged perpetrator when staff reported it to management. The TPD stated staff could use the call light or could call out for help if in that situation. He also stated all staff members were required to take and pass a quiz with a score of 100 percent. He explained the Guardian Angel Rounds, which were when the department heads rounded the entire unit and checked residents' rooms, to make sure there no hazards, were clean, and the residents had everything they needed. The TPD stated any concerns found during the rounds were to be reported immediately if they were serious; if not serious, the form was completed and put in the DON's office. In an interview with the Scheduler on 10/21/2023 at 2:39 PM, she stated agency staff members were given a training packet to complete at the front door prior to their shift. She also stated any staff who were scheduled as needed (PRN) were contacted via telephone, and training was done with them. She stated two (2) staff were required for any verbal training to be conducted. She said she highlighted all agency staff on the schedule and informed the receptionist those staff had a packet to complete prior to their shift. She stated once the training was done, the agency staff would be given their computer log in. In an interview with the ADON on 10/21/2023 at 2:54 PM, she stated all staff were provided a copy of the abuse policy, they were told who abuse allegations were to be reported to, shown where the phone numbers were listed, and informed they were to report all concerns of abuse immediately. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she made sure all staff were reeducated on abuse, through meeting them at the door, calling them at home, or whatever it took to ensure all staff members were trained. She stated any staff who could not be reached would be educated prior to working a shift. The SSA Surveyor attempted an interview with LPN #12 on 10/21/2023 at 3:01 PM; CNA #42 at 3:04 PM; CNA #21 at 3:06 PM; CNA #44 at 3:08 PM; and Kentucky Medication Aide (KMA #4) at 3:11 PM. However, the SSA Surveyor was unable to contact these staff, and voice messages were left on phones where it was possible to leave a message. 12. Review of education on abuse signature sheet, dated 10/20/2023, revealed education was completed by the CNO to all management staff. In an interview with the Activities Director on 10/21/2023 at 10:36 AM, she stated she was provided reeducation on abuse by the Chief Nursing Officer (CNO). She stated the policy was reviewed and they discussed the changes from QA to QAPI. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated the CNO discussed the importance of QAPI and having an Ad-Hoc meeting after an allegation of abuse or when an injury had happened. The ADON also stated the wording in the policy was changed[TRUNCATED]

Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. The facility failed to ensure the facility's abuse policy was implemented, and no action was taken to protect the resident from further potential abuse. The facility's failure to ensure residents were protected from abuse/neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/18/2023 and determined to exist on 10/12/2023 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F607) and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy (IJ) on 10/18/2023. The State Survey Agency (SSA) received an acceptable IJ Removal Plan on 10/20/2023 alleging removal of the IJ on 10/20/2023. The SSA validated the removal of the IJ on 10/21/2023, prior to exit on 10/21/2023, which lowered the S/S to a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 10/22/2022, revealed staff members who were suspected of abuse or misconduct would be immediately removed and barred from any further contact with residents of the facility and would be suspended from duty, pending the outcome of the investigation. Further review revealed supervisors would monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs, and situations such as inappropriate language and insensitive handling. Continued review revealed the policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that were necessary to attain and maintain physical, mental and psychosocial well-being. Additional review revealed the policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Physical abuse included hitting, slapping, pinching, kicking, etc. and controlling behavior through corporal punishment. Further review revealed upon receiving reports of physical abuse, the Charge Nurse would immediately examine the resident and the findings of the examination must be recorded in a separate incident report. Continued review of the facility's policy, titled, Abuse Prevention Program, dated 10/22/2022, revealed when an alleged case of abuse or neglect was reported, the Administrator, or person in charge of the facility, would notify the following person or agencies immediately per Kentucky Revised Statute, Chapter 209: Kentucky Cabinet for Health and Family Services, Office of the Inspector General, Division of Long Term Care (LTC), Law Enforcement Officials as per the Policy on Reporting Reasonable Suspicions of a crime in LTC facility, Section 1150B of the Social Security Act. Policy Number 2.11a., the resident representative and the physician. Additionally, review of the policy revealed to prevent resident abuse and if an employee suspected abuse, they were to separate the alleged perpetrator and assure all residents' safety. Additional review of the Abuse Prevention Program policy, dated 10/22/2022, revealed the final investigation would be submitted within five (5) working days of the incident and should contain facts determined during the process of the investigation, the conclusion of the investigation, the police report, and a summary of all interviews conducted with names, addresses, phone numbers, and willingness to testify of all witnesses. Further review revealed the Administrator or DON would request a representative of the Social Services department monitor the resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation and, unless otherwise requested by the resident, the Social Services representative would provide the Administrator and the DON with a written report of his/her findings in the resident's medical record. Review of Resident #9's Admission Record revealed the facility admitted Resident #9, on 02/24/2022, with diagnoses which included Muscle Weakness, Alzheimer's Disease, and Dementia with Mood Disturbance and Anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 08/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15), which indicated severe cognitive impairment. Review of Resident #9's Comprehensive Care Plan, dated 03/02/2022, revealed the facility determined the resident to be at risk for elopement/wandering related to a diagnosis of Alzheimer's Disease with interventions that included: on 03/02/2022 for Wander Guard (an electronic bracelet on the resident's ankle that caused the door alarm to sound if the resident went through the door) per order, to check Wander Guard function/placement as ordered, complete Elopement/Wander Assessment as indicated, redirect wandering as needed, and staff to provide one-to-one (1:1) supervision as needed. Review of the facility's initial report, dated 10/12/2023, revealed CNA #33 heard a scream, went down the hall where she witnessed CNA #35 push Resident #9 in the chest down into the bed while telling the resident to keep his/her ass in the bed. Review of the facility's one-to-one (1:1) sheets revealed CNA #35 was sitting one-to-one (1:1) with Resident #9 from 10/11/2023 at 11:15 PM until 10/12/2023 at 2:15 AM. Review of Certified Nursing Assistant (CNA) #35's time card punch for 10/12/2023 revealed she clocked out at 2:12 AM. Review of the Kentucky Incident Based Reporting System (KYIBRS) Report form, dated 10/12/2023 by Officer #1 of the local police department, CNA #35 was charged with Assault and Wanton Abuse. Review of the facility's five (5) day final report, dated 10/16/2023, revealed Resident #9 no longer resided in the facility, and staff interviews were conducted by Administrator #2 and the Director of Nursing (DON). Further review revealed the nurse immediately did a head to toe skin assessment and no redness or abnormalities were noted. Resident #9 stated I just had to go to the bathroom. All residents on the unit with a Brief Interview for Mental Status (BIMS) score of eight (8) or above were interviewed and no other care concerns were identified by other residents. Skin audits were completed for residents with a BIMS score of seven (7) or below (which indicated cognitive impairment) and no areas of concern were identified. Per the report, the facility concluded, based on a thorough investigation and interview with the accused, physical abuse can not be ruled out; out of an abundance of caution, CNA #35 was terminated from the facility; Resident #9 was noticed to be her usual self the rest of the night without signs or symptoms of any distress or emotional trauma. However, through interviews with staff, the resident exhibited crying episodes, being flustered, and agitation after the incident. The State Survey Agency (SSA) Surveyor attempted to contact CNA #35 by phone three (3) times, but CNA #35 did not return the calls. These attempts occurred on 10/17/2023 at 3:32 PM and 8:55 PM and on 10/18/2023 at 11:02 AM. In an interview with CNA #33 on 10/17/2023 at 5:21 PM, she stated, on 10/12/2023, she was in a resident's room when she heard screaming from Resident #9's room. She further stated she went into Resident #9's room and witnessed the resident standing beside the bed with his/her walker. She stated she then witnessed CNA #35 (who was sitting 1:1 with Resident #9) stand up and use her right hand to push Resident #9 in the chest, causing the resident to fall backward onto the bed with his/her feet flying up into the air. Additionally, she stated CNA #35 said I'm not dealing with your ass tonight. She stated she did not say anything to CNA #35, but left the room and notified Licensed Practical Nurse (LPN) #13, who stated she was unaware of the facility policy. She stated LPN #13 asked her to call the Director of Nursing (DON). She further stated she went to the front lobby area bathroom and called the DON using her cellphone. She stated as she walked toward the front bathroom, she saw CNA #35 come out into the hallway and ask CNA #34 to relieve her so she could take a break. Additionally, she stated the DON told her she was going to call Administrator #2, but did not mention anything else to her about Resident #9 or CNA #35. She stated she walked back to the nurses' station where LPN #13 was standing, and LPN #13 said, I have to send CNA #35 home and I'm nervous. On 10/17/2023 at 5:21 PM, CNA #33 further stated she did not want to be close to CNA #35 when CNA #35 was told to go home because CNA #35 could get ugly quickly. She stated everyone was aware of CNA #35's attitude but denied reporting any concerns to the DON or Administrator #2. Additionally, she stated after CNA #35 left the building, she went back to Resident #9's room where the resident was upset and told another CNA, I'm too little, I can't fight her. She stated the resident had to be taken out of the room into the lobby area to calm down. She further stated she was not aware of the abuse policy and had not been told not to leave the resident alone with CNA #35 after she witnessed her push the resident. She stated she had been told to report the abuse immediately which was why she left the room to get the nurse. In an interview with Certified Nursing Assistant (CNA) #34 on 10/17/2023 at 6:35 PM, she stated she was working on 10/12/2023 when she heard yelling in Resident #9's room and went into the hallway. She further stated CNA #33 went into Resident #9's room, and she went to another resident's room. She stated CNA #33 pulled her aside and told her she had witnessed CNA #35 push Resident #9. She stated she went with CNA #35 to report to Licensed Practical Nurse (LPN) #13. She further stated CNA #35 asked her to relieve her sitting one-on-one (1:1) so she could take a break. She stated when she went into Resident #9's room, Resident #9 was crying and told her she pushed me. She stated CNA #35 told CNA #34 to sit in that chair and don't let him/her get up or touch anything. Additionally, she stated CNA #35 seemed aggravated. She stated LPN #13 came into the room and talked with the resident. She stated CNA #35 came back into the room and CNA #34 left, leaving LPN #13 and CNA #35 in Resident #9's room. She further stated she believed the staff did a good job protecting Resident #9 and reporting timely to administration. In an interview with Licensed Practical Nurse (LPN) #13, on 10/17/2023 at 7:55 PM, she stated on 10/12/2023 around 2:00 AM, she was caring for a resident about two (2) doors down the hall from Resident #9's room. She stated she heard crying coming from Resident #9's room and a high pitched sound, and Resident #9 said, All I wanted to do was go to the bathroom. She further stated she was attending to another resident, and CNA #33 went into Resident #9's room. She stated CNA #33 came to her a few minutes later and told her I need to report abuse. LPN #13 stated CNA #33 told her she had witnessed CNA #35 push Resident #9 back onto the bed, and the resident's limbs went up into the air. She stated CNA #33 told her CNA #35 said to Resident #9 it's time for bed and used vulgar words to address Resident #9. In a continued interview with LPN #13, on 10/17/2023 at 7:55 PM, she stated she told CNA #33 to call the DON. She stated the DON called her and told her to tell CNA #35 to go home pending the investigation of the incident. She stated she went to Resident #9's room where CNA #35 was sitting with Resident #9, and she told CNA #35 she had to go home and watched as she left the building. She further stated she sat with Resident #9 because he/she was so upset and crying. She stated the resident knew she had reported the incident and told her, I'm glad she's gone but you just made it worse; now I'm going to get worse treatment. Additionally, she stated she would definitely consider the resident to be in psychosocial distress. She stated the DON called her back a while later to tell her to call the police, which she did. She further stated the police and family came into the building around 4:00 AM. Additionally, she stated she felt she had signed an abuse policy for the facility but had just been told to sign something and was not sure what the policy was specifically. She stated she felt the staff handled the situation correctly, although CNA #35 should probably have been removed from the facility earlier than she was. In an interview with Officer #1 on 10/17/2023 at 9:08 PM, he stated the local police were called over an hour after the incident occurred, and he responded to the facility on [DATE] at approximately 3:50 AM. He stated he was told by staff that CNA #35 pushed Resident #9 back onto the bed so his/her legs flew up in the air. He further stated Resident #9 was not able to recollect exactly what happened but was visibly upset and flustered. He stated, based on his report, CNA #35 would be arrested and charged with assault and wanton abuse. In an interview with the Director of Nursing (DON) on 10/18/2023 at 9:32 AM, she stated she was called on 10/12/2023 between 2:00 AM and 2:30 AM by CNA #33. She stated CNA #33 told her CNA #35 was sitting one-to-one (1:1) with Resident #9, and she witnessed CNA #35 push Resident #9 in the chest, causing the resident to fall down onto the bed. She further stated she called CNA #35 and told her to leave the building, and she was not sure if CNA #35 was still sitting with Resident #9 at that time or not. She stated she called and notified the Administrator #2. She stated she then called and talked to a nurse, and told her to call the police. Additionally, she stated she left a voice mail for the family. She stated she was not in the building and was unsure how long it took to remove CNA #35 from Resident #9's room. However, she stated from the time the incident occurred until CNA #35 was sent home was approximately ten to fifteen (10-15) minutes. She further stated the Social Services Director (SSD) should have followed up with a psychosocial assessment, but she was not sure if she had time as the resident discharged from the building later that day (10/12/2023). She stated she was aware the police came to the building but was not sure what they did. In an interview with the Medical Director on 10/18/2023 at 7:35 PM, he stated he was not made aware of the situation with Resident #9. In an interview with Administrator #2 on 10/18/2023 at 10:18 AM, he stated he was the Abuse Coordinator and was unaware of any other abuse policy other than the Abuse and Neglect Reporting Policy. He stated he would reach out to the Regional Nurse Consultant to see if another policy was in effect. He further stated he received a call from the DON on 10/12/2023 (unsure of the time, around 2:00 AM) with abuse allegations and proceeded to do an initial report. He stated, once he was notified, he told staff to remove CNA #35 from the facility and do a head-to-toe assessment and skin check on Resident #9. He stated he then told staff to do a skin assessment for all residents with a Brief Interview for Mental Status (BIMS) score below eight (8), which indicated cognitive impairment. He stated he also told staff to interview any residents with a BIMS score of eight (8) or higher and to call the police if needed. Further interview, on 10/18/2023 at 10:18 AM, with the Administrator, he stated the Social Services Director (SSD) did follow up assessments for psychosocial harm. He stated these assessments should have been done throughout the shift during which the alleged abuse occurred and daily until the resident showed no signs of psychosocial harm. He further stated if the SSD was not available, other staff could assist with completing the psychosocial assessments. He stated he interviewed the two (2) witnesses (LPN #13 and CNA #33), the alleged perpetrator, and other staff members. He stated, other than LPN #13 and CNA #33, no one else saw or heard anything. Additionally, he stated he had CNA #33 come into the building and reenact the situation for him and the DON. He stated he did not need to list everyone he interviewed in his report and that the conclusion said based on interviews. He further stated since he could not rule out abuse, CNA #35 had been suspended and would be terminated. 43694 The facility provided an acceptable Immediate Jeopardy Removal Plan on 10/20/2023, alleging removal of the Immediate Jeopardy on 10/20/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #9 no longer resided in the facility. According to Certified Nursing Assistant (CNA) #33 (witness), CNA #35 immediately left the room of Resident #9 when asked what is going on and exited to the outside of the facility. The Director of Nursing (DON) was immediately called by CNA #33. The DON asked to speak to Licensed Practical Nurse (LPN) #13 and instructed her to suspend CNA #35 immediately. CNA #35 left the facility grounds without further incident according to LPN #13. 2. Local law enforcement, family, and appropriate officials were notified of the incident by the DON and the Administrator immediately following the allegation on 10/12/2023. 3. Staff interviews were conducted by the Director of Nursing (DON) and the Administrator on 10/12/2023. Staff members were asked if they ever witnessed or heard of any abuse or mistreatment of residents. All interviews revealed no issues or concerns with potential abuse or mistreatment. 4. On 10/12/2023, Resident #9 had a second skin assessment completed by the Unit Manager. The skin assessment revealed no redness, bruising, or injury. 5. The DON and Assistant Director of Nursing (ADON) conducted a pain evaluation for Resident #9 on 10/12/2023, and the resident voiced no complaints of pain. The DON and ADON did not observe any behavior of pain by Resident #9. 6. The DON and ADON interviewed residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher on 10/12/2023 regarding any experience or recollection of potential mistreatment or abuse with no concerns found. 7. The DON and ADON performed a skin assessment on residents with a BIMS of seven (7) and below on 10/12/2023 with no signs of redness, bruising, or injury found. 8. The Chief Nursing Officer (CNO) from the consultant team reviewed and updated the Abuse Policy & Procedure on 10/19/2023 to ensure it included all required elements. 9. The CNO held an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting on 10/19/2023. Those in attendance included the Medical Director (MD), the DON, ADON, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator #1 and #2, Activity Director (AD), and the Regional Travel DON. The attendees reviewed the abuse allegation regarding Resident #9. The attendees considered the incident to be isolated and determined it was addressed appropriately. The CNO shared updates to the Abuse Policy with the attendees. 10. The Regional Director of Operations (RDO), on 10/13/2023, trained the administrative staff on the Abuse Policy, and knowledge was measured by a post-test which required one hundred percent (100%) of correct answers to pass. Administrative staff included the DON, ADON, Minimum Data Set (MDS) Coordinator #1 and #2, SSD, Activity Director (AD), and the Business Office Manager (BOM). 11. The Administrator, DON and ADON educated all facility staff members in all departments on abuse education beginning 10/12/2023 through 10/19/2023. The entire Abuse Policy was reviewed with an emphasis on ensuring resident safety and separating residents from the alleged perpetrator immediately. In addition, education included to immediately report concerns of abuse to the Administrator or an immediate supervisor who would immediately report the allegation to the Administrator. Any staff members who did not complete the education would be reeducated prior to returning to work. Education would be completed by the DON, ADON, Administrator, MDS Coordinator, or SSD. The Administrator would be responsible for overseeing the process. Any staff who failed to comply with the points of the in servicing would be further educated and/or progressively disciplined by their Department Manager or Administrator as indicated up to and including termination. 12. The CNO, on 10/19/2023, retrained the administrative staff on the Abuse Policy and QAPI requirements related to abuse. The retraining included what measures would be put into place and what systemic changes would be made to ensure the deficient practice did not reoccur. 13. All staff members received abuse training upon hire and at least annually. Knowledge and retention would be validated by a posttest and a 100 percent score was required to pass. The Administrator would be responsible for compliance. All contracted staff would receive abuse training prior to resident contact. Knowledge and retention would be validated by a posttest and a 100 percent score would be required to pass. The DON and ADON would complete and monitor this. 14. Department Managers/Administrative Staff conducted daily Guardian Angel Rounds until the Immediate Jeopardy (IJ) was removed. Once IJ was removed, the Guardian Angel Rounds would continue at least three to five (3-5) times per week. Staff would ask each resident if they were being treated appropriately by staff during Guardian Angel Rounds. All identified concerns would be shared at the Morning Meeting and followed up on by the Administrator, DON, ADON, or SSD. Morning meetings would occur seven (7) days a week until the IJ was removed. 15. An Ad-Hoc QAPI meeting would be held within twenty-four (24) hours of any abuse allegation to determine appropriate action and necessary follow-up, seven (7) days a week, and would include the Administrator, DON, and other Department Managers as appropriate. 16. The new facility Administrator began on 10/20/2023. The CNO and Chief Operating Officer (COO) of the consultant team would educate the new Administrator on the Abuse Policy, inform her of her responsibilities as the Abuse Coordinator, and her competency would be validated. The Administrator reports to the Governing Body. 17. The QAPI Committee, consisting of the Administrator, DON, ADON, SSD, and MD would oversee all facility processes related to abuse and neglect and determine whether more systemic actions were necessary. 18. The Administrator, DON, and ADON would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. 19. A member of the consultant team would make daily walking rounds to observe staff and resident interactions to ensure a safe environment. This would be completed daily until the IJ was removed. The State Survey Agency (SSA) validated the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 10/21/2023 as follows: 1. Record review revealed Resident #9 discharged from the facility the morning of the incident. CNA #35 was suspended pending investigation. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she said she was told Certified Nursing Assistant (CNA) #35 exited the building, she assumed to smoke or something. The DON said she was told someone sat with Resident #9. The DON said once she talked to CNA #33 about the allegation of abuse, she called CNA #35 directly and made her leave the facility and made Licensed Practical Nurse (LPN) #13 aware. She stated there was little if any time in which CNA #35 was left alone with Resident #9. The DON further stated LPN #13 did not document Resident #9's skin assessment at the time of the alleged incident. She said the management team started skin assessments the morning of 10/12/2023. 2. Review of the Police Report, completed on 10/12/2023, revealed the police were contacted and arrived at the facility at 3:50 AM, and it was noted the incident took place at approximately 2:40 AM. 3. In an interview with the Activity Director (AD) on 10/21/2023 at 10:36 AM, she stated she was interviewed by the DON about the incident with Resident #9. She stated she had not witnessed any abuse and/or mistreatment of residents in the facility. In an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #6 on 10/21/2023 at 10:58 AM, she stated the DON interviewed her on topics of witnessing any type of abuse. She further stated she had not witnessed abuse. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she could not recall the last dates for abuse training, but she said after the incident with Resident #9, the DON provided reeducation with management. She stated management then did reeducation with the rest of the staff. In an interview with the Human Resources Director (HRD) on 10/21/2023 at 1:44 PM, she stated she was interviewed by the DON. She said she had not witnessed abuse or mistreatment in the facility. In an interview with the Dietary Manager on 10/21/2023 at 1:57 PM, she said she could not remember who talked to her about abuse, but she thought it was discussed in the morning meeting. She also said, in the morning meeting, education was provided about abuse. She further stated staff members were required to take a quiz and pass with a one-hundred (100) percent score. In an interview with the Social Services Director (SSD) on 10/21/2023 at 2:25 PM, she stated the DON interviewed her and asked her if she had witnessed any abuse in the facility. She stated she had not. In an interview with the Director of Nursing (DON) on 10/21/2023 at 3:45 PM, she stated, we interviewed all staff in the building about abuse and called everyone who was not in the building. She stated all staff reported they had not witnessed any abuse and had no new concerns to report. 4. Review of Resident #9's skin assessment, dated 10/12/2023, revealed no new injuries were present. In an interview with the Assistant Director of Nursing (ADON) on 10/21/2023 at 2:35 PM, she stated LPN #13 was directed to complete the skin assessment the night of the alleged incident; however, she failed to document it. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated LPN #13 did not do a skin assessment for Resident #9 at the time of the incident. She reported management completed a skin assessment for Resident #9 upon arriving to the facility on [DATE] at approximately 8:30 AM, with no concerns noted. 5. Review of Resident #9's pain assessment form, completed on 10/12/2023 by the DON, revealed the resident was noted to be absent of signs or symptoms of pain related to the abuse allegation. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated she had completed a pain assessment on Resident #9 and no complaints were voiced. 6. Review of interview sheets used by the facility on 10/12/2023, for interviews completed on sixteen (16) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) and higher to determine if they felt safe, witnessed any type of abuse, and knew how and who to report concerns to, revealed no concerns. The interview form consisted of the following questions: a) Did they feel safe in the facility? b) Has anyone ever caused you any harm or made you feel afraid, embarrassed since you have been a resident here? c) Have you ever witnessed another resident being treated or spoken to in a manner you felt was unacceptable? and d) Do you know who to report to if you felt threatened, afraid, or spoken to, or treated in an unacceptable manner? Review of completed interview forms on 10/21/2023, revealed all sixteen (16) residents answered the questions appropriately and voiced no concerns. In an interview with Resident #37, on 10/21/2023 at 1:30 PM, he/she stated abuse was discussed with the residents in the Resident Council meetings and they met on the first of every month. The resident stated staff always treated him/her well. In an interview with Resident #39 on 10/21/2023 at 1:35 PM, he/she stated staff treated him/her well and provided good care. In an interview with Resident #38 and Resident #40 (husband and wife) on 10/21/2023 at 1:45 PM, they stated they received good care in the facility and did not have any concerns to report. In an interview with the Social Serviced Director (SSD) on 10/21/2023 at 2:25 PM, she stated the ADON, DON, and she had talked to residents in the facility who had a BIMS score of eight (8) and higher regarding abuse. She stated all interviews were documented on a facility interview sheet. She stated all the residents answered the questions appropriately, and no concerns were found. In an interview with the ADON on 10/21/2023 at 2:53 PM, she stated she, the SSD, and the DON went room to room and talked with interviewable residents about abuse. She stated no concerns were identified during the interviews. In an interview with the DON on 10/21/2023 at 3:45 PM, she stated the ADON and the SSD went with her room to room and talked with all residents who had a BIMS score of eight (8) or higher about abuse. She stated all the residents were fine, and nobody had any concerns. 7. Review of sixty-one (61) resident Skin Assessment documents, dated 10/12/2023, revealed Licensed Practical Nurse (LPN) #6 and LPN #7 conducted skin assessments on residents with a BIMS score of seven (7) and lower. Further review of the documents revealed one (1) form was not checked off to show no new areas noted or of any new areas noted. In an interview with LPN/UM #6 on 10/21/2023 10:58 AM, she stated she signed a skin assessment form with the missing check mark. She stated she must have been sidetracked when completing it and recalled the resident did not have any new concerns. In an interview with LPN/UM #7 on 10/21/2023 at 11:19 AM, she stated she completed several head-to-toe assessments on residents with a BIMS score of seven (7) and under and found no concerns related to abuse. In an interview with the Assistant Director of Nursing (DON) on 10/21/2023 at 2:53 PM, and the DON on 10/21/2023 at 3:45 PM, they stated they had assisted in conducting the skin assessments of residents with a BIMS score of seven (7) and under. They stated the Unit Managers were also present, and they completed the paperwork. They further stated no new skin concerns were found. 8. Review of the Abuse Policy revealed it was revised to address the Quality Assurance and Performance Improvement (QAPI) changes from Quality Assurance (QA). In an interview with the Chief Nursing Officer (CNO) on 10/21/2023 at 3:11 PM, she stated the facility's previous Abuse Policy did not have the word Quality Assurance and Performance Improvement (QAPI) and was on [TRUNCATED]

Based on review of the Resident's Advanced Directives, it was determined the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment, and to formulate an advanced directive for one (1) of twenty-five (25) sampled residents (Resident #10). Review of the resident's Advanced Directives revealed the resident had an Advanced Directive for Full Code on [DATE]. However, there was no evidence the Advanced Directive was updated to ensure accuracy. Review of Resident #10's Admission Record revealed the facility admitted the resident on [DATE] with an Advanced Directive designated as Full Code. Further review revealed the resident's code status had changed on [DATE] to Do Not Resuscitate (DNR). However, review of the resident's Face Sheet revealed the facility failed to update the resident's code status to DNR on [DATE]. The facility transferred the resident to the hospital on [DATE] with a Full Code status and the resident was intubated and placed on a ventilator. The facility's failure to have an effective system to ensure the residents' rights to requrest, refuse, and/or discontinue treatment, and formulate an advanced directive is likely to cause serious harm or serious injury to residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 at the highest S/S of a J. The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. IJ is ongoing. (Refer to F657) The findings include: Review of the facility's policy, Advance Directives Policy, dated [DATE], revealed the facility provided to all residents the right to accept or refuse medical and surgical treatment and, at the resident's option, formulate an Advanced Directive. Further review revealed the facility would periodically assess the resident for decision-making capacity and invoke the health care agent or legal representative if the resident was determined not to have decision-making capacity. Continued review revealed the facility would establish mechanisms for documenting and communicating resident choices to the Interdisciplinary Team (IDT). Additionally, if the resident or resident's legal representative executed one or more Advanced Directives, the facility would incorporate the resident's wishes into their plan of care and the resident's desires would be re-evaluated as indicated to ensure the resident's or legal representative's choices were honored timely. Review of the facility's Director of Social Services Job Description, signed by the Social Services Director (SSD) on [DATE], revealed the SSD was responsible for reviewing and explaining the facility's Cardiopulmonary Resuscitation (CPR) policy and DNR regulations, rights, and obligations. Further review revealed the SSD was responsible for obtaining updated information from the Hospital Discharge Planner to prepare various departments of the resident's needs and updating any new assessment information on the resident's chart. Review of Resident #10's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses which included Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Anxiety, Dementia, Essential Tremor, and Diabetes. Review of Resident #10's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Review of Resident #10's Comprehensive Care Plan, dated [DATE], revealed the resident had an Advanced Directive for a Full Code with interventions which included to honor the resident's choices and perform CPR. Review of Resident #10's Electronic Medical Record revealed the resident was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Further review revealed an order was initiated on [DATE] for a Full Code status. Review of Resident #10's Advanced Directives revealed a Full Code Advanced Directive, dated [DATE], and signed by the resident's spouse. Further review revealed an Advanced Directive for a Kentucky Emergency Medical Services (EMS) DNR order signed and notarized on [DATE]. Review of Resident #10's hospital records revealed the hospital admitted the resident on [DATE]. Continued review of the emergency room (ER) physican summary revealed the ER staff believed the resident was a Full Code as the resident's Face Sheet listed him/her as a Full Code and an EMS DNR form was not presented at the time of the transfer to the hospital. Continued review revealed the resident was intubated prior to the family's arrival to the hospital. During an interview with Registered Nurse (RN) #2, on [DATE] at 4:40 PM, she stated a discharge summary should be obtained with orders for a resident admitting or readmitting to the facility prior to the resident's arrival. She stated this did not always happen, and, in some cases, the resident arrived with the orders and the discharge summary. RN #2 stated the floor nurses entered the orders from the discharge summary. Additionally, she stated when a resident was sent to the hospital, the nurse should send a copy of their Face Sheet, orders, and the EMS DNR form if applicable. Based on the policy, she stated the resident's Code Status should have been updated appropriately on the Face Sheet and orders, and a EMS DNR form signed. During an interview with the SSD, on [DATE] at 2:45 PM, she stated she discussed Advanced Directives with the resident or their representative upon admission and completed the Advanced Directive as Full Code or DNR at that time. She further stated the nurses were required to have a discharge summary prior to admitting residents to the facility, both at admission and readmission. The SSD stated she communicated frequently with the Discharge Planner/Case Manager at the hospital to determine any needs for any facility residents in the hospital. Additionally, she stated the clinical team discussed during daily clinical meeting any orders, assessments, and Code Status for any admissions or readmissions. The SSD stated she should have been told by the hospital Discharge Planner if the resident changed to a DNR while at the hospital, and should have asked the hospital Discharge Planner to clarify any new orders, including the code status. Additionally, she stated she should have discussed the code status with the resident and his/her family when the resident readmitted to the hospital. She stated if she had been aware the code status had changed, she would have changed the information in Point Click Care (PCC) (the computer's charting system) that flowed to the Face Sheet so the Face Sheet would have shown Do Not Resuscitate as the code status. During an interview with Minimum Data Set (MDS) Nurse #1, on [DATE] at 3:20 PM, she stated she scanned the resident's EMS DNR form into the Point Click Care (PCC) computer system in [DATE]. She further stated she inherited a stack of papers to scan in from the previous person because the facility did not have a Medical Records Clerk. The MDS Nurse stated she was unaware when the facility received a copy of the EMS DNR. The EMS DNR form was signed and notorized at the hospital on [DATE] prior to the resident returning to the facility that date. During an interview with Family Member #3, on [DATE] at 5:51 PM, he stated he did not remember the facility staff informing him that he was signing a Full Code Advanced Directive on [DATE] because we all knew Resident #10 did not want to be placed on a ventilator. He further stated the hospital had placed Resident #10 on a ventilator in the ER prior to the family arriving to the hospital. Family Member #3 stated the family had to inform the hospital staff that the resident did not want to be intubated. During an interview with the Medical Director (MD), on [DATE] at 7:35 PM, he stated it was his expectation the facility followed the Advanced Directive wishes of the resident and/or the resident's responsible party. He further stated Code Status should be evaluated with any significant change of the resident, upon admission, and upon readmission at a minimum. During an interview with the Director of Nursing (DON), on [DATE] at 3:19 PM, she stated she expected staff to correctly enter Physician's Orders into the computer and for the resident's choice of Advanced Directives be honored. She stated the SSD was responsible for making sure the Advanced Directives were updated as the resident's wishes changed. During an interview with the Administrator, on [DATE] at 3:45 PM, she stated she expected new admission and readmission orders to be discussed during the morning interdisciplinary team (IDT)/clinical meeting. She further stated she expected staff to follow the facility's policies and revise the Medical Record to reflect the resident's wishes to formulate an advanced directive.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to inform the physician when a change in condition occurred for one (1) of five (5) sampled residents (Resident #11). The facility readmitted Resident #11 to the facility on [DATE] after admission to a sister facility for treatment of COVID-19. Review of the resident's food and fluid records from [DATE] through [DATE], revealed Resident #11 had a decreased food intake and was not meting his/her assessed fluid needs. However, the facility failed to recognize the resident's decreased intake and did not notify the resident's physician. In addition, although staff also recognized Resident #11 was no longer able to feed self, or hold a drinking cup, was increasingly lethargic preventing the resident from participating in therapies, there was no evidence found to indicate the staff notified the physician of the resident's decline. On [DATE], the facility transferred Resident #11 to the hospital for evaluation and treatment after staff found the resident pocketing food and was unable to swallow. The hospital diagnosed Resident #11 with Severe Dehydration, Acute Kidney Injury, Septic Shock and Displaced Intertrochanteric Fracture of Left Femur. The facility's failure to ensure the resident's physician was notified when a change in the resident's condition occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged, prior to exit on [DATE], which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Change in a Resident Condition, undated, revealed staff would notify the resident's physician and representative of significant changes in the resident's medical, mental or psychological status. Further review of the policy revealed a significant change in condition was a decline or improvement in the resident's status that impacted more than one area of the resident's health, and required interdisciplinary review and/or revision of the care plan. Review of Resident #11's closed record revealed the facility admitted the resident on [DATE] with diagnoses including Alzheimer's disease, Dementia, Diabetes Mellitus, Pain, a Fractured Left Humerus and Nutritional Anemia. Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE],1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed the resident to have a functional limitation in range of motion to an upper extremity on one side and required set-up and supervision for meals. Review of a Nutritional Risk Assessment completed for Resident #11, by the facility's Dietary Manager on [DATE], revealed the resident's assessed fluid need was 1650 milliliters (ml) of fluid per day, assessed calorie need was 1650 calories per day and the resident required 61 grams of protein per day. Continued review of Resident #11's medical record revealed on [DATE], the facility transferred Resident #11 to a sister facility to receive treatment for COVID-19. The facility readmitted the resident on [DATE]. Review of Resident #11's Comprehensive Care Plan, dated [DATE], revealed the resident had a self-care deficit related to a Left Humeral Fracture and a diagnosis of Alzheimer's disease. The care plan stated Resident #11 required supervision and set-up help with meals and may require the assistance of one staff member at times. The care plan further revealed Resident #11 was at risk for nutrition and hydration, and the goal was for the resident to safely consume adequate nutrition and fluids to maintain weight and hydration status. Continued review of the care plan revealed interventions included, monitoring the resident for changes in appetite, assessing and anticipating the resident's food and thirst needs, and monitoring and reporting changes in the resident's intake. Review Resident #11's recorded fluid intakes from [DATE] through [DATE], revealed the resident failed to meet his/her recommended fluid needs on any of the days. On [DATE] the resident consumed 360 ml of fluid, on [DATE] 1080 ml of fluids, on [DATE] 1010 ml of fluid, on [DATE] 900 ml of fluids and on [DATE] and [DATE], the resident consumed 1080 ml of fluids both days. However, there was no evidence the facility reviewed fluid intakes, or recognized the resident was not meeting his/her assessed fluid needs. Further record review revealed no evidence the facility notified the resident's physician that Resident #11 was not meeting his/her fluid needs. Review of Resident #11's food intake records, for the sixteen (16) meals from [DATE] through [DATE], revealed the resident refused to eat for three of the meals, consumed 25 percent or less for twelve (12) of the meals and consumed fifty (50) percent or less for one meal. In addition, review of a Mini Nutritional Assessment completed on [DATE], by Licensed Practical Nurse (LPN) #6, revealed Resident #11 was at risk of malnutrition. However, there was no evidence found in the resident's medical record to indicate the facility notified the resident's physician that Resident #11 was not eating very well, or that LPN #6 notified the resident's physician of the assessment completed on [DATE], which identified that Resident #11 was at risk for malnutrition. Interview with State Registered Nursing Assistant (SRNA) #14, on [DATE] at 9:47 AM, revealed she cared for Resident #11, on [DATE], during day shift; Interview with SRNA #18 on [DATE] at 4:44 PM, revealed she picked up the resident' evening meal tray on [DATE] and cared for the resident on [DATE] and [DATE]; Interview with SRNA #13 on [DATE] at 5:22 PM revealed he cared for Resident #11 on [DATE] during evening shift; Interview with SRNA #21, on [DATE] at 12:11 PM, and [DATE] at 1:34 PM, revealed she cared for Resident #11, on [DATE] and [DATE], from 7:00 AM until 11:00 PM; and interview on [DATE] at 3:59 PM, with SRNA #17, revealed she cared for the resident on [DATE] and [DATE] during the evening shift. The SRNA's interviewed all stated Resident #11 had decreased food and/or fluid intake when they cared for the resident, and stated the resident was not as vocal as normal. In addition, SRNA #21 stated when she cared for Resident #11 on [DATE] and [DATE], the resident would just stare. Each of the staff interviewed stated they reported to the nurse on duty each time they cared for Resident #11 that the resident was not eating and/or drinking well. Interview with Registered Nurse (RN) #4, on [DATE] at 2:09 PM, revealed Resident #11 was no longer able to feed self after the facility readmitted the resident on [DATE]. RN #4 stated she cared for the resident on [DATE] and [DATE] on the 3:00 PM to 11:00 PM shift. RN #4 stated she was able to recall notifying the oncoming shift on [DATE] that staff had to feed Resident #11, but stated she didn't think any of the staff reported to her on [DATE] or [DATE], that the resident was not eating or drinking. RN #4 stated she never reviewed Resident #11's food/fluid intake records and therefore was not aware the resident had not met his/her assessed needs for several days and therefore, did not contact the resident's physician. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 3:20 PM, and on [DATE] at 10:30 AM and 6:38 PM, revealed after Resident #11 returned to the facility on [DATE], the resident's condition declined. LPN #7 stated staff had to feed Resident #11 meals and the resident was dependent on staff for fluids and the resident was unable to hold a cup independently. LPN #7 stated she cared for Resident #11 on [DATE], [DATE], [DATE] and [DATE] during day shift. Continued interview with LPN #7 stated none of the staff informed her on those days she cared for Resident #11, that the resident was not eating/drinking sufficiently. LPN #7 stated, I felt like (Resident #11) was OK. LPN #7 revealed she attempted to feed Resident #11 breakfast on [DATE], but stated the resident would not eat, so she got the resident a cup of ice cream and stated the resident ate approximately fifty (50) percent of it. LPN #7 then stated staff might have told her on [DATE] that the resident's appetite was decreased, but stated she just could not remember. LPN #7 stated she did not review Resident #11's food/fluid intake records and did not realize the resident's food intake was low or the resident was not meeting his/her assessed fluid needs, and therefore did not call the resident 's physician to report the deficits. Interview with LPN #6 on [DATE] at 1:50 PM and 1:52 PM, revealed when she completed the nutritional assessment for Resident #11 on [DATE], she was not caring for the resident and only completed the assessment because staff had not done it when readmitting the resident on [DATE]. LPN #6 stated she did not recall that the assessment had determined the resident was at risk for malnutrition, and did not call the resident's physician to notify him of the assessment results. Interview with Speech Therapist (ST) #1, on [DATE] at 10:50 AM, revealed she attempted to assess Resident #11 on [DATE], but stated the resident was lethargic to the point where the ST was not able to evaluate the resident. Interview with Physical Therapist (PT) #1, on [DATE] at 10:22 AM, revealed after Resident #11's re-admission to the facility on [DATE], the resident's decline was dramatic. The PT stated to the best of her recollection the resident done pretty well the first two (2) to three (3) days after re-admission, then on [DATE], it's just like one day I walked in, (he/she) couldn't follow commands and just stared through me. The PT stated Resident #11 eventually was unable to participate at all with therapy. However, review of Resident #11's medical record revealed no documentation that any staff members contacted Resident #11's physician to report Resident #11's decline of no longer being able to feed self, having a decreased food/fluid intake, being at risk for malnutrition, having increased lethargy and not being able to participate in therapies. Continued interview with Physical Therapist (PT) #1 on [DATE] at 10:22 AM, revealed on [DATE] during breakfast, she heard Resident #11 yelling out and went into the resident's room. PT #1 stated the resident was in the room alone with the breakfast tray in front of the resident. PT #1 stated the resident had a fixed stare and she could see the resident had food in his/her mouth. PT #1 stated she had to dig eggs out of the resident's mouth, and then notified LPN #7 of the resident's condition. Continued interview with LPN #7, on [DATE] at 3:20 PM, and on [DATE] at 10:30 AM and 6:38 PM, revealed after PT #1 informed her about Resident #11 on [DATE], she went to the resident's room and observed Resident #1 to still have some food in his/her mouth, but would not swallow it. The LPN stated she notified the Unit Manager (UM) and Director of Nursing (DON), of the resident's condition, because it was not normal behavior for the resident. Review of a Change in Condition Evaluation completed by LPN #7, on [DATE] at 9:15 AM, for Resident #11 revealed staff assessed the resident to have a neurological change, was requiring more assistance with activities of daily living (ADL's), had decreased mobility, was holding food in his/her mouth and was unable to swallow. In addition, the evaluation stated the resident was unable to move arms or squeeze the nurse's hand. Review of a progress note for Resident #11, dated [DATE] at 9:30 AM, revealed the facility transferred the resident to the emergency room for evaluation and treatment. Review of a Hospital Admission History and Physical for Resident #11, on [DATE], revealed the hospital admitted the resident with diagnoses of Acute Renal Failure and Hyperkalemia (abnormally high potassium level). Further review of hospital record revealed documentation that Resident #11 nodded yes when asked if (he/she) was thirsty. Continued review of the hospital records revealed a Nephrology Consult, dated [DATE], revealed Resident #11's acute renal failure was likely due to Tubular Necrosis of the kidneys (a condition resulting from a lack of oxygen and blood flow to the kidneys) caused by severe dehydration. Interviews with Unit Manager (UM) #1, on [DATE] at 11:39 AM, on [DATE] at 12:45 PM, on [DATE] at 2:17 PM and on [DATE] at 5:16 PM, revealed UM #1 stated she was never notified that Resident #11 was having deceased intake of food was not meeting assessed fluid needs. The UM stated the first time she recalled being informed about anything regarding Resident #11 was on the morning of [DATE], when LPN #7 called her. UM #1 stated if SRNA's determined the resident's food/fluid intake was decreased they would notify the nurse who would then use their own judgement to determine if the physician should be notified. Continued interview with the UM revealed if a resident was not meeting their assessed fluid needs, but did not appear dehydrated and did not appear to have a change in condition, they may choose not to notify the physician. Further interview with UM #1 revealed the only way a nurse would know if a resident was not meeting their assessed fluid needs or had a decrease in food intake would be to manually review and tally the resident's fluid and food intake records. However, the UM stated to her knowledge there was not a staff routinely assigned to calculate intake records. Interviews with the former Director of Nursing (DON), on [DATE] at 3:47 PM , [DATE] at 2:32 PM and 4:23 PM, and on [DATE] at 3:05 PM, revealed she assumed if nursing staff thought a resident was dehydrated they should call and notify the physician. However, the DON stated if a resident was merely not meeting their assessed fluid needs or had an occasional decreased appetite, she did not think staff should notify the physician until there was a significant problem. Continued interview with the DON, revealed Unit Manager #1 was responsible for hydration and should have identified Resident #11 was not meeting his/her fluid needs. Review of Resident #1's Physician Progress Notes dated [DATE] revealed no evidence the staff notified the physician of Resident #1's decrease in food/fluid intake on [DATE], or that the physician assessed or addressed Resident #11's food/fluid intake. Interview with Resident #11's Physician, who also served as the facility's Medical Director, on [DATE] at 3:53 PM, and review of a written statement submitted by the physician, dated [DATE], revealed the physician stated I can not say if I was notified of a decrease in appetite or intake by the facility related to Resident #11. The Physician also stated he did not document notifications each time the facility contacted him stating For example, if I am notified of a non-injury fall not requiring emergency treatment or x-rays, I do not document the facility's notification of said fall. The physician went on to state for new or readmitted residents, the facility assessed the resident's needs with the help of a Registered Dietician who would then made recommendations to him regarding the course of treatment for the resident or if changes in the resident's care needed to be made. The Physician stated the facility had a meeting scheduled to discuss these issues with him, on [DATE], but, Resident #11 was sent out of the facility on [DATE]. However, the physician stated if a new or re-admission to the facility had a significant change or decline prior to a scheduled meeting with the facility, he would expect to be notified. Interview with the Administrator, on [DATE] at 4:53 PM, revealed, he was responsible to ensure day-to-day operations of the facility. However, he was unsure of the facility process that ensured residents received adequate fluids intake according to their assessed need. The Administrator stated he relied on nursing management staff to ensure resident care needs were met and MD notification was completed. The Administrator revealed he had not identified any care concerns. **The facility alleged the following actions were implement to remove Immediate Jeopardy effective [DATE]: 1. All residents were assessed by the Director of Nursing (DON) and Unit Manager (UM) on [DATE] to ensure any resident with a Change in Condition related to nutrition and hydration was immediately addressed to include the following: the appropriate assessment was completed, the physician notification as needed, and the resident's care plan was revised if needed. 2. Nursing staff were in-serviced between [DATE] and [DATE] by the DON and UM regarding change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Staff were required to complete a pre-test and post-test with a 100 percent (%) score to ensure understanding of the education. Any staff that failed to score 100% on both tests received further education and/or disciplinary action. 3. Daily Continuous Quality Improvement (CQI) meetings would be held Monday through Friday. The DON/Designee would monitor the progress notes for the previous 24 hours on Tuesday through Friday and previous 72 hours on Monday, to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol, including residents that consumed less than 50% of three (3) consecutive meals. Monitoring would also ensure that clinical staff completed a 72-hour follow up related to change in condition monitoring and/or placement on Skin, Weight, Assessment Team (SWAT) tracking for long-term monitoring. Resident Changes of Condition identified during SWAT meetings would be reported to the Registered Dietitian (RD) for assessment. Residents considered at risk would be placed on the ongoing list by the DON/Designee and reviewed in the weekly SWAT meetings. 4. A Stop and Watch tool was incorporated to facilitate communication of changes in nutrition and hydration between the State Registered Nursing Assistant (SRNA) and the nurse. The floor nurse was responsible to address the concern by completion of necessary clinical assessments; documentation of the resident assessment; and notification of the Medical Director, Resident Representative, and Registered Dietitian (RD). 5. Monitoring of ten (10) residents weekly for four (4) weeks was initiated on [DATE] by the DON/Designee to ensure Change in Condition related to decreased meal consumption or fluid intake from the prior week was identified and addressed per facility policy. 6. The DON/Designee presented audit findings to the Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns identified through audits. A Regional Office member would attend the weekly QAPI meetings in person or remotely until compliance was achieved. 7. On [DATE], the RD completed a medical record review of all facility residents and created a list of residents considered at risk for hydration and/or nutrition decline. The RD determined the estimated hydration and nutritional needs for each resident considered to be at risk. The Minimum Data Set nurse updated the residents' comprehensive care plan as well as the SRNA Kardex to include resident specific needs when identified. 8. On [DATE], the RD completed a medical record review of all new admissions, readmissions, and residents that experienced a significant change in condition to determine the residents' required nutritional and hydration needs and reported the at-risk residents to SWAT. 9. The DON/Designee reviewed nutrition and fluid intake data daily for residents identified at risk during CQI meetings Monday through Friday to ensure residents were meeting their daily-required needs. 10. Fluid intake and meal consumption was reviewed Monday through Friday during CQI meetings by the DON/Designee of residents identified to be at nutritional/hydration risk to ensure the residents were meeting their fluids and/or nutrition requirements as set by the RD and the residents' comprehensive care plan. 11. The DON/Designee began monitoring on [DATE], 10 resident care plans for four (4) weeks to ensure the residents met their nutrition and fluid requirements, and thereafter three (3) residents weekly for three (3) months to ensure continued compliance. 12. New admissions, readmissions, and/or residents who had a significant change of condition, for whom the RD determined to be at risk for nutrition and hydration were monitored by the DON/Designee weekly for three (3) months to ensure the RD's continued monitoring and to ensure at risk residents were identified. 13. Residents identified at risk for nutrition and/or fluid deficits and consumed less than their assessed fluid needs would be assessed for dehydration by the UM and/or ADON for intervention. 14. The daily CQI and morning meetings were attended by the Administrator with documented attendance. The Administrator was responsible for ensuring any noted change of condition, failure of an at risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. This would continue for three (3) months and would be reviewed/validated weekly by a Regional team member to ensure identified concerns were acted upon timely. 15. The Administrator received 1:1 education from the Regional Director of Operations (RDO), on [DATE], regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. The Administrator was required to complete a pre-test and post-test to determine understanding with a 100% score required, failure to score 100% on tests resulted in further education and/or disciplinary action. 16. The Regional Director of Operations (RDO) reviewed daily Morning Meeting and CQI documentation by the Administrator beginning [DATE] regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. The RDO presented monitoring of the Administrator's documentation of Morning Meetings and CQI to the weekly QAPI meetings. Any concerns identified would be immediately addressed and if needed the RDO/Regional Team would complete an Action Plan. 18. The Administrator along with the Interdisciplinary Team (IDT) conducted monthly QAPI meeting beginning on [DATE], per policy to discuss and review collected data related to: Quality Indicators, Consult Reports, and survey findings. Results that indicated a pattern of concern would be listed and an Action Plan or Performance Improvement Plan (PIP) would be written to address concerns and monitored weekly by the IDT until resolved. The RDO or other Regional Team Member attended monthly QAPI meeting and would continue to attend for six (6) months to ensure data was collected properly, reviewed, monitored, and followed until resolution. Any written Action Plan or Performance Improvement Plan (PIP) would be reviewed for appropriateness, accuracy and progression toward resolution. 19. On [DATE], The RDO completed education with the IDT on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. The IDT completed pre-test and post-test to ensure understanding with a 100% score required, staff that did not score 100% received further education and/or disciplinary action. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on [DATE], as alleged by the facility: 1. Interviews with the UM, on [DATE] at 12:46 PM, and the DON on [DATE] at 2:29 PM, revealed they assessed all residents to ensure any resident, which experienced a change in condition related to nutrition and/or hydration was immediately addressed. This included performing the appropriate assessment, physician notification for orders, and revision of the resident's care plan. They revealed they did not identify any concerns. 2. Review of staff in-service records for [DATE] through [DATE], revealed nursing staff had received education on change in condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with the UM, on [DATE] at 12:46 PM, and the DON on [DATE] at 2:29 PM, revealed they provided education for licensed staff from [DATE] through [DATE]. The education included change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with SRNA #12, on [DATE] at 1:59 PM, SRNA #22, on [DATE] at 3:58 PM, SRNA #18, on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) #13, on [DATE] at 2:28 PM, LPN #8, on [DATE] at 2:58 PM, and LPN #12, on [DATE] at 11:32 AM revealed they received the above education to include a pre-test and post-test. 3. Review of the daily CQI meetings held Monday through Friday, revealed the DON, ADON, and UM monitored the progress notes for the previous 24 hours Tuesday through Friday and 72 hours on Monday to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol to include residents that consumed less than 50% of three (3) consecutive meals. Review of Sampled residents (Resident #19, Resident #26, and Resident #27) revealed their records were reviewed daily for change in condition related to nutrition and hydration and were placed on the SWAT list for further monitoring. No concerns were identified. 4. Interviews with SRNA #12, on [DATE] at 1:59 PM, SRNA #22 on [DATE] at 3:58 PM, SRNA #18 on [DATE] at 4:30 PM, Licensed Practical Nurse (LPN) #13 on [DATE] at 2:28 PM, LPN #8 on [DATE] at 2:58 PM, and LPN #12, on [DATE] at 11:32 AM, revealed they received education regarding the use of the Stop and Watch tool. They stated the tool was utilized when a SRNA observed a change in condition. Once completed, the SRNA utilized the tool to report the change in condition to the floor nurse and the floor nurse was then responsible for addressing the concern and completion of any required assessments, physician notification, Resident Representative notification, and RD notification. 5. Record review revealed the facility monitored ten (10) residents weekly and no concerns were identified with change of condition related to decreased meal consumption or fluid intake, nor physician notification. 6. Review of QAPI meeting documentation revealed the last weekly meeting was on [DATE], with attendees, which included the Administrator, DON, and RDO. Per the meeting notes, there were no identified concerns. Interview with the DON, on [DATE] at 2:29 PM, revealed she presented all audit findings weekly during the QAPI meetings. Interview with the RDO, on [DATE] at 2:07 PM, revealed she attended the weekly QAPI meetings to ensure compliance with audits being performed. 7. Review of Sampled Resident #19, Resident #26, and Resident #27's medical records, revealed the RD performed a medical record review on [DATE] at which time the residents who were identified at risk (related to nutrition and/or hydration) were placed on SWAT monitoring. In addition, their care plan was updated with interventions and the RD documented the residents' estimated nutritional and fluid needs. Review of the records revealed no concerns were identified. Interview with the RD, on [DATE] at 12:26 PM, revealed she performed record reviews of all residents to determine their estimated nutritional and fluid needs. She stated she also reviewed records to ensure at risk residents were placed on SWAT for increased monitoring. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 11:10 AM, revealed she revised the care plans of residents considered at risk by the RD to include appropriate interventions. 8. At the time of the review/survey there had not been any new resident admissions or re-admissions since the facility's alleged IJ removal date. Interview with the RD, on [DATE] at 12:26 PM, revealed she would perform a medical record review of all new admissions, re-admissions, and residents who experienced a change in condition related to nutritional and/or hydration to determine the residents' estimated nutritional and fluid needs. She stated new admissions and re-admissions were placed on the SWAT list for four (4) weeks for monitoring and if the resident was stable at the end of the four (4) week period, they would be removed from the SWAT program. 9. Review of the CQI meetings documentation and interviews with the UM, on [DATE] at 12:46 PM and the DON, on [DATE] at 2:29 PM, revealed they reviewed resident nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs. 10. Review of the CQI meetings documentation and interviews with the UM, on [DATE] at 12:46 PM, and the DON, on [DATE] at 2:29 PM, revealed they reviewed nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs, as well as ensuring the resident care plans addressed their needs. 11. Record review revealed the facility reviewed ten (10) resident records weekly and there were no identified concerns with change of condition related to decreased meal consumption and/or fluid intake. Interviews with the UM, on [DATE] at 12:46 PM, and the DON on [DATE] at 2:29 PM, revealed they reviewed 10 resident records weekly to ensure their care plans were updated to address their nutritional and fluid requirements. 12. Review of daily monitoring revealed no new admissions or readmissions had occurred since the facility's alleged IJ removal date [DATE]. Review of Residents #19, Resident #26, and Resident #27's medical records revealed they were determined to be at risk and were discussed and monitored daily Monday through Friday. [TRUNCATED]

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of five (5) sampled (Resident #11) residents maintained sufficient fluid and nutritional intake to maintain proper hydration, nutrition, and health. From 03/23-29/2021, Resident #11 did not meet his/her fluid or nutritional needs. Interviews with staff revealed the resident did not eat or ate very little and they reported their concerns to nursing staff. However, there was no evidence that any action was taken to address the resident's poor intake. Staff completed a hydration and nutrition risk assessment during this time frame; however, the assessments were inaccurate and did not reflect the resident's needs/concerns; subsequently, the facility failed to identify the resident was at risk for dehydration and was malnourished. According to the Speech Therapist on 03/25/2021, the resident was not alert enough to conduct an evaluation. Further interview revealed on 03/26/202, the Physical Therapist stated the resident took a shift and could not stand. Interview with staff revealed the resident just stared and did not eat on 03/27/2021 and 03/28/2021. However, no action was taken to address/assess the resident's fluid and nutritional status. On 03/29/2021, the Physical Therapist found Resident #11 with food pocketed in his/her mouth and had to manually remove the food. Resident #11 was transferred to the hospital where the resident had critical laboratory values and was diagnosed with Severe Dehydration, Acute Kidney Injury, Septic Shock and Displaced Intertrochanteric Fracture of Left Femur. The facility's failure to ensure residents maintained sufficient nutrition and fluids has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/19/2021, and determined to exist on 03/23/2021 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 05/19/2021. An acceptable Allegation of Compliance was received on 05/27/2021, which alleged removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency determined the Immediate Jeopardy was removed as alleged, prior to exit on 06/04/2021, which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Hydration Management, undated, revealed the facility would monitor the resident's fluid balance for assessed needs or problems. The policy further revealed the Dietary Manager or Registered Dietician (RD) would calculate each resident's fluid requirements. The professional nurse would notify the resident's physician when fluid intake had decreased from normal, for signs and symptoms of dehydration, and/or when a resident change of condition was identified. Review of the facility's policy titled S.W.A.T. Program (Skin and Weight Assessment Team), undated, revealed it was the facility's policy to assess the nutritional status of each resident. The policy stated the SWAT Program was designed to aggressively review and address those residents exhibiting significant weight change. The policy stated these residents would be monitored by the team on a weekly basis. According to the policy, the SWAT program would be implemented for residents with an undesirable weight change of five (5) percent or more in 30 days, residents readmitted to the facility, residents with a clinically unavoidable weight loss, etc. The program revealed the total dining experience would be assessed for each resident reviewed and listed points of consideration that had the potential to impact a resident's diet. The team was responsible for appropriately determining clinical and dietary interventions to best address each individual resident's needs based on observation, assessment, and review. The policy stated any dietary issues that were more than routine in nature, would require immediate contact of the Dietitian for review and input and emergent issues would be immediately referred to the attending physician. Review of a closed record for Resident #11 revealed the facility admitted the resident on 02/17/2021, and readmitted to the facility on [DATE]. The resident had diagnoses that include Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Pain, Nondisplaced Fracture of Surgical Neck of Left Humerus and Nutritional Anemia and Major Depressive Disorder, and a history of a urinary tract infection (UTI) on 02/22/2021. Review of the Nutritional Risk assessment dated [DATE], signed by the Dietary Manager, revealed Resident #11's estimated fluid needs was 1650 milliliters (ml) per day, required 1650 calories per day, and 61 grams of protein. According to the assessment, the resident ate 26-50% of meals. Review of Resident's #11 laboratory results from 02/26/2021 revealed the resident's Blood Urea Nitrogen (BUN) level was within normal range at 18 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and Creatinine level was normal 1.10 mg/dL (normal range 0.50-1.20 mg/dL). A review of Resident #11's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was assessed to have severe impaired cognition. Further review of the MDS revealed the resident required assistance with setting up meals and supervision (oversight, encouragement or cueing) with meals. Resident #11 also required two (2) staffs ' assistance with bed mobility and toileting, and did not ambulate. Review of Resident #11's Care Plan, dated on 02/17/202, revealed the facility developed a care pan that stated Resident #11 required staff assistance with set up and supervision with eating and may need assist of one person at times. The care plan further revealed the facility identified that the resident was at risk for nutrition and hydration. The goal was for the resident to safely consume adequate nutrition and fluids to maintain weight and hydration to the extent possible. Staff were required to encourage good fluid intake and offer substitutes for foods not eaten or disliked. Further review of Resident #11's care plan revealed the resident had interventions that included monitoring the resident for change in appetite; assessing and anticipating the resident's food and thirst needs; and monitoring for and reporting changes in output/intake. Review of Resident #11's medical record revealed on 03/03/2021, the resident weighed 183.2 pounds. On 03/09/2021, the resident was transferred to the hospital due to an increase in behaviors. Review of laboratory results from the 03/09/2021 hospital visit revealed the resident's Blood Urea Nitrogen (BUN) level was high at 36 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and his/her Creatinine level was high at 1.50 mg/dL (normal range 0.50-1.20 mg/dL). Resident #11 tested positive for COVID-19 at the hospital and was transferred to a COVID-19 unit at a sister facility on 03/09/2021. Review of Resident #11's medical record from the sister facility revealed on 03/10/2021, the resident weighed 155.8 pounds, an approximate 30-pound weight loss since the resident was last weighed at the facility on 03/03/2021. Review of the Registered Dietitian's (RD) assessment of Resident #11 at the sister facility on 03/18/2021, revealed the resident's average meal intake was 47%, and average snack intake was 86%. According to the RD, the resident was meeting 69% of his/her calories. Review of a transfer form revealed the sister facility transferred the resident back to the facility on [DATE]. Review of Resident #11's Hydration Risk Assessment, dated 03/23/2021, upon readmission to the facility, revealed staff documented the resident scored five (5), at minimal risk for dehydration. The documentation stated the resident had sustained no weight loss and had 1-2 predisposition factors for dehydration. However, review of the factors revealed the resident met four (4) of the criteria, history of UTI in the last 30 days, COVID -19 positive (Infection), Depression, and Diabetes. In addition, according to the resident's record, the resident had sustained a significant unplanned weight loss (17.2%) in the last thirty days, which would have made the resident's score eight (8), at risk for dehydration. Further review of the assessment and interview with the Interim Director of Nursing (DON), on 05/19/2021 at 4:37 PM, revealed if a resident's hydration risk assessment total score was eight (8) or above, the resident should have been placed on the facility's SWAT program and monitored closely. However, the facility failed to identify the assessment was inaccurately completed and no action was taken to address the resident's risk for dehydration. Interview with Licensed Practical Nurse (LPN) #6, on 04/27/2021 at 1:50 PM, revealed she completed the Hydration Risk Assessment for Resident #11 on 03/23/2021. She stated she was not assigned to care for the resident that day, but completed the form to help the nurse who was assigned. She stated she must have overlooked the weight loss and the predisposition factors for the resident. Review of a Mini Nutritional assessment dated [DATE] revealed an LPN (the form was not signed) completed the assessment for Resident #11. According to the instructions, staff were required to review the resident's medical record to determine whether the resident had an involuntary weight loss in the last three (3) months. Even though the resident had sustained a significant weight loss, staff documented does not know. Further, staff were required to answer whether the resident was able to get out of a bed, a chair, or a wheelchair without the assistance of another person. Staff documented the resident was able; however, review of the resident's record revealed he/she required two staffs' assistance with transfers. Further review revealed staff had to answer whether the resident had any neuropsychological problems. Staff answered one (1) for mild Dementia, however, Resident #11's medical record revealed the resident also suffered from Depression. The facility determined the resident was at risk of malnutrition based on the assessment; however, according to the assessment instructions, the resident should have scored seven (7), which meant the resident was Malnourished. Interview with the DON on 06/04/2021 at 2:29 PM revealed staff were required to complete a mini nutrition assessment and hydration assessment for all residents admitted or readmitted to the facility. She stated any resident that was assessed to be at risk should be placed on the SWAT list and monitored by the RD to ensure they were meeting their daily-assessed requirements. However, interview with the former DON, on 04/27/2021 at 3:47 PM, revealed Resident #11 was never placed on/monitored through the facility's SWAT program because they were still collecting data on the resident. According to the former DON, the resident would have triggered for the SWAT program on 03/31/2021, after the resident had already been discharged from the facility and diagnosed with severe dehydration. A review of the fluid intake records for Resident #11, revealed the facility documented the resident had the following fluid intake: 360 ml on 03/23/2021, 1080 ml on 03/24/2021, 1010 ml on 03/25/2021, 900 ml on 03/26/2021, 1080 ml on 03/27/2021 and 1080 ml on 03/28/2021, none of which met the residents estimated fluid needs of 1650 milliliters. A review of the food intake records for Resident #11, revealed the facility documented the resident consumed the following: on 03/23/2021 after readmission, the resident did not eat lunch and ate 0-25% for dinner (the evening meal); on 03/24/2021, 0-25% for breakfast and dinner and 26-50% for lunch; on 03/25/2021, 0-25% for breakfast and lunch and refused dinner; on 03/26/2021, 0-25% for all three meals; 03/27/2021, refused breakfast and dinner and 0-25% for lunch; on 03/28/2021, 0-25% for all three meals; and on 03/29/2021, had no food intake prior to being transferred to the hospital. Review of Resident #11 medical record revealed no documented evidence that staff assessed the resident's nutrition/hydration status (mucous membranes, skin turgor, etc.) nor notified the physician or dietician of the resident's decreased nutrition and hydration status. Interview with State Registered Nurse Aide (SRNA) #14, on 04/27/2021 at 9:47 AM, revealed she provided care for Resident #11 on 03/23/2021. She stated the resident did not eat/drink and she notified a nurse, but stated she could not recall if the nurse followed up to check on the resident. Interview with SRNA #18, on 04/27/2021 at 4:22 PM, revealed she provided care for Resident #11, on 03/24/2021 and 03/25/2021. She stated she reported to the nurses that Resident #11 had not eaten or drank much, and they told her to document the intake and push fluids as much as possible. Interview with SRNA #1,3 on 04/26/2021 at 5:22 PM, revealed he provided care for Resident #11. on 03/25/2021 and 03/27/2021. He stated Resident #11 refused to eat the evening meal on 03/25/2021; however, the resident drank plenty of fluids that shift (1010 cc documented for the day). He further revealed that he notified the nurse that the resident refused to eat; however, the nurse did not attempt to feed the resident. In addition, SRNA #13 stated on 03/28/2021, during his shift, he noticed Resident #11 did not call out like usual. Interview with SRNA #17 on 04/27/2021 at 3:59 PM, revealed she provided care for Resident #11, on 03/27/2021 and 03/28/2021. She stated the resident required assistance with eating/drinking for meals at times. However, the resident did not want to eat because he/she did not like the food. According to SRNA #17, she reported this information to Registered Nurse (RN) #4 because she was required to report if a resident ate less than 50% for a meal. Interview with SRNA #21, on 04/28/21 at 12:11 PM, and 04/29/2021 at 1:34 PM, revealed she provided care for Resident #11 on 03/27/2021 and 03/28/2021. She stated she notified LPN #7 that Resident #11 would not eat. She stated Resident #11 just sat there and stared at you. Interview with LPN #7 on 04/26/2021 at 3:20 PM, revealed she provided care for Resident #11 on 03/24/2021, 03/25/2021, 03/28/2021 and 03/29/2021. She denied any staff reported that Resident #11 was not eating/drinking. Interview with RN #4 on 04/28/2021 at 2:09 PM revealed she provided care for Resident #11 on 03/25/2021 and 03/27/2021. According to the RN, she did not observe staff provide water (to be available for residents ' between meals) either day. She however, denied any staff informing her of the resident not eating or drinking. Interview with the Speech Therapist (ST), on 04/30/2021 at 10:50 AM, revealed she attempted to assess Resident #11 on Thursday, 03/25/2021; however, the resident's alertness was not adequate to even evaluate. The ST stated she was off on Friday, Saturday, and Sunday, and when she returned to work on Monday, 03/29/2021, the resident was transferred to the hospital. Interview with the former Director of Nursing (DON), on 05/11/2021 at 3:05 PM, revealed she would assume if nursing staff thought a resident was dehydrated, they would call and notify the physician. She further revealed that the Unit Manager #1 was responsible for hydration and should have identified that Resident #11 was not meeting his/her fluid needs. Interview with Unit Manager #1, on 4/26/2021 at 11:39 AM, 04/28/2021 at 12:45 PM, and 05/11/2021 at 2:17 PM, revealed she was not notified that Resident #11 had decreased intake of fluids and/or food until the morning of 03/29/2021. She stated the facility did not have a system that would alert them if a resident did not meet their hydration needs and the only way to identify hydration status was to manually calculate a resident's intake. She stated to her knowledge, no one was calculating/reviewing each resident's hydration status daily. However, then stated nursing staff was responsible for monitoring fluid intake and assessing for signs and symptoms of dehydration. Continued interview revealed Resident #11's fluid intake would have been reviewed the following week, once the facility had approximately a week of data. Interview with the Administrator, on 05/11/2021 at 3:56 PM, revealed staff documented resident food and fluid intake in the computer system. He stated the computer system did not alert staff if a resident did not meet his/her fluid needs and was not aware of any other system to monitor hydration. He stated unless a resident was on strict intake and output monitoring or was being monitored weekly during SWAT meetings, no one monitored daily intake. Interview with the Physical Therapist, on 04/30/2021 at 10:22 AM, revealed things took a shift for Resident #11 on Friday, 03/26/2021. She stated the resident was not able to stand that day and she had to provide therapy while the resident was lying in bed. She stated when she returned to work on Monday morning, 03/29/2021, she went in Resident #11's room and found the resident with pocketed food in his/her mouth. She stated the resident was alone with his/her food tray in front of him/her and she had to manually clear the food from the resident's mouth. A review of a Change in Condition Evaluation completed, on 03/29/2021 at 9:15 AM, revealed Resident #11 was assessed to have a Neurological Change. The evaluation revealed Resident #11 needed more assistance with activities of daily living (ADL's) and had decreased mobility and swallowing difficulty. The evaluation stated that Resident #11 was unable to swallow and holds food in mouth and unable to perform task of move arms or squeeze nurse hand. Review of progress notes revealed Resident #11 was transferred to Emergency Department (ED) for evaluation and treatment, at 9:30 AM on 03/29/2021. Review of Resident #11's hospital laboratory results for 03/29/2021, revealed Resident #11's Blood Urea Nitrogen (BUN) level was abnormal at 132 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and Creatinine level was at a critical level of 8.60 mg/dL (normal range 0.50-1.20 mg/dL) (indicators of dehydration and kidney failure. The ED record stated, First the patient is severely dehydrated and this raises concern for neglect. A review of the Hospital Admission History and Physical on 03/29/2021, revealed Resident #11 was admitted with diagnoses that included Acute Renal Failure (kidney failure), Hyperkalemia (increased potassium level is an indicator of dehydration), Pelvic Ring Fracture, Displaced Intertrochanteric Fracture of Left Femur (hip) and Dementia. Further review of the record revealed Resident #11 nodded when asked if he/she was thirsty. A review of the Nephrology Consult on 03/29/2021, revealed Resident #11 had Acute Kidney Failure most probably secondary to Acute Tubular Necrosis secondary to Severe Dehydration (with acute tubular necrosis, the kidneys are damaged when the flow of blood and oxygen is compromised). According to the Nephrology Consult, the resident also had Severe Lactic Acidosis (build-up of lactic acid in the body), Hyperkalemia (high potassium levels are also an indicator of dehydration and kidney failure), and Severe Anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of the hospital consultation on 03/29/2021, revealed further diagnosis of Septic Shock (Sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. Sepsis may progress to septic shock, which can lead to severe organ problems and death. Signs and symptoms of sepsis include a change in mental status.) and Neutrophilic Leukocytosis (Neutrophils are a type of white blood cell that help the body fight infections and heal injuries). According to the hospital record, palliative care was consulted. Interview with Medical Doctor #2 (Emergency Department Physician), on 04/28/2021 at 3:10 PM, revealed he had seen Resident #11 multiple times over the few months prior to 03/29/2021. He stated when Resident #11 was brought to the ED on 03/29/2021, he did not even recognize the resident. He stated the resident was dramatically different and kept saying, Help me. Help me. He further stated the resident appeared emaciated and the renal failure was new compared to the laboratory data 20 days prior on 03/09/2021. He further stated, It seems like somebody just put [the resident] back to bed and said the hell with [him/her]. We will feed [him/her] and water [him/her] if we feel like it and [the resident] just sort of languished until [the resident] came back and saw us. Interview with Resident #11's Responsible Party, on 04/28/2021 at 1:11 PM, revealed the resident lived with him prior to his/her admission to the facility. He stated he seen the resident at the hospital on 03/29/2021. He stated the resident's face was sunken in and the resident did not know him. He stated it looked like he/she had lost a significant amount of weight; however, no one from the facility had told him that the resident was not eating and had lost weight. He stated the ED physician told him that the resident had lost approximately 77 pounds. **The facility alleged the following actions were implement to remove Immediate Jeopardy effective 05/26/2021: 1. All residents were assessed by the Director of Nursing (DON) and Unit Manager (UM) on 05/24/2021 to ensure any resident with a Change in Condition related to nutrition and hydration was immediately addressed to include the following: the appropriate assessment was completed, the physician notification as needed, and the resident's care plan was revised if needed. 2. Nursing staff were in-serviced between 05/21/2021 and 05/24/2021 by the DON and UM regarding change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Staff were required to complete a pre-test and post-test with a 100 percent (%) score to ensure understanding of the education. Any staff that failed to score 100% on both tests received further education and/or disciplinary action. 3. Daily Continuous Quality Improvement (CQI) meetings would be held Monday through Friday. The DON/Designee would monitor the progress notes for the previous 24 hours on Tuesday through Friday and previous 72 hours on Monday, to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol, including residents that consumed less than 50% of three (3) consecutive meals. Monitoring would also ensure that clinical staff completed a 72-hour follow up related to change in condition monitoring and/or placement on Skin, Weight, Assessment Team (SWAT) tracking for long-term monitoring. Resident Changes of Condition identified during SWAT meetings would be reported to the Registered Dietitian (RD) for assessment. Residents considered at risk would be placed on the ongoing list by the DON/Designee and reviewed in the weekly SWAT meetings. 4. A Stop and Watch tool was incorporated to facilitate communication of changes in nutrition and hydration between the State Registered Nursing Assistant (SRNA) and the nurse. The floor nurse was responsible to address the concern by completion of necessary clinical assessments; documentation of the resident assessment; and notification of the Medical Director, Resident Representative, and Registered Dietitian (RD). 5. Monitoring of ten (10) residents weekly for four (4) weeks was initiated on 05/21/2021 by the DON/Designee to ensure Change in Condition related to decreased meal consumption or fluid intake from the prior week was identified and addressed per facility policy. 6. The DON/Designee presented audit findings to the Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns identified through audits. A Regional Office member would attend the weekly QAPI meetings in person or remotely until compliance was achieved. 7. On 05/24/2021, the RD completed a medical record review of all facility residents and created a list of residents considered at risk for hydration and/or nutrition decline. The RD determined the estimated hydration and nutritional needs for each resident considered to be at risk. The Minimum Data Set nurse updated the residents' comprehensive care plan as well as the SRNA Kardex to include resident specific needs when identified. 8. On 05/24/2021, the RD completed a medical record review of all new admissions, readmissions, and residents that experienced a significant change in condition to determine the residents' required nutritional and hydration needs and reported the at-risk residents to SWAT. 9. The DON/Designee reviewed nutrition and fluid intake data daily for residents identified at risk during CQI meetings Monday through Friday to ensure residents were meeting their daily-required needs. 10. Fluid intake and meal consumption was reviewed Monday through Friday during CQI meetings by the DON/Designee of residents identified to be at nutritional/hydration risk to ensure the residents were meeting their fluids and/or nutrition requirements as set by the RD and the residents' comprehensive care plan. 11. The DON/Designee began monitoring on 05/24/2021, 10 resident care plans for four (4) weeks to ensure the residents met their nutrition and fluid requirements, and thereafter three (3) residents weekly for three (3) months to ensure continued compliance. 12. New admissions, readmissions, and/or residents who had a significant change of condition, for whom the RD determined to be at risk for nutrition and hydration were monitored by the DON/Designee weekly for three (3) months to ensure the RD's continued monitoring and to ensure at risk residents were identified. 13. Residents identified at risk for nutrition and/or fluid deficits and consumed less than their assessed fluid needs would be assessed for dehydration by the UM and/or ADON for intervention. 14. The daily CQI and morning meetings were attended by the Administrator with documented attendance. The Administrator was responsible for ensuring any noted change of condition, failure of an at risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. This would continue for three (3) months and would be reviewed/validated weekly by a Regional team member to ensure identified concerns were acted upon timely. 15. The Administrator received 1:1 education from the Regional Director of Operations (RDO), on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. The Administrator was required to complete a pre-test and post-test to determine understanding with a 100% score required, failure to score 100% on tests resulted in further education and/or disciplinary action. 16. The Regional Director of Operations (RDO) reviewed daily Morning Meeting and CQI documentation by the Administrator beginning 05/21/2021 regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. The RDO presented monitoring of the Administrator's documentation of Morning Meetings and CQI to the weekly QAPI meetings. Any concerns identified would be immediately addressed and if needed the RDO/Regional Team would complete an Action Plan. 18. The Administrator along with the Interdisciplinary Team (IDT) conducted monthly QAPI meeting beginning on 05/21/2021, per policy to discuss and review collected data related to: Quality Indicators, Consult Reports, and survey findings. Results that indicated a pattern of concern would be listed and an Action Plan or Performance Improvement Plan (PIP) would be written to address concerns and monitored weekly by the IDT until resolved. The RDO or other Regional Team Member attended monthly QAPI meeting and would continue to attend for six (6) months to ensure data was collected properly, reviewed, monitored, and followed until resolution. Any written Action Plan or Performance Improvement Plan (PIP) would be reviewed for appropriateness, accuracy and progression toward resolution. 19. On 05/21/2021, The RDO completed education with the IDT on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. The IDT completed pre-test and post-test to ensure understanding with a 100% score required, staff that did not score 100% received further education and/or disciplinary action. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 05/26/2021, as alleged by the facility: 1. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they assessed all residents to ensure any resident, which experienced a change in condition related to nutrition and/or hydration was immediately addressed. This included performing the appropriate assessment, physician notification for orders, and revision of the resident's care plan. They revealed they did not identify any concerns. 2. Review of staff in-service records for 05/21/2021 through 05/24/2021, revealed nursing staff had received education on change in condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they provided education for licensed staff from 05/21/2021 through 05/24/2021. The education included change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22, on 06/03/2021 at 3:58 PM, SRNA #18, on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13, on 06/03/2021 at 2:28 PM, LPN #8, on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM revealed they received the above education to include a pre-test and post-test. 3. Review of the daily CQI meetings held Monday through Friday, revealed the DON, ADON, and UM monitored the progress notes for the previous 24 hours Tuesday through Friday and 72 hours on Monday to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol to include residents that consumed less than 50% of three (3) consecutive meals. Review of Sampled residents (Resident #19, Resident #26, and Resident #27) revealed their records were reviewed daily for change in condition related to nutrition and hydration and were placed on the SWAT list for further monitoring. No concerns w [TRUNCATED]

Based on interview, record review, review of facility Job Descriptions, and review of the facility's policy, it was determined the facility failed to be administered in a manner to use its resources effectively and efficiently to ensure residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being for one (1) of five (5) sampled residents (Resident #11). Interview and record review revealed the facility failed to identify Resident #11 had not met his/her fluid needs from 03/23-29/2021 and his/her nutritional intake had decreased, nor was there any action taken to address the resident's deficits. Resident #11 was transferred to the hospital on 03/29/2021 where he/she was determined to be severely dehydrated with acute renal failure. On 02/26/2021, a Standard Abbreviated survey identified deficient practice related to the failure to implement care plans, monitor residents' hydration status, and failure to notify residents' physicians when a change in condition occurred. The facility's Administrator submitted a plan of correction which stated care plans, hydration, and change of conditions would be monitored to prevent reoccurrence of the deficient practices. The facility alleged compliance effective 03/19/2021, with plans to monitor to ensure compliance was maintained. However, interview with the Administrator (Administrator ), revealed he was unsure of the facility process that ensured residents received adequate fluids according to their assessed need. The ADOM stated he relied on nursing management staff to ensure resident care needs were met and audits were completed accurately. The Administrator stated he had not identified any care concerns. He further revealed he ensured compliance with the POC by reviewing documents for completion, on Fridays. According to the Administrator, he believed the audits would have identified Resident #11's inadequate intake the following week on 03/31/2021, but the resident was discharged on [DATE]. The facility's failure to ensure it was administered in a manner to use its resources effectively and efficiently to ensure residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/19/2021, and determined to exist on 03/23/2021 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 05/19/2021. An acceptable Allegation of Compliance was received on 05/27/2021, which alleged removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency determined the Immediate Jeopardy was removed as alleged, prior to exit on 06/04/2021, which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867), while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F580, F656, F684 and F692). The findings include: Review of the facility's Job Description for the Administrator, not dated, revealed the Administrator led and directed the overall operations of the facility in accordance with the resident needs, federal and state government regulations and company policies to maintain quality care for the resident while achieving the facility's business objectives. The Administrator's essential job duties included conducting regular rounds to ensure staff addressed resident needs and to monitor operations of all departments. The Administrator managed turnover and ensured adequate staffing through the development of recruitment sources, and through appropriate selection, orientation, training and staff education. Additional roles and responsibilities included recognizing potential hazards and monitoring personnel to ensure safety procedures were followed. The Administrator would ensure the understanding of and compliance with, all rules regarding residents' rights. The Administrator would work with the facility management staff and consultants in planning all aspects of facility's operations, including setting priorities and job assignments. Review of a closed record for Resident #11 revealed the facility admitted the resident on 02/17/2021 and readmitted to the facility on [DATE] with diagnoses, which included Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Pain, Non-displaced Fracture of Surgical Neck of Left Humerus and Nutritional Anemia. Review of the Nutritional Risk assessment dated [DATE], signed by the Dietary Manager, revealed Resident #11's estimated fluid needs to be 1650 milliliters (ml) per day of fluid. Review of the Mini Nutritional assessment dated [DATE], revealed Resident #11 was at risk of malnutrition based on the assessment. Further review of the assessment, revealed a score of 8 points (8-11 points indicated at risk of malnutrition). A review of the fluid intake records for Resident #11, revealed the facility documented the resident had not met his/her fluid requirement on the following dates: 360 ml on 03/23/2021, 1080 ml on 03/24/2021, 1010 ml on 03/25/2021, 900 ml on 03/26/2021, 1080 ml on 03/27/2021 and 1080 ml on 03/28/2021. A review of the food intake records for Resident #11, revealed the resident consumed 0-25 % for twelve (12) out of sixteen (16) meals from 03/23/2021-03/29/2021 and refused 3 (three) out of sixteen (16) meals from 03/23/2021-03/29/2021. Further review revealed one (1) meal out of sixteen (16) which Resident #11 consumed 26-50%. Review of medical record revealed no evidence staff notified the physician Resident #11's food and fluid intake decreased, refused or eating 0-25% for most meals during 03/23/2021 to 03/29/2021 until Physical Therapist #1 identified a significant decline in Resident #11 on 03/29/2021. Review of the Change in Condition Evaluation form, completed on 03/29/2021 at 9:15 AM, revealed Resident #11 was assessed with a Neurological Change, needed more assistance with activities of daily living (ADL's), and had decreased mobility. The evaluation stated Resident #11 was unable to swallow and holds food in mouth and unable to perform task of move arms or squeeze nurse hand. Review of progress notes revealed Resident #11 was transferred to emergency room for evaluation and treatment at 9:30 AM. A review of the Hospital Admission History and Physical on 03/29/2021 revealed Resident #11 was admitted with diagnoses, which included Acute Renal Failure, Hyperkalemia, Pelvic Ring Fracture, Displaced Intertrochanteric Fracture of Left Femur and Dementia. Further review of the record revealed Resident #11 nodded when asked if he/she was thirsty. A Nephrology Consult conducted, on 03/29/2021 revealed Acute Kidney Failure most probably secondary to acute Tubular Necrosis secondary to Severe Dehydration, Severe Lactic Acidosis, Hyperkalemia, Severe Dehydration and Severe Anemia. Further review of the hospital consult, revealed diagnoses of Septic Shock and Neutrophilic Leukocytosis. In addition, the review revealed palliative care was consulted. Review of the facility Plan of Correction (POC) for the Abbreviate Standard survey, conducted on 02/26/2021, revealed the facility's Administrator submitted a plan of correction which stated care plans, hydration, and resident change of condition would be monitored to prevent reoccurrence of the deficient practices. Specifically, the plan of correction stated the Unit Supervisor would complete daily audits (Monday - Friday) to ensure resident fluid intake was documented for all meals and hydration passes. Further review of the POC, revealed the Interdisciplinary Team (IDT) Meetings would review resident information to ensure compliance with physician notification when there was a change in a resident's condition, to ensure care plans were developed and implemented related to hydration, and to ensure residents maintained sufficient fluid intake to maintain proper hydration. The POC stated the Administrator would attend the IDT meetings as required. The plan stated results would be presented to Quality Assurance Performance Improvement (QAPI) and action plans would be written if indicated. The Administrator would then monitor any action plan weekly until resolved. The facility alleged compliance effective 03/19/2021, with plans to monitor to ensure compliance was maintained. Review of the POC audits, dated 03/16/2021 through 03/18/2021, revealed Unit Manager #1 had audited random residents' hydration status to ensure intake was documented in the computer. Further review revealed Unit Manager #1 had completed audits of random residents' to ensure the resident had care plan interventions to address hydration and nursing had performed an assessment to identify signs and symptoms of dehydration. Further review of the audits revealed no evidence the facility had identified staff had failed to implement Resident #11's care plan, not identified the resident had decrease intake, or failed to notify the physician, when Resident #11 had inadequate food/fluid intake. On 05/11/2021 at 2:17 PM, interview with Unit Manager (UM) #1, revealed she was responsible for auditing documentation to ensure each resident had food/fluid charted. However, stated she was only auditing to ensure the documentation was in the computer, not reviewing the fluid/food intake to ensure it was meeting resident needs. The Unit Manager stated Resident #11 was not reviewed during the audits. The Unit Manager, stated the facility had no method related to calculating daily food/fluid intake to ensure resident nutritional/hydration needs had been met. She stated there was no alert in the electronic medical record either that notified staff of decreased intake. She stated the facility relied on nursing judgement and assessment to identify sign and symptoms of dehydration. On 05/19/2021 at 4:37 PM, interview with Interim Director of Nursing, revealed the facility was completing random audits as described in the POC, and relied on nursing judgement for assessment of signs and symptoms of dehydration. However, she stated the IDT did not audit/monitor all residents to ensure residents' were receiving adequate fluids. On 05/19/2021 at 4:53 PM, interview with the Administrator revealed, he was responsible to ensure day-to-day operations of the facility. The Administrator also agreed he would be the person who was responsible for leading and directing the overall operations of the facility in accordance with the resident needs, federal and state government regulations and company policies to maintain quality care for the residents. However, he was unsure of the facility process that ensured residents received adequate fluids according to their assessed need. The Administrator stated he relied on nursing management staff to ensure resident care needs were met and audits were completed accurately. The Administrator revealed he had not identified any care concerns. He further revealed he ensured compliance with the POC by reviewing documents on Friday, to ensure completion. According to the Administrator, he believed the audits would have identified Resident #11's inadequate intake the following week on 03/31/2021, but the resident was discharged on [DATE]. **The facility alleged the following actions were implement to remove Immediate Jeopardy effective 05/26/2021: 1. All residents were assessed by the Director of Nursing (DON) and Unit Manager (UM) on 05/24/2021 to ensure any resident with a Change in Condition related to nutrition and hydration was immediately addressed to include the following: the appropriate assessment was completed, the physician notification as needed, and the resident's care plan was revised if needed. 2. Nursing staff were in-serviced between 05/21/2021 and 05/24/2021 by the DON and UM regarding change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Staff were required to complete a pre-test and post-test with a 100 percent (%) score to ensure understanding of the education. Any staff that failed to score 100% on both tests received further education and/or disciplinary action. 3. Daily Continuous Quality Improvement (CQI) meetings would be held Monday through Friday. The DON/Designee would monitor the progress notes for the previous 24 hours on Tuesday through Friday and previous 72 hours on Monday, to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol, including residents that consumed less than 50% of three (3) consecutive meals. Monitoring would also ensure that clinical staff completed a 72-hour follow up related to change in condition monitoring and/or placement on Skin, Weight, Assessment Team (SWAT) tracking for long-term monitoring. Resident Changes of Condition identified during SWAT meetings would be reported to the Registered Dietitian (RD) for assessment. Residents considered at risk would be placed on the ongoing list by the DON/Designee and reviewed in the weekly SWAT meetings. 4. A Stop and Watch tool was incorporated to facilitate communication of changes in nutrition and hydration between the State Registered Nursing Assistant (SRNA) and the nurse. The floor nurse was responsible to address the concern by completion of necessary clinical assessments; documentation of the resident assessment; and notification of the Medical Director, Resident Representative, and Registered Dietitian (RD). 5. Monitoring of ten (10) residents weekly for four (4) weeks was initiated on 05/21/2021 by the DON/Designee to ensure Change in Condition related to decreased meal consumption or fluid intake from the prior week was identified and addressed per facility policy. 6. The DON/Designee presented audit findings to the Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns identified through audits. A Regional Office member would attend the weekly QAPI meetings in person or remotely until compliance was achieved. 7. On 05/24/2021, the RD completed a medical record review of all facility residents and created a list of residents considered at risk for hydration and/or nutrition decline. The RD determined the estimated hydration and nutritional needs for each resident considered to be at risk. The Minimum Data Set nurse updated the residents' comprehensive care plan as well as the SRNA Kardex to include resident specific needs when identified. 8. On 05/24/2021, the RD completed a medical record review of all new admissions, readmissions, and residents that experienced a significant change in condition to determine the residents' required nutritional and hydration needs and reported the at-risk residents to SWAT. 9. The DON/Designee reviewed nutrition and fluid intake data daily for residents identified at risk during CQI meetings Monday through Friday to ensure residents were meeting their daily-required needs. 10. Fluid intake and meal consumption was reviewed Monday through Friday during CQI meetings by the DON/Designee of residents identified to be at nutritional/hydration risk to ensure the residents were meeting their fluids and/or nutrition requirements as set by the RD and the residents' comprehensive care plan. 11. The DON/Designee began monitoring on 05/24/2021, 10 resident care plans for four (4) weeks to ensure the residents met their nutrition and fluid requirements, and thereafter three (3) residents weekly for three (3) months to ensure continued compliance. 12. New admissions, readmissions, and/or residents who had a significant change of condition, for whom the RD determined to be at risk for nutrition and hydration were monitored by the DON/Designee weekly for three (3) months to ensure the RD's continued monitoring and to ensure at risk residents were identified. 13. Residents identified at risk for nutrition and/or fluid deficits and consumed less than their assessed fluid needs would be assessed for dehydration by the UM and/or ADON for intervention. 14. The daily CQI and morning meetings were attended by the Administrator with documented attendance. The Administrator was responsible for ensuring any noted change of condition, failure of an at risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. This would continue for three (3) months and would be reviewed/validated weekly by a Regional team member to ensure identified concerns were acted upon timely. 15. The Administrator received 1:1 education from the Regional Director of Operations (RDO), on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. The Administrator was required to complete a pre-test and post-test to determine understanding with a 100% score required, failure to score 100% on tests resulted in further education and/or disciplinary action. 16. The Regional Director of Operations (RDO) reviewed daily Morning Meeting and CQI documentation by the Administrator beginning 05/21/2021 regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. The RDO presented monitoring of the Administrator's documentation of Morning Meetings and CQI to the weekly QAPI meetings. Any concerns identified would be immediately addressed and if needed the RDO/Regional Team would complete an Action Plan. 18. The Administrator along with the Interdisciplinary Team (IDT) conducted monthly QAPI meeting beginning on 05/21/2021, per policy to discuss and review collected data related to: Quality Indicators, Consult Reports, and survey findings. Results that indicated a pattern of concern would be listed and an Action Plan or Performance Improvement Plan (PIP) would be written to address concerns and monitored weekly by the IDT until resolved. The RDO or other Regional Team Member attended monthly QAPI meeting and would continue to attend for six (6) months to ensure data was collected properly, reviewed, monitored, and followed until resolution. Any written Action Plan or Performance Improvement Plan (PIP) would be reviewed for appropriateness, accuracy and progression toward resolution. 19. On 05/21/2021, The RDO completed education with the IDT on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. The IDT completed pre-test and post-test to ensure understanding with a 100% score required, staff that did not score 100% received further education and/or disciplinary action. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 05/26/2021, as alleged by the facility: 1. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they assessed all residents to ensure any resident, which experienced a change in condition related to nutrition and/or hydration was immediately addressed. This included performing the appropriate assessment, physician notification for orders, and revision of the resident's care plan. They revealed they did not identify any concerns. 2. Review of staff in-service records for 05/21/2021 through 05/24/2021, revealed nursing staff had received education on change in condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they provided education for licensed staff from 05/21/2021 through 05/24/2021. The education included change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22, on 06/03/2021 at 3:58 PM, SRNA #18, on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13, on 06/03/2021 at 2:28 PM, LPN #8, on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM revealed they received the above education to include a pre-test and post-test. 3. Review of the daily CQI meetings held Monday through Friday, revealed the DON, ADON, and UM monitored the progress notes for the previous 24 hours Tuesday through Friday and 72 hours on Monday to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol to include residents that consumed less than 50% of three (3) consecutive meals. Review of Sampled residents (Resident #19, Resident #26, and Resident #27) revealed their records were reviewed daily for change in condition related to nutrition and hydration and were placed on the SWAT list for further monitoring. No concerns were identified. 4. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22 on 06/03/2021 at 3:58 PM, SRNA #18 on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13 on 06/03/2021 at 2:28 PM, LPN #8 on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM, revealed they received education regarding the use of the Stop and Watch tool. They stated the tool was utilized when a SRNA observed a change in condition. Once completed, the SRNA utilized the tool to report the change in condition to the floor nurse and the floor nurse was then responsible for addressing the concern and completion of any required assessments, physician notification, Resident Representative notification, and RD notification. 5. Record review revealed the facility monitored ten (10) residents weekly and no concerns were identified with change of condition related to decreased meal consumption or fluid intake, nor physician notification. 6. Review of QAPI meeting documentation revealed the last weekly meeting was on 05/28/2021, with attendees, which included the Administrator, DON, and RDO. Per the meeting notes, there were no identified concerns. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she presented all audit findings weekly during the QAPI meetings. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she attended the weekly QAPI meetings to ensure compliance with audits being performed. 7. Review of Sampled Resident #19, Resident #26, and Resident #27's medical records, revealed the RD performed a medical record review on 05/24/2021 at which time the residents who were identified at risk (related to nutrition and/or hydration) were placed on SWAT monitoring. In addition, their care plan was updated with interventions and the RD documented the residents' estimated nutritional and fluid needs. Review of the records revealed no concerns were identified. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she performed record reviews of all residents to determine their estimated nutritional and fluid needs. She stated she also reviewed records to ensure at risk residents were placed on SWAT for increased monitoring. Interview with the Minimum Data Set (MDS) Coordinator, on 06/04/2021 at 11:10 AM, revealed she revised the care plans of residents considered at risk by the RD to include appropriate interventions. 8. At the time of the review/survey there had not been any new resident admissions or re-admissions since the facility's alleged IJ removal date. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she would perform a medical record review of all new admissions, re-admissions, and residents who experienced a change in condition related to nutritional and/or hydration to determine the residents' estimated nutritional and fluid needs. She stated new admissions and re-admissions were placed on the SWAT list for four (4) weeks for monitoring and if the resident was stable at the end of the four (4) week period, they would be removed from the SWAT program. 9. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed resident nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs. 10. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs, as well as ensuring the resident care plans addressed their needs. 11. Record review revealed the facility reviewed ten (10) resident records weekly and there were no identified concerns with change of condition related to decreased meal consumption and/or fluid intake. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they reviewed 10 resident records weekly to ensure their care plans were updated to address their nutritional and fluid requirements. 12. Review of daily monitoring revealed no new admissions or readmissions had occurred since the facility's alleged IJ removal date 05/26/2021. Review of Residents #19, Resident #26, and Resident #27's medical records revealed they were determined to be at risk and were discussed and monitored daily Monday through Friday. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she reviewed all at risk residents daily Monday through Friday to ensure the RD was monitoring residents nutritional and fluid intake. 13. Review of audits and medical records of Residents #19, Resident #26, and Resident #27, revealed the UM or ADON completed a dehydration assessment. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the ADON, on 06/04/2021 at 11:41 AM, revealed they performed dehydration assessments on residents that consumed less than their nutritional and/or fluid needs to ensure the appropriate interventions were put into place. 14. Review of the daily CQI and morning meeting documentation revealed the Administrator was present at all meetings Monday through Friday. No concerns were identified. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed he attended daily morning meetings and CQI meetings Monday through Friday. He stated he was responsible to ensure any noted change of condition, failure of an at-risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. He further stated the monitoring would continue for three (3) months. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she reviewed morning meeting and CQI meeting minutes by the Administrator weekly to ensure identified concerns were acted upon timely. 15. Review of education provided on 05/21/2021, by the RDO, revealed the Administrator received education regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed he received 1:1 education from the RDO on 05/21/2021 regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she provided 1:1 education to the Administrator on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. 16. Review of monitoring audits and interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she reviewed daily morning meeting and CQI documentation by the Administrator, beginning 05/21/2021, regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. Review of QAPI minutes from the last weekly meeting dated 05/28/2021 revealed the RDO presented monitoring of the Administrator's documentation of the daily morning meetings and CQI meetings. No concerns were identified. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she presented monitoring of the Administrator's documentation of the morning meetings and CQI meetings to the 05/28/2021 weekly QAPI meeting. 18. Review of the 05/21/2021, monthly QAPI meeting minutes, revealed Quality Indicators, Consult Reports, and survey findings were discussed. Further review revealed the RDO was present during the QAPI meeting. No concerns were identified. 19. Review of education completed on 05/21/2021, by the RDO revealed the IDT received education related to the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. Interviews with the Administrator, on 06/04/2021 at 3:04 PM, the UM on 06/04/2021 at 12:46 PM, the ADON, on 06/04/2021 at 11:41 AM, the DON on 06/04/2021 at 2:29 PM, and the Administrator on 06/04/2021 at 3:04 PM, revealed they received education by the RDO, on 05/21/2021, related to the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. They stated they completed a pre-test and post-test to measure their understanding of the education. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she performed an in-service on 05/21/2021 with the IDT to educate them on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs.

Based on interview, record review, review of facility policy, and review of the facility's Plan of Correction submitted for a 02/26/2021 survey, it was determined the facility failed to have an effective system in place to identify quality issues and/or develop and implement an effective plan to correct identified deficiencies through the Quality Assurance Performance Improvement (QAPI) Program. On 02/02/2021, Immediate Jeopardy was determined to exist at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656). The state agency exited with the facility on 02/26/2021, with additional deficient practice identified at F692 for failure to ensure residents maintained sufficient hydration. The facility submitted an acceptable plan of correction (POC) alleging compliance as of 03/19/2021. However, from 03/23-28/2021, Resident #11 did not meet his/her recommended food or fluid intake. Staff interviews revealed they were only monitoring to ensure intake numbers were documented and were not monitoring to ensure residents met their recommended daily fluid needs. Subsequently, there was no evidence the facility identified Resident #11 did not meet his/her recommended daily fluid intake, nor was there evidence the facility took any action to address the resident ' s decreased food and fluid intake. On 03/29/2021, Resident #11 was transferred to the hospital, where he/she was determined to be severely dehydrated with acute renal failure. The facility's failure to ensure an effective Quality Assurance Performance Improvement (QAPI) Program was in place has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/19/2021, and determined to exist on 03/23/2021 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 05/19/2021. An acceptable Allegation of Compliance was received on 05/27/2021, which alleged removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency determined the Immediate Jeopardy was removed as alleged, prior to exit on 06/04/2021, which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy Quality Assurance Performance Improvement Policy, not dated, revealed the facility's Quality Assurance and Performance Improvement Program (QAPI) represented the facility's commitment to continuous quality improvement. The program ensured a systematic performance evaluation, problem analysis, and implementation of improvement strategies to achieve performance goals. The policy stated the QAPI Committee met at least quarterly to review facility data, identify opportunities for improvement, and review the activities of its Performance Improvement Project (PIP) sub-committees. According to the policy, the QAPI Committee's oversight responsibilities included, but were not limited to, utilizing facility data to identify opportunities to improve systems and care. Data may include, but was not limited to; grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatment logs, staffing trends, incident and accident reports, quality measures, survey outcomes, etc. Review of the facility's plan of correction (POC) for the statement of deficiencies with an exit date of 02/26/2021, revealed the facility was cited at tags F580 (failure to notify the resident's physician for a change in condition) and F656 (failure to revise the care plan) at Immediate Jeopardy. In addition, F692 was cited at D level for failure to maintain proper hydration. The facility developed a POC and alleged compliance effective 03/19/2021. The plan of correction stated staff were educated with instructions to notify the physician of changes in a resident's condition, following the plan of care, documenting fluid intake, and identifying signs/symptoms of inadequate fluids. The plan also included monitoring/audits to include daily monitoring of fluid intake documentation by the Unit Manager, daily rounds by the ADON and DON to observe for resident change in condition, etc. The POC stated any concerns would be addressed immediately. According to the POC, the results of these audits and findings would be presented to the QAPI Committee monthly. If indicated, an Action Plan would be written by the committee and any written Action Plan would be monitored weekly by the Administrator until resolved. Review of a closed record for Resident #11 revealed the facility admitted the resident on 02/17/2021 and was readmitted on [DATE]. The resident had diagnoses, which included Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Pain, Non-displaced Fracture of Surgical Neck of Left Humerus, Major Depressive Disorder, and Nutritional Anemia. Review of Resident #11's care plan, dated 02/17/202, revealed the facility developed a care plan that stated Resident #11 required staff assistance with set up and supervision with eating and may need assist of one person at times. The care plan further revealed the facility identified the resident was at risk for nutrition and hydration. The goal was for the resident to safely consume adequate nutrition and fluids to maintain weight and hydration to the extent possible. Staff were required to encourage good fluid intake and offer substitutes for foods not eaten or disliked. Further review of Resident #11's care plan revealed the resident had interventions that included monitoring the resident for change in appetite; assessing and anticipating the resident's food and thirst needs; and monitoring for and reporting changes in output/intake. Review of the Nutritional Risk assessment dated [DATE], signed by the Dietary Manager, revealed Resident #11's estimated fluid were 1650 milliliters (ml) per day. However, a review of the fluid intake records for Resident #11, revealed the resident did not meet his/her estimated needs from 03/23/2021 through 03/29/2021. The facility documented the resident had the following fluid intake: 360 ml on 03/23/2021, 1080 ml on 03/24/2021, 1010 ml on 03/25/2021, 900 ml on 03/26/2021, 1080 ml on 03/27/2021 and 1080 ml on 03/28/2021. A review of the food intake records for Resident #11, revealed the resident consumed 0-25% for twelve (12) of sixteen (16) meals, from 03/23/2021-03/29/2021, and refused 3 (three) of sixteen (16) meals from 03/23/2021-03/29/2021. Further review revealed the resident the most the resident consumed during this time span, was 26-50% for the lunch meal on 03/24/2021. Review of Resident #11's medical record revealed no evidence staff identified nor addressed the resident's decrease in fluids or that the resident refused or only ate 0-25% for most meals from 03/23/2021, until the morning of 03/29/2021, when the resident could not swallow. A review of the Change in Condition Evaluation completed, on 03/29/2021 at 9:15 AM, revealed Resident #11 had a Neurological Change. The resident needed more assistance with activities of daily living (ADL's), had decreased mobility and had swallowing difficulty. The evaluation stated Resident #11 was unable to swallow and holds food in mouth and unable move arms or squeeze nurse hand. Review of progress notes revealed Resident #11 was transferred to emergency room for evaluation and treatment at 9:30 AM. Review of hospital laboratory results for 03/29/2021, revealed Resident #11's Blood Urea Nitrogen (BUN) level was abnormal at 132 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and Creatinine level was at a critical level of 8.60 mg/dL (normal range 0.50-1.20 mg/dL) (indicators of dehydration and kidney failure. The ED record stated, First the patient is severely dehydrated and this raises concern for neglect. The resident was admitted to the hospital on 03/29/2021, with diagnoses that included Acute Renal Failure (kidney failure), Hyperkalemia (increased potassium level is an indicator of dehydration), Pelvic Ring Fracture, Displaced Intertrochanteric Fracture of Left Femur (hip), and Dementia. According to a Nephrology Consult on 03/29/2021, Resident #11 had Acute Kidney Failure most probably secondary to Acute Tubular Necrosis secondary to Severe Dehydration (with acute tubular necrosis, the kidneys are damaged when the flow of blood and oxygen is compromised). According to the Nephrology Consult, the resident also had Severe Lactic Acidosis (build-up of lactic acid in the body), and Severe Anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). Further review revealed on 03/29/2021, Resident #11 was also diagnosed with Septic Shock (Sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. Sepsis may progress to septic shock, which can lead to severe organ problems and death. Signs and symptoms of sepsis include a change in mental status.) and Neutrophilic Leukocytosis (Neutrophils are a type of white blood cell that help the body fight infections and heal injuries). According to the hospital record, palliative care was consulted. Review of the facility's POC audits 03/19/2021 through 03/29/2021, revealed Unit Manager #1 had audited random residents' hydration status to ensure intake was documented in the computer. There was no evidence anyone was reviewing residents ' intake to ensure it was adequate. Further review revealed Unit Manager #1 was completing audits of random residents to ensure the resident had care plan interventions to address hydration. There was no evidence she was monitoring to ensure the interventions were implemented. In addition, the Unit Manager had conducted random resident assessments for signs and symptoms of dehydration. Further review of the audits, revealed no evidence the facility had identified Resident #11 was not meeting his/her hydration/calorie needs, nor that the resident's care plan was not implemented and the resident's physician was not notified when Resident #11 had inadequate food/fluid intake. Interview with Unit Manager #1, on 05/11/2021 at 2:17 PM, revealed she was responsible for auditing documentation to ensure each resident had food/fluids charted. She stated she was only auditing to ensure the documentation was in the computer, not reviewing the fluid/food intake to ensure residents' needs were being met. Further interview revealed she was reviewing ten (10) random residents' records to ensure the resident had care plan interventions to address hydration, but was not ensuring the interventions were being implemented. In addition, the Unit Manager stated she was conducting dehydration assessments of the randomly chosen ten (10) residents. The Unit Manager confirmed Resident #11 was not assessed/reviewed during the audits. Per the Unit Manager, the facility had no method to monitor residents' fluid intake to ensure it was adequate and relied on nursing judgement and assessment to identify sign and symptoms of dehydration. Interview with the Assistant Director of Nursing, on 05/19/2021 at 10:20 AM, revealed she completed daily rounds to assess for any concerns, including change of condition, etc. She stated she had not identified any concerns related to Resident #11 or his/her hydration status. Interview with Interim Director of Nursing, on 05/19/2021 at 4:37 PM, revealed the facility was completing random audits as described in the POC and relied on nursing judgement for assessment of signs and symptoms of dehydration. The Interim DON also confirmed the facility did not monitor all residents to ensure they were receiving adequate fluids. Interview with the Administrator, on 05/19/2021 at 4:53 PM, revealed he attended the facility's monthly QAPI meetings. The Administrator stated he ensured compliance by reviewing audits/documents on Fridays to ensure they were completed, and had not identified any concerns. The Administrator stated he relied on nursing management staff to ensure each audit was completed accurately. Continued interview revealed no concerns had been identified with Resident #11's intake. However, he stated he was unsure how nursing staff was ensuring residents were receiving adequate fluids. **The facility alleged the following actions were implement to remove Immediate Jeopardy effective 05/26/2021: 1. All residents were assessed by the Director of Nursing (DON) and Unit Manager (UM) on 05/24/2021 to ensure any resident with a Change in Condition related to nutrition and hydration was immediately addressed to include the following: the appropriate assessment was completed, the physician notification as needed, and the resident's care plan was revised if needed. 2. Nursing staff were in-serviced between 05/21/2021 and 05/24/2021 by the DON and UM regarding change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Staff were required to complete a pre-test and post-test with a 100 percent (%) score to ensure understanding of the education. Any staff that failed to score 100% on both tests received further education and/or disciplinary action. 3. Daily Continuous Quality Improvement (CQI) meetings would be held Monday through Friday. The DON/Designee would monitor the progress notes for the previous 24 hours on Tuesday through Friday and previous 72 hours on Monday, to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol, including residents that consumed less than 50% of three (3) consecutive meals. Monitoring would also ensure that clinical staff completed a 72-hour follow up related to change in condition monitoring and/or placement on Skin, Weight, Assessment Team (SWAT) tracking for long-term monitoring. Resident Changes of Condition identified during SWAT meetings would be reported to the Registered Dietitian (RD) for assessment. Residents considered at risk would be placed on the ongoing list by the DON/Designee and reviewed in the weekly SWAT meetings. 4. A Stop and Watch tool was incorporated to facilitate communication of changes in nutrition and hydration between the State Registered Nursing Assistant (SRNA) and the nurse. The floor nurse was responsible to address the concern by completion of necessary clinical assessments; documentation of the resident assessment; and notification of the Medical Director, Resident Representative, and Registered Dietitian (RD). 5. Monitoring of ten (10) residents weekly for four (4) weeks was initiated on 05/21/2021 by the DON/Designee to ensure Change in Condition related to decreased meal consumption or fluid intake from the prior week was identified and addressed per facility policy. 6. The DON/Designee presented audit findings to the Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns identified through audits. A Regional Office member would attend the weekly QAPI meetings in person or remotely until compliance was achieved. 7. On 05/24/2021, the RD completed a medical record review of all facility residents and created a list of residents considered at risk for hydration and/or nutrition decline. The RD determined the estimated hydration and nutritional needs for each resident considered to be at risk. The Minimum Data Set nurse updated the residents' comprehensive care plan as well as the SRNA Kardex to include resident specific needs when identified. 8. On 05/24/2021, the RD completed a medical record review of all new admissions, readmissions, and residents that experienced a significant change in condition to determine the residents' required nutritional and hydration needs and reported the at-risk residents to SWAT. 9. The DON/Designee reviewed nutrition and fluid intake data daily for residents identified at risk during CQI meetings Monday through Friday to ensure residents were meeting their daily-required needs. 10. Fluid intake and meal consumption was reviewed Monday through Friday during CQI meetings by the DON/Designee of residents identified to be at nutritional/hydration risk to ensure the residents were meeting their fluids and/or nutrition requirements as set by the RD and the residents' comprehensive care plan. 11. The DON/Designee began monitoring on 05/24/2021, 10 resident care plans for four (4) weeks to ensure the residents met their nutrition and fluid requirements, and thereafter three (3) residents weekly for three (3) months to ensure continued compliance. 12. New admissions, readmissions, and/or residents who had a significant change of condition, for whom the RD determined to be at risk for nutrition and hydration were monitored by the DON/Designee weekly for three (3) months to ensure the RD's continued monitoring and to ensure at risk residents were identified. 13. Residents identified at risk for nutrition and/or fluid deficits and consumed less than their assessed fluid needs would be assessed for dehydration by the UM and/or ADON for intervention. 14. The daily CQI and morning meetings were attended by the Administrator with documented attendance. The Administrator was responsible for ensuring any noted change of condition, failure of an at risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. This would continue for three (3) months and would be reviewed/validated weekly by a Regional team member to ensure identified concerns were acted upon timely. 15. The Administrator received 1:1 education from the Regional Director of Operations (RDO), on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. The Administrator was required to complete a pre-test and post-test to determine understanding with a 100% score required, failure to score 100% on tests resulted in further education and/or disciplinary action. 16. The Regional Director of Operations (RDO) reviewed daily Morning Meeting and CQI documentation by the Administrator beginning 05/21/2021 regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. The RDO presented monitoring of the Administrator's documentation of Morning Meetings and CQI to the weekly QAPI meetings. Any concerns identified would be immediately addressed and if needed the RDO/Regional Team would complete an Action Plan. 18. The Administrator along with the Interdisciplinary Team (IDT) conducted monthly QAPI meeting beginning on 05/21/2021, per policy to discuss and review collected data related to: Quality Indicators, Consult Reports, and survey findings. Results that indicated a pattern of concern would be listed and an Action Plan or Performance Improvement Plan (PIP) would be written to address concerns and monitored weekly by the IDT until resolved. The RDO or other Regional Team Member attended monthly QAPI meeting and would continue to attend for six (6) months to ensure data was collected properly, reviewed, monitored, and followed until resolution. Any written Action Plan or Performance Improvement Plan (PIP) would be reviewed for appropriateness, accuracy and progression toward resolution. 19. On 05/21/2021, The RDO completed education with the IDT on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. The IDT completed pre-test and post-test to ensure understanding with a 100% score required, staff that did not score 100% received further education and/or disciplinary action. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 05/26/2021, as alleged by the facility: 1. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they assessed all residents to ensure any resident, which experienced a change in condition related to nutrition and/or hydration was immediately addressed. This included performing the appropriate assessment, physician notification for orders, and revision of the resident's care plan. They revealed they did not identify any concerns. 2. Review of staff in-service records for 05/21/2021 through 05/24/2021, revealed nursing staff had received education on change in condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they provided education for licensed staff from 05/21/2021 through 05/24/2021. The education included change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22, on 06/03/2021 at 3:58 PM, SRNA #18, on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13, on 06/03/2021 at 2:28 PM, LPN #8, on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM revealed they received the above education to include a pre-test and post-test. 3. Review of the daily CQI meetings held Monday through Friday, revealed the DON, ADON, and UM monitored the progress notes for the previous 24 hours Tuesday through Friday and 72 hours on Monday to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol to include residents that consumed less than 50% of three (3) consecutive meals. Review of Sampled residents (Resident #19, Resident #26, and Resident #27) revealed their records were reviewed daily for change in condition related to nutrition and hydration and were placed on the SWAT list for further monitoring. No concerns were identified. 4. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22 on 06/03/2021 at 3:58 PM, SRNA #18 on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13 on 06/03/2021 at 2:28 PM, LPN #8 on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM, revealed they received education regarding the use of the Stop and Watch tool. They stated the tool was utilized when a SRNA observed a change in condition. Once completed, the SRNA utilized the tool to report the change in condition to the floor nurse and the floor nurse was then responsible for addressing the concern and completion of any required assessments, physician notification, Resident Representative notification, and RD notification. 5. Record review revealed the facility monitored ten (10) residents weekly and no concerns were identified with change of condition related to decreased meal consumption or fluid intake, nor physician notification. 6. Review of QAPI meeting documentation revealed the last weekly meeting was on 05/28/2021, with attendees, which included the Administrator, DON, and RDO. Per the meeting notes, there were no identified concerns. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she presented all audit findings weekly during the QAPI meetings. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she attended the weekly QAPI meetings to ensure compliance with audits being performed. 7. Review of Sampled Resident #19, Resident #26, and Resident #27's medical records, revealed the RD performed a medical record review on 05/24/2021 at which time the residents who were identified at risk (related to nutrition and/or hydration) were placed on SWAT monitoring. In addition, their care plan was updated with interventions and the RD documented the residents' estimated nutritional and fluid needs. Review of the records revealed no concerns were identified. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she performed record reviews of all residents to determine their estimated nutritional and fluid needs. She stated she also reviewed records to ensure at risk residents were placed on SWAT for increased monitoring. Interview with the Minimum Data Set (MDS) Coordinator, on 06/04/2021 at 11:10 AM, revealed she revised the care plans of residents considered at risk by the RD to include appropriate interventions. 8. At the time of the review/survey there had not been any new resident admissions or re-admissions since the facility's alleged IJ removal date. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she would perform a medical record review of all new admissions, re-admissions, and residents who experienced a change in condition related to nutritional and/or hydration to determine the residents' estimated nutritional and fluid needs. She stated new admissions and re-admissions were placed on the SWAT list for four (4) weeks for monitoring and if the resident was stable at the end of the four (4) week period, they would be removed from the SWAT program. 9. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed resident nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs. 10. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs, as well as ensuring the resident care plans addressed their needs. 11. Record review revealed the facility reviewed ten (10) resident records weekly and there were no identified concerns with change of condition related to decreased meal consumption and/or fluid intake. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they reviewed 10 resident records weekly to ensure their care plans were updated to address their nutritional and fluid requirements. 12. Review of daily monitoring revealed no new admissions or readmissions had occurred since the facility's alleged IJ removal date 05/26/2021. Review of Residents #19, Resident #26, and Resident #27's medical records revealed they were determined to be at risk and were discussed and monitored daily Monday through Friday. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she reviewed all at risk residents daily Monday through Friday to ensure the RD was monitoring residents nutritional and fluid intake. 13. Review of audits and medical records of Residents #19, Resident #26, and Resident #27, revealed the UM or ADON completed a dehydration assessment. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the ADON, on 06/04/2021 at 11:41 AM, revealed they performed dehydration assessments on residents that consumed less than their nutritional and/or fluid needs to ensure the appropriate interventions were put into place. 14. Review of the daily CQI and morning meeting documentation revealed the Administrator was present at all meetings Monday through Friday. No concerns were identified. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed he attended daily morning meetings and CQI meetings Monday through Friday. He stated he was responsible to ensure any noted change of condition, failure of an at-risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. He further stated the monitoring would continue for three (3) months. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she reviewed morning meeting and CQI meeting minutes by the Administrator weekly to ensure identified concerns were acted upon timely. 15. Review of education provided on 05/21/2021, by the RDO, revealed the Administrator received education regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed he received 1:1 education from the RDO on 05/21/2021 regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she provided 1:1 education to the Administrator on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. 16. Review of monitoring audits and interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she reviewed daily morning meeting and CQI documentation by the Administrator, beginning 05/21/2021, regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. Review of QAPI minutes from the last weekly meeting dated 05/28/2021 revealed the RDO presented monitoring of the Administrator's documentation of the daily morning meetings and CQI meetings. No concerns were identified. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she presented monitoring of the Administrator's documentation of the morning meetings and CQI meetings to the 05/28/2021 weekly QAPI meeting. 18. Review of the 05/21/2021, monthly QAPI meeting minutes, revealed Quality Indicators, Consult Reports, and survey findings were discussed. Further review revealed the RDO was present during the QAPI meeting. No concerns were identified. 19. Review of education completed on 05/21/2021, by the RDO revealed the IDT received education related to the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. Interviews with the Administrator, on 06/04/2021 at 3:04 PM, the UM on 06/04/2021 at 12:46 PM, the ADON, on 06/04/2021 at 11:41 AM, the DON on 06/04/2021 at 2:29 PM, and the Administrator on 06/04/2021 at 3:04 PM, revealed they received education by the RDO, on 05/21/2021, related to the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. They stated they completed a pre-test and post-test to measure their understanding of the education. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she performed an in-service on 05/21/2021 with the IDT to educate them on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #11) had a person-centered comprehensive care plan related to monitoring hydration and nutritional status. The facility readmitted Resident #11 on 03/23/2021, after transferring the resident to a sister facility on 03/09/2021, for treatment of COVID-19. Review of Resident #11's fluid intake records from 03/23/2021 until 03/29/201, revealed the resident failed to meet his/her assessed fluid needs of 1650 ml daily on any of those days. In addition, the resident had a decrease in food intake and was refusing meals at times. However, the facility failed to monitor staff to ensure they were providing Resident #11 with the correct amount of assistance needed for meals, encouraged the resident to eat and offered food substitutions when the resident refused to eat. In addition, there was no evidence the nursing staff identified the resident's decline in appetite or reported to the resident's physician when the resident did not meet his/her fluid needs or had a decreased food intake. On 03/29/2021, the facility transferred Resident #11 to the hospital, which admitted and diagnosed the resident with Severe Dehydration, Acute Kidney Injury and Septic Shock. The facility's failure to ensure resident care plans were implemented and followed by staff has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/19/2021, and determined to exist on 03/23/2021 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 05/19/2021. An acceptable Allegation of Compliance was received on 05/27/2021, which alleged removal of the Immediate Jeopardy on 05/26/2021. The State Survey Agency determined the Immediate Jeopardy was removed as alleged, prior to exit on 06/04/2021, which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), 42 CFR 483.25 Quality of Care (F692), 483.70 Administration (F835), and 483.75 Quality Assurance and Performance Improvement (F867), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy Baseline Care Plan Assessment/Comprehensive Care Plans, updated 09/18/2018, revealed the care plan would include a resident's risks, goals and the intervention initiated using a Person-Centered plan of care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical function, mental an psychosocial needs. The policy also stated as the assessed needs of the resident changed, the facility would update the care plan. Further, the care plan policy stated the Minimum Data Set (MDS) Coordinator or ancillary MDS staff would attend the Morning Continuous Quality Improvement (CQI) meetings, where in-depth reviews would occur of various topics, including re-admissions to the facility and other pertinent circumstances regarding the resident. Review of Resident #11's closed record revealed the facility admitted the resident on 02/17/2021 with diagnoses including Alzheimer's disease, Dementia, Diabetes Mellitus, Pain, a Fractured Left Humerus and Nutritional Anemia. Further review of the record revealed the facility readmitted Resident #11 on 03/23/2021, after the resident received treatment for COVID-19 at a sister facility. Review of Resident #11's MDS assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident required set-up help and supervision for eating. In addition, review of a Nutritional Risk Assessment completed on 02/19/2021 by the facility's Dietary Manager revealed Resident #11's estimated fluid needs were 1650 milliliters (ml) of fluids per day. Review of Resident #11's Care Plan, dated 02/17/2021, revealed Resident #11 had a self-care deficit related to a left Humeral fracture, Dementia and Alzheimer's disease. The resident also required staff assistance with set-up and supervision with eating and may need assist of one person at times. The care plan further revealed the resident was at risk for nutrition and hydration. The goal was for Resident #11 to safely consume adequate nutrition and fluids to maintain weight and hydration to the extent possible. Staff was to encourage good fluid intake and offer substitutes for foods not eaten or disliked. Further review of Resident #11's care plan revealed the resident had interventions that included monitoring the resident for changes in appetite; assessing and anticipating the resident's food and thirst needs, and reporting changes in the resident's output/intake and appetite to the physician. Review of Resident #11's recorded fluid intakes for six (6) days from the time the resident was readmitted to the facility on ,d+[DATE] until the resident was transferred to the hospital on the morning of 03/29/202, revealed the resident failed to meet his/her recommended fluid needs on any of the days. The average daily intake for Resident #11 from 03/23/2020 through 03/28/2020 was 990 ml of fluids. However, there was no evidence found in the record to indicate the facility recognized the resident was not meeting his/her assessed needs or that the facility notified the resident's physician. Review of food intake records for Resident #11 from 03/23/2021 through 03/28/2021, revealed the resident refused to eat for three of the meals, consumed 25 percent or less for twelve (12) of the meals and consumed fifty (50) percent or less for one meal. In addition, review of a Mini Nutritional Assessment completed on 03/26/2021, for Resident #11 by Licensed Practical Nurse (LPN) #6, revealed Resident #11 was at risk of malnutrition. However, there was no evidence found in the resident's medical record to indicate the facility notified the resident's physician regarding the low food intake or informed the physician that the resident was at risk for malnutrition. Continued review of Resident #11's record revealed the facility documented how much Resident #11 ate and drank, there was no evidence the facility evaluated that data to ensure the resident met his/her needs or the resident's physician was notified when the resident failed to meet his/her needs. In addition, Resident #1's care plan indicated the resident may need the assistance of staff for meals at times, however, there was nothing in place for staff to determine when they should provide assistance to the resident. Staff was to monitor the resident for a change in appetite, assess and anticipate the resident's food and thirst needs, and report changes in the resident's output/intake and appetite to the physician. However, there was no evidence found in the resident's medical record to indicate the facility had a system on place to ensure staff implemented the care plan. There was no direction given on the care plan or in the resident's medical record for staff to know how to assess the resident's appetite, anticipate food and fluid needs, or how to utilize the data derived from recording food and fluid intakes to ensure the resident's physician was notified timely of concerns. Interview with State Registered Nurse Assistant (SRNA) #14, on 04/27/2021 at 9:47 AM, SRNA #18 on 04/27/2021 at 4:44 PM, SRNA #13 on 04/26/2021 at 5:22 PM, SRNA #21 on 04/28/2021 at 12:11 PM and SRNA #17 on 04/29/2021 at 1:34 PM, revealed all the SRNA's had cared for Resident #11 between the dates of 03/23/2021 and 03/29/2021. All the staff interviewed stated when they cared for Resident #11 during the period, the resident was not eating or drinking as much as usual. In addition, the staff stated Resident #11's behavior was different, stating the resident was not yelling out as usual. SRNA #21 stated he cared for the resident on 03/27/2021 and 03/28/2021 from 7:00 AM until 11:00 PM, and stated during those times Resident #11 just stared at you. Continued interview with the SRNA's revealed they all stated they reported Resident #11's decreased intake of food/fluids to the nurse. Further interview with SRNA #14, on 04/27/2021 at 9:47 AM, and SRNA #18 on 04/27/2021 at 4:44 PM, revealed SRNA #18 cared for Resident #11 on 03/24/2021 and 03/025/2021. SRNA #18 stated she reported to the nurse on both days she cared for Resident #11, that the resident did not eat or drink much. However, SRNA #18 stated she had not attempted to feed the resident or offer fluids because she was told (unable to identify by whom) the resident could feed (him/herself) and the resident was just a set-up for meals. SRNA #18 stated she thought the resident's Kardex (quick reference for resident care needs) listed the assistance a resident required for eating, but stated she had not looked at Resident #11's Kardex and just went by what other staff told her. SRNA #14 cared for Resident #11 on 03/25/2021 and 03/28/2021, and stated she reported to the nurse on both evenings that the resident refused to eat the evening meal on both evenings. However, SRNA #14 stated the nurse did not attempt to feed the resident on 03/25/2021 or 03/28/2021. Interviews with Licensed Practical Nurse (LPN) #7, on 04/26/2021 at 3:20 PM, and on 04/29/2021 at 10:30 AM and 6:38 PM, RN #2 on 04/28/2021 at 1:01 PM and 4:35 PM, and on 05/03/2021 at 3:37 PM, and Registered Nurse (RN) #4, on 04/28/2021 at 2:09 PM, revealed all of the nurses cared for Resident #11 during the period of 03/23/2021 through 03/29/2021. All the nurses interviewed denied any staff reporting to them that Resident #11 was not eating or drinking well, or had refused meals. However, LPN #7 did state after Resident #11 returned to the facility on [DATE], the resident's condition declined, staff had to feed the resident and Resident #11 was unable to hold a cup independently. Continued interviews with the nurses revealed none of them had reviewed Resident #1's food/fluid intake records during the period of 03/23/2021 through 03/29/2021. Further, review of Resident #11's medical record revealed no evidence the nurses had assessed the resident's appetite or reported the resident's decreased intake of food/fluids as required by Resident #11's care plan. Interview with the Minimum Data Set MDS coordinator on 05/10/2021, at 10:56 AM, and on 05/11/2021 at 1:57 PM, revealed she monitored care plans to ensure interventions were in place to address hydration and nutrition needs, but did not conduct monitoring to ensure the interventions were implemented by staff. The MDS Coordinator stated when the facility readmitted Resident #11 on 03/23/2021, she just re-activated the resident's care plan that was in place prior to the facility transferring the resident to a sister facility for treatment of COVID-19. The MDS coordinator stated she did not assess the resident or review the care plan prior to re-activating it to ensure Resident #11's needs had not changed and that the interventions on the care plan were still applicable and safe for Resident #11. Continued interview with the MDS coordinator revealed Kardex information automatically generated when a comprehensive care plan was completed, and therefore, it contained the same information that was on Resident #11's care plan prior to the transfer. The MDS Coordinator stated the facility usually received a transfer of care form, from the transferring facility that listed the resident's care needs, and the medical records department and the receiving nurse scans it into the system. However, the MDS Coordinator stated she did not typically get the transfer forms, and did not get one for Resident #11. The MDS Coordinator stated she could not remember if she looked at Resident #11's admission record on 03/23/2021 or not, and could not recall discussing Resident #11 in the morning meeting after the facility readmitted the resident. The MDS coordinator acknowledged the resident's care plan for eating stated the resident required supervision to one (1) assist. However, the MDS coordinator stated she had never instructed staff on what criteria to utilize to make a determination on whether the resident needed assistance or not or how much assistance for any given meal. In addition, the MDS Coordinator stated staff never informed her that Resident #11 was more lethargic, unable to participate in therapy, was unable to hold a cup at times and was not consuming an adequate amount of food or fluids. Review of a Change in Condition Evaluation, completed on 03/29/2021 at 9:15 AM, revealed staff documented Resident #11 had a Neurological Change. In addition, the assessment stated Resident #11 needed more assistance with activities of daily living (ADL's), and had a decrease in mobility. The evaluation also stated the resident was unable to swallow and holds food in mouth and was unable to move arms or squeeze nurse hand. Continued review revealed staff transferred Resident #11 to the emergency room for evaluation and treatment. Review of Resident #11's hospital record revealed the Hospital admitted the resident on 03/29/2021, with diagnoses including Acute Renal Failure and Hyperkalemia. Further review of the record revealed Resident #11 nodded yes when asked if he/she was thirsty. Continued review of the hospital record revealed a Nephrology Consult on 03/29/2021 stated the resident had Acute Kidney Failure secondary to severe dehydration. Interview with Unit Manager (UM) #1, on 04/26/2021 at 11:39 AM, revealed she was present when the facility readmitted Resident #11, and made the initial nursing entry. However, she stated she did not recall reviewing and documentation for the transferring facility. The UM stated after the facility readmitted Resident #11 on 03/23/2021, the resident was not eating or drinking and required more assistance with meals. However, the UM stated she had not conducted any observations of resident care to ensure staff were following the resident's care plan by assisting the resident with meals, encouraging the resident to drink fluids, and were offering substitutes when the resident did not eat or disliked the food served. Interview with the former Director of Nursing (DON), on 04/27/2021 at 3:47 PM, 04/29/2021 at 2:32 PM and 4:23 PM, and on 05/11/2021 at 3:05 PM, revealed she did not conduct monitoring to ensure resident care plans were appropriate to meet their individualized needs. The DON stated that was the responsibility of the MDS Coordinator and she did not feel like she should have to monitor that. In addition, the DON stated it was the responsibility of the UM to ensure staff implemented the care plan, and therefore she did not monitor that either. The DON stated she had not been aware that resident #11 was not meeting his/her assessed fluid needs and was not eating well until the resident was sent to the hospital on 03/29/2021. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed the admitting nurse reviewed documents from the transferring facility, if applicable, and initiated care plans for new or readmitted residents. The Administrator stated the MDS Coordinator was responsible to developing care plans and or revising when changes occurred. The Administrator stated implementation of the care plan and ensuring it was followed was the responsibility of the nursing/clinical staff, and stated he did not audit or perform any evaluation to ensure the care plan was implemented and that staff were following the care plan. The Administrator stated he could not recall discussing Resident #11 in the morning meeting after re-admission to the facility on [DATE]. Continued interview with the Administrator revealed he stated he was not aware that Resident #11 was not eating well or meeting his/her assessed fluid needs after returning to the facility on [DATE], and had not been aware of any concerns regarding implementation of the resident's care plan. **The facility alleged the following actions were implement to remove Immediate Jeopardy effective 05/26/2021: 1. All residents were assessed by the Director of Nursing (DON) and Unit Manager (UM) on 05/24/2021 to ensure any resident with a Change in Condition related to nutrition and hydration was immediately addressed to include the following: the appropriate assessment was completed, the physician notification as needed, and the resident's care plan was revised if needed. 2. Nursing staff were in-serviced between 05/21/2021 and 05/24/2021 by the DON and UM regarding change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Staff were required to complete a pre-test and post-test with a 100 percent (%) score to ensure understanding of the education. Any staff that failed to score 100% on both tests received further education and/or disciplinary action. 3. Daily Continuous Quality Improvement (CQI) meetings would be held Monday through Friday. The DON/Designee would monitor the progress notes for the previous 24 hours on Tuesday through Friday and previous 72 hours on Monday, to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol, including residents that consumed less than 50% of three (3) consecutive meals. Monitoring would also ensure that clinical staff completed a 72-hour follow up related to change in condition monitoring and/or placement on Skin, Weight, Assessment Team (SWAT) tracking for long-term monitoring. Resident Changes of Condition identified during SWAT meetings would be reported to the Registered Dietitian (RD) for assessment. Residents considered at risk would be placed on the ongoing list by the DON/Designee and reviewed in the weekly SWAT meetings. 4. A Stop and Watch tool was incorporated to facilitate communication of changes in nutrition and hydration between the State Registered Nursing Assistant (SRNA) and the nurse. The floor nurse was responsible to address the concern by completion of necessary clinical assessments; documentation of the resident assessment; and notification of the Medical Director, Resident Representative, and Registered Dietitian (RD). 5. Monitoring of ten (10) residents weekly for four (4) weeks was initiated on 05/21/2021 by the DON/Designee to ensure Change in Condition related to decreased meal consumption or fluid intake from the prior week was identified and addressed per facility policy. 6. The DON/Designee presented audit findings to the Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns identified through audits. A Regional Office member would attend the weekly QAPI meetings in person or remotely until compliance was achieved. 7. On 05/24/2021, the RD completed a medical record review of all facility residents and created a list of residents considered at risk for hydration and/or nutrition decline. The RD determined the estimated hydration and nutritional needs for each resident considered to be at risk. The Minimum Data Set nurse updated the residents' comprehensive care plan as well as the SRNA Kardex to include resident specific needs when identified. 8. On 05/24/2021, the RD completed a medical record review of all new admissions, readmissions, and residents that experienced a significant change in condition to determine the residents' required nutritional and hydration needs and reported the at-risk residents to SWAT. 9. The DON/Designee reviewed nutrition and fluid intake data daily for residents identified at risk during CQI meetings Monday through Friday to ensure residents were meeting their daily-required needs. 10. Fluid intake and meal consumption was reviewed Monday through Friday during CQI meetings by the DON/Designee of residents identified to be at nutritional/hydration risk to ensure the residents were meeting their fluids and/or nutrition requirements as set by the RD and the residents' comprehensive care plan. 11. The DON/Designee began monitoring on 05/24/2021, 10 resident care plans for four (4) weeks to ensure the residents met their nutrition and fluid requirements, and thereafter three (3) residents weekly for three (3) months to ensure continued compliance. 12. New admissions, readmissions, and/or residents who had a significant change of condition, for whom the RD determined to be at risk for nutrition and hydration were monitored by the DON/Designee weekly for three (3) months to ensure the RD's continued monitoring and to ensure at risk residents were identified. 13. Residents identified at risk for nutrition and/or fluid deficits and consumed less than their assessed fluid needs would be assessed for dehydration by the UM and/or ADON for intervention. 14. The daily CQI and morning meetings were attended by the Administrator with documented attendance. The Administrator was responsible for ensuring any noted change of condition, failure of an at risk resident to consume adequate fluids and nutrition, and development and implementation of care plans were identified and addressed immediately. This would continue for three (3) months and would be reviewed/validated weekly by a Regional team member to ensure identified concerns were acted upon timely. 15. The Administrator received 1:1 education from the Regional Director of Operations (RDO), on 05/21/2021, regarding morning meetings, CQI Meetings, Stand Down Meetings, Action Plans, QAPI Process, Weekly QAPI Meetings, and Plans of Correction. The Administrator was required to complete a pre-test and post-test to determine understanding with a 100% score required, failure to score 100% on tests resulted in further education and/or disciplinary action. 16. The Regional Director of Operations (RDO) reviewed daily Morning Meeting and CQI documentation by the Administrator beginning 05/21/2021 regarding monitoring for change of condition, nutrition and hydration intake deficits, care plan revisions weekly and would continue for three (3) months. 17. The RDO presented monitoring of the Administrator's documentation of Morning Meetings and CQI to the weekly QAPI meetings. Any concerns identified would be immediately addressed and if needed the RDO/Regional Team would complete an Action Plan. 18. The Administrator along with the Interdisciplinary Team (IDT) conducted monthly QAPI meeting beginning on 05/21/2021, per policy to discuss and review collected data related to: Quality Indicators, Consult Reports, and survey findings. Results that indicated a pattern of concern would be listed and an Action Plan or Performance Improvement Plan (PIP) would be written to address concerns and monitored weekly by the IDT until resolved. The RDO or other Regional Team Member attended monthly QAPI meeting and would continue to attend for six (6) months to ensure data was collected properly, reviewed, monitored, and followed until resolution. Any written Action Plan or Performance Improvement Plan (PIP) would be reviewed for appropriateness, accuracy and progression toward resolution. 19. On 05/21/2021, The RDO completed education with the IDT on the QAPI policy, the role of the Administrator and Department heads in the QAPI process, and the formulation of Action Plans and/or PIPs. The IDT completed pre-test and post-test to ensure understanding with a 100% score required, staff that did not score 100% received further education and/or disciplinary action. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on 05/26/2021, as alleged by the facility: 1. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they assessed all residents to ensure any resident, which experienced a change in condition related to nutrition and/or hydration was immediately addressed. This included performing the appropriate assessment, physician notification for orders, and revision of the resident's care plan. They revealed they did not identify any concerns. 2. Review of staff in-service records for 05/21/2021 through 05/24/2021, revealed nursing staff had received education on change in condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they provided education for licensed staff from 05/21/2021 through 05/24/2021. The education included change of condition, roles and responsibilities, physician notification regarding change of condition, care plan implementation and monitoring, nutrition/hydration consumption and documentation, monitoring for signs and symptoms of dehydration, and performing nutrition and/or hydration assessments. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22, on 06/03/2021 at 3:58 PM, SRNA #18, on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13, on 06/03/2021 at 2:28 PM, LPN #8, on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM revealed they received the above education to include a pre-test and post-test. 3. Review of the daily CQI meetings held Monday through Friday, revealed the DON, ADON, and UM monitored the progress notes for the previous 24 hours Tuesday through Friday and 72 hours on Monday to ensure any situation that constituted a Change in Condition was identified and addressed per facility protocol to include residents that consumed less than 50% of three (3) consecutive meals. Review of Sampled residents (Resident #19, Resident #26, and Resident #27) revealed their records were reviewed daily for change in condition related to nutrition and hydration and were placed on the SWAT list for further monitoring. No concerns were identified. 4. Interviews with SRNA #12, on 06/02/2021 at 1:59 PM, SRNA #22 on 06/03/2021 at 3:58 PM, SRNA #18 on 06/03/2021 at 4:30 PM, Licensed Practical Nurse (LPN) #13 on 06/03/2021 at 2:28 PM, LPN #8 on 06/03/2021 at 2:58 PM, and LPN #12, on 06/04/2021 at 11:32 AM, revealed they received education regarding the use of the Stop and Watch tool. They stated the tool was utilized when a SRNA observed a change in condition. Once completed, the SRNA utilized the tool to report the change in condition to the floor nurse and the floor nurse was then responsible for addressing the concern and completion of any required assessments, physician notification, Resident Representative notification, and RD notification. 5. Record review revealed the facility monitored ten (10) residents weekly and no concerns were identified with change of condition related to decreased meal consumption or fluid intake, nor physician notification. 6. Review of QAPI meeting documentation revealed the last weekly meeting was on 05/28/2021, with attendees, which included the Administrator, DON, and RDO. Per the meeting notes, there were no identified concerns. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she presented all audit findings weekly during the QAPI meetings. Interview with the RDO, on 06/04/2021 at 2:07 PM, revealed she attended the weekly QAPI meetings to ensure compliance with audits being performed. 7. Review of Sampled Resident #19, Resident #26, and Resident #27's medical records, revealed the RD performed a medical record review on 05/24/2021 at which time the residents who were identified at risk (related to nutrition and/or hydration) were placed on SWAT monitoring. In addition, their care plan was updated with interventions and the RD documented the residents' estimated nutritional and fluid needs. Review of the records revealed no concerns were identified. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she performed record reviews of all residents to determine their estimated nutritional and fluid needs. She stated she also reviewed records to ensure at risk residents were placed on SWAT for increased monitoring. Interview with the Minimum Data Set (MDS) Coordinator, on 06/04/2021 at 11:10 AM, revealed she revised the care plans of residents considered at risk by the RD to include appropriate interventions. 8. At the time of the review/survey there had not been any new resident admissions or re-admissions since the facility's alleged IJ removal date. Interview with the RD, on 06/04/2021 at 12:26 PM, revealed she would perform a medical record review of all new admissions, re-admissions, and residents who experienced a change in condition related to nutritional and/or hydration to determine the residents' estimated nutritional and fluid needs. She stated new admissions and re-admissions were placed on the SWAT list for four (4) weeks for monitoring and if the resident was stable at the end of the four (4) week period, they would be removed from the SWAT program. 9. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed resident nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs. 10. Review of the CQI meetings documentation and interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON, on 06/04/2021 at 2:29 PM, revealed they reviewed nutrition and fluid intake Monday through Friday of all residents considered at risk to ensure the residents were meeting their daily required nutritional and/or fluid needs, as well as ensuring the resident care plans addressed their needs. 11. Record review revealed the facility reviewed ten (10) resident records weekly and there were no identified concerns with change of condition related to decreased meal consumption and/or fluid intake. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the DON on 06/04/2021 at 2:29 PM, revealed they reviewed 10 resident records weekly to ensure their care plans were updated to address their nutritional and fluid requirements. 12. Review of daily monitoring revealed no new admissions or readmissions had occurred since the facility's alleged IJ removal date 05/26/2021. Review of Residents #19, Resident #26, and Resident #27's medical records revealed they were determined to be at risk and were discussed and monitored daily Monday through Friday. Interview with the DON, on 06/04/2021 at 2:29 PM, revealed she reviewed all at risk residents daily Monday through Friday to ensure the RD was monitoring residents nutritional and fluid intake. 13. Review of audits and medical records of Residents #19, Resident #26, and Resident #27, revealed the UM or ADON completed a dehydration assessment. Interviews with the UM, on 06/04/2021 at 12:46 PM, and the ADON, on 06/04/2021 at 11:41 AM, revealed they performed dehydration assessments on residents that consumed less than their nutritional and/or fluid needs to ensure the appropriate interventions were put into place. 14. Review of the daily CQI and morning meeting documentation revealed the Administrator was present at all meetings Monday through Friday. No concerns were identified. Interview with the Administrator, on 06/04/2021 at 3:04 PM, revealed he attended daily morning meetings and CQI meetings Monday through Friday. He stated he was responsible to ensure any noted change of condition, failure of an at-risk resident to consume adequate fluids and n [TRUNCATED]

Based on interview, record review, and a review of the facility policies, it was determined the facility failed to provide necessary care and services, in accordance with professional standards of practice and facility policy for (1) of five (5) sampled residents (Resident #11). The facility failed to assess Resident #11's pain to include location, frequency, what made it better or worse, etc. and failed to assess him/her when a change in condition was identified staring into space. Resident #11 was admitted to the hospital on 03/29/2021 with diagnoses that included Acute Renal Failure, Hyperkalemia, Pelvic Ring Fracture, Displaced Intertrochanteric Fracture of Left Femur, Severe Dehydration and Dementia. The findings include: Review of the facility policy Assessments, dated August 2017, revealed Nurses and other qualified health professionals would perform appropriate assessments of the resident when a change in condition or circumstances and/or an event took place that required assessment by a qualified medical professional. Review of the facility's policy, Charge in a Resident Condition, undated, revealed that a significant change in condition was a decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status; and required interdisciplinary review. Review of the facility's policy titled Management of Pain, undated, revealed the facility's mission was to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of the policy was to accomplish that mission through an effective pain management program, providing residents the means to receive necessary comfort. The policy stated upon readmission and change of resident condition, a Pain Assessment would be completed that measured the impact of pain on the resident's function, assessing the resident's physical condition, history, mental status, and activities of daily living. The assessment will cover the following areas: intensity, location, onset, type and frequency, description, change, treatment effect, and what makes it better or worse. The policy did not address assessing a resident's pain after readmission. The policy stated the nurse would complete a physical evaluation of the resident that included an objective observation of the painful area, but was not specific when the evaluation would be completed. Review of a hospital record for Resident #11 revealed prior to admission to the facility, the resident was evaluated in the Emergency Department (ED) on 02/06/2021 for leg pain. The resident suffered a fall at home, per Emergency Medical Services (EMS), and complained of left leg, left hip and left arm pain. Per EMS, the left leg was slightly shorter than the right, with slight bruising and swelling noted. According to the ED documentation, Resident #11 exhibited significant discomfort with attempts at range of motion of the left shoulder and had tenderness to palpitation. In addition, there was discomfort with range of motion of the left knee and left hip without gross deformity. An x-ray of the left humerus (upper arm bone) revealed a humeral neck fracture. However, an x-ray of the left femur and left knee revealed no acute fracture. In addition, review of a computerized tomography (CT) scan of the resident's pelvis revealed the resident had mild bilateral hip osteoarthritis, but no fracture or dislocation to the pelvis. According to the record, Resident #11 was stable and discharged to home. Review of a hospital record revealed on 02/09/2021, Resident #11 returned to the ED for complaints of shoulder pain. Per the physical exam, the musculoskeletal system was grossly intact with notable deformity about the left humeral head/shoulder region. The resident's skin was assessed to have a significant hematoma development and contusion surrounding the circumferential aspect of the left upper extremity extending down the hand, which was edematous (trace). The resident was negative for a blood clot and was discharged home. Review of the home health medical record for Resident #11, revealed the resident was admitted to home health services on 02/09/2021. On 02/10/2021 at 12:39 PM, an Occupational Therapy Evaluation Visit note revealed the Occupational Therapist (OT) was unable to stand or ambulate the resident because the resident required total assistance with transfers. Further review revealed Resident #11 required total assistance with wheelchair mobility and total assistance of three (3) people for bed mobility. Review of a pain assessment, revealed Resident #11 reported pain at a nine (9) out of ten (10) to the left upper extremity. Per OT documentation, she recommended swing bed rehabilitation or inpatient rehabilitation services due to the complexity of resident's medical issues secondary to the left Humerus Fracture (unable to bear weight to left upper extremity) and severe Osteoarthritis to bilateral knees. On 02/11/2021 at 12:42 PM, a Physical Therapy (PT) Evaluation Visit, revealed the resident required maximum assistance of one person for transfers with poor posture, balance, and safety; and buckling of bilateral knees. The PT also noted that Resident #11 would benefit from a short-term inpatient rehabilitation stay. The resident and family were agreeable to a referral for an inpatient rehabilitation facility. Review of a closed medical record for Resident #11 revealed the facility admitted the resident on 02/17/2021 with diagnoses that included Nondisplaced Fracture of Surgical Neck of Left Humerus, Type 2 Diabetes, Essential Hypertension, Heart Failure, Alzheimer ' s disease, Dementia, Bilateral Primary Osteoarthritis of Knee, Unspecified Pain, Depression, and Other Idiopathic Peripheral Autonomic Neuropathy. A review of Resident #11's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe impaired cognition. The resident was assessed to require assistance with bed mobility, transfers, dressing, toileting, and hygiene. According to the assessment, the facility identified the resident had fallen in the last month prior to admission and sustained a fracture. The assessment stated the resident had not sustained any falls at the facility. Further review of the assessment revealed the resident had frequent, moderate pain that made it hard to sleep and limited day-to-day activities. . Review of a hospital record for Resident #11 revealed the facility transferred the resident to the ED on 02/26/2021 at 11:05 AM, with a chief complaint of shoulder pain. Per the history and physical, the resident reported that he/she had right lower and left upper extremity pain. Review of the physical examination revealed the resident's musculoskeletal system was grossly intake, with no deformities. There was tenderness to palpitation in the right distal leg and right circumferential knee without obvious deformity or open injury. Furthermore, there was tenderness to the left shoulder. An x-ray of the right knee revealed osteoarthritis with a mild to moderate Suprapatellar effusion (Excessive accumulation of fluid in the knee joint that results in swelling, stiffness and pain in the knee). Resident #11 was observed to be stable/improved and was discharged back to the facility. On 03/09/2021, the facility transferred the resident to the hospital due to an increase in behaviors; however, the resident tested positive for COVID-19 and was transferred to the facility's, sister facility to a COVID-19 unit. Review of a transfer form revealed the resident was transferred back to the facility on [DATE], after 14 days of quarantine. Review of Resident #11's facility progress notes revealed the resident arrived back to the facility, at 1:13 PM on 03/23/2021. Further review revealed Resident #11 rated his/her pain at zero (0) on a scale of zero (0) to ten (10) with zero (0) being no pain and ten (10) being the worst pain you can imagine. Continued review revealed Resident #11 was oriented to self and verbally responsive to care. Further review of the medical record revealed Resident #11 sustained a fall, on 03/23/2021 at 5:55 PM, approximately six (6) hours after readmission. The Situation Background Assessment Recommendation (SBAR) Change in Condition form, revealed Resident #11 yelled for help. The nurse entered the room where she found Resident #11 lying on the floor and urine was on the floor. According to the form, there was no indication of injury. However, continued review of Resident #11's medical record revealed, at 6:19 PM on 03/23/2021, approximately 24 minutes later, Resident #11 was yelling in pain. Staff documented that the resident's pain was a five (5). Further review revealed pain medication was administered that was ordered for shoulder pain; however, review of the record revealed no documented evidence that staff assessed the resident to identify the location, frequency, etc. of Resident #11's pain and there was no documented evidence a Pain Assessment was completed upon readmission as required by the facility's policy. Interview with Registered Nurse (RN) #3, on 05/03/2021 at 4:19 PM, revealed she worked at the facility on 03/23/2021. She stated she worked for an agency and only worked at the facility one (1) or two (2) days. She stated she did not remember anything about Resident #11 or the resident's fall. Further review revealed Registered Nurse (RN) #2 completed a Pain Interview for the resident, on 03/24/2021 at 4:32 AM. According to the form, staff were required to complete the form sections A-D, if the resident could communicate appropriately, if not, staff were instructed to skip to section E. Review of the form revealed staff interviewed the resident (A-D) and the resident stated he/she had not had pain in the last five (5) days; subsequently, pain frequency, effect on function, and pain intensity were not assessed. However, there was no evidence found to indicate the RN conducted any type of assessment to ensure the resident's cognitive status was intact and the information the resident gave was reliable. Further, because the RN believed the resident could communicate appropriately, she did not assess indicators of pain or possible pain, frequency, nor the resident's pain management. Interview with RN #2, on 04/28/2021 at 1:01 PM, revealed she completed Resident #11's Pain Interview on 03/24/2021. She stated she asked the resident if he/she had pain and the resident stated, No. She stated if a resident stated they had no pain, she had to document no pain. She stated the assessment was completed on night shift and the resident was in bed; however, stated she assessed the resident's range of motion. According to the RN, even though the resident had a fractured arm, the resident voiced no pain when she assessed the resident's range of motion in that extremity. Further review of Resident #11's medical record revealed RN #4 documented that the resident experienced pain on 03/25/2021 at 10:21 PM, with a rating of four (4) and administered Norco 7.5/325 mg tablet. On 03/26/2021 at 8:13 PM, LPN #7 documented the resident had pain with rating of five (5) and also administered Norco. Further review revealed LPN #7 gave the resident Tylenol on 03/27/2021 at 5:24 PM, due to a pain rating of three (3). On 03/28/2021 at 12:07 AM, LPN #10 administered Norco due to a pain rating of four (4) and documented the resident yells out repeatedly. According to documentation, the pain medication for all dates was effective; however, there was no documented evidence the facility assessed the resident to identify the location, frequency, etc. of Resident #11's pain. Interview with RN #4, on 04/28/2021 at 2:09 PM, revealed she provided care for Resident #11 on 03/25/2021 and 03/27/2021. She stated the resident was miserable. RN #4 stated the resident did yell a lot and required pain medication. However, she was unable to recall if Resident #11 told her where he/she was having pain. Further interview with RN #4 revealed she had been taught as a nurse to document the location, frequency, duration and any alleviating interventions related to assessing pain to ensure the patient/resident received quality care and in an attempt to relieve the pain for the patient/resident. However, RN #2 stated she could not say why she had not done this when assessing Resident #11. Interview with Licensed Practical Nurse (LPN) #7, on 04/26/2021 at 3:20 PM, and on 04/29/2021 at 10:30 AM and 6:38 PM, revealed she provided care for Resident #11, on 03/26/2021 and 03/27/2021. She stated the resident cried out in pain prior to being transferred to the hospital/sister facility. The LPN stated once the resident was readmitted , the resident continued to yell for his/her spouse and said, Help Me. She stated she would attempt to redirect the resident; however, he/she continued to yell. According to LPN #7, the resident replied No when asked if the resident had pain. However, there was no documentation that the LPN assessed the resident when he/she called out/yelled. Continued interview with LPN #7 revealed, that although the resident replied no when asked about pain, the RN stated the best standard of practice would have been to conduct an assessment of the resident due to the resident yelling out Help me and displaying non-verbal signs/symptoms of pain. Interviews were attempted with LPN #10, on 5/15/2021 at 9 PM, and on 05/23/2021 at 7:35 PM. Voicemails were left for the LPN; however, attempts to reach her were unsuccessful. Interview with State Registered Nurse Aide (SRNA) #13, on 04/26/2021 at 5:22 PM, revealed he provided care for Resident #11, on 03/25/2021 and 03/28/2021. He revealed on 03/28/2021, he noticed that the resident was quiet, rested a lot and did not call out like [he/she] usually did. Interview with SRNA #17, on 04/27/2021 at 3:59 PM, revealed she provided care for Resident #11, on 03/27/2021 and 03/28/2021. She stated the resident would scream and holler a lot. She stated when the resident received medication; it would help calm the resident down some but not much. However, the resident screamed most of the time. Interview with SRNA #21, on 04/28/21 at 12:11 PM and 04/29/2021 at 1:34 PM, revealed she provided care for Resident #11, on 03/27/2021 and 03/28/2021. She stated that she noticed that the resident just stared at you and didn't holler much. Interview with the Physical Therapist, on 04/30/2021 at 10:22 AM, revealed on the morning of 03/29/2021, she entered Resident #11 room after hearing him/her yelling out. She entered the room and identified a big change in the resident's status. She found the resident with pocketed food in his/her mouth. She stated the resident was alone with his/her food tray in front of him/her and she had to manually clear the food from the resident's mouth. She further revealed that the resident had a fixated stare. A review of a Change in Condition Evaluation, completed on 03/29/2021 at 9:15 AM, revealed Resident #11 was assessed to have a Neurological Change and Resident #11 needed more assistance with activities of daily living (ADL's), had decreased mobility and swallowing difficulty. The evaluation stated that Resident #11 was unable to swallow and holds food in mouth or move arms or squeeze nurse hand. Review of progress notes revealed Resident #11 was transferred to emergency room for evaluation and treatment at 9:30 AM. A review of the Hospital Admission History and Physical on 03/29/2021 revealed Resident #11 was admitted with diagnoses that include Acute Renal Failure, Hyperkalemia, Pelvic Ring Fracture, Displaced Intertrochanteric Fracture of Left Femur (hip area) and Dementia. A review of the computerized tomography (CT) scan on 03/29/2021, revealed findings to include comminuted intertrochanteric left femur fracture with superior displacement of the distal fragments (bone fragments), left superior and inferior pubic [NAME] fractures (pelvis), and a comminuted left sacral fracture (tailbone). Interview with the Director of Nursing (DON) on 04/29/2021 at 4:23 PM, revealed she felt Resident #11 sustained the fractures at home before he/she was admitted to the facility and the hospital didn't catch when [he/she] was there before. She stated the resident had uncontrolled pain and EMS stated his/her left leg was shorter than the other (x-rays and CT scan showed no fractures prior to admission). According to the DON, she felt the facility had done everything they could to assess and control Resident #11's pain. Review of the facility's investigation of Resident #11's injuries revealed the facility concluded that the resident's injuries did not occur at the facility and possibly occurred prior to admission to the facility or during transfer to the hospital ED on 03/29/2021. There was no documented evidence that the facility Administrator identified any concerns with the facility's assessments, or lack thereof, or issues with Resident #11's pain. However, interview with Medical Doctor #3 (Radiologist), on 04/28/2021 at 3:50 PM, revealed the fractures from the CT scan on 03/29/2021, for Resident #11 appeared to be acute fractures. Interview with Medical Doctor (MD) #2 (Emergency Department Physician), on 04/28/2021 at 3:10 PM, revealed he had seen Resident #11 multiple times over the last few months. However, when Resident #11 was brought to the ED on 03/29/2021, he did not even recognize the resident until after visit. Continued interview revealed the resident was dramatically different and kept saying, Help me, help me. He stated the resident's fractures were not accounted for, no one knew what happened. He further stated the resident was sent to the ED with neurological changes, but after the resident's labs showed severe dehydration, he ordered a CT scan of his/her abdomen to see if the resident had an ischemic (dead) bowel and that was how they found the fractures. The MD stated the resident had acute fractures, was in renal failure and severe pain. The ED physician stated it did not appear Resident #11 had received much care at all in the facility and the care he/she did receive could not have been of good quality. The ED physician stated he called law enforcement because in sixteen (16) years as an ED physician, this resident's condition sent up red flags and he thought this needed an investigation. On 05/19/2021 at 4:53 PM, interview with the Administrator revealed, he was responsible for the day-to-day operations of the facility and the quality care that was provided to residents. The Administrator stated he relied on nursing management staff to ensure resident care needs were met. The Administrator revealed he had not identified any care concerns.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately inform the physician when a significant change in condition occurred for one (1) of six (6) sampled residents (Resident #1). On [DATE], at approximately 11:30 PM, Resident #1 complained of chest pain to State Registered Nursing Assistants (SRNA) and the resident was yelling out Lord help me. The SRNAs reported the change in Resident #1's condition to the nurse, but stated they did not see the nurse assess the resident. Continued interviews with the SRNAs revealed the resident continued to complain of chest pain until approximately 12:30 AM. Interview with the nurse revealed staff reported Resident #1's complaints of chest pain and she obtained the resident's vital signs at approximately 1:00 AM. However, the nurse failed to notify the resident's physician of the resident's chest pain and change in condition. At approximately 5:00 AM, on [DATE], SRNAs found Resident #1 pale and cold from the chest up without a pulse or signs of life. Resident #1 was pronounced deceased at the facility on [DATE] at 5:30 AM. The facility's failure to ensure residents physician was immediately notified when a change in condition occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was not removed until [DATE], prior to exit on [DATE], which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684) , while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Change in a Resident Condition, undated, revealed staff would notify the resident's physician and representative of significant changes in the resident's medical, mental or psychological status. Further review of the policy revealed a significant change in condition was a decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status; and required interdisciplinary review and/or revision of the care plan. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Essential Hypertension, Heart Failure, Gastroesophageal Reflux Disease, Anxiety, Pain and Shortness of Breath. Review of Resident's #1 Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. The facility assessed the resident to require limited assistance of two (2) staff members with bed mobility and one (1) staff member with transfers and toileting. The facility further assessed that Resident #1 was able to make self-understood and understand others. Review of Resident #1's Care Plan, dated [DATE], with last review date of [DATE], revealed the staff identified the resident had concerns related to his/her respiratory status. The care plan revealed staff were to observe for signs/symptoms of impaired respiratory status and document/report to physician. Further review revealed the staff identified the resident has concerns related to his/her cardiac status. The care plan revealed staff were to observe/document/report, as needed to physician any signs/symptoms of difficulty breathing (dyspnea). Interview with Registered Nurse (RN) #1, on [DATE] at 1:05 PM, revealed she had cared for Resident #1, on [DATE] from 7:00 AM until 3:00 PM. The RN stated Resident #1 had never complained of chest pain to her and she noticed to no change in the resident's condition, on [DATE] during the day shift. Interview SRNA #3, on [DATE] at 3:55 PM, revealed she had cared for Resident #1 the evening of [DATE] from 3:00 PM until 11:00 PM. She revealed that she did not identify anything abnormal with Resident #1 on her shift or remember the resident having any complaints of chest pain. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 3:40 PM, revealed he had cared for Resident #1 the evening of [DATE] until 9:00 PM. He revealed that he did not identify anything abnormal or any change in the resident's condition during his shift. The LPN further stated Resident #1 did not have complaints of chest pain during his shift on [DATE]. On [DATE] at 1:35 PM, interview with SRNA #1, revealed she had cared for Resident #1 on the night of [DATE]. The SRNA stated she came on shift at approximately 11:00 PM on [DATE] and at approximately 11:30 PM - 12:00 AM, Resident #1 utilized his/her call light. Upon entering the room, Resident #1 complained of chest pain to SRNA #1. Per the SRNA, she immediately notified LPN #1 of the resident's complaint. The SRNA stated LPN #1 instructed her to give Resident #1 a drink of water. SRNA #1 stated she re-entered Resident #1's room and provided her with a drink of water. However, approximately 15 minutes later, Resident #1 utilized his/her call bell again, and SRNA #2 answered the call bell. SRNA #1 stated she was unaware if LPN #1 entered Resident #1's room following the report of Resident #1's chest pain. At approximately 12:30 AM to 1:00 AM, SRNA #1 entered Resident #1 room to provide resident with company to calm the resident. The SRNA stated at that time the resident did not complain of chest pain. On [DATE] at 2:10 PM, interview with SRNA #2, revealed she had cared for Resident #1 on the night of [DATE]. She stated she started her shift, at approximately 10:30 PM on [DATE]. The SRNA stated around 12:30 AM on [DATE], Resident #1 utilized the call light and when she entered the room, Resident #1 complained of chest pain. Per the SRNA, Resident #1 had history of frequent complaints regarding about difficulty breathing and generalized pain; however, she felt that night was different and to her knowledge the resident had not previously complained of chest pain. The SRNA stated the resident was yelling out. The SRNA stated she notified LPN #1 of the resident's complaint of chest pain and status, and LPN #1 instructed her to provide Resident #1 with a drink of water. SRNA #2 stated she declined to give Resident #1 a drink of water and informed LPN #1 that she needed to assess the resident. SRNA #2 revealed that she was unaware if LPN #1 entered Resident #1's room following the report. She further revealed that she completed rounds at approximately 1:30 AM and 3:00 AM and had identified that Resident #1 was breathing; however, did not awaken him/her. At approximately, 5:00 AM on [DATE] SRNA #2 entered the room to find Resident #1 not breathing and stated he/she was already gone. She stated that she proceeded to notify LPN #1 who then entered Resident #'1 room. On [DATE] at 7:50 AM, interview with Patient Care Assistant (PCA) #1, revealed she began her shift on [DATE] and worked from 11:00 PM to 7:00 AM on [DATE]. The PCA stated she observed Resident #1 yelling (hollering) out in distress (i.e. Lord help me, Jesus help me). Per the PCA, she witnessed both SRNA #1 and SRNA #2 notify LPN #1 of Resident #1 complaints of chest pain. However, was unable to recall time of occurrence. On [DATE] at 2:55 PM, Interview with LPN #1, revealed she cared for Resident #1 on [DATE] at 11:00 PM. LPN #1 stated she made an observation of Resident #1 from the hallway at the beginning of her shift, approximately 11:00 PM. Further, LPN #1 revealed around 1:00 AM on [DATE], SRNA #2 notified her that Resident #1 was complaining of chest pain. The LPN stated she entered Resident #1's room and obtained vitals which were temperature of 98.0 degrees, heart rate of 80 beat per minute, 98.0% oxygen saturation, ,d+[DATE] blood pressure and 20 respirations per minute. The LPN stated, Resident #1 had a history of yelling out can't breathe or chest hurts nightly or every other night. The LPN stated Resident #1 complained of chest pain at 1:00 AM. LPN #1 revealed that she provided the resident with a drink of water as he/she would only drink a limited amount of water with medication and felt that could be the reason behind the complaints of chest pain. The LPN stated Resident #1 calmed down after she provided the resident with a drink. LPN #1 further stated Resident #1 preferred staff to be routinely in the room because he/she was lonely. Per the LPN, she felt the resident just needed company and had a history of multiple complaints regarding breathing; therefore, she did not identify the chest pain as a change of condition. The LPN stated she did not notify Resident #1's physician regarding the chest pain. She further revealed that the resident stated the chest pain was now better after the drink of water. LPN #1 exited the room and did not enter or observe Resident #1 again until approximately 5:00 AM when SRNA #2 reported to her the resident was not breathing. The LPN stated upon entering the room, Resident #1 had a white chest from middle of chest upward toward head. She revealed that the resident was warm from the chest down with no pulse. The LPN stated she instructed SRNA #2 to notify RN #2 who was on another unit. Per the LPN, RN #2 assessed Resident #1 and identified no pulse, no respirations or no blood pressure. On [DATE] at 8:10 AM, interview with RN #2, revealed she was on duty the night of [DATE]; however, was not caring for Resident #1. The RN stated on [DATE] at approximately 5:00 AM, SRNA #2 alerted her to the status of Resident #1. Upon entering the room of Resident #1, LPN #1 was at the resident bedside along with SRNA #1 and SRNA #2. RN #2 stated that she obtained vital signs on Resident #1 and concluded Resident #1 had no pulse, respirations or blood pressure. Further review of the medical record for the evening of [DATE] until the morning of [DATE], revealed no documented evidence facility staff contacted the resident's physician when Resident #1 experienced a change in condition until 5:30 AM on [DATE], when the resident was assessed without signs of life and was pronounced deceased . The record contained no mention of the resident's complaints of chest pain. On [DATE] at 5:40 PM, interview with Physician #1, revealed he expected staff to inform him when a change in a resident's condition occurred. The physician revealed he expected the facility to notify him when Resident #1 complained of chest pain. Physician #1 stated chest pain was not normal for Resident #1. The Physician stated Resident #1 had routine complaints of difficulty with breathing related to his/her disease process. Physician #1 stated that in his opinion the cause of death for Resident #1 was Pulmonary Embolism or Myocardial Infarction. He further revealed he came to this conclusion based on sudden death associated with the resident's complaints of chest pain. On [DATE] at 3:00 PM, interview with Director of Nursing (DON), revealed she expected staff to notify the physician when a change in a resident's condition occurred. She further stated staff should have notified the physician when Resident #1 initially complained of chest pain. On [DATE] at 3:55 PM, interview with Administrator, revealed he expected staff to notify the physician when a change in a resident's condition occurred. He further stated staff should have notified the physician when Resident #1 reported complaints of chest pain. **The facility implemented the following actions to remove Immediate Jeopardy: 1). All residents were assessed by the DON between [DATE] to [DATE] to ensure each resident had a current (within 30 days) pain assessment with appropriate interventions in place. 2). All resident were assessed by the DON between [DATE] to [DATE] to ensure each resident Change of Condition had been identified if applicable. 3). All resident had physical assessments completed between [DATE] to [DATE] by nurses on shift to address any immediate concerns. 4). Nursing staff were in-serviced on [DATE] by the Director of Nursing regarding pain management, pain assessments, pain interventions, change of condition and roles and responsibilities and physician notification regarding change of condition. 5). In-service education was completed with State Registered Nurse Aide (SRNA) #2 to address change of condition notification procedures in the event the available nurse is not able to immediately address the needs of the resident. 6). Monitoring of ten (10) residents weekly to ensure that their pain needs are being met for four (4) weeks began on [DATE] by the DON/ADON/Designee. 7). Monitoring of three (3) resident weekly for three (3) months following the four weeks beginning on [DATE]. 8). Beginning on [DATE] to [DATE], five (5) nursing staff, three (3) management staff employees and ten (10) residents will be interviewed daily regarding resident pain and change in condition. If staff were not able to interview a resident was, then nursing staff would assess for pain and change in condition. In addition, concerns will be reported to the DON and physician as required. However, concerns (Resident #13 and #14's complaints of pain and Resident #15's change in condition) identified during the audits on [DATE], on [DATE] and on [DATE] were not addressed by the Administrator as directed in the AOC. Also, review of monitoring revealed no evidence of completion of the audits as per the AOC on [DATE] and [DATE]. In correction of Administrator failure to report change of condition and pain to nursing staff on [DATE], [DATE] and [DATE] and failure to complete interviews on [DATE]-[DATE], the facility implemented the following actions (A-G): A). Interview with all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were conducted by Social Services on [DATE] regarding pain and change of condition. One concern was noted with pain however, had previously been addressed by nursing staff. B). All residents with BIMS score of below eight (8) were assessed for pain and change of condition on [DATE]. No concerns were identified. C). Education was provided to the Administrator by Regional Director of Operation (RDO), on [DATE]-[DATE], regarding expectations of writing and following actions of an Allegation of Compliance. Further education was completed with the Administrator on [DATE] regarding Clinical Follow Ups, Interview Procedures, Documentation Procedures, DON/ Regional Director of Operation (RDO) reporting, Clinical Assessment as Administrator, Change of Condition Observation and Reporting, Auditing Procedures and Change of Condition follow up. D). Resident #13 was assessed for pain on [DATE] and was interviewed by facility staff and revealed that he/she was referring to the complaints of chest pain on [DATE], which was addressed by nursing staff on [DATE]. E). Resident #14 was assessed for pain on [DATE] and revealed no pain and denied need for pain medication. The resident was repositioned with no need for further intervention. Resident #14 was further assessed for pain on [DATE] with no identified concerns. F). Resident #15 was assessed for tremor on [DATE] which was unremarkable. Staff placed Resident #15 on 72 hour charting for monitoring of tremor. Further, Resident #15 physician was notified with no further orders. G). The Interdisciplinary Team (IDT) reviewed of all audits completed by Administrator on [DATE]-[DATE] to ensure all concerns were addressed. 9). The DON/ADON/ Designee monitors all Changes of Condition in the morning meeting for the previous 24 hours (72 hours on Monday). 10). Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns regarding auditing. 11). Monthly QAPI meetings to include the audits completed in the allegation of compliance. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on [DATE], as alleged by the facility: 1). Interview with the DON, on [DATE] at 4:10 PM, revealed she assessed all residents to ensure each resident had a current pain assessment with appropriate interventions in place. She revealed that she did not identify any concerns. Review of census on [DATE], [DATE] and [DATE] revealed all residents in the facility between [DATE] and [DATE] had a pain assessment completed with interventions in place to aide in pain management. 2). Interview with the DON, on [DATE] at 2:41 PM, revealed she assessed all residents between [DATE] and [DATE], for change in condition and had not identified any change of condition that was not addressed by nursing staff. Record review revealed all residents residing in the facility between [DATE] and [DATE] were assessed for change in condition. 3). Sampled residents (Resident #3, #4, #5, #7, #8, #9 and #10) were reviewed for physical assessment. No concerns were identified. 4). Interview with the DON, on [DATE] at 4:10 PM, revealed she had provided education for staff and utilized question and answer for evidence of comprehension of training. Further interview with the DON revealed she utilized scenarios for examples and completed verbal education with staff as needed for any additional concerns. Interview on [DATE] at 5:50 PM, with LPN #9, on [DATE] with SRNA #8 at 6:05 PM, SRNA #10 at 1:30 PM, LPN #6 at 2:00 PM, LPN #7 at 2:55 PM, LPN #8 at 5:00 PM, LPN #10 at 4:30 PM, and on [DATE] at 3:05 PM with SRNA #9, revealed staff were re-educated on pain management, change of condition and physician notification. Review of staff in-service records for [DATE], revealed nursing staff had received education on pain management, change in condition and physician notification. 5). Interview with the DON, on [DATE] at 4:10 PM, revealed she had completed education with SRNA #2 and had the SRNA verbalize comprehension. Interview with SRNA #2, on [DATE] at 2:45 PM, revealed she was re-educated on change of condition, resident pain and who to notify in the chain of command. 6). Review of 10 residents monitoring weekly for four (4) weeks revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON on [DATE] at 2:41 PM revealed she reviews all pain assessments, change of condition and physician notification on all residents including the 10 sampled residents during each morning meeting. 7). Review of Week one from [DATE]-[DATE] and Week two from [DATE]-[DATE] (of the weekly monitoring) for three (3) months revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON, on [DATE] at 4:10 PM, revealed she had reviewed the monitoring for the above during morning meetings. She further revealed she had identified that Resident #13 had complaints of chest pain on [DATE]; however, her review revealed that appropriate actions were completed including assessment, physician notification and monitoring per physician order. She revealed no further concerns had been identified. 8). Review of interviews of five (5) nursing staff, three (3) management staff employees and ten (10) residents revealed on [DATE] a staff member had reported to the Administrator that Resident #15 had a change in condition (shaking more than usual) and on [DATE], three therapist had reported the same change in condition to the Administrator. Continued review of the audits revealed on [DATE], Resident #14 had voiced complaints of pain and on [DATE], Resident #13 voiced complaints of chest pain last night. The Administrator was aware of the complaints but failed to ensure the complaints were addressed and reported to the DON/physician as required by the AOC. Further review of the Audits revealed no evidence the audits were completed on [DATE] and [DATE]. A). Review of the resident interviews for all residents with a BIMS score greater than eight (8) or greater revealed the interviews were completed on [DATE] with one identified concern. Record review revealed nursing staff had already addressed the voiced concern. Interview with Social Services, on [DATE] at 12:05 PM, Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all individuals with a BIMS score of eight (8) or greater were interviewed regarding pain, change of condition and needs being met with one voiced concern that had already previously been addressed. B). Record review revealed all residents with BIMS score of below eight (8) were assessed by nursing staff [DATE] with no concerns identified. Interview with Assistant Director of Nursing (ADON), on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all residents with BIMS score of below eight (8) were assessed by nursing staff for any pain or change of condition with no identified concerns. C) Interview of Administrator, on [DATE] at 2:35 PM, revealed he had received education on [DATE] and re-educated on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-up with Nursing, etc. He further revealed that all the audits he had completed had been reviewed by the RDO and DON. Interview with RDO on [DATE] at 10:49 AM, revealed she had provided re-education to Administrator on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-Up with Nursing, etc. D) Interview with Resident #13, on [DATE] at 4:15 PM, revealed the resident has had chest pain and when staff is notified they contact the physician. Resident #13 further revealed that he/she had chest pain the other night, staff notified the physician and he/she received medication which resolved the chest pain. Interview with LPN, #10, on [DATE] at 4:30 PM, revealed that Resident #13 had not complained of chest pain on her shift 11:00 PM on [DATE] to 7:00 AM on [DATE]. Review of medical record for Resident #13 revealed he/she voiced chest pain on [DATE], no concerns were identified with assessment, change of condition and/or physician notification. E) Review of assessment of Resident #14 completed on [DATE] revealed no identified concerns regarding unmet pain needs or change of condition. F) Review of assessment on Resident #15 completed on [DATE] revealed no identified tremor. Further review revealed resident physician was notified with no new orders. G) Review of documentation related to audit review of [DATE]-[DATE] audits revealed no additional unmet concerns. Interview with RDO, on [DATE] at 10:07 AM, and DON on [DATE] at 2:41, PM revealed all audits on [DATE]-[DATE] were reviewed for any outstanding change of conditions with no further concerns identified. 9). Interview with Social Services, on [DATE] at 12:05 PM, revealed that during the morning clinical meeting the 24-hour report was reviewed. During the meeting, the team discuss pain assessments, change of condition, etc. She further revealed that all items are placed on a follow up list, which will be reviewed at the evening meeting. Interview with Director of Nursing, on [DATE] at 4:10 PM, revealed that during the morning clinical meeting the 24 hour report was reviewed and the team discussed resident pain assessments, change of condition, significant decline, etc. She further revealed that all items were reviewed and followed up on as indicated. 10). Review of QAPI meeting documentation revealed the last weekly meeting was on [DATE], with attendees that included the Administrator and Director of Nursing. Per the meeting notes, there were no identified concerns. Interview with Administrator, on [DATE] at 2:35 PM, revealed the audits he completed during the past week had not been brought to QAPI committee yet as the next meeting was scheduled for [DATE]. 11). Interview with Administrator, on [DATE] at 2:35 PM, revealed the monthly QAPI meeting was scheduled for [DATE]. However, the meeting had not been held yet. He further stated that during the meeting, the committee would discuss all audit results and any other items scheduled for review.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one of six residents (Resident #1) had a person-centered comprehensive care plan with interventions developed and implemented related to complaints of chest pain. In addition, the facility failed to ensure that four (4) of six (6) Residents (Resident #2, Resident #3, Resident #4, and Resident #5) had a person-centered comprehensive care plan developed and implemented related to monitoring hydration status. On [DATE], at approximately 11:30 PM, Resident #1 complained of chest pain to State Registered Nursing Assistants (SRNA) and the resident was yelling out Lord help me. The SRNAs reported the change in Resident #1's condition to the nurse. Continued interviews with the SRNAs revealed the resident continued to complain of chest pain until approximately 12:30 AM. Interview with the nurse revealed staff reported Resident #1's complaints of chest pain and she obtained the resident's vital signs at approximately 1:00 AM. Review of the resident's plan of care revealed staff were to notify the resident's physician for complaint of substernal chest pain. However, the nurse failed to notify the resident's physician of the resident's chest pain as directed in the plan of care. At approximately 5:00 AM, on [DATE], SRNAs found Resident #1 pale and cold from the chest up without a pulse or signs of life. Resident #1 was pronounced deceased at the facility on [DATE] at 5:30 AM. The facility's failure to implement the resident's plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was not removed until [DATE], prior to exit on [DATE], which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, updated [DATE], revealed the care plan would include resident's risks, goals and intervention using Person-Centered plan of care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical function, mental an psychosocial needs. Interview on [DATE] at 4:10 PM, with the Director of Nursing (DON), revealed the goal intake for all residents was 1500 milliliters (ml) per day unless contradicted. She further revealed the nursing staff should be monitoring for signs and symptoms of dehydration daily throughout each shift. 1). Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Essential Hypertension, Heart Failure, Gastroesophageal Reflux Disease, Anxiety, Pain and Shortness of Breath. Review of Resident's #1 Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. The facility further assessed that Resident #1 was able to make self-understood and understand others. Review of Resident #1's Care Plan, dated [DATE], with last review date of [DATE], revealed the staff identified the resident had concerns related to his/her diagnosis of Gastroesophageal Reflux Disease. The care plan revealed staff were to observe for signs/symptoms of Gastroesophageal Reflux Disease including substernal chest pain, belching, coughing/choking when lying down, heart burn, dyspepsia, nausea/vomiting, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia and increased gag response. In addition, the care plan directed staff to document and report to physician. On [DATE] at 1:35 PM, interview with SRNA #1, revealed at approximately 11:30 PM - 12:00 AM, Resident #1 utilized his/her call light and complained of chest pain. The SRNA stated she immediately notified LPN #1 of the resident's complaint. SRNA #1 revealed LPN #1 instructed her to give Resident #1 a drink of water. SRNA #1 stated she provided Resident #1's a drink of water. However, approximately 15 minutes later, Resident #1 utilized his/her call bell again, and SRNA #2 answered the call bell. SRNA #1 stated she was unaware if LPN #1 entered Resident's #1's room following the report of Resident #1's chest pain. On [DATE] at 2:10 PM, interview with SRNA #2, revealed around 12:30 AM on [DATE], Resident #1 utilized his/her call light and when she entered the room, Resident #1 complained of chest pain. Per the SRNA, Resident #1 had history of frequent complaints regarding his/her breathing status and generalized pain; however, she felt that night was different and to her knowledge the resident had not previously complained of chest pain. The SRNA stated the resident was yelling out and she notified LPN #1 of the resident's complaint of chest pain and current status. She stated LPN #1 instructed her to provide Resident #1 with a drink of water. However, she declined to give Resident #1 a drink of water and informed LPN #1 that she needed to assess the resident. SRNA #2 revealed she was unaware if LPN #1 entered Resident #1's room following the report. She further revealed that she completed rounds at approximately 1:30 AM and 3:00 AM and had identified that Resident #1 was breathing; however, did not awaken him/her. At approximately, 5:00 AM on [DATE] SRNA #2 entered the room to find Resident #1 not breathing and stated he/she was already gone. She stated that she proceeded to notify LPN #1 who then entered Resident #'1 room. On [DATE] at 7:50 AM, interview with Patient Care Assistant (PCA) #1, revealed she began her shift on [DATE] and worked from 11:00 PM to 7:00 AM on [DATE]. The PCA stated she observed Resident #1 yelling (hollering) out in distress (i.e. Lord help me, Jesus help me). Per the PCA, she witnessed both SRNA #1 and SRNA #2 notify LPN #1 of Resident #1 complaints of chest pain. However, was unable to recall time of occurrence. On [DATE] at 2:55 PM, Interview with LPN #1, revealed she cared for Resident #1 on [DATE] at 11:00 PM. LPN #1 stated at approximately 11:00 PM, she made an observation of Resident #1 from the hallway. LPN #1 stated around 1:00 AM on [DATE], SRNA #2 notified her that Resident #1 was complaining of chest pain. The LPN stated she entered Resident #1's room and obtained vitals which were temperature of 98.0 degrees, heart rate of 80 beat per minute, 98.0% oxygen saturation, ,d+[DATE] blood pressure and 20 respirations per minute. The LPN stated, Resident #1 had a history of yelling out can't breathe or chest hurts nightly or every other night. LPN #1 revealed she provided the resident with a drink of water as he/she would only drink a limited amount of water with medication and felt that could be the reason behind the complaints of chest pain. The LPN stated Resident #1 calmed down after she provided the resident with a drink. The LPN stated she did not notify Resident #1's physician regarding the chest pain. LPN #1 exited the room and did not enter or observe Resident #1 until approximately 5:00 AM when SRNA #2 reported the resident was not breathing. Upon entering the room, Resident #1 was noted to have a white chest from middle of chest upward toward head. She revealed that the resident was warm from the chest down with no pulse. The LPN stated she instructed SRNA #2 to notify RN #2 who was assigned to other unit. Per the LPN, RN #2 assessed Resident #1 and identified no pulse, no respirations or no blood pressure. On [DATE] at 8:10 AM, interview with RN #2, revealed she was on duty the night of [DATE]; however, was not caring for Resident #1. The RN stated on [DATE] at approximately 5:00 AM, SRNA #2 alerted her to the status of Resident #1. Upon entering the room of Resident #1, LPN #1 was at the resident bedside along with SRNA #1 and SRNA #2. RN #2 stated that she obtained vital signs on Resident #1 and concluded Resident #1 had no pulse, respirations or blood pressure. Further review of the medical record for the evening of [DATE] until the morning of [DATE], revealed no documented evidence facility staff contacted the resident's physician when Resident #1 experienced chest pain as directed in the plan of care. On [DATE] at 5:40 PM, interview with Physician #1, revealed he expected staff to inform him when a change in a resident's condition occurred. The physician revealed he expected the facility to notify him when Resident #1 complained of chest pain. Physician #1 stated chest pain was not normal for Resident #1. The Physician stated Resident #1 had routine complaints of difficulty with breathing related to his/her disease process. Physician #1 stated that in his opinion the cause of death for Resident #1 was Pulmonary Embolism or Myocardial Infarction. He further revealed he came to this conclusion based on sudden death associated with the resident's complaints of chest pain. On [DATE] at 3:00 PM, interview with Director of Nursing (DON), revealed Resident #1's physician should have been notified when the resident complained of chest pain. The DON stated she was not monitoring the staff to ensure staff were monitoring daily for signs or symptoms as per the plan of care; she was relying on the staffs nursing assessment and clinical knowledge to report change of condition. On [DATE] at 3:55 PM, interview with Administrator, revealed he expected staff to notify the physician when a change in a resident's condition occurred. He further stated Resident #1's physician should have been notified after Resident #1 reported complaints of chest pain, as per the plan of care. 2). A review of a closed record for Resident #2 revealed the facility admitted the resident on [DATE] with diagnoses that include Neuropathy, Dementia, Type 2 Diabetes, Anxiety and Paranoid Personality Disorder. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required set-up assistance for eating. A review of the Nutritional Risk Quarterly Review dated [DATE] had not been completed by the Dietary Manager or Registered Dietician to assess Resident #1 hydration needs. A review of the fluid intake records for Resident #2, revealed the facility documented the resident consumed less than 500 ml for 10 of 19 days between [DATE] and [DATE]. Further review of the intake record revealed the resident had only received 240 milliliters (ml) on [DATE], 120 ml on [DATE], 480 ml on [DATE], 240 ml on [DATE], 360 ml on [DATE], 360 ml on [DATE], 360 ml on [DATE], 140 ml on [DATE], 480 ml on [DATE] and 240 on [DATE]. A review of the baseline/admission care plan dated [DATE], revealed a hydration care plan due to the resident being at risk for hydration; however, the care plan contained no person-centered interventions addressing the resident's fluid needs or directing staff to monitor the resident's hydration status. 3). A review of the medical record for Resident #3 revealed the facility admitted the resident on [DATE] with diagnoses that include Fracture of Left Fibula, Gout, Pain, Osteoarthritis and Chronic Kidney Disease Stage 3. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the facility assessed the resident to be cognitively intact. Further review of the MDS revealed the resident required the assistance of one person for eating. Observation of Resident #3 on [DATE] at 11:54 AM revealed the resident had fluids on the over bed table and had no visible signs and symptoms of dehydration. Interview with Resident #3 on [DATE] at 11:54 AM revealed the facility provides him/her with fluids routinely. A review of the Nutritional Risk assessment dated [DATE] signed by the RD revealed Resident #3's estimated fluid needs to be 2200 milliliters (ml) per day of fluid. A review of the fluid intake records for Resident #3, revealed the facility documented the resident had not met his/her fluid intake requirement on the following dates: 720 ml on [DATE]; 600 ml on [DATE]; 360 ml on [DATE]; 480 mils on [DATE]; 840 ml on [DATE]; 120 ml on [DATE]; 840 ml on [DATE]; 360 ml on [DATE]; 1080 ml on [DATE]; 360 ml on [DATE]; 720 ml on [DATE]; 300 ml on [DATE]; 360 ml on [DATE]; 630 ml on [DATE]; 360 ml on [DATE]; 240 ml on [DATE]; 840 ml on [DATE]; 840 ml on [DATE]; 480 ml on [DATE]; 600 ml on [DATE]; 1210 ml on [DATE]; 840 ml on [DATE]; 360 ml on [DATE]; 720 ml on [DATE]; 240 ml on [DATE]; 960 ml on [DATE]; 480 ml on [DATE]; 840 ml on [DATE]; 480 ml on [DATE]; 840 ml on [DATE]; 480 ml on [DATE]; and 600 ml on [DATE]. A review of the care plan dated [DATE], revealed a hydration care plan due to the resident being at risk for nutrition/hydration; however, the care plan contained no intervention regarding the resident's fluid needs or monitoring of hydration. 4). A review of the medical record for Resident #4 revealed the facility admitted the resident on [DATE] with diagnoses that include End State Renal Disease, Type 2 Diabetes and Obstructive Sleep Apnea. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the facility assessed the resident to be cognitively intact. Further review of the MDS revealed the resident required the assistance one person for eating. On [DATE] at 12:09 PM, Resident #4 was observed consuming food and fluids with no visible signs and symptoms of dehydration. Fluids were also observed on the resident's over bed table. Interview with Resident #4 on [DATE] at 12:15 PM revealed he/she receives fluid regularly. A review of the Nutritional Risk Assessment on [DATE] signed by the RD revealed Resident #4's estimated fluid needs to be ,d+[DATE] milliliters (ml) per day of fluid. A review of the fluid intake records for Resident #4, revealed the facility documented the resident had not met his/her fluid intake requirement on the following days: 720 ml on [DATE]; 840 ml on [DATE]; 1080 ml on [DATE]; 480 ml on [DATE]; 1080 ml on [DATE]; 720 ml on [DATE]; 1080 on [DATE]; 1080 ml on [DATE]; 600 ml on [DATE]; 300 ml on [DATE]; 720 ml on [DATE]; 1080 ml on [DATE]; 240 ml on [DATE]; 720 ml on [DATE]; 840 ml on [DATE]; 720 ml on [DATE]; 840 ml on [DATE]; 960 ml on [DATE]; 1080 ml on [DATE]; 960 ml on [DATE]; 1120 ml on [DATE];and 960 ml on [DATE]. A review of the care plan dated [DATE], revealed a hydration care plan due to the resident being at risk for nutrition/hydration; however, the care plan contained no intervention regarding the resident's fluid needs or monitoring of hydration. 5). A review of the medical record for Resident #5 revealed the facility readmitted the resident on [DATE] with diagnoses that include Neuropathy, Type 2 Diabetes, Alzheimer's and Heart Failure. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required the assistance of one person for eating. Observation of Resident #5 on [DATE] at 1:00 PM revealed no signs and symptoms of dehydration. Further observation revealed Resident #5's family assisting the resident with food and fluid intake. Further review of Resident #5 medical record revealed on [DATE] a Nutritional Risk Quarterly Review was completed by RD which revealed fluid intake less than 1000 milliliters (ml) per day. A review of the Nutritional Risk Assessment on [DATE] signed by the RD revealed Resident #5's estimated fluid needs to be 1560 milliliters (ml) per day of fluid. A review of the fluid intake records for Resident #5, revealed the facility documented the resident had not met his/her fluid intake requirements on the following dates: 880 ml on [DATE]; 1280 ml on [DATE]; 600 ml on [DATE]; 480 ml on [DATE]; 720 ml on [DATE]; 960 ml on [DATE]; 720 ml on [DATE]; 720 ml on [DATE]; 600 ml on [DATE]; 520 ml on [DATE]; 120 ml on [DATE]; 480 ml on [DATE]; 360 ml on [DATE]; 570 ml on [DATE]; 600 ml on [DATE]; 240 ml on [DATE]; 600 ml on [DATE]; 600 ml on [DATE]; 600 ml on [DATE]; 480 ml on [DATE]; 720 ml on [DATE]; 600 ml on [DATE]; 240 ml on [DATE]; and 360 ml on [DATE]. A review of the care plan dated [DATE], revealed a hydration care plan with intervention to observe for signs and symptoms of altered fluid balance. Interview with SRNA #10, on [DATE] at 1:30 PM, revealed she was required to document resident's fluid intake in the computer. The SRNA stated if she noticed a decrease in intake she reported it to the nurse. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 2:00 PM, revealed she was unaware of how much fluids each resident needed. She revealed she monitored for signs and symptoms of fluid overload and dehydration; however, stated she did not look at fluid intake daily. Interview with Registered Nurse (RN) #1, on [DATE] at 1:05 PM, revealed that she monitors for dehydration based on vital signs and assessment. The RN stated that she did not review resident fluid intake daily Interview with the Dietary Manager, on [DATE] at 9:55 AM, nursing staff was responsible for monitoring fluid intake. Interview on [DATE] at 11:10 AM with the facility Dietitian revealed that she completes a nutritional assessment that identifies the estimated fluid needs of each resident. The Dietician stated that during the quarterly review if she identifies that the resident is not having adequate intake of fluids, she would write a recommendation for offering or encouraging fluids. Per the Dietician, she did not have a set amount of fluids each resident should receive and relied on the nursing staff's clinical assessment to identify signs and symptoms of dehydration. Interview with the Unit Manager, on [DATE] at 3:15 PM, revealed nursing staff was responsible for monitoring fluid intake and signs and symptoms of dehydration. Interview with the MDS Nurse on [DATE] at 2:20 PM revealed she completes the comprehensive care plans using the MDS. The MDS Nurse was unable to explain how the hydration care plans were developed or why the care plans had no interventions due to not being responsible for the care plans of the above residents when they were developed. **The facility implemented the following actions to remove Immediate Jeopardy: 1). All residents were assessed by the DON between [DATE] to [DATE] to ensure each resident had a current (within 30 days) pain assessment with appropriate interventions in place. 2). All resident were assessed by the DON between [DATE] to [DATE] to ensure each resident Change of Condition had been identified if applicable. 3). All resident had physical assessments completed between [DATE] to [DATE] by nurses on shift to address any immediate concerns. 4). Nursing staff were in-serviced on [DATE] by the Director of Nursing regarding pain management, pain assessments, pain interventions, change of condition and roles and responsibilities and physician notification regarding change of condition. 5). In-service education was completed with State Registered Nurse Aide (SRNA) #2 to address change of condition notification procedures in the event the available nurse is not able to immediately address the needs of the resident. 6). Monitoring of ten (10) residents weekly to ensure that their pain needs are being met for four (4) weeks began on [DATE] by the DON/ADON/Designee. 7). Monitoring of three (3) resident weekly for three (3) months following the four weeks beginning on [DATE]. 8). Beginning on [DATE] to [DATE], five (5) nursing staff, three (3) management staff employees and ten (10) residents will be interviewed daily regarding resident pain and change in condition. If staff were not able to interview a resident was, then nursing staff would assess for pain and change in condition. In addition, concerns will be reported to the DON and physician as required. However, concerns (Resident #13 and #14's complaints of pain and Resident #15's change in condition) identified during the audits on [DATE], on [DATE] and on [DATE] were not addressed by the Administrator as directed in the AOC. Also, review of monitoring revealed no evidence of completion of the audits as per the AOC on [DATE] and [DATE]. In correction of Administrator failure to report change of condition and pain to nursing staff on [DATE], [DATE] and [DATE] and failure to complete interviews on [DATE]-[DATE], the facility implemented the following actions (A-G): A). Interview with all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were conducted by Social Services on [DATE] regarding pain and change of condition. One concern was noted with pain however, had previously been addressed by nursing staff. B). All residents with BIMS score of below eight (8) were assessed for pain and change of condition on [DATE]. No concerns were identified. C). Education was provided to the Administrator by Regional Director of Operation (RDO), on [DATE]-[DATE], regarding expectations of writing and following actions of an Allegation of Compliance. Further education was completed with the Administrator on [DATE] regarding Clinical Follow Ups, Interview Procedures, Documentation Procedures, DON/ Regional Director of Operation (RDO) reporting, Clinical Assessment as Administrator, Change of Condition Observation and Reporting, Auditing Procedures and Change of Condition follow up. D). Resident #13 was assessed for pain on [DATE] and was interviewed by facility staff and revealed that he/she was referring to the complaints of chest pain on [DATE], which was addressed by nursing staff on [DATE]. E). Resident #14 was assessed for pain on [DATE] and revealed no pain and denied need for pain medication. The resident was repositioned with no need for further intervention. Resident #14 was further assessed for pain on [DATE] with no identified concerns. F). Resident #15 was assessed for tremor on [DATE] which was unremarkable. Staff placed Resident #15 on 72 hour charting for monitoring of tremor. Further, Resident #15 physician was notified with no further orders. G). The Interdisciplinary Team (IDT) reviewed of all audits completed by Administrator on [DATE]-[DATE] to ensure all concerns were addressed. 9). The DON/ADON/ Designee monitors all Changes of Condition in the morning meeting for the previous 24 hours (72 hours on Monday). 10). Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns regarding auditing. 11). Monthly QAPI meetings to include the audits completed in the allegation of compliance. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on [DATE], as alleged by the facility: 1). Interview with the DON, on [DATE] at 4:10 PM, revealed she assessed all residents to ensure each resident had a current pain assessment with appropriate interventions in place. She revealed that she did not identify any concerns. Review of census on [DATE], [DATE] and [DATE] revealed all residents in the facility between [DATE] and [DATE] had a pain assessment completed with interventions in place to aide in pain management. 2). Interview with the DON, on [DATE] at 2:41 PM, revealed she assessed all residents between [DATE] and [DATE], for change in condition and had not identified any change of condition that was not addressed by nursing staff. Record review revealed all residents residing in the facility between [DATE] and [DATE] were assessed for change in condition. 3). Sampled residents (Resident #3, #4, #5, #7, #8, #9 and #10) were reviewed for physical assessment. No concerns were identified. 4). Interview with the DON, on [DATE] at 4:10 PM, revealed she had provided education for staff and utilized question and answer for evidence of comprehension of training. Further interview with the DON revealed she utilized scenarios for examples and completed verbal education with staff as needed for any additional concerns. Interview on [DATE] at 5:50 PM, with LPN #9, on [DATE] with SRNA #8 at 6:05 PM, SRNA #10 at 1:30 PM, LPN #6 at 2:00 PM, LPN #7 at 2:55 PM, LPN #8 at 5:00 PM, LPN #10 at 4:30 PM, and on [DATE] at 3:05 PM with SRNA #9, revealed staff were re-educated on pain management, change of condition and physician notification. Review of staff in-service records for [DATE], revealed nursing staff had received education on pain management, change in condition and physician notification. 5). Interview with the DON, on [DATE] at 4:10 PM, revealed she had completed education with SRNA #2 and had the SRNA verbalize comprehension. Interview with SRNA #2, on [DATE] at 2:45 PM, revealed she was re-educated on change of condition, resident pain and who to notify in the chain of command. 6). Review of 10 residents monitoring weekly for four (4) weeks revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON on [DATE] at 2:41 PM revealed she reviews all pain assessments, change of condition and physician notification on all residents including the 10 sampled residents during each morning meeting. 7). Review of Week one from [DATE]-[DATE] and Week two from [DATE]-[DATE] (of the weekly monitoring) for three (3) months revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON, on [DATE] at 4:10 PM, revealed she had reviewed the monitoring for the above during morning meetings. She further revealed she had identified that Resident #13 had complaints of chest pain on [DATE]; however, her review revealed that appropriate actions were completed including assessment, physician notification and monitoring per physician order. She revealed no further concerns had been identified. 8). Review of interviews of five (5) nursing staff, three (3) management staff employees and ten (10) residents revealed on [DATE] a staff member had reported to the Administrator that Resident #15 had a change in condition (shaking more than usual) and on [DATE], three therapist had reported the same change in condition to the Administrator. Continued review of the audits revealed on [DATE], Resident #14 had voiced complaints of pain and on [DATE], Resident #13 voiced complaints of chest pain last night. The Administrator was aware of the complaints but failed to ensure the complaints were addressed and reported to the DON/physician as required by the AOC. Further review of the Audits revealed no evidence the audits were completed on [DATE] and [DATE]. A). Review of the resident interviews for all residents with a BIMS score greater than eight (8) or greater revealed the interviews were completed on [DATE] with one identified concern. Record review revealed nursing staff had already addressed the voiced concern. Interview with Social Services, on [DATE] at 12:05 PM, Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all individuals with a BIMS score of eight (8) or greater were interviewed regarding pain, change of condition and needs being met with one voiced concern that had already previously been addressed. B). Record review revealed all residents with BIMS score of below eight (8) were assessed by nursing staff [DATE] with no concerns identified. Interview with Assistant Director of Nursing (ADON), on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all residents with BIMS score of below eight (8) were assessed by nursing staff for any pain or change of condition with no identified concerns. C) Interview of Administrator, on [DATE] at 2:35 PM, revealed he had received education on [DATE] and re-educated on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-up with Nursing, etc. He further revealed that all the audits he had completed had been reviewed by the RDO and DON. Interview with RDO on [DATE] at 10:49 AM, revealed she had provided re-education to Administrator on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-Up with Nursing, etc. D) Interview with Resident #13, on [DATE] at 4:15 PM, revealed the resident has had chest pain and when staff is notified they contact the physician. Resident #13 further revealed that he/she had chest pain the other night, staff notified the physician and he/she received medication which resolved the chest pain. Interview with LPN, #10, on [DATE] at 4:30 PM, revealed that Resident #13 had not complained of chest pain on her shift 11:00 PM on [DATE] to 7:00 AM on [DATE]. Review of medical record for Resident #13 revealed he/she voiced chest pain on [DATE], no concerns were identified with assessment, change of condition and/or physician notification. E) Review of assessment of Resident #14 completed on [DATE] revealed no identified concerns regarding unmet pain needs or change of condition. F) Review of assessment on Resident #15 completed on [DATE] revealed no identified tremor. Further review revealed resident physician was notified with no new orders. G) Review of documentation related to audit review of [DATE]-[DATE] audits revealed no additional unmet concerns. Interview with RDO, on [DATE] at 10:07 AM, and DON on [DATE] at 2:41, PM revealed all audits on [DATE]-[DATE] were reviewed for any outstanding change of conditions with no further concerns identified. 9). Interview with Social Services, on [DATE] at 12:05 PM, revealed that during the morning clinical meeting the 24-hour report was reviewed. During the me [TRUNCATED]

Based on interview, record review, and a review of facility policies, it was determined the facility failed to have an effective system to provide care and services when a change in condition occurred for one (1) of six (6) sampled residents (Resident #1). On [DATE] at approximately 11:30 PM, Resident #1 began to voice complaints of chest pain to State Registered Nursing Assistants (SRNA) and the resident was yelling out Lord help me. The SRNAs reported the change in Resident #1's condition to the nurse, but stated they did not see the nurse assess the resident. Continued interviews with the SRNAs revealed the resident continued to complain of chest pain until approximately 12:30 AM. Interview with the nurse revealed she was not notified of Resident #1's complaints of chest pain until approximately 1:00 AM. She obtained and documented the resident's vital signs. However, the nurse did not assess Resident #1 again until approximately 5:00 AM, when SRNAs found Resident #1 pale and cold from the chest up without a pulse or vital signs of life. Resident #1 was pronounced deceased at the facility on [DATE] at 5:30 AM. The facility's failure to ensure residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was not removed until [DATE], prior to exit on [DATE], which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care (F684) , while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy Assessments, dated [DATE], revealed Nurses and other qualified health professionals would perform appropriate assessments of the resident when a change in condition or circumstances and/or an event took place that required assessment by a qualified medical professional. Review of the facility's policy, Charge in a Resident Condition, undated, revealed that a significant change in condition was a decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status; and required interdisciplinary review and/or revision of the care plan. Review of Resident #1's medical revealed the facility admitted the resident on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Essential Hypertension, Heart Failure, Gastroesophageal Reflux Disease, Anxiety, Pain and Shortness of Breath. Further review of Resident's #1 Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. The facility assessed the resident to require limited assistance of two (2) staff members with bed mobility and one (1) staff member with transfers and toileting. Resident #1 was identified to be frequently incontinent of bladder and bowel. The facility further assessed that Resident #1 was able to make self-understood and understand others. Continued review revealed the resident had verbal behavioral symptoms directed toward others occurring one (1) to three (3) days and other behavioral symptoms not directed toward others occurring one (1) to three (3) days during the lookback period. Review of Nurses' Notes dated [DATE] at 6:00 AM, revealed LPN #1 documented at 5:30 AM staff alerted nurse that resident was not breathing. Walked into room, resident had no pulse, breath, nor blood pressure. Continued review revealed RN #2 pronounced the resident deceased . Interview with SRNA #1, on [DATE] at 1:35 PM, revealed she had cared for Resident #1 on the night of [DATE]. The SRNA stated Resident #1 rang the call light at around 11:30 PM and when she entered the resident's room the resident complained of chest pain. SRNA #1 stated she immediately notified LPN #1 of the resident's complaints of chest pain, who told her to give the resident a drink of water. SRNA #1 stated she did not know if LPN #1 went to the resident's room or assessed the resident after she reported the resident's complaints. SRNA #1 stated she last observed Resident #1 was at 12:30 AM when the resident called out for help to move the trash can. Interview with SRNA #2, on [DATE] at 2:10 PM revealed she had cared for Resident #1 on the night of [DATE]. The SRNA stated that at approximately 12:30 AM on [DATE], Resident #1 rang the call light and when she entered the room, Resident #1 complained of chest pain. Per the SRNA, Resident #1 had history of frequent complaints regarding his/her breathing status and generalized pain; however, she felt that night was different and to her knowledge the resident had not previously complained of chest pain. The SRNA stated the resident was yelling out. The SRNA stated she notified LPN #1 of the resident's complaint of chest pain and current status, and LPN #1 instructed her to provide Resident #1 with a drink of water. SRNA #2 stated she declined to give Resident #1 a drink of water and informed LPN #1 that she needed to assess the resident. SRNA #2 revealed that she was unaware if LPN #1 entered Resident #1's room following the report. At approximately, 5:00 AM on [DATE] SRNA #2 stated she found Resident #1 not breathing and notified LPN #1. SRNA #2 stated she had last heard Resident #1 hollering out at approximately 12:30 AM. SRNA #2 revealed at approximately 1:30 AM Resident #1 appeared to be sleeping in his/her room. Further interview, revealed that upon entering the room at approximately 3:00 AM to provide care to Resident #1 roommate, Resident #1 was observed to appear to be asleep and breathing. Interview with Patient Care Assistant (PCA) #10, on [DATE] at 7:50 AM, revealed she was on duty on [DATE] from 11:00 PM to 7:00 AM on [DATE]. The PCA stated she observed Resident #1 yelling out in distress (i.e. Lord help me, Jesus help me). Per the PCA, she witnessed both SRNA #1 and SRNA #2 notify LPN #1 of Resident #1 complaints of chest pain. However, was unable to recall time of occurrence. Interview with LPN #1, on [DATE] at 2:55 PM, revealed she began caring for Resident #1, on [DATE] at approximately 11:00 PM. LPN #1 revealed at the beginning of her shift at approximately 11:00 PM, she made an observation of Resident #1 from the hallway. LPN #1 revealed that at approximately 1:00 AM on [DATE] she was notified by SRNA #2 that resident complained of chest pain. She revealed that she entered the room of Resident #1 and obtained vitals which were temperature of 98.0 degrees, heart rate of 80 beat per minute, and 98.0% oxygen saturation, ,d+[DATE] blood pressure and 20 respirations per minute. She stated that Resident #1 had a history of yelling out can't breathe or chest hurts nightly or every other night. She revealed that she did not perform an assessment on Resident #1, only obtained vital signs. She revealed that she did not identify this as a change of condition because the resident did this all time. She stated if she did think it was a change of condition she would have notified the MD. LPN #1 exited the room and did not enter or observe Resident #1 until approximately 5:00 AM, when SRNA #2 reported that resident was not breathing. The LPN stated Resident #1 was noted to have a white chest from middle of chest upward toward head. She revealed that the resident was warm from the chest down with no pulse. The LPN stated she instructed SRNA #2 to notify RN #2 who was assigned to other unit. Per the LPN, RN #2 assessed Resident #1 and identified no pulse, no respirations or no blood pressure. Further review of the medical record for the evening of [DATE] until the morning of [DATE], revealed no documented assessment of the resident's condition until 5:30 AM on [DATE], when the resident was assessed without signs of life and was pronounced deceased . The record contained no mention of the resident's complaints of chest pain. Interview with Physician #1, on [DATE] at 5:40 PM, revealed he would have expected staff to assess a resident when a change in condition occurred and to notify him after assessing the resident. Interview with Director of Nursing (DON), on [DATE] at 3:00 PM, revealed staff were trained to assess facility residents when a change in condition occurred. Per the DON, when Resident #1 complained of chest pain, the nurse should have assessed the resident immediately. The DON stated at a minimum a physical assessment should include a thorough observation of the resident and the nurse should obtain vital signs and perform other relevant assessments dependent on the situation. Interview with Administrator, on [DATE] at 3:55 PM, revealed he expected staff to assess a resident when a change in their condition occurred. He further revealed that even if a resident complained every day, an assessment was still warranted. **The facility implemented the following actions to remove Immediate Jeopardy: 1). All residents were assessed by the DON between [DATE] to [DATE] to ensure each resident had a current (within 30 days) pain assessment with appropriate interventions in place. 2). All resident were assessed by the DON between [DATE] to [DATE] to ensure each resident Change of Condition had been identified if applicable. 3). All resident had physical assessments completed between [DATE] to [DATE] by nurses on shift to address any immediate concerns. 4). Nursing staff were in-serviced on [DATE] by the Director of Nursing regarding pain management, pain assessments, pain interventions, change of condition and roles and responsibilities and physician notification regarding change of condition. 5). In-service education was completed with State Registered Nurse Aide (SRNA) #2 to address change of condition notification procedures in the event the available nurse is not able to immediately address the needs of the resident. 6). Monitoring of ten (10) residents weekly to ensure that their pain needs are being met for four (4) weeks began on [DATE] by the DON/ADON/Designee. 7). Monitoring of three (3) resident weekly for three (3) months following the four weeks beginning on [DATE]. 8). Beginning on [DATE] to [DATE], five (5) nursing staff, three (3) management staff employees and ten (10) residents will be interviewed daily regarding resident pain and change in condition. If staff were not able to interview a resident was, then nursing staff would assess for pain and change in condition. In addition, concerns will be reported to the DON and physician as required. However, concerns (Resident #13 and #14's complaints of pain and Resident #15's change in condition) identified during the audits on [DATE], on [DATE] and on [DATE] were not addressed by the Administrator as directed in the AOC. Also, review of monitoring revealed no evidence of completion of the audits as per the AOC on [DATE] and [DATE]. In correction of Administrator failure to report change of condition and pain to nursing staff on [DATE], [DATE] and [DATE] and failure to complete interviews on [DATE]-[DATE], the facility implemented the following actions (A-G): A). Interview with all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were conducted by Social Services on [DATE] regarding pain and change of condition. One concern was noted with pain however, had previously been addressed by nursing staff. B). All residents with BIMS score of below eight (8) were assessed for pain and change of condition on [DATE]. No concerns were identified. C). Education was provided to the Administrator by Regional Director of Operation (RDO), on [DATE]-[DATE], regarding expectations of writing and following actions of an Allegation of Compliance. Further education was completed with the Administrator on [DATE] regarding Clinical Follow Ups, Interview Procedures, Documentation Procedures, DON/ Regional Director of Operation (RDO) reporting, Clinical Assessment as Administrator, Change of Condition Observation and Reporting, Auditing Procedures and Change of Condition follow up. D). Resident #13 was assessed for pain on [DATE] and was interviewed by facility staff and revealed that he/she was referring to the complaints of chest pain on [DATE], which was addressed by nursing staff on [DATE]. E). Resident #14 was assessed for pain on [DATE] and revealed no pain and denied need for pain medication. The resident was repositioned with no need for further intervention. Resident #14 was further assessed for pain on [DATE] with no identified concerns. F). Resident #15 was assessed for tremor on [DATE] which was unremarkable. Staff placed Resident #15 on 72 hour charting for monitoring of tremor. Further, Resident #15 physician was notified with no further orders. G). The Interdisciplinary Team (IDT) reviewed of all audits completed by Administrator on [DATE]-[DATE] to ensure all concerns were addressed. 9). The DON/ADON/ Designee monitors all Changes of Condition in the morning meeting for the previous 24 hours (72 hours on Monday). 10). Weekly add on Quality Assurance and Performance Improvement (QAPI) meetings to address any concerns regarding auditing. 11). Monthly QAPI meetings to include the audits completed in the allegation of compliance. ***The state agency confirmed the following actions were implemented to remove Immediate Jeopardy on [DATE], as alleged by the facility: 1). Interview with the DON, on [DATE] at 4:10 PM, revealed she assessed all residents to ensure each resident had a current pain assessment with appropriate interventions in place. She revealed that she did not identify any concerns. Review of census on [DATE], [DATE] and [DATE] revealed all residents in the facility between [DATE] and [DATE] had a pain assessment completed with interventions in place to aide in pain management. 2). Interview with the DON, on [DATE] at 2:41 PM, revealed she assessed all residents between [DATE] and [DATE], for change in condition and had not identified any change of condition that was not addressed by nursing staff. Record review revealed all residents residing in the facility between [DATE] and [DATE] were assessed for change in condition. 3). Sampled residents (Resident #3, #4, #5, #7, #8, #9 and #10) were reviewed for physical assessment. No concerns were identified. 4). Interview with the DON, on [DATE] at 4:10 PM, revealed she had provided education for staff and utilized question and answer for evidence of comprehension of training. Further interview with the DON revealed she utilized scenarios for examples and completed verbal education with staff as needed for any additional concerns. Interview on [DATE] at 5:50 PM, with LPN #9, on [DATE] with SRNA #8 at 6:05 PM, SRNA #10 at 1:30 PM, LPN #6 at 2:00 PM, LPN #7 at 2:55 PM, LPN #8 at 5:00 PM, LPN #10 at 4:30 PM, and on [DATE] at 3:05 PM with SRNA #9, revealed staff were re-educated on pain management, change of condition and physician notification. Review of staff in-service records for [DATE], revealed nursing staff had received education on pain management, change in condition and physician notification. 5). Interview with the DON, on [DATE] at 4:10 PM, revealed she had completed education with SRNA #2 and had the SRNA verbalize comprehension. Interview with SRNA #2, on [DATE] at 2:45 PM, revealed she was re-educated on change of condition, resident pain and who to notify in the chain of command. 6). Review of 10 residents monitoring weekly for four (4) weeks revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON on [DATE] at 2:41 PM revealed she reviews all pain assessments, change of condition and physician notification on all residents including the 10 sampled residents during each morning meeting. 7). Review of Week one from [DATE]-[DATE] and Week two from [DATE]-[DATE] (of the weekly monitoring) for three (3) months revealed no identified concerns with unmet pain needs, change of condition or physician notification. Interview with DON, on [DATE] at 4:10 PM, revealed she had reviewed the monitoring for the above during morning meetings. She further revealed she had identified that Resident #13 had complaints of chest pain on [DATE]; however, her review revealed that appropriate actions were completed including assessment, physician notification and monitoring per physician order. She revealed no further concerns had been identified. 8). Review of interviews of five (5) nursing staff, three (3) management staff employees and ten (10) residents revealed on [DATE] a staff member had reported to the Administrator that Resident #15 had a change in condition (shaking more than usual) and on [DATE], three therapist had reported the same change in condition to the Administrator. Continued review of the audits revealed on [DATE], Resident #14 had voiced complaints of pain and on [DATE], Resident #13 voiced complaints of chest pain last night. The Administrator was aware of the complaints but failed to ensure the complaints were addressed and reported to the DON/physician as required by the AOC. Further review of the Audits revealed no evidence the audits were completed on [DATE] and [DATE]. A). Review of the resident interviews for all residents with a BIMS score greater than eight (8) or greater revealed the interviews were completed on [DATE] with one identified concern. Record review revealed nursing staff had already addressed the voiced concern. Interview with Social Services, on [DATE] at 12:05 PM, Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all individuals with a BIMS score of eight (8) or greater were interviewed regarding pain, change of condition and needs being met with one voiced concern that had already previously been addressed. B). Record review revealed all residents with BIMS score of below eight (8) were assessed by nursing staff [DATE] with no concerns identified. Interview with Assistant Director of Nursing (ADON), on [DATE] at 12:30 PM, DON on [DATE] at 2:41 PM, Administrator on [DATE] at 2:35 PM and RDO on [DATE] 10:07 AM, revealed all residents with BIMS score of below eight (8) were assessed by nursing staff for any pain or change of condition with no identified concerns. C) Interview of Administrator, on [DATE] at 2:35 PM, revealed he had received education on [DATE] and re-educated on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-up with Nursing, etc. He further revealed that all the audits he had completed had been reviewed by the RDO and DON. Interview with RDO on [DATE] at 10:49 AM, revealed she had provided re-education to Administrator on [DATE] regarding his responsibilities and duties related to the Allegation of Compliance, Identification of Change of Condition, and when to Follow-Up with Nursing, etc. D) Interview with Resident #13, on [DATE] at 4:15 PM, revealed the resident has had chest pain and when staff is notified they contact the physician. Resident #13 further revealed that he/she had chest pain the other night, staff notified the physician and he/she received medication which resolved the chest pain. Interview with LPN, #10, on [DATE] at 4:30 PM, revealed that Resident #13 had not complained of chest pain on her shift 11:00 PM on [DATE] to 7:00 AM on [DATE]. Review of medical record for Resident #13 revealed he/she voiced chest pain on [DATE], no concerns were identified with assessment, change of condition and/or physician notification. E) Review of assessment of Resident #14 completed on [DATE] revealed no identified concerns regarding unmet pain needs or change of condition. F) Review of assessment on Resident #15 completed on [DATE] revealed no identified tremor. Further review revealed resident physician was notified with no new orders. G) Review of documentation related to audit review of [DATE]-[DATE] audits revealed no additional unmet concerns. Interview with RDO, on [DATE] at 10:07 AM, and DON on [DATE] at 2:41, PM revealed all audits on [DATE]-[DATE] were reviewed for any outstanding change of conditions with no further concerns identified. 9). Interview with Social Services, on [DATE] at 12:05 PM, revealed that during the morning clinical meeting the 24-hour report was reviewed. During the meeting, the team discuss pain assessments, change of condition, etc. She further revealed that all items are placed on a follow up list, which will be reviewed at the evening meeting. Interview with Director of Nursing, on [DATE] at 4:10 PM, revealed that during the morning clinical meeting the 24 hour report was reviewed and the team discussed resident pain assessments, change of condition, significant decline, etc. She further revealed that all items were reviewed and followed up on as indicated. 10). Review of QAPI meeting documentation revealed the last weekly meeting was on [DATE], with attendees that included the Administrator and Director of Nursing. Per the meeting notes, there were no identified concerns. Interview with Administrator, on [DATE] at 2:35 PM, revealed the audits he completed during the past week had not been brought to QAPI committee yet as the next meeting was scheduled for [DATE]. 11). Interview with Administrator, on [DATE] at 2:35 PM, revealed the monthly QAPI meeting was scheduled for [DATE]. However, the meeting had not been held yet. He further stated that during the meeting, the committee would discuss all audit results and any other items scheduled for review.

Based on interview, record review, and review of the facility's policy for physician notification related to change of condition it was determined the facility failed to notify the resident's primary care physician for one (1) of three (3) sampled residents (Resident #1) when the resident sustained [REDACTED]. Resident #1 sustained a fall from the wheelchair on 01/18/17. Immediately after the fall, the resident had leg pain and wanted to go to the Emergency Department (ED). The facility documented that the Advanced Practice Registered Nurse (APRN) was contacted regarding the resident's fall. Interview with the APRN revealed that had she been told the resident had leg pain and had hit his/her head, she would have sent the resident to the ED for evaluation. In addition, there was no evidence the resident's physician was notified of the resident's fall and leg pain. Resident #1 continued to have leg pain for the next two days; however, there was no evidence the facility contacted the resident's physician. The facility sent the resident for [MEDICAL TREATMENT] on 01/20/17, and the physician at the [MEDICAL TREATMENT] clinic assessed the resident for complaints of excruciating bilateral leg pain and the resident was transferred to the hospital for treatment. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled Acute Condition Changes - Clinical Protocol, undated, revealed nursing staff would contact the physician based on the urgency of the situation and would call or page the physician and request a prompt response. According to the policy, the attending physician or a practitioner providing backup coverage would respond in a timely manner for notification of problems or changes in condition and status. Review of the medical record for Resident #1 revealed the facility readmitted the resident on 10/07/16 with [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes revealed Resident #1 sustained a fall from a wheelchair on 01/18/17 at 8:00 PM. Further review of the Notes revealed the resident sustained [REDACTED]. The Progress Notes stated [MEDICATION NAME] (pain medication) was given for pain relief, the physician was notified, and no treatment was ordered. The Notes further stated neurological checks were initiated for Resident #1. Review of the Follow up 72 hour Charting completed after the fall revealed the documentation stated on 01/18/17 from 11:00 PM to 7:00 AM, and on 01/19/17 from 7:00 AM to 3:00 PM, Resident #1 had no apparent injuries and no complaints, even though according to the Medication Administration Record [REDACTED]. In addition, on 01/19/17 at 10:00 PM, staff documented that the resident's bruising remained to the right temple from the recent fall and bilateral lower extremity pain with no injuries noted. On 01/20/17 during the 11:00 PM to 7:00 AM shift (exact time not documented), staff documented Resident #1 was resting in bed, had no complaints of pain, continued to have bruising to the right temple and had right lower leg discoloration. Further review of assessments from the 72-hour charting revealed at 12:00 PM on 01/20/17, Resident #1 was complaining of bilateral lower leg pain prior to leaving the facility for [MEDICAL TREATMENT]. Staff contacted Resident #1's physician and x-rays of both legs were ordered on [DATE] at 1:00 PM. According to Progress Notes, on 01/20/17 at 1:43 PM staff administered [MEDICATION NAME] medication for pain, the medication was effective, and the resident was transported to the [MEDICAL TREATMENT] clinic. Review of Resident #1's hospital medical record revealed x-ray reports dated 01/20/17 showed the resident had fractures of the tibia and fibula in both legs. Review of a Progress Note from an Orthopedic Specialist, dated 01/24/17, revealed the resident had fallen a little over a week earlier when he/she slid out of a wheelchair and fell . According to the Orthopedic Specialist, the resident's fractures appeared to be acute and traumatic related to the resident's fall. Interview with Resident #1 conducted on 02/08/17 at 10:37 AM revealed the resident's legs were hurting after his/her fall on 01/18/17. The resident stated he/she was in pain and wanted to go to the hospital, but staff would not send him/her to the hospital. Resident #1 stated he/she did not receive any pain medications that helped the pain. According to Resident #1, it was as if he/she was being ignored. Further interview with Resident #1 revealed on 01/20/17, his/her legs were still hurting and he/she wanted to go to the hospital, but staff encouraged him/her to go to [MEDICAL TREATMENT]. The resident stated he/she went to the [MEDICAL TREATMENT] clinic for his/her appointment and was sent to the hospital after only receiving two (2) hours of his/her [MEDICAL TREATMENT] treatment and was told he/she had two broke legs. Interview with Licensed Practical Nurse (LPN) #1 on 02/08/17 at 1:45 PM revealed on 01/18/17 during an assessment after a fall, Resident #1 was complaining of pain to his/her head, arms, and legs. According to LPN #1, the resident was assessed to have a knot to the forehead, a bruise to the right knee, and no visible injury to the left leg. LPN #1 stated she notified the On-Call Provider; however, the On-Call Provider did not order that the resident be transferred to the hospital. Further interview with LPN #1 revealed she also provided care to Resident #1 on 01/20/17 and the resident complained of leg, arm, and head pain. LPN #1 stated the bruise had gotten bigger. LPN #1 stated she had assessed Resident #1 on 01/18/17 and 01/20/17 and did not observe the resident to be in any additional pain than normal. According to LPN #1, the resident complained of leg pain, arm pain, and head pain; however, the bruising to the right leg was larger on 01/20/17. The nurse stated she administered pain medication to the resident prior to [MEDICAL TREATMENT] and called the resident's provider who ordered x-rays that were scheduled to be completed after the resident returned to the facility from [MEDICAL TREATMENT]. Interview with the APRN on 02/08/17 at 4:05 PM, who was the On-Call Provider on 01/18/17 revealed the APRN did not remember being contacted about Resident #1 falling. She stated she would have instructed the nurse to send the resident to the hospital for evaluation and treatment if staff told her that the resident was complaining of leg pain and had hit his/her head when the fall occurred. Interview with the Director of Nursing (DON) on 02/09/17 at 1:20 PM revealed that after a resident had a fall the nurse was to assess the resident and notify the physician and family of the fall. After notification of the physician, a plan of care was made based on assessment and the resident was treated as ordered by the physician. According to the DON the attending physician for Resident #1 had a Practitioner that took call and the facility nurses would contact the On-Call Practitioner for orders for treatment or if the resident had a change of condition and provide treatment as ordered.

Based on observation, interview, and record review it was determined the facility failed to ensure care was provided in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1's care plan required staff to observe the resident for signs and symptoms of pain and document the assessment in the resident's medical record to ensure the resident had no episodes of uncontrolled pain. Resident #1 sustained a fall on 01/18/17. According to the resident and staff, Resident #1 complained of severe pain in both legs; however, even though staff administered pain medication to the resident on five (5) occasions after the fall, staff did not thoroughly assess the resident's pain. On 01/20/17, staff transferred the resident to a [MEDICAL TREATMENT] clinic for treatment; however, [MEDICAL TREATMENT] staff had to transfer Resident #1 to the Emergency Department for evaluation of excruciating pain and swelling and bruising to the resident's legs. At the hospital, the resident was diagnosed with [REDACTED]. According to the Orthopedic Specialist, the fractures appeared to be acute and traumatic related to the resident's fall (refer to F309). The findings include: Interview with the Director of Nursing (DON) on 02/09/17 at 1:20 PM revealed the facility did not have a written policy related to following a resident's plan of care. However, the DON stated the facility's practice was for nurses to review residents' care plan interventions as needed. According to the DON, the residents' care plans were computerized and were available to reference as needed when providing care. Review of the medical record for Resident #1 revealed the facility readmitted the resident on 10/07/16 with [DIAGNOSES REDACTED]. According to Resident #1's most recent Minimum Data Set (MDS) assessment with a reference date of 12/02/16, the facility assessed the resident to be interviewable with a Brief Interview for Mental Status (BIMS) score of eleven (11). Further review revealed the resident had occasional pain at a moderate level. Review of Resident #1's care plan with a revision date of 01/11/17 revealed the facility identified that the resident had the potential for pain related to a history of ankle/foot fracture and [MEDICAL CONDITION]. The care plan goal was for the resident to have no episodes of uncontrolled pain. According to the care plan, staff was required to observe the resident for signs and symptoms of pain, which included crying, tearfulness, changes in skin color, yelling or cursing, or decreased activities of daily living abilities and/or participation. In addition, Resident #1's plan of care required staff to document if pain was verbalized or suspected. Review of Resident #1's physician's orders [REDACTED]. Review of Progress Notes dated 01/18/17 revealed Resident #1 sustained a fall from a wheelchair on 01/18/17 at 8:00 PM. According to the Notes, the resident sustained [REDACTED]. According to the Nurse's Notes dated 01/18/17, after the fall staff administered [MEDICATION NAME] (pain medication) to the resident for pain relief, the physician was notified with no treatment ordered, and staff started the resident's neurological status. However, there was no evidence staff assessed the resident to see if the medication was effective. Review of the 72-hour follow-up revealed the resident complained of bilateral lower extremity/leg pain during the 3:00 PM to 11:00 PM shift, and on 01/20/17 during the 7:00 AM to 3:00 PM shift. Review of the Medication Administration Record [REDACTED]. According to the MAR, the medication was effective. However, there was no documented evidence the staff assessed the resident's pain according to the care plan. Staff was to observe the resident for signs and symptoms of pain, which included crying, tearfulness, changes in skin color, yelling or cursing, or decreased activities of daily living abilities and/or participation. Interview with Resident #1 conducted on 02/08/17 at 10:37 AM revealed the resident's legs were hurting bad after his/her fall on 01/18/17. The resident stated he/she was in pain and wanted to go to the hospital, but staff would not send him/her to the hospital. Resident #1 stated he/she stayed in bed for three (3) days, hurting, and did not receive any pain medications that helped the pain. According to Resident #1, it was as if he/she was being ignored. Further interview with Resident #1 revealed on 01/20/17, his/her legs were still hurting badly and he/she wanted to go to the hospital, but staff encouraged him/her to go to [MEDICAL TREATMENT]. The resident stated he/she went to the [MEDICAL TREATMENT] clinic for his/her appointment; however, [MEDICAL TREATMENT] staff sent the resident to the hospital where he/she was diagnosed with [REDACTED]. According to the resident, he/she did not notice an improvement in the pain until he/she received a different pain medication at the hospital. Interview with Licensed Practical Nurse (LPN) #1 on 02/08/17 at 1:45 PM revealed on 01/18/17 State Registered Nurse Aide (SRNA) #1 reported that Resident #1 fell from his/her wheelchair on 01/18/17. LPN #1 stated the resident was complaining of pain to the head, arms, and legs. According to LPN #1, the resident was assessed to have a knot to the forehead, a bruise to the right knee, and no visible injury to the left leg. LPN #1 stated she notified the on-call provider; however, the provider did not give an order that the resident be transferred to the hospital. Further interview with LPN #1 revealed she also provided care to Resident #1 on 01/20/17 and the resident complained of leg, arm, and head pain. LPN #1 stated the bruise had gotten bigger. LPN #1 stated she assessed Resident #1 on 01/18/17 and 01/20/17 and did not observe the resident to be in any more pain than normal. The LPN stated she forgot to document a pain assessment and the effectiveness of the pain medications on 01/18/17 and 01/20/17. Interview with SRNA #3 on 02/08/17 at 3:50 PM revealed after Resident #1 fell on [DATE], the resident was lying on the floor screaming oh my legs and crying. SRNA #3 stated the resident complained of leg pain when the nurse was assessing the resident and would scream out when his/her legs were touched. Interview with LPN #4 on 02/09/17 at 11:30 AM and RN #1 on 02/09/17 at 12:30 PM revealed they cared for Resident #1 on 01/19/17. The nurses stated they administered pain medication to the resident, but did not assess the resident's pain. LPN #4 stated Resident #1 reported his/her legs are killing him/her but the resident always used those words to describe his/her pain. RN #1 stated she didn't really assess Resident #1's pain. She stated the resident asked for pain medication quite often, but she did not notice any difference in the resident's demeanor. Interview with the Director of Nursing (DON) on 02/09/17 at 1:20 PM revealed staff should have asked Resident #1 to rate the pain and to identify if the pain was worse than the previous pain or if the pain was any different. The DON stated staff should have also assessed the resident to see if the pain medications were effective. Further interview with the DON revealed she had interviewed Resident #1 on 01/19/17 to follow up with the resident after the fall, and the resident did not have any concerns with his/her legs at that time. According to the DON, she was not aware the resident was not getting any pain relief or that the resident had concerns with pain until the resident returned from the hospital. According to the DON, she checked charting and followed up after falls, but she was not aware staff was not following the care plan related to assessment and monitoring of Resident #1's pain.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary care and services to ensure one (1) of three (3) sampled residents (Resident #1) maintained the highest practicable physical and mental well-being related to pain management. Resident #1 sustained a fall at the facility on 01/18/17, when he/she slid from a wheelchair to the floor. The resident and three (3) State Registered Nurse Aides (SRNAs) stated the resident cried/yelled with leg pain immediately after the fall. The resident continued to complain of leg pain not wanting to be touched, until 01/20/17. On 01/20/17, staff transferred the resident to [MEDICAL TREATMENT] for treatment; however, [MEDICAL TREATMENT] staff sent the resident to the Emergency Department due to excruciating pain, swelling, bruising to both legs, and bruising to the right knee and calf. Once at the hospital, the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled Resident Examination and Assessment, dated December 2011, revealed a resident should be assessed for any abnormalities in health status, which provides a basis for the care plan. According to the policy, the procedure for assessing a resident's pain was to obtain a description of the pain, location, duration, severity, factors that worsened pain, and factors that relieved pain. Staff should also assess how pain affected the resident's activities of daily living and assess current medications and treatments for pain. Further review of the policy revealed all assessment data obtained should be recorded in the resident's medical record. Review of Resident #1's medical record revealed the facility readmitted the resident on 10/07/16 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment for Resident #1 with a reference date of 12/02/16, revealed the facility determined the resident was interviewable, with a Brief Interview for Mental Status (BIMS) score of eleven (11) and was assessed to have occasional pain at a moderate level. Review of the resident's plan of care with a revision date of 01/11/17, revealed the resident had the potential for pain related to a history of an ankle/foot fracture and [MEDICAL CONDITION]. According to the care plan interventions, staff was required to observe and document if pain was verbalized or suspected and observe for signs and symptoms of pain which included crying, tearfulness, changes in skin color, yelling or cursing, or decreased activities of daily living abilities or participation. The care plan goal was for the resident to have no episodes of uncontrolled pain. Observation of Resident #1 on 02/08/17 at 10:30 AM revealed the resident in bed and a staff person was checking braces on the resident's legs. Interview with Resident #1 on 02/08/17 at 10:37 AM revealed on the evening of 01/18/17, he/she was sitting in a wheelchair when he/she slid out of the wheelchair and fell to the floor. The resident stated he/she hit his/her head on the floor and hurt his/her legs bad. Resident #1 stated he/she was in pain and wanted to go to the hospital; however, staff would not send the resident to the hospital. Resident #1 stated he/she did not recall getting any pain medications that helped with the pain. According to Resident #1, it was as if he/she was being ignored. Resident #1 stated that on 01/20/17 his/her legs were still hurting badly and he/she wanted to go to the hospital, but staff encouraged the resident to go to [MEDICAL TREATMENT] instead. The resident stated staff assisted him/her to a wheelchair and he/she went to [MEDICAL TREATMENT]. Resident #1 stated he/she was in pain at the [MEDICAL TREATMENT] clinic and told staff he/she had fallen at the facility. The resident stated staff at the [MEDICAL TREATMENT] clinic sent him/her to the hospital where he/she was diagnosed with [REDACTED]. Review of Nursing Progress Notes revealed Resident #1 sustained a fall from a wheelchair on 01/18/17 at 8:00 PM. According to the Note, the resident wanted to go to bed and while the State Registered Nurse Aide (SRNA) was getting ready to assist the resident, the resident fell out of a wheelchair onto the floor. Further review of the Note, revealed the resident sustained [REDACTED]. The Progress Note stated [MEDICATION NAME] (pain medication) was given for pain relief, the physician was notified and no treatment was ordered, and staff started conducting neurological checks on Resident #1. Interview with SRNA #1 on 02/08/17 at 2:55 PM revealed Resident #1 requested to go to bed on the evening of 01/18/17. She stated while another SRNA was getting a lift to transfer the resident to bed, she was arranging the resident's room to make room for the lift. According to the SRNA, she had her back to Resident #1 when she heard a noise. She turned around and the resident was lying on the floor in the doorway of the resident's room. According to SRNA #1, several staff members responded immediately. Further interview revealed Resident #1 was crying and complaining of leg pain. According to SRNA #1, the nurse assessed the resident, and then staff transferred the resident to bed where they assisted the resident with putting on a hospital gown so the nurse could check the resident more thoroughly. Further interview with SRNA #1 revealed she provided care to Resident #1 the next day, 01/19/17, and the resident was complaining of pain, but she did not feel the pain was unusual for the resident. An interview with SRNA #3 on 02/08/17 at 3:50 PM revealed she went to get a lift to assist SRNA #1 with transferring Resident #1 to bed on 01/18/17. She stated when she arrived at the resident's room, Resident #1 was lying on the floor screaming that his/her legs were hurting. Further interview with SRNA #3 revealed the resident kept complaining of leg pain when the nurse was assessing the resident. SRNA #3 stated the resident was screaming oh my legs and crying. The SRNA stated the resident had bruising and swelling to one knee and if staff touched the resident's legs, the resident would scream out. An interview with SRNA #2 on 02/08/17 at 3:38 PM revealed she was in the hallway on 01/18/17 and noticed Resident #1 lying on the floor complaining of leg pain. According to SRNA #2, Resident #1 was yelling oh my legs constantly and could be heard throughout the hallway. Interview with Licensed Practical Nurse (LPN) #1 on 02/08/17 at 1:45 PM revealed that on 01/18/17, SRNA #1 reported that Resident #1 had fallen. The resident was observed to be on the floor in the doorway to the resident's room on his/her right side. According to the LPN, she assessed the resident and staff transferred the resident to bed where the LPN assessed the resident more thoroughly. LPN #1 stated the resident was assessed to have a knot to the forehead, and a bruise on the right knee, but there was no visible injury to the resident's left leg. The resident complained of leg, arm, and head pain. LPN #1 stated she contacted the On-call Provider to notify her of the fall, to report neurological checks were being conducted, and to notify her that she administered pain medication to the resident. According to the nurse, she did not send the resident to the hospital for an evaluation because the resident's provider did not give any orders to transfer the resident and the resident did not request to go to the hospital. Interview with SRNA #6 on 02/08/17 at 4:05 PM revealed she cared for Resident #1 on 01/19/17, the day after the resident fell . SRNA #6 stated the resident stayed in bed and did not want to be touched. SRNA #6 stated the resident was obviously in pain and was hollering out in pain. Interview with LPN #4 on 02/09/17 at 11:30 AM and Registered Nurse (RN) #1 on 02/09/17 at 12:30 PM revealed they cared for Resident #1 on 01/19/17. The nurses stated they administered pain medication to the resident, but did not assess the resident according to facility policy by obtaining a description of the pain, location, duration, severity, factors that worsened pain, and factors that relieved pain. LPN #4 stated Resident #1 stated his/her legs are killing him/her but the LPN stated the resident always used those words to describe his/her pain. RN #1 stated she didn't really assess Resident #1's pain. She stated the resident asked for pain medication quite often, but the nurse did not notice any difference in the resident's demeanor. Review of Follow up 72 hour Charting after the fall revealed on 01/18/17 from 11:00 PM to 7:00 AM and on 01/19/17 from 7:00 AM to 3:00 PM, Resident #1 had no apparent injuries and no complaints, even though according to the MAR indicated [REDACTED]. In addition, on 01/19/17 at 10:00 PM, staff documented the resident's bruising remained to the right temple from a recent fall and there was bilateral lower extremity pain with no injuries noted. On 01/20/17 during the 11:00 PM to 7:00 AM shift (exact time not documented), staff documented Resident #1 was resting in bed had no complaints of pain, continued to have bruising to the right temple and had right lower leg discoloration. Further review of assessments revealed at 12:00 PM on 01/20/17, Resident #1 was complaining of bilateral lower leg pain prior to leaving the facility for [MEDICAL TREATMENT]. Staff contacted Resident #1's Physician and received orders for x-rays of both legs on 01/20/17 at 1:00 PM. According to Progress Notes, on 01/20/17 at 1:43 PM staff administered [MEDICATION NAME] medication for pain, the medication was effective, and the resident was transported to [MEDICAL TREATMENT]. There was no evidence staff conducted an assessment of Resident #1's pain as required by the facility's policy or any evidence the facility had identified that the resident's bruising and swelling had gotten worse until 01/20/17 when the resident was assessed prior to transfer to the [MEDICAL TREATMENT] center. transported to [MEDICAL TREATMENT]. There was no evidence staff conducted an assessment of Resident #1's pain as required by the facility's policy or any evidence the facility had identified that the resident's bruising and swelling had gotten worse until 01/20/17 when the resident was assessed prior to transfer to the [MEDICAL TREATMENT] Center. Review of the January Medication Administration Record [REDACTED]. On the 11:00 PM to 7:00 AM shift on 01/18/17 the resident's pain was rated an eight (8) out of ten (10). On the 7:00 AM to 3:00 PM (7-3) shift on 01/19/17, the resident's pain was rated a zero. There was no documented evidence of a pain scale rating documented on the 3:00 PM-11:00 PM shift or the 11:00 PM-7:00 AM shift on 01/19/17 on the MAR. The resident's pain was documented at a rating of four (4) on the 7:00 AM-3:00 PM shift on 01/20/17. Further review of Resident #1's MAR indicated [REDACTED]. According to the MAR, staff documented that the medication was effective. Interview with LPN #1 on 02/08/17 at 1:45 PM revealed she also provided care to Resident #1 on 01/20/17. She stated the resident complained of leg pain, arm pain, and head pain; however, the bruising to the right leg was larger than it had been. The nurse stated she administered pain medication to the resident prior to [MEDICAL TREATMENT] and called the resident's provider who ordered x-rays. Review of Resident #1's medical record from the [MEDICAL TREATMENT] Center revealed the resident complained of pain and had visible bruising to both legs, with bruising around the knee and calf of the right leg. The record stated the resident was transferred to the Emergency Department as ordered by the physician at [MEDICAL TREATMENT]. Interview with the [MEDICAL TREATMENT] Nurse on 02/08/17 at 11:55 AM revealed Resident #1 arrived at the [MEDICAL TREATMENT] center on 01/20/17 at approximately 2:30 PM complaining of excruciating leg pain from a fall. According to the nurse, the resident had a bruise the size of a golf ball to the forehead and bruising and swelling to the right leg. The attending physician was contacted, who stated he would come in to see the resident. The [MEDICAL TREATMENT] center contacted the nursing facility and thought the resident had received x-rays and treatment. However, Resident #1 informed the [MEDICAL TREATMENT] center that he/she had not had x-rays or received treatment. The nurse stated the resident was transferred to the hospital after completing two (2) hours of a four (4) hour [MEDICAL TREATMENT] treatment due to pain and bruising and swelling of the legs. Interview with the Advanced Practice Registered Nurse (APRN) on 02/08/17 at 4:05 PM, who was the On-call Provider on 01/18/17 revealed the APRN did not remember being contacted about Resident #1 falling. She stated she would have instructed the nurse to send the resident to the hospital for evaluation and treatment if staff told her that the resident was screaming with leg pain and had hit his/her head when the fall occurred. Review of Resident #1's hospital medical record revealed x-ray reports, dated 01/20/17 showed the resident had fractures of the tibia and fibula in both legs. Review of a progress note from an Orthopedic Specialist, dated 01/24/17, revealed the resident had fallen a little over a week earlier when he/she slid out of a wheelchair and fell . According to the Orthopedic Specialist, the resident's fractures appeared to be acute and traumatic related to the resident's fall.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to provide adequate supervision and assistive devices for five of eighteen sampled residents (Residents #1, #2, #4, #14, and #15) to prevent accident hazards; Residents #4, #14, and #15 related to exiting the facility unsupervised, and Residents #1 and #2 related to falls. Based on interviews conducted with facility staff, Resident #4 had a history of [REDACTED]. Resident #4 exited the facility on 05/20/13 in his/her wheelchair and was found over an embankment behind the facility without injury. Observations conducted on 10/08/13 revealed Resident #4 pushed an exit door open, without staff present, and an alarm sounded; however, observation revealed facility staff was not in the immediate area and failed to respond to the alarm for three minutes. On 09/30/13, Resident #14 exited the facility, went to the facility parking lot without supervision or assistance, and was observed by a State Registered Nurse Aide (SRNA) attempting to get into a truck. In addition, Resident #15, on 03/15/13, exited out the back door of the facility, without supervision or assistance, walked around the building, and sat down under a tree. Continued interviews and record reviews revealed on 09/19/13, SRNA #9 was assisting Resident #2 to the bed and the resident sustained [REDACTED].#9 failed to use a gait belt for the transfer and attempted to transfer the resident without other staff to assist even though the resident was assessed to require the extensive assistance of two persons for transfers. Continued interviews and record reviews revealed Resident #1 sustained a fall with injury and was assisted back into a wheelchair by SRNA #10; however, the SRNA failed to report the fall to the nurse. The facility's failure to provide adequate supervision and assistive devices placed residents at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 10/16/13 and is ongoing at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 10/16/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Elopements," not dated, revealed staff should investigate and report all cases of missing residents. The policy did not provide staff with guidance related to what actions to take, to prevent further elopements, when an elopement occurred. Review of the facility's policy titled "Fall Procedure," not dated, revealed when staff observes a resident fall, staff should allow the resident to lie on the floor and examine carefully. The policy review further revealed if a resident was found on the floor, staff was not to move the resident until the resident could be assessed by the Charge Nurse. Review of the facility's policy titled "Transfer of Residents (Use of Gait Belts)," not dated, revealed a gait belt should be used in the transfer or ambulation of any resident that required the assistance of a staff member. 1. Review of Resident #15's medical record revealed the facility admitted the resident on 10/03/12 with [DIAGNOSES REDACTED]. Review of Resident #15's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 required supervision/oversight with ambulation and was cognitively intact. Review of the Risk of Elopement/Wandering Review for Resident #15 dated 10/11/12 revealed the facility assessed the resident and determined the resident was an elopement risk due to facility staff being unable to redirect the resident from going outside unsupervised. Review of the resident's care plan dated 10/11/12 revealed a Wanderguard bracelet (placed on the resident's person and triggers an alarm at the exit door if the resident attempts to exit the facility without staff knowledge) was placed on the resident and every hour checks were initiated at that time. Further review of Resident #15's care plan (not dated when revised) revealed the resident had removed the Wanderguard bracelet and the bracelet was replaced. Review of Social Services Notes dated 01/02/13 revealed the resident was not allowed to move into a community setting because the resident was considered to be an elopement risk by the resident's State Guardian. Further review of Resident #15's care plan revealed the resident utilized a rolling walker for ambulation in the hallway and could ambulate outdoors when the weather permitted. Although the resident's MDS assessment revealed the resident required supervision/oversight with ambulation, the care plan did not specify the level of supervision required outdoors. Review of the facility's incident reports completed for Resident #15 on 03/15/13 (time not specified) revealed Resident #15 was agitated and wanted to go outside the facility and walk around the parking lot. Licensed Practical Nurse (LPN) #1 told the resident she would take the resident for a walk but, for safety reasons, the resident had to wait for the LPN to go with him/her. According to the incident report, Resident #15 went past the nurses' station, down the hallway into the break room, and out the back door. The incident report revealed the resident left his/her rolling walker inside the facility at the back door. The incident report stated Resident #15 walked around the facility, up an embankment, and was found seated under a tree. According to the incident report, the resident stated he/she got tired and sat down. The incident report did not address how long the resident was outside the facility without staff supervision. Further review of the incident report revealed the resident complained of right knee pain and was assessed to have no injury. According to the incident report, the resident stated he/she was going for a walk and got lost. Interview with LPN #1 on 10/15/13 at 1:50 PM revealed Resident #15 wanted to go outside for a walk on 03/15/13 at approximately 3:00 PM. LPN #1 told the resident he/she had to wait for her to complete a task before she could take the resident for a walk. According to LPN #1, she left Resident #15, completed a task, and approximately 15 minutes later went to find the resident to take the resident for a walk. LPN #1 stated she could not locate the resident and asked facility staff to assist her in searching for the resident. Further interview revealed the LPN went to the back door of the facility and the Wanderguard system alarm was sounding; however, she did not hear the alarm until she had almost reached the back door. According to the LPN, she went out the door, around the building, and Resident #15 was found under a tree beside a facility office building. According to the LPN, Resident #15 had traveled about 500 feet from the building. On 10/16/13 at 9:40 AM, observations were conducted of the area outside the back door of the facility where Resident #15 was located after he/she exited the building unsupervised. Observations revealed the area just outside the back door of the facility was within 100 feet of a retaining basin that was approximately 7 feet deep and a ditch that was approximately 12 feet deep. Further observation revealed the back door of the facility was within 8 feet of a hill with a sloping grade of approximately 25 degrees. According to the facility's Executive Director, the total property consisted of five acres. Interview with the Director of Nursing (DON) on 10/15/13 at 4:20 PM revealed that elopement incidents were discussed during the facility's weekly safety meeting. According to the DON, Resident #15's elopement had been discussed; however, the facility did not conduct a thorough investigation to determine how the resident was able to leave the facility without staff knowledge and be gone for an undetermined amount of time or revise the resident's care plan to prevent further potential elopements. The DON stated the facility's Wanderguard system had not been considered to be ineffective because the system was checked and working. Further interview revealed the incident was not reported to state agencies because the facility's administrative staff felt that because the resident had not left the facility property it was not an allegation of neglect. Interview with the Executive Director on 10/16/13 at 12:40 PM revealed she reviewed the incident reports and conducted investigations regarding elopements. According to the Executive Director, Resident #15 exiting the building was not considered an elopement because the resident had not left the facility's property; the allegation was not reported to the required state agencies because neglect was not considered. Further interview revealed the Executive Director had reviewed the incident, but had not considered that the facility's Wanderguard system may not be effective because the system was functioning, even though Resident #15 was able to exit the building without staff knowledge. 2. Review of the medical record for Resident #4 revealed the facility admitted the resident on 02/03/12 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with transfers, dressing, and bathing, and utilized a wheelchair for mobility. Further review of the assessment revealed staff identified Resident #4 had behaviors of wandering, which had occurred one to three days during the assessment period. Review of documentation in Resident #4's medical record revealed the facility assessed the resident on 04/25/12 to be an elopement risk and applied a Wanderguard bracelet to the resident's ankle at that time. Observations conducted on 10/08/13 at 3:41 PM revealed Resident #4 was on the back hallway of the facility; Resident #4 was wearing a "Wanderguard bracelet" on his/her right ankle. Continued observation revealed Resident #4 pushed open an exit door located on the back hallway of the facility and an alarm sounded. However, facility staff was not in the immediate area when the resident pushed the door open and staff failed to respond to the alarm for three minutes. The resident opened the door but did not go out the door. Interview conducted with Licensed Practical Nurse (LPN) #1 on 10/16/13 at 11:40 AM revealed Resident #4 had been "missing" from the facility but was unable to remember when the incident occurred. The LPN stated that at the time of the incident she realized that she had not seen the resident in a while and tried to locate the resident. Continued interview revealed she was unable to locate the resident and notified other staff the resident was "missing." The LPN stated the search continued outside the facility and Resident #4's wheelchair, with a lap belt restraint attached, was located in a graveled parking area at the back of the facility. LPN #1 stated another nurse located the resident beside a bush on a hill that was located approximately 100 feet away from the resident's wheelchair. The LPN stated the Wanderguard bracelet was still attached to Resident #4's right ankle. According to LPN #1, she had not heard an alarm sound prior to being unable to locate Resident #4 at the time of the incident. The LPN stated the door alarms were supposed to sound when a resident attempted to exit the doors; she stated she could not always hear the facility's door alarms because the alarm was not loud enough to be heard at times. The LPN stated the resident was assessed to have no injuries as a result of the incident. In addition, according to LPN #1, she had not documented the incident in the medical record or notified administrative staff of the incident because that was the responsibility of the Charge Nurse; however, the LPN could not recall who the Charge Nurse was at the time of the incident. LPN #1 stated that, although she could not recall the date, she had notified the Director of Nursing (DON) and the Executive Director (ED) of the inability to hear the door alarms from all areas of the facility. LPN #2 confirmed in interview on 10/16/13 at 3:50 PM that, although she did not recall the date, Resident #4 had been missing from the facility possibly in March 2013. The LPN stated she was notified Resident #4 was missing and assisted in the search for the resident; however, LPN #2 stated she had not heard any door alarms sound prior to the search for the resident. LPN #2 stated she located Resident #4 at the "bottom of the hill, at the gated area, located in back of the facility." The LPN stated she was unable to recall if she documented the incident, or notified administrative staff. The LPN continued to state the facility's exit door alarms do not work "half the time" and administrative staff "know they don't work." Continued review of Resident #4's medical record revealed facility staff had not documented that Resident #4 had left the facility without staff knowledge in March 2013. However, a review of an incident report entitled "Elopement," dated 05/20/13, revealed Resident #4 had exited the facility in a wheelchair and wheeled his/her self over an embankment located in back of the facility. Resident #4 did not sustain any injuries. Interview with LPN #3 on 10/15/13 at 2:03 PM revealed she had been assigned to care for Resident #4 when the elopement occurred on 05/20/13. LPN #3 stated she heard the back door alarm and when she responded, the resident had "rolled down the slight embankment" in his/her wheelchair. LPN #3 also stated she had not implemented any interventions after the incident occurred and stated staff nurses "don't update care plans." The LPN stated, although she had not reported the incident to administrative staff, she "passed" the information to the oncoming shift and documented the incident on the 24-hour report. Continued interview revealed, "If a resident's sock is pulled up over their Wanderguard bracelet, or if the bracelet is turned a certain way, it will not work properly to sound the exit alarms." The LPN further stated she had not reported the concern related to the exit alarm system to Administration, but "should have." Interview with State Registered Nurse Aide (SRNA) #14 on 10/16/13 at 10:00 AM revealed she was working at the time the elopement occurred on 05/20/13. The SRNA stated she never heard an exit alarm sounding, and was only aware of the resident's elopement when notified by the nurse after the incident had occurred. The SRNA stated the exit door alarms, on the back hall where Resident #4 exited the facility, "never worked." The SRNA also stated facility staffing was "horrible" and staff was not able to answer fall alarms or exit door alarms timely. Interview with SRNA #15 on 10/15/13 at 3:50 PM revealed the facility was short-staffed most of the time. The SRNA stated the facility had a lot of "wanderers," alarms, and falls, and with all the other work required to be completed during their shift, it was "hard to do things timely." Observations and interviews on 10/16/13 at 9:40 AM conducted with Maintenance Staff Person #1 and Human Resources (HR) Staff Person #1, who assisted in transporting the resident back into the facility on [DATE], revealed the resident had gone down an approximate 25 to 30-degree sloped, grassy area in a wheelchair. Further observations and interview with the HR staff revealed the resident was approximately 100 feet from the facility. Interview with the DON on 10/15/13 at 4:20 PM revealed she had not been notified of an elopement incident, which involved Resident #4, any time before the documented elopement that occurred on 05/20/13. The DON stated staff had not notified her, and she had not been made aware that Resident #4 had ever been missing from the facility. However, she had reviewed an elopement incident sometime in May 2013 for Resident #4. She acknowledged she had not investigated the incident or implemented any new interventions to prevent further elopements for the resident. The DON further stated she had not considered the incident a true elopement, because she had been trained that if residents remained on facility property they had not eloped. The DON stated staff had never notified her that the door alarms could not be heard at times. However, she stated Maintenance had adjusted the alarms, but could not recall when or why the alarms were adjusted. Interview with the Executive Director (ED) on 10/16/13 at 12:40 PM revealed she was responsible for investigating incidents of elopement. The ED stated she had not been notified of an elopement that occurred around March 2013. She acknowledged Resident #4 had exit-seeking behaviors, and had exited the facility in May 2013. However, no evidence was provided to ensure Resident #4's elopement had been investigated, or that new interventions had been implemented to prevent further elopements from occurring. She stated she was not aware of concerns related to the exit doors' alarms. 3. Review of the medical record for Resident #14 revealed the facility admitted the resident on 07/25/13 with [DIAGNOSES REDACTED]. Further review of the medical record revealed Nurse's Progress Notes dated 07/25/13 through 10/17/13 that revealed Resident #14 began having exit-seeking behaviors on 08/04/13. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the facility assessed Resident #14 as being cognitively impaired and required supervision with the assistance of one person for ambulation. Review of the Plan of Care revealed the facility revised the Plan of Care on 08/05/13 and documented the resident had exit-seeking behaviors. Based on the Plan of Care, facility staff was to implement and place a Wanderguard bracelet on the resident's ankle at all times as an intervention for staff to be alerted if the resident attempted to exit the facility without staff knowledge unassisted. Review of an incident report dated 09/30/13 revealed SRNA #11 found Resident #14 outside the facility in the parking lot attempting to get into a truck. There was no documented evidence of how long the resident was outside of the facility or how staff was made aware the resident was outside of the facility. Interview on 10/16/13 at 3:50 PM with SRNA #11 revealed on 09/30/13, between 6:30 and 7:00 PM, she was informed by someone (unable to remember who) that Resident #14 was outside of the facility. The interview further revealed the SRNA found the resident in the facility's parking lot attempting to get into a truck. SRNA #11 stated she assisted Resident #14 back into the facility and a nurse was informed of the incident. The SRNA stated Resident #14 exits the facility "all the time" without staff knowledge or assistance. During an interview on 10/17/13 at 1:15 PM, LPN #8 revealed she was on a break when Resident #14 exited the facility on 09/30/13, and was not made aware of the incident until the resident was assisted back inside the building by facility staff. The interview further revealed the LPN was not aware how long the resident was outside of the facility or who identified and/or reported Resident #14 was outside of the facility. According to LPN #8, Resident #14 often attempted to leave the facility unassisted, but staff usually witnessed Resident #14's efforts to exit the building and redirected him/her back inside the building. Interview on 10/17/13 at 1:30 PM with Registered Nurse (RN) #2 revealed the RN was aware Resident #14 got outside of the facility into the parking lot on 09/30/13 but was not aware of how long the resident was outside of the facility or who discovered the resident outside the facility. The interview further revealed Resident #14 exited the facility, unassisted, on numerous occasions but staff usually observed the resident and assisted the resident back inside the building. Interviews on 10/17/13 with SRNA #13 at 2:04 PM, and SRNA #6 at 2:09 PM, revealed Resident #14 often made attempts to exit and/or had exited the facility; however, according to SRNA #13 and SRNA #6, staff usually witnessed the resident's attempts and redirected and/or assisted the resident back into the facility. Interview on 10/17/13 at 1:51 PM with the DON revealed she was aware Resident #14 had exited the facility on 09/30/13 but was unaware of how long Resident #14 was outside of the facility. The DON was unable to find documented evidence of the facility's hourly safety checks for Resident #14 for 09/30/13. An interview with the ED on 10/16/13 at 12:40 PM revealed she was responsible to investigate incidents of elopement. She acknowledged Resident #14 had exit-seeking behaviors and had exited the facility on 09/30/13. However, the ED failed to provide documentation that the incident of Resident #14 exiting the facility had been investigated, or that new interventions had been implemented to prevent further elopements from occurring. 4. Review of the medical record for Resident #2 revealed the facility admitted the resident on 08/13/12 with [DIAGNOSES REDACTED]. A review of Resident #2's Nurse Aide's Information Sheet dated 02/11/13 revealed the resident required assistance of one to two persons with transfers. A review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #2 required extensive assistance of two persons for bed mobility, transfers, and ambulation. However, review of Resident #1's Plan of Care, revision date of 10/01/13, revealed staff had failed to document the assistance required by the resident for transfers. A review of an incident report dated 09/19/13 revealed SRNA #9 was assisting Resident #2 by herself to bed and the resident fell to the floor. Documentation revealed at the time of the incident Resident #2 stated he/she heard his/her ankle pop and complained of ankle pain. LPN #5 assessed Resident #2 and made arrangements for Resident #2 to be transferred to the hospital emergency room for examination. Review of the facility's investigation revealed that as a result of the examination performed by the staff in the emergency room , Resident #2 was diagnosed with [REDACTED]. A review of the facility's investigation of the incident dated 09/25/13 revealed SRNA #9 failed to use a gait belt for the transfer of Resident #2 and the resident had fallen. However, the facility's investigation failed to address that the resident had been assessed to need the extensive assistance of two persons for transfers and that the SRNA had transferred the resident without another staff person to assist. Further review of the facility's investigation of the fall revealed the facility substantiated caretaker neglect and terminated SRNA #9's employment due to failure to use a gait belt when she had transferred Resident #2 on 09/19/13. Interview on 10/02/13 at 4:25 PM with LPN #5 revealed SRNA #9 had informed the LPN that she had attempted to transfer Resident #2 from the wheelchair to the bed by herself without a gait belt, the resident's legs "gave out," and the resident fell and complained of pain. The interview confirmed facility staff assessed Resident #2 after the fall and transferred the resident to the hospital emergency room for an evaluation. Interview on 10/02/13 at 4:38 PM with the DON revealed the DON was responsible to update each resident's Plan of Care, Monday through Friday, and to make changes as needed. The interview further revealed the DON was not aware Resident #2's Plan of Care and the Nurse Aide's Information Sheet failed to contain the updated information related to the requirement of two staff persons to assist Resident #2 with transfers. Interview on 10/02/13 at 3:25 PM with the ED revealed the facility had investigated Resident #2's fall and had determined the fall was the result of SRNA #9's failure to use a gait belt when attempting to transfer Resident #2 from the wheelchair to the bed. The ED stated she was not aware Resident #2 had been assessed to require two staff persons for transfers. The interview further revealed that based on the facility's investigation the facility had determined SRNA #9 had failed to transfer the resident with the gait belt and had terminated the SRNA's employment at the facility. 5. A review of the medical record of Resident #1 revealed the facility admitted the resident on 09/21/10, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set assessment, completed on 08/19/13, revealed the facility assessed Resident #1 to require the extensive assistance of one staff person with bed mobility, transfers, and ambulation. The facility also noted Resident #1 utilized a walker and a wheelchair for mobility. In addition, based on the assessment, facility staff was to utilize a trunk physical restraint for Resident #1 when he/she was up in the wheelchair. Review of a fall incident report dated 09/09/13 revealed a family member of Resident #1's roommate informed a nurse that Resident #1 had fallen to the floor, and an SRNA had assisted the resident back into a wheelchair. Further review of the incident report revealed facility staff assessed Resident #1 after being informed of the fall and noted the resident had a laceration on the left side of the head. The incident report revealed Resident #1 was assessed and transferred to the hospital emergency room for further evaluation and treatment at which time the resident received staples to the laceration on the left side of the head. A review of the facility's investigation of the fall, dated 09/10/13, revealed on 09/09/13 SRNA #10 assisted Resident #1 back into his/her wheelchair after the resident had fallen and failed to inform the nurse of the resident's fall. Further review of the investigation revealed after the resident's fall SRNA took a break and never reported the resident's fall to anyone. Continued review of the investigation revealed staff arranged for Resident #1 to be transferred to the hospital emergency room for evaluation and treatment; and based on the report, Resident #1 returned to the facility with staples intact to a head wound. The investigation further revealed SRNA #10 was sent home, not allowed further contact with the residents on 09/09/13, the day of the incident, and was terminated from employment on 09/10/13. Review of Resident #1's Plan of Care, revision date of 09/24/13, revealed the facility assessed the resident to have a history of multiple falls, with minor injuries, since his/her admission to the facility. The facility had assessed the resident to require the use of a soft lap belt, fall mats at the bedside, a bed alarm, and hipster briefs as an intervention to prevent falls/injuries. Interview on 10/02/13 at 3:00 PM with SRNA #8 revealed the SRNA was in orientation with SRNA #10 on 09/09/13, the day Resident #1 had the fall that resulted in the laceration. The interview further revealed SRNAs #8 and #10 were walking down the hall to go on break and overheard someone yell for help. SRNA #8 stated she and SRNA #10 walked into Resident #1's room and observed the resident attempting to get up from the floor. Based on interviews, SRNA #10 assisted the resident into the wheelchair, attached the resident's restraint, and then SRNAs #8 and #10 continued to go outside the facility for a break. SRNA #8 stated she was not aware Resident #1 had an injury. SRNA #8 revealed when she was hired she was trained to not move a resident that had fallen and to report all falls immediately to the nurse; however, SRNA #8 stated since she was in orientation she thought SRNA #10 would report the incident. Interview on 10/02/13 at 11:23 AM with SRNA #4 revealed she had been assigned to assist and provide care to Resident #1 on 09/09/13 when the fall occurred but she did not witness the fall. SRNA #4 stated after her break she was assessing the residents, noticed the cut on Resident #1's head, and immediately informed the nurse. Interview on 10/02/13 at 11:41 AM with SRNA #5 revealed the SRNA was making a round with SRNA #4 and noticed Resident #1 sitting in the wheelchair with a laceration on his/her head. The interview further revealed Resident #1's roommate's family member informed SRNA #5 that SRNAs #8 and #10 had assisted the resident back into the resident's wheelchair after the resident had fallen and was concerned that they had failed to report the resident's fall to the nurse. The interview further revealed the nurse immediately came to the room to assess the resident and the resident was sent to the hospital for an evaluation. Interview on 10/02/13 at 12:20 PM with LPN #4 revealed the LPN was informed of Resident #1's fall on 09/09/13 by SRNAs #4 and #5. The interview further revealed the SRNAs had reported to the LPN they had been informed by a family member that SRNAs #8 and #10 had assisted Resident #1 back into a wheelchair after the resident had fallen. The LPN stated neither SRNA #8 nor SRNA #10 had informed her of the resident's fall and stated she immediately assessed Resident #1 and sent the resident to the hospital for an evaluation. The interview further revealed LPN #4 immediately reported the incident to the ED and SRNA #10 was immediately removed from resident care. Interview on 10/02/13 at 3:25 PM with the ED revealed the incident involving Resident #1's fall on 09/09/13 was investigated immediately. According to the ED, SRNA #10 was removed from care and then terminated for failure to report a resident's fall. The interview further revealed SRNA #10 admitted to finding Resident #1 on the floor, assisting the resident back into the resident's wheelchair, and reapplying the resident's restraint. The ED further revealed SRNA #10 denied being aware the resident was injured. The interview further revealed SRNA #8 was still in orientation with SRNA #10 at the time of the incident so SRNA #8 was retrained on proper fall procedures.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to provide adequate supervision and assistive devices for five of eighteen sampled residents (Residents #1, #2, #4, #14, and #15) to prevent accident hazards; Residents #4, #14, and #15 related to exiting the facility unsupervised, and Residents #1 and #2 related to falls. Based on interviews conducted with facility staff, Resident #4 had a history of [REDACTED]. Resident #4 exited the facility on 05/20/13 in his/her wheelchair and was found over an embankment behind the facility without injury. Observations conducted on 10/08/13 revealed Resident #4 pushed an exit door open, without staff present, and an alarm sounded; however, observation revealed facility staff was not in the immediate area and failed to respond to the alarm for three minutes. On 09/30/13, Resident #14 exited the facility, went to the facility parking lot without supervision or assistance, and was observed by a State Registered Nurse Aide (SRNA) attempting to get into a truck. In addition, Resident #15, on 03/15/13, exited out the back door of the facility, without supervision or assistance, walked around the building, and sat down under a tree. Continued interviews and record reviews revealed on 09/19/13, SRNA #9 was assisting Resident #2 to the bed and the resident sustained [REDACTED]. Continued interviews and record reviews revealed Resident #1 sustained a fall with injury and was assisted back into a wheelchair by SRNA #10; however, the SRNA failed to report the fall to the nurse. The facility's failure to provide adequate supervision and assistive devices placed residents at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 10/16/13 and is ongoing at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 10/16/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Elopements," not dated, revealed staff should investigate and report all cases of missing residents. The policy did not provide staff with guidance related to what actions to take, to prevent further elopements, when an elopement occurred. Review of the facility's policy titled "Fall Procedure," not dated, revealed when staff observes a resident fall, staff should allow the resident to lie on the floor and examine carefully. The policy review further revealed if a resident was found on the floor, staff was not to move the resident until the resident could be assessed by the Charge Nurse. Review of the facility's policy titled "Transfer of Residents (Use of Gait Belts)," not dated, revealed a gait belt should be used in the transfer or ambulation of any resident that required the assistance of a staff member. 1. Review of Resident #15's medical record revealed the facility admitted the resident on 10/03/12 with [DIAGNOSES REDACTED]. Review of Resident #15's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 required supervision/oversight with ambulation and was cognitively intact. Review of the Risk of Elopement/Wandering Review for Resident #15 dated 10/11/12 revealed the facility assessed the resident and determined the resident was an elopement risk due to facility staff being unable to redirect the resident from going outside unsupervised. Review of the resident's care plan dated 10/11/12 revealed a Wanderguard bracelet (placed on the resident's person and triggers an alarm at the exit door if the resident attempts to exit the facility without staff knowledge) was placed on the resident and every hour checks were initiated at that time. Further review of Resident #15's care plan (not dated when revised) revealed the resident had removed the Wanderguard bracelet and the bracelet was replaced. Review of Social Services Notes dated 01/02/13 revealed the resident was not allowed to move into a community setting because the resident was considered to be an elopement risk by the resident's State Guardian. Further review of Resident #15's care plan revealed the resident utilized a rolling walker for ambulation in the hallway and could ambulate outdoors when the weather permitted. Although the resident's MDS assessment revealed the resident required supervision/oversight with ambulation, the care plan did not specify the level of supervision required outdoors. Review of the facility's incident reports completed for Resident #15 on 03/15/13 (time not specified) revealed Resident #15 was agitated and wanted to go outside the facility and walk around the parking lot. Licensed Practical Nurse (LPN) #1 told the resident she would take the resident for a walk but, for safety reasons, the resident had to wait for the LPN to go with him/her. According to the incident report, Resident #15 went past the nurses' station, down the hallway into the break room, and out the back door. The incident report revealed the resident left his/her rolling walker inside the facility at the back door. The incident report stated Resident #15 walked around the facility, up an embankment, and was found seated under a tree. According to the incident report, the resident stated he/she got tired and sat down. The incident report did not address how long the resident was outside the facility without staff supervision. Further review of the incident report revealed the resident complained of right knee pain and was assessed to have no injury. According to the incident report, the resident stated he/she was going for a walk and got lost. Interview with LPN #1 on 10/15/13 at 1:50 PM revealed Resident #15 wanted to go outside for a walk on 03/15/13 at approximately 3:00 PM. LPN #1 told the resident he/she had to wait for her to complete a task before she could take the resident for a walk. According to LPN #1, she left Resident #15, completed a task, and approximately 15 minutes later went to find the resident to take the resident for a walk. LPN #1 stated she could not locate the resident and asked facility staff to assist her in searching for the resident. Further interview revealed the LPN went to the back door of the facility and the Wanderguard system alarm was sounding; however, she did not hear the alarm until she had almost reached the back door. According to the LPN, she went out the door, around the building, and Resident #15 was found under a tree beside a facility office building. According to the LPN, Resident #15 had traveled about 500 feet from the building. On 10/16/13 at 9:40 AM, observations were conducted of the area outside the back door of the facility where Resident #15 was located after he/she exited the building unsupervised. Observations revealed the area just outside the back door of the facility was within 100 feet of a retaining basin that was approximately 7 feet deep and a ditch that was approximately 12 feet deep. Further observation revealed the back door of the facility was within 8 feet of a hill with a sloping grade of approximately 25 degrees. According to the facility's Executive Director, the total property consisted of five acres. Interview with the Director of Nursing (DON) on 10/15/13 at 4:20 PM revealed that elopement incidents were discussed during the facility's weekly safety meeting. According to the DON, Resident #15's elopement had been discussed; however, the facility did not conduct a thorough investigation to determine how the resident was able to leave the facility without staff knowledge and be gone for an undetermined amount of time or revise the resident's care plan to prevent further potential elopements. The DON stated the facility's Wanderguard system had not been considered to be ineffective because the system was checked and working. Further interview revealed the incident was not reported to state agencies because the facility's administrative staff felt that because the resident had not left the facility property it was not an allegation of neglect. Interview with the Executive Director on 10/16/13 at 12:40 PM revealed she reviewed the incident reports and conducted investigations regarding elopements. According to the Executive Director, Resident #15 exiting the building was not considered an elopement because the resident had not left the facility's property; the allegation was not reported to the required state agencies because neglect was not considered. Further interview revealed the Executive Director had reviewed the incident, but had not considered that the facility's Wanderguard system may not be effective because the system was functioning, even though Resident #15 was able to exit the building without staff knowledge. 2. Review of the medical record for Resident #4 revealed the facility admitted the resident on 02/03/12 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with transfers, dressing, and bathing, and utilized a wheelchair for mobility. Further review of the assessment revealed staff identified Resident #4 had behaviors of wandering, which had occurred one to three days during the assessment period. Review of documentation in Resident #4's medical record revealed the facility assessed the resident on 04/25/12 to be an elopement risk and applied a Wanderguard bracelet to the resident's ankle at that time. Observations conducted on 10/08/13 at 3:41 PM revealed Resident #4 was on the back hallway of the facility; Resident #4 was wearing a "Wanderguard bracelet" on his/her right ankle. Continued observation revealed Resident #4 pushed open an exit door located on the back hallway of the facility and an alarm sounded. However, facility staff was not in the immediate area when the resident pushed the door open and staff failed to respond to the alarm for three minutes. The resident opened the door but did not go out the door. Interview conducted with Licensed Practical Nurse (LPN) #1 on 10/16/13 at 11:40 AM revealed Resident #4 had been "missing" from the facility but was unable to remember when the incident occurred. The LPN stated that at the time of the incident she realized that she had not seen the resident in a while and tried to locate the resident. Continued interview revealed she was unable to locate the resident and notified other staff the resident was "missing." The LPN stated the search continued outside the facility and Resident #4's wheelchair, with a lap belt restraint attached, was located in a graveled parking area at the back of the facility. LPN #1 stated another nurse located the resident beside a bush on a hill that was located approximately 100 feet away from the resident's wheelchair. The LPN stated the Wanderguard bracelet was still attached to Resident #4's right ankle. According to LPN #1, she had not heard an alarm sound prior to being unable to locate Resident #4 at the time of the incident. The LPN stated the door alarms were supposed to sound when a resident attempted to exit the doors; she stated she could not always hear the facility's door alarms because the alarm was not loud enough to be heard at times. The LPN stated the resident was assessed to have no injuries as a result of the incident. In addition, according to LPN #1, she had not documented the incident in the medical record or notified administrative staff of the incident because that was the responsibility of the Charge Nurse; however, the LPN could not recall who the Charge Nurse was at the time of the incident. LPN #1 stated that, although she could not recall the date, she had notified the Director of Nursing (DON) and the Executive Director (ED) of the inability to hear the door alarms from all areas of the facility. LPN #2 confirmed in interview on 10/16/13 at 3:50 PM that, although she did not recall the date, Resident #4 had been missing from the facility possibly in March 2013. The LPN stated she was notified Resident #4 was missing and assisted in the search for the resident; however, LPN #2 stated she had not heard any door alarms sound prior to the search for the resident. LPN #2 stated she located Resident #4 at the "bottom of the hill, at the gated area, located in back of the facility." The LPN stated she was unable to recall if she documented the incident, or notified administrative staff. The LPN continued to state the facility's exit door alarms do not work "half the time" and administrative staff "know they don't work." Continued review of Resident #4's medical record revealed facility staff had not documented that Resident #4 had left the facility without staff knowledge in March 2013. However, a review of an incident report entitled "Elopement," dated 05/20/13, revealed Resident #4 had exited the facility in a wheelchair and wheeled his/her self over an embankment located in back of the facility. Resident #4 did not sustain any injuries. Interview with LPN #3 on 10/15/13 at 2:03 PM revealed she had been assigned to care for Resident #4 when the elopement occurred on 05/20/13. LPN #3 stated she heard the back door alarm and when she responded, the resident had "rolled down the slight embankment" in his/her wheelchair. LPN #3 also stated she had not implemented any interventions after the incident occurred and stated staff nurses "don't update care plans." The LPN stated, although she had not reported the incident to administrative staff, she "passed" the information to the oncoming shift and documented the incident on the 24-hour report. Continued interview revealed, "If a resident's sock is pulled up over their Wanderguard bracelet, or if the bracelet is turned a certain way, it will not work properly to sound the exit alarms." The LPN further stated she had not reported the concern related to the exit alarm system to Administration, but "should have." Interview with State Registered Nurse Aide (SRNA) #14 on 10/16/13 at 10:00 AM revealed she was working at the time the elopement occurred on 05/20/13. The SRNA stated she never heard an exit alarm sounding, and was only aware of the resident's elopement when notified by the nurse after the incident had occurred. The SRNA stated the exit door alarms, on the back hall where Resident #4 exited the facility, "never worked." The SRNA also stated facility staffing was "horrible" and staff was not able to answer fall alarms or exit door alarms timely. Interview with SRNA #15 on 10/15/13 at 3:50 PM revealed the facility was short-staffed most of the time. The SRNA stated the facility had a lot of "wanderers," alarms, and falls, and with all the other work required to be completed during their shift, it was "hard to do things timely." Observations and interviews on 10/16/13 at 9:40 AM conducted with Maintenance Staff Person #1 and Human Resources (HR) Staff Person #1, who assisted in transporting the resident back into the facility on [DATE], revealed the resident had gone down an approximate 25 to 30-degree sloped, grassy area in a wheelchair. Further observations and interview with the HR staff revealed the resident was approximately 100 feet from the facility. Interview with the DON on 10/15/13 at 4:20 PM revealed she had not been notified of an elopement incident, which involved Resident #4, any time before the documented elopement that occurred on 05/20/13. The DON stated staff had not notified her, and she had not been made aware that Resident #4 had ever been missing from the facility. However, she had reviewed an elopement incident sometime in May 2013 for Resident #4. She acknowledged she had not investigated the incident or implemented any new interventions to prevent further elopements for the resident. The DON further stated she had not considered the incident a true elopement, because she had been trained that if residents remained on facility property they had not eloped. The DON stated staff had never notified her that the door alarms could not be heard at times. However, she stated Maintenance had adjusted the alarms, but could not recall when or why the alarms were adjusted. Interview with the Executive Director (ED) on 10/16/13 at 12:40 PM revealed she was responsible for investigating incidents of elopement. The ED stated she had not been notified of an elopement that occurred around March 2013. She acknowledged Resident #4 had exit-seeking behaviors, and had exited the facility in May 2013. However, no evidence was provided to ensure Resident #4's elopement had been investigated, or that new interventions had been implemented to prevent further elopements from occurring. She stated she was not aware of concerns related to the exit doors' alarms. 3. Review of the medical record for Resident #14 revealed the facility admitted the resident on 07/25/13 with [DIAGNOSES REDACTED]. Further review of the medical record revealed Nurse's Progress Notes dated 07/25/13 through 10/17/13 that revealed Resident #14 began having exit-seeking behaviors on 08/04/13. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the facility assessed Resident #14 as being cognitively impaired and required supervision with the assistance of one person for ambulation. Review of the Plan of Care revealed the facility revised the Plan of Care on 08/05/13 and documented the resident had exit-seeking behaviors. Based on the Plan of Care, facility staff was to implement and place a Wanderguard bracelet on the resident's ankle at all times as an intervention for staff to be alerted if the resident attempted to exit the facility without staff knowledge unassisted. Review of an incident report dated 09/30/13 revealed SRNA #11 found Resident #14 outside the facility in the parking lot attempting to get into a truck. There was no documented evidence of how long the resident was outside of the facility or how staff was made aware the resident was outside of the facility. Interview on 10/16/13 at 3:50 PM with SRNA #11 revealed on 09/30/13, between 6:30 and 7:00 PM, she was informed by someone (unable to remember who) that Resident #14 was outside of the facility. The interview further revealed the SRNA found the resident in the facility's parking lot attempting to get into a truck. SRNA #11 stated she assisted Resident #14 back into the facility and a nurse was informed of the incident. The SRNA stated Resident #14 exits the facility "all the time" without staff knowledge or assistance. During an interview on 10/17/13 at 1:15 PM, LPN #8 revealed she was on a break when Resident #14 exited the facility on 09/30/13, and was not made aware of the incident until the resident was assisted back inside the building by facility staff. The interview further revealed the LPN was not aware how long the resident was outside of the facility or who identified and/or reported Resident #14 was outside of the facility. According to LPN #8, Resident #14 often attempted to leave the facility unassisted, but staff usually witnessed Resident #14's efforts to exit the building and redirected him/her back inside the building. Interview on 10/17/13 at 1:30 PM with Registered Nurse (RN) #2 revealed the RN was aware Resident #14 got outside of the facility into the parking lot on 09/30/13 but was not aware of how long the resident was outside of the facility or who discovered the resident outside the facility. The interview further revealed Resident #14 exited the facility, unassisted, on numerous occasions but staff usually observed the resident and assisted the resident back inside the building. Interviews on 10/17/13 with SRNA #13 at 2:04 PM, and SRNA #6 at 2:09 PM, revealed Resident #14 often made attempts to exit and/or had exited the facility; however, according to SRNA #13 and SRNA #6, staff usually witnessed the resident's attempts and redirected and/or assisted the resident back into the facility. Interview on 10/17/13 at 1:51 PM with the DON revealed she was aware Resident #14 had exited the facility on 09/30/13 but was unaware of how long Resident #14 was outside of the facility. The DON was unable to find documented evidence of the facility's hourly safety checks for Resident #14 for 09/30/13. An interview with the ED on 10/16/13 at 12:40 PM revealed she was responsible to investigate incidents of elopement. She acknowledged Resident #14 had exit-seeking behaviors and had exited the facility on 09/30/13. However, the ED failed to provide documentation that the incident of Resident #14 exiting the facility had been investigated, or that new interventions had been implemented to prevent further elopements from occurring. 4. Review of the medical record for Resident #2 revealed the facility admitted the resident on 08/13/12 with [DIAGNOSES REDACTED]. A review of Resident #2's Nurse Aide's Information Sheet dated 02/11/13 revealed the resident required assistance of one to two persons with transfers. A review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #2 required extensive assistance of two persons for bed mobility, transfers, and ambulation. However, review of Resident #1's Plan of Care, revision date of 10/01/13, revealed staff had failed to document the assistance required by the resident for transfers. A review of an incident report dated 09/19/13 revealed SRNA #9 was assisting Resident #2 by herself to bed and the resident fell to the floor. Documentation revealed at the time of the incident Resident #2 stated he/she heard his/her ankle pop and complained of ankle pain. LPN #5 assessed Resident #2 and made arrangements for Resident #2 to be transferred to the hospital emergency room for examination. Review of the facility's investigation revealed that as a result of the examination performed by the staff in the emergency room , Resident #2 was diagnosed with [REDACTED]. A review of the facility's investigation of the incident dated 09/25/13 revealed SRNA #9 failed to use a gait belt for the transfer of Resident #2 and the resident had fallen. However, the facility's investigation failed to address that the resident had been assessed to need the extensive assistance of two persons for transfers and that the SRNA had transferred the resident without another staff person to assist. Further review of the facility's investigation of the fall revealed the facility substantiated caretaker neglect and terminated SRNA #9's employment due to failure to use a gait belt when she had transferred Resident #2 on 09/19/13. Interview on 10/02/13 at 4:25 PM with LPN #5 revealed SRNA #9 had informed the LPN that she had attempted to transfer Resident #2 from the wheelchair to the bed by herself without a gait belt, the resident's legs "gave out," and the resident fell and complained of pain. The interview confirmed facility staff assessed Resident #2 after the fall and transferred the resident to the hospital emergency room for an evaluation. Interview on 10/02/13 at 4:38 PM with the DON revealed the DON was responsible to update each resident's Plan of Care, Monday through Friday, and to make changes as needed. The interview further revealed the DON was not aware Resident #2's Plan of Care and the Nurse Aide's Information Sheet failed to contain the updated information related to the requirement of two staff persons to assist Resident #2 with transfers. Interview on 10/02/13 at 3:25 PM with the ED revealed the facility had investigated Resident #2's fall and had determined the fall was the result of SRNA #9's failure to use a gait belt when attempting to transfer Resident #2 from the wheelchair to the bed. The ED stated she was not aware Resident #2 had been assessed to require two staff persons for transfers. The interview further revealed that based on the facility's investigation the facility had determined SRNA #9 had failed to transfer the resident with the gait belt and had terminated the SRNA's employment at the facility. 5. A review of the medical record of Resident #1 revealed the facility admitted the resident on 09/21/10, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set assessment, completed on 08/19/13, revealed the facility assessed Resident #1 to require the extensive assistance of one staff person with bed mobility, transfers, and ambulation. The facility also noted Resident #1 utilized a walker and a wheelchair for mobility. In addition, based on the assessment, facility staff was to utilize a trunk physical restraint for Resident #1 when he/she was up in the wheelchair. Review of a fall incident report dated 09/09/13 revealed a family member of Resident #1's roommate informed a nurse that Resident #1 had fallen to the floor, and an SRNA had assisted the resident back into a wheelchair. Further review of the incident report revealed facility staff assessed Resident #1 after being informed of the fall and noted the resident had a laceration on the left side of the head. The incident report revealed Resident #1 was assessed and transferred to the hospital emergency room for further evaluation and treatment at which time the resident received staples to the laceration on the left side of the head. A review of the facility's investigation of the fall, dated 09/10/13, revealed on 09/09/13 SRNA #10 assisted Resident #1 back into his/her wheelchair after the resident had fallen and failed to inform the nurse of the resident's fall. Further review of the investigation revealed after the resident's fall SRNA took a break and never reported the resident's fall to anyone. Continued review of the investigation revealed staff arranged for Resident #1 to be transferred to the hospital emergency room for evaluation and treatment; and based on the report, Resident #1 returned to the facility with staples intact to a head wound. The investigation further revealed SRNA #10 was sent home, not allowed further contact with the residents on 09/09/13, the day of the incident, and was terminated from employment on 09/10/13. Review of Resident #1's Plan of Care, revision date of 09/24/13, revealed the facility assessed the resident to have a history of multiple falls, with minor injuries, since his/her admission to the facility. The facility had assessed the resident to require the use of a soft lap belt, fall mats at the bedside, a bed alarm, and hipster briefs as an intervention to prevent falls/injuries. Interview on 10/02/13 at 3:00 PM with SRNA #8 revealed the SRNA was in orientation with SRNA #10 on 09/09/13, the day Resident #1 had the fall that resulted in the laceration. The interview further revealed SRNAs #8 and #10 were walking down the hall to go on break and overheard someone yell for help. SRNA #8 stated she and SRNA #10 walked into Resident #1's room and observed the resident attempting to get up from the floor. Based on interviews, SRNA #10 assisted the resident into the wheelchair, attached the resident's restraint, and then SRNAs #8 and #10 continued to go outside the facility for a break. SRNA #8 stated she was not aware Resident #1 had an injury. SRNA #8 revealed when she was hired she was trained to not move a resident that had fallen and to report all falls immediately to the nurse; however, SRNA #8 stated since she was in orientation she thought SRNA #10 would report the incident. Interview on 10/02/13 at 11:23 AM with SRNA #4 revealed she had been assigned to assist and provide care to Resident #1 on 09/09/13 when the fall occurred but she did not witness the fall. SRNA #4 stated after her break she was assessing the residents, noticed the cut on Resident #1's head, and immediately informed the nurse. Interview on 10/02/13 at 11:41 AM with SRNA #5 revealed the SRNA was making a round with SRNA #4 and noticed Resident #1 sitting in the wheelchair with a laceration on his/her head. The interview further revealed Resident #1's roommate's family member informed SRNA #5 that SRNAs #8 and #10 had assisted the resident back into the resident's wheelchair after the resident had fallen and was concerned that they had failed to report the resident's fall to the nurse. The interview further revealed the nurse immediately came to the room to assess the resident and the resident was sent to the hospital for an evaluation. Interview on 10/02/13 at 12:20 PM with LPN #4 revealed the LPN was informed of Resident #1's fall on 09/09/13 by SRNAs #4 and #5. The interview further revealed the SRNAs had reported to the LPN they had been informed by a family member that SRNAs #8 and #10 had assisted Resident #1 back into a wheelchair after the resident had fallen. The LPN stated neither SRNA #8 nor SRNA #10 had informed her of the resident's fall and stated she immediately assessed Resident #1 and sent the resident to the hospital for an evaluation. The interview further revealed LPN #4 immediately reported the incident to the ED and SRNA #10 was immediately removed from resident care. Interview on 10/02/13 at 3:25 PM with the ED revealed the incident involving Resident #1's fall on 09/09/13 was investigated immediately. According to the ED, SRNA #10 was removed from care and then terminated for failure to report a resident's fall. The interview further revealed SRNA #10 admitted to finding Resident #1 on the floor, assisting the resident back into the resident's wheelchair, and reapplying the resident's restraint. The ED further revealed SRNA #10 denied being aware the resident was injured. The interview further revealed SRNA #8 was still in orientation with SRNA #10 at the time of the incident so SRNA #8 was retrained on proper fall procedures. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on 10/29/13, which alleged the Immediate Jeopardy was removed on 10/26/13; however, observations and interviews revealed the Immediate Jeopardy was removed on 10/31/13. A review of the AOC revealed the Comprehensive Care Plan (CCP) and State Registered Nurse Aide (SRNA) Care Plan for Resident #1 were revised on 10/23/13 by the MDS Coordinator to include a cushion in the wheelchair, a sensor pad in the wheelchair, and the termination of the physical restraint. The resident was evaluated by Rehabilitation for wheelchair position and safety. The AOC revealed the CCP and SRNA Care Plan had been updated by the MDS Coordinator on 10/23/13 and Therapy staff was providing services to Resident #2. As a result of the incident with Resident #2, the facility terminated SRNA # 9 from employment on 09/20/13. Continued review of the AOC revealed on 10/23/13 the MDS Coordinator revised the CCPs, and the SRNA Care Plans for Residents #4, #14, and #15 were revised on 10/23/13, and addressed the residents' high risk for elopement. The intervention of the use of the wander guard ankle bracelet was ongoing and a "Wander Book" identification, which included interventions and diversions, was implemented. Staff was educated on the "Wander Book" on 10/25/13 and the Social Services Director was responsible for updating the resident's risk for elopement each week. The revisions were a result of wandering/elopement assessments completed by the MDS Coordinator on 10/18/13. On 10/17/13, the facility implemented the use of a "safety employee" who was assigned to conduct observations of the residents every 15 minutes to ensure the safety of the residents in the facility. The AOC revealed the Administrator and Executive Director implemented a new "wandering" program on 10/17/13. Further review of the AOC revealed each resident identified as being high risk for wandering/and or elopement was monitored every 15 minutes for safety and a picture and description of

Based on observation, interview, record review, and a review of facility policy it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility Administration failed to ensure Residents #4, #14, and #15, who were assessed to be an elopement risk and were utilizing a Wanderguard bracelet, received adequate supervision and assistive devices to prevent accidents. Residents #4 and #15 exited out the back door of the facility without staff knowledge. On 03/15/13, Resident #15 was gone for an undetermined amount of time and was found under a tree approximately 500 feet from where the resident exited the facility. Resident #4 exited the facility on 05/20/13, was gone for an undetermined amount of time, and was located approximately 100 feet from the facility. The resident was found on the ground approximately 50 feet from his/her wheelchair. On 09/30/13, Resident #14 exited the facility and was found in the parking lot attempting to get into a vehicle. The facility Administration failed to ensure the incidents were documented, failed to thoroughly investigate how the residents were able to exit the building without staff knowledge, and failed to implement corrective action in an attempt to prevent further resident elopement (Refer to F280 and F323). In addition, the facility Administration failed to ensure there was an effective system to assess the necessary and safe use of physical restraints for Residents #1, #5, #6, #7, and #8. Resident #1 utilized a lap belt restraint that the resident was able to remove and sustained falls. The facility revised the resident's care plan to tie the physical restraint underneath the wheelchair so the resident could not remove the device, which was not in accordance with the manufacturer's guidelines. Resident #1 then attempted to remove the restraint and slid under the restraint which was contraindications for use per the manufacturer's guidelines; however, the facility failed to assess the resident's risk factors for injury, and Resident #1 continued to utilize the lap belt restraint (Refer to F221 and F280). The facility Administration's failure to ensure residents received adequate supervision and assistive devices to prevent accidents and failure to ensure residents were free from physical restraints placed residents in the facility at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.75 Administration. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: An interview conducted with the facility Executive Director on 10/17/13 at 3:30 PM revealed the facility administration policy consisted of an Organizational Chart. Additional interview revealed the Executive Director and the Administrator met as needed to discuss incidents in the facility and to evaluate the facility systems for improvement. A review of the facility's policy titled "Restraint Policy," not dated, revealed the facility limited the use of restraints to circumstances in which the resident had medical symptoms that warranted the use of restraints, and the resident was to be fully informed of the potential risks and benefits of use of the restraint. Further review of the restraint policy revealed the facility would use a systematic and gradual process toward reducing the restraints. A review of the manufacturer's instructions for the application of the Soft Belt restraint revealed the use of the Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off of the chair and become suspended or entrapped. Observations, interviews, and record reviews completed during the abbreviated survey revealed a soft lap belt restraint was not utilized in accordance with manufacturer's guidelines for Resident #1 when the resident exhibited behaviors of trying to remove/slide under the physical restraint. Further investigation revealed Residents #1, #5, #6, #7, and #8 had no evidence of a medical symptom that required the use of a physical restraint. In addition, the facility failed to evaluate/assess Residents #5, #7 and #8's physical restraint in order to reduce/eliminate the restraint. A review of the facility policy titled "Elopements," not dated, revealed staff should investigate and report all cases of missing residents. The policy did not provide staff with guidance related to what actions to take to prevent further elopements when an elopement occurred. Observations, interviews, and record review completed for residents who were identified by the facility as elopement risk revealed Residents #4, #14, and #15 had exited the building without staff knowledge. There was no evidence the facility conducted thorough investigations to identify causative factors to prevent residents from exiting the building without staff knowledge. The facility failed to evaluate the effectiveness of interventions that were in place for these residents and review/revise the residents' plan of care with interventions to meet the needs of these residents. An interview conducted with the Executive Director (ED) on 10/16/13 at 12:40 PM and on 10/17/13 at 3:30 PM revealed administrative staff had discussed the resident elopement incidents, but failed to evaluate the interventions in place to prevent residents from eloping without staff knowledge, and did not implement any other actions. The ED stated the facility checked to see that the alarm system was functioning properly when the residents eloped, and since the alarms were functioning properly administrative staff felt no other action was needed. Further interview revealed that all incidents were discussed in the weekly safety meeting, which was attended by the Executive Director, and the facility Wanderguard system was not identified as a concern. The ED revealed administrative staff did not consider residents leaving the facility without staff knowledge as an "elopement" because the residents were found on facility property. Further interview with the ED revealed administrative staff did not provide any oversight for any aspect of restraint use, and restraint use was determined by the Director of Nursing and Registered Nurse #1. Interview with the Director of Nursing (DON) on 10/08/13 at 2:55 PM revealed the facility did not attempt physical restraint reductions/eliminations as long as the resident had no negative outcome, for example, no pressure sores. The DON stated she was aware Resident #1 had slid under the restraint and sustained a fall, but did not consider the risks of the resident sliding under the restraint, thus, failed to re-evaluate the continued usage of the restraint.

Based on observation, interview, record review, and a review of facility policy it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility Administration failed to ensure Residents #4, #14, and #15, who were assessed to be an elopement risk and were utilizing a Wanderguard bracelet, received adequate supervision and assistive devices to prevent accidents. Residents #4 and #15 exited out the back door of the facility without staff knowledge. On 03/15/13, Resident #15 was gone for an undetermined amount of time and was found under a tree approximately 500 feet from where the resident exited the facility. Resident #4 exited the facility on 05/20/13, was gone for an undetermined amount of time, and was located approximately 100 feet from the facility. The resident was found on the ground approximately 50 feet from his/her wheelchair. On 09/30/13, Resident #14 exited the facility and was found in the parking lot attempting to get into a vehicle. The facility Administration failed to ensure the incidents were documented, failed to thoroughly investigate how the residents were able to exit the building without staff knowledge, and failed to implement corrective action in an attempt to prevent further resident elopement (Refer to F280 and F323). In addition, the facility Administration failed to ensure there was an effective system to assess the necessary and safe use of physical restraints for Residents #1, #5, #6, #7, and #8. Resident #1 utilized a lap belt restraint that the resident was able to remove and sustained falls. The facility revised the resident's care plan to tie the physical restraint underneath the wheelchair so the resident could not remove the device, which was not in accordance with the manufacturer's guidelines. Resident #1 then attempted to remove the restraint and slid under the restraint which was contraindications for use per the manufacturer's guidelines; however, the facility failed to assess the resident's risk factors for injury, and Resident #1 continued to utilize the lap belt restraint (Refer to F221 and F280). The facility Administration's failure to ensure residents received adequate supervision and assistive devices to prevent accidents and failure to ensure residents were free from physical restraints placed residents in the facility at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.75 Administration. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: An interview conducted with the facility Executive Director on 10/17/13 at 3:30 PM revealed the facility administration policy consisted of an Organizational Chart. Additional interview revealed the Executive Director and the Administrator met as needed to discuss incidents in the facility and to evaluate the facility systems for improvement. A review of the facility's policy titled "Restraint Policy," not dated, revealed the facility limited the use of restraints to circumstances in which the resident had medical symptoms that warranted the use of restraints, and the resident was to be fully informed of the potential risks and benefits of use of the restraint. Further review of the restraint policy revealed the facility would use a systematic and gradual process toward reducing the restraints. A review of the manufacturer's instructions for the application of the Soft Belt restraint revealed the use of the Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off of the chair and become suspended or entrapped. Observations, interviews, and record reviews completed during the abbreviated survey revealed a soft lap belt restraint was not utilized in accordance with manufacturer's guidelines for Resident #1 when the resident exhibited behaviors of trying to remove/slide under the physical restraint. Further investigation revealed Residents #1, #5, #6, #7, and #8 had no evidence of a medical symptom that required the use of a physical restraint. In addition, the facility failed to evaluate/assess Residents #5, #7 and #8's physical restraint in order to reduce/eliminate the restraint. A review of the facility policy titled "Elopements," not dated, revealed staff should investigate and report all cases of missing residents. The policy did not provide staff with guidance related to what actions to take to prevent further elopements when an elopement occurred. Observations, interviews, and record review completed for residents who were identified by the facility as elopement risk revealed Residents #4, #14, and #15 had exited the building without staff knowledge. There was no evidence the facility conducted thorough investigations to identify causative factors to prevent residents from exiting the building without staff knowledge. The facility failed to evaluate the effectiveness of interventions that were in place for these residents and review/revise the residents' plan of care with interventions to meet the needs of these residents. An interview conducted with the Executive Director (ED) on 10/16/13 at 12:40 PM and on 10/17/13 at 3:30 PM revealed administrative staff had discussed the resident elopement incidents, but failed to evaluate the interventions in place to prevent residents from eloping without staff knowledge, and did not implement any other actions. The ED stated the facility checked to see that the alarm system was functioning properly when the residents eloped, and since the alarms were functioning properly administrative staff felt no other action was needed. Further interview revealed that all incidents were discussed in the weekly safety meeting, which was attended by the Executive Director, and the facility Wanderguard system was not identified as a concern. The ED revealed administrative staff did not consider residents leaving the facility without staff knowledge as an "elopement" because the residents were found on facility property. Further interview with the ED revealed administrative staff did not provide any oversight for any aspect of restraint use, and restraint use was determined by the Director of Nursing and Registered Nurse #1. Interview with the Director of Nursing (DON) on 10/08/13 at 2:55 PM revealed the facility did not attempt physical restraint reductions/eliminations as long as the resident had no negative outcome, for example, no pressure sores. The DON stated she was aware Resident #1 had slid under the restraint and sustained a fall, but did not consider the risks of the resident sliding under the restraint, thus, failed to re-evaluate the continued usage of the restraint. *A review of the AOC revealed the facility alleged Immediate Jeopardy had been removed at F490 Administration on 10/26/13. However, observations and interviews revealed Immediate Jeopardy was removed on 10/31/13. A review of the AOC revealed on 10/18/13, the Administrator hired a Consultant to immediately help the facility put systematic changes in place to enhance the facility's ability to use resources effectively and efficiently to attain and maintain the highest well-being for each resident. A review of the AOC revealed on 10/20/13, the Consultant educated the Executive Director (ED) and Administrator on physical restraints, elopement, required reporting of incidents, incident reports and investigations, quality assurance, and regulatory compliance. The AOC further stated day-to-day operations were discussed and modified to achieve compliance and promote well-being for all residents. Further review of the AOC revealed on 10/20/13, the facility's Consultant reviewed campus property and the facility to help the Administrator and the Executive Director identify additional concerns and help rectify regulatory concerns. The AOC stated the Consultant would oversee all abatement and regulatory issues, the consulting Executive Director, and the Administrator on a daily basis. The AOC revealed on 10/21/13, the facility's Consultant provided continued education training to the Administrator and the Executive Director. The Consultant helped revise policies, assisted with staff meetings and assignments, and trained Clinical Administrative nursing staff. The Consultant provided extensive training with the DON pertaining to care plans, reeducation of restraints, and operations. The AOC further revealed on 10/20/13, at the request of the Administrator, the Consultant began providing monitoring. The AOC stated the Consultant would work daily with the Administrator to validate monitoring of all new systems and to ensure all components were working and that Immediate Jeopardy would be removed. The Administrator will monitor to oversee systematic changes with regards, but not limited to, the facility's security system, elopement, physical restraints, incidents, and documentation and then will report, on a daily basis, to the Quality Assurance Committee. **The surveyors validated the corrective action taken by the facility as follows: An interview with the ED on 10/31/13 and a review of facility documentation revealed on 10/18/13 the Administrator hired a Consultant to immediately help the facility put systematic changes in place to enhance the facility and to enable the facility to use resources effectively and efficiently to attain and maintain the highest well-being for each resident. An interview with the Consultant on 10/30/13 confirmed she had provided education to the Executive Director and Administrator related to physical restraints, elopement, required reporting, incident reports and investigations, quality assurance, and regulatory compliance on 10/20/13. The Consultant further stated she had consulted with Administrative Staff related to day-to-day operations to achieve compliance and promote well-being for all residents. Further interview with the facility's Consultant on 10/30/13, revealed she had conducted observations of the facility's campus and of the facility on 10/20/13 in an effort to help the Administrator and the Executive Director identify additional concerns and help rectify regulatory concerns. The Consultant stated she has provided oversight of all abatement and regulatory issues, and has consulted with the Executive Director and Administrator on a daily basis. Review of the facility's documentation revealed on 10/21/13, the facility's Consultant continued to provide education training to the Administrator and Executive Director. The Consultant stated in interview on 10/30/13 she had helped revise policies, assisted with staff meetings and assignments, and trained Clinical Administrative nursing staff. The Consultant confirmed she had provided extensive training with the DON pertaining to care plans, reeducation of restraints, and operations. An interview with the Consultant on 10/30/13 further revealed on 10/20/13, at the request of the Administrator, she had provided monitoring and had worked daily with the Administrator to validate monitoring of all new systems and ensure all components were working and Immediate Jeopardy was removed. The Administrator confirmed in interview on 10/31/13 that he is monitoring to oversee systematic changes with regards to, but not limited to, the facility's security system, elopement, physical restraints, incidents, and documentation, and then reports daily to the Quality Assurance Committee.

Based on interview and record review it was determined the facility failed to have an effective quality assessment and assurance program to identify quality deficiencies, and to develop and implement appropriate plans of action to correct identified quality deficiencies. There was no evidence the facility Quality Assurance Committee identified accident hazards and unnecessary restraints as quality concerns in the facility. The facility failed to ensure that utilized physical restraints were necessary to treat a medical symptom for Residents #1, #5, #6, #7, and #8. In addition, the facility failed to ensure restraint reduction and/or elimination attempts were completed for Residents #5, #7, and #8. The facility further failed to ensure a lap belt restraint was utilized in accordance with manufacturer's guidelines for Resident #1. Resident #1 untied/attempted to untie the restraint and attempted to slide under the restraint. According to the manufacturer's warnings, when these behaviors were exhibited restraint use should be discontinued. However, the facility was unaware the manufacturer's warnings existed, failed to identify the risk factors for Resident #1, and failed to reassess the continued usage of the restraint. Interviews with staff revealed restraint use was not part of the facility's Quality Assurance Program. In addition, the facility was aware Residents #4, #14, and #15 had eloped from the facility without staff knowledge but failed to develop and implement actions to prevent further elopement. The facility failed to identify that the Wanderguard system alarm was not audible throughout the facility, and failed to identify that residents were exiting the facility by pushing on the doors for 30 seconds which released the door lock. (Refer to F221, F280, F323 and F490). The facility's failure to ensure a Quality Assurance Committee was in place, which identified quality concerns in the facility, and implemented action plans to correct the concerns placed residents at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.75 Administration. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: A review of the facility's policy titled "Quality Assessment and Assurance (QA) Plan," with a revision date of October 2012, revealed the purpose of QA was to provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. Additional review of the policy revealed the QA Coordinator would attend and review minutes of meetings or other committees as needed. According to the policy, the focus of the committee was to monitor areas of resident behavior and facility practices, physical environment, and safety for quality and appropriateness of resident care and any trends in performance and outcomes. In addition, the QA Committee was to help define issues, plan and implement actions, and ensure monitoring and follow-up. Record review revealed Residents #1, #5, #6, #7, and #8 utilized physical restraints. The facility failed to attempt restraint reductions/elimination for Resident #5, #7, and #8, and failed to ensure Residents #1, #5, #6, #7, and #8 had a medical symptom that necessitated the use of a physical restraint. Resident #1 utilized a lap belt restraint that the resident was able to remove. Because the resident was able to remove the restraint, the facility revised the resident's care plan to tie the restraint underneath the wheelchair, which was not in accordance with the manufacturer's guidelines. There was no evidence the facility was aware of the manufacturer's guidelines/warnings and did not identify and reassess Resident #1's risk factors of continuing to remove/attempt to remove the restraint and sliding/attempting to slide underneath the restraint. According to the manufacturer's warnings, the restraint should have been discontinued when this behavior occurred; however, the facility continued to apply the restraint on Resident #1. Residents #4, #14, and #15 were assessed to be an elopement risk and were utilizing a Wanderguard bracelet. Residents #4 and #15 exited out the back door of the facility without staff knowledge. Resident #15 was gone for an undetermined amount of time and was found under a tree approximately 500 feet from where the resident exited the facility. The Wanderguard alarm was sounding; however, interviews with staff revealed the alarm was not audible throughout the facility. Further interviews with staff revealed staff was aware that the residents were exiting the facility because the exit doors would open after a resident pushed on the door for 15 seconds (observation of the facility doors revealed the door would open in 30 seconds). Resident #4 exited the facility on one occasion, was gone for an undetermined amount of time, and was located approximately 100 feet from the facility. The resident was found on the ground approximately 50 feet from his/her wheelchair. Resident #14 exited the facility and was found in the parking lot attempting to get into a vehicle. An interview conducted with the Executive Director (ED) on 10/17/13 at 3:30 PM, revealed the ED was the Quality Assurance Coordinator and chaired the QA Committee. Additional interview revealed meetings were conducted weekly and monthly in the facility to review concerns and the full QA Committee met quarterly to review all concerns monitored by QA. According to documentation provided by the facility, the facility tracked the number of elopements but never investigated/trended the elopements, had not identified that the Wanderguard alarm was not audible throughout the facility, or that residents were exiting the facility after pushing on exit doors for 30 seconds. However, the facility's policy stated the QA Committee was to help define issues, plan and implement actions, and ensure monitoring and follow-up. Further interview with the ED revealed the facility had not identified a concern with restraints and restraints were not reviewed as part of the facility's QA program.

Based on interview and record review it was determined the facility failed to have an effective quality assessment and assurance program to identify quality deficiencies, and to develop and implement appropriate plans of action to correct identified quality deficiencies. There was no evidence the facility Quality Assurance Committee identified accident hazards and unnecessary restraints as quality concerns in the facility. The facility failed to ensure that utilized physical restraints were necessary to treat a medical symptom for Residents #1, #5, #6, #7, and #8. In addition, the facility failed to ensure restraint reduction and/or elimination attempts were completed for Residents #5, #7, and #8. The facility further failed to ensure a lap belt restraint was utilized in accordance with manufacturer's guidelines for Resident #1. Resident #1 untied/attempted to untie the restraint and attempted to slide under the restraint. According to the manufacturer's warnings, when these behaviors were exhibited restraint use should be discontinued. However, the facility was unaware the manufacturer's warnings existed, failed to identify the risk factors for Resident #1, and failed to reassess the continued usage of the restraint. Interviews with staff revealed restraint use was not part of the facility's Quality Assurance Program. In addition, the facility was aware Residents #4, #14, and #15 had eloped from the facility without staff knowledge but failed to develop and implement actions to prevent further elopement. The facility failed to identify that the Wanderguard system alarm was not audible throughout the facility, and failed to identify that residents were exiting the facility by pushing on the doors for 30 seconds which released the door lock. (Refer to F221, F280, F323 and F490). The facility's failure to ensure a Quality Assurance Committee was in place, which identified quality concerns in the facility, and implemented action plans to correct the concerns placed residents at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.75 Administration. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: A review of the facility's policy titled "Quality Assessment and Assurance (QA) Plan," with a revision date of October 2012, revealed the purpose of QA was to provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. Additional review of the policy revealed the QA Coordinator would attend and review minutes of meetings or other committees as needed. According to the policy, the focus of the committee was to monitor areas of resident behavior and facility practices, physical environment, and safety for quality and appropriateness of resident care and any trends in performance and outcomes. In addition, the QA Committee was to help define issues, plan and implement actions, and ensure monitoring and follow-up. Record review revealed Residents #1, #5, #6, #7, and #8 utilized physical restraints. The facility failed to attempt restraint reductions/elimination for Resident #5, #7, and #8, and failed to ensure Residents #1, #5, #6, #7, and #8 had a medical symptom that necessitated the use of a physical restraint. Resident #1 utilized a lap belt restraint that the resident was able to remove. Because the resident was able to remove the restraint, the facility revised the resident's care plan to tie the restraint underneath the wheelchair, which was not in accordance with the manufacturer's guidelines. There was no evidence the facility was aware of the manufacturer's guidelines/warnings and did not identify and reassess Resident #1's risk factors of continuing to remove/attempt to remove the restraint and sliding/attempting to slide underneath the restraint. According to the manufacturer's warnings, the restraint should have been discontinued when this behavior occurred; however, the facility continued to apply the restraint on Resident #1. Residents #4, #14, and #15 were assessed to be an elopement risk and were utilizing a Wanderguard bracelet. Residents #4 and #15 exited out the back door of the facility without staff knowledge. Resident #15 was gone for an undetermined amount of time and was found under a tree approximately 500 feet from where the resident exited the facility. The Wanderguard alarm was sounding; however, interviews with staff revealed the alarm was not audible throughout the facility. Further interviews with staff revealed staff was aware that the residents were exiting the facility because the exit doors would open after a resident pushed on the door for 15 seconds (observation of the facility doors revealed the door would open in 30 seconds). Resident #4 exited the facility on one occasion, was gone for an undetermined amount of time, and was located approximately 100 feet from the facility. The resident was found on the ground approximately 50 feet from his/her wheelchair. Resident #14 exited the facility and was found in the parking lot attempting to get into a vehicle. An interview conducted with the Executive Director (ED) on 10/17/13 at 3:30 PM, revealed the ED was the Quality Assurance Coordinator and chaired the QA Committee. Additional interview revealed meetings were conducted weekly and monthly in the facility to review concerns and the full QA Committee met quarterly to review all concerns monitored by QA. According to documentation provided by the facility, the facility tracked the number of elopements but never investigated/trended the elopements, had not identified that the Wanderguard alarm was not audible throughout the facility, or that residents were exiting the facility after pushing on exit doors for 30 seconds. However, the facility's policy stated the QA Committee was to help define issues, plan and implement actions, and ensure monitoring and follow-up. Further interview with the ED revealed the facility had not identified a concern with restraints and restraints were not reviewed as part of the facility's QA program. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on 10/29/13. The AOC alleged the Immediate Jeopardy was removed on 10/26/13, however, observations and interviews revealed Immediate Jeopardy was removed on 10/31/13. The AOC revealed on 10/20/13, the facility Consultant educated the Executive Director and the Administrator. The education provided by the Consultant consisted of physical restraints, elopement, required reporting, incident reports and investigations, quality assurance, and regulatory compliance. In addition, day-to-day operations were discussed and modified to achieve compliance and promote well-being for all residents. The AOC revealed on 10/20/13, the Consultant conducted observations of the facility's campus property and of the facility to help the Administrator and the Executive Director identify additional concerns and help rectify regulatory concerns. The Consultant will oversee all abetment and regulatory issues, and consulting with the Executive Director and Administrator on a daily basis. The AOC revealed the Consultant helped restructure the facility's Quality Assurance Committee and its members. The facility had significantly decreased the number of committee members to become more effective. The Quality Assurance Committee will meet daily to monitor the facility's status and evaluate any changes. Quality Assurance training had been conducted by the Consultant on 10/20-21/13 to all new Quality Assurance Committee members. The Quality Assurance Committee met on 10/21/13 while the facility's Consultant was present to validate the committee was capable and had knowledge of monitoring by implementing recommendations that the Consultant suggested. The AOC revealed non-Committee members were trained on 10/25/13 using a CQI Assessment tool to help identify continuous quality improvement areas. The CQI Assessment paper will be pink in color, and will be kept at each nurses' station and in all offices for staff convenience. The AOC revealed the Quality Assurance Committee will continue to monitor, but will not be limited to monitoring the following: 15-minute monitoring log, sign in/out sheet, CQI assessment tool, Risk Records Audit, wander guard system, wandering risk/elopement risk assessment, review of clinical documentation, new policies that pertain to elopement when residents leave the facility, wandering elopement precautions, elopement interventions, "wander book," immediate intervention tools for the wandering resident, physical restraints, physical restraint assessments, physical restraint QA tool, and restraint reduction on a daily basis. The Quality Assurance Committee will immediately address any negative findings. The Quality Assurance Committee will retrain, order more audits, and modify as needed to validate any regulatory concerns. **The surveyors validated the corrective action taken by the facility as follows: Interview with the facility's Consultant on 10/30/13, revealed on 10/20/13, she educated the Executive Director and the Administrator, related to physical restraints, elopement, required reporting, incident reports and investigations, quality assurance, and regulatory compliance. Continued interview with the Consultant revealed day-to-day operations were discussed and modified to achieve compliance and promote well-being for all residents. Further interview with the Consultant on 10/30/13 verified she had observed the facility's campus property and the facility to help the Administrator and the Executive Director identify additional concerns and help rectify regulatory concerns on 10/20/13. The Consultant stated she had overseen all abatement and regulatory issues, and consulted with the Executive Director and Administrator on a daily basis. The Consultant confirmed during interview on 10/30/13 that she had helped restructure the facility's Quality Assurance Committee and members. Review of the facility's documentation revealed the Quality Assurance Committee met daily to monitor the facility's progress with recent changes and evaluate any changes. A review of the in-service records revealed the Quality Assurance training had been conducted by the Consultant on 10/20-21/13 to all new Quality Assurance Committee members. A review of facility documentation revealed the Quality Assurance Committee met on 10/21/13 while the Consultant was present, and she validated that the Committee was capable and had knowledge of monitoring and implementing recommendations that the Consultant suggested. Further review of facility documentation revealed non-Committee members were trained on 10/25/13 using a CQI Assessment tool to help identify continuous quality improvement areas. Observations conducted in the facility on 10/30/13, revealed CQI Assessment tools were located at each nurses' station and in all offices for staff convenience. Interview with the ED and the Administrator on 10/31/13 revealed the Quality Assurance Committee would continue to monitor, but would not be limited to monitoring the following: the 15-minute monitoring log, sign in/out sheet, Continuous Quality Improvement (CQI) assessment tool, risk records audit, the wander guard system, wandering risk/elopement risk assessment, review of clinical documentation, new policies related to elopement when residents leave the facility, wandering elopement precautions, elopement interventions, "Wander Book," immediate intervention tools for the wandering resident, physical restraints, physical restraint assessments, physical restraint QA tool, and restraint reduction on a daily basis. The ED further stated the Quality Assurance Committee would immediately address any negative findings, and would retrain, order more audits, and modify as needed to validate any regulatory concerns.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure staff periodically reviewed and revised the comprehensive care plan after each assessment for five of eighteen sampled residents (Residents #1, #2, #4, #14, and #15). Resident #1 experienced multiple falls as a result of removing or sliding under a soft lap belt (used as a physical restraint) out of the wheelchair onto the floor. However, the facility failed to ensure the resident's care plan included revisions related to these issues. Interview and record review revealed Resident #4 exited the facility on 05/20/13 in his/her wheelchair, without supervision or assistance, and rolled down an embankment on facility grounds. Review of Resident #4's care plan revealed the facility failed to develop or modify interventions related to the resident's unassisted/unsupervised exit from the facility. Interview and record review revealed on 03/15/13 Resident #15 exited the back door of the facility, without supervision or assistance, walked around the building, and sat down under a tree. Review of the resident's care plan revealed no documented evidence the facility implemented new interventions to prevent Resident #15 from exiting the facility without supervision. The facility conducted a Minimum Data Set (MDS) assessment (dated 07/28/13) of Resident #2 and noted the resident required the extensive assistance of two persons for transfers; however, review of the Plan of Care for Resident #2 revealed the facility failed to document the number of staff required to assist the resident with transfers. Review of the Nurse Aide's Information Sheet revealed Resident #2 required one to two persons to assist with transfers. Documentation revealed Resident #14 exited the facility multiple times without staff knowledge/assistance. Review of the Plan of Care revealed the facility failed to ensure the resident's Plan of Care addressed the resident's risk for elopement after each occurrence and failed to develop/modify interventions related to the resident's unsupervised/unassisted exit from the facility. The facility's failure to review and revise residents' plans of care when residents exited the facility without staff knowledge, and when residents removed and slid underneath/attempted to slide underneath a restraint, placed residents in the facility at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.20 Resident Assessment. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Care Plans-Comprehensive," revision date of October 2011, revealed assessments of residents were ongoing and care plans were to be revised as information about the residents and the residents' condition changed. Review of the application instructions for the Posey Soft Belt (soft foam lap belt) revealed the use of the Posey Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off the chair and become suspended or entrapped. Review of the application instructions revealed the soft foam belt should be laid across the resident's thighs with the connecting straps down at a 45-degree angle between the seat and the wheelchair sides with the straps crisscrossed behind the chair and tied using a quick-release knot to the opposite side kick spurs. Observations revealed the application instructions were not followed. 1. Review of the medical record for Resident #1 revealed the facility admitted the resident on 09/21/10 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment completed on 08/19/13 revealed the facility assessed the resident to require extensive assistance of one staff person with bed mobility, transferring, and ambulation. The facility also identified Resident #1 to utilize a walker and a wheelchair for mobility. The assessment revealed Resident #1 utilized a trunk physical restraint. Review of incident reports dated 09/11/13 and 09/23/13 revealed Resident #1 had sustained falls from the wheelchair related to the resident removing the soft lap belt. However, review of the Plan of Care, revision date of 10/01/13, revealed the facility failed to re-evaluate the use of the restraint for the resident and failed to revise the Plan of Care after each assessment. In addition, review of incident reports dated 09/17/13 and 09/30/13 revealed Resident #1 sustained falls as the result of sliding under the soft lap belt out of the wheelchair onto the floor. There was no documented evidence the safety of the use of the restraint was re-evaluated and revisions made to the resident's Plan of Care. Interview on 10/03/13 at 7:15 PM with the Director of Nursing (DON) revealed she was not aware the instructions for use of the Posey Soft Belt (soft lap belt) indicated the use of the device was to be stopped if the resident was able to self-remove the device or able to slide under the device. The interview further revealed the Safety Committee had looked at all of Resident #1's falls and the risk of the resident removing the soft lap belt had been addressed but the Committee had not recommended discontinuing the use of the soft lap belt. The DON revealed that the Safety Committee met after the fall on 09/30/13 and put an intervention in place to apply "Dycem" (a non-slip rubber-like material) to the seat of the wheelchair to prevent the resident from sliding under the seat belt. Interview on 10/17/13 at 3:30 PM with the Executive Director (ED) revealed all of Resident #1's falls had been discussed in the Safety Committee meetings; however the Committee had not identified the risk of the resident sliding under the soft lap belt out of the wheelchair as a concern and had recommended continuing use of the soft lap belt. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 10/03/12. Further review revealed the facility assessed the resident to be at risk for elopement on 10/11/12 because the resident was difficult to redirect back into the building when he/she would go outside unsupervised. Review of the care plan the facility developed for Resident #15 on 10/11/12 revealed interventions for a Wanderguard bracelet. Further review revealed staff was required to check the resident's whereabouts every hour. Review of the facility's incident reports completed on 03/15/13 (time not specified) revealed Resident #15 went out the back door of the facility unsupervised and without staff knowledge. Licensed Practical Nurse (LPN) #1 found the Wanderguard system alarm sounding at the back door and went out and searched for the resident. The resident was found on the ground underneath a tree. Further record review revealed the incident report did not give a time period for how long the resident was outside unsupervised and there was no evidence the facility investigated the incident to determine how the resident was able to leave the facility without staff knowledge while wearing a Wanderguard bracelet. Review of the Safety Committee Note for Resident #15 dated 03/21/13 revealed after the incident on 03/15/13 when the resident left the facility without staff knowledge, an x-ray of the resident's right knee was obtained on 03/15/13; a new mattress was placed on the resident's bed; and the resident's physician was consulted because the Committee believed the resident's elopement was attention-seeking behavior. There was no evidence the resident's Plan of Care was revised when the Wanderguard system and the hourly checks were not effective in preventing Resident #15 from exiting the facility without staff knowledge. Interview with the DON on 10/16/13 at 12:40 PM revealed she was responsible for updating the resident's care plan. The DON indicated she had not considered that the Wanderguard and hourly checks were not effective, and she had not considered additional interventions because the Wanderguard system was checked and was functioning properly. 3. Review of the medical record for Resident #4 revealed the facility admitted the resident on 02/03/12 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with transfers, dressing, and bathing. Continued review of the assessment revealed staff assessed the resident to have a behavior of wandering, which occurred one to three days during the assessment period. Review of an incident report dated 03/17/13 revealed Resident #4 had sustained a skin tear when he/she attempted to exit the facility "out the front door." Further review of the resident's incident reports revealed the resident exited the facility and rolled over an embankment in his/her wheelchair on 05/20/13. Continued review revealed the resident's fingers "were stuck" in the front lobby door of the facility on 08/31/13, which resulted in no injury to the resident. Review of Resident #4's Plan of Care, with a revision date of 09/26/13, revealed the facility assessed the resident to be at risk for wandering and injury. However, the facility failed to address the resident's risk for elopement, or the resident's exit-seeking behaviors; and failed to revise the Plan of Care after the resident attempted to exit the building unsupervised. Interview with the DON on 10/15/13 at 4:20 PM revealed she reviewed all incident reports daily and was responsible for updating the residents' care plans. The DON acknowledged reviewing the incidents related to Resident #4's exit-seeking behaviors and the elopement incident on 05/20/13. The DON stated she had not updated the resident's care plan or implemented any new interventions related to Resident #4's exit-seeking behaviors. 4. Review of the medical record for Resident #14 revealed the facility admitted the resident on 07/25/13 with [DIAGNOSES REDACTED]. Further review of the Nurse's Progress Notes, dated 07/25/13 through 10/17/13, revealed on 08/04/13, Resident #14 began exhibiting exit-seeking behaviors. Review of the Admission MDS assessment, dated 08/01/13, revealed the facility assessed Resident #14 to require one-person assistance with supervision for ambulation. Review of Resident #14's Plan of Care, revised 08/05/13, revealed the facility implemented the use of a Wanderguard bracelet to the resident's ankle at all times due to the resident's exit-seeking behaviors. Further review of the Plan of Care revealed no documented evidence the Plan of Care was reviewed and revised after the elopement incident on 09/30/13. Review of the facility's elopement incident report for Resident #14, dated 09/30/13, revealed the resident had exited the facility and was found by a State Registered Nurse Aide (SRNA) in the facility parking lot attempting to get into a truck. Interview on 10/17/13 at 1:51 PM with the DON revealed she was responsible for updating the residents' care plans but had not considered the intervention of the Wanderguard as ineffective and had not considered additional interventions due to the Wanderguard system functioning properly, even though the resident was able to exit the facility without staff's knowledge. 5. Review of the medical record for Resident #2 revealed the facility admitted the resident on 08/13/12 with [DIAGNOSES REDACTED]. Review of Resident #2's Nurse Aide's Information Sheet, dated 02/11/13, revealed the resident required the assistance of one to two persons with transfers. Review of the annual MDS assessment dated [DATE] revealed the facility assessed the resident to need the extensive assistance of two persons for ambulation, transfers, and bed mobility. Review of Resident #2's Plan of Care, revised 10/01/13, revealed no documented evidence of the number of staff persons needed by the resident for transfers. Review of the facility's final investigation report of a fall on 09/19/13, dated 09/25/13, revealed SRNA #9 failed to use a gait belt when transferring Resident #2 which resulted in a fall; however, the investigation did not address that the resident was assessed to need two-person extensive assistance for transfers, and the SRNA transferred the resident without another staff person to assist. Further review of the facility's investigation revealed Resident #2 was transferred to the hospital emergency room for an evaluation and diagnosed with [REDACTED]. Interview on 10/02/13 at 4:38 PM with the DON revealed she was responsible for updating and making changes to the resident's Plan of Care as needed Monday through Friday. The interview further revealed the DON was not aware Resident #2's Plan of Care and Nurse Aide's Information Sheet had not been updated with the information related to Resident #2 requiring the assistance of two staff persons for transfers.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure staff periodically reviewed and revised the comprehensive care plan after each assessment for five of eighteen sampled residents (Residents #1, #2, #4, #14, and #15). Resident #1 experienced multiple falls as a result of removing or sliding under a soft lap belt (used as a physical restraint) out of the wheelchair onto the floor. However, the facility failed to ensure the resident's care plan included revisions related to these issues. Interview and record review revealed Resident #4 exited the facility on 05/20/13 in his/her wheelchair, without supervision or assistance, and rolled down an embankment on facility grounds. Review of Resident #4's care plan revealed the facility failed to develop or modify interventions related to the resident's unassisted/unsupervised exit from the facility. Interview and record review revealed on 03/15/13 Resident #15 exited the back door of the facility, without supervision or assistance, walked around the building, and sat down under a tree. Review of the resident's care plan revealed no documented evidence the facility implemented new interventions to prevent Resident #15 from exiting the facility without supervision. The facility conducted a Minimum Data Set (MDS) assessment (dated 07/28/13) of Resident #2 and noted the resident required the extensive assistance of two persons for transfers; however, review of the Plan of Care for Resident #2 revealed the facility failed to document the number of staff required to assist the resident with transfers. Review of the Nurse Aide's Information Sheet revealed Resident #2 required one to two persons to assist with transfers. Documentation revealed Resident #14 exited the facility multiple times without staff knowledge/assistance. Review of the Plan of Care revealed the facility failed to ensure the resident's Plan of Care addressed the resident's risk for elopement after each occurrence and failed to develop/modify interventions related to the resident's unsupervised/unassisted exit from the facility. The facility's failure to review and revise residents' plans of care when residents exited the facility without staff knowledge, and when residents removed and slid underneath/attempted to slide underneath a restraint, placed residents in the facility at risk for serious injury, harm, impairment, or death. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/15/13 and is ongoing at 42 CFR 483.20 Resident Assessment. The facility was notified of the Immediate Jeopardy on 10/17/13 and was informed on 10/17/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Care Plans-Comprehensive," revision date of October 2011, revealed assessments of residents were ongoing and care plans were to be revised as information about the residents and the residents' condition changed. Review of the application instructions for the Posey Soft Belt (soft foam lap belt) revealed the use of the Posey Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off the chair and become suspended or entrapped. Review of the application instructions revealed the soft foam belt should be laid across the resident's thighs with the connecting straps down at a 45-degree angle between the seat and the wheelchair sides with the straps crisscrossed behind the chair and tied using a quick-release knot to the opposite side kick spurs. Observations revealed the application instructions were not followed. 1. Review of the medical record for Resident #1 revealed the facility admitted the resident on 09/21/10 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment completed on 08/19/13 revealed the facility assessed the resident to require extensive assistance of one staff person with bed mobility, transferring, and ambulation. The facility also identified Resident #1 to utilize a walker and a wheelchair for mobility. The assessment revealed Resident #1 utilized a trunk physical restraint. Review of incident reports dated 09/11/13 and 09/23/13 revealed Resident #1 had sustained falls from the wheelchair related to the resident removing the soft lap belt. However, review of the Plan of Care, revision date of 10/01/13, revealed the facility failed to re-evaluate the use of the restraint for the resident and failed to revise the Plan of Care after each assessment. In addition, review of incident reports dated 09/17/13 and 09/30/13 revealed Resident #1 sustained falls as the result of sliding under the soft lap belt out of the wheelchair onto the floor. There was no documented evidence the safety of the use of the restraint was re-evaluated and revisions made to the resident's Plan of Care. Interview on 10/03/13 at 7:15 PM with the Director of Nursing (DON) revealed she was not aware the instructions for use of the Posey Soft Belt (soft lap belt) indicated the use of the device was to be stopped if the resident was able to self-remove the device or able to slide under the device. The interview further revealed the Safety Committee had looked at all of Resident #1's falls and the risk of the resident removing the soft lap belt had been addressed but the Committee had not recommended discontinuing the use of the soft lap belt. The DON revealed that the Safety Committee met after the fall on 09/30/13 and put an intervention in place to apply "Dycem" (a non-slip rubber-like material) to the seat of the wheelchair to prevent the resident from sliding under the seat belt. Interview on 10/17/13 at 3:30 PM with the Executive Director (ED) revealed all of Resident #1's falls had been discussed in the Safety Committee meetings; however the Committee had not identified the risk of the resident sliding under the soft lap belt out of the wheelchair as a concern and had recommended continuing use of the soft lap belt. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 10/03/12. Further review revealed the facility assessed the resident to be at risk for elopement on 10/11/12 because the resident was difficult to redirect back into the building when he/she would go outside unsupervised. Review of the care plan the facility developed for Resident #15 on 10/11/12 revealed interventions for a Wanderguard bracelet. Further review revealed staff was required to check the resident's whereabouts every hour. Review of the facility's incident reports completed on 03/15/13 (time not specified) revealed Resident #15 went out the back door of the facility unsupervised and without staff knowledge. Licensed Practical Nurse (LPN) #1 found the Wanderguard system alarm sounding at the back door and went out and searched for the resident. The resident was found on the ground underneath a tree. Further record review revealed the incident report did not give a time period for how long the resident was outside unsupervised and there was no evidence the facility investigated the incident to determine how the resident was able to leave the facility without staff knowledge while wearing a Wanderguard bracelet. Review of the Safety Committee Note for Resident #15 dated 03/21/13 revealed after the incident on 03/15/13 when the resident left the facility without staff knowledge, an x-ray of the resident's right knee was obtained on 03/15/13; a new mattress was placed on the resident's bed; and the resident's physician was consulted because the Committee believed the resident's elopement was attention-seeking behavior. There was no evidence the resident's Plan of Care was revised when the Wanderguard system and the hourly checks were not effective in preventing Resident #15 from exiting the facility without staff knowledge. Interview with the DON on 10/16/13 at 12:40 PM revealed she was responsible for updating the resident's care plan. The DON indicated she had not considered that the Wanderguard and hourly checks were not effective, and she had not considered additional interventions because the Wanderguard system was checked and was functioning properly. 3. Review of the medical record for Resident #4 revealed the facility admitted the resident on 02/03/12 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with transfers, dressing, and bathing. Continued review of the assessment revealed staff assessed the resident to have a behavior of wandering, which occurred one to three days during the assessment period. Review of an incident report dated 03/17/13 revealed Resident #4 had sustained a skin tear when he/she attempted to exit the facility "out the front door." Further review of the resident's incident reports revealed the resident exited the facility and rolled over an embankment in his/her wheelchair on 05/20/13. Continued review revealed the resident's fingers "were stuck" in the front lobby door of the facility on 08/31/13, which resulted in no injury to the resident. Review of Resident #4's Plan of Care, with a revision date of 09/26/13, revealed the facility assessed the resident to be at risk for wandering and injury. However, the facility failed to address the resident's risk for elopement, or the resident's exit-seeking behaviors; and failed to revise the Plan of Care after the resident attempted to exit the building unsupervised. Interview with the DON on 10/15/13 at 4:20 PM revealed she reviewed all incident reports daily and was responsible for updating the residents' care plans. The DON acknowledged reviewing the incidents related to Resident #4's exit-seeking behaviors and the elopement incident on 05/20/13. The DON stated she had not updated the resident's care plan or implemented any new interventions related to Resident #4's exit-seeking behaviors. 4. Review of the medical record for Resident #14 revealed the facility admitted the resident on 07/25/13 with [DIAGNOSES REDACTED]. Further review of the Nurse's Progress Notes, dated 07/25/13 through 10/17/13, revealed on 08/04/13, Resident #14 began exhibiting exit-seeking behaviors. Review of the Admission MDS assessment, dated 08/01/13, revealed the facility assessed Resident #14 to require one-person assistance with supervision for ambulation. Review of Resident #14's Plan of Care, revised 08/05/13, revealed the facility implemented the use of a Wanderguard bracelet to the resident's ankle at all times due to the resident's exit-seeking behaviors. Further review of the Plan of Care revealed no documented evidence the Plan of Care was reviewed and revised after the elopement incident on 09/30/13. Review of the facility's elopement incident report for Resident #14, dated 09/30/13, revealed the resident had exited the facility and was found by a State Registered Nurse Aide (SRNA) in the facility parking lot attempting to get into a truck. Interview on 10/17/13 at 1:51 PM with the DON revealed she was responsible for updating the residents' care plans but had not considered the intervention of the Wanderguard as ineffective and had not considered additional interventions due to the Wanderguard system functioning properly, even though the resident was able to exit the facility without staff's knowledge. 5. Review of the medical record for Resident #2 revealed the facility admitted the resident on 08/13/12 with [DIAGNOSES REDACTED]. Review of Resident #2's Nurse Aide's Information Sheet, dated 02/11/13, revealed the resident required the assistance of one to two persons with transfers. Review of the annual MDS assessment dated [DATE] revealed the facility assessed the resident to need the extensive assistance of two persons for ambulation, transfers, and bed mobility. Review of Resident #2's Plan of Care, revised 10/01/13, revealed no documented evidence of the number of staff persons needed by the resident for transfers. Review of the facility's final investigation report of a fall on 09/19/13, dated 09/25/13, revealed SRNA #9 failed to use a gait belt when transferring Resident #2 which resulted in a fall; however, the investigation did not address that the resident was assessed to need two-person extensive assistance for transfers, and the SRNA transferred the resident without another staff person to assist. Further review of the facility's investigation revealed Resident #2 was transferred to the hospital emergency room for an evaluation and diagnosed with [REDACTED]. Interview on 10/02/13 at 4:38 PM with the DON revealed she was responsible for updating and making changes to the resident's Plan of Care as needed Monday through Friday. The interview further revealed the DON was not aware Resident #2's Plan of Care and Nurse Aide's Information Sheet had not been updated with the information related to Resident #2 requiring the assistance of two staff persons for transfers. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy identified on 10/16/13 was received on 10/29/13, which alleged the Immediate Jeopardy was removed on 10/26/13; however, observations and interviews revealed the Immediate Jeopardy was removed on 10/31/13. A review of the AOC revealed the Comprehensive Care Plan (CCP) and State Registered Nurse Aide (SRNA) Care Plan for Resident #1 were revised on 10/23/13 by the MDS Coordinator. Further review of the AOC revealed the CCP was updated to address the risk of falls and the removal of the physical restraint. Review of the AOC further revealed the restorative and activity Care Plans were updated on 10/23/13. Review of the AOC revealed the CCP and SRNA Care Plan for Resident #2 was revised on 10/23/13 by the MDS Coordinator. Further review of the AOC revealed the CCP was updated to include the use of two staff to transfer the resident. The AOC revealed the CCPs and SRNA Care Plans for Residents #4, #14, and #15 were revised on 10/23/13 by the MDS Coordinator to address the residents' high risk for elopement. Further review of the AOC revealed the intervention of the use of the wander guard ankle bracelet was ongoing and a "wander book" identification, which included interventions and diversions, was implemented and maintained at each nurses' station located near exits and the front office. Staff was educated on the "wander book" on 10/25/13 and the Social Services Director was responsible for updating the resident's risk for elopement each week in the "wander book." Continued review of the AOC revealed the revisions were a result of wandering/elopement assessments completed by the MDS Coordinator on 10/18/13. Further review of the AOC revealed on 10/17/13 the facility implemented a system of a "safety employee" to complete 15-minute checks on residents for placement and safety in the facility. Continued review of the AOC revealed facility staff was educated on 10/25/13 on the use of the "wander book" and the new policies related to Residents Leaving the Facility, Sign In/Out Sheet, New Wandering/Elopement Precautions, Suggested Elopement Interventions, Code Green, and Interventions and Tools for the Wandering Resident by the DON, Compliance Director, Quality Assurance/Safety Administrative Assistant, Executive Director, and Human Resources Coordinator. Further review of the AOC revealed the staff was educated on all the above topics before being allowed to continue employment and had to complete a return demonstration by going through the facility to find the new books and policies. In addition, a review of the AOC revealed on 10/21/13 a Consultant trained and educated the DON, Corporate RN, MDS Coordinator, MDS Nurse, and Administrative LPN on developing and completion of care plans and the SRNA care plans to ensure revisions are made when a change occurs in a resident. Further review of the AOC revealed the Consultant provided education related to the regulation tag F280. The AOC revealed on 10/21/13 the Administrator and Executive Director (ED) directed the DON, Corporate RN, MDS Coordinator, MDS Nurse, and Administrative LPN to complete a review of each resident's CCP, MDS, and SRNA Care Plan and for all revisions to be completed by 10/25/13. The Administrator and Executive Director were to oversee the audits. The AOC further revealed on 10/22/13 the Administrator and the ED directed weekly revisions of CCPs and SRNA Care Plans pertaining to physical restraints, falls, and elopement. Further review of the AOC revealed an Interdisciplinary Plan of Care (IPOC) meeting will be held each weekday morning with the Administrator, ED, Social Services Director (SSD), Rehab Coordinator, MDS Coordinator, Administrative LPN, Dietary Director, Activity Coordinator, and DON. The AOC revealed the meetings will start with the review of the 24-hour report from the previous day and any new physician's orders or new occurrences will be discussed. Continued review of the AOC revealed the MDS Coordinator revises the CCP and SRNA Care Plan at the time of the meeting if needed. According to a review of the AOC, the Administrative LPN will audit the records of newly admitted residents to validate that the care plan addresses fall risk, elopement risk, and physical restraints. Further review of the AOC revealed the DON reviews the audits of the new resident care plans to verify care plan revisions and development are completed. **The surveyors validated the corrective action taken by the facility as follows: A review of the medical record of Resident #1 on 10/30/13, revealed the resident's CCP and SRNA Care Plan had been updated as stated in the AOC. Observations on 10/30/13 of Resident #1 revealed the resident had an alarm attached to the wheelchair, a cushion in the wheelchair, and did not have a physical restraint in use. A review of the medical record of Resident #2 on 10/30/13, revealed the resident's CCP and SRNA Care Plan had been updated to include the assistance of two staff members to transfer the resident. A review of the medical records of Residents #4, #14, and #15 on 10/30/13, revealed the resident's CCPs were updated to address the resident's high risk for elopement with an intervention of continued use of the wander guard ankle bracelet. Further review of the resident's CCPs revealed interventions that included the use of a "wander book" that listed interventions and diversions to address the residents' risk for elopement were put in place. Continued review of the medical records of Residents #4, #14, and #15 revealed a wandering/elopement assessment was completed on 10/18/13. A review of the employee safety checks revealed the checks were initiated on 10/17/13; however, the safety checks were not done consistently every 15 minutes as per the AOC until 10/30/13. Review of the in-services revealed the facility staff was in-serviced on 10/25/13 related to the wander book. Observations on 10/30/13, of Residents #4, #14, and #15 revealed the resident had a wander guard ankle bracelet in place and identification information about the residents was in the "wander book." Review of the facility's in-service sign-in sheets and interviews on 10/30/13 with staff (Dietary Staff Member #1, Housekeeping Staff Members #2 and #3, SRNAs #3, #16, #17, #18, #19, #20, and #21, and Licensed Practical Nurses #3, #7, and #9) verified staff had been in-serviced on 10/25/13, as stated in the AOC. Staff further revealed they had been in-serviced on the use of the "wander books," the new policy of Residents Leaving the Facility, Sign In/Out Sheet, New Wandering/Elopement Precautions, Suggested Elopement Interventions, Code Green, and Interventions and Tools for the Wandering Resident. Further staff interviews revealed the staff had to participate in mock elopement drills and to locate the wander book and policies. Interviews on 10/30/13 with Administrative Staff (the DON, Corporate RN, MDS Coordinator, MDS Nurse, and the Administrative LPN) revealed the staff was educated on 10/21/13 on the development and completion of CCPs and SRNA Care Plans and revisions of all Care Plans when a change occurs with a resident. Interviews on 10/30/13 with Administrative Staff (the DON, Corporate RN, MDS Coordinator, MDS Nurse, and the Administrative LPN) revealed review of all resident CCPs, MDS assessments, and SRNA Care Plans was initiated on 10/21/13 with revisions completed on 10/25/13. Interviews on 10/30/13 with the MDS Coordinator revealed daily reviews and revisions of the CCP and SRNA Care Plan were initiated on 10/22/13. Interviews on 10/30/13 and 10/31/13 with the Administrator, ED, Social Services Director (SSD), MDS Coordinator, Administrative LPN, Dietary Director, Activity Coordinator, and DON revealed an IPOC meeting was conducted daily to discuss the previous day's 24-hour report, new physician's orders, and any new occurrences. Interview with the MDS Coordinator revealed the resident's CCP and SRNA Care Plan were updated with new interventions, if needed, at the time of the meeting. Interview on 10/30/13 with the Administrative LPN revealed the facility had not admitted any new admissions; however, the LPN revealed when the facility did have a new admission the care plan would be audited to ensure the resident's CCP addressed fall risk, elopement risk, or use of a physical restraint if needed. Interview on 10/30/13 with the DON revealed the DON reviewed the audits of new admissions to verify care plan revisions and developments were completed.

Based on observation, interview, record review, review of the facility's policy, and a review of the manufacturer's guidelines, the facility failed to ensure five of eighteen sampled residents (Residents #1, #5, #6, #7, and #8) were free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Resident #1 was observed during the survey on 10/01/13, 10/02/13, 10/03/13, and 10/04/13 to be in a wheelchair with a soft lap belt restraint around the resident's waist and tied in a slipknot (a quick release knot) behind the back of the wheelchair. Staff interviews revealed Resident #1 was able to remove the soft lap belt and, at times, would slide under the soft lap belt restraint to the floor. In addition, the facility failed to systemically evaluate and/or assess the use of a restraint device to attempt to reduce or eliminate the use of the restraint for Residents #5, #7, and #8. There was no documented evidence the facility had identified a medical symptom that required the restriction of standing/movement for Residents #1, #5, #6, #7, and #8. The facility's failure to ensure residents were free from physical restraints that were not required to treat the resident's medical symptoms, failure to reassess the continued need for restraints, and failure to ensure restraints were utilized safely in accordance with manufacturer's guidelines placed residents in the facility at risk for serious injury, harm, impairment, or death. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 09/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 10/04/13 and was informed on 10/17/13 that the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Restraint Policy," not dated, revealed the facility limited the use of restraints to circumstances in which the resident had medical symptoms that warranted the use of restraints. Further review of the restraint policy revealed the facility would use a systematic and gradual process toward reducing the restraints. In addition, a review of the policy revealed the resident was to be fully informed of the potential risks and benefits of the use of the restraint. Review of the manufacturer's instructions for the application of the Soft Belt restraint revealed the use of the Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off of the chair and become suspended or entrapped. Continued review of the application instructions revealed the Soft Belt restraint should be laid across the resident's thighs with the connecting straps down at a 45-degree angle between the seat and the wheelchair sides with the straps crisscrossed behind the chair and tied using a quick-release knot to the opposite side kick spurs. 1. Record review revealed the facility admitted Resident #1 on 09/21/10, with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set assessment, completed on 08/19/13, revealed the facility assessed the resident to require extensive assistance of one staff person with bed mobility, transferring, and ambulation. The facility also documented Resident #1 to utilize a walker and a wheelchair for mobility. The assessment also revealed Resident #1 utilized a trunk physical restraint. Review of Resident #1's physician's orders [REDACTED]. Review of the Pre-restraining assessment dated [DATE] revealed the facility also assessed Resident #1 and noted the resident required the use of a foam lap belt due to medical necessity, related to [MEDICATION NAME] Degeneration, and to aid with positioning and safety. Although the facility had identified the soft belt as a restraint for this resident and had included the restraint on the Plan of Care, there was no documented evidence the facility had assessed the risk factors associated with the use of the restraint for Resident #1. Review of an incident report dated 09/11/13 revealed Resident #1 sustained a fall from the wheelchair after removing the foam lap belt and attempting to get into bed unassisted. Review of an incident report dated 09/17/13 revealed Resident #1 was found by staff sitting on the floor in front of his/her wheelchair with the foam belt still attached to the wheelchair. Review of an incident report dated 09/23/13 revealed Resident #1 was found by staff in front of the resident's bed with the soft foam belt on the floor beside the resident. Review of the incident report dated 09/30/13 revealed Resident #1 had slid out of the soft foam belt and wheelchair onto the floor. However, review of Resident #1's medical record revealed no documented evidence the soft lap belt had been reassessed for necessity, or for the risk of injury after the resident's falls in which the lap belt was in use. Interview on 10/03/13 at 1:35 PM with Resident #1 revealed if he/she wanted to get out of the wheelchair, he/she would attempt to slide under the soft lap belt or try to untie the soft lap belt. The interview further revealed Resident #1 had the lap belt to prevent the resident from falling but the resident did not feel like the lap belt was effective because he/she was able to get out of the restraint and up from the wheelchair. Observations of Resident #1 on 10/01/13 at 12:45 PM, on 10/02/13 at 10:30 AM, 11:55 AM, and 4:15 PM, on 10/03/13 at 4:26 PM, and on 10/04/13 at 12:38 PM, revealed Resident #1 was sitting up in a wheelchair with a soft foam lap belt in place, tied behind the wheelchair back in a slipknot (a quick release knot). However, review of the manufacturer's application instructions revealed the soft lap belt should be tied in a crisscross manner with two quick-release knots. Interviews on 10/02/13 with State Registered Nurse Aide (SRNA) #3 at 10:45 AM, SRNA #4 at 11:23 AM, SRNA #5 at 11:41 AM, SRNA #1 at 4:55 PM, and SRNA #6 at 5:15 PM, revealed Resident #1 often removed the soft lap belt and/or attempted to slide under the soft lap belt. Further interview with direct care staff revealed the staff had been trained to tie the restraint behind the resident's wheelchair back in a slipknot. However, review of the manufacturer's guidelines revealed staff failed to apply the soft belt restraint in accordance with the guidelines to ensure the resident's safety. Interview on 10/03/13 at 5:05 PM with Licensed Practical Nurse (LPN) #6 revealed Resident #1 often attempted to slide under the soft foam lap belt and/or to remove the soft belt restraint. The interview further revealed Resident #1 sustained a fall on 09/30/13 as a result of the resident sliding under the soft foam lap belt onto the floor. Interview on 10/03/13 at 7:29 PM with LPN #7 revealed Resident #1 often removed the soft foam lap belt and/or would attempt to slide under the lap belt. The interview further revealed the resident sustained [REDACTED]. Further interview revealed Resident #1 sustained a fall on 09/17/13 when the resident slid under the foam lap belt onto the floor while the soft lap belt was attached to the wheelchair. Interview on 10/03/13 at 4:39 PM with Registered Nurse (RN) #1 revealed Resident #1 had experienced numerous falls that included sliding out of the lap belt when it was attached to the chair, removing the lap belt restraint from the chair, and from unassisted transfers. The interview further revealed RN #1 was not aware of the risks of the resident sliding out of the wheelchair under the soft lab belt until the fall on 09/30/13 and at that time "Dycem" (a no-slip rubber-like material) was placed on the seat of the wheelchair as an intervention to prevent the resident from sliding. Interview on 10/03/13 at 7:15 PM with the Director of Nursing (DON) revealed the DON had not read the soft belt application instructions and was not aware of the specific guidelines for tying the soft belt restraint. The DON acknowledged she was not aware the use of the belt was to be discontinued if a resident had a tendency to slide forward or down in the device or was able to self-release the device. According to the DON, nursing staff had not been trained on how to apply soft lap belt restraints in accordance with the manufacturer's application instructions. The interview further revealed the facility had not addressed the risk of Resident #1 sliding under the lap belt out of the wheelchair onto the floor until the fall on 09/30/13 and at that time "Dycem" was added as an intervention to prevent further falls. 2. Record review revealed the facility admitted Resident #5 on 03/19/12, with [DIAGNOSES REDACTED]. Review of a pre-restraining assessment conducted by the facility on 05/12/12 revealed the facility had initiated a foam lap belt restraint for Resident #5 on 05/12/12. Based on the assessment, the use of the restraint for Resident #5 was due to the resident's instability of his/her gait, a history of [MEDICAL CONDITION], and a history of bilateral knee replacement. However, record review revealed no documented evidence the facility identified a medical symptom that warranted the use of the restraint. Review of the consent form for use of the resident's restraint revealed the resident's responsible party signed the consent on 03/19/12. However, the consent form failed to include a medical symptom or what type of restraint was utilized for the resident. Review of the Physical Restraint Elimination Assessment conducted by facility staff revealed the resident was assessed for elimination of the restraint on 06/20/12, 09/19/12, 12/12/12, 03/13/13, 06/12/13, and 09/10/13. However, the facility documented Resident #5 was not a candidate for a restraint reduction or elimination program because the resident had not experienced negative outcomes, did not have skin breakdown, and tended "to be impulsive and is easily distracted." Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment completed on 09/04/13 revealed the facility assessed the resident to be cognitively impaired and required extensive assistance of two staff persons with bed mobility, transferring, and toileting. The facility also documented Resident #5 utilized a walker and wheelchair for mobility and had not sustained any falls during the assessment period. The facility's assessment also revealed Resident #5 utilized a trunk restraint daily. Observations of Resident #5 on 10/07/13 at 11:04 AM, 12:00 PM, and 1:15 PM revealed the resident was alert, but did not respond appropriately to questions asked. The resident was sitting in a wheelchair with a foam lap belt restraint device. The lap belt restraint was observed to be tied to the back of the resident's wheelchair seat which, based on review of the application instructions in the manufacturer's guidelines, was contraindicated. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #5 had sustained falls in the facility and was impulsive, and based on an assessment of the resident the soft lap belt restraint was initiated on 05/12/12 to prevent further falls. Further interview revealed the facility had not attempted to reduce or eliminate the resident's restraint since the restraint was initiated (a timeframe of 17 months). 3. Record review revealed the facility admitted Resident #6 on 06/04/13 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to be cognitively impaired and required extensive assistance of two staff persons with transferring, ambulation, and toileting. The facility also documented Resident #6 utilized a walker and wheelchair for mobility and had sustained three falls, without major injury, during the assessment period. The assessment revealed Resident #6 required a trunk restraint daily. Review of a pre-restraining assessment conducted by the facility on 09/05/13 revealed the facility had initiated a foam lap belt restraint for Resident #6 on 09/05/13. The facility had identified the restraint was necessary due to the resident's history of a [MEDICAL CONDITIONS], weakness, and the resident's cognitive impairment that affected the resident's ability to make decisions related to safety issues. However, the facility had failed to identify a medical symptom that warranted the use of the restraint. Observations of Resident #6 on 10/03/13 at 6:00 PM revealed the resident was sitting in a wheelchair holding his/her soft lap belt restraint in his/her hand. Continued observations revealed SRNA #1 reapplied the resident's restraint. The SRNA was observed to tie the resident's restraint to the back of the resident's wheelchair which was contraindicated based on review of the application instructions in the manufacturer's guidelines. Interview with the DON on 10/03/13 at 7:30 PM revealed Resident #6 had sustained falls in the facility and the soft lap belt restraint was initiated to prevent further falls from occurring. Further interview revealed staff had been trained to tie the restraints in the back or under the seating area of the wheelchair. The DON stated she was not aware, based on the manufacturer's guidelines, that the restraint should not be tied in the back or underneath the seating area of the resident's wheelchair. 4. Record review revealed the facility admitted Resident #8 on 08/31/13 with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set assessment completed on 09/10/13 revealed Resident #8 was cognitively impaired and required extensive assistance of two staff persons with bed mobility, transferring, and ambulation. The facility also documented Resident #8 utilized a walker and wheelchair for mobility and had sustained two or more falls in the facility since admission. Based on review of the assessment, Resident #8 did not utilize physical restraints. Review of a pre-restraining assessment conducted by the facility on 09/24/13 revealed the facility had initiated a lap buddy restraint for Resident #8 on 09/24/13. The facility had identified that the necessity of the lap buddy for Resident #8 was due to poor cognition and his/her lack of safety awareness. However, the facility failed to identify a medical symptom that warranted the use of the restraint. Observations of Resident #8 on 10/07/13 at 11:00 AM and 1:39 PM revealed the resident sitting in a wheelchair with a lap buddy restraint device in place. Resident #8 was alert and would make eye contact, but would not respond when spoken to. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #8 had sustained falls in the facility and the lap buddy had been initiated to prevent further falls and injury. 5. Record review revealed the facility admitted Resident #7 on 12/17/08 with [DIAGNOSES REDACTED]. Review of a pre-restraining assessment conducted by the facility on 01/10/13 revealed a torso restraint had been initiated for Resident #7 on 01/01/13. The facility documented the torso restraint was necessary due to the resident's history of [MEDICAL CONDITION] and a left [MEDICAL CONDITION]. However, the facility failed to identify a medical symptom that warranted the use of the restraint. Review of Resident #7's quarterly Minimum Data Set assessment completed on 08/12/13 revealed the resident was severely cognitively impaired, required extensive assistance of two staff persons with bed mobility and transferring, and was non-ambulatory and dependent on staff for mobility via wheelchair. According to the assessment, Resident #7 utilized a trunk restraint daily and had not sustained any falls since the facility's prior assessment. Continued review of Resident #7's medical record revealed the facility completed a Physical Restraint Elimination Assessment for Resident #7 on 02/19/13, 05/20/13, and 08/15/13, and had determined on all three of the assessments that the resident was not a candidate for a restraint reduction or elimination program because the resident had not had any negative outcomes from the use of the torso restraint. Observations of Resident #7 on 10/07/13 at 11:13 AM and 1:15 PM revealed the resident sitting in a wheelchair with a torso restraint in place. Resident #7 was alert but made no attempts at communication and talked in a mumble. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #7's restraint had been initiated as a fall intervention. According to the DON, attempts to reduce the use of the restraint for Resident #7 had not been conducted because facility staff released the resident's restraint during meals and activities. Interview with the Executive Director (ED) on 10/17/13 at 3:30 PM revealed resident restraint use was determined by the DON and RN #1 and administrative staff did not provide any oversight for any aspect of restraint use.

Based on observation, interview, record review, review of the facility's policy, and a review of the manufacturer's guidelines, the facility failed to ensure five of eighteen sampled residents (Residents #1, #5, #6, #7, and #8) were free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Resident #1 was observed during the survey on 10/01/13, 10/02/13, 10/03/13, and 10/04/13 to be in a wheelchair with a soft lap belt restraint around the resident's waist and tied in a slipknot (a quick release knot) behind the back of the wheelchair. Staff interviews revealed Resident #1 was able to remove the soft lap belt and, at times, would slide under the soft lap belt restraint to the floor. In addition, the facility failed to systemically evaluate and/or assess the use of a restraint device to attempt to reduce or eliminate the use of the restraint for Residents #5, #7, and #8. There was no documented evidence the facility had identified a medical symptom that required the restriction of standing/movement for Residents #1, #5, #6, #7, and #8. The facility's failure to ensure residents were free from physical restraints that were not required to treat the resident's medical symptoms, failure to reassess the continued need for restraints, and failure to ensure restraints were utilized safely in accordance with manufacturer's guidelines placed residents in the facility at risk for serious injury, harm, impairment, or death. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 09/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 10/04/13 and was informed on 10/17/13 that the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy titled "Restraint Policy," not dated, revealed the facility limited the use of restraints to circumstances in which the resident had medical symptoms that warranted the use of restraints. Further review of the restraint policy revealed the facility would use a systematic and gradual process toward reducing the restraints. In addition, a review of the policy revealed the resident was to be fully informed of the potential risks and benefits of the use of the restraint. Review of the manufacturer's instructions for the application of the Soft Belt restraint revealed the use of the Soft Belt should be stopped at once if the resident has the tendency to slide forward or down in the device or is able to self-release the device. Further review of the application instructions revealed the resident should be monitored per facility policy to ensure the resident cannot slide down or fall off of the chair and become suspended or entrapped. Continued review of the application instructions revealed the Soft Belt restraint should be laid across the resident's thighs with the connecting straps down at a 45-degree angle between the seat and the wheelchair sides with the straps crisscrossed behind the chair and tied using a quick-release knot to the opposite side kick spurs. 1. Record review revealed the facility admitted Resident #1 on 09/21/10, with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Quarterly Minimum Data Set assessment, completed on 08/19/13, revealed the facility assessed the resident to require extensive assistance of one staff person with bed mobility, transferring, and ambulation. The facility also documented Resident #1 to utilize a walker and a wheelchair for mobility. The assessment also revealed Resident #1 utilized a trunk physical restraint. Review of Resident #1's physician's orders [REDACTED]. Review of the Pre-restraining assessment dated [DATE] revealed the facility also assessed Resident #1 and noted the resident required the use of a foam lap belt due to medical necessity, related to [MEDICATION NAME] Degeneration, and to aid with positioning and safety. Although the facility had identified the soft belt as a restraint for this resident and had included the restraint on the Plan of Care, there was no documented evidence the facility had assessed the risk factors associated with the use of the restraint for Resident #1. Review of an incident report dated 09/11/13 revealed Resident #1 sustained a fall from the wheelchair after removing the foam lap belt and attempting to get into bed unassisted. Review of an incident report dated 09/17/13 revealed Resident #1 was found by staff sitting on the floor in front of his/her wheelchair with the foam belt still attached to the wheelchair. Review of an incident report dated 09/23/13 revealed Resident #1 was found by staff in front of the resident's bed with the soft foam belt on the floor beside the resident. Review of the incident report dated 09/30/13 revealed Resident #1 had slid out of the soft foam belt and wheelchair onto the floor. However, review of Resident #1's medical record revealed no documented evidence the soft lap belt had been reassessed for necessity, or for the risk of injury after the resident's falls in which the lap belt was in use. Interview on 10/03/13 at 1:35 PM with Resident #1 revealed if he/she wanted to get out of the wheelchair, he/she would attempt to slide under the soft lap belt or try to untie the soft lap belt. The interview further revealed Resident #1 had the lap belt to prevent the resident from falling but the resident did not feel like the lap belt was effective because he/she was able to get out of the restraint and up from the wheelchair. Observations of Resident #1 on 10/01/13 at 12:45 PM, on 10/02/13 at 10:30 AM, 11:55 AM, and 4:15 PM, on 10/03/13 at 4:26 PM, and on 10/04/13 at 12:38 PM, revealed Resident #1 was sitting up in a wheelchair with a soft foam lap belt in place, tied behind the wheelchair back in a slipknot (a quick release knot). However, review of the manufacturer's application instructions revealed the soft lap belt should be tied in a crisscross manner with two quick-release knots. Interviews on 10/02/13 with State Registered Nurse Aide (SRNA) #3 at 10:45 AM, SRNA #4 at 11:23 AM, SRNA #5 at 11:41 AM, SRNA #1 at 4:55 PM, and SRNA #6 at 5:15 PM, revealed Resident #1 often removed the soft lap belt and/or attempted to slide under the soft lap belt. Further interview with direct care staff revealed the staff had been trained to tie the restraint behind the resident's wheelchair back in a slipknot. However, review of the manufacturer's guidelines revealed staff failed to apply the soft belt restraint in accordance with the guidelines to ensure the resident's safety. Interview on 10/03/13 at 5:05 PM with Licensed Practical Nurse (LPN) #6 revealed Resident #1 often attempted to slide under the soft foam lap belt and/or to remove the soft belt restraint. The interview further revealed Resident #1 sustained a fall on 09/30/13 as a result of the resident sliding under the soft foam lap belt onto the floor. Interview on 10/03/13 at 7:29 PM with LPN #7 revealed Resident #1 often removed the soft foam lap belt and/or would attempt to slide under the lap belt. The interview further revealed the resident sustained [REDACTED]. Further interview revealed Resident #1 sustained a fall on 09/17/13 when the resident slid under the foam lap belt onto the floor while the soft lap belt was attached to the wheelchair. Interview on 10/03/13 at 4:39 PM with Registered Nurse (RN) #1 revealed Resident #1 had experienced numerous falls that included sliding out of the lap belt when it was attached to the chair, removing the lap belt restraint from the chair, and from unassisted transfers. The interview further revealed RN #1 was not aware of the risks of the resident sliding out of the wheelchair under the soft lab belt until the fall on 09/30/13 and at that time "Dycem" (a no-slip rubber-like material) was placed on the seat of the wheelchair as an intervention to prevent the resident from sliding. Interview on 10/03/13 at 7:15 PM with the Director of Nursing (DON) revealed the DON had not read the soft belt application instructions and was not aware of the specific guidelines for tying the soft belt restraint. The DON acknowledged she was not aware the use of the belt was to be discontinued if a resident had a tendency to slide forward or down in the device or was able to self-release the device. According to the DON, nursing staff had not been trained on how to apply soft lap belt restraints in accordance with the manufacturer's application instructions. The interview further revealed the facility had not addressed the risk of Resident #1 sliding under the lap belt out of the wheelchair onto the floor until the fall on 09/30/13 and at that time "Dycem" was added as an intervention to prevent further falls. 2. Record review revealed the facility admitted Resident #5 on 03/19/12, with [DIAGNOSES REDACTED]. Review of a pre-restraining assessment conducted by the facility on 05/12/12 revealed the facility had initiated a foam lap belt restraint for Resident #5 on 05/12/12. Based on the assessment, the use of the restraint for Resident #5 was due to the resident's instability of his/her gait, a history of [MEDICAL CONDITION], and a history of bilateral knee replacement. However, record review revealed no documented evidence the facility identified a medical symptom that warranted the use of the restraint. Review of the consent form for use of the resident's restraint revealed the resident's responsible party signed the consent on 03/19/12. However, the consent form failed to include a medical symptom or what type of restraint was utilized for the resident. Review of the Physical Restraint Elimination Assessment conducted by facility staff revealed the resident was assessed for elimination of the restraint on 06/20/12, 09/19/12, 12/12/12, 03/13/13, 06/12/13, and 09/10/13. However, the facility documented Resident #5 was not a candidate for a restraint reduction or elimination program because the resident had not experienced negative outcomes, did not have skin breakdown, and tended "to be impulsive and is easily distracted." Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment completed on 09/04/13 revealed the facility assessed the resident to be cognitively impaired and required extensive assistance of two staff persons with bed mobility, transferring, and toileting. The facility also documented Resident #5 utilized a walker and wheelchair for mobility and had not sustained any falls during the assessment period. The facility's assessment also revealed Resident #5 utilized a trunk restraint daily. Observations of Resident #5 on 10/07/13 at 11:04 AM, 12:00 PM, and 1:15 PM revealed the resident was alert, but did not respond appropriately to questions asked. The resident was sitting in a wheelchair with a foam lap belt restraint device. The lap belt restraint was observed to be tied to the back of the resident's wheelchair seat which, based on review of the application instructions in the manufacturer's guidelines, was contraindicated. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #5 had sustained falls in the facility and was impulsive, and based on an assessment of the resident the soft lap belt restraint was initiated on 05/12/12 to prevent further falls. Further interview revealed the facility had not attempted to reduce or eliminate the resident's restraint since the restraint was initiated (a timeframe of 17 months). 3. Record review revealed the facility admitted Resident #6 on 06/04/13 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to be cognitively impaired and required extensive assistance of two staff persons with transferring, ambulation, and toileting. The facility also documented Resident #6 utilized a walker and wheelchair for mobility and had sustained three falls, without major injury, during the assessment period. The assessment revealed Resident #6 required a trunk restraint daily. Review of a pre-restraining assessment conducted by the facility on 09/05/13 revealed the facility had initiated a foam lap belt restraint for Resident #6 on 09/05/13. The facility had identified the restraint was necessary due to the resident's history of a [MEDICAL CONDITIONS], weakness, and the resident's cognitive impairment that affected the resident's ability to make decisions related to safety issues. However, the facility had failed to identify a medical symptom that warranted the use of the restraint. Observations of Resident #6 on 10/03/13 at 6:00 PM revealed the resident was sitting in a wheelchair holding his/her soft lap belt restraint in his/her hand. Continued observations revealed SRNA #1 reapplied the resident's restraint. The SRNA was observed to tie the resident's restraint to the back of the resident's wheelchair which was contraindicated based on review of the application instructions in the manufacturer's guidelines. Interview with the DON on 10/03/13 at 7:30 PM revealed Resident #6 had sustained falls in the facility and the soft lap belt restraint was initiated to prevent further falls from occurring. Further interview revealed staff had been trained to tie the restraints in the back or under the seating area of the wheelchair. The DON stated she was not aware, based on the manufacturer's guidelines, that the restraint should not be tied in the back or underneath the seating area of the resident's wheelchair. 4. Record review revealed the facility admitted Resident #8 on 08/31/13 with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set assessment completed on 09/10/13 revealed Resident #8 was cognitively impaired and required extensive assistance of two staff persons with bed mobility, transferring, and ambulation. The facility also documented Resident #8 utilized a walker and wheelchair for mobility and had sustained two or more falls in the facility since admission. Based on review of the assessment, Resident #8 did not utilize physical restraints. Review of a pre-restraining assessment conducted by the facility on 09/24/13 revealed the facility had initiated a lap buddy restraint for Resident #8 on 09/24/13. The facility had identified that the necessity of the lap buddy for Resident #8 was due to poor cognition and his/her lack of safety awareness. However, the facility failed to identify a medical symptom that warranted the use of the restraint. Observations of Resident #8 on 10/07/13 at 11:00 AM and 1:39 PM revealed the resident sitting in a wheelchair with a lap buddy restraint device in place. Resident #8 was alert and would make eye contact, but would not respond when spoken to. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #8 had sustained falls in the facility and the lap buddy had been initiated to prevent further falls and injury. 5. Record review revealed the facility admitted Resident #7 on 12/17/08 with [DIAGNOSES REDACTED]. Review of a pre-restraining assessment conducted by the facility on 01/10/13 revealed a torso restraint had been initiated for Resident #7 on 01/01/13. The facility documented the torso restraint was necessary due to the resident's history of [MEDICAL CONDITION] and a left [MEDICAL CONDITION]. However, the facility failed to identify a medical symptom that warranted the use of the restraint. Review of Resident #7's quarterly Minimum Data Set assessment completed on 08/12/13 revealed the resident was severely cognitively impaired, required extensive assistance of two staff persons with bed mobility and transferring, and was non-ambulatory and dependent on staff for mobility via wheelchair. According to the assessment, Resident #7 utilized a trunk restraint daily and had not sustained any falls since the facility's prior assessment. Continued review of Resident #7's medical record revealed the facility completed a Physical Restraint Elimination Assessment for Resident #7 on 02/19/13, 05/20/13, and 08/15/13, and had determined on all three of the assessments that the resident was not a candidate for a restraint reduction or elimination program because the resident had not had any negative outcomes from the use of the torso restraint. Observations of Resident #7 on 10/07/13 at 11:13 AM and 1:15 PM revealed the resident sitting in a wheelchair with a torso restraint in place. Resident #7 was alert but made no attempts at communication and talked in a mumble. Interview with the DON on 10/08/13 at 2:55 PM revealed Resident #7's restraint had been initiated as a fall intervention. According to the DON, attempts to reduce the use of the restraint for Resident #7 had not been conducted because facility staff released the resident's restraint during meals and activities. Interview with the Executive Director (ED) on 10/17/13 at 3:30 PM revealed resident restraint use was determined by the DON and RN #1 and administrative staff did not provide any oversight for any aspect of restraint use. *An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was received on 10/29/13. The AOC alleged the Immediate Jeopardy was removed on 10/26/13. However, observations and interviews revealed Immediate Jeopardy was removed on 10/31/13. Review of the AOC revealed Resident #1's physical restraint had been discontinued on 10/04/13, related to safety concerns. Resident #1 was assessed by the facility's Rehabilitation Department for wheelchair management, positioning, and safety. The AOC stated the facility's Rehabilitation staff had applied an anti-thrust cushion to the resident's wheelchair. The resident's Comprehensive Care Plan (CCP) and SRNA Care Plan had been reviewed and revised. The AOC stated a physician's orders [REDACTED].# 1 on 10/08/13. Review of the AOC revealed the facility's Rehabilitation staff had screened Resident #5 on 10/10/13 to evaluate safety concerns with the resident's current wheelchair positioning. The Assistant Medical Director validated the proper use for the resident's restraint on 10/16/13 and 10/23/13. The AOC stated facility staff conducted a restraint and restorative program assessment for Resident #5 on 10/08/13. The AOC further stated Resident #5 was assessed on 10/07/13 by Social Services and Activity staff to assist in reducing the resident's restraint. The AOC stated on 10/09/13 the MDS Coordinator audited the MDS to validate documentation. The AOC stated staff monitored Resident #5 every 15 minutes on 10/23/13 to validate the resident's safety. The AOC revealed Resident #5's restraint was discontinued per physician's orders [REDACTED]. Continued review revealed the resident's CCP was updated on 10/23/13 and the SRNA care plan was updated on 10/25/13. The AOC revealed the MDS Coordinator completed a physical restraint assessment for Resident #6 on 10/08/13. The AOC further stated the MDS Coordinator audited the resident's MDS on 10/09/13. The facility's Rehabilitation staff screened Resident #6 on 10/11/13, to observe the resident's seating system when up in the wheelchair. On 10/14/13 the resident's physical restraint was discontinued related to the resident's ability to remove the restraint. The AOC stated on 10/22/13 the resident's CCP and SRNA Care Plan were reviewed and revised by the MDS Coordinator. Review of the facility's AOC revealed Resident #7 received Occupational Therapy for wheelchair management on 10/04/13. On 10/07/13, Social Services and Activity Directors assessed the resident to assist in reducing the resident's restraint. The MDS Coordinator conducted a restraint assessment for Resident #7 on 10/08/13. The resident's MDS was audited and validated on 10/09/13 by the MDS Coordinator. The resident was assessed on 10/16/13 by the Assistant Medical Director for proper use of the resident's restraint. The MDS Coordinator updated the resident's restraint assessment and the SRNA care plan on 10/21/13. A physician's orders [REDACTED]. The resident's CCP was updated on 10/23/13. The AOC stated the MDS Coordinator completed a restraint assessment for Resident #8 on 10/08/13. On 10/08/13, Restorative staff and Social Services addressed the resident's current care plan to help reduce the use of the resident's restraint. On 10/07/13, the Activity Coordinator evaluated the resident to ensure activities were provided to benefit the resident. The resident's MDS was audited on 10/09/13 by the MDS Coordinator. The AOC revealed Resident #8 was assessed by Occupational Therapy for wheelchair positioning under the direction of the Administrator. The Assistant Medical Director evaluated Resident #8 on 10/16/13 for proper use of the resident's physical restraint. The resident's SRNA Care Plan was updated by the MDS Coordinator on 10/21/13. On 10/22/13, the resident's physical restraint assessment was updated by the MDS Coordinator. Facility staff conducted safety checks every 15 minutes for Resident #8 on 10/23/13. The MDS Coordinator revised the resident's CCP on 10/24/13. On 10/25/13, the MDS Coordinator updated the resident's physical restraint assessment. The AOC further revealed a physician's orders [REDACTED]. The AOC stated a sensor pad was added to the resident's wheelchair on 10/25/13, and the resident received one-hour safety checks. The AOC revealed the facility was restraint free on 10/25/13. The AOC revealed the Facility's Restraint Assessment was completed by the facility's Administrative LPN on 10/08/13 to determine the need for physical restraints. The AOC stated that to determine the continued need on all residents who already had physical restraints, a weekly Restraint Assessment would continue as part of the facility's Quality Assurance Program. All Restraint Assessments would be submitted to the Restraint Committee which would meet every day Monday through Friday. The Restraint Committee was to report the results of all physical Restraint Assessments to the Quality Assurance Committee every week. The facility's AOC revealed that each resident's MDS, Comprehensive Care Plan, and SRNA Care plan would be updated to reflect any needed changes identified by the Restraint Assessment. On 10/04-08/13, the Administrative LPN conducted a Restraint Assessment for each resident who had a current physician's orders [REDACTED]. The resident's Restraint Assessment included reviews of the resident's CCP related to the use of physical restraint, and validated that medical symptoms were present to support the use of the physical restraint. The assessments were also utilized to validate that the existing restraint was the least restrictive restraint in use for the least amount of time and validated whether the resident's environment or activities could be modified to reduce the resident's restraint. The AOC revealed on 10/04/13 the Facility's Director of Rehabilitation, Physical Therapist, and Occupational Therapist assessed all residents with physical restraints to determine if a restraint reduction was appropriate. The therapists evaluated if current physical restraints could be updated or modified to better ensure the resident's comfort and safety. The therapists also conducted an evaluation of each resident's environment to determine whether changes were appropriate. The facility's AOC revealed on 10/07/13, the Facility's Assistant Medical Director audited the Restraint Assessment for each resident using a physical restraint. The AOC stated the audits of Restraint Assessments included review of the resident's CCP related to the use of physical restraint. The AOC revealed the audit also validated that supporting medical symptoms were present for the use of a physical restraint. The audits validated that the existing restraint was the least restrictive restraint, was in use for the least amount of time, and whether the resident's environment or activities could be modified to reduce the restraint. On 10/07/13, the Assistant Medical Director validated all use of current physical restraints. The AOC further revealed the Assistant Medical Director would continue all restraint audits weekly until all restraints were discontinued. The AOC revealed each resident who utilized a physical restraint was assessed on 10/07/13, by the facility's Social Services Director and Recreational Coordinator to ensure personal preferences had been updated and meaningful activities had been provided. Continued review of the AOC also revealed on 10/08/13, the Administrative LPN audited restorative care plans in cooperation with the Rehab Director, Physical Therapist, and Occupational Therapist for each resident using a physical restraint. The AOC stated the audit ensured the facility was providing restorative care to enhance resident abilities to stand, transfer, and walk safely in attempt to decrease physical restraints. The AOC also revealed on 10/09/13 a Posey Company Representative conducted in-person training for all clinical staff regarding restraint programs, application, and instruction for each Posey product in use at the facility, as well as restraint reduction programs. The presentation was taped, and will be used in training for all new hires and annual training and review purposes. All clinical staff attended in-service training on 10/09/13. All clinical staff was required to demonstrate the correct application for each physical restraint currently used in the facility. The Posey Company Representative, Quality Assurance and Safety Administrative Assistant, and Compliance Director monitored training on the correct application of physical restraint. On 10/07/13, instructions for the appropriate application of each Posey brand physical restraint in use were posted at each nurses' station and in the SRNA book. Further review of the AOC revealed the facility's Quality Assurance and Safety Administrative Assistant educated all non-clinical, laundry, housekeeping, and dietary, which included all employees were trained on application and position of physical restraints starting on 10/22/13; all non-clinical staff will be completely educated by 10/25/13. This education ensured all employees, facilitywide, were educated on the proper application and positioning of all physical restraints. The education provided will be used to continually monitor residents with physical restraints to ensure the facility has a systemic team approach to identify sliding, falling, or attempts of removal of the physical restraint. Non-clinical staff members were educated to communicate with Charge Nurses to provide communication assistance. The AOC revealed on 10/07/13, the facility reviewed and updated policies and procedures regarding the safe and effective use of physical restraints. The updated policy stated that physical restraint may not be used unless for the safety and well-being of the patient and only after other alternatives had been evaluated. The AOC revealed the facility had increased physical restraint monitoring to ensure the safety of residents who utilized physical restraints. According to the AOC, on 10/11/13, all clinical staff participated in training given by the MDS Coordinator and Compliance Director on the new QA monitoring tool for residents using physical restraints to ensure the restraints were applied safely and effectively and to identify any potential accidents before they occur. Further review of the AOC revealed the facility established this new Quality Assessment Tool on 10/11/13. Charge Nurses would document using the required QA monitoring tool each shift for each resident with a physical restraint. All clinical staff was successfully trained on 10/11/13 on the new QA monitoring tool for physical restraints. The Quality Assessment Tool required Charge Nurses to observe whether the physical restraint was properly applied, confirm whether the restraint was being released and removed on schedule, and confirm whether there was documentation of appropriate toileting. The AOC stated the monitoring tool would be reviewed each day by the Administrator and Executive Director. All information would be submitted to the Quality Assurance Committee each day. The AOC revealed on 10/15/13, the facility's Charge Nurses began monitoring each resident that utilized a physical restraint every two hours. Charge Nurses were to document restraint monitoring in Point Click Care under Restraint Note. The AOC stated nurses would monitor to identify if the restraint was in use and applied correctly and if the resident had any discomfort due to the application of the physical restraint. If any negative findings were identified, then Charge Nurses were to immediately call the physician. A new assessment and revision to the CCP and SRNA Care Plan would follow. All nurses were educated on physical restraint safety checks every two hours successfully on 10/11/13. The Compliance Director and Executive Director were monitoring nurses that completed safety checks every two hours with residents who have physical restraints daily on all shifts. The Restraint Note was part of the resident's clinical record. The Compliance Director and Executive Director reported all findings to the Quality Assurance Committee daily. The AOC revealed on 10/24/13 the facility began monitoring every resident with a physical restraint every 15 minutes. The Human Resource Coordinator will be assigning a clinical staff member each day each shift. The clinical staff member assigned a staff member to monitor the time, the location of the resident, the status of the resident, and initialing of the monitoring process on each resident with a physical restraint. As safety monitoring was conducted, any negative findings identified would be immediately communicated to the Charge Nurse. The AOC revealed the Charge Nurses who encountered an incident that involved the safety or security of a resident using physical restraints, including that a restraint was improperly applied, were required to immediately report the incident to the Primary Care Physician, Nurse on Call, and the Executive Director. If any concerns were identified related to the application of restraints, the Charge Nurse or superior would immediately remove applicable personnel from the floor and require reeducation before returning staff to resident care. The Nurse on Call and Executive Director would be available to respond to restraint incident reports 24 hours per day, seven days per week, and all information obtained would be reported to the Quality Assurance Committee on a daily basis. The AOC revealed the Quality Assurance Committee would provide oversight of restraint use. The AOC revealed on 10/21/13, the Director of Nursing began monitoring, documenting and overseeing all clinical nursing staff, which included, SRNA's, KMAs, LPN's, and RN's on their performance of physical restraint application documentation. The AOC stated the DON will continue to check each resident Monday thru Friday on 7-3 shift and 3-11 shifts to ensure that each resident is positioned properly, restraint is applied properly, and resident is not showing signs of discomfort due to the use of the restraint. The DON will continue this process until all physical restraints are successfully removed. Any negative findings will immediately be addressed, and staff would be retrained before continuing care. Information will be submitted to the Restraint Committee and the Quality Assurance Committee each day. The AOC revealed effective 10/11/13, the MDS Coordinator would be reassessing each physical restraint assessment after each incident or change in condition. Assessments would be comple

Based on interview, record review, facility investigation review, and facility policies review, it was determined the facility failed to ensure the facility's policy/procedures were implemented related to abuse, neglect, and mistreatment for two (2) of twenty-two (22) sampled residents (Residents #1 and #2). The facility failed to ensure all allegations of abuse were reported immediately to administrative staff and the appropriate state agencies as per policy, failed to protect residents from abuse, and failed to thoroughly investigate all allegations of abuse. On 07/19/11, SRNA #8 was observed to be physically and verbally abusive to Resident #2 and, based on interviews, the allegation was reported to the DON; however, the DON denied the report. Resident #2 reported on 07/21/11, SRNA #8 abused the resident the previous evening. The allegation was reported to the DON. On 08/10/11, SRNA #2 witnessed and reported SRNA #8 lay in the bed and "spooned" Resident #1. In addition, interviews revealed throughout SRNA #8's employment staff witnessed SRNA #8 inappropriately kiss female residents and reported SRNA #8's behaviors to the DON and the Human Resources Director (HRD). (Refer to F223 and F225.) The facility's failure to implement the policies related to abuse has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and Resident #2 and other residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 07/19/11. An acceptable Allegation of Compliance (AOC) was received on 08/31/11, which alleged removal of Immediate Jeopardy on 08/31/11. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Abuse Policy (revised 09/06/00) revealed, "In the event of any evidence to cause to believe that a resident has suffered any abuse, the employee, visitor or family member are requested to report any/all allegations, suspicion, or incidents to the administration of the facility, i.e. charge nurses, supervisors, DON, SSD, or administrator." According to the policy, "Upon report of any allegations or violations, the administration will thoroughly investigate the situation. Any employee suspected of abuse, neglect, or disregard for resident welfare will be suspended from direct resident care while the investigation is in progress." The review revealed the investigation would include, but not be limited to, the following: names of all individuals involved, witnesses that actually viewed the incident, the resident's/family's statement concerning the incident, when and where the incident occurred, and any evidence of injury or abuse present on the resident's body or in the resident's actions. In addition, the policy revealed, "The results of the investigation shall be documented and placed in the investigation file." The policy also revealed, "After knowledge of an allegation of abuse, the administrator, director of nursing or social service director shall report it to Adult Protective Services and the Cabinet for Human Resources immediately. The results of all investigations will be reported to the same agencies within five (5) working days of the incident." 1. An interview conducted on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on 07/19/11, she witnessed State Registered Nurse Aide (SRNA) #8 being physically, mentally, and verbally rough with Resident #2 and Resident #8. The CMA reported SRNA #8's behavior to the Director of Nursing (DON) the next morning on 07/20/11. Interview on 08/24/11 at 7:05 PM, with the DON revealed she did not recall CMA #1's allegation against SRNA #8. Therefore SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified. 2. An interview conducted on 08/22/11 at 6:15 PM, with Resident #2 revealed SRNA #8 was not good to the resident. Resident #2 stated, "He tried to kill me," had placed a pillow over the resident's face, and "tried to smother me." The resident stated SRNA #8 "hit me four times," two times on each side of the resident's head. The interview revealed this was the only time SRNA #8 physically abused the resident. A review of the facility's investigation of Resident #2's allegation revealed staff reported Resident #2 said SRNA #8 "beat" up the resident. The investigation included staff statements; however, there was no documentation of the investigative findings, a conclusion, or that the appropriate state agencies had been notified of the allegation as per policy. The review revealed SRNA #8 continued to provide direct care to the residents for three days following the allegation made by Resident #2 on 07/21/11. An interview conducted on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on 07/19/11, she witnessed SRNA #8 being physically, mentally, and verbally rough with Resident #2 and Resident #8 and reported SRNA #8's behavior to the charge nurse that night (07/19/11) and to the DON the next morning (07/20/11). However, there was no documentation the facility implemented the Abuse policy by conducting an investigation or reporting the allegation to the appropriate state agencies. An interview conducted on 08/22/11 at 5:20 PM, with SRNA #1 revealed SRNA #8 was rude and threatened/intimidated Resident #2 by saying to the resident, "You apologize or else," "No, you're not getting up," and refused to transfer the resident to the chair. SRNA #1 did not report this allegation to administrative staff in accordance with facility policy. Therefore, the allegation was not investigated or reported to the appropriate state agencies. A review of the facility's investigation of Resident #2's allegation revealed staff reported Resident #2 said SRNA #8 "beat" up the resident. The investigation included staff statements; however, there was no documentation of a conclusion or results of investigative findings or that the appropriate state agencies were notified of the allegation in accordance with facility policy. An interview conducted on 08/22/11 at 6:30 PM, and on 08/24/11 at 7:05 PM, with the DON revealed on the morning of 07/21/11, staff reported Resident #2 had made an allegation that SRNA #8 had beat the resident up. The DON informed the Administrator and was instructed not to report the allegation. According to the DON, and an interview conducted on 08/22/11 at 7:00 PM, with the Assistant Administrator, SRNA #8 continued to work on 07/22/11, 07/23/11, and 07/24/11, after the allegation was reported and had not been suspended in accordance with facility policy. In addition, the DON confirmed there were no results to the facility's investigation or that the allegation had been reported to the state survey and certification agency in accordance with facility policy. An interview conducted on 08/25/11 at 6:05 PM, with the Administrator revealed Resident #2 was "delusional" so the allegation was not reported to all state agencies per policy. 3. An interview conducted on 08/23/11 at 10:10 AM, with SRNA #2 revealed on 08/10/11, she witnessed SRNA #8 come into Resident #1's room, lie down on the bed with the resident, "spoon" and kiss the resident, and leave the room. SRNA #2 reported the allegation to her supervisor (RA #2). An interview conducted on 08/25/11 at 8:10 AM, with RA #2 revealed she did not report the allegation to administrative staff. An interview conducted on 08/29/11 at 4:30 PM, with SRNA #9 revealed on 08/11/11, Resident #3 told her SRNA #8 was observed to be lying on top of a [AGE] year-old woman. The interview revealed SRNA #9 immediately reported the allegation to LPN #6. An interview conducted on 08/24/11 at 5:15 PM, with LPN #6 revealed she was informed of the allegation at approximately 6:45 AM on 08/11/11. LPN #6 waited approximately 26 hours before reporting the allegation to the HRD the next morning on 08/12/11. A review of the facility's investigation involving SRNA #8 spooning with Resident #1 revealed there was no documentation of results of investigative findings or that all the appropriate state agencies had been notified of the allegation as per policy. 4. Additional information addressing SRNA #8's history of abusive behaviors was obtained during interviews: An interview conducted on 08/22/11 at 5:20 PM, with SRNA #1 revealed since 02/11 she had witnessed SRNA #8 inappropriately kiss several female residents and had reported the behaviors to the charge nurses and the HRD several times. There was no documentation this allegation was investigated or reported to the appropriate state agencies as per policy. Interviews conducted on 08/23/11 at 3:50 PM, with SRNA #6, and on 08/23/11 at 3:30 PM, with SRNA #5 revealed SRNA #8 kissed the female residents inappropriately. SRNA #6 stated Resident #8 would scream hysterically when SRNA #8 came into the resident's room. The interviews revealed neither SRNA reported SRNA #8's inappropriate behaviors to administrative staff (charge nurses, supervisors, DON, SSD, or Administrator) as required by facility policy. Interviews conducted on 08/23/11 at 2:27 PM, with LPN #3, and on 08/23/11 at 4:25 PM, with LPN #5 also revealed the LPNs had witnessed SRNA #8 kiss several female residents. The interviews revealed prior to 07/11, both LPNs had separately "counseled" SRNA #8 and informed the SRNA that it was inappropriate to kiss the residents. LPN #3 stated she reported the SRNA's behaviors to the HRD on two occasions. LPN #5 stated she counseled SRNA #8 about his inappropriate behavior in the presence of the HRD. LPN #5 thought the HRD would inform the DON of SRNA #8's inappropriate behaviors. There was no documentation these allegations were reported to administrative staff (charge nurses, supervisors, DON, SSD, or Administrator), investigated, or reported to the appropriate state agencies as per policy. An interview conducted on 08/22/11 at 4:45 PM, and on 08/24/11 at 6:35 PM, with the HRD revealed staff had not reported SRNA #8's actions to her prior to 08/12/11. The HRD stated that in 06/11 she witnessed SRNA #8 kiss Resident #4, and had counseled the SRNA. The interview revealed the HRD discussed the SRNA's behaviors with the DON the next day. There was no documentation this allegation was investigated or reported to the appropriate state agencies as per policy. An interview conducted on 08/24/11 at 7:05 PM, with the DON revealed she had not been informed of SRNA #8's inappropriate behaviors prior to the 08/12/11 allegation. Therefore, there were no investigations conducted. --A review of the Allegation of Compliance revealed the following: The facility terminated SRNA #8 on 08/12/11, when administrative staff was made aware of the allegation involving SRNA #8 and Resident #1. The facility initiated an investigation of the allegation involving SRNA #8 and Resident #1. On 08/12/11, the Assistant Administrator and the HRD conducted interviews with all staff members who may have information regarding the allegation. The facility had nursing staff conduct physical examinations of all residents SRNA #8 had provided care to during the timeframe of 08/06/11 through 08/12/11, to determine if there were any signs/symptoms of abuse. On 08/30/11, RN #1 and LPN #1 conducted interviews with the alert and oriented residents about possible abuse issues. On 08/30/11, the Assistant Administrator and the Co-Owner conducted interviews with 13 family members/visitors, which included family members of non-oriented residents to determine if there were any signs/symptoms of abuse or any complaints. On 08/25/11, Legal Counsel was contacted concerning the Immediate Jeopardy in abuse investigation, protection, and reporting. Legal Counsel and Administration immediately began review and revisions to the facility's Abuse policy. The final revisions were completed on 08/30/11. Policy changes involved the supervision of staff concerning the supervisory staff's duty to monitor and evaluate the staff that may have greater potential for abuse. The policy instructs staff to advise supervisors of problems dealing with stress. Other policy changes involved the screening procedure to include a screening process for Administration to use upon hire, in addition to the criminal record checks, abuse registry screens, license/certification verification, and reference checks. The investigation section of the policy was also strengthened to ensure investigations are initiated upon reports of suspected abuse as defined in the Investigation Protocol. The protection section of the policy was revised to state that if a report of abuse is made that involves an employee, that employee will be reassigned from resident care or suspended during the investigation. On 08/25/11 and 08/30/11, the Assistant Administrator and the Administrator received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by Legal Counsel. On 08/26/11, the Education Assistant, the DON, and the Co-Owner received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by the Assistant Administrator. On 08/26/11, training was conducted for all 150 staff members including non-clinical staff during each shift (10 AM, 2 PM, 4 PM, and 11 PM) concerning abuse prevention, abuse investigation, and abuse reporting. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. Upon completion of the training all staff was given a written quiz to verify the staff's comprehension of the material. The facility currently has one staff person on medical leave that will receive this training upon returning to work. All new staff will receive this training upon date of hire. Continued abuse training will be conducted on a bi-annual basis for all staff. On 08/26/11, supervisory staff received specific training on recognizing situations that may indicate stress on staff because staff working under excessive emotional stress was more likely to be impatient with a greater likelihood of committing abuse. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11 and 08/30/11, all Department Heads received specific training about the new policies/procedures emphasizing that potential abuse must be reported to both the OIG and DCBS with the final results of the investigation communicated within five working days. Upon completion of the training all Department Heads were given a written quiz to verify the staff's comprehension of the material. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11, an Abuse Response Checklist File was developed and distributed to the Department Heads to assist the staff in following the correct procedures. The Checklist File consists of the Self Reporting Form published by the OIG. The DON will review compliance with training requirements and will report any and all findings to the Quality Assurance committee on a quarterly basis, which will monitor the facility's compliance. The treatment nurse will monitor residents on a daily basis for any skin changes or signs of potential abuse. Any suspected or actual abuse discovered by the treatment nurse will be reported to the charge nurse. The charge nurse is required to report the findings to the DON, who will immediately report to the Assistant Administrator. The Abuse Response Checklist File for the Department Heads will walk the individual through the steps that should be taken when abuse is suspected or reported. All reports of suspected abuse will be immediately reported to the charge nurse. The charge nurse will immediately report the suspected abuse to the DON, who will document the allegation on the 24-hour nurses' report. The DON and the Assistant Administrator will review the 24-hour nurses' report on a daily basis and will report any alleged abuse to the Administrator and the appropriate state agencies. Upon report of any alleged violations the Administration will thoroughly investigate the allegation. The Administrator and the Assistant Administrator will monitor any suspected or actual abuse according to facility policy to ensure the resident is protected by suspending or reassigning the alleged perpetrator, if an employee, during the investigation process. The Administrator and the Assistant Administrator will also monitor that a conclusion to the investigation is completed and that reporting has been made to the appropriate agencies. The Quality Assurance Committee will receive all reports of suspected or actual abuse and will monitor to ensure compliance with facility policy and regulation. --The surveyors validated the corrective actions taken by the facility as follows: A review of the Employee Master Change Sheet revealed SRNA #8 was terminated effective 08/12/11, by the Human Resources Director. A review was conducted of the facility's investigation. The investigation was initiated on 08/12/11, when administrative staff received the report of the abuse and SRNA #8 was immediately removed from the facility and escorted off the premises by local Police. A review of the physical examinations of residents cared for by SRNA #8 on 08/06/11 through 08/12/11, was conducted. Skin assessments for eight residents under the care of SRNA #8 were conducted and documented by LPN #3 and each resident was questioned by LPN #8. Interview with LPN #3 on 09/01/11, revealed the LPN had conducted the skin assessments at the request of the Human Resources Director after SRNA #8 was escorted from the facility. According to LPN #3, no injuries or skin changes were noted. Skin assessments conducted during the survey revealed no injuries of unknown source. Interviews were conducted with family members of Residents #1 and #4. The family members denied any injuries or mistreatment of the residents. A review of the documentation of interviews with alert/oriented residents and family members conducted by RN #1 revealed no identified problems from the interviews. A resident group interview was conducted by surveyors on 08/30/11 at 10:00 AM, and no reports of abuse/neglect were reported. A review of the facility's revised policy/procedure for abuse/neglect revealed the facility had addressed all requirements for the policy/procedure. The revised policy/procedure included education to address staff behaviors that would indicate a potential for abuse. The investigation section of the policy/procedure addressed the need to immediately notify state agencies and reporting requirements for suspected abuse/neglect of residents. Interview on 09/01/11 at 10:35 AM, with the facility's Legal Counsel revealed the Legal Counsel had educated the Administrator and Assistant Administrator on abuse/neglect and the regulatory requirements for Long Term Care Facilities from 08/12/11 through 08/30/11. According to Legal Counsel, the Administrator and Assistant Administrator were educated on reporting requirements of suspected abuse and what the definitions for abuse/neglect/misappropriation were. Review of the revised facility policy/procedure revealed the policy met regulatory requirements. A review of the facility's training records revealed evidence that all employees of the facility except for one had received training on abuse/neglect from administrative staff on 08/26/11. One facility employee was on medical leave and will be educated prior to being allowed to work. The attendance rosters for the training were compared to the facility's time reports for active working employees and confirmed all employees had received education in abuse/neglect and had received a copy of the facility policy/procedure. The facility's documentation included evidence of each staff member having successfully passed a quiz concerning the information given in the abuse/neglect training. Staff interviews were conducted on 08/31/11 from 3:40 PM to 4:30 PM, and on 09/01/11 at 11:42 AM, with LPN #11, LPN #12, KMA #2, SRNA #14, SRNA #15, Housekeeper #1, and Housekeeper #2 related to the facility's abuse/neglect training. Staff verified the receipt of training and each had received a copy of the facility's revised policy/procedure. A review of the facility's training records revealed evidence the facility's Department Heads had received training in abuse/neglect and reporting. The Checklist File was included in the facility's documentation. A review of the facility's 24-hour Nursing Report, used as the monitoring tool for signs of abuse, revealed documentation of daily monitoring of residents including any changes in condition or new orders. Interview with the Assistant Administrator on 09/01/11 at 11:10 AM, revealed the 24-hour Nursing Report was reviewed on a daily basis and any concerns were investigated. The Assistant Administrator stated the results of the monitoring would be part of the facility's Quality Assurance process. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systematic changes and quality assurance activities.

Based on interview, record review, and review of the facility's investigations and policies, it was determined the facility failed to have an effective system in place to ensure two (2) of twenty-two (22) sampled residents (Residents #1 and #2) were free from verbal, sexual, physical, and mental abuse. The facility failed to ensure allegations of abuse were immediately reported to administrative staff, failed to ensure residents were protected from abuse and allowed an alleged perpetrator to continue to work during the facility's investigation, failed to conduct a thorough investigation in order to reach a conclusion that an allegation of abuse was substantiated/unsubstantiated, and failed to report all allegations of abuse to the appropriate state agencies. On 07/19/11, Certified Medication Aide (CMA) #1 witnessed State Registered Nurse Aide (SRNA) #8 being physically and verbally rough with Resident #2 and reported the incident to the Director of Nursing (DON). However, SRNA #8 was not suspended, an investigation was not conducted, and the appropriate state agencies were not notified. On 07/21/11, Resident #2 reported SRNA #8 physically abused the resident on the evening of 07/20/11. The resident's allegation was reported to the DON and statements were obtained from staff. However, the facility failed to conduct a thorough investigation and the appropriate state agencies were not notified of the allegation. The facility also failed to protect Resident #2 during the investigation and allowed SRNA #8 to continue to work for three days following the resident's report of the allegation. The SRNA was suspended for two days (07/25-26/11). On 08/10/11, SRNA #2 witnessed SRNA #8 "jump" onto the bed with Resident #1 and to "spoon" and kiss the resident. SRNA #2 reported the allegation to her supervisor but the supervisor failed to report the allegation. The allegation was overheard by Resident #3 and this resident informed SRNA #9. SRNA #9 reported the allegation to Licensed Practical Nurse (LPN) #6 on 08/11/11 at approximately 6:45 AM; however, LPN #6 waited 26 hours before informing the Human Resources Director (HRD) on 08/12/11 at 8:30 AM, about the allegation. The Assistant Administrator was informed of the allegation at approximately 10:30 AM on 08/12/11, and SRNA #8 was removed from the facility, terminated, and escorted off the premises by Law Enforcement. The Assistant Administrator confirmed the appropriate state agencies had not been notified of the allegation and a thorough investigation had not been conducted. During the state agency's investigation, interviews revealed SRNA #8 had a history of [REDACTED]. The facility's failure to ensure staff immediately reported all allegations of abuse to administrative staff, failure to protect residents from abuse during the facility's investigation, failure to conduct a thorough investigation, and failure to report all allegations of abuse to the appropriate state agencies, has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and Resident #2 and other residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 07/19/11. An acceptable Allegation of Compliance (AOC) was received on 08/31/11, and alleged removal of Immediate Jeopardy on 08/31/11. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Abuse Policy (revised 09/06/00) revealed, "In the event of any evidence to cause to believe that a resident has suffered any abuse, the employee, visitor or family member are requested to report any/all allegations, suspicion, or incidents to the administration of the facility, i.e. charge nurses, supervisors, DON, SSD, or administrator." The policy stated, "Upon report of any allegations or violations, the administration will thoroughly investigate the situation. Any employee suspected of abuse, neglect, or disregard for resident welfare will be suspended from direct resident care while the investigation is in progress." The review revealed the investigation would include, but not be limited, to the following: names of all individuals involved, witnesses that actually viewed the incident, the resident's/family's statement concerning the incident, when and where the incident occurred and any evidence of injury or abuse present on the resident's body or in the resident's actions. The policy revealed, "The results of the investigation shall be documented and placed in the investigation file." The policy also revealed, "After knowledge of an allegation of abuse, the administrator, director of nursing or social service director shall report it to Adult Protective Services and the Cabinet for Human Resources immediately. The results of all investigations will be reported to the same agencies within five (5) working days of the incident." 1. An interview conducted on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on 07/19/11, she witnessed SRNA #8 being physically, mentally, and verbally abusive to Resident #2 and Resident #8. The CMA reported SRNA #8's behavior to the DON the next morning on 07/20/11. Interview on 08/24/11 at 7:05 PM, with the DON revealed she did not recall CMA #1's allegation against SRNA #8. Therefore, SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified. An interview conducted on 08/22/11 at 5:20 PM, with State Registered Nurse Aide (SRNA) #1, revealed SRNA #8 had a history of [REDACTED]. getting up," and would refuse to transfer the resident to the chair. According to SRNA #1, she could not remember when she witnessed this incident but she did report SRNA #8's behaviors to the Human Resources Director (HRD). Interview on 08/24/11 at 6:35 PM, with the HRD revealed she did not recall SRNA #1's allegation against SRNA #8. Therefore, SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified. Interviews conducted on 08/22/11 at 7:00 PM, with the Assistant Administrator, and on 08/25/11 at 6:05 PM, with the Administrator revealed they were unaware of the above allegations against SRNA #8. 2. A review of the facility's investigation of Resident #2's allegation, undated, revealed the facility had obtained statements from eight employees, the DON, and the alleged perpetrator. The DON's statement dated 07/21/11, revealed staff reported Resident #2 said SRNA #8 "beat" the resident up during the 3-11 PM shift on 07/20/11. The statement revealed the Administrator was notified of the allegation at approximately 8:20 AM on 07/21/11, and stated, "Not to report as this didn't happen." The review revealed Resident #2 came to the DON at approximately 10:55 AM on 07/21/11, and asked, "What are you going to do about" SRNA #8 and the resident proceeded to inform the DON that SRNA #8 "put a pillow over my face and then hit me on each side of my head." The statement revealed at 12:10 PM on 07/21/11, the DON reported the allegation again to the Administrator who stated, "Quit worrying about this;" the resident is "crazy." The review revealed SRNA #8 was suspended on 07/25/11 at 3:00 PM, four days after the allegation was made. There was no evidence a thorough investigation had been completed or that the appropriate state agencies had been notified of the allegation. A review of Resident #2's medical record revealed the facility admitted the resident on 09/14/10, with [DIAGNOSES REDACTED]. A review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident's cognition was intact and the resident required extensive assistance of two staff persons with bed mobility, transfers, dressing, and toileting. An interview conducted on 08/22/11 at 6:15 PM, with Resident #2 revealed SRNA #8 was not good to him/her. Resident #2 stated, "He tried to kill me," by placing a pillow over the resident's face and "tried to smother me." According to the resident, SRNA #8 "hit me four times," two times on each side of the resident's head. An interview conducted on 08/22/11 at 2:11 PM, with the Minimum Data Set (MDS) Coordinator revealed she assisted Resident #2 on the morning of 07/21/11, and at that time the resident reported SRNA #8 had hit the resident on the head. The interview revealed the MDS Coordinator reported Resident #2's allegation to the DON. Interviews conducted on 08/22/11 at 3:30 PM, with Registered Nurse (RN) #1 and on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on 07/21/11, Resident #2 reported SRNA #8 put a pillow over the resident's face and hit the resident on the head four times. RN #1 stated Resident #2 was "very convincing" and the allegation was reported to the DON. CMA #1 stated at the time of the allegation she noted a small bruise to the left side of the resident's face on the cheek area that was not present the previous day. The CMA reported Resident #2's allegation to the MDS Coordinator and wrote a statement. An interview conducted on 08/22/11 at 6:30 PM, and on 08/24/11 at 7:05 PM, with the DON revealed on the morning of 07/21/11, staff reported to her that Resident #2 alleged SRNA #8 had physically beat the resident. The DON informed the Administrator and was instructed not to report the allegation. The interview revealed later that same day Resident #2 came to the DON and asked what she was going to do about SRNA #8 putting a pillow over the resident's face and beating the resident up. The DON again informed the Administrator of the allegation and was instructed to "stop worrying," that Resident #2 was "crazy." According to the DON, staff statements were obtained; however, SRNA #8 continued to work on 07/22/11, 07/23/11, and 07/24/11, until the Assistant Administrator returned from vacation and was informed of the allegation. The interview revealed SRNA #8 was suspended on 07/25/11 and 07/26/11, and was assigned to a different unit and shift when he returned to work. The DON stated an investigation had been conducted with no conclusion reached and stated the Assistant Administrator notified the Department for Community Based Services (DCBS) on 07/25/11. However, based on interview, the facility failed to ensure all appropriate agencies had been notified of the allegations. The DON denied that staff had reported SRNA #8 had been rough with any of the residents prior to this allegation. An interview conducted on 08/22/11 at 7:00 PM, with the Assistant Administrator, confirmed SRNA #8 worked on 07/22-24/11, and was suspended on 07/25/11, until the investigation was completed. The Assistant Administrator stated the SRNA was allowed to return to work on 07/27/11, on a different shift and unit. The Assistant Administrator stated due to Resident #2's history of head injury and that the resident recanted the allegation the facility felt the allegation was not true and did not report the allegation to the appropriate state agencies. An interview conducted on 08/25/11 at 6:05 PM, with the Administrator revealed the Administrator was informed of Resident #2's allegation on 07/21/11, and due to the resident's "delusional" status the allegation was not reported to the appropriate state agencies. 3. A review of the facility's undated investigation of the allegation that SRNA #8 laid on the bed with Resident #1 and spooned with the resident revealed statements were obtained from 12 staff members and the Assistant Administrator. There was no documentation of a conclusion, summary of investigative findings, or that all appropriate state agencies had been notified of the allegation. A review of Resident #1's medical record revealed the facility admitted the resident on 11/06/09, with [DIAGNOSES REDACTED]. A review of Resident #1's comprehensive Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired and the resident was independent with no setup needed for transfers, dressing, toileting, and hygiene. An interview conducted on 08/23/11 at 10:10 AM, with SRNA #2 revealed on 08/10/11, during the 7 AM-3 PM shift, she witnessed SRNA #8 come into Resident #1's room, jump on the bed, lie down on the bed, and "spoon" the resident. SRNA #8 proceeded to kiss Resident #1, got off the bed, and left the room. SRNA #2 ensured Resident #1 was all right and completed her duties and then reported the allegation to her supervisor (Restorative Aide #2). An interview conducted on 08/25/11 at 8:10 AM, with Restorative Aide (RA) #2 confirmed SRNA #2 reported the allegation but staff failed to report the allegation to administrative staff. An interview conducted on 08/22/11 at 3:11 PM, with SRNA #7 revealed SRNA #2 informed SRNA #7, in the presence of Resident #3, that she (SRNA #2) witnessed SRNA #8 get in bed with a female resident and lie with his body against the resident's body. An interview conducted on 08/29/11 at 4:30 PM, with SRNA #9 revealed in the early morning on 08/11/11, Resident #3 informed her that another SRNA found SRNA #8 on top of a [AGE] year-old female resident. The interview revealed SRNA #9 immediately reported the allegation to LPN #6. An interview conducted on 08/24/11 at 5:15 PM, with LPN #6 confirmed she was informed at approximately 6:45 AM on 08/11/11, by SRNA #9, that Resident #3 reported SRNA #8 was found in bed with a female resident. The LPN waited 26 hours after being informed of the allegation to report the allegation to the HRD on 08/12/11. Interviews conducted on 08/22/11 at 4:45 PM, with the HRD, and on 08/22/11 at 2:11 PM, with the MDS Coordinator revealed on 08/12/11 at approximately 8:30 AM, LPN #6 stated that Resident #3 reported that an aide found a male SRNA on top of a female resident. The Assistant Administrator was notified of the allegation on 08/12/11 at approximately 10:30 AM, by the HRD and MDS Coordinator. An interview conducted on 08/22/11 at 7:00 PM, and 08/24/11 at 7:50 PM, with the Assistant Administrator confirmed she had been notified of the allegation. The Assistant Administrator stated she informed the Administrator of the allegation. The Assistant Administrator stated within 30 minutes of being informed of the allegation, SRNA #8 was terminated and removed from the facility. According to the Assistant Administrator, DCBS was notified of the allegation and other state agencies were not notified. An interview conducted on 08/25/11 at 6:05 PM, with the Administrator revealed upon being informed of the allegation on the morning of 08/12/11, SRNA #8 was terminated and escorted off the premises by local Law Enforcement to ensure the safety of residents and staff. An interview conducted on 08/25/11 at 2:50 PM, with SRNA #8 revealed he was told not to kiss or hug the residents. SRNA #8 acknowledged that he had kissed the residents on the cheek and that he had lain in bed with Resident #1. 4. In addition, interviews during the state agency's investigation revealed SRNA #8 had a history of [REDACTED]. An interview conducted with SRNA #1 on 08/22/11 at 5:20 PM, revealed she witnessed SRNA #8 inappropriately kiss several female residents since 02/11. The SRNA stated she reported SRNA #8's inappropriate behaviors to the charge nurses several times and also reported the SRNA's behaviors to the HRD. According to SRNA #1, LPN #3 instructed SRNA #8 to stop kissing the female residents but the behaviors continued. An interview conducted on 08/23/11 at 2:27 PM, with LPN #3 revealed she had witnessed SRNA #8 kiss several female residents. LPN #3 stated prior to 07/11 she counseled SRNA #8 that kissing on the residents was inappropriate. The LPN stated she reported to the HRD that she observed SRNA #8 inappropriately kiss female residents and was instructed to "counsel" the SRNA if she observed the behavior again. An interview conducted on 08/23/11 at 4:25 PM, with LPN #5 revealed she witnessed SRNA #8 kiss several female residents in an inappropriate manner. LPN #5 stated she and another LPN counseled SRNA #8 about his inappropriate actions in the presence of the HRD. The interview revealed the LPN thought the HRD would inform the DON of SRNA #8's inappropriate behaviors and therefore the LPN did not report the incident to administrative staff. An interview conducted on 08/23/11 at 3:50 PM, with SRNA #6 revealed she witnessed SRNA #8 kiss the female residents on their neck and face in a way that seemed inappropriate. The interview revealed SRNA #6 had not reported the incidents to administrative staff. An interview conducted on 08/23/11 at 3:30 PM, with SRNA #5 revealed she also observed SRNA #8 kiss female residents on their cheeks and close to their mouth. The interview revealed SRNA #5 had not reported the incidents because other staff had also observed incidents and had not reported/stopped them. An interview conducted on 08/22/11 at 4:45 PM, and on 08/24/11 at 6:35 PM, with the HRD revealed she did not recall staff reporting SRNA #8's inappropriate behaviors with female residents prior to 08/12/11. However, the HRD stated that toward the end of 06/11 she witnessed SRNA #8 kiss Resident #4, and she counseled the SRNA concerning his inappropriate behaviors. The interview revealed the HRD had not documented SRNA #8 was counseled but discussed the incident with the DON the next day. An interview conducted on 08/24/11 at 7:05 PM, with the DON revealed she was unaware of SRNA #8's inappropriate behaviors prior the 08/12/11 allegation. Therefore SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified prior to the 08/12/11 allegation. --A review of the Allegation of Compliance revealed the following: The facility terminated SRNA #8 on 08/12/11, when administrative staff was made aware of the allegation involving SRNA #8 and Resident #1. The facility initiated an investigation of the allegation involving SRNA #8 and Resident #1. On 08/12/11, the Assistant Administrator and the HRD conducted interviews with all staff members who may have information regarding the allegation. The facility had nursing staff conduct physical examinations of all residents SRNA #8 had provided care to during the timeframe of 08/06-12/11, to determine if there were any signs/symptoms of abuse. On 08/30/11, RN #1 and LPN #1 conducted interviews with the alert and oriented residents about possible abuse issues. On 08/30/11, the Assistant Administrator and the Co-Owner conducted interviews with 13 family members/visitors, which included family members of non-oriented residents, to determine if there were any signs/symptoms of abuse or any complaints. On 08/25/11, Legal Counsel was contacted concerning the Immediate Jeopardy in abuse investigation, protection, and reporting. Legal Counsel and Administration immediately began review and revisions to the facility's Abuse policy. The final revisions were completed on 08/30/11. Policy changes involved the supervision of staff concerning the supervisory staff's duty to monitor and evaluate the staff that may have greater potential for abuse. The policy instructs staff to advise supervisors of problems dealing with stress. Other policy changes involved the screening procedure to include a screening process for Administration to use upon hire, in addition to the criminal record checks, abuse registry screens, license/certification verification, and reference checks. The investigation section of the policy was also strengthened to ensure all investigations were initiated upon reports of suspected abuse as defined in the Investigation Protocol. The protection section of the policy was revised to state that if a report of abuse was made that involved an employee, that employee would be reassigned from resident care or suspended during the investigation. On 08/25/11 and 08/30/11, the Assistant Administrator and the Administrator received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by Legal Counsel. On 08/26/11, the Education Assistant, the DON, and the Co-Owner received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by the Assistant Administrator. On 08/26/11, training was conducted for all 150 staff members including non-clinical staff during each shift (10 AM, 2 PM, 4 PM, and 11 PM) concerning abuse prevention, abuse investigation, and abuse reporting. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. Upon completion of the training all staff was given a written quiz to verify the staff's comprehension of the material. The facility currently has one staff person on medical leave that will receive this training upon returning to work. All new staff will receive this training upon date of hire. Continued abuse training will be conducted on a bi-annual basis for all staff. On 08/26/11, supervisory staff received specific training on recognizing situations that may indicate stress on staff, because staff working under excessive emotional stress was more likely to be impatient with a greater likelihood of committing abuse. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11 and 08/30/11, all Department Heads received specific training about the new policies/procedures emphasis that potential abuse must be reported to both the OIG and DCBS with the final results of the investigation communicated within five working days. Upon completion of the training all Department Heads were given a written quiz to verify the staff's comprehension of the material. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11, an Abuse Response Checklist File was developed and distributed to the Department Heads to assist the staff in following the correct procedures. The Checklist File consists of the Self Reporting Form published by the OIG. The DON will review compliance with training requirements and will report any and all findings to the Quality Assurance committee on a quarterly basis, which will monitor the facility's compliance. The treatment nurse will monitor residents on a daily basis for any skin changes or signs of potential abuse. Any suspected or actual abuse discovered by the treatment nurse will be reported to the charge nurse. The charge nurse is required to report the findings to the DON, who will immediately report to the Assistant Administrator. The Abuse Response Checklist File for the Department Heads will walk the individual through the steps that should be taken when abuse is suspected or reported. All reports of suspected abuse will be immediately reported to the charge nurse. The charge nurse will immediately report the suspected abuse to the DON, who will document the allegation on the 24-hour nurses' report. The DON and the Assistant Administrator will review the 24-hour nurses' report on a daily basis and will report any alleged abuse to the Administrator and the appropriate state agencies. Upon report of any alleged violations the Administration will thoroughly investigate the allegation. The Administrator and the Assistant Administrator will monitor any suspected or actual abuse according to facility policy to ensure the resident is protected by suspending or reassigning the alleged perpetrator, if an employee, during the investigation process. The Administrator and the Assistant Administrator will also monitor that a conclusion to the investigation is completed and that reporting has been made to the appropriate agencies. The Quality Assurance Committee will receive all reports of suspected or actual abuse and will monitor to ensure compliance with facility policy and regulation. --The surveyors validated the corrective actions taken by the facility as follows: A review of the Employee Master Change Sheet revealed SRNA #8 was terminated effective 08/12/11, by the Human Resources Director. A review was conducted of the facility's investigation. The investigation was initiated on 08/12/11, when administrative staff received the report of the abuse and SRNA #8 was immediately removed from the facility and escorted off the premises by local Police. A review of the physical examinations of residents cared for by SRNA #8 on 08/06-12/11, was conducted. Skin assessments for eight residents under the care of SRNA #8 were conducted and documented by LPN #3 and each resident was questioned by LPN #8. Interview with LPN #3 on 09/01/11, revealed the LPN conducted the skin assessments at the request of the Human Resources Director after SRNA #8 was escorted from the facility. According to LPN #3, no injuries or skin changes were noted. Skin assessments conducted during the survey revealed no injuries of unknown source. Interviews were conducted with family members of Residents #1 and #4. The family members denied any injuries or mistreatment of [REDACTED]. A review of the documentation of interviews with alert/oriented residents and family members conducted by RN #1 revealed no identified problems from the interviews. A resident group interview was conducted by surveyors on 08/30/11 at 10:00 AM, and no reports of abuse/neglect were reported. A review of the facility's revised policy/procedure for abuse/neglect revealed the facility addressed all requirements for the policy/procedure. The revised policy/procedure included education to address staff behaviors that would indicate a potential for abuse. The investigation section of the policy/procedure addressed the need to immediately notify state agencies and reporting requirements for suspected abuse/neglect of residents. Interview on 09/01/11 at 10:35 AM, with the facility's Legal Counsel revealed the Legal Counsel educated the Administrator and Assistant Administrator on abuse/neglect and the regulatory requirements for Long Term Care Facilities from 08/12/11 through 08/30/11. According to Legal Counsel, the Administrator and Assistant Administrator were educated on reporting requirements of suspected abuse and what the definitions for abuse/neglect/misappropriation were. Review of the revised facility policy/procedure revealed the policy met regulatory requirements. A review of the facility's training records revealed evidence that all employees of the facility except for one received training on abuse/neglect from administrative staff on 08/26/11. One facility employee was on medical leave and will be educated prior to being allowed to work. The attendance rosters for the training were compared to the facility's time reports for active working employees and confirmed all employees received education in abuse/neglect and received a copy of the facility policy/procedure. The facility's documentation included evidence of each staff member having successfully passed a quiz concerning the information given in the abuse/neglect training. Staff interviews were conducted on 08/31/11 from 3:40 PM to 4:30 PM, and on 09/01/11 at 11:42 AM, with LPN #11, LPN #12, KMA #2, SRNA #14, SRNA #15, Housekeeper #1, and Housekeeper #2 related to the facility's abuse/neglect training. Staff verified the receipt of training and each received a copy of the facility's revised policy/procedure. A review of the facility's training records revealed evidence the facility's Department Heads received training in abuse/neglect and reporting. The Checklist File was included in the facility's documentation. A review of the facility's 24-hour Nursing Report, used as the monitoring tool for signs of abuse, revealed documentation of daily monitoring of residents including any changes in condition or new orders. Interview with the Assistant Administrator on 09/01/11 at 11:10 AM, revealed the 24-hour Nursing Report was reviewed on a daily basis and any concerns were investigated. The Assistant Administrator stated the results of the monitoring would be part of the facility's Quality Assurance process. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systematic changes and quality assurance activities.

Based on interview, record review, and review of the facility's investigation and policies, it was determined the facility failed to have an effective system in place to ensure all allegations of abuse were immediately reported to administrative staff and to the appropriate state agencies. A review of documentation and interviews conducted revealed facility staff became aware that an employee of the building had exhibited abusive behavior toward two (2) of twenty-two (22) sampled residents (Resident #1 and #2). The facility failed to ensure allegations of abuse were immediately reported to the appropriate state agencies. The facility also failed to protect residents from abuse by allowing an alleged perpetrator to continue to work after an allegation of abuse had been reported, and failed to conduct a thorough investigation of a reported abuse allegation. The facility's failure to ensure staff immediately reported all allegations of abuse to administrative staff and the appropriate state agencies, failure to protect residents from abuse during the facility's investigation, and failure to conduct a thorough investigation has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1, Resident #2, and other residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 07/19/11. (Refer to F223.) An acceptable Allegation of Compliance (AOC) was received on 08/31/11, which alleged removal of Immediate Jeopardy on 08/31/11. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Abuse Policy (revised 09/06/00) revealed, "In the event of any evidence to cause to believe that a resident has suffered any abuse, the employee, visitor or family member are requested to report any/all allegations, suspicion, or incidents to the administration of the facility, i.e. charge nurses, supervisors, DON, SSD, or administrator." The policy revealed, "Upon report of any allegations or violations, the administration will thoroughly investigate the situation. Any employee suspected of abuse, neglect, or disregard for resident welfare will be suspended from direct resident care while the investigation is in progress." The review revealed the investigation would include, but not be limited to, the following: names of all individuals involved, witnesses that actually viewed the incident, the resident's/family's statement concerning the incident, when and where the incident occurred, and any evidence of injury or abuse present on the resident's body or in the resident's actions. The policy revealed, "The results of the investigation shall be documented and place in the investigation file." The policy also revealed, "After knowledge of an allegation of abuse, the administrator, director of nursing or social service director shall report it to Adult Protective Services and the Cabinet for Human Resources immediately. The results of all investigations will be reported to the same agencies within five (5) working days of the incident." 1. An interview conducted on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on 07/19/11, she witnessed State Registered Nurse Aide (SRNA) #8 being physically, mentally, and verbally rough with Resident #2 and Resident #8. The CMA reported SRNA #8's behavior to the Director of Nursing (DON) the next morning on 07/20/11. Interview on 08/24/11 at 7:05 PM, with the DON revealed she did not recall CMA #1's allegation against SRNA #8. Therefore, SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified. An interview conducted on 08/22/11 at 5:20 PM, with State Registered Nurse Aide (SRNA) #1 revealed SRNA #8 had a history of [REDACTED]. getting up," and would refuse to transfer the resident to the chair. According to SRNA #1, she could not remember when she witnessed this incident but she did report SRNA #8's behaviors to the Human Resources Director (HRD). Interview on 08/24/11 at 6:35 PM, with the HRD revealed she did not recall SRNA #1's allegation against SRNA #8. Therefore SRNA #8 was not suspended, no investigation was conducted, and the appropriate state agencies were not notified. Interviews conducted on 08/22/11 at 7:00 PM, with the Assistant Administrator, and on 08/25/11 at 6:05 PM, with the Administrator revealed they were unaware of the above allegations against SRNA #8. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 09/14/10, with [DIAGNOSES REDACTED]. A review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact and the resident required extensive assistance of two staff persons with bed mobility, transfers, dressing and toileting. A review of an investigative report, undated and provided by the facility, revealed statements had been obtained from eight employees, the DON, and an alleged perpetrator related to an allegation made by Resident #2 that SRNA #8 had "beat" the resident on the evening of 07/20/11. An interview conducted on 08/22/11 at 6:15 PM, with Resident #2 revealed SRNA #8 was not good to the resident. Resident #2 stated, "He tried to kill me." Resident #2 stated SRNA #8 had placed a pillow over the resident's face and "tried to smother me." The resident stated SRNA #8 "hit me four times," and indicated SRNA #8 had hit the resident two times on each side of the head. Interviews conducted on 08/22/11 at 2:11 PM, with the Minimum Data Set (MDS) Coordinator, on 08/22/11 at 3:30 PM, with Registered Nurse (RN) #1, and on 08/22/11 at 2:45 PM, with Certified Medication Aide (CMA) #1 revealed on the morning of 07/21/11, Resident #2 reported that SRNA #8 put a pillow over the resident's face and hit the resident on the resident's head four times. CMA #1 stated a small bruise was noted to the left side of the resident's face that was not present the previous day. The interviews revealed the staff reported Resident #2's allegation to the DON and the HRD. An interview conducted on 08/22/11 at 6:30 PM, and on 08/24/11 at 7:05 PM, with the DON and a review of documentation revealed Resident #2 informed the DON at approximately 10:55 AM on 07/21/11, that SRNA #8 "put a pillow over my face and then hit me on each side of my head," and asked, "What are you going to do about" SRNA #8. The DON revealed the Administrator was notified of the allegation at approximately 8:20 AM on 07/21/11, and stated, "Not to report as this didn't happen." On 07/21/11 at 12:10 PM, the DON reported the allegation again to the Administrator and was told, "Quit worrying about this;" the resident is "crazy." The DON stated the Assistant Administrator notified the Department for Community Based Services (DCBS) of the resident's allegation on 07/25/11. An interview conducted on 08/22/11 at 7:00 PM, with the Assistant Administrator revealed SRNA #8 continued to work on 07/22/11, 07/23/11, and 07/24/11, until the Assistant Administrator returned from vacation and was informed of the allegation. The Assistant Administrator stated due to Resident #3's history of head injury and because the resident recanted the allegation the facility felt the allegation was not true and did not need to be reported to the state survey and certification agency. An interview conducted on 08/25/11 at 6:05 PM, with the Administrator revealed the Administrator was informed of Resident #2's allegation on 07/21/11, and due to the resident being "delusional" the allegation was not reported to the state agencies. 3. The facility admitted Resident #1 on 11/06/09. A review of Resident #1's comprehensive Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired and the resident was independent with no setup needed for transfers, dressing, toileting, and hygiene. An interview conducted on 08/23/11 at 10:10 AM, with SRNA #2 revealed on 08/10/11, during the 7 AM-3 PM shift, SRNA #8 came into Resident #1's room, lay down on the bed, and "spooned" the resident. SRNA #2 completed her duties and then reported her observation to her supervisor (Restorative Aide #2) within ten minutes. However, an interview conducted on 08/25/11 at 8:10 AM, with Restorative Aide (RA) #2 revealed she did not report the allegation to administrative staff because she thought the report was a rumor. An interview conducted on 08/22/11 at 3:11 PM, with SRNA #7 revealed while providing care to Resident #3, SRNA #2 informed SRNA #7 of the allegation that SRNA #8 had been in the bed with a female resident. SRNA #7 stated she thought the allegation had already been reported and therefore did not report the allegation to administrative staff. An interview conducted on 08/24/11 at 5:15 PM, with LPN #6 revealed she was informed at approximately 6:45 AM on 08/11/11, by SRNA #9 that Resident #3 reported SRNA #8 was caught in bed with a female resident. LPN #6 went home and returned to work that same day at 7:00 PM, at which time she informed LPN #2 of the allegation. LPN #6 waited 26 hours after being informed of the allegation on 08/11/11, to report the allegation to the Human Resources Director (HRD) on 08/12/11. An interview conducted on 08/22/11 at 4:05 PM, with LPN #2 revealed she did not report the allegation to administrative staff as required because LPN #6 was initially informed of the allegation. Interviews conducted on 08/22/11 at 2:11 PM, with the MDS Coordinator and on 08/22/11 at 4:45 PM, with the HRD revealed on 08/12/11, at approximately 8:30 AM, they were informed of the allegation. At that time, the Assistant Administrator and the Administrator were informed of the allegation, Law Enforcement was notified, and SRNA #8 was escorted off the premises. Interviews conducted on 08/22/11 at 7:00 PM, and 08/24/11 at 7:50 PM, with the Assistant Administrator, and on 08/25/11 at 6:05 PM, with the Administrator revealed on 08/12/11 at approximately 10:30 AM, they were notified of the allegation that SRNA #8 had been in the bed of a female resident. The interviews revealed at that time SRNA #8 was terminated and removed from the facility. The Assistant Administrator confirmed the state survey and certification agency was not notified of this allegation. A review of the facility's investigation, undated, involving SRNA #8 lying on the bed and spooning Resident #1 revealed statements were obtained, however, the appropriate state agencies had not been notified of the allegation. 4. In addition, based on interviews, SRNA #8 exhibited a history of unacceptable behaviors that facility staff failed to report. Interviews conducted on 08/22/11 at 5:20 PM, with SRNA #1, on 08/23/11 at 2:27 PM, with LPN #3, and on 08/23/11 at 4:25 PM, with LPN #5 revealed the staff had witnessed SRNA #8 inappropriately kiss several female residents and reported SRNA #8's inappropriate behaviors to the charge nurses, the HRD, and the DON prior to 07/11. There was no documented evidence that these allegations were thoroughly investigated, reported to the Administrator, or the appropriate state agencies. Interviews conducted on 08/23/11 at 3:50 PM, with SRNA #6 and on 08/23/11 at 3:30 PM, with SRNA #5 revealed SRNA #8 would kiss on the female residents in a way that seemed inappropriate. SRNA #6 stated Resident #8 would scream hysterically when SRNA #8 came into the resident's room. However, these allegations were not reported to administrative staff because the nurses had already asked SRNA #8 to stop this behavior, according to SRNA #6. An interview conducted on 08/22/11 at 4:45 PM, and on 08/24/11 at 6:35 PM, with the HRD revealed she did not recall staff had reported SRNA #8's inappropriate behaviors with female residents prior to 08/12/11. However, the HRD stated that toward the end of 06/11, she witnessed SRNA #8 kiss Resident #4 and she "counseled" the SRNA concerning his inappropriate behaviors. There was no documentation provided that the HRD had "counseled" SRNA #8 or that the allegation was thoroughly investigated and reported to the Administrator or the appropriate state agencies. An interview conducted on 08/24/11 at 7:05 PM, with the DON revealed she did not recall that staff had informed her of SRNA #8's inappropriate behaviors prior to the 08/12/11 allegation. --A review of the Allegation of Compliance revealed the following: The facility terminated SRNA #8 on 08/12/11, when administrative staff was made aware of the allegation involving SRNA #8 and Resident #1. The facility initiated an investigation of the allegation involving SRNA #8 and Resident #1. On 08/12/11, the Assistant Administrator and the HRD conducted interviews with all staff members who may have information regarding the allegation. The facility had nursing staff conduct physical examinations of all residents SRNA #8 had provided care to during the timeframe of 08/06/11 through 08/12/11, to determine if there were any signs/symptoms of abuse. On 08/30/11, RN #1 and LPN #1 conducted interviews with the alert and oriented residents about possible abuse issues. On 08/30/11, the Assistant Administrator and the Co-Owner conducted interviews with 13 family members/visitors, which included family members of non-oriented residents to determine if there were any signs/symptoms of abuse or any complaints. On 08/25/11, Legal Counsel was contacted concerning the Immediate Jeopardy in abuse investigation, protection, and reporting. Legal Counsel and Administration immediately began review and revisions to the facility's Abuse policy. The final revisions were completed on 08/30/11. Policy changes involved the supervision of staff concerning the supervisory staff's duty to monitor and evaluate the staff that may have greater potential for abuse. The policy instructs staff to advise supervisors of problems dealing with stress. Other policy changes involved the screening procedure to include a screening process for administration to use upon hire, in addition to the criminal record checks, abuse registry screens, license/certification verification, and reference checks. The investigation section of the policy was also strengthened to ensure investigations are initiated upon reports of suspected abuse as defined in the Investigation Protocol. The protection section of the policy was revised to state that if a report of abuse is made that involves an employee, that employee will be reassigned from resident care or suspended during the investigation. On 08/25/11 and 08/30/11, the Assistant Administrator and the Administrator received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by Legal Counsel. On 08/26/11, the Education Assistant, the DON, and the Co-Owner received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by the Assistant Administrator. On 08/26/11, training was conducted for all 150 staff members including non-clinical staff during each shift (10 AM, 2 PM, 4 PM, and 11 PM) concerning abuse prevention, abuse investigation, and abuse reporting. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. Upon completion of the training all staff was given a written quiz to verify the staff's comprehension of the material. The facility currently has one staff person on medical leave that will receive this training upon returning to work. All new staff will receive this training upon date of hire. Continued abuse training will be conducted on a bi-annual basis for all staff. On 08/26/11, supervisory staff received specific training on recognizing situations that may indicate stress on staff because staff working under excessive emotional stress was more likely to be impatient with a greater likelihood of committing abuse. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11 and 08/30/11, all Department Heads received specific training about the new policies/procedures emphasizing that potential abuse must be reported to both the OIG and DCBS with the final results of the investigation communicated within five working days. Upon completion of the training all Department Heads were given a written quiz to verify the staff's comprehension of the material. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11, an Abuse Response Checklist File was developed and distributed to the Department Heads to assist the staff in following the correct procedures. The Checklist File consists of the Self Reporting Form published by the OIG. The DON will review compliance with training requirements and will report any and all findings to the Quality Assurance committee on a quarterly basis, which will monitor the facility's compliance. The treatment nurse will monitor residents on a daily basis for any skin changes or signs of potential abuse. Any suspected or actual abuse discovered by the treatment nurse will be reported to the charge nurse. The charge nurse is required to report the findings to the DON, who will immediately report to the Assistant Administrator. The Abuse Response Checklist File for the Department Heads will walk the individual through the steps that should be taken when abuse is suspected or reported. All reports of suspected abuse will be immediately reported to the charge nurse. The charge nurse will immediately report the suspected abuse to the DON, who will document the allegation on the 24-hour nurses' report. The DON and the Assistant Administrator will review the 24-hour nurses' report on a daily basis and will report any alleged abuse to the Administrator and the appropriate state agencies. Upon report of any alleged violations the Administration will thoroughly investigate the allegation. The Administrator and the Assistant Administrator will monitor any suspected or actual abuse according to facility policy to ensure the resident is protected by suspending or reassigning the alleged perpetrator, if an employee, during the investigation process. The Administrator and the Assistant Administrator will also monitor that a conclusion to the investigation is completed and that reporting has been made to the appropriate agencies. The Quality Assurance Committee will receive all reports of suspected or actual abuse and will monitor to ensure compliance with facility policy and regulation. --The surveyors validated the corrective actions taken by the facility as follows: A review of the Employee Master Change Sheet revealed SRNA #8 was terminated effective 08/12/11, by the Human Resources Director. A review was conducted of the facility's investigation. The investigation was initiated on 08/12/11, when administrative staff received the report of the abuse and SRNA #8 was immediately removed from the facility and escorted off the premises by local Police. A review of the physical examinations of residents cared for by SRNA #8 on 08/06/11 through 08/12/11, was conducted. Skin assessments for eight residents under the care of SRNA #8 were conducted and documented by LPN #3 and each resident was questioned by LPN #8. Interview with LPN #3 on 09/01/11, revealed the LPN conducted the skin assessments at the request of the Human Resources Director after SRNA #8 was escorted from the facility. According to LPN #3, no injuries or skin changes were noted. Skin assessments conducted during the survey revealed no injuries of unknown source. Interviews were conducted with family members of Residents #1 and #4. The family members denied any injuries or mistreatment of [REDACTED]. A review of the documentation of interviews with alert/oriented residents and family members conducted by RN #1 revealed no identified problems from the interviews. A resident group interview was conducted by surveyors on 08/30/11 at 10:00 AM, and no reports of abuse/neglect were reported. A review of the facility's revised policy/procedure for abuse/neglect revealed the facility had addressed all requirements for the policy/procedure. The revised policy/procedure included education to address staff behaviors that would indicate a potential for abuse. The investigation section of the policy/procedure addressed the need to immediately notify state agencies and reporting requirements for suspected abuse/neglect of residents. Interview on 09/01/11 at 10:35 AM, with the facility's Legal Counsel revealed the Legal Counsel had educated the Administrator and Assistant Administrator on abuse/neglect and the regulatory requirements for Long Term Care Facilities from 08/12/11 through 08/30/11. According to Legal Counsel, the Administrator and Assistant Administrator were educated on reporting requirements of suspected abuse and what the definitions for abuse/neglect/misappropriation were. Review of the revised facility policy/procedure revealed the policy met regulatory requirements. A review of the facility's training records revealed evidence that all employees of the facility except for one received training on abuse/neglect from administrative staff on 08/26/11. One facility employee was on medical leave and will be educated prior to being allowed to work. The attendance rosters for the training were compared to the facility's time reports for active working employees and confirmed all employees received education in abuse/neglect and had received a copy of the facility policy/procedure. The facility's documentation included evidence of each staff member having successfully passed a quiz concerning the information given in the abuse/neglect training. Staff interviews were conducted on 08/31/11 from 3:40 PM to 4:30 PM, and on 09/01/11 at 11:42 AM, of LPN #11, LPN #12, KMA #2, SRNA #14, SRNA #15, Housekeeper #1, and Housekeeper #2 related to the facility's abuse/neglect training. Staff verified the receipt of training and each had received a copy of the facility's revised policy/procedure. A review of the facility's training records revealed evidence the facility's Department Heads had received training in abuse/neglect and reporting. The Checklist File was included in the facility's documentation. A review of the facility's 24-hour Nursing Report, used as the monitoring tool for signs of abuse, revealed documentation of daily monitoring of residents including any changes in condition or new orders. Interview with the Assistant Administrator on 09/01/11 at 11:10 AM, revealed the 24-hour Nursing Report was reviewed on a daily basis and any concerns were investigated. The Assistant Administrator stated the results of the monitoring would be part of the facility's Quality Assurance process. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systematic changes and quality assurance activities.

Based on interview, record review, facility investigation review, and facility policy review, it was determined the facility failed to be effectively/efficiently administered in a manner that maintained the highest physical well-being for two (2) of twenty-two (22) sampled residents (Residents #1 and #2). The facility failed to have an effective system in place to ensure facility policies/procedures related to abuse/neglect prevention were implemented. A review of documentation and interviews conducted revealed during the months from 07/11 until 08/11 facility staff became aware that SRNA #8 had exhibited abusive behavior toward two of seventeen sampled residents (Residents #1 and #2). The facility's Administration failed to ensure staff immediately reported all allegations of abuse to administrative staff and appropriate state agencies. In addition, the Administration failed to ensure residents were protected from abuse during the facility's investigation by allowing the alleged perpetrator to continue to provide direct resident care and failed to ensure a thorough investigation was conducted of all allegations. (Refer to F223, F225, and F226.) The Administrator's failure to ensure facility policies/procedures related to abuse/neglect prevention were implemented caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility, to include Residents #1 and #2. Immediate Jeopardy and Substandard Quality of Care (SQC) was determined to exist on 07/19/11. An acceptable Allegation of Compliance (AOC) was received on 08/31/11, which alleged removal of Immediate Jeopardy on 08/31/11. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's Abuse Policy (revised 09/06/00) revealed, "In the event of any evidence to cause to believe that a resident has suffered any abuse, the employee, visitor or family member are requested to report any/all allegations, suspicion, or incidents to the administration of the facility, i.e. charge nurses, supervisors, DON, SSD, or administrator." The policy stated, "Upon report of any allegations or violations, the administration will thoroughly investigate the situation. Any employee suspected of abuse, neglect, or disregard for resident welfare will be suspended from direct resident care while the investigation is in progress." The review revealed the investigation would include, but not be limited to, the following: names of all individuals involved, witnesses that actually viewed the incident, the resident's/family's statement concerning the incident, when and where the incident occurred, and any evidence of injury or abuse present on the resident's body or in the resident's actions. The policy revealed, "The results of the investigation shall be documented and place in the investigation file." The policy also revealed, "After knowledge of an allegation of abuse, the administrator, director of nursing or social service director shall report it to Adult Protective Services and the Cabinet for Human Resources immediately. The results of all investigations will be reported to the same agencies within five (5) working days of the incident." 1. An interview with Certified Medication Aide (CMA) #1 on 08/22/11 at 2:45 PM, revealed on 07/20/11, Certified Medication Aide (CMA) #1 reported to the Director of Nursing (DON) that State Registered Nurse Aide (SRNA) #8 had been physically, mentally, and verbally rough with Resident #2 and Resident #8. Interviews with the DON on 08/22/11 at 6:30 PM, the Assistant Administrator on 08/22/11 at 7:00 PM, and the Assistant Administrator and Administrator on 08/25/11 at 6:05 PM, revealed they were unaware of this allegation. Therefore, the facility had no documentation that administrative staff investigated or notified the appropriate state agencies regarding this allegation or protected the residents from further potential abuse. 2. On 07/21/11, Resident #2 reported SRNA #8 had physically abused Resident #2. A review of the facility's undated investigation revealed the Administrator was notified of the allegation at approximately 8:20 AM on 07/21/11, and instructed the DON "not to report as this didn't happen." The DON's statement revealed at 12:10 PM on 07/21/11, the DON reported the allegation again to the Administrator who stated, "Quit worrying about this;" the resident is "crazy." Further review of the investigation revealed SRNA #8 continued to provide direct care to residents from the time the allegation was reported on 07/21/11, until 07/25/11 at 3:00 PM, when the SRNA was suspended for two days. A review of the investigation revealed the facility had failed to determine a conclusion of their investigative findings and the appropriate state agencies had not been notified of the allegation. An interview with the DON on 08/22/11 at 6:30 PM, revealed staff reported Resident #2's allegation on 07/21/11; however, SRNA #8 continued to provide direct care to residents on 07/22/11, 07/23/11, and 07/24/11. The DON confirmed she did not conduct a conclusion to the facility's investigation and no one notified the appropriate state agencies of the allegations. An interview with the Administrator on 08/25/11 at 6:05 PM, revealed he was informed of Resident #2's allegation on 07/21/11, and, due to the resident being "delusional," the allegation was not reported to the appropriate state agencies. 3. An interview with SRNA #2 on 08/23/11 at 10:10 AM, revealed on 08/10/11, SRNA #2 reported to her supervisor (Restorative Aide #2) she had witnessed SRNA #8 lie on the bed and "spoon" Resident #1, however, the Restorative Aide (RA) did not report the allegation to administrative staff (charge nurse, supervisor, DON, SSD, or Administrator) as required. Interview with Licensed Practical Nurse (LPN) #6 on 08/24/11 at 5:15 PM, revealed she was informed at approximately 6:45 AM on 08/11/11, that SRNA #8 was in the bed with a female resident. LPN #6 waited 26 hours before she reported the allegation to the Human Resources Director (HRD). Interview with the HRD on 08/22/11 at 4:45 PM, revealed she reported the allegation to the Assistant Administrator on 08/12/11 at approximately 10:30 AM, and the allegation was reported to the Administrator. At that time, based on interviews and record review, SRNA #8's employment was terminated and he was escorted off the premises. However, according to an interview with the Assistant Administrator on 08/24/11 at 7:50 PM, she did not notify the Office of Inspector General (OIG) because she was unaware of the regulation that required reporting of alleged abuse. The facility's undated investigation related to the allegation revealed the Assistant Administrator failed to conduct a thorough investigation of the allegation and failed to notify the appropriate state agencies of the allegation. 4. In addition, based on interviews, SRNA #8 exhibited a history of unacceptable behaviors that facility staff failed to report. Interviews conducted on 08/22/11 at 5:20 PM, with SRNA #1, on 08/23/11 at 2:27 PM, with LPN #3, and on 08/23/11 at 4:25 PM, with LPN #5 revealed staff had witnessed SRNA #8 inappropriately kiss several female residents. SRNA #1 reported SRNA #8's inappropriate behaviors to the charge nurses on numerous occasions and to the HRD. LPN #3 discussed the SRNA's inappropriate behaviors with SRNA #8 and reported his behaviors to the HRD on two occasions. LPN #5 counseled SRNA #8 on the inappropriateness of kissing the residents, in the presence of the HRD. The interview revealed LPN #5 was under the impression the HRD would inform the DON of SRNA #8's inappropriate behaviors. Interviews with the HRD and the DON on 08/22/11 at 6:30 PM, revealed they were unable to recall if staff had reported SRNA #8's inappropriate behaviors. The facility failed to conduct an investigation and did not notify the appropriate state agencies of the allegations. Interview with the HRD on 08/22/11 at 4:45 PM, revealed in 06/11 she witnessed SRNA #8 inappropriately kiss Resident #4. The interview revealed the HRD had a discussion with SRNA #8 about his inappropriate behaviors and had reported her observations and discussion with SRNA #8 to the DON the following day. Interview with the DON on 08/22/11 at 6:30 PM, revealed she could not recall that the HRD had reported SRNA #8's inappropriate behaviors to her. There was no evidence the facility investigated or reported the allegations to the appropriate state agencies. In addition, there was no evidence the facility protected the residents from further potential abuse. --A review of the Allegation of Compliance revealed the following: The facility terminated SRNA #8 on 08/12/11, when administrative staff was made aware of the allegation involving SRNA #8 and Resident #1. The facility initiated an investigation of the allegation involving SRNA #8 and Resident #1. On 08/12/11, the Assistant Administrator and the HRD conducted interviews with all staff members who may have information regarding the allegation. The facility had nursing staff conduct physical examinations of all residents SRNA #8 had provided care to during the time frame of 08/06/11 through 08/12/11, to determine if there were any signs/symptoms of abuse. On 08/30/11, RN #1 and LPN #1 conducted interviews with the alert and oriented residents about possible abuse issues. On 08/30/11, the Assistant Administrator and the Co-Owner conducted interviews with 13 family members/visitors, which included family members of non-oriented residents to determine if there were any signs/symptoms of abuse or any complaints. On 08/25/11, Legal Counsel was contacted concerning the Immediate Jeopardy in abuse investigation, protection, and reporting. Legal Counsel and Administration immediately began review and revisions to the facility's Abuse policy. The final revisions were completed on 08/30/11. Policy changes involved the supervision of staff concerning the supervisory staff's duty to monitor and evaluate the staff that may have greater potential for abuse. The policy instructs staff to advise supervisors of problems dealing with stress. Other policy changes involved the screening procedure to include a screening process for administration to use upon hire, in addition to the criminal record checks, abuse registry screens, license/certification verification, and reference checks. The investigation section of the policy was also strengthened to ensure investigations are initiated upon reports of suspected abuse as defined in the Investigation Protocol. The protection section of the policy was revised to state that if a report of abuse is made that involves an employee, that employee will be reassigned from resident care or suspended during the investigation. On 08/25/11 and 08/30/11, the Assistant Administrator and the Administrator received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by Legal Counsel. On 08/26/11, the Education Assistant, the DON, and the Co-Owner received training concerning abuse prevention, abuse protection, abuse investigation, and abuse reporting by the Assistant Administrator. On 08/26/11, training was conducted for all 150 staff members including non-clinical staff during each shift (10 AM, 2 PM, 4 PM, and 11 PM) concerning abuse prevention, abuse investigation, and abuse reporting. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. Upon completion of the training all staff was given a written quiz to verify the staff's comprehension of the material. The facility currently has one staff person on medical leave that will receive this training upon returning to work. All new staff will receive this training upon date of hire. Continued abuse training will be conducted on a bi-annual basis for all staff. On 08/26/11, supervisory staff received specific training on recognizing situations that may indicate stress on staff because staff working under excessive emotional stress were more likely to be impatient with a greater likelihood of committing abuse. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11 and 08/30/11, all Department Heads received specific training about the new policies/procedures emphasizing that potential abuse must be reported to both the OIG and DCBS with the final results of the investigation communicated within five working days. Upon completion of the training all Department Heads were given a written quiz to verify the staff's comprehension of the material. The training was conducted by the Education Assistant, the Assistant Administrator, and the Co-Owner. On 08/26/11, an Abuse Response Checklist File was developed and distributed to the Department Heads to assist the staff in following the correct procedures. The Checklist File consists of the Self Reporting Form published by the OIG. The DON will review compliance with training requirements and will report any and all findings to the Quality Assurance committee on a quarterly basis, which will monitor the facility's compliance. The treatment nurse will monitor residents on a daily basis for any skin changes or signs of potential abuse. Any suspected or actual abuse discovered by the treatment nurse will be reported to the charge nurse. The charge nurse is required to report the findings to the DON, who will immediately report to the Assistant Administrator. The Abuse Response Checklist File for the Department Heads will walk the individual through the steps that should be taken when abuse is suspected or reported. All reports of suspected abuse will be immediately reported to the charge nurse. The charge nurse will immediately report the suspected abuse to the DON, who will document the allegation on the 24-hour nurses' report. The DON and the Assistant Administrator will review the 24-hour nurses' report on a daily basis and will report any alleged abuse to the Administrator and the appropriate state agencies. Upon report of any alleged violations the Administration will thoroughly investigate the allegation. The Administrator and the Assistant Administrator will monitor any suspected or actual abuse according to facility policy to ensure the resident is protected by suspending or reassigning the alleged perpetrator, if an employee, during the investigation process. The Administrator and the Assistant Administrator will also monitor that a conclusion to the investigation is completed and that reporting has been made to the appropriate agencies. The Quality Assurance Committee will receive all reports of suspected or actual abuse and will monitor to ensure compliance with facility policy and regulation. --The surveyors validated the corrective actions taken by the facility as follows: A review of the Employee Master Change Sheet revealed SRNA #8 was terminated effective 08/12/11, by the Human Resources Director. A review was conducted of the facility's investigation. The investigation was initiated on 08/12/11, when administrative staff received the report of the abuse and SRNA #8 was immediately removed from the facility and escorted off the premises by local Police. A review of the physical examinations of residents cared for by SRNA #8 on 08/06/11 through 08/12/11, was conducted. Skin assessments for eight residents under the care of SRNA #8 had been conducted and documented by LPN #3 and each resident was questioned by LPN #8. Interview with LPN #3 on 09/01/11, revealed the LPN had conducted the skin assessments at the request of the Human Resources Director after SRNA #8 had been escorted from the facility. According to LPN #3, no injuries or skin changes had been noted. Skin assessments conducted during the survey revealed no injuries of unknown source. Interviews were conducted with family members of Residents #1 and #4. The family members denied any injuries or mistreatment of [REDACTED]. A review of the documentation of interviews with alert/oriented residents and family members conducted by RN #1 revealed no identified problems from the interviews. A resident group interview was conducted by surveyors on 08/30/11 at 10:00 AM, and no reports of abuse/neglect were reported. A review of the facility's revised policy/procedure for abuse/neglect revealed the facility had addressed all requirements for the policy/procedure. The revised policy/procedure included education to address staff behaviors that would indicate a potential for abuse. The investigation section of the policy/procedure addressed the need to immediately notify state agencies and reporting requirements for suspected abuse/neglect of residents. Interview on 09/01/11 at 10:35 AM, with the facility's Legal Counsel revealed the Legal Counsel had educated the Administrator and Assistant Administrator on abuse/neglect and the regulatory requirements for Long Term Care Facilities from 08/12/11 through 08/30/11. According to Legal Counsel, the Administrator and Assistant Administrator were educated on reporting requirements of suspected abuse and what the definitions for abuse/neglect/misappropriation were. Review of the revised facility policy/procedure revealed the policy met regulatory requirements. A review of the facility's training records revealed evidence that all employees of the facility except for one had received training on abuse/neglect from administrative staff on 08/26/11. One facility employee was on medical leave and will be educated prior to being allowed to work. The attendance rosters for the training were compared to the facility's time reports for active working employees and confirmed all employees had received education in abuse/neglect and had received a copy of the facility policy/procedure. The facility's documentation included evidence of each staff member having successfully passed a quiz concerning the information given in the abuse/neglect training. Staff interviews were conducted on 08/31/11 from 3:40 PM to 4:30 PM, and on 09/01/11 at 11:42 AM, with LPN #11, LPN #12, KMA #2, SRNA #14, SRNA #15, Housekeeper #1, and Housekeeper #2 related to the facility's abuse/neglect training. Staff verified the receipt of training and each had received a copy of the facility's revised policy/procedure. A review of the facility's training records revealed evidence the facility's Department Heads had received training in abuse/neglect and reporting. The Checklist File was included in the facility's documentation. A review of the facility's 24-hour Nursing Report, used as the monitoring tool for signs of abuse, revealed documentation of daily monitoring of residents including any changes in condition or new orders. Interview with the Assistant Administrator on 09/01/11 at 11:10 AM, revealed the 24-hour Nursing Report was reviewed on a daily basis and any concerns investigated. The Assistant Administrator stated the results of the monitoring would be part of the facility's Quality Assurance process. The State Agency determined the Immediate Jeopardy was removed on 08/31/11, prior to exit, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systematic changes and quality assurance activities.