Every finding on record at Home of the Innocents

483.12 freedom from abuse, neglect and exploitation F603 DBased on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free from involuntary seclusion for 1 of 3 residents sampled for abuse out of the total sample of 20 residents, (Resident (R)14). The findings include:Review of the facility policy titled, Protecting Residents from Abuse and Neglect, revised July 2024, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Continued review revealed abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain physical, mental, and psychosocial well-being. Review of the facility policy titled, Protecting Residents From Abuse and Neglect 02.05.01, defined involuntary seclusion as separation of a resident, from other residents or from her/his room or confinement to his/her room (with or without roommates) against the resident's will or the will of the resident's representative. Review of the facility policy titled, Resident Monitoring and Supervision 02.01.14.02, revealed involuntary seclusion included but was not limited to in attempt to isolate a resident to prevent him/her from leaving an area, the resident is involuntarily confined to an area by staff placing furniture, carts, chairs in front of doorways or areas of egress. Further review revealed involuntary seclusion also included a resident physically placed in an area without access to call lights, and/or other methods of communication creating an environment of seclusion and isolation.Record review revealed the facility admitted the resident on 09/09/2002, with diagnoses of Hypoxic Ischemic Encephalopathy; severe intellectual disabilities; spastic quadriplegic Cerebral Palsy; Bronchopulmonary Dysplasia; Tracheostomy Status; and Gastrostomy Status.Review of R14's Comprehensive Care Plan 01/15/2024, revealed the facility care planned the resident as at risk for injury related to lack of self-mobility with lack of safety awareness, behaviors including history of self-injurious behaviors, and presence of enteral feeding tube and tracheostomy tube. Per review of the care plan, staff direct supervision was required for residents who ambulated or had active mobility in wheelchair. Continued review of the care plan revealed active intervention was required to prevent them from wandering in unsupervised areas or exiting the facility. Further review revealed the care plan noted R14 must not be left unattended when up in his wheelchair, including in his room.Review of the Progress Notes dated 03/21/2024, revealed on that date, R14 had been in isolation due to having Rhinovirus (the virus causing the common cold which was highly contagious and spread through respiratory droplets). Review of the Progress Notes dated 03/21/2024, revealed Licensed Practical Nurse (LPN) 13 noted on at 2:47 PM on that date, that R14 reported no new changes and remained in droplet precautions.Review of the facility's investigation initiated on 03/21/2024, revealed it was noted at approximately 3:00 PM that day, Nurse Manager (NM) 3 observed R14 in his room on Maple Way, with his bed positioned in a way preventing him from reaching his doorway. Per review, the Physician, family, and Department for Community Based Services (DCBS) were notified. Witness statements were attached to the report. R14 care plan, safety assessment, face sheet and history and physical were attached to the report. Continued review of the investigation revealed the facility confirmed its team members had positioned R14's bed in a way that did not allow the resident to exit his room freely. Review of the investigation revealed the team members voiced concerns, they had attempted to allow R14 to have movement in his wheelchair while following the facility's requirements for infection prevention related to the resident being on droplet precautions. Further review revealed all team members received re-education immediately, and the team members assigned to R14 received a documented disciplinary coaching regarding the facility's policy/procedures, 02.05.01.01-Protecting Residents from Abuse and Neglect and 02.01.14.02. Resident Monitoring and Supervision.In interview with NM 3 on 09/12/2025 at 10:00 AM, she stated she had been the unit manager since February 2024, and her duties were to oversee the unit referred to as Maple Way. She reported on 03/21/2024, she had been making rounds with the Director of Support Services (DSS) and observed R14's in his room, through the window which had the blinds pulled up. NM 3 said she observed R14 up in his wheelchair, with the bed positioned behind him in a manner prohibiting him from exiting his room. She explained she entered R14's room and moved his bed to its original position, and made sure the resident was okay. NM 3 further stated she educated the staff on the unit, and informed them blocking R14 from leavings his room had not been safe and that action was considered seclusion.In interview with LPN 11 on 09/13/2025 at 10:40 AM, he stated he had been the nurse on the unit on 03/21/2024, and recalled the incident involving R14. He said he had been the nurse taking care of two of the four residents living in that room. LPN 11 reported the residents in the room were all in isolation and on droplet precautions. He explained the residents' curtains had been drawn around the beds for droplet precautions. The LPN said he visualized R14 in his wheelchair, from the window on the day of the incident. He reported he did not recall how long R14 was up in the wheelchair, and said the resident should have been on one to one (1:1) supervision as he could not stay in bed all day. LPN 11 further stated the unit manager was to be notified for any concerns regarding situations like what happened to R14.In interview with LPN 13 on 09/13/2025 at 12:30 PM, she stated she dis not typically work on the unit where R14 resided. She said she had been taking care of R14 on 03/21/2024; however, did not recall all the details of the incident and could not recall what time it occurred. LPN 13 reported she remembered one of the Certified Nursing Assistants (CNA's) had positioned R14's bed, preventing the resident from getting out of his area. She said however, she did not recall the CNA's name she had been working with on the day of the incident. LPN 13 stated as she did not work on R14's unit often, she thought that placing the bed in that position was something that was done. She further stated NM 3 had notified her close to 3:00 PM, it was not allowed for R14's bed to be placed that way, and she also said she received education on abuse/ neglect and seclusion.In interview with CNA3 on 09/12/2025 at 2:47 PM, stated she had worked here (at the facility) for 37 years and worked as a restorative aide (RA). She reported R14 needed to be on 1:1 supervision because he could become excited at times and somewhat difficult to work with. CNA 3 said stated she had not been aware of anyone blocking residents in their rooms. She further stated it was the residents rights to be able to freely wheel in their rooms. In interview with CNA 10 on 09/13/2025 at 12:21 PM, stated R14 had been in isolation on the date of the incident, and the safety monitor (the additional, CNA on the unit) refused to go in and sit with the resident because he had been in isolation. She said she and another aide had gone in and gave R14 a bed bath that day, and the other CNA positioned the resident's bed so he could not leave the room. CNA 10 reported the other CNA told her to position the bed in that manner and told her the nurses working there did not say anything about it. She stated when the blinds were up in R14's room, you could see the resident and what he was doing in his room. She further stated she received a verbal warning and had been re-educated on the facility's abuse/neglect and seclusion policies/procedures.In interview with the Quality Assurance Performance Improvement (QAPI) Manager on 09/13/2025 1:06 PM, she stated all residents were assessed for safety, and the safety monitor was responsible for monitoring, to ensure the safety of all residents. She said those staff were to help during mealtimes by monitoring the alarms. The QAPI Manager stated R14 should have been on 1:1 supervision, when up in his chair. She further stated she had initiated the facility's report and made notifications the same day.In interview on 09/13/2025 at 3:16 PM, the Compliance Officer stated the facility's process, when it came to allegations of any type of abuse, was to get documentation and video footage, interview the resident if interview able, then interview the team members. The Compliance Officer said the purpose was to identify if there were any gaps in training, identify learning needs or correct procedures, or updating compliance and quality improvement. In further interview the Compliance Officer further stated the purpose was to report it to the external investigators, and it was the responsibility of the external reviewer to determine as to whether occurrences had occurred, or were substantiated.In interview with the Administrator on 09/13/2025 at 4:00 PM, she stated she expected any reports of abuse and neglect to be reported immediately. She said, regarding the incident that occurred on 03/21/2024 involving R14, had been handled appropriately. She reported R14 had been in isolation precautions on the day of the incident, and resident had been care planned to be 1:1 when up in his wheelchair. The Administrator stated the aide blocked R14 in, by re-positioning his bed and that was seclusion, and all staff working on the Maple Unit (R14's unit) had been re-educated. She further stated she had not placed anyone on leave, because she felt like the education they received immediately had been sufficient.

483.12 freedom from abuse, neglect, and exploitation F607 EBased on interview, record review, and review of the facility policy, the facility failed to ensure all allegations of abuse and injuries of unknown origin were reported within 2 hours to the State Survey Agency (SSA) for 1 of 3 residents sampled for abuse out of the total sample of 20 residents, (Resident (R)77). The findings include:Review of the facility policy titled, KCC DTI Protecting Residents from Abuse and Neglect, effective 11/2018 and revised 07/2024, revealed the facility was obligated to report a suspicion of a crime to law enforcement and report any allegations of abuse, neglect, exploitation, or misappropriation of resident property to the appropriate authorities, which included Child or Adult Protective Services (CPS/APS) and the Office of Inspector General (OIG). The policy also stated leadership team members were to report incidents/allegations to the state agencies immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury.Review of the admission Record for R77 revealed the facility admitted the resident on 04/12/2021, with diagnoses including Lesch Nyhan Syndrome (a rare congenital disorder occurring at birth that affects a child's brain and behaviors causing symptoms of uncontrollable self-injury, including lip and finger biting or head banging); spastic quadriplegic cerebral palsy; and moderate intellectual abilities. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/21/2025, revealed the facility assessed R77 to have a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating severe cognitive impairment. Review of the facility document titled, Initial Report, submitted to the OIG on 07/07/2025, revealed R77 reported to staff on 07/05/2025, that Certified Nursing Assistant (CNA) 8 had been hitting him at night.In interview on 09/13/2025 at 10:25 AM, the Quality Assurance and Performance Improvement (QAPI) Manager stated staff were trained to report all allegations of abuse to leadership immediately and leadership was expected to report the allegation within 2 hours to OIG. When asked about the delay in submitting the Initial Report until 07/07/2025, after being aware of the allegation on 07/05/2025, she stated she had been made aware of R77's allegation of abuse on 07/05/2025 and initiated an internal investigation. The QAPI Manager reported however, she had not initially planned to report the resident's allegation to the OIG. She explained because of R77's Lesch Nyhan Syndrome (LNS) diagnosis, he frequently made false accusations and made outlandish statements such as his bus being involved in a crash on the way home from school or a family member hitting him though they were not even in the building. The QAPI Manager said CNA 8 had not worked in the days leading up to R77's accusation, so staff thought the allegation was odd. She said after consulting with the facility's Chief Quality and Compliance Officer (CQCO) on 07/07/2025; however, it was decided the facility should go ahead and report the incident to OIG to ensure they were not missing things. The QAPI Manager reported since the discussion with the CQCO on 07/07/2025, if R77 made an allegation of physical abuse we do the whole process. She further said residents could have an injury or emotional distress and we could miss something, or it could happen again if all allegations were not reported as required.During interview with CNA 8 on 09/13/2025 at 11:47 AM, he stated R77 said I hit him. He loved to say things like that. He stated (when asked how staff were trained to respond to a resident's allegation of abuse) he responded, tell the supervisor so leadership can investigate it. CNA 8 further stated, I was suspended while they investigated this, and then after the investigation I got to come back.In interview with Neighborhood Nurse Manager (NM) 2 on 09/13/2025 at 12:11 PM, he said R77 tended to fabricate things; however, stated it doesn't change anything related to the facility's abuse policy and procedures. He reported staff were trained to immediately notify a member of leadership if a resident reported an allegation of abuse, adding, there is no confusion about that as far as I know.During interview with the Director of Nursing (DON) on 09/13/2025 at 2:38 PM, she stated her expectation was for staff to immediately notify leadership of any resident allegation of abuse so it can be assessed appropriately. She explained leadership should relay the resident allegation information to her, and then she would notify either the QAPI Manager or the Administrator. The DON said, The QAPI Manager then notifies OIG if it is reportable. She further stated (when asked about the required timeframes for reporting allegations of abuse to OIG), I am not exactly sure. The QAPI Manager handles that, I rely on her to make the determination and to do the reporting.During interview with the Administrator on 09/13/2025 at 4:00 PM, she stated abuse allegations were to be immediately reported to a leader and then we determine our next steps. She said allegations come to me or the QAPI Manager. We get together to discuss it and determine when to report. The Administrator stated, If it is a report of abuse, we need to report it within 2 hours. She reported if a resident had a history of making false reports and we can't find corroborating evidence; we don't report it (to OIG). The Administrator explained specifically with R77, because of his disease he isn't a reliable reporter, so if we can't find validity, we don't report it. We might wait to see if he perseverates on it. She said (regarding the allegation R77 made against CNA 8), the CNA hadn't worked with R77 recently and there had been inconsistencies in his (R77's) reporting. The Administrator stated there had been no evidence of injury to R77, and nothing had been observed by team members. We do investigate but don't report. So, there are caveats. If there is only a remote possibility it may have happened, we don't report it. She further stated (related to why the facility ultimately reported the allegation), I think we decided to err on the side of caution. The Administrator additionally said if abuse allegations were not reported to OIG in a timely manner, It could potentially delay the investigation, which could put the child (resident) at risk.In interview with the Quality and Compliance Officer (QCO) on 09/13/2025 at 3:15 PM, she reported, I rely heavily on [the QAPI Manager] to determine whether an incident is a 2-hour reportable or 24 hours, reportable incident. She said, Abuse should be reported immediately or at least within 2 hours. The QCO stated continued mistakes, errors, harm to residents could occur if reports were not made as required. She explained R77 can say beautiful, sweet things and then also say that people mistreat him; however, when the QAPI Manager told her about the allegation, I told her we can't take any chances, even with his diagnosis, so we made a report. The QCO stated (when asked whether the facility's Initial Report had been submitted to OIG within the required timeframe) the allegation should have been reported sooner, saying it had, not been handled appropriately. She further stated, When I heard about it, I said, 'I know it is constant, but we have to report it because if it is true, it is our job to protect him and if it isn't we will find it out. The QCO additionally said, I am not over there working with him on a regular basis, but I know this is something constant with R77.

483.12 Freedom from abuse, neglect, and exploitation F610 DBased on observation, interview, and record review, the facility failed to ensure it conducted a complete and thorough investigation for an injury of unknown origin for 1 of 3 residents sampled for abuse out of the total sample of 20 residents, (Resident (R)75). The findings include:Review of the facility's policy titled, Protecting Residents from Abuse and Neglect, effective 11/2018, revealed the Quality Assurance and Performance Improvement (QAPI) Manager or assigned designee was to initiate an investigation of any allegation of abuse, neglect, or misappropriation. Further review revealed the QAPI Manager or assigned designee was to take immediate action to ensure the safety of residents.Review of R75's medical record revealed the facility admitted the resident on 08/08/2025, with diagnoses that included cerebral palsy. Review of the Progress Notes for R75 dated 08/08/2025, revealed no documented evidence the facility noted discovering an abdominal bruise on the resident. Review of the facility's, Final Report/5 Day Follow Up, dated 08/08/2025, revealed the facility had not initiated their own full internal investigation of the injury of unknown origin (abdominal bruise) for R75. Continued review of the Final Report/5 Day Follow Up revealed it was noted, CPS is currently investigating, so interviews have been paused to prevent interfering in their investigation. No team members were named by CPS as potential perpetrators of abuse or neglect. In interview on 09/12/2025 at 3:31PM, the QAPI Manager stated Per KRS, what we have been told as a childcare agency is that interviewing during an investigation is obstructing. The QAPI Manager said my supervisor said we are told not to interview or discuss incident during an investigation. We do investigate, but we do not interview. The QAPI Manager reported Once CPS come in and officially open an investigation, we stop interviews. Based on our experience as a childcare facility, we do not interview. KRS 620-we address this in our overarching procedure, and we follow those. In interview on 09/12/2025 at 1:47 PM, the Child Protective Services (CPS) Case Manager stated, CPS never advised the facility that they could not investigate until the CPS investigation was complete. She reported CPS do not ever advise any facility not to investigate, and said, most facilities start their internal investigation immediately. The CPS Case Manager explained the hospital did not have any concerns of abuse which is why R75 was released back to the facility. She further stated she was still investigating at the time. In interview on 09/13/2025 at 2:37 PM, the Director of Nursing (DON) stated, I did not participate in this investigation. Since this occurred, we had a QAPI meeting on Monday. I do not recall discussion of this incident during the QAPI meeting. She said Anytime CPS is involved, we are not allowed to ask until resolved, as CPS performs their own investigation. The DON reported it was her understanding if CPS was involved, we do not interfere, nor ask questions. She stated there were certain things the QAPI Manager might discuss with CPS, but otherwise we stop all processes and let them investigate. The DON said if we do not know the cause, of an injury we report that. She explained the facility still conducted their investigation to see if we can determine how the bruise (or injury) occurred. The DON reported the purpose of the facility's investigation was to determine if someone had not followed the facility's policies/procedures; if retraining was needed to protect residents; and to ensure staff had the information they needed. She stated if a facility investigation was not done, we may miss interviews, which are necessary to determine how and what happened, and what needs to be done to prevent recurrence. The DON said QAPI made the determination to report the injury of unknown origin and did the reporting, and she did not personally have access to make reports. She further stated her understanding was the investigation was still pending. In interview on 09/13/2025 at 3:14 PM, the Chief Quality and Compliance Officer (CQCO) stated the purpose of investigating injuries of unknown origin was to determine why the resident had been harmed, with a goal to protect the resident. She reported if the facility's investigation was not completed the potential issues included, continued mistakes, errors, or harm. The CQCO said the purpose of reporting to the state agency was to ensure the external reviewers determine abuse/neglect, as the facility did not substantiate abuse internally. She stated, by the 5-day report, the facility had summarized interviews, did the documentation, performed physician consults, and completed medical chart information.In interview on 09/13/2025 at 3:59PM, the Administrator stated the facility investigation continues to ensure protection, root cause, and training. The Administrator further stated, CPS/APS investigations take precedence; we do not interview when they are involved.

Based on interview, record review, and facility policy review, the facility failed to ensure residents received medications in accordance with professional standards of practice related a discontinued medication order not being communicated to the resident's school and pharmacy, resulting in administration of a discontinued medication for 1 of 3 residents sampled for medications out of the total sample of 20 residents, (Resident (R)40).The findings include:Review of the facility's policy titled, KCC DTI Off-site School Medication Distribution, revised 03/2025, revealed the Resident Education Nurse Coordinator (NC) or designee was required to conduct daily order reviews to identify any changes to medication orders, complete a new order form reflecting any changes, and send it to the contracted pharmacy. Further review revealed however, no documented evidence the policy addressed completing school forms or updating the school regarding residents' medication changes.Review of the admission Record for R40 revealed the facility admitted him on 06/13/2024, with diagnoses including autism, spastic quadriplegic cerebral palsy, and restlessness. Review of the admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/19/2024, revealed the facility assessed R40 as demonstrating refusals of care and behaviors of hitting and grabbing.Review of the physician's order dated 07/11/2025, revealed the provider prescribed R40 Aripiprazole (an atypical antipsychotic used to treat mental conditions which included irritability associated with autism) 3 milligram (mg) daily, increasing to 5 mg after three days. Review of the facility document titled, Permission Form for Prescribed or Over-the-Counter Drugs, dated 07/11/2025, revealed the Resident Education NC notified R40's school on 07/11/2025 of the new aripiprazole order. Review of the facility document titled, School Medication Order Form, dated 07/11/2025, revealed the contract pharmacy had been notified by the facility of the physician's order on that date. Review of the facility document titled, School Medication Order Form revealed the contract pharmacy delivered the Aripiprazole to R40's school on 08/04/2025. Review of the facility document titled, Order Listing Report, dated 08/18/2025, revealed however, the Aripiprazole order was discontinued on 07/25/2025 (10 days prior to the medication being delivered to R40's school). Review of the facility's investigative report revealed R40 experienced a change in mental status and was transported to the hospital on [DATE].Review of the hospital Discharge summary dated [DATE], revealed that during medication reconciliation at the hospital, it was discovered the school continued to administer the Aripiprazole 5 mg to R40 after the medication had been discontinued on 07/25/2025. Further review of the hospital discharge summary revealed however, the treating physicians at the hospital determined there had been no connection between the Aripiprazole medication and R40's altered mental status.Review of the facility's document titled, 5 Whys Root Cause Analysis Template, dated 08/21/2025, revealed the facility determined there had been a process failure that allowed the Aripiprazole medication error to bypass the facility's medication-order double-check process. Review further revealed there had been no communication to the school and contract pharmacy about the Aripiprazole medication having been discontinued.During interview with the contract pharmacy's Director of Pharmacy Services on 09/12/2025 at 9:07 AM, he stated the pharmacy had been notified of the Aripiprazole order for R40 on 07/11/2025. He further stated the pharmacy received no further notification of any medication change regarding the Aripiprazole medication until 08/29/2025.During interview with R40's school nurse on 09/12/2025 at 9:48 AM, she stated the school did not accept verbal orders and required written forms for all medications. She said she received the routine medication and over-the-counter medicine form for R40 that included the Aripiprazole medication on 08/06/2025. The school nurse reported she had not became aware the Aripiprazole medication had been discontinued until after R40's hospitalization on 08/15/2025. She further stated R40 received the first dose of Aripiprazole on 08/07/2025, his first day of school, and continued to receive it at school until 08/15/2025 (a total of eight days).During interview with the Resident Education NC on 09/11/2025 at 2:40 PM, she stated she called and spoke with a nurse at R40's school and verbally discontinued the resident's Aripiprazole order. When questioned regarding the process for communicating medication changes to schools, she stated there was a school form that was to be completed and faxed or emailed. The Resident Education NC acknowledged however, that form had not been completed for the discontinuation of R40's Aripiprazole medication. She further stated the facility sometimes called verbal orders to the schools.During interview with the Director of Support Services (DSS) on 09/11/2025 at 3:15 PM, she stated the process for school medications involved the use of two forms. She reported the two forms were the School Medication Order Form, referred to in the policy as the Monthly School Medication Order Form. and the school Permission Form for Prescribed or Over the Counter Drugs. The DSS said the School Medication Order Form was to be scanned to the pharmacy and the school Permission Form for Prescribed or Over the Counter Drugs, was to be faxed or emailed to the school nurse. She further stated she personally audited residents' medications to ensure accuracy at both the pharmacy and the school.During interview with the Quality Assurance Nurse (QAN) on 09/12/2025 at 9:40 AM, she stated the team reviewed the root cause analysis for the medication error involving R40 in the August QAPI meeting, and identified failures in the facility's process. When asked what types of outcomes could occur when medication changes were not communicated, she stated there could be a negative outcome if a resident continued receiving a discontinued medication, such as an allergic reaction or even a fatal event.During interview with the Director of Nursing (DON) on 09/12/2025 at 2:28 PM, she stated orders were to be checked daily and medication changes should be communicated to the pharmacy and the school within 24 hours of any changes. She further stated the potential for a negative outcome involving a resident receiving a discontinued medication could include overdose, or even death.During interview with the Administrator on 09/13/2025 at 3:59 PM, she stated when a medication order was changed, the expectation was for the Nursing Education Coordinator to receive the order change information, and fill out the correct school forms. The Administrator said the Nursing Education Coordinator was expected to send the order change information via email or fax to the school and the facility's contracted pharmacy. She stated, The breakdown was that when the medication was changed, the double check did not occur, and the form was not filled out and the change was not communicated to the school. The Administrator further stated the potential outcome to not communicating medication order changes could be a serious injury up to death for a client receiving a discontinued medication.

483.60 Food and Nutrition Services F812The facility failed to ensure food service safety in accordance with professional standards in regards to use of beard guards, which had the potential to affect all residents consuming food from the kitchen. The findings include:Review of the facility's policy titled, Personal Hygiene SOP, effective 06/27/2024, revealed staff were to: Wear suitable and effective hair restraints while in the kitchen. Additionally, review of the Infection Control - Kitchen section of the Dietary Rounds checklist (undated), revealed: All employees are wearing a head covering while in the kitchen. Review of the facility's training orientation packet revealed the dietary staff were required to review the facility's policy and procedure titled, Food Safety Plan (undated), Review further revealed dietary staff were then to sign and date for acknowledgement of the procedure for wearing effective hair restraints while in the kitchen.Observation on 09/09/2025 at 9:50 AM, revealed the Dietary Director, who had a full beard, was observed in the main kitchen without wearing a beard guard. Continued observation revealed the Dietary Director's beard was uncovered and unrestrained while he was completing inventory directly in front of food that was being prepared. Observation on 09/10/2025 at 09:30 AM, revealed the Dietary Director carrying a tray of meat into the walk-in refrigerator without wearing a beard guard, despite having facial hair extending below the chin. Further observation revealed the tray of meat the Dietary Director was uncovered and fully exposed. Observation on 09/10/2025 at 10:42 AM, revealed [NAME] 1 preparing lunch in the main kitchen, while also transporting uncovered pans of food from the oven to the warmer. Further observation revealed [NAME] 1 was preparing food and transporting uncovered pans of food without wearing a beard guard over his beard, which ranged approximately in length of 1/2 inch to 1-2 inches.In interview with the Dietary Director on 09/10/2025 at 1:42 PM, he stated beard and hair nets were stored in the his office and staff must come to the office to obtain those items. He said [NAME] 1 was the first male dietary employee in months and acknowledged he had not been instructed on use of a beard guard if his beard was trimmed up. The Dietary Director reported he had not advised [NAME] 1 to wear a beard guard as his beard was trimmed up. He stated the daily internal audits and monthly dietician audits performed included checks for uniforms, shoes, hair nets, and beard nets. He acknowledged he knew [NAME] 1 was not wearing a beard guard and added that beard guard use was not in written policy.In interview with the Manager of Food Service on 09/10/2025 at 1:42 PM, she stated she ensured staff wore hair nets, washed hands, and wore proper uniforms, including beard guards, to prevent hair contamination in food. She reported training was given verbally and reiterated multiple times weekly. The Manager of Food Service said community meetings were held 2-3 times per week with dietary staff to cover kitchen expectations and requirements. She further stated, I have made both male staff (Dietary Director and [NAME] 1) aware of the importance of wearing hair nets and beard guards, but it is disregarded because the Dietary Director does not enforce this. In interview with [NAME] 1 on 09/11/2025 at 1:00 PM, he stated he received training when he initially started approximately two months ago (07/2025) in the form of handouts, verbal instruction, and hands-on guidance. He reported he had been provided the policy on hair restraints and had previously spoken with the Dietary Director, who believed his beard was short enough that a beard guard was not required. [NAME] 1 further stated the importance of hair nets and beard guards was to ensure hair did not fall into food, emphasizing accountability since his name is associated with the meals he prepared.

Based on observation, interviews, record review, document review, and facility policy review, it was determined the facility failed to ensure the care planned intervention to provide continuous line-of-sight monitoring was consistently implemented for one (1) of twelve (12) sampled residents (Resident #66). The facility developed a care plan that included an intervention for Resident #66 to always be within staff's line of sight when he/she was up in a wheelchair. However, on 12/14/2022, the facility failed to supervise Resident #66. Resident #66 exited the facility through the emergency/fire exit doors located on the Ocean Avenue Unit without staff's knowledge. Immediate Jeopardy (IJ) was identified on 02/10/2023 and determined to exist on 12/14/2022. The facility was notified of the IJ on 02/10/2023 at 6:05 PM. The State Survey Agency (SSA) received an acceptable IJ removal plan on 02/12/2023. The SSA validated the removal plan and determined the Immediate Jeopardy had been removed, before exit on 02/12/2023. Noncompliance was lowered to a scope and severity of D The findings include: Review of the facility's policy, titled Resident Care Plan and Physician Orders, revised March 2022, revealed, Care Plans shall focus on the treatment of actual and prevention of potential problems for each resident considering the resident's strengths and unique characteristics. The policy also stated, Care Plans shall be developed and implemented to meet the resident and/or guardian's preferences and goals and provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Review of the facility's job description for Certified Nursing Assistants (CNAs), dated as reviewed 2022, revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of the facility's job description for Staff Nurses (Registered Nurses and Licensed Practical Nurses), dated 2022 revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of an Admission Record revealed the facility admitted Resident #66 on 06/30/2021 with diagnoses that included spastic quadriplegic cerebral palsy (the most severe type of cerebral palsy, a group of disorders that affect movement, muscle tone, balance, and posture, marked by the inability to control and use the legs, arms, and body), epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), restlessness, and agitation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) should not be completed. Further review revealed Resident #66 had severely impaired cognitive skills for daily decision-making per a staff's assessment for mental status. The MDS indicated the resident used a wheelchair for mobility and required extensive assistance with locomotion on and off the unit. According to the MDS, the resident had not exhibited wandering behavior during the seven-day assessment period. Review of the care plan, dated as initiated 06/30/2021, revealed the resident was at risk for injury related to an inability to protect self from injury; self-mobility in bed, on mat and in wheelchair; and behavioral symptoms including resisting care, screaming out, crying out, entering other residents' rooms or unauthorized spaces, elopement, impulsivity; and had limited self-preservation skills. Review of an intervention dated 06/30/2021, indicated the resident was at risk for Wandering/Elopement and an intervention, dated 07/01/2021, revealed the resident must be in line of sight of staff while up in the wheelchair for safety. Review of the Long Term Care Facility-Self-Reported Incident Form revealed that on 12/14/2022 at approximately 2000 [8:00 PM], {Resident #66} exited the building through a fire door onto the patio in a wheelchair. Review of the facility's Continued 5 [Five] Day Follow Up report for the 12/14/2022 incident revealed the facility identified that Resident #66 was able to exit a faulty fire exit door due to damaged wiring in the ceiling that disabled the alarm, allowing the door to be opened without a proximity card. According to the report, the team members were all providing care in residents' rooms during the time the resident was able to exit through the fire doors during the beginning of a new shift. The facility identified that clear communication regarding monitoring and supervision of the common area had not occurred during shift change. Additionally, the report indicated while team members moved in and out of the area, no one had been directly assigned to monitor the common area as expected. On 02/09/2023 at 11:25 AM, review of the facility's video surveillance footage revealed at 7:46:21 PM, Resident #66 was at the fire exit door and exited the facility at 7:48:25 PM. At 7:56:08 PM, a staff member came to the door to get help with bringing Resident #66 into the facility. The resident was outside from 7:48:45 PM to 7:56:08 PM. Telephone interview, on 02/08/2023 at 7:10 PM with CNA #15, revealed she was assigned to take care of Resident #66 on 12/14/2022 from 3:00 PM to 7:00 PM. She stated prior to leaving the facility at 7:00 PM, Resident #66 was by the nursing station. CNA #15 stated she gave report to CNA #14 and believed she was taking the resident to his/her room or for a snack or a shower. According to CNA #15, she read the residents' Kardex and care plans before taking care of the residents. She stated staff also gave report about resident care. CNA #15 stated she did not think Resident #66 required one-on-one supervision prior to the incident, but the facility normally had a sitter (Cottage Safety Monitor [CSM]) to supervise the residents. CNA #15 stated if they did not have a sitter, a staff member would have to sit with the residents. CNA #15 stated Resident #66 had not tried to get out of the door before the incident, and she did not think Resident #66 was at risk for elopement, but that he/she was just monitored like other residents in the common area. During a telephone interview, on 02/08/2023 at 6:22 PM, CNA #14 stated on 12/14/2022, she worked the night shift and was assigned to take care of Resident #66. She stated she saw Resident #66 in the common area at 7:00 PM before she began doing rounds on other residents. She stated she and the nurse were in the same room providing resident care when staff found the resident outside. CNA #14 stated at that time, she was unaware there was not a CSM in the common area to monitor the residents. The CNA stated she reviewed residents' Kardex/care plans for information on how to take care of the residents and staff also did walking rounds and discussed resident care prior to each shift. Continued interview revealed the nurses updated the care plans if there were any changes; however, CNA #15 stated she was unaware, prior to the 12/14/2022 incident, that Resident #66 was required to always be within staff's line of sight when up in a wheelchair. Attempts were made to interview Registered Nurse (RN) #22, via telephone on 02/08/2022 at 7:41 PM, on 02/09/2022 at 6:35 PM, and on 02/10/2023 at 7:49 AM. Unsuccessful attempts were made via telephone on 02/09/2023 at 4:03 PM and 02/09/2023 at 6:35 PM to reach CSM #20, who was scheduled on 12/14/2022. During an interview, on 02/09/2023 at 12:40 PM, the Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist stated on 12/14/2022, the facility was supposed to have a CSM on duty until 8:00 PM. However, CSM #20 clocked out at approximately 2:40 PM without notifying anyone. She stated staff should have recognized there was no CSM and made sure all residents were supervised in the common area, as required. She stated the incident happened at shift change while the staff were doing their rounds. During an interview, on 02/09/2023 at 3:48 PM, the Manager of Resident Care stated she updated the care plan after the incident, she thought by distracting the resident, the resident would be more occupied by the distraction instead of trying to leave. The Manager of Resident Care stated she was aware this might not prevent the resident from eloping but might distract the resident from being interested in going toward the exit doors. During an interview, on 02/10/2023 at 4:14 PM, the [NAME] President of Nursing (VPN) stated she expected staff to follow resident care plans and to constantly monitor the residents. She stated that the incident related to Resident #66 occurred because staff failed to supervise Resident #66 as care planned. During an interview on 02/10/2023 at 8:49 AM, the Administrator stated the 12/14/2022 incident occurred because supervision was not provided to prevent Resident #66 from exiting the building. She stated Resident #66 was in the common area and staff left the resident unsupervised while they did rounds. Further review revealed staff were present on the unit but did not keep Resident #66 in their line of sight. According to the Administrator, staff knew Resident #66's care plan required the resident to always be within staff's line of sight. She stated staff may have thought the CSM was present to monitor the residents, but either way, Resident #66 was not supervised as required. The Administrator stated she expected staff to follow the care plans and that staff should have recognized and supervised Resident #66. The facility provided an acceptable Immediate Jeopardy Removal Plan alleging removal of the IJ on 02/12/2023. Review of the IJ Removal Plan revealed the facility implemented the following: 1. The following action steps were taken to remove immediate jeopardy from Resident #66. The direct threat in which Resident #66 experienced an elopement was removed on 12/14/2022 when Resident #66 was brought back into the facility by a nurse. Actions taken to further remove the immediacy and severity of the threat included: a review and revision of the Care Plan for Resident #66 on 12/14/2022 by the Manager of Resident Care to add a risk of wandering and elopement along with resident-centered interventions. The interventions included: distraction and redirection and offering engaging activities to mitigate risk of exit seeking and elopement. Review of all residents' Care Plans was conducted to determine if any resident was affected by the same deficient practice of failure to provide line-of-sight supervision on 12/15/2022 by the Manager of Resident Care. No other residents were found to be affected as no other residents required line-of-sight supervision. The Care Plan assessment conducted by the Manager of Resident Care identified 16 residents at risk for elopement and wandering. On 12/15/2022, the Manager of Resident Care revised the Care Plans of the 16 residents identified at risk to include goals and resident-centered interventions to mitigate the risk of elopement including but not limited to distraction and redirection and offering engaging activities to mitigate risk of wandering and elopement. 2. Further action taken on 02/10/2023 included Mandatory Retraining and Notification of Immediate Jeopardy created by the Manager of Resident Care and implemented for all team members. This training included an attestation statement of requirement, responsibility, and expectation in reading, understanding, and following information found in the resident Care Plan and Kardex, before providing care to residents and implementing the plan of care for each resident including providing continuous supervision of residents in the community areas. The Standard of Care Audit Form was revised on 02/10/2023 by the Senior [NAME] President/Administrator to include monitoring elopement risk interventions to the Safety category of Care Plan Auditing Care Task. The Standard of Care Audit Form will be used by the Leadership Team including Manager of Resident Care, Manager of Training and Development, Neighborhood Nurse Managers, Manager of Respiratory Therapy, [NAME] President of Therapy, Manager of Support Services, Director of Medical Social Services, Director of Nursing, and [NAME] President of Nursing to document findings of audits of care delivery to ensure care delivery will be implemented according to the residents' Care Plan. Standards of Care Audits will be conducted weekly on at least ten (10) residents to ensure their person-centered Care Plan will be implemented as written. 9/26 Administrative, 48/90 Nursing, 43/70 CNAs, 2/11 Resident Enrichment Specialists, 13/28 Respiratory Therapists, 1/24 Ancillary Therapists, and 2/4 contractors have completed training as of 2/12/2023 at 9 AM [9:00 AM]. All team members will be required to complete the retraining prior to the start of their next shift. 3. The Medical Director was notified of the Office of Inspector General's finding of immediate jeopardy, including mitigation efforts that included, but were not limited to the review of all residents' care plans, implementation of dedicated team members to provide supervision of residents in the community areas, training of all team members, contractors, and students prior to providing care or service, and standard of care auditing to ensure care plan and physician's orders were implemented as written, on Friday, 02/10/2023, at 8:47 PM by the Senior [NAME] President/Administrator. 4. Outcome measures for completion of Standards of Care Audit Tools will be monitored weekly and tabulated monthly by the [NAME] President of Nursing and reported monthly to the IP/QAPI Specialist. The IP/QAPI Specialist shall report outcomes measures quarterly to the Quality Improvement Committee. The [NAME] President of Nursing shall monitor for trends in non-compliance and address concerns with team members when identified. The [NAME] President of Nursing shall report all findings to the IP/QAPI Specialist monthly for 12 months. IP/QAPI Specialist shall report outcomes measures quarterly Quality Improvement Committee for 12 months. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: The survey team conducted observations, record/document reviews, and interviews on 02/12/2023 to ensure the facility's removal plan was fully implemented and the immediacy was removed, as follows: 1. Review of Resident #66's care plan revealed the facility revised the care plan on 12/14/2022 with interventions that included distracting the resident from wandering by offering pleasant diversions (preferred toys), conversation, television, or a book. Observations of Resident #66 during the survey from 02/07/2023 through 02/12/2023 revealed the resident was within a staff member's line of sight during all observations. Staff provided supervision of the resident as required by the resident's care plan. An interview with the Manager of Resident Care on 02/12/2023 at 12:49 PM revealed the care plans for 16 residents (Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70), who were assessed at risk for elopement/wandering, were updated. Review of the care plans for Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70, revealed the facility revised the care plans with resident-centered interventions to address elopement prevention. Observations of these residents on 02/12/2023 revealed the facility had implemented their care plans. 2. A review of re-training documentation, dated 02/10/2023 through 02/12/2023, revealed the Manager of Resident Care provided retraining regarding understanding and following residents' care plan/Kardex before providing care and implementing the care plan for each resident. Interview with the IP/QAPI Specialist, on 02/12/2023 at 9:40 AM revealed the agency staff that had returned to the facility had been re-trained, and the additional agency staff had been notified they were not to return to work at the facility until the training was completed. She stated she ensured all staff were trained prior to working their next shift. A phone interview with Nursing Supervisor #39 on 02/12/2023 at 11:45 AM revealed staff were responsible to review the care plan/Kardex to be informed of residents' care needs. A phone interview with CNA #40 on 02/12/2023 at 11:50 AM revealed she received training related to reviewing the care plan/Kardex and to read and understand the care plan/Kardex. A phone interview with RN #41 on 02/12/2023 at 11:55 AM revealed she received training regarding reviewing care plans to make sure staff knew how to take care of the residents. During a phone interview with CNA #42 on 02/12/2023 at 12:10 PM, she stated she received training to always review the Kardex/care plan and if there were any questions to ask the supervisor. A phone interview with CNA #43 on 02/12/2023 at 12:17 PM revealed she also she received training related to always reviewing the care plan/Kardex prior to providing any resident care. During an interview with CNA #44 on 02/12/2023 at 12:25 PM, she stated staff were to review the Kardex before the beginning of each shift and notify staff of any alerts on the Kardex/care plan. An interview with Nursing Supervisor #45, on 02/12/2023 at 12:40 PM, revealed that, based on the training, staff were supposed to check the Kardex/care plan before taking care of the residents. An interview with CNA #46, on 02/12/2023 at 12:50 PM revealed she recently received training that staff were to review care plans/Kardex prior to taking care of the residents. Interview with CNA #47, on 02/12/2023 at 1:10 PM, revealed she received training that the care plans/Kardex were to be reviewed before the shift and during the shift if needed. She stated the care plan had information about the care of the residents, their behaviors, and the care they required. 3. A review of an email to the Medical Director, dated 02/11/2023, revealed the facility notified him of the Immediate Jeopardy findings. 4. Interview with the IP/QAPI Specialist, on 02/12/2023 at 9:40 AM, revealed the agency staff that had returned to the facility had been re-trained, and the additional agency staff had been notified they were not to return to work at the facility until the training was completed. She stated she ensured all staff were trained prior to working their next shift. An interview with the IP/QAPI Specialist on 02/12/2023 at 1:03 PM revealed all staff were trained to review residents' care plan/Kardex at the start of every shift.

Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of three (3) sampled residents reviewed for accidents (Resident #66). The facility assessed Resident #66 to be at risk for elopement and was care planned for him/her to always be within staff's line of sight when up in a wheelchair. However, the resident exited the facility undetected by staff on 12/14/2022 at 7:48 PM and was outside unsupervised for approximately eight (8) minutes. Immediate Jeopardy (IJ) was identified on 02/10/2023. The IJ was determined to exist on 12/14/2022, when Resident #66 exited the facility through the emergency/fire exit doors located on the Ocean Avenue unit and accessed the outside patio unsupervised for eight (8) minutes. The State Survey Agency (SSA) received an acceptable IJ removal plan on 02/12/2023. The SSA validated the Immediate Jeopardy had been removed, before exit on 02/12/2023. Noncompliance was lowered to a scope and severity of D The findings include: Review of a facility policy titled, Resident Monitoring and Supervision, revised March 2022, revealed the Facility shall provide resident monitoring and supervision as an intervention and a means of mitigating risks. Monitoring and supervision shall be determined based on the residents' assessed needs, including behavioral health needs, and identified hazards in the care environment. Levels of supervision may vary from resident to resident and from time to time for the same resident. Review of job descriptions for the facility's staff nurses (Registered Nurses and Licensed Practical Nurses) and for Certified Nursing Assistants (CNAs) revealed, The general purpose of your job is to keep children who are clients of [the facility] safe at all times and to be respectful of the children and their families as valued customers. Review of an undated facility training document titled, Cottage Safety Monitor: [Contract Agency Name] Training, revealed, Cottage Safety Monitoring shall be utilized during working hours on cottages where additional supervision is required to monitor residents and mitigate the risk of injury, abuse or neglect. The document also indicated the primary roles of Cottage Safety Monitors (CSMs) included, Provide continuous oversight and supervision of residents. Monitor mobile residents at all times in the community area. Maintain awareness of where residents are on the cottage, paying particular attention when residents leave the community area activities. Ensure continuous coverage of the cottage by delegating the CSM role to another available team member. The document indicated additional expectations of the CSMs included, When the CSM needs to leave the community area for breaks and meal times, team members on the cottages shall provide coverage and supervision until the CSM has returned. Review of the Admission Record revealed the facility admitted Resident #66 on 06/30/2021 with diagnoses that included spastic quadriplegic cerebral palsy (the most severe type of cerebral palsy, a group of disorders that affect movement, muscle tone, balance, and posture, marked by the inability to control and use the legs, arms, and body), epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), restlessness, and agitation. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) should not be completed. Further review revealed Resident #66 had severely impaired cognitive skills for daily decision-making per an assessment for mental status. The MDS assessment indicated the resident used a wheelchair for mobility and required extensive assistance with locomotion on and off the unit. According to the MDS, the resident had not exhibited wandering behavior during the seven-day assessment period. Per the MDS, the cognitive assessment was the staff's assessment for mental status - they did not complete a BIMS. Review of a care plan, dated as initiated 06/30/2021, revealed the resident was at risk for injury related to an inability to protect himself/herself from injury; self-mobility in bed, on mat, and in wheelchair; behavioral symptoms including resisting care, screaming out, crying out, entering other residents' rooms or unauthorized spaces, elopement, impulsivity, and had limited self-preservation skills. Interventions included for staff to monitor for and respond to behavioral symptoms which placed the resident at risk for injury, as the resident was self-mobile in a wheelchair and had a RED Safety Circle Designation. An intervention dated as initiated 06/30/2021 indicated, Wandering/Elopement, and an intervention dated as initiated 07/01/2021 indicated the resident must be in line of sight of staff while up in wheelchair for safety. A review of an incident report, dated 12/14/2022 at 8:02 PM, revealed Resident #66 went out the back door of the facility after last having been seen by Registered Nurse (RN) #22 at approximately 7:00 PM in the common area. The report indicated the emergency exit door alarm did not sound to alert staff that the door had been opened. The report indicated Licensed Practical Nurse (LPN) #16 went outside for a break and saw the resident outside in his/her wheelchair, unattended. The report revealed LPN #16 attempted to take the resident back inside, but the resident held the wheels of the wheelchair and repeatedly said no. LPN then locked the brakes on the resident's wheelchair, went to the door, and called for assistance, after which LPN #23 came and assisted LPN #16 to get the resident inside the building. The report indicated upon entering the unit, all team members were in other residents' rooms. Further review of the facility's investigation revealed the resident was assessed to have no injuries and all facility doors were assessed to ensure proper functioning. Further review revealed the investigation indicated the door through which the resident exited the building was found to have a malfunctioning fire exit bar that did not alarm and allowed the door to open by just pushing the door. Continued review revealed that Resident #66 was able to exit the facility through the malfunctioning fire door while the team members who were assigned to the resident's unit were all providing care in other residents' rooms. The investigation revealed clear communication regarding monitoring and supervision of the common area had not occurred during shift changes. While team members moved in and out of the area, no one had been directly assigned to monitor the common area as expected. A review of an online Weather History report at (https://www.wunderground.com/history/daily/us/ky/louisville) revealed on 12/14/2022 at 7:56 PM, the temperature in the city where the facility was located was 56 degrees Fahrenheit (F) with no precipitation noted. Review of Progress Notes revealed a Social Services Note, dated 12/15/2022 at 5:15 PM, which indicated Resident #66 had a temporary elopement from the facility last night. Further review of the Progress Notes revealed a Parent/Guardian Contact Note, dated 12/15/2022 at 3:30 PM which indicated staff had a conference call with Resident #66's guardian and provided a recap of the resident's elopement. Observation on 02/07/2023 at 11:10 AM revealed Resident #66 in bed. Observation of Resident #66 on 02/07/2023 at 1:15 PM revealed the resident was sitting in a wheelchair participating in an activity with a staff member. During a telephone interview, on 02/08/2023 at 6:22 PM, Certified Nursing Assistant (CNA) #14 stated that on 12/14/2022, she worked the night shift (7:00 PM - 7:00 AM) and was assigned to Resident #66's hall that night. She stated that when she started her rounds, Resident #66 was in the common area, and CNA #14 was unaware supervision was not being provided by a CSM at that time. She stated she and RN #22 went into a room to assist other residents and did not see Resident #66 go outside. CNA #14 stated she was unaware that the exit door was malfunctioning prior to the incident with Resident #66. During a telephone interview, on 02/08/2023 at 7:10 PM, CNA #15 stated that on 12/14/2022, she was assigned to take care of Resident #66 from 3:00 PM to 7:00 PM. She stated the last time she saw Resident #66 was at 7:00 PM in the common area of the cottage when she gave report to CNA #14. She stated CNA #14 was assigned to take care of Resident #66 for the 7:00 PM to 7:00 AM shift on 12/14/2022. During a telephone interview on 02/08/2023 at 7:23 PM, LPN #16 stated on 12/14/2022 at 8:00 PM, she stepped outside from another unit to get some fresh air and noticed a resident sitting in a wheelchair in the grass near the patio area. She stated it was not cold or raining and that the resident was fully dressed. LPN #16 indicated she looked to see if any staff were with the resident but found no one. She stated she attempted to take Resident #66 back inside the facility, but the resident grabbed the wheels of the wheelchair and yelled no. The LPN stated she locked the wheelchair brakes and went to the door to yell for assistance. She stated no one came to help the first time she called out, but then LPN #23 came and helped her get Resident #66 back into the facility. Further interview revealed she was told RN #22 was assigned to Resident #66, but she was in another resident's room at the time of the incident. LPN #16 stated the supervisors asked about the monitors (CSMs), and she informed them that she did not see a monitor and that the monitors often left the area without telling anyone they were leaving. On 02/09/2023 at 11:25 AM, the SSA team reviewed the video footage for the date/time of the incident. The video footage timestamp at 7:46:21 PM revealed Resident #66 was at the exit door. At 7:48:25 PM, the resident exited the facility. At 7:56:08 PM, a staff member came to the door to get help with bringing Resident #66 back into the facility. The resident was outside from 7:46 PM to 7:56 PM. During an interview on 02/09/2023 at 10:09 AM, the Maintenance Director stated he was not aware of any doors not working properly prior to the incident on 12/14/2022 with Resident #66. He stated he was not notified about the door not working properly until the next day. He asserted that he checked the doors on a weekly basis but did not keep a log. He stated he expected staff to notify maintenance if they had any issues with the doors. During an interview, on 02/09/2023 at 12:40 PM, the Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist stated that on 12/14/2022, the facility was supposed to have a CSM to monitor the residents in the common area until 8:00 PM, but the CSM (CSM #20) left at 3:00 PM without notifying anyone. She stated the staff did not realize there was no one monitoring the residents in the common area. During an interview, on 02/09/2023 at 5:14 PM, the [NAME] President of Nursing (VPN) stated after the elopement of Resident #66 on 12/14/2022, the facility immediately checked all the exit doors to ensure they were locking and alarming appropriately. He stated the exit door through which Resident #66 exited the building was fixed the following day and monitored until it was fixed. The VPN indicated she expected all facility staff to be responsible for the residents. During an interview, on 02/10/2023 at 8:49 AM, the Administrator stated that immediately after the incident on 12/14/2022, the door company was contacted and came that night to assess the door, which was fixed the next day. She stated all residents were accounted for to ensure resident safety. The Administrator indicated she expected staff to keep all the residents safe and prevent any type of injury. She stated the failure occurred because supervision was not provided to prevent Resident #66 from exiting the building. She stated the CSM was scheduled to work until 8:00 PM but left around 3:00 PM without notifying anyone. The Administrator stated the staff should have recognized this and supervised the resident. She stated Resident #66 was in the common area, and staff left the resident unsupervised while they did their rounds. She stated they were unaware the door did not work properly until after this incident. The State Survey Agency validated the facility had taken the following actions: 1. The following action steps were taken to remove immediate jeopardy from Resident #66. Further action was taken to remove the immediate jeopardy from Resident #66 including conducting 30-minute checks on Resident #66 immediately following the elopement throughout the night while Resident #66 slept from 12/14/2022 - 12/15/2022. The RN Clinical Supervisor circulated each Neighborhood on 12/14/2022 and confirmed the whereabouts and safety of all residents on all Neighborhoods. All residents were accounted for and safe. 2. Actions taken to further remove the immediacy and severity of the threat included a review and revision of the Care Plan for Resident #66 on 12/14/2022 by the Manager of Resident Care to add a risk of wandering and elopement along with personalized interventions which included but were not limited to distraction and redirection, offering engaging activities to mitigate the risk of exit seeking. A review of all resident Care Plans was conducted on 12/15/2022 by the Manager of Resident Care which identified 16 residents at risk for elopement and wandering. On 12/15/2022, the Manager of Resident Care revised the Care Plans of the 16 residents identified at risk to include goals and interventions to mitigate the risk of elopement. 3. The RN Clinical Supervisor confirmed that all exit doors were secured, locked, prox [proximity] card readers were properly functioning, alarms were sounding, with the exception of the Ocean Avenue Patio door. The Ocean Avenue Patio door through which the resident eloped was unlocked and no alarm was functional. The Ocean Avenue Patio door was then continuously monitored by a [Company Name] team member until the vendor arrived on-site on 12/15/2022 and repaired the door securing it and ensuring the door was working properly with the exception of 7:00 AM to 8:00 AM, during which time Resident #66 was off campus and other residents at risk for elopement were supervised by team members. 4. Actions taken to further remove the immediacy and severity of the threat also included checks of all exit doors every two (2) hours by the RN Clinical Supervisor on shift beginning 12/14/2022 documenting findings on the Neighborhood Emergency Door Rounding Log. The checks will be documented on the Neighborhood Emergency Door Rounding Log and will include the expectation to ensure the door was locked, could not be opened without using the prox card, alarm sounded when the fire egress bar was compressed, door opened after the fire egress bar was compressed for 15-30 seconds, door closed completely, and was locked following the check. The RN Clinical Supervisor on shift shall notify the Maintenance on-call team member if any issues were identified and assign a team member to continuously monitor the door until a Maintenance team member arrived. The RN Clinical Supervisors will continue checks until the door hardware has been replaced by a certified vendor and the vendor certified the door functioned as expected. RN Clinical Supervisors were trained on the expectation of door checks. 5. Further action included implementing routine door checks by Maintenance or Information Management Technology team members beginning on 02/10/2023 twice daily between 7:00 AM and 4:00 PM, and again between 4:00 PM and 10:00 PM. This will continue until the immediacy has been abated; the door hardware has been replaced; and, the vendor has verified the doors were fully functioning as expected. Team members or contractor will be assigned to supervise residents when in community areas to ensure residents remain in the building and will complete training prior to providing care. Routine door checks by Maintenance or Information Management Technology team members shall continue daily for 30 days, then weekly for 12 months. Door checks shall ensure: the door was locked; cannot be opened without using the prox card; alarm sounded when the fire egress bar was compressed; door opened after the fire egress bar was compressed for 15-30 seconds; door closed completely and was secure following the check. Maintenance and Information Technology team members completing door checks shall take immediate action to correct the identified issue and/or request the vendor to report to the facility and repair the door. Maintenance and Information Technology team members were provided retraining by the Chief Operations Officer on their role to check doors or will be trained prior to completing door checks. Maintenance and Information Technology team members signed an attestation of training and commitment. 6. Further action taken included the purchase of replacement delayed egress crash bar hardware and access control through the vendor on 2/10/2023 by the Director of Information Technology and the purchase of Alarm Mats on 02/08/2023 by the Director of Procurement to serve as a secondary alarm notification of a resident approaching an exit door. The alarm mats were expected to be delivered on 02/14/2023. Mitigation interventions included the above-noted door checks and Maintenance door checks shall continue until doors are certified by the vendor to function as expected. 7. Further action taken to remove the Immediate Jeopardy includes the implementation of unannounced rounding observations on each Neighborhood by leadership team members, including the Manager of Resident Care, Manager of Training and Development, Neighborhood Nurse Managers, Manager of Respiratory Therapy, [NAME] President of Therapy, Manager of Support Services, RN Clinical Supervisors, Director of Medical Social Services, and [NAME] President of Nursing, twice daily beginning on 12/20/2022 to ensure compliance of supervision expectations. Leadership team members document findings on the Neighborhood Supervision Compliance Auditing Tool. Observations were completed twice daily and will continue until replacement of the door hardware, then completed daily for 30 days and at least twice weekly for 12 months to ensure continued compliance. 8. Further action taken on 12/16/2022 included immediate mandatory retraining of all team members on their role and expectations for providing resident supervision while residents were in the community areas to prevent resident elopement. Supervision and Safety Training with Attestation of Commitment was created by the Manager of Training and Development and expectation for completion was communicated via email by the Senior [NAME] President/ Administrator on 12/16/2022 to all team members. All team members, contractors, and students were required to complete the mandatory training prior to the start of their next shift. 23/23 Administrative, 92/93 Nurses, 67/69 CNAs, 27/27 Respiratory Therapists, 30/30 Ancillary Therapists/Resident Enrichment have completed training as of 02/11/2023. Agency team members, if used, will complete retraining on providing supervision. They cannot be sitting at the door and providing supervision simultaneously. Supervision of residents while residents are in the community area prevents any resident elopement. 9. Further action taken on 02/10/2023 to mitigate risk included assigning team members, or select contractors, to provide dedicated supervision and monitoring of residents on all Neighborhoods from 8:00 AM to 10:00 PM while residents were present in common areas to prevent resident elopement, accidents, and hazards. 10. Further action was taken to remove Immediate Jeopardy on 02/10/2023 including Mandatory Retraining and Notification of Immediate Jeopardy created by the Manager of Resident Care and implemented for all team members. This training included Expectations for Resident Supervision and an Acknowledgement Attestation of Training and Expectations of Supervision. 09/26 Administrative, 48/90 Nursing, 43/70 CNAs, 02/11 Resident Enrichment Specialists, 13/28 Respiratory Therapists, 01/24 Ancillary Therapists, and 2/4 contractors have completed training as of 02/12/2023 at 9:00 AM. All team members, contractors, and students were required to complete the retraining prior to the start of their next shift. 11. Further action taken on 02/11/2023 included notification of contracted agency by the [NAME] President of Nursing that the individual contractor, who was assigned to Ocean Avenue on 12/14/2022, and left the Neighborhood prior to the end of her shift without notifying members of her departure was no longer permitted to return to the facility. Contractors will complete retraining prior to the start of their shift should they be permitted to provide services. RN Clinical Supervisor on shift shall ensure training was completed prior to the team member, contractor, or student providing care or service. To ensure coverage, the facility continued to ensure each individual had the required training prior to providing care or service. 12. Outcome measures for completion of [Company Initials] Incident Response Attestation and Immediate Jeopardy Notification and Retraining with Acknowledgment Attestation of Training and Expectations for Supervision, will be tabulated weekly by the Manager of Training and Development and reported weekly to the IP/QAPI Specialist for quarterly reporting to the Quality Improvement Committee for review and compliance. Outcome measures from the completion of Neighborhood Supervision Compliance Observation Tools will be tabulated and reported by the [NAME] President of Nursing weekly for 12 months. The [NAME] President of Nursing shall monitor for trends in non-compliance and address concerns with team members when identified. The [NAME] President of Nursing shall report all findings to the IP/QAPI Specialist monthly for 12 months. IP/QAPI Specialist shall report outcomes measures quarterly Quality Improvement Committee for 12 months. The State Survey Agency validated the facility took the following actions: 1. Review of Resident #66's medical record revealed the facility staff brought the resident back into the facility on [DATE]. The resident was assessed to have no injuries. Multiple observations were made of Resident #66 throughout the survey, and the resident was always in line of sight of staff. Resident #66 was observed from 10:00 AM to 3:00 PM on 02/11/2023 and from 10:00 AM to 11:20 AM on 02/12/2023, with no concerns identified. Staff provided ongoing supervision, as per the care plan. 2. Review of Resident #66's Progress Notes revealed RN #22 documented 30-minute checks on 12/14/2022 through 12/15/2022. A phone interview with CNA #14 on 02/08/2023 at 6:22 PM revealed the staff did 30-minute checks on Resident #66 from 12/14/2022 through 12/15/2022. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the resident was placed on 30-minute checks from 12/14/2022 to 12/15/2022. Interview with RN #17 on 02/09/2023 at 5:04 PM revealed she confirmed the safety and whereabouts of all residents on 12/14/2022. She stated all residents were accounted for and were safe. Review of Resident #66's care plan revealed the facility revised the care plan on 12/14/2022 with interventions that included distracting the resident from wandering by offering pleasant diversions (preferred toys), conversation, television, or a book. An interview with the Manager of Resident Care, on 02/12/2023 at 12:49 PM revealed on 02/10/2023, the care plans for 16 residents, who were assessed for elopement/wandering, were updated with interventions. Review of the care plans for Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70, identified by the facility as at risk for elopement/wandering, revealed the facility had revised the care plans with resident-centered interventions to prevent elopement. Observations of Residents #5, #10, #45, #39, #19, #46, #69, #64, #72, #52, #66, #56, #8, #58, #22, and #70 on 02/12/2023 revealed the facility was implementing their care plans. 3. During an interview on 02/09/2023 at 5:14 PM, the VPN confirmed that all other exit doors were secured, the card readers were properly functioning, and alarms were sounding. She stated the Ocean Avenue patio door through which the resident eloped was unlocked and the alarm was not functional at the time of the incident on 12/14/2022 so she ensured a staff member continuously monitored the Ocean Avenue patio door until a vendor arrived on-site on 12/15/2022. On 12/15/2022, the vendor repaired the door, securing it and ensuring the door was working properly. An interview with the Maintenance Director on 02/09/2023 at 10:09 AM revealed the door company came to the facility on [DATE] to assess the exit door and then returned at 8:00 AM on 12/15/2022 to repair the door. 4. Review of Neighborhood Emergency Door Rounding Logs revealed the RN Clinical Supervisors monitored all exit doors every two hours beginning 12/14/2022. Interviews with RN #17 on 02/09/2023 at 5:04 PM and Nursing Supervisor #45 on 02/12/2023 at 12:40 PM revealed they were monitoring all exit doors every two hours to ensure the doors were locked, could not be opened without using a proximity card, alarms sounded when fire egress bars were compressed, doors opened after fire egress bars were compressed for 15-30 seconds, closed completely, and were locked following the checks. Nursing Supervisor #45 indicated she was still checking the doors every two hours and if she found any concerns, she would notify maintenance or administration. 5. Review of Maintenance Door Checks revealed routine door checks were completed twice daily by the maintenance staff or information management staff beginning on 02/10/2023 between 7:00 AM and 4:00 PM and again between 4:00 PM and 10:00 PM. An interview with Maintenance on 02/12/2023 at 12:10 PM revealed since 02/10/2023, the maintenance department had monitored the doors twice daily. 6. A review of purchase invoices revealed the facility purchased delayed egress crash bar hardware and alarm mats. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the door mats and replacement egress crash bar hardware had been ordered for all exit doors. 7. A review of Neighborhood Supervision Compliance Auditing Tools revealed observation rounds were completed twice daily beginning 12/20/2022 by members of the leadership team. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed leadership continued to do unannounced observations twice daily since 12/20/2022. 8. A review of training documentation dated 12/16/2022 revealed staff received Supervision and Safety Training. During a phone interview with CNA #14 on 02/08/2023 at 6:22 PM, she stated after the incident, she completed an online training about resident safety and staff responsibilities. During a phone interview with CNA #50 on 02/08/2023 at 6:59 PM, she stated she received retraining about resident supervision responsibilities after the incident on 12/14/2022. A phone interview with LPN #16 on 02/08/2023 at 7:23 PM revealed she had an online training after the incident on 12/14/2022. 9. Review of staffing schedules revealed staff were assigned to provide dedicated supervision on all Neighborhoods from 8:00 AM-10:00 PM daily, starting 02/10/2023. An interview with the Administrator on 02/12/2023 at 9:50 AM revealed staff knew that supervisors, along with staff, were to continuously monitor the residents at all times. She indicated staff were aware they were responsible to not leave the residents until someone else was monitoring or supervising them. 10. Review of training documentation dated 02/10/2023 through 02/12/2023 revealed staff were trained on the expectations for resident supervision. A phone interview with Nursing Supervisor #39 on 02/12/2023 at 11:45 AM revealed staff were responsible for the residents and, if there were no CSMs, the staff were responsible for the safety of the residents. She stated staff were responsible for monitoring the doors/residents at all times. A phone interview with CNA #40 on 02/12/2023 at 11:50 AM revealed she received training related to supervision responsibilities and monitoring the doors and residents at all times. A phone interview with RN #41 on 02/12/2023 at 11:55 AM revealed she received training on supervision and monitoring the doors and residents at all times. A phone interview with CNA #42 on 02/12/2023 at 12:10 PM revealed all staff were responsible to keep the residents safe at all times and if there was no CSM then they need to supervise/monitor the residents at all times. During a phone interview with CNA #43 on 02/12/2023 at 12:17 PM, she stated she received training that residents should always be in staff' line of sight while in the common area, and they were to always monitor/supervise all of the residents to make sure the residents were safe. During an interview with CNA #44 on 02/12/2023 at 12:25 PM, she stated the trainings were about how the staff were to protect the residents at all times, and if no CSM was present, the staff would rotate to make sure the residents were kept safe. She stated it was everyone's responsibility to keep the residents safe. During an interview with Nursing Supervisor #45 on 02/12/2023 at 12:40 PM, she stated the trainings were about supervision of the residents to include always having someone monitoring the residents. She indicated it was the staff's responsibility to monitor and supervise the residents. 11. A review of training documentation dated 02/10/2023 through 02/12/2023 revealed contract staff had been retrained to ensure each staff member had the required training prior to providing care and services to the facility's residents. Review of an e-mail, dated 02/11/2023, revealed notification to the contract company that the CSM on duty on 12/14/2022 was no longer allowed to work at the facility. An interview with the Administrator on 02/10/2023 at 8:49 AM revealed the issue with the CSM was addressed with the agency company. 12. Interview with IP/QAPI staff on 02/12/2023 at 9:40 AM, revealed they trained the agency staff that had returned to the facility and the additional staff had been notified they were not to return to work until this training was completed. An interview with Agency CSM #48 on 02/12/2023 at 1:14 PM revealed she received training on her roles and responsibilities as a CSM. She stated if a resident was in a common area, they were to monitor the resident and listen for any alarms. She stated she would keep the residents safe at all times.

Based on interviews, document review, and facility policy review, it was determined the facility failed to ensure its abuse prohibition policy was implemented, by failing to verify and maintain documentation of screening and training, including criminal record checks, for contract agency employees. This had the potential to affect all residents. The findings include: Review of the facility's policy titled, Protecting Residents from Abuse and Neglect, revised October 2022, revealed; Screening 1. (The facility) shall make reasonable inquiries pre-employment/before entering contractual arrangements, and follow-up checks thereafter, and require applicant/team member self-disclosure to ensure that we shall not knowingly employ or enter a contractual relationship with any person or entity who: a. Has been convicted of a felony or any criminal offense including offenses involving neglect, violence, theft, dishonesty, and financial misconduct b. Is listed on any abuse registries c. Is listed as debarred, excluded, or otherwise ineligible for participation in federally funded healthcare programs. During an interview on 02/09/2023 at 12:40 PM, the Infection Preventionist/Quality Assurance Performance Improvement (IP/QAPI) Specialist stated the facility utilized sitters from a staffing agency. During an interview, on 02/09/2023 at 1:05 PM, the Administrator stated the contract company that provided the sitters was responsible for the screening and training of contract/agency employees. She stated the facility did not maintain any evidence on site that the required abuse screening and training was completed for agency staff. During an interview on 02/09/2023 at 5:14 PM, the [NAME] President of Nursing (VPN) stated the agency company was responsible for maintaining the agency staff files and the facility did not have a hard copy of those files. She indicated the facility did not do any spot checks on the agency employees' files.

Based on interviews, document review, and facility policy review, it was determined the facility failed to: Consistently monitor and document temperatures and sanitizer levels for the dishwasher to ensure dishes were thoroughly cleaned and sanitized. The facility failed to consistently monitor and document the refrigerator/freezer temperatures to ensure perishable food items were stored at safe temperatures. The facility also failed to consistently monitor and document the temperature of food on the steam table to ensure food was served at safe temperatures and prevent potential food borne illness for residents who received meals from the kitchen. The findings include: 1. Review of the facility's policy titled, Dish Machine Temperature Log, copyright 2019, revealed Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Further review revealed, 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. a. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. During tour of the facility's kitchen, on 02/07/2023 at 9:45 AM, review of the temperature/sanitizer log for the dish machine (Machine Warewashing Low Temperature Monitoring Form) for December 2022 through January 2023 revealed inconsistent documentation of dishwasher temperatures and/or sanitizer levels on the following dates: 12/07/2022 lunch and dinner: no documentation of a sanitizer check; 12/12/2022 lunch: no documentation of the wash and rinse temperatures and the sanitizer check; 12/13/2022 dinner: no documentation of the wash and rinse temperatures and the sanitizer check; 12/16/2022 lunch: no documentation of the wash and rinse temperatures; 12/20/2022 breakfast: no documentation of the wash and rinse; 12/29/2022 dinner: no documentation of the wash and rinse temperatures and the sanitizer check; 01/16/2023 breakfast, lunch, and dinner: no documentation of the wash and rinse temperatures and the sanitizer check; 01/22/2023 breakfast: no documentation of the wash and rinse temperatures and the sanitizer check; 01/25/2023 lunch: no documentation of the wash and rinse temperatures and the sanitizer check; 01/25/2023 dinner: no documentation of the wash and rinse temperatures and the sanitizer check; 01/26/2023 dinner: no documentation of a sanitizer check; and on 01/31/2023 dinner: no documentation of the wash and rinse temperatures and no documentation of a sanitizer check. During an interview with Cook #24 on 02/09/2023 at 12:22 PM, she stated she had received training on documenting the temperatures for the dishwasher. Interview, on 02/09/2023 at 12:26 PM with the Dietary Manager, revealed staff were trained on keeping the logs up to date and accurate. She stated she did not do spot checks on the temperature logs. During an interview with Administrator, on 02/10/2023 at 8:49 AM, she stated she expected dietary staff to follow the regulations and the facility's policy and keep the temperatures logs up to date. 2. Review of the facility's policy titled, Food Temperatures, copyright 2019, revealed The temperatures of all food items will be taken and properly recorded prior to service of each meal. During tour of the kitchen on 02/07/2023 at 9:45 AM, review of the steamtable, Temperature Logs for December 2022 through February 2023 revealed steamtable temperatures were not recorded for the following meals: 12/05/2022, breakfast; 12/18/2022, dinner; 01/22/2023,breakfast, lunch, and dinner; 01/24/2023, breakfast, lunch, and dinner; 01/29/2022, breakfast, lunch, and dinner; and on 02/02/2023: dinner. During an interview on 02/09/2023 at 11:45 AM, Cook #21 stated the food temperatures were to be checked before food was placed on the steam tables. The Cook stated this would ensure the food was the right temperature to be served to the residents. She stated they had to document the temperatures and if there were any issues, they were to report them to the supervisor. Cook #1 stated she did not know why the logs were not completed, but when she worked, she filled them out. During an interview with Cook #24, on 02/09/2023 at 12:22 PM, she stated she had received training on documenting the temperatures for the steamtable. She stated food temperatures were to be checked when the food was placed on the steamtable. During an interview with the Dietary Manager on 02/09/2023 at 12:26 PM, she stated staff were trained on their duty of keeping the temperature logs up to date and accurate. She stated steamtable temperatures should be taken when the food was placed on the steamtable. The Dietary Manager stated she did not do spot checks on the logs but she expected staff to keep the log sheets up to date and accurate. During an interview with Administrator on 02/10/2023 at 8:49 AM, she stated she expected dietary staff to follow the regulations and the facility's policy. She stated she expected staff to keep the temperatures logs up to date. 3. During tour of the kitchen, on 02/07/2023 at 9:45 AM, review of the Refrigerator/Freezer Temperature Chart for December 2022 through February 2023 revealed the temperatures were to be checked and recorded three (3) times a day, at 6:00 AM, 10:00 AM, and 5:30 PM. Further review revealed there were no temperatures documented for the following dates and times: 12/01/2022 at 6:00 AM; 12/02/2022 at 6:00 AM; 12/04/2022 at 5:30 PM; 12/09/2022 at 6:00 AM, 10:00 AM, and 5:30 PM; 12/13/2022 at 5:30 PM; 12/21/2022 at 10:00 AM and 5:30 PM; 12/25/2022 at 10:00 AM and 5:30 PM; 12/30/2022 at 6:00 AM, 10:00 AM and 5:30 PM; 01/26/2023 at 10:00 AM and 5:30 PM ; and on 02/01/2023 at 5:30 PM. During an interview on 02/09/2023 at 11:45 AM, Cook #21 stated the refrigerator and freezer logs were to be completed three (3) times a day. She stated she did not know if anyone checked to see if the logs were completed. During an interview with Cook #24 on 02/09/2023 at 12:22 PM, she stated she had received training on documenting temperatures for the freezers and refrigerators. She stated temperatures for the refrigerator and freezer were to be checked three (3) times a day. During an interview with the Dietary Manager on 02/09/2023 at 12:26 PM, she stated staff were trained on their duty of keeping the temperature logs up to date and accurate. She stated refrigerator and freezer temperatures were to be checked three (3) times a day. The Dietary Manager stated she did not do spot checks on the logs, but she expected staff to keep the log sheets up to date and accurate. During an interview with the Administrator, on 02/10/2023 at 8:49 AM, she stated she expected dietary staff to follow the regulations and the facility's policy and keep the temperatures logs up to date.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with dignity and respect, and failed to care for each resident in a manner and environment that promoted maintenance or enhancement of the resident's quality of life for one (1) of sixteen (16) sampled residents (Resident #102). Resident #102 did not feel well and requested to lie down. The Enrichment Specialist (ES) requested Resident #102 attend an activity which the resident and Clinic Nurse #1 stated he/she did not want to attend. The ES attempted multiple times to get Resident #102 to go to the activity with the resident continuing to refuse. After multiple attempts, the ES informed Resident #102 she was going to report him/her for not attending activities. The findings include: Review of the facility's policy titled, Ethical Boundaries, revised June 2022, and reviewed April 2023, revealed ethical boundaries foster appropriate professional relationships which ensure respect for the rights and dignity of others. Continued review revealed ethical boundaries also set limits for safe, acceptable, equitable, and effective behavior by team members in providing care and treatment for recipients. Review of Resident #102's medical record revealed the facility admitted the resident on 12/16/2021, with diagnoses which included Duchenne or [NAME] Muscular Dystrophy (condition that weakens skeletal and heart muscle that quickly gets worse with time), Anxiety Disorder, and Developmental Disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #102, dated 03/18/2023, revealed the facility assessed the resident as having a score of fifteen (15) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the facility's Investigation Report, dated 04/04/2023, revealed a witness statement provided by the Clinic Nurse, on 04/05/2023 at 9:40 AM, which noted the ES was adamant about Resident #102 attending an activity after multiple attempts to explain to the ES he/she did not want to go. Continued review of the witness statement revealed the ES stated, Fuck it. Further review of the witness statement revealed the ES stated she would notify the DON to report Resident #102 for not participating in the activity. Review of the facility's Investigation Report revealed a phone interview conducted by the Infection Preventionist (IP)/Quality Assurance Performance Improvement (QAPI) Specialist and the Administrator, dated 04/04/2023. Per review, the ES reported she was frustrated about the situation due to Resident #102 not wanting to attend the activity. Continued review of the phone interview documentation revealed the ES reported she told Resident #102 she was tired of him/her not doing your activities. Review of the report revealed the ES then told Resident #102, I am going to fucking report you to the DON. Further review revealed the ES stated if Resident #102 did not do his/her activities, I can't do my job. During interview on 05/15/2023 at 4:47 PM, with Resident #102, he/she stated he/she recalled the incident with the ES. Resident #102 stated the ES was upset that he/she did not want to attend an activity. Continued interview revealed the resident had not been feeling well and wanted to lie down. According to Resident #102, the ES used the F-word. However, the resident could not remember the ES's exact statement. Further interview revealed Resident #102 was upset because he/she and the ES had a friend-like relationship before the incident, and he/she did not understand why the ES said that towards him/her. The State Survey Agency (SSA) Surveyor attempted to contact the ES twice by telephone. However, the attempts were unsuccessful. An attempt on 05/15/2023 at 5:38 PM, revealed an automated message stating, the line was no longer in service. Interview, on 05/16/2023 at 8:44 AM, with Clinic Nurse #1 revealed she witnessed the incident between Resident #102 and the ES. Per interview, she and Resident #102 were returning to his/her room when the ES approached them and the resident was told he/she needed to attend an activity. During continued interview Clinic Nurse #1 stated she informed the ES, that Resident #102 did not feel well and needed to lie down after just returning from the hospital following surgery. Per interview, the ES was adamant about Resident #102 attending the activity after the resident repeatedly told the ES he/she did not want to go. Clinic Nurse #1 stated she heard the ES make the statement, fuck it after the multiple attempts to get the resident to attend the activity. Interview on 05/16/2023 at 8:57 AM, with the IP/QAPI Specialist revealed she received a message from the Director of Nursing (DON) regarding the incident who requested the IP/QAPI assist with the follow-up of the incident. Continued interview revealed she and the Administrator completed a phone interview with the ES on the alleged incident date, 04/04/2023. Per the IP/QAPI Specialist the ES stated Resident #102 was supposed to do the yard sale activity and he/she needed to attend it. Further interview revealed the ES told them she was tired of Resident #102 not doing his/her activities and was going to report him/her to the DON. In addition, the ES reported she was frustrated with the situation due to the amount of work put into the activity that was specific towards Resident #102's wants and/or needs. Interview, on 05/16/2023 at 9:10 AM, with the Social Services Director (SSD), revealed she followed up with Resident #102 regarding the incident with the ES. Per the SSD, Resident #102 reported he/she was upset and felt as if he/she lost the ES as a friend. She stated Resident #102 had not wanted to upset the ES; however, the resident thought the ES was upset by him/her not attending the activity. Further interview revealed the SSD stated the ES received training regarding resident rights and abuse in March of 2023. Interview on 05/16/2023 at 9:34 AM, with the Administrator revealed education and training were provided on resident rights and abuse and completed by the ES on 03/27/2023 prior to the incident on 04/04/2023. Per the Administrator, the incident was reported, and the ES was placed on administrative leave pending the results of the investigation. The Administrator stated after the investigation and discussion with Human Resources (HR), review of the findings revealed actions of the ES did not align with the facility's core values and was a violation of the code of conduct which ultimately led to the termination of the ES. During interview on 05/17/2023 at 3:48 PM, with the Director of Nursing (DON), she stated at first when she received the information regarding the incident from Resident #102 it was concerning verbal abuse. However, after further investigation Resident #102 had been upset due to his/her close relationship with the ES and not understanding why the ES made the statement with the foul language and acts of frustration. The DON stated she was aware the ES put together the activity for Resident #102 and after multiple attempts to try to get him/her to go, she was frustrated that the resident did not want to attend. She stated there were good intentions on the part of the ES; however, the ES could not make the resident do activities if he/she chose not to.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with dignity and respect, and failed to care for each resident in a manner and environment that promoted maintenance or enhancement of the resident's quality of life for one (1) of sixteen (16) sampled residents (Resident #102). Resident #102 did not feel well and requested to lie down. The Enrichment Specialist (ES) requested Resident #102 attend an activity which the resident and Clinic Nurse #1 stated he/she did not want to attend. The ES attempted multiple times to get Resident #102 to go to the activity with the resident continuing to refuse. After multiple attempts, the ES informed Resident #102 she was going to report him/her for not attending activities. The findings include: Review of the facility's policy titled, Ethical Boundaries, revised June 2022, and reviewed April 2023, revealed ethical boundaries foster appropriate professional relationships which ensure respect for the rights and dignity of others. Continued review revealed ethical boundaries also set limits for safe, acceptable, equitable, and effective behavior by team members in providing care and treatment for recipients. Review of Resident #102's medical record revealed the facility admitted the resident on 12/16/2021, with diagnoses which included Duchenne or [NAME] Muscular Dystrophy (condition that weakens skeletal and heart muscle that quickly gets worse with time), Anxiety Disorder, and Developmental Disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #102, dated 03/18/2023, revealed the facility assessed the resident as having a score of fifteen (15) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the facility's Investigation Report, dated 04/04/2023, revealed a witness statement provided by the Clinic Nurse, on 04/05/2023 at 9:40 AM, which noted the ES was adamant about Resident #102 attending an activity after multiple attempts to explain to the ES he/she did not want to go. Continued review of the witness statement revealed the ES stated, Fuck it. Further review of the witness statement revealed the ES stated she would notify the DON to report Resident #102 for not participating in the activity. Review of the facility's Investigation Report revealed a phone interview conducted by the Infection Preventionist (IP)/Quality Assurance Performance Improvement (QAPI) Specialist and the Administrator, dated 04/04/2023. Per review, the ES reported she was frustrated about the situation due to Resident #102 not wanting to attend the activity. Continued review of the phone interview documentation revealed the ES reported she told Resident #102 she was tired of him/her not doing your activities. Review of the report revealed the ES then told Resident #102, I am going to fucking report you to the DON. Further review revealed the ES stated if Resident #102 did not do his/her activities, I can't do my job. During interview on 05/15/2023 at 4:47 PM, with Resident #102, he/she stated he/she recalled the incident with the ES. Resident #102 stated the ES was upset that he/she did not want to attend an activity. Continued interview revealed the resident had not been feeling well and wanted to lie down. According to Resident #102, the ES used the F-word. However, the resident could not remember the ES's exact statement. Further interview revealed Resident #102 was upset because he/she and the ES had a friend-like relationship before the incident, and he/she did not understand why the ES said that towards him/her. The State Survey Agency (SSA) Surveyor attempted to contact the ES twice by telephone. However, the attempts were unsuccessful. An attempt on 05/15/2023 at 5:38 PM, revealed an automated message stating, the line was no longer in service. Interview, on 05/16/2023 at 8:44 AM, with Clinic Nurse #1 revealed she witnessed the incident between Resident #102 and the ES. Per interview, she and Resident #102 were returning to his/her room when the ES approached them and the resident was told he/she needed to attend an activity. During continued interview Clinic Nurse #1 stated she informed the ES, that Resident #102 did not feel well and needed to lie down after just returning from the hospital following surgery. Per interview, the ES was adamant about Resident #102 attending the activity after the resident repeatedly told the ES he/she did not want to go. Clinic Nurse #1 stated she heard the ES make the statement, fuck it after the multiple attempts to get the resident to attend the activity. Interview on 05/16/2023 at 8:57 AM, with the IP/QAPI Specialist revealed she received a message from the Director of Nursing (DON) regarding the incident who requested the IP/QAPI assist with the follow-up of the incident. Continued interview revealed she and the Administrator completed a phone interview with the ES on the alleged incident date, 04/04/2023. Per the IP/QAPI Specialist the ES stated Resident #102 was supposed to do the yard sale activity and he/she needed to attend it. Further interview revealed the ES told them she was tired of Resident #102 not doing his/her activities and was going to report him/her to the DON. In addition, the ES reported she was frustrated with the situation due to the amount of work put into the activity that was specific towards Resident #102's wants and/or needs. Interview, on 05/16/2023 at 9:10 AM, with the Social Services Director (SSD), revealed she followed up with Resident #102 regarding the incident with the ES. Per the SSD, Resident #102 reported he/she was upset and felt as if he/she lost the ES as a friend. She stated Resident #102 had not wanted to upset the ES; however, the resident thought the ES was upset by him/her not attending the activity. Further interview revealed the SSD stated the ES received training regarding resident rights and abuse in March of 2023. Interview on 05/16/2023 at 9:34 AM, with the Administrator revealed education and training were provided on resident rights and abuse and completed by the ES on 03/27/2023 prior to the incident on 04/04/2023. Per the Administrator, the incident was reported, and the ES was placed on administrative leave pending the results of the investigation. The Administrator stated after the investigation and discussion with Human Resources (HR), review of the findings revealed actions of the ES did not align with the facility's core values and was a violation of the code of conduct which ultimately led to the termination of the ES. During interview on 05/17/2023 at 3:48 PM, with the Director of Nursing (DON), she stated at first when she received the information regarding the incident from Resident #102 it was concerning verbal abuse. However, after further investigation Resident #102 had been upset due to his/her close relationship with the ES and not understanding why the ES made the statement with the foul language and acts of frustration. The DON stated she was aware the ES put together the activity for Resident #102 and after multiple attempts to try to get him/her to go, she was frustrated that the resident did not want to attend. She stated there were good intentions on the part of the ES; however, the ES could not make the resident do activities if he/she chose not to.

Based on interviews, record reviews and review of the facility's policy, it was determined the facility failed to ensure two (2) residents (Resident #2 and Resident #3) of five (5) residents sampled for chemical restraints were free from chemical restraints. The clinical staff administered Resident #2 and Resident #3 Benadryl (an antihistamine that causes drowsiness) for sleep. However, the medication was not ordered for a sleep related condition. The facility's deficient practice had potential to affect Resident #2's and Resident #3's safety and/or adverse medication reactions. The findings include: Review of the facility's policy titled, Protective Devices and Restraints revised 07/2015, revealed, The resident has the right to be free from any physical or chemical restraints . Chemical Restraints is defined as any drug that is used for discipline or convenience and not required to treat medical symptoms. Medications shall not be used as restraints. Review of the facility-provided document titled, Long Term Care Facility-Self Reported Incident Form, dated 04/15/2022, revealed on 04/15/2022, a report was made that a resident had received medications for reasons other than indicated in the Physician's Orders. It was reported that [Registered Nurse (RN) 2] had reported administering Benadryl to [Resident #3] to 'help (him/her) sleep'. Physician's orders written for itching, not insomnia. Investigation is underway and a follow up report will be submitted. Review of the facility-provided document, dated 04/20/2022, titled Long Term Care Facility-Self Reported Incident Form 5 Day Follow-Up revealed, No allegation of abuse or neglect was made initially, however a report was made based on the concern of administration of a PRN [as needed] for a reason other than prescribed by physician. During the investigation it was confirmed that [RN #2] administered Benadryl to [Residents #2 and #3's] for sleep when sleep was not an indication prescribed by the physician. Review of the facility-provided undated document titled, Interviews revealed during a phone interview with RN #2, the RN stated, I had been giving (him/her) Benadryl to help (him/her) stay asleep .I knew I wasn't documenting it. When asked if there were any other residents that you administered Benadryl to for sleep that was not documented, RN #2 stated, Maybe. 1. Review of Resident #3's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted Resident #3 on 05/10/2020 and readmitted him/her on 10/06/2020 with diagnoses which included spastic quadriplegic cerebral palsy, epilepsy, severe intellectual disabilities, and insomnia due to medical condition. Review of Resident #3's Physician's Orders revealed .DIPHENHYDRAMINE [Benadryl] 12.5 MG/MG Give 50 mg via G-Tube every 8 hours as needed for itching. Only to be given at 0500 [5:00 AM],1300 [1:00 PM], or 2200 [10:00 PM] . with a start date of 04/15/21. Review of Resident #3's Medication Administration Record (MAR) for the month of April revealed .DIPHENHYDRAMINE [Benadryl] 12.5 MG/MG Give 50 mg via G-Tube every 8 hours as needed for itching. Only to be given at 0500,1300, or 2200 .with a start date of 04/15/2021. The MAR did not have any staff initials to indicate the medication was administered. During an interview, on 09/13/2022 at 3:47 PM, Licensed Practical Nurse (LPN) #3 confirmed she identified suspicion of chemical restraint administration by Registered Nurse (RN) #2 to Resident #3 after noticing Resident #3's Benadryl was re-ordered frequently and did not have documentation on his/her MAR for administration. LPN #3 stated Registered Nurse #2 had reported to her during change of shift report that she administered Benadryl to Resident #3 for sleep and that she did not document the administration on Resident #3's MAR. Continued interview revealed she reported her suspicions to the Director of Nursing (DON); printed Resident #3's MAR; and printed his/her refill orders from pharmacy for Benadryl, and provided the information to the DON. During an interview, on 09/14/2022 at 1:52 PM, the facility's Medical Director confirmed facility staff administered Benadryl to Resident #3 and this was administered as a chemical restraint. The Medical Director stated it was her expectation for the nursing staff to administer residents' medications for the indication on the resident's Physician's Order. The Medical Director stated she had concerns with abuse of Benadryl and discontinued Resident #3's orders for the medication. 2. Review of Resident #2's Admission Record, located in the resident's EMR under the Profile tab revealed the facility readmitted Resident #2 on 10/16/2014. The resident's diagnoses included cerebral palsy, epilepsy, severe intellectual disabilities, and dependent on supplemental oxygen. Review of Resident #2's Physician's Orders under the Orders tab of the resident's EMR revealed DIPHENHYDRAMINE [Benadryl] 12.5 MG/MG Give 50 mg via G-Tube every 8 hours as needed for itching. Only to be given at 0500,1300, or 2200 .with a start date of 09/01/21. Review of Resident #2's MAR for the month of April revealed .DIPHENHYDRAMINE [Benadryl] 12.5 MG/MG give 50 mg via G-Tube every 8 hours as needed for itching. Only to be given at 0500,1300, or 2200 .with a start date of 04/15/2021. The MAR did not have any staff initials to indicate the medication was administered. During a phone interview, on 09/13/2022 at 12:53 PM, Licensed Practical Nurse (LPN) #10 confirmed the facility expected the nurses to follow the Physician's Orders for medication administration including the ordered indication. LPN #10 stated the facility expected nurses to document administration of medications on the resident's Medication Administration Record (MAR). During an interview, on 09/13/2022 at 4:27 PM, LPN #9 stated any type of medication used to sedate the residents was considered a chemical restraint. LPN #9 stated it was not ok for the staff to administer medications to chemically restrain residents. Interview, on 09/14/2022 at 2:23 PM, with the DON revealed RN #2 had administered the Benadryl medication as a chemical restraint for two (2) residents (Residents #2 and #3). The DON also stated RN #2 did not document the administration of Benadryl on Resident #2's and Resident #3's MAR. Interview, on 09/14/2022 at 3:38 PM with the [NAME] President of Nursing (VP), revealed the facility substantiated the investigation of Registered Nurse #2 administering medication to Resident #2 and Resident #3 to sedate the residents. The VP confirmed it was a form of chemical restraint. During interview, on 09/14/2022 at 4:53 PM, the Quality Assurance Performance Improvement Specialist QAPIS) stated RN #2 administered Benadryl to Resident #2 and Resident #3 for sleep and misused the medications. The QAPIS stated during the phone interview for the facility's investigation with RN #2, she admitted administering the medication to Resident #2 and Resident #3 for sleep. The QAPIS also stated RN #2 admitted she did not document the Benadryl administration. Further interview revealed the facility substantiated the allegation regarding RN #2 administering a medication for use of a chemical restraint to both Resident #2 and Resident #3.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure residents remained free of accidents and hazards as possible for one of eleven (11) sampled residents (Resident # 1). Specifically, during activities of daily living (ADL) care the facility staff failed to ensure the resident's side rails/mesh siding were in place prior to walking away from the resident's bedside. This deficient practice placed the resident at risk for a fall. The findings include: Review of the facility's policy titled, Resident Care and Treatment, revised 03/2022, revealed that enclosed bed systems may be utilized to provide safety. Enclosed bed systems may include full bottom side rails, full top side rails, and enclosed mesh siding. Zippers on all sides must be zipped up to the top left or right-hand corner on each side of the bed when the resident is not attended. Bed rails must be firmly locked in place when the resident is not attended. Team members shall provide continual visual and physical contact [hands-on physical assistance] with residents whenever side rails are lowered and/or mesh is unzipped to prevent falls and/or injury to residents and team members. Improper use of a bed or enclosed bed system shall result in progressive disciplinary action up to and including separation of employment. Review of Resident #1's Admission Record located in the resident's electronic medical record (EMR) revealed the facility readmitted the resident on 02/02/2017. His/her diagnoses included spastic quadriplegic cerebral palsy, fetal alcohol syndrome, newborn affected by maternal use of other drugs of addiction, full incontinence of feces and urine, and severe intellectual disabilities. The facility discharged Resident #1 on 08/04/2022. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2022, revealed a Brief Interview for Mental Status (BIMS) assessment was not able to be completed. However, the facility assessed Resident #1 to be moderately cognitively impaired and totally dependent for personal hygiene and toileting. Review of Resident #1's Care Plan revealed .Risk of injury . initiated date of 02/20/17 .BOUNCING BUNNY ALERT-Enclosed bed (mesh sides with padded side rails) to allow maximum freedom of movement and access to self. Must maintain Visual and physical contact [HANDS ON] resident at all times . with a target date of 09/24/2022. Review of the facility-provided document which was part of the facility's investigation, titled Summary of Findings revealed on 07/05/2022, it was reported to leadership that two (2) employees had engaged in a verbal altercation. The verbal altercation occurred between Certified Nursing Assistant (CNA) #5 and CNA #13, just inside the doorway of Resident #1's room. Licensed Practical Nurse (LPN) #10 reported witnessing the argument. The LPN stated she approached both team members to intervene and upon doing so observed Resident #1 laying in his/her bed, without a brief or pants on. The resident was on his/her right side facing away from the door without safety devices in place. The LPN stated the side rail was down and the mesh siding [of the enclosed bed] was unzipped and over the top of the bed. Further review revealed LPN #10 stated the privacy curtain was not pulled closed and Resident #1 was visible from the doorway. LPN #10 immediately stated to both CNAs that the resident could not be left in that position because he/she could fall from the bed. Continued interview revealed LPN #10 went to the bed immediately and put the side rail in place. Further review of the Summary of Findings revealed that when CNA #13 was to assume care for Resident #1, CNA #5 was initially assigned to provide care to the resident. CNA #5 was changing Resident #5's brief. When CNA #13 entered the room she turned over the resident's care to CNA #5, prior to finishing care. CNA #13 stated CNA #5 moved away from the resident's bedside prior to applying his/her brief and clothing. Upon interview, CNA #13 confirmed that she had left the bed mesh unzipped and the siderail down. Review of the video footage supports statements obtained and shows both CNAs appearing to engage in a heated conversation at the entrance of the resident's room. Further review revealed that Resident #1 was consider a Bouncing Bunny meaning he/she required hands on eyes on care anytime his/her safety devices were not secured due to his mobility and risk for injury .Based on investigation findings, we have determined that CNA #13 failed to follow Procedure. Review of the facility provided document titled, Interview With, dated 07/05/2022 revealed when CNA #5 was asked, When you left the room did you put the rails up or zip the enclosure?, the CNA answered,No, I did not put the rail up or zip it. Review of the facility-provided document titled, Interview With, dated 07/06/2022, and part of the facility's investigation, revealed an interview with CNA #13. Further review revealed when asked, .when you walked away from the bed .was the rails up and the mesh zipped?. CNA #13 stated, No. This was signed by QAPIS. Review of the facility-provided document titled, Interview With, dated 07/05/2022 and part of the facility's investigation, revealed an interview with LPN #10. The LPN stated, .the railing was down, and the mesh was unzipped. If (he/she) had rolled over, (he/she) would have fallen from the bed, (he/she) is very active so I was worried (he/she) would fall. This was signed by QAPIS. During an interview, on 09/12/2022 at 12:43 PM, CNA#12 confirmed the facility expected staff to raise residents' bed rails and close/zip the enclosure when the resident was on their bed to ensure resident's safety. During an interview, on 09/12/2022 at 5:16 PM, CNA #8 stated the facility expected staff to secure residents' bed by raising the bed rails and closing the mesh to ensure the resident's safety when the resident was in their bed. During an interview, on 09/13/2022 at 12:53 PM, LPN #10 confirmed Resident #1's bed rail and mesh siding were not secured and Resident #1 was unattended on 07/05/2022, when ADL care was being provided. During an interview, on 09/13/2022 at 3:37 PM, LPN #3 confirmed the facility expected staff to always keep hands on residents when the resident's bed was not secured (bed rails down and/or the enclosure was not closed). LPN #3 stated the residents' name plates near their beds included a picture of a bunny bouncing to indicate and alert staff the resident was very active and had an increased safety risk of falling. LPN #3 stated while Resident #1 was a resident at the facility, his/her name plate included a bouncing bunny which indicated he/she was very active and was at risk for falling. During an interview, on 09/14/2022 at 9:24 AM, LPN #4 confirmed the facility expected staff to always keep hands on residents when the residents' beds were not secured (bed rails down and the enclosure was not closed). During an interview, on 09/14/2022 at 10:38 AM, CNA #5 stated Resident #1's bed rail and mesh siding was not secured and Resident #1 was unattended on 07/05/2022. During an interview, on 09/14/2022 at 2:23 PM, the Director of Nursing (DON) confirmed Resident #1's bed rail and mesh siding were not secured and Resident #1 was unattended during ADL care on 07/05/2022. During an interview, on 09/14/2022 at 4:22 PM, the QAPIS confirmed Resident #1's bed rail and mesh siding were not secured and R1 was left unattended on 07/05/2022 during ADL care.

Based on interviews and record reviews, it was determined the facility failed to promote residents' dignity and privacy for one of eleven (11) sampled residents (Resident #1). Specifically, on 07/05/2022 during activities of daily living (ADL) care, staff failed to ensure Resident #1 had full privacy from public view. The facility's failure placed Resident #1 at risk for psychosocial harm. The findings include: Review of Resident #1's, Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility readmitted Resident #1 on 02/02/2017. The resident's diagnoses included spastic quadriplegic cerebral palsy, fetal alcohol syndrome, newborn affected by maternal use of other drugs of addiction, bowel and bladder incontinence, and severe intellectual disabilities. The facility discharged Resident #1 on 08/04/2022. Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2022, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) could not be completed. However, the facility assessed Resident #1 to be moderately cognitively impaired and totally dependent for personal hygiene and toileting. Review of the facility-provided document titled, Summary of Findings, which was part of the facility's investigation, revealed on 07/05/2022 .it was reported to leadership two employees had engaged in a verbal altercation .The verbal altercation occurred between CNA (Certified Nursing Assistant) #5 and CNA #13 just inside the doorway of Resident #1's room. LPN (Licensed Practical Nurse) #10 reported she witnessed the argument and approached both team members to intervene. Upon doing so, she observed Resident #1 laying in his/her bed, without a brief or pants on. Further review revealed the resident was on his/her right side facing away from the door without safety devices in place. LPN #10 stated the side rail was down and the mesh siding [of the enclosed bed] was unzipped and over the top of the bed. The LPN stated the privacy curtain was not pulled closed and Resident #1 was visible from the doorway. LPN #10 stated she immediately stated to both CNAs that Resident #1 could not be left in that position because he/she could fall from the bed. Further review of the investigation revealed CNA #13 confirmed she left the bed mesh unzipped and the siderail down along with leaving Resident #1 without a brief, exposed to view from the hallway while she was arguing with CNA #5. Review of video footage supports statements obtained and showed both CNAs appearing to engage in a heated conversation at the entrance of resident room. Review of the document from the facility's investigation, dated 07/05/2022 and titled, Interview With CNA #5 revealed the statement, When you left the room did [Resident #1] have a brief on? The response was No and signed by QAPIS. Review of the facility-provided document, dated 07/06/2022 and titled Interview with CNA #13 revealed the question, Was (Resident #11) wearing a brief. CNA #13 answered No, (he/she) wasn't. This was signed by QAPIS. Review of the document from the facility's investigation, dated 07/05/2022 and titled, Interview with (LPN #10) revealed Resident #1, was visible from the doorway .Definitely .in bed with (his/her) bottom exposed .(he/she) was not wearing a brief . This was signed by QAPIS. During an interview, on 09/12/2022 at 5:16 PM, CNA #8 stated it was important to provide privacy for residents for the resident's rights and safety. CNA #8 stated the facility expected the staff to keep residents covered and to keep the curtains closed while changing them. Continued interview revealed CNA #8 stated the facility didn't want to expose the undressed residents to the other residents or their roommate. During an interview, on 09/13/2022 at 12:53 PM, LPN #10, who was the nurse assigned to Resident #1, confirmed during ADL care on 07/05/2022, the facility's staff did not provide Resident #1 with privacy from public view. Continued interview revealed staff failed to pull the resident's privacy curtain, close his/her door, provide clothing, or draping to prevent exposure of his/her body parts. LPN #10 stated the facility failed to honor Resident #1's privacy during activities of daily living care. During an interview, on 09/14/2022 at 10:38 AM, CNA #5, who was the CNA assigned to Resident #1 confirmed during ADL care on 07/05/2022, she removed the resident's brief and cleaned his/her buttock. However, she did not put a brief back on the resident. The CNA stated she did not remove him/her from public view to prevent exposure of his/her body parts. CNA #5 stated the facility failed to honor Resident #1's privacy during activities of daily living care. During an interview, on 09/14/2022 at 2:23 PM, the Director of Nursing (DON) confirmed during the delivery of personal care and services on 07/05/2022, the facility's staff did not remove Resident #1 from public view. Staff did not pull his/her privacy curtain, close his/her door, provide clothing, or drape to prevent exposure of his/her body. The DON confirmed the facility failed to honor Resident #1's privacy during activities of daily living care. During an interview, on 09/14/2022 at 4:22 PM, the QAIPS confirmed during ADL care on 07/05/2022, the facility's staff did not remove Resident #1 from public view. The Quality Assurance Performance Improvement Specialist confirmed the facility failed to honor R1's privacy during activities of daily living care.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure care plans were developed and/or implemented for three (4) of six (6) sampled residents, Resident #1, Resident #2, Resident #3, and Resident #4. Certified Nurse Assistant (CNA) #1 failed to follow the care plan for Residet #1, when she independently transferred the resident to his/her bed. Staff inflated the balloon of Resident #2's supra-pubic catheter with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to follow the care plan to monitor and protect Resident #3 from injury; and Licensed Practical Nurse (LPN) #7 did not ensure Resident #4 had required equipment on his/her wheelchair as care planned before the resident was placed in the common area, resulting in resident to resident contact. The findings include: Review of the facility's policy, Assessment and Service Planning, revised February 2020, revealed the facility developed and implemented care plans to meet each resident's preferences and goals as well as assist residents to attain and maintain his/her highest practicable quality of life. Care plans were used in addition to physician orders, the resident Kardex, and the entire medical record to provide a comprehensive plan of care for each resident. Review of the facility's policy, Resident Care and Treatment, procedure titled, Behavior Management, revised May 2020, revealed the facility monitored and supervised residents as an intervention and a means to mitigate risks. Consideration was made for residents with a history of challenging behaviors. The care plan included any identified risks to the resident or to other residents. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 09/08/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan, dated 01/12/2021, revealed the resident required two (2) person-assist for transfers due to weight and the mechanical lift was not to used. Interview with CNA #1, on 02/16/2022 at 3:15 PM, revealed she knew Resident #1 was care planned for a two (2) person transfer but she transferred him/her on her own because she could not find a staff member to help her. She also revealed she knew it was important to follow the care plan because that was what the resident needed to keep him/her safe. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 02/09/2011, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician Orders, dated 08/17/2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were directed not to inflate the catheter's balloon but directed to secure the catheter by other means. Review of Resident #2's Care Plan, dated 10/11/2021, revealed the resident had bladder incontinence related to Neuromuscular Impairment, Renal Insufficiency and Vesicostomy with intermittent and overnight catheterization. Further review of the plan of care revealed no evidence of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #2, on 02/17/2022 at 11:30 AM, revealed the resident was seated behind the nurse's station and accompanied by staff members. The resident was observed to play video games. Resident#2 was dressed, clean and had a smile on his/her face. Interview with LPN #1, on 02/18/2022 at 3:55 PM, revealed he provided care for Resident #2 for several years until the resident moved to a different neighborhood in October of 2021. He revealed Resident #2 had an order to have a catheter placed every evening at 8:00 PM and to be kept in place until 8:00 AM. He also revealed the resident's catheter orders were not to inflate the balloon. LPN #1 revealed he believed this information was on the care plan. Interview with LPN #6, on 02/21/2022 at 9:40 AM, revealed the care plan was used to inform staff what needed to be done for each resident. LPN #6 revealed he did not review Resident #2's care plan and inserted the suprapubic catheter then inflated the balloon to hold the catheter in place. The LPN revealed while he inflated the balloon, Resident #2 asked him why he put medicine in the catheter, and he told the resident he had to do it that way to keep the catheter secured. Continued interview with LPN #6 revealed staff should review the care plan. Interview with Nurse Manager (NM) #2, on 02/17/2022 at 2:10 PM, revealed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #3's clinical record revealed the facility admitted the resident on 06/21/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan revealed the resident had an alteration of musculoskeletal status and increased risk of fracture related to (R/T) Osteopenia, dated 06/19/2021. Review of the care plan revealed Resident #3 at risk of injury related to his/her inability to protect self from injury, he/she had no self-preservation skills. The resident also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included a lap tray on at all times, to include transportation, dated 09/20/2019, and staff were to monitor and document behavioral symptoms that placed the child and others as risk for abuse, neglect and injury, dated, 1/27/2018. Observation of facility video footage, dated 11/01/2021, revealed Resident #3 and Resident #4 to be sitting in their perspective wheelchairs in the common area, unsupervised by staff. The residents appeared to be three (3) feet apart based on the number of tiles on the floor between the two residents. Continued observation of the video footage revealed Resident #4 did not have the required lap tray or foot straps in place. Resident #4 was observed to use his/her right hand to propel one (1) of the wheels on the w/c in a circle. Per observation, the resident propelled his/herself directly next to Resident #3's wheelchair. Continued observation revealed Resident #4 placed his/her right hand on Resident #3's hair. After the incident, a staff member was observed to enter the common area and removed Resident #3. Review of a Physician Episodic Visit Note, dated 11/02/2021 at 2:39 PM, revealed staff notified the physician to assess Resident #3. The note continued to state Resident #3 was noted to have a scratch on his/her left neck as well as marks on his/her left arm. There were noted [CONDITION(S)] on the resident's left arm which had faded overnight, and the left neck area had a superficial abrasion 4. Review of Resident #4's clinical record revealed the facility admitted the resident on 06/21/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review, the resident could have the lap tray off while he/she traveled on the bus. The foot straps were discontinued, on 02/03/2022, per doctor's orders. Review of Resident #4's care plan, dated 07/18/2018, and 11/04/2021, revealed the resident displayed inappropriate behaviors which included head banging, bucking in his/her w/c, pulling his/her own hair, hitting, and kicking staff and other residents. Continued review of the care plan revealed the resident had behaviors which placed self, and others at risk of injury. Per review, the resident was to be monitored closely for changes in his/her mood and/or behavior. The care plan revealed the resident had a Red Safety Circle designation (a three (3) foot perimeter around the resident at all times, to prevent resident to resident contact. Continued review of Resident #4's care plan revealed the resident received 1:1 intervention regularly by team members, and about weekly through specialized services. Interview with Physical Therapist Assistant (PTA) #1, on 02/18/2022 at 1:25 PM, revealed care plans were resident specific and addressed safety and care for each resident. The care plan was important to ensure residents received the best practicable care. She revealed care plans were reviewed weekly by the Care Plan Team. She also revealed staff should know that Resident #4 could self-propel in his/her w/c and should be care planned. Interview with Registered Nurse (RN) #1, on 02/15/2022 at 1:00 PM, revealed she worked with Resident #4 often. She revealed Resident #4 could not move his/her w/c purposefully. She revealed the resident would rock his/her body and move the chair that way. She revealed most residents had a Red Safety Circle and that required residents to be Six feet apart, to prevent residents to resident contact. She revealed this type of information should be care planned. Interview with RN #4, on 02/17/2022 at 2:20 PM, revealed she was not aware of what Resident #4's care plan stated about the resident's w/c and the need for the lap tray. RN #4 was unable to state the purpose of the care plan. Interview with the Staff Development Coordinator (SDC), on 02/21/2022 at 2:00 PM, revealed she organized all staff training and was accountable to ensure all staff were trained in accordance with federal and state requirements. The SDC revealed the care plan was important because it drives the care for the residents. She went onto state the facility expectation was that all staff would review the care plan before they provided care for a resident. She reviewed the policy and stated the policy did reveal the baseline care plan shall be reviewed before providing care. She revealed shall means it was an expectation of the staff. Interview with the Manager of Resident Care (MRC), on 02/18/2022 at 3:45 PM, revealed it was expected for all care staff to review at the minimum the Kardex, every shift. She revealed it would be beneficial for them to check it multiple times per shift because it was updated in real time. Additionally, the MRC revealed there should never be a time when nurses do not know the required care for their residents. She revealed the care plans were very specific to each resident and were used to keep the residents safe and to ensure the residents received the best care possible. The MRC also stated that if staff did not follow the Care Plan, they would not provide the proper level of care. Interview with the Senior Vice President/Administrator (SVPA), on 02/21/2022 at 4:00 PM, revealed it was each staff members responsibility to know how to find the procedures and ensure they were followed. Continued interview with the SVPA revealed the care plan was how staff knew the specialized care for each resident. She also revealed the care plan needed to be followed to prevent potential negative outcomes, and the minimum expectation was that staff were to review the care plan before each shift.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care provided met professional standards of quality for two (2) of six (6) sampled residents, Resident #2, and Resident #4. Licensed Practical Nurse (LPN) #5 failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the policy, Assessment and Service Planning, revised 01/2020, revealed the baseline care plan provided effective and person-centered care of the resident that met professional standard of quality of care. The baseline care plan addressed resident specific health and safety concerns to prevent decline or injury and it would include physician orders. 1. Review of Resident #2's clinical record revealed the facility admitted the resident on 02/09/2011, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician Orders, dated 08/17/2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the staff were also directed by the order not to inflate the balloon on the supra pubic catheter with directions to use other means to secure the catheter. Interview with LPN #1, on 02/18/2022 at 3:55 PM, revealed he provided care for Resident #2 for several years. He revealed he provided training to new staff during their orientation on how to correctly take care of Resident #2's suprapubic catheter, because the catheter had unique requirements. He stated Resident #2 was very aware of the care required for the catheter and he/she would direct staff if they did not perform the care of the catheter properly. Interview with LPN #6, on 02/21/2022 at 9:40 AM, revealed he had only provided care for Resident #2 one (1) time and that was, on 10/07/2021. LPN #6 revealed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He also revealed he was not aware that Resident #2 had a specific physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #6 revealed he did not regularly check the Kardex because staff needed to get to know the residents, and the care plan could only tell staff so much. 2. Observation of Resident #4, on 02/15/2022 at 12:30 PM, revealed the resident sitting in his/her wheelchair with a lap tray in place. Continued observation revealed a staff member pushing Resident #4 around the neighborhood. Observation, on 02/16/2022 at 12:50 PM, of facility video footage, dated 11/01/2021, revealed Resident #3 and Resident #4 sitting in the common area at least three feet apart from each other. Resident #4 was observed without his/her lap tray on his/her w/c and without his/her foot straps in place. Resident #4 was observed to place his/her right hand on the right wheel of his/her wheelchair and move him/herself in a circular motion and ending up directly next to Resident #3. Per observation, Resident #4 grabbed Resident #3 by his/her hair. Review of Resident #4's clinical record revealed the facility admitted the resident, on 06/21/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the lap tray could be removed when the resident was on the bus. Continued review revealed, on 02/03/2022, the foot straps had been discontinued by physician. Review of Resident #3's clinical record revealed the facility admitted the resident, on 06/21/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse (LPN) # 2, on 02/16/2022 at 12:55 PM, revealed she provided care for Resident #3 on 11/01/2022 and when she arrived at the facility to start her shift, Resident #3 and Resident #4 were already in the common area. She stated it would have been the responsibility of the staff who cared for Resident #4 to ensure he/she had the required equipment on his/her w/c. Interview with Registered Nurse (RN) #4, on 02/17/2022 at 2:20 PM, revealed she was unaware of who placed Resident #4 in the common area, on 11/01/2021. She revealed she was unsure if Resident #4 had been required to always have the lap tray intact while sitting in his/her w/c. She stated she worked with Resident #4 several times, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Nurse Manager #2, on 02/17/2022 at 2:10 PM, revealed all staff should follow the physician orders. If staff were concerned about an order, they should immediately notify the supervisor or the physician. She went onto state care should be held until the order had been clarified. Interview with the Manger of Resident Care (MRC), on 02/18/2022 at 3:45 PM, revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Staff Development Coordinator (SDC), on 02/21/2022 at 2:00 PM, revealed staff was trained during their orientation to the facility on the importance of following the physician orders. Interview with Assistant Director of Nursing (ADON) on 02/18/2022 at 3:15 PM, revealed because there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed if the lap tray had been broken, it could be fixed timely because the facility had wheelchair staff on site. Continued interview with the ADON revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Vice President of Nursing (VPN), on 02/21/2022 at 1:30 PM, revealed it was very important for staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Senior Vice President/Administrator (SVPA), on 02/21/2022 at 4:00 PM, revealed following the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the facility Medical Director (MD), on 02/21/2022 at 5:00 PM, revealed it was her expectation staff followed her orders. She revealed if any staff member had questions or concerns with an order, she was always available to talk with them. She revealed if orders were not followed, it could be very dangerous and it could have a negative impact on the resident. She stated, I always feel like it is a serious threat not to follow orders.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to provide adequate supervision to prevent hazards to one (1) of six (6) sampled residents, Resident #3. The resident's hair was pulled, and the resident sustained scratches to his/her neck, and arm by Resident #4. The finding include: Review of the policy titled, Resident Monitoring and Supervision, dated 05/2020, revealed the facility shall have provide nursing and related services to assure resident safety and to attain the highest practicable physical, mental, and psychosocial well-being. Also, the facility provided resident monitoring and supervision as an intervention and means of mitigating risks. Further review of the policy revealed special consideration shall be made for resident's who had a prior history of challenging behaviors, hitting, kicking, grabbing, and scratching. These residents would be given the Red Safety Circle designation which required team members to actively intervene and assist them to maintain a distance of at least three (3) feet from other residents. Review of Resident #3's clinical record revealed the facility admitted the resident on 06/21/2017, with diagnoses including Spastic Quadriplegic Palsy, Intellectual Disabilities, and Hypoxic Ischemic [CONDITION(S)] (HIE). Review of Resident #3's care plan revealed the facility assessed the resident to have an alteration of musculoskeletal status and increased risk of fracture related to (R/T) Osteopenia (dated 06/19/2021). Continued review of the care plan revealed Resident #3 at risk of injury related to his/her inability to protect self from injury, he/she had no self- preservation skills. The resident also had a history of resisting care, screaming out, pushing others away (dated 07/06/2017). Interventions included a lap tray on at all times, to include transportation (dated 09/20/2019), and staff monitored and documented behavioral symptoms that placed the child and others as risk for abuse, neglect and injury (dated 01/27/2018). Review of Resident #4's clinical record revealed the facility admitted the resident on 06/21/2017, with diagnoses of Spastic Quadriplegic Cerebral Palsy, Anxiety Disorder, [CONDITION(S)], and Lack of Expected Normal Physiological Development in Childhood. Review of Resident #4's physician orders, dated 07/24/2018, revealed the resident required a chest harness, lap tray, seatbelt and foot straps while up in w/c except while he/she was on the bus, and then the lap tray could be removed. On 02/03/2022, the foot straps were discontinued by physician. Review of Resident #4's Care Plan revealed due to resident's self-harm and other behaviors he/she required the Red Safety Circle Designation. The Care Plan also revealed the resident was required to have seatbelt, lap tray, and shoe holders with foot straps in place at all times except for transportation on the bus. It was noted these were used for positioning and alignment while in w/c. Observation of facility video footage, dated 11/01/2021, revealed Resident #3 and Resident #4 sat in their perspective wheelchairs in the common area, unsupervised by staff. The residents appeared to be three (3) feet apart based on the number of tiles on the floor between the two residents. Continued observation of the video footage revealed Resident #4 did not have the required lap tray or foot straps in place. Resident #4 was observed to use his/her right hand to propel one (1) of the wheels on the w/c in a circle. Per observation, the resident propelled his/herself directly next to Resident #3's wheelchair. Continued observation revealed Resident #4 placed his/her right hand on Resident #3's hair. After the incident, a staff member was observed to enter the common area and removed Resident #3. Observation of Resident #3, on 02/15/2022 at 1:10 PM, revealed the resident in his/her room. The resident was sitting in his/her w/c and was dressed and clean. The resident played with a toy and the television was on. Review of a Physician Episodic Visit Note, dated 11/02/2021 at 2:39 PM, revealed staff notified the physician to assess Resident #3. The note continued to state Resident #3 was noted to have a scratch on his/her left neck as well as marks on his/her left arm. There were noted [CONDITION(S)] on the resident's left arm which had faded overnight, and the left neck area had a superficial abrasion. Review of Resident #4's Progress Notes revealed, on 11/01/2021 at 9:42 PM, Registered Nurse (RN) #4 documented Resident #4 pulled another resident's hair and scratched the resident. Continued review revealed Resident #4 had clawed at the nurse when she removed the resident from the common area. Observation of Resident #4, on 02/18/2022 at 9:10 AM, revealed the resident to repeatedly hit him/herself in the head, and banged the lap tray. Continued observation revealed no evidence of staff were present in the common area. The Wheelchair Maintenance Staff entered the common area during the event and were familiar with Resident #4. The w/c Maintenance Staff spoke to the resident to calm him/her down, and removed the lap tray completely from the w/c. Interview with Physical Therapy Assistant (PTA) #1, on 02/18/2022 at 1:25 PM, revealed the Red Safety Circle was incorporated with supervision to ensure resident to resident contact was prevented. She further stated she was aware Resident #4 could and would buck self in the w/c, which caused the w/c to move. Interview with Licensed Practical Nurse (LPN) #2, on 02/16/2022 at 12:55 PM, revealed on 11/01/2021, she provided care for Resident #3. She revealed when her shift started Resident #3 and Resident #4 were already placed in the common area. She stated she took Resident #3 to his/her room and completed his/her assessment. She revealed she then returned the resident to the common area and went on to do another resident assessment. She stated she observed Resident #4 moving his/her arms around, so she went back to the common area and observed the situation. Continued interview with LPN #2 revealed when she arrived at the common area, she observed Resident #4 to have Resident #3 by the arm with one (1) hand and his/her other hand was in the air. She revealed she had not observed Resident #4 to have his/her hands in Resident #3 hair, however, she did observe hair on Resident #3's shirt. LPN #2 stated she removed Resident #3 from the common area, and reported the incident to his/her supervisor. LPN #2 revealed she was responsible for the safety of Resident #3. She stated the CNA and nurse assigned to Resident #4 would have been responsible to ensure the resident had the required equipment on his/her w/c. Interview with Registered Nurse (RN) #1, on 02/15/2022 at 1:00 PM, revealed she regularly provided care for Resident #4. She revealed the resident was unable to move his/her w/c purposefully but could cause the w/c to move when he/she rocked or bucked in it. RN #1 revealed most of their residents had a Red Safety Circle designation which required residents to be six (6) feet apart for their safety. She also revealed Resident #4 would often grab and touch residents, staff, and equipment which was a safety concern. Interview with RN #4, on 02/17/2022 at 2:20 PM, revealed, on 11/01/2021, a Certified Nursing Assistant (CNA) reported to her Resident #4 pulled Resident #3's hair and some of the resident's hair came out. The RN acknowledged the lap tray was not placed on Resident #4's wheelchair at the time of the incident. Continued interview revealed she regularly cared for Resident #4 and was aware the resident could remove the lap tray on his/her own. However, sometimes, the staff removed the lap tray because the resident would bang on the tray. RN #4 revealed she was not aware Resident #4 could move his/her w/c on their own, however, she was aware the resident would buck in his/her w/c, which caused the w/c to move. She stated the Red Safety Circle was a designation which required certain residents to be kept three (3) feet away from other residents to prevent harm, and additional staff were needed to supervise the residents during rounds because it was difficult for the nurses to observe all the residents in the common area because the pit (a structure) blocked the view. Interview with the Nurse Manager (NM) #1, on 02/16/2022 at 2:30 PM, revealed she was the supervisor on duty, on 11/01/2021. When she arrived on the second floor, she observed Resident #3 with a scratch. She revealed Resident #3 and Resident #4 should not have been able to get together. She stated all staff were responsible to ensure residents were safe. Continued interview with NM #1 revealed resident to resident contact could happen at any time and some residents were able to move their w/c's. NM #1 revealed the Red Safety Circle was used to ensure residents were kept three (3) feet apart from each other. She went onto state all staff were expected to provide supervision to the residents and to ensure residents were unable to harm others. Interview with the Assistant Director of Nursing (ADON), on 02/18/2022 at 3:15 PM, revealed the nurse and/or the CNA were responsible to provide supervision. The ADON revealed the Red Safety Circle was used for all residents who had the potential to harm other residents, and these residents were required to have a three (3) foot distance between themselves and other residents. She also revealed it was the responsibility of the CSM to watch the residents, interact with the residents and attend to residents who may cry out for help. Continued interview with the ADON revealed if a CSM was not on duty, the other staff were expected to take turns with supervision of the residents. She revealed a staff member should be present in the common area to supervise the residents and to ensure the residents were safe. She revealed the team that was on duty on 11/01/2021, should have communicated to each other that one staff would need to stay in the common area. Interview with the Senior Vice President/Administrator (SVPA), on 02/21/2022 at 4:00 PM, revealed CSM's were employed to monitor resident alarms, and provide notification to the nurse when an alarm sounded. She stated the CSM's were also employed to observe resident to resident interactions and help to ensure safety of the residents. She went onto state Resident #4 should not have been unsupervised by staff while he/she was in the common area. She stated Resident #4 did not have the lap tray ordered for therapeutical purposes, it was ordered for safety reasons. She revealed it was believed, on 11/01/2021, Resident #4 did not have his/her lap tray on because the resident had been very irritable. The SVPA revealed the Red Safety Circle was a designation given to residents, such as Resident #4, who had more freedom of movement and required a larger space around them. She revealed these residents required increased monitoring, and supervision by the staff to ensure they did not come within three (3) feet of each other.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure allegations of suspected abuse were reported immediately for one (1) of six (6) sampled residents, Resident #1. An agency Cottage Safety Monitor (CSM) reported to the facility on [DATE] she witnessed Certified Nursing Assistant (CNA) #1 roughly handle and force feed Resident #1 on 01/05/2021. The findings include: Review of the facility's policy and procedure, Child Abuse, Neglect, Maltreatment and Harm Guidelines, revised 12/2020, revealed the facility trained all staff on abuse beginning in orientation and ongoing through facility in-services. Training included procedures and expectations for reporting incidents of abuse and understanding the consequences for not reporting. The facility encouraged team members to report any concerns of resident abuse and neglect immediately without fear of retaliation. Continued policy review revealed any person who witnessed, observed, discovered, or suspected abuse took steps to provide protection of residents and reported the incident/allegation to the Clinical Supervisor or Relief Charge Nurse. Review of the facility policy and procedure, Critical Incident/Adverse Event Review and Reporting Requirements, revised 10/2020, revealed team members immediately reported all critical incidents to the Registered Nurse (RN) Clinical Supervisor or Charge Nurse. Review of Resident #1's clinical record revealed the facility admitted the resident on 09/08/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan, dated 01/12/2021, revealed the facility assessed the resident with developmental delays and gross motor skill deficits as evidenced by limited physical mobility, bilateral profound hearing loss, and receptive/expressive language difficulty. Continued review revealed, the resident required a two (2) person lift for transfer and was not cleared for a mechanical lift. Continued review of Resident #1's Care Plan revealed the resident had difficulty swallowing food and/or fluids related to limited experience and incoordination of the muscles of the mouth and throat. Staff used a specialized spoon and resident was to be followed by Speech Therapy as ordered by the physician. Any emesis episodes were be monitored and documented. Review of the facility's Investigative Report, dated 01/11/2021, revealed in an interview with CSM #7 on 01/05/2022, in which CSM s#7 stated CNA #1 rough handled and force fed Resident #1. She revealed the resident hit his/her head when CNA #1 placed him/her in the bed. CNA #1 quickly shoved food into the resident's mouth which caused the resident to throw up. Per review, the incident was not reported to the facility until six (6) days after the CSM witnessed the incident. Observation of Resident #1, on 02/15/2022 at 12:15 PM, revealed the resident had a lap tray on his/her wheelchair (w/c) and attempted to push it off. There was a 1:1 sitter in place. Observation of Resident #1, on 02/18/2022 at 12:45 PM, revealed CNA #3 fed the resident his/her lunch. No concerns noted. Attempted interview with CSM #7, on 02/21/2022 at 4:00 PM, revealed her phone number was no longer in service. The Senior Vice President/Administrator (SVPA) reported CSM #7 was not employed at the agency since February 2021. Interview with the Assistant Director of Nursing (ADON), on 02/18/2022 at 3:15 PM, revealed Resident #1 could not be safely transferred by one (1) staff member. She revealed CNAs could call for help and would need to leave the resident until help arrived. She revealed a resident could be injured if a staff member did an improper transfer. She stated Resident #1 was a very difficult transfer and sometimes required three (3) staff members. She revealed she would make sure the residents were safe and immediately contact the supervisor if she suspected abuse. She also revealed she knew how to report outside of the facility to the state agencies. Interview with the Staff Development Coordinator (SDC), on 02/21/2022 at 2:00 PM, revealed she was responsible to ensure all facility, and agency staff were trained on abuse to ensure the facility followed State and Federal Regulations. She stated she provided a special packet for the CSMs to ensure they were trained on abuse, how to recognize abuse and to report abuse immediately. Interview with Clinical Quality Assurance and Performance Improvement Specialist (CQAPIS), on 02/21/2022 at 1:00 PM, revealed she usually completed the abuse investigations, but the SVPA was also very involved. She stated the CSM did not report her observations of suspected abuse until six (6) days after the event. The CQAPIS revealed the facility was responsible to ensure all agency staff were trained on abuse and the requirements to immediately report to management any concerns of abuse as required by law. Interview with the Vice President of Nursing (VPN), on 02/21/2022 at 1:30 PM, revealed she was over the entire Nursing Department and part of the Administration Team. She revealed when there was an allegation of abuse, the nurse supervisor was to gather immediate information and make sure the resident was safe. She revealed agency staff were included in facility abuse training and it was the responsibility of the facility to ensure staff were trained on abuse, when to report allegations and whom to report them too. Interview with SVPA, on 02/21/2022 at 4:00 PM, revealed the facility had the agency CSMs come to the facility to complete their abuse training. The SVPA revealed it was the responsibility of the facility to ensure all staff members, agency and/or full time staff were trained on abuse, the requirement to immediately report and to whom. She revealed it concerned her that CSM #7 did not report an allegation of abuse immediately. She revealed staff were expected to report all allegations of abuse to a supervisor immediately, and staff were not to make their own determination if suspected abuse should be reported or not.

Based on interview, record review, and review of the facility's Abuse Prevention Policy, it was determined the facility failed to protect one (1) of three (3) sampled residents, Resident #1, from verbal abuse. On 03/08/2020, direct care staff heard State Registered Nurse Aide (SRNA) #6 tell Resident #1 she wanted to beat the[OBSCENITY]out of the resident. The findings include: Review of the facility's policy titled, Protecting Service Recipients from Abuse/Neglect, revised December 2019, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through technology. Continued review of the policy, Roman Numeral IV, Identification, Number 5, revealed mental and verbal abuse was conduct that caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This included, but was not limited to, the use of oral, written, gestured communication, or sounds, to a resident within hearing distance, regardless of their age, ability to comprehend, or disability. The policy further cited examples of verbally aggressive behavior as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, and of an intimidating nature. Review of an initial report from the facility's investigation, dated 03/10/2020, revealed SRNA #4 reported an incident that occurred, on 03/08/2020, at the Ocean Avenue Cottage. The report revealed, on 03/10/2020 at approximately 6:00 PM, SRNA #4 reported the incident between Resident #1 and SRNA #6 that occurred, on 03/08/2020, to the Medical Social Services Manager (MSSM). SRNA #4 told the MSSM Resident #1 was following SRNA #6 and calling her names. Further review revealed SRNA #6 made the comment, referring to Resident #1, I'd like to beat the[OBSCENITY]out of him/her. Additional review of the facility's investigation, dated 03/10/2020, revealed SRNA #4 was interviewed by the MSSM, on 03/10/2020 at 6:48 PM. SRNA #4 stated she knew Resident #1 heard SRNA #6's statement because later that evening, while she was in Resident #1's room, Resident #1 told SRNA #4 he/she would get in trouble for his/her comments to SRNA #6 but did not think SRNA #6 would get in trouble for what she said to him/her. Review of an interview with SRNA #8, within the facility's investigation, conducted by the DON and the Clinical QAPI Specialist on 03/11/2020 at 2:39 PM, revealed SRNA #8 told the DON that she heard SRNA#6 make the statement that she was going to slap the[OBSCENITY]out of him/her. She stated Resident #1 continued to follow SRNA #6 and responded to her statement by saying, bring it [OBSCENITY] . Review of Resident #1's medical record revealed the facility admitted the resident on 07/17/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note, dated 03/09/2020 at 1:18 AM, revealed Licensed Practical Nurse (LPN) #3 documented Resident #1's behaviors, on 03/08/2020, during the first three (3) hours of the shift. These behaviors included throwing food trays on the floor and cursing staff. Further review revealed LPN #3 did not document any issue Resident #1 had with specific staff members. Review of Resident #1's Basic Interview for Mental Status (BIMS) score within the Quarterly Minimum Data Set (MDS) assessment, dated 12/28/2019, revealed the resident scored fifteen (15) out of a possible fifteen (15) indicating the resident was interviewable. Review of Resident #1's BIMS score for the Quarterly MDS Assessment, dated 03/28/2020, revealed the resident again scored a fifteen (15) out of a possible fifteen (15) on the assessment. Review of Resident #1's Comprehensive Care Plan (CCP) component, initiated on 07/31/17, was based on the resident's identified ineffective coping skills, age, awareness of [CONDITION(S)] diagnosis, varied intelligibility, history of high risk behavior including striking a classmate at school, and self-injurious behavior. Further review revealed interventions were temporary loss of privileges and other consequences for inappropriate behaviors. The CCP listed some of the resident's inappropriate behaviors included hitting others, cursing, entering other residents' rooms, and/or not treating others in an appropriate/respectful manner. Review of the Kardex Plan available to direct care staff (SRNAs), who provided Resident #1's care, revealed the document listed a safety plan for the resident, as well as expectations and consequences related to the resident's display of certain inappropriate behaviors, such as destructive behaviors and use of curse words when speaking to staff. Interview with the Clinical Quality Assurance Performance Improvement (QAPI) Specialist, on 08/12/2020 at 3:22 PM, revealed SRNA #6 worked the entire evening shift, from 7:00 PM on 03/08/2020 to 7:00 AM on 03/09/2020. She stated LPN #3 took care of Resident #1 during the evening shift of 03/08/2020; the evening Clinical Shift Supervisor also came on duty at 7:00 PM. In addition, she said SRNA #6 would have begun her shift on Ocean Avenue Cottage at 7:00 PM. The Clinical QAPI Specialist stated SRNA #4 was assigned to Resident #1's care, but SRNA #6 was assigned to assist Resident #1 with his/her shower. Interview with LPN #3, on 08/13/2020 at 8:52 AM, revealed she was assigned to care for Resident #1 during the evening of 03/08/2020. The LPN initially said she could not recall the resident having behaviors on that day. However, she stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she remembered Resident #1 was having a bad day, had been verbally aggressive toward SRNA #6, and seemed to be trying to aggravate SRNA #6. She stated she did not think SRNA #6 wanted to provide Resident #1's care because the resident would sometimes try to get SRNA's in trouble. LPN #3 said she left the cottage to get the Clinical Shift Supervisor because of the behaviors Resident #1 was having, but she could not remember exactly what the resident was doing. She said she returned to the cottage and heard Resident #1 had tried to close SRNA #6 in the linen closet and had been following the SRNA by rolling up behind her in his/her wheelchair. She stated it was about 9:00 PM when she returned to the cottage with the Clinical Shift Supervisor. LPN #3 said Resident #1 had closed his/her room door and initially would not let anyone in the room. She stated the Clinical Shift Supervisor had initially instructed her to address the resident's behavior using the behavior care plan, and she did, but it was not effective. She stated she did not receive any reports from staff on duty that SRNA #6 had made an inappropriate comment to Resident #1. However, after the alleged incident, she heard SRNA #6 mumbled something under her breath. She said she heard the comment made by the SRNA could have been something like spank his/her butt, but she could not recall the exact nature of the comment. LPN #3 stated it did not cross her mind to report the incident to anyone else because the Clinical Shift Supervisor would have known about the incident; the Clinical Shift Supervisor was in the room when Resident #1 told the MSSM SRNA #6 had cursed at him/her. LPN #3 stated she and the Clinical Shift Supervisor did not think the comment sounded like something SRNA #6 would have said. LPN #3 said she did not think the Clinical Shift Supervisor conducted additional interviews with Resident #1 or staff that evening. She said SRNA #6 did not work with Resident #1 anymore that night, even though the SRNA completed her shift working with other residents. Interview with SRNA #4, on 08/13/2020 at 9:01 AM, revealed Resident #1 was following SRNA #6 around the cottage the evening of 03/08/2020; he/she tried to barricade SRNA #6 in the linen room, using his/her wheelchair. SRNA #4 said she thought SRNA #6 might have been getting linen/towels for Resident # 1's shower. She stated when Resident #1 let SRNA #6 out of the linen room, and as SRNA #6 was walking toward the nurses' station, SRNA #4 said she heard SRNA #6 say she was going to beat the[OBSCENITY]out of him/her or if you were my child (referring to Resident #1), I would beat the[OBSCENITY]out of you. SRNA #4 said, after making that statement, SRNA #6 went on with her work, and as far as she knew, SRNA #6 had no further contact with Resident #1. SRNA #4 said she was standing at the nurses' station looking over the assignment sheet when she heard SRNA #6 make the comment. SRNA #4 stated she reported the comment made by SRNA #6 to LPN #3. Further, she stated she thought LPN #3 told her to go tell the Clinical Shift Supervisor. However, SRNA #4 stated she got very busy and did not report to the Supervisor what she heard SRNA #6 say to Resident #1. SRNA #4 stated she was under the impression LPN #3 would make the report once things calmed down for the evening. SRNA #4 stated she spoke with the MSSM about the incident on either 03/09/2020 or 03/10/2020. Per interview, SRNA #4 stated the facility had provided abuse prevention training. She stated if staff witnessed or heard about abuse of a resident, staff should report it immediately in order to keep all residents safe and prevent anything else from happening to the resident involved or any other residents living at the facility. Interview with the 03/08/2020 evening Clinical Shift Supervisor (Supervisor), on 08/13/2020 at 2:22 PM, revealed LPN #3 and SRNA #6 reported to her that Resident #1 was racing around the cottage in his/her wheelchair and was cursing at staff. She said when she went to the cottage she approached Resident #1, and the resident cursed her too. She said she tried to talk to the resident, but he/she never did respond. The Supervisor said LPN #3 told her Resident #1 was unhappy because family members had not visited him/her, and the resident did not want SRNA #6 to assist with bathing. The Supervisor said when it was clear she was unable to help the resident, she placed a call to the MSSM and asked her to speak to the resident by phone. The Supervisor said she and LPN #3 were in the room with Resident #1 when this telephone call occurred. The Supervisor stated Resident #1 told the MSSM SRNA #6 had cussed him/her, but LPN #3 immediately spoke up and said, That did not happen. The Supervisor said she did not hear the comment SRNA #6 allegedly made. She stated she only heard that SRNA #6 was calling the resident names, and she did not hear the actual comment about beating the resident. Further, the Supervisor said she did not try to interview SRNA #6 that night about the comment. She said SRNA #6 remained on duty until the end of her shift. The Supervisor said she was only a Relief Clinical Shift Supervisor and was not routinely in that role. She stated her main concern was getting Resident #1 to calm down; and that was why she asked the MSSM to talk with Resident #1 by phone. Per interview, the Supervisor stated the MSSM did not advise her to remove any staff from duty that evening and did not provide additional direction regarding SRNA #6. She said the MSSM stated she would meet with Resident #1 the next day after he/she returned from school. The Supervisor stated the facility had provided abuse prevention training, and if she or other staff heard about or witnessed abuse, they were to immediately report, so the issue could be immediately addressed. Another interview with the Clinical QAPI Specialist, on 08/13/2020 at 3:30 PM, revealed, upon completing their investigation, the facility substantiated the allegation. She said the facility ended SRNA #6's employment at the facility because her behavior was inappropriate, and she had not followed the facility's code of conduct. Interview with the Facility's Medical Social Services Manager (MSSM), on 08/13/2020 at 4:00 PM, revealed she became aware of the incident between Resident #1 and SRNA #6 on 03/10/2020 at about 6:00 PM. She said SRNA #4 told her she spent time with Resident #1 during the afternoon of 03/08/2020 because he/she was unhappy family members missed a planned visit with him/her. She stated, during the conversation, SRNA #4 referred to that whole thing with SRNA #6 and Resident #1. The MSSM said she asked SRNA #4 to explain, and SRNA #4 told her Resident #1 and SRNA #6 got into an argument on the evening of 03/08/2020. The MSSM stated SRNA #4 told her Resident #1 was also upset about the way he/she had been offered an evening shower, and SRNA #6 was assigned to assist him/her with the shower. SRNA #4 told her the resident felt SRNA #6 should have asked him/her about preferences for having a shower that night. The MSSM revealed SRNA #4 told her it seemed Resident #1 did not want to take the shower, but wanted to go to bed. Continued interview with the MSSM revealed SRNA #4 further explained Resident #1 had been following SRNA #6 around the cottage and had been calling SRNA #6 names. The MSSM stated SRNA #4 told her, in response to the resident's behavior, SRNA #6 said I'd like to beat the[OBSCENITY]out of you or something to that effect, in the presence of Resident #1. The MSSM said after the report from SRNA #4, she immediately called the Clinical QAPI Specialist and the Director of Nursing (DON). The MSSM stated SRNA #6 was on the schedule to work that night (03/10/2020), so she said a Leadership Team meeting was held, and it was decided SRNA #6 should not report to work due to the allegation of verbal abuse and until an investigation of the incident was completed. The MSSM stated SRNA #6 was notified of this. Additional interview with the MSSM, on 08/13/2020 at 5:08 PM, revealed Resident #1 was aware of his/her behavior plan within the CCP and had agreed to consequences for certain behaviors. The MSSM stated she had a phone conversation with Resident #1, on the evening of 03/08/2020, because the Clinical Shift Supervisor did not know Resident #1 very well and wanted her to speak with him/her. She said she and Resident #1 discussed his/her behavior plan/contract on the phone. She said she discussed calming strategies with Resident #1. The MSSM stated when the phone conversation was ending, there was some background noise, and she thought she might have heard the resident say something about someone cussing at him/her. However, she stated she immediately heard both LPN #3 and the Clinical Shift Supervisor say that was not true. The MSSM said she did not follow-up with LPN #3 or the Clinical Shift Supervisor about this. Per interview, the MSSM stated SRNA #4 should have reported SRNA #6's comment to the Clinical Shift Supervisor right after she heard it. She said it was not acceptable for LPN #3 to tell SRNA #4 to tell the Supervisor when SRNA #4 had reported it to her. The MSSM said no staff member was absolved from reporting. She stated, even if the first person reported to did not take the information seriously, all staff had been trained to report immediately the incident to a member of the Leadership Team, such as the DON; the Vice President (VP) of Clinical Services; the Assistant Director of Nursing (ADON), or to her. The MSSM stated SRNA #6 should have been removed from the cottage immediately after SRNA #4 made the allegation. Interview with SRNA #5, on 08/14/2020 at 1:40 PM, revealed she was on duty for the entire incident, on 03/08/2020, and stated Resident #1 followed SRNA #6 to the linen closet and tried to hit the back of SRNA #6's feet using his/her wheelchair. She said, at that point, she heard SRNA #6 say I can't do this anymore while Resident #1 kept speeding toward SRNA #6 in his/her wheelchair. She said Resident #1 stated he/she was going to smack the[OBSCENITY]out of SRNA #6. She said she only heard SRNA #6 say to the resident you might not want to do that. SRNA #5 denied hearing SRNA #6 say she wanted to, or was going to slap the[OBSCENITY]out of Resident #1. SRNA #5 said she did not report the incident to LPN #3 because she was sure LPN #3 was aware of the alleged statement made by SRNA #6. Per interview, she said, after the residents were in bed, staff were talking about the comment SRNA #6 made, and LPN #3 was in on that conversation. SRNA #5 stated this group thought SRNA #6 should have walked away from Resident #1 and taken a short break. Interview with SRNA #8, on 08/17/2020 at 8:41 PM, revealed she was on duty at Ocean Cottage on 03/08/2020. She stated SRNA #6 was assigned to provide Resident #1's shower because SRNA #4, the assigned staff member for the resident, was orienting a new employee. She stated Resident #1 did not want SRNA #6 to give his/her shower. She said Resident #1 was upset with everyone in the cottage and cursed at many of the staff. SRNA #8 stated the staff implemented the resident's behavior plan to address his/her behavior. Per interview, she stated she and LPN #3 were in another resident's room providing care, and when she walked into the hallway, she saw Resident #1 trying to barricade SRNA #6 in the linen closet. She stated Resident #1 cursed at SRNA #6, and SRNA #6 responded by saying someone get him/her away from me before I slap the[OBSCENITY]out of him/her. SRNA #8 stated she told SRNA #4 to report this to LPN #3. SRNA #8 said LPN #3 tried to get the Clinical Shift Supervisor to assist but thought the Supervisor told LPN#3 to handle it herself. Further interview revealed SRNA #8 stated the Supervisor eventually came to Ocean Avenue Cottage, and she and LPN #3 went to talk with Resident #1. SRNA #8 stated she and SRNA #5, who was in orientation, both heard SRNA #6 make the above statement. Interview with the DON, on 08/13/2020 at 9:50 AM, revealed upon completion of the investigation, the facility terminated SRNA #6's employment because of the inappropriate comment she made to Resident #1. The DON stated there were two (2) instances where individuals reported hearing SRNA #6 make the comment to Resident #1; the first, in an interview between the MSSM and Resident #1 when the resident confirmed the comment, and the second, when at least one (1) staff member at the cottage stated she heard it. She said when she interviewed SRNA #6, the SRNA denied making the comment and claimed she was only repeating something the resident had said to her. The DON further stated SRNA #4 should have immediately reported the allegation to the Supervisor on duty. She stated, from her interview with LPN #3, the LPN stated she did not hear SRNA #6 make the comment. The DON further stated if a staff member reported any allegation of abuse to LPN #3, the nurse should have told the SRNA that the comment must be reported. Then, she stated the LPN could have gone with the SRNA to report the matter to the Clinical Shift Supervisor. The DON stated staff members received abuse prevention training upon hire and at least annually. She said staff were required to complete a written knowledge check, which was the facility's method for evaluating each employee's understanding of the training. She stated the facility provided additional abuse prevention education during Resident Rights Training. The DON stated the facility informed staff there was a policy to address any form of retaliation, and the facility also stressed confidentiality of the reporting source would be honored. Interview with the Administrator/Senior Vice President, on 08/17/2020 at 1:30 PM, revealed he knew staff had received abuse prevention training many times. In addition, he could not say why staff involved with the 03/08/2020 incident did not follow through with reporting the incident to the Supervisor or to members of the Leadership Team if SRNA #4 had wanted to go further than reporting to the Supervisor. He stated the facility informed staff members it was their responsibility to protect residents. Per interview, the Administrator/Senior Vice President said he would have expected LPN #3 to report the allegation to the Supervisor when SRNA #4 told the LPN what she heard SRNA #6 say in the presence of Resident #1.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement immediately its Abuse Prevention Policy, on 03/08/2020. An allegation was made that State Registered Nurse Aide (SRNA) #6 made a verbally abusive comment to one (1) of three (3) sampled residents, Resident #1; but, SRNA #6 continued to provide direct care to residents until the end of her shift. In addition, the facility did not immediately initiate an investigation of the incident. The findings include: Review of the facility's policy titled, Protecting Service Recipients from Abuse/Neglect, revised December 2019, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review revealed this included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through technology. Continued review of the policy, under Roman Numeral III, Prevention, Number 2, revealed team members, volunteers, residents, and their families would be encouraged to report any concerns of resident abuse and neglect immediately without fear of retaliation. The leadership and management team would immediately investigate any allegation of abuse, neglect, or misappropriation, with immediate action taken to ensure the safety of residents. Review of Roman Numeral III, Prevention, Number 3, revealed in the event an allegation of abuse was made against a team member, volunteer, or visitor, the alleged perpetrator would be immediately removed from resident care and would not be permitted to have any contact with residents until a thorough investigation had been completed. Further review revealed the alleged perpetrator could only resume care of residents if the allegations had been unsubstantiated. Review of an initial report from the facility's investigation, dated 03/10/2020, revealed SRNA #4 reported an incident that occurred, on 03/08/2020, at the Ocean Avenue Cottage. The report revealed, on 03/10/2020 at approximately 6:00 PM, SRNA #4 reported the incident between Resident #1 and SRNA #6 that occurred, on 03/08/2020, to the Medical Social Services Manager (MSSM). SRNA #4 told the MSSM Resident #1 was following SRNA #6 and calling her names. Further review revealed SRNA #6 made the comment, referring to Resident #1, I'd like to beat the[OBSCENITY]out of him/her. Review of SRNA #6's time card report revealed, on 03/08/2020, the SRNA clocked in for work at 6:58 PM and clocked out from work, on 03/09/2020 at 8:48 AM. There were no additional reports of SRNA #6 working at the facility. Review of Resident #1's medical record revealed the facility admitted the resident on 07/17/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Basic Interview for Mental Status (BIMS) score within the Quarterly Minimum Data Set (MDS) Assessment, dated 12/28/2019, revealed the resident scored fifteen (15) out of a possible fifteen (15) indicating the resident was interviewable. Review of Resident #1's BIMS score for the Quarterly MDS Assessment, dated 03/28/2020, revealed the resident again scored a fifteen (15) out of a possible fifteen (15) on the assessment. Review of Resident #1's Comprehensive Care Plan (CCP) component, initiated on 07/31/17, was based on the resident's identified ineffective coping skills, age, awareness of [CONDITION(S)] diagnosis, varied intelligibility, history of high risk behavior including striking a classmate at school, and self-injurious behavior. Further review revealed interventions were temporary loss of privileges and other consequences for inappropriate behaviors. The CCP listed some of the resident's inappropriate behaviors included hitting others, cursing, entering other residents' rooms, and/or not treating others in an appropriate/respectful manner. Interview with the Clinical Quality Assurance Performance Improvement (QAPI) Specialist, on 08/12/2020 at 3:22 PM, revealed SRNA #6 worked the entire evening shift, from 7:00 PM on 03/08/2020 to 7:00 AM on 03/09/2020. She stated Licensed Practical Nurse (LPN) #3 took care of Resident #1 during the evening shift of 03/08/2020; the evening Clinical Shift Supervisor also came on duty at 7:00 PM. In addition, she said SRNA #6 would have started her shift on Ocean Avenue Cottage at 7:00 PM. The Clinical QAPI Specialist stated SRNA #4 was assigned to Resident #1's care, but SRNA #6 was assigned to assist Resident #1 with his/her shower. Interview with the DON, on 08/13/2020 at 9:50 AM, revealed SRNA #6 had some Skills Validation training to complete the morning of 03/09/2020 and that was why she did not clock out of the building until 8:48 AM on 03/09/2020. Interview with LPN #3, on 08/13/2020 at 8:52 AM, revealed she and the Clinical Shift Supervisor talked with Resident #1 around 9:00 PM, and then the Supervisor called the MSSM so she could speak with the resident and perhaps calm the resident. LPN #3 said she was in the room when the MSSM talked with Resident #1 by phone and said it did not cross her mind to report the incident to anyone. She said the Clinical Shift Supervisor would have known about the incident because she was also in the room when Resident #1 told the MSSM that SRNA #6 had cursed at him/her. LPN #3 stated she and the Clinical Shift Supervisor did not think the comment sounded like something SRNA #6 would have said. LPN #3 said she did not think the Clinical Shift Supervisor conducted additional interviews with Resident #1 or staff that evening. She stated SRNA #6 did not work with Resident #1 anymore that night, even though the SRNA completed her shift working with other residents. Interview with SRNA #4, on 08/13/2020 at 9:01 AM, revealed she heard SRNA #6 make the comment toward Resident #1 that she would like to beat the[OBSCENITY]out of him/her. She stated Resident #1 had been following SRNA #6 around the cottage and was calling her names. SRNA #4 stated she reported the comment made by SRNA #6 to LPN #3. Further, she stated she thought LPN #3 told her to tell the Clinical Shift Supervisor. However, SRNA #4 stated she got very busy and did not report to the Supervisor what she heard SRNA #6 say to Resident #1. SRNA #4 stated she was under the impression LPN #3 would make the report once things calmed down for the evening. SRNA #4 stated she spoke with the MSSM about the incident on either 03/09/2020 or 03/10/2020. Another interview with the Clinical QAPI Specialist, on 08/13/2020 at 3:30 PM, revealed upon completing their investigation, the facility substantiated the allegation. She said the facility ended SRNA #6's employment at the facility because her behavior was inappropriate, and she had not followed the facility's code of conduct. Interview with the Facility's Medical Social Services Manager (MSSM), on 08/13/2020 at 4:00 PM, revealed she became aware of the incident between Resident #1 and SRNA #6 on 03/10/2020 at about 6:00 PM. She said SRNA #4 told her she spent time with Resident #1 during the afternoon of 03/08/2020 because he/she was unhappy family members missed a planned visit with him/her. She stated, during the conversation, SRNA #4 referred to that whole thing with SRNA #6 and Resident #1. The MSSM said she asked SRNA #4 to explain, and SRNA #4 told her Resident #1 and SRNA #6 got into an argument on the evening of 03/08/2020. The MSSM stated SRNA #4 told her Resident #1 was also upset about the way he/she had been offered an evening shower, and SRNA #6 was assigned to assist him/her with the shower. Continued interview with the MSSM revealed SRNA #4 further explained Resident #1 had been following SRNA #6 around the cottage and had been calling SRNA #6 names. The MSSM stated SRNA #4 told her, in response to the resident's behavior, SRNA #6 said I'd like to beat the[OBSCENITY]out of you or something to that effect, in the presence of Resident #1. The MSSM said after the report from SRNA #4, she immediately called the Clinical QAPI Specialist and the Director of Nursing (DON). The MSSM stated SRNA #6 was on the schedule to work that night (03/10/2020), so she said a Leadership Team meeting was held, and it was decided SRNA #6 should not report to work due to the allegation of verbal abuse and until an investigation of the incident was completed. The MSSM stated SRNA #6 was notified of this. An additional interview with the MSSM, on 08/13/2020 at 5:08 PM, stated she had a phone conversation with Resident #1, on the evening of 03/08/2020, because the Clinical Shift Supervisor did not know Resident #1 very well and wanted her to speak with him/her. She said she discussed calming strategies with Resident #1. The MSSM stated when the phone conversation was ending, there was some background noise, and she thought she might have heard the resident say something about someone cussing at him/her. However, she stated she immediately heard both LPN #3 and the Clinical Shift Supervisor say that was not true. The MSSM said she did not follow-up with LPN #3 or the Clinical Shift Supervisor about this. Per interview, the MSSM stated SRNA #4 should have reported SRNA #6's comment to the Clinical Shift Supervisor right after she heard it. She said it was not acceptable for LPN #3 to tell SRNA #4 to tell the Supervisor if SRNA #4 had reported it to her. The MSSM said no staff member was absolved from reporting. She stated, even if the first person reported to did not take the information seriously, all staff had been trained to immediately report the incident to a member of the Leadership Team, such as the DON; the Vice President (VP) of Clinical Services; the Assistant Director of Nursing (ADON), or to her. The MSSM stated SRNA #6 should have been removed from the cottage immediately after SRNA #4 made the allegation, and the investigation should have begun at that point. Continued interview with the DON, on 08/13/2020 at 9:50 AM, revealed upon completion of the investigation, the facility terminated SRNA #6's employment because of the inappropriate comment she made, directed toward Resident #1. She stated when the MSSM interviewed Resident #1 he/she told her SRNA #6 made the comment. Additionally, the DON said at least one (1) staff member at the cottage heard the SRNA make the comment. Further, the DON stated when she interviewed Resident #1 he/she confirmed that SRNA #6 stated she wanted to smack the[OBSCENITY]out of him/her. The DON stated when SRNA #4 reported SRNA #6's statement to LPN #3, which was an allegation of abuse, SRNA #6 should have been immediately removed from the cottage. The DON stated if things had been conducted according to the facility's policy, on 03/08/2020, the facility would have started the investigation immediately. In addition, the DON stated immediately removing the SRNA #6 from the cottage would have ensured protection of other residents from potential verbal abuse. Interview with the Administrator/Senior Vice President (VP), on 08/17/2020 at 1:30 PM, revealed his understanding was that the incident actually occurred on 03/08/2020, but the MSSM did not start the investigation until 03/10/2020, after her conversation with SRNA #4. The Administrator/Senior VP stated he thought proper communication of an allegation of abuse was key to others taking immediate action. He said that perhaps SRNA #4's report to LPN #3 was not as strong as it could have been. However, he stated the LPN should have acted on that information and should have assisted the SRNA with reporting the incident to the Clinical Shift Supervisor, on 03/08/2020. He stated the facility had provided every staff member with frequent and detailed training in abuse prevention, and he thought staff knew what they were supposed to do. Further, he stated staff members should also know they could report an allegation of abuse to more than one (1) staff member. Per interview, he stated the facility instructed staff to report any form of resident abuse to any member of the Leadership Team if they thought the staff member they reported to did not take immediate action. The Administrator/Senior VP stated when he looked at allegations of this nature, there could be breakdowns in the process, and there was always room for improvement.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services' (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for one (1) of ten (10) sampled residents (Resident #1). Resident #1's Quarterly Care Plan Evaluation Note, dated [DATE], revealed the resident had behaviors including self [MEDICAL CONDITION] devaluation (removal of the tube placed in the windpipe to enable the resident to breathe). In addition, interviews with multiple staff members revealed the resident swatted at the Heat Moisture Exchanger (HME) (HME is a device attached to the [MEDICAL CONDITION] to add moisture) attached to his/her trach, creating the potential for dislodging the tracheotomy tube. However, the resident's risk of self injury Comprehensive Care Plan was not developed to include the risk for self [MEDICAL CONDITION] decannulation, nor were interventions implemented to increase supervision related to this behavior. On [DATE], Resident #1 experienced self [MEDICAL CONDITION] decannulation while seated in the common living area on the Sunshine Lane Cottage Unit. Video surveillance revealed staff was not supervising the resident when the resident's [MEDICAL CONDITION] (trach) became dislodged, nor was the resident immediately assessed by staff members who were in the general vicinity of the common living area when the resident lowered his/her head and did not show obvious movements. Although the pulse oximeter (a device placed on the body to monitor oxygenation level of blood) report revealed the resident's oxygen level decreased from ninety-seven percent (97%) to zero (0) percent at 12:39 PM, staff interviews revealed the pulse oximeter was not alarming. Resident #1's nurse discovered the resident at 1:00 PM to be cyanotic (bluish discoloration of the skin resulting in poor circulation or inadequate oxygenation in the blood) and unresponsive. Staff called a Code Blue, inserted a replacement tube and initiated resuscitation measures until Emergency Medical Services (EMS) arrived and transported the resident to the local hospital. Resident #1 expired at the hospital on [DATE]. The hospital discharge [DIAGNOSES REDACTED]. Refer to F-689 The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was developed and implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy had been removed on [DATE], as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity (S/S) of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Assessment and Service Planning: Resident Care Plan Policy, revised [DATE], revealed all residents will have an ongoing, interdisciplinary, comprehensive, and person-centered care plan consistent with resident rights that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Care plans shall focus on treatment of [REDACTED]. The care plan is inclusive of the initial baseline care plan, comprehensive care plan, Kardex, physician's orders [REDACTED]. Further review of the policy, revealed the resident care plan shall be revised as needed, and evaluated at least monthly by skilled staff during Monthly Care Plan Evaluations, quarterly by the Interdisciplinary Care Team following the required RAI (Resident Assessment Instrument) Assessments, and whenever a significant change requires revision. Review of the facility's Kosair Charities Pediatric Convalescent Center (KCPCC) Desktop Instruction: Resident Supervision Policy, revised February 2020, revealed the facility shall have sufficient staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and [DIAGNOSES REDACTED]. Under the subtitle, Procedures, Section A, Number 2, the policy listed behaviorally specific items that may place a resident or others at risk for injury, abuse or neglect, and the risk of resident to resident altercation. Sixteen (16) behaviorally specific items were identified, and among those items, the following were included: Item b. Rocking or thrashing in wheelchair or bed; Item n. History of self-injurious behaviors including hitting or biting self, self-decannulation, rolling or wrapping self in tubing, cords or respiratory circuits, disconnecting self from pulse oximeter probe or tubing. Section A of the policy further revealed functional status and dependence on staff for the provision of care shall also be assessed. Additional review of the policy, Section B., revealed team members shall be assigned to cottages in sufficient numbers to provide supervision, oversight and monitoring of residents with particular attention to times when residents are gathering in groups in the common areas, at the bus stop, and during activities when residents may be positioned in close proximity to other residents. All team members are responsible for providing supervision and monitoring of residents. Cottage Safety Monitoring (CSM) shall occur during waking hours on cottages where additional supervision is required to monitor residents and mitigate risk of injury, abuse, and/or neglect. Review of Section C of the policy, revealed team members shall immediately report any, and all concerns related to resident supervision to the Registered Nurse (RN) Clinical Supervisor or to a KCPCC Leadership Team member. Review of the Centers for Medicare and Medicaid Services', Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, initiated [DATE], revealed the resident was at risk for injury related to an inability to protect self from injury due to congenital anomalies of hands, fingers, feet and toes, and history of high risk behavior including falling face first and kicking others. The goal stated the resident would remain free from injury through [DATE]. Interventions included monitoring the resident for behavioral symptoms such as pushing away caregivers and others, removal of his/her leg prosthesis and pulse oximeter probe, kicking caregivers, falling face first into side rails, and rocking in his/her wheelchair that placed the resident and others at risk for injury or abuse. Additional interventions included emergency respiratory support supplies to be kept at the resident's bedside including a back-[MEDICAL CONDITION] obturator, and Red Safety Circle (Red Safety Circle means the resident must be at least three (3) feet from other residents in the group). Additional review of the Comprehensive Care Plan, initiated [DATE], revealed the resident had ineffective airway function resulting in [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED]. The goal stated the resident would exhibit no symptoms of respiratory complications or distress through the next review date of [DATE]. There were several interventions including supplemental oxygen; nebulization treatments; assessment of breath sounds every shift; and assess for signs and symptoms of respiratory distress as evidenced by increased respiratory rate, increased work of breathing, nasal flaring, wheezing, and any increased demand for supplemental oxygen every shift, and as needed. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as having severe cognitive impairment and as unable to complete the Brief Interview for Mental Status (BIMS). Additional review revealed the facility assessed the resident as totally dependent on staff for transfers between surfaces, locomotion on the unit, dressing, eating, toilet use, personal hygiene, and bathing. Continued review revealed the facility assessed the resident as incontinent of both bowel and bladder. Further, the facility assessed the resident as having Functional Limitations in Range of Motion (ROM) of the bilateral upper and lower extremities, with a prostheses to the left foot/ leg, and a wheelchair for mobility. Per the MDS Assessment, Nutrition was provided through a feeding tube, and the resident had a [MEDICAL CONDITION] (breathing tube) and required [MEDICAL CONDITION] care and suctioning. Review of the Quarterly Care Plan Evaluation Note, dated [DATE], written by Registered Nurse (RN) Supervisor #8, revealed Resident #1 was at risk for injury due to his/her inability to protect self as well as behaviors. Staff noted the resident will hit or swat at them while care is provided and he/she is able to buck or rock his/her wheelchair moving it across the floor. Further review revealed Resident #1 moved his/her pulse oximeter probe, decannulates self and had been observed banging his/her head against his/her wheelchair. Continued review revealed the resident should have no hard toys in his/her bed with him/her, or in the small padded play pit, and the upper and lower bed rails should all be used when the resident is in bed as he/she is able to move freely and reposition self. Review of the Quarterly Care Plan Evaluation Note, dated [DATE], revealed the resident decannulates self and staff interviews revealed the resident had a history of [REDACTED]. However, there was no documented evidence the Comprehensive Care Plan was developed to indicate the risk of self [MEDICAL CONDITION] decannulation with interventions to prevent further occurrences, or the need for increased supervision. Interview on [DATE] at 10:45 AM, with Nursing Supervisor #8, revealed prior to writing a Quarterly Care Plan Evaluation Note, she would review the resident's medical record related to behaviors and care needs over the last twelve (12) week period. She stated once the evaluation note was completed, it would be read in the presence of the Interdisciplinary Team (IDT) members at the quarterly care plan meeting. Nursing Supervisor #8 stated the note would also be available in hard copy for IDT members to review during the meeting. She stated that the Care Plan Evaluation Notes were one source of information used to update/develop a resident's care plan. Further interview with Nursing Supervisor #8, revealed she did write the Quarterly Care Plan Evaluation Note, dated [DATE] for Resident #1, and prior to writing the note she would have talked with direct care nursing staff and reviewed the resident's Progress Notes to obtain information related to the resident's care and behaviors. She stated she documented that the resident decannulates self, and she must have obtained this information from the Progress Notes. Nursing Supervisor #8 stated she was ninety percent (90%) sure she had a conversation with staff on the Sunshine Lane Cottage about Resident #1's history of decannulating himself/herself before the quarterly care plan meeting. Per interview, the conversation might have been that the resident decannulated self with his/her frequent movements. Nursing Supervisor #8 stated she did not ensure the Comprehensive Care Plan was developed related to the resident's risk for self [MEDICAL CONDITION] decannulation. She stated she would have assumed someone would have already reported the resident's self [MEDICAL CONDITION] decannulation behavior to his/her other direct care givers and care planned the concern. Review of the Kardex Care Plan, undated, (guide utilized by the State Registered Nurse Aides (SRNAs) as a reference for providing care), revealed the SRNAs were to monitor Resident #1 for behavioral symptoms such as pushing away caregivers and others, removal of prosthesis and pulse oximeter probe, kicking caregivers, falling face first into side rails, and rocking in wheelchair that places the resident and others at risk for injury or abuse. Additional interventions included Red Safety Circle; SRNAs to monitor and document symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, or symptoms of anxiety or depression. However, the Kardex did not list the resident's behavior of swatting at his/her Heat Moisture Exchanger (HME) connected to the trach, or the behavior of self-removal of the trach. Review of the Progress Note, dated [DATE] at 14:18 (2:18 PM), signed by Licensed Practical Nurse (LPN) #1, revealed she approached Resident #1 at 1300 (1:00 PM) with medication and found the resident slumped over in his/her chair, not responsive to his/her name. The Note further revealed she lifted Resident #1's head and noted his/[MEDICAL CONDITION] out, his/her skin was gray, and lips were blue. Per the Note, LPN #1 attempted to reinsert the trach, but was unsuccessful. A Code Blue was called, and the resident's chair was tilted back to reinsert the trach. Nursing Supervisor #7 arrived with respiratory staff and additional nurses equipped with the Automatic External Defibrillator (AED) and code supplies. Further review revealed the Emergency Medical Services (EMS) were called and the resident was transferred to the hospital. Per the Note, the resident's parents were notified of the status change by Nursing Supervisor #7. Review of the pulse oximetry data downloaded from the pulse oximeter in use for Resident #1 on [DATE], revealed the resident's SPO2 (oxygen saturation) readings beginning on [DATE] at 12:35.56. According to the data with readings every two (2) seconds, the resident's SPO2 was measuring in the range from ninety-five percent (95%) to ninety-eight percent (98%) which was within the acceptable range according to the physician's orders [REDACTED]. In addition, data recorded in the last column of the document at 12:39.28, revealed (Pulse Ox) Sensor off Patient. Review of Resident #1's Emergency Department (ED) to Hospital Admission in Pediatric Intensive Care Unit (PICU) Face Sheet, dated [DATE], revealed the resident arrived at the ED via ambulance at 1:40 PM with primary [DIAGNOSES REDACTED]. The resident was assessed as still in asystole (without a heart rate/rhythm), and received a total of seventy (70) minutes of Cardiopulmonary Resuscitation (CPR), ten (10) doses of [MEDICATION NAME] (cardiac stimulating medication) and two (2) rounds of cardiac defibrillation. Per the document, the resident was placed on a ventilator and an intravenous (IV) infusion of [MEDICATION NAME] was started. Resident #1 was transferred to the hospital's Pediatric Intensive Care Unit (PICU) for further evaluation and management. Review of Resident #1's Emergency Department (ED) to Hospital Discharge Summary/Death Note, revealed Resident #1's parents arrived at the hospital, and were understanding of the resident's severe neurological damage and grim prognosis. Continued review revealed the parents were amenable to brain death examinations (exams) and withdrawal of care. Brain death exams were conducted and the resident's death was declared at 1:14 PM on [DATE]. Interview on [DATE] at 6:11 PM, [DATE] at 12:48 PM, and [DATE] at 7:15 PM, with LPN #1, revealed she was Resident #1's assigned nurse on [DATE]. Per interview, the resident had a Heat Moisture Exchanger (HME) attached to his/her [MEDICAL CONDITION] which was a device that provided moisture to the air the resident breathed through [MEDICAL CONDITION]. She stated the resident did not like the HME, and would often swat at it or grab at the HME, pull it off, and throw it on the floor. Further interview revealed Resident #1 spent most of the morning in the common living area on [DATE], and was seated in his/her wheelchair in front of the television along with two (2) other residents when she went to lunch about 12:00 noon. LPN #1 stated when she returned at about 12:30 PM, she did not see any staff members in the common living area with the two (2) residents who were still sitting in front of the television. Additional interview with LPN #1, revealed on [DATE], at approximately 1:00 PM, she noticed Resident #1 was bent over with his/her head on the lap tray on the wheelchair. She stated the resident's skin color was gray and his/[MEDICAL CONDITION] was out. She further stated the collar was still flush against the resident's neck, and [MEDICAL CONDITION] still attached to the collar and laying against the resident's neck, slightly below the stoma (trach opening). Further, she briefly attempted to reinsert [MEDICAL CONDITION], but within a few seconds she realized that was not working, so she yelled for help and started wheeling the resident to his/her room. LPN #1 stated a Code Blue was called with the Respiratory Therapist (RT) on duty, other nurses and the Nursing Supervisor responding. Per interview, she was not exactly sure who replaced the resident's trach, but the resident was transferred to his/her bed, and staff started providing CPR. Further, after EMS staff arrived the resident was transferred to the local hospital emergency department. Continued interview with LPN #1, revealed in her opinion, Resident #1 may have been pulling at the HME on [MEDICAL CONDITIONS] dislodge because he/she had that behavior. Per interview, the resident's Care Plan should have been developed with information and interventions that would have prompted staff to monitor him/her for the risk of self [MEDICAL CONDITION] decannulation. She further stated one (1) of the goals within the resident's plan of care was to ensure the resident did not exhibit signs and symptoms of respiratory complications or distress; however, staff did not sufficiently monitor Resident #1 which meant care plan interventions were not implemented to prevent him/her from experiencing respiratory distress. Per interview, if staff had closely monitored residents in the common living area on [DATE], someone would have been available to immediately respond to Resident #1 when his/[MEDICAL CONDITION] dislodged. Interview, on [DATE] at 11:15 AM and on [DATE] at 7:41 PM, with LPN #3, revealed she had not heard anything about Resident #1 being able to self decannulate his/her [MEDICAL CONDITION] prior to the incident on [DATE], but she was aware the resident tried to pull off the HME device connected to his/her trach. She stated if there had been a CSM in the common living area on [DATE] to monitor residents, the incident related to Resident #1 this may not have happened. Continued interview revealed the purpose of of the interdisciplinary care plan was to provide person-centered care and the resident's actions and behaviors should be considered in order for the care plan to address the resident's specific needs. She stated even though she had not personally seen the resident pull out his/her trach, there was the potential when pulling off or hitting at the HME device attached to the trach. Per interview, this type of behavior put the resident at risk for injury and should have been included in his/her care plan with interventions implemented to prevent injury. Interview, on [DATE] at 3:58 PM, with Respiratory Therapist (RT) #10, revealed she had heard through the grapevine, that Resident #1 had previously pulled out his/[MEDICAL CONDITION] to the incident on [DATE], but she had not seen that happen. Per interview, she was unable to identify the person who provided that information or a timeframe in which she heard the resident had previously pulled out his/her trach. Interview, on [DATE] at 9:30 AM, with the Respiratory Therapist Manager (RTM), revealed Resident #1 was very active, and even though Resident #1 had only three (3) fingers on one (1) hand, he/she was able to play with an I-Pad and with toys. The RTM stated the Heat Moisture Exchanger (HME) on Resident #1'[MEDICAL CONDITION] additional humidification of the air the resident breathed and was designed to slide over [MEDICAL CONDITION], and could be easily removed for suctioning the resident. Further, Resident #1 was not one to leave anything alone, and he understood the resident would swat at the HME attached to the trach. Continued interview revealed Resident #1 was very adaptive with the use of his/her fingers, and he could definitely say he had seen the resident get his/her fingers behind the phalange of his/her trach. Per interview, Resident #1 had a [MEDICAL CONDITION] and if he/she was swatting at the HME, and got his/her fingers under the phalange, he/she could potentially move [MEDICAL CONDITION] which could result in decannulation. Interview on [DATE] at 8:30 AM, with LPN #4, revealed the resident liked to manipulate the HME attached to his/her trach. Per interview, the resident could actually remove the HME from the trach. Interview, on [DATE] at 12:22 PM, with LPN #7, revealed there were many residents on Sunshine Lane Cottage with pulse oximeters, and with the television on and kids making noises, it would be difficult to hear an alarm going off in the common living area, if staff was working in areas far away from the common living area. Additional interview with LPN #7, revealed there needed to be a staff member in the common living area to closely observe Resident #1 due to his/her high level of activity and behavior of swatting and hitting at the HME. She stated these behaviors should have been care planned because this placed him/her at increased risk for injury, and close monitoring should have been implemented. Interview on [DATE] at 3:40 PM, with the Director of Nursing (DON), revealed Resident #1's Care Plan should have been developed to include the risk for self [MEDICAL CONDITION] decannulation and interventions should have been implemented for supervision and monitoring. Per interview, at a minimum, the resident was supposed to be supervised to prevent him/her from coming into close proximity to other residents via the red safety circle intervention; however, this did not happen as review of the camera footage revealed staff did not immediately respond to the resident when he/she lowered his/her head and showed no further movement. The DON stated the resident's care plan goal to prevent respiratory distress was not met. Interview, on [DATE] at 12:51 PM and [DATE] at 12:47 PM, with the Vice President (VP) of Clinical Services, revealed the facility reviewed resident care plans at least quarterly, and more often as needed. Per interview, Nursing Supervisors should review the past three (3) months of documentation in the resident's record including the physician's orders [REDACTED]., prior to writing the Quarterly Care Plan Evaluation Notes. Per interview, the IDT involved in the resident's care attended the formal care plan meetings where care plans and goals for care were evaluated. Further interview revealed the care plans were developed and/or revised during the meetings. The VP of Clinical Services stated she usually coordinated the care plan meetings, but on the day Resident #1's care plan was up for review, on [DATE], she was unable to attend the care plan meeting. Further interview with the VP of Clinical Services, revealed she had recently reviewed the Quarterly Care Plan Evaluation Note entered by Nursing Supervisor #8 on [DATE]. She stated the note was surprising to her, because as far as she knew, there was no evidence in the progress notes, nor in the MDS Assessment that Resident #1 had pulled out his/her trach. The VP of Clinical Services stated the RN Supervisor would have had to read that information in the resident's record in order to include it in the Quarterly Care Plan Evaluation Note. She further stated she had spoken with Nursing Supervisor #8, who was unable to say where she identified the information about the resident's history of pulling out the trach. Further interview revealed she and the Medical Director viewed the facility camera footage of Resident #1 sitting in the common living area on [DATE], and they agreed it seemed at one point the resident turned to the right and hyperextended his/her head. Per interview, with that movement, the resident may have popped out the trach, but she could not definitively say what happened. She stated one of her major concerns was related to proper function of the pulse oximetry device that day and the nurses' ability to hear the alarm if it went off. She stated if the pulse oximeter was alarming, it should have been heard. The VP of Clinical Services stated the quarterly care plan review note dated [DATE], written by Nursing Supervisor #8, should have been investigated and Resident #1's Care Plan could have been developed to include the risk for self-decannulation of the trach, and appropriate interventions should have been implemented to protect him/her from harm. Interview, on [DATE] at 3:02 PM, with the Clinical Quality Assurance Performance Improvement (QAPI) Specialist, revealed resident behaviors such as self-removal of a trach, or resident removal of other devices such as gastrostomy tube should be documented as an Unusual Occurrence, in the progress notes. She stated the Supervisors should routinely look for notes titled as such when reviewing the record for behaviors or mishaps that could affect the resident's well-being. During further interview she stated the nursing staff in this instance, did not record Resident #1's behavior [MEDICAL CONDITION] as an Unusual Occurrence. She stated the RN Supervisor found some notes in Resident #1's record that indicated the resident had removed his/[MEDICAL CONDITION] that was why she recorded that behavior in her Quarterly Care Plan Evaluation Note on [DATE]. She stated it was determined that Resident #1's care plan should have been thoroughly reviewed against the quarterly care plan documentation used to review and potentially develop/update the resident's care plan and the risk for self decannulation of [MEDICAL CONDITION] have been addressed. Further, interventions should have been implemented for close supervision of the resident in order to prevent the occurrence of self decannulation of the trach. Interview on [DATE] at 4:45 PM with the Administrator, revealed he was responsible for the day-to-day operation of the facility, and ensuring staff provided proper and safe care for the residents. He stated if there were things that deviated from what was normal or safe for the residents, they should be addressed in the Care Plan. He further stated he would definitely expect staff to report that a resident had removed his/her [MEDICAL CONDITION], and follow up by increasing monitoring of the resident. He stated this was a behavior the Interdisciplinary Team should have addressed through the care planning process. The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC/IJ Removal Plan revealed the facility implemented the following: 1. On [DATE], at 1:00 PM, Licensed Practical Nurse (LPN) #1 found Resident #1 unresponsive, having a blue-gray color to his/her skin, and with his/her [MEDICAL CONDITION] dislodged. Facility staff was able to reinsert [MEDICAL CONDITION], initiate Code Blue Protocol, providing immediate resuscitation measures until Emergency Medical Services (EMS) Personnel transferred the resident to an acute care hospital emergency department. 2. On [DATE], [DATE], and [DATE], the Respiratory Therapy Manager (RTM) and Respiratory Therapy Staff evaluated all pulse oximetry devices in use to ensure the devices were functional, appropriately used, and that the alarm settings were correct. 3. On [DATE], [DATE] and [DATE], the Clinical Quality Assurance Performance Improvement, (QAPI) Specialist facilitated Root Cause Analysis (RCA) sessions with Leadership Team Members to determine how the facility failed to ensure Resident #1's environment remained free of accidents and hazards, and how the facility failed to adequately supervise the resident. During the [DATE] RCA session, the need for additional resident supervision was identified. Leadership team members in attendance for the Root Cause Analysis (RCA) sessions included: Clinical QAPI Specialist; Chief Executive of Operations; Administrator; Executive Vice President (VP) of Quality Improvement and Corporate Compliance; Executive VP of Support; VP of Clinical Services; Director of Nursing (DON); Assistant Director of Nursing (ADON); VP of Therapy Services; Medical Social Services Manager; Respiratory Therapy (RT) Manager; Lead RT; Registered Nurse (RN) Clinical Supervisors, and Activity Coordinator. 4. On [DATE] the Leadership Team members reviewed the facility's Desktop Instruction 02.01.14.02 Resident Monitoring and Supervision Policy, and on that date the Policy was revised by the VP of Clinical Services. 5. On [DATE], Leadership Team members including the Administrator, VP of Clinical Services, and the ADON reinstituted dedicated Cottage Safety Monitors (CSM) on all cottages. CMSs are assigned to cottages each shift by the RN Clinical Supervisor in collaboration with the ADON. CSMs will be utilized on all cottages to provide targeted monitoring and supervision of residents and to actively listen and respond to pulse oximeter alarms. 6. Training was provided by the Leadership Team members including the Administrator; VP of Clinical Services; DON; ADON; VP of Therapy Services; Medical Social Services Manager; Medical Social Services Coordinator; Respiratory Therapy (RT) Manager; Lead RT; Registered Nurse (RN) Clinical Supervisors; Activity Coordinator; Resident Education Coordinator; Clinical Spec (TRUNCATED)

Based on observation, interview, record review, review of facility policy, and review of video surveillance provided by the facility, it was determined the facility failed to ensure the residents' environment remains as free of accident hazards as is possible; and each resident receives adequate supervision to prevent accidents for one (1) of ten (10) sampled residents (Resident #1). On [DATE], Resident #1 experienced self [MEDICAL CONDITION] decannulation (removal of the tube placed in the windpipe to enable the resident to breathe) while he/she was seated in the common living area on the Sunshine Lane Cottage. Video surveillance revealed staff was not supervising the resident when the resident's [MEDICAL CONDITION] (trach) tube became dislodged. Resident #1 was not immediately assessed by staff members in the general vicinity of the common living area when the resident lowered his/her head and did not show any obvious movements. Review of the Pulse Oximeter (a device placed on the body to monitor oxygenation level of blood) Report revealed the resident's oxygen level decreased from ninety-seven percent (97%) to zero (0) percent at 12:39 PM; however, Resident #1's nurse did not discover the resident until approximately 1:00 PM. Staff interviews revealed the pulse oximeter was not alarming. A Code Blue was called, staff inserted a replacement tube, and initiated resuscitation measures until Emergency Medical Services (EMS) arrived and transported the resident to the hospital. After seventy (70) minutes of Cardiopulmonary Resuscitation (CPR), and administration of cardiac stimulating medications, the hospital Physician placed Resident #1 on life support; however, the resident passed away at the hospital on [DATE]. The discharge [DIAGNOSES REDACTED].#1 was found at the Long Term Care (LTC) facility with his/[MEDICAL CONDITION] for an unknown period of time. Staff interviews revealed they were unable to sufficiently monitor residents seated in the common living area on the Sunshine Lane Cottage. Refer to F-656 The facility's failure to have an effective system in place to ensure adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy had been removed on [DATE], as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity (S/S) of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Kosair Charities Pediatric Convalescent Center (KCPCC) Desktop Instruction: Resident Supervision Policy, revised February 2020, revealed the facility shall have sufficient staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by the resident's assessments and individual plans of care, considering the number, acuity, and [DIAGNOSES REDACTED]. Under the subtitle, Procedures, Section A, Number 2, the policy listed behaviorally specific items that may place a resident or others at risk for injury, abuse or neglect, and the risk of resident to resident altercation. Sixteen (16) behaviorally specific items were identified, and among those items, the following were included: Item b. Rocking or thrashing in wheelchair or bed; Item n. History of self-injurious behaviors including hitting or biting self, self-decannulation, rolling or wrapping self in tubing, cords or respiratory circuits, disconnecting self from pulse oximeter probe or tubing. Section A of the policy further revealed functional status and dependence on staff for the provision of care shall also be assessed. Additional review of the policy, Section B, revealed team members shall be assigned to cottages in sufficient numbers to provide supervision, oversight and monitoring of residents with particular attention to times when residents are gathering in groups in the common areas, at the bus stop, and during activities when residents may be positioned in close proximity to other residents. All team members are responsible for providing supervision and monitoring of residents. Cottage Safety Monitoring (CSM) shall occur during waking hours on cottages where additional supervision is required to monitor residents and mitigate risk of injury, abuse, and/or neglect. Review of Section C of the policy, revealed Team Members shall immediately report any, and all concerns related to resident supervision to the Registered Nurse (RN) Clinical Supervisor or to a KCPCC Leadership Team member. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, initiated [DATE], revealed a Focus Area of risk for injury related to inability to protect self from injury, congenital anomalies of hands, fingers, feet and toes, bilateral absent radi, and history of high risk behavior including falling face first and kicking others without self-preservation skills. The goal stated the resident would remain free from injury through the next review date of [DATE]. Interventions included monitoring the resident for behavioral symptoms including pushing away caregivers and others, removal of his/her leg prosthesis and pulse oximeter probe, kicking caregivers, falling face first into side rails, and rocking in his/her wheelchair. Further interventions included emergency respiratory support supplies to be kept at the resident's bedside including a back-[MEDICAL CONDITION] obturator and Red Safety Circle. Interview, on [DATE] at 8:30 AM with the Vice President (VP) of Clinical Services, revealed the Red Safety Circle intervention meant staff was to make sure Resident #1 was situated in group gatherings so that his/her wheelchair was kept at least three (3) feet from other residents in the group. Continued review of the Comprehensive Care Plan, initiated [DATE], revealed a Focus Area for ineffective airway function resulting in [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED]. The goal stated the resident would exhibit no symptoms of respiratory complications or distress through the next review date of [DATE]. Interventions included supplemental oxygen; nebulization treatments; assessment of breath sounds every shift, and assess for signs and symptoms of respiratory distress as evidenced by increased respiratory rate, increased work of breathing, nasal flaring, wheezing, and any increased demand for supplemental oxygen every shift, and as needed. Review of the Kardex Care Plan, undated, which was the guide utilized by the State Registered Nurse Aides (SRNAs) as a reference for providing care, revealed the SRNAs were to monitor Resident #1 for behavioral symptoms such as pushing away caregivers and others, removal of prosthesis and pulse oximeter probe, kicking caregivers, falling face first into side rails, and rocking in wheelchair that places the resident and others at risk for injury or abuse. Further interventions included Red Safety Circle; SRNAs to monitor and document symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, and withdrawal, or symptoms of anxiety or depression. Review, of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as cognitively severely impaired, and unable to complete the Brief Interview for Mental Status (BIMS). Further review revealed the facility assessed Resident #1 as totally dependent on staff for transfers between surfaces, locomotion on the unit, dressing, eating, toilet use, personal hygiene, and bathing. Continued review revealed the resident was incontinent of both bowel and bladder. Per the MDS Assessment, Resident #1 had Limitations in Functional Range of Motion (ROM) of bilateral upper and lower extremities, with a prostheses to one (1) leg, and his/her mobility device was listed as a wheelchair. Additional review of the MDS Assessment, revealed Nutrition was provided through a feeding tube, and the resident required [MEDICAL CONDITION] (breathing tube) care and suctioning. Review of the Quarterly Care Plan Evaluation Note, dated [DATE], written by Registered Nurse (RN) Supervisor #8, revealed Resident #1 was at risk for injury due to his/her inability to protect self as well as he/she has behaviors. Further review revealed staff stated, Resident #1) would hit or swat at them while care was provided and the resident was also able to buck or rock his/her wheelchair moving it across the floor. Continued review revealed Resident #1 moves his/her pulse oximeter probe, decannulates self and has been observed banging his/her head against his/her wheelchair. Further review revealed the resident should have no hard toys in his/her bed with him/her, or in the small padded play pit. The resident should have all upper and lower bed rails used when in bed as he/she is able to move freely and reposition self. Although the Quarterly Care Plan Summary dated [DATE], revealed the resident had a behavior of self decannulation, there was no documented evidence this behavior was addressed in the Care Plan. Refer to F-656 Interview on [DATE] at 10:45 AM, with Nursing Supervisor #8, revealed she did write the Quarterly Care Plan Evaluation Note, dated [DATE], for Resident #1 and prior to writing the note she would have talked with direct care nursing staff and reviewed the resident's Progress Notes to obtain information related to the resident's care and behaviors. She further stated she documented that the resident decannulates self, and she must have obtained this information from the Progress Notes. Nurse Supervisor #8 further stated, she was ninety percent (90%) sure she had a conversation with staff on the Sunshine Lane Cottage about Resident #1's history of decannulating himself/herself, before the quarterly care plan meeting. Per interview, the conversation might have been that the resident decannulated self with his/her frequent movements. Review of the Progress Note, dated [DATE], time stamped 14:18 (2:18 PM) authored by Licensed Practical Nurse (LPN) #1, revealed she approached Resident #1 at 1300 (1:00 PM) with medication. The Note further revealed she found the resident slumped over in his/her chair, not responsive to his/her name. Per the Note, LPN #1 lifted Resident #1's head and the resident'[MEDICAL CONDITION] out, his/her skin was gray, and lips were blue. Further review of the Note, revealed LPN #1 attempted to reinsert the trach, but was unsuccessful and a Code Blue was called. The resident's chair was tilted back to reinsert the trach. Nursing Supervisor #7 arrived with respiratory staff and additional nurses equipped with an Automated External Defibrillator (AED) and code supplies. EMS was called and the resident was transferred to the hospital. Per the Note, the resident's parents were notified of the status change by Nursing Supervisor #7. Review of the Metro Emergency Medical Services (EMS) Record of Response, dated [DATE], revealed at 1:11 PM, EMS personnel assessed Resident #1 at the facility, unresponsive with no pulse or respiratory effect with Cardiac [MEDICAL CONDITION] Resuscitation (CPR) in progress. According to the narrative within the report, staff reported to EMS personnel the resident was last seen at approximately 12:30 PM sitting in his/her wheelchair acting normally. At approximately 1:00 PM, staff found Resident #1 unresponsive, cyanotic (bluish discoloration of the skin resulting in poor circulation or inadequate oxygenation in the blood), with no pulse and noticed the resident'[MEDICAL CONDITION] been removed. Staff told EMS personnel the resident was normally non-verbal, but was very active with his/her hands and there was high probability the resident had removed his/her trach. EMS staff continued to provide resuscitation measures and placed the resident on a cardiac monitor, but no heart rate/rhythm was detected. Resuscitation efforts continued as EMS Staff moved the resident to a stretcher and transported him/her to a local acute care hospital. Review of the Emergency Department (ED) to Hospital Admission in Pediatric Intensive Care Unit (PICU) Face Sheet, dated [DATE], revealed Resident #1 arrived at the ED via ambulance at 1:40 PM with primary [DIAGNOSES REDACTED]. The resident was assessed as still in asystole (without a heart rate/rhythm), and required a total of seventy (70) minutes of CPR, ten (10) doses of [MEDICATION NAME] (cardiac stimulating medication) and two (2) rounds of cardiac defibrillation. Per the record, the resident was placed on a ventilator and an intravenous (IV) infusion of [MEDICATION NAME] was started. Resident #1 was transferred to the hospital's Pediatric Intensive Care Unit (PICU) for further evaluation and management. Review of the Emergency Department (ED) to Hospital Discharge Summary/Death Note, filed [DATE] at 4:48 PM, revealed Resident #1's parents arrived at the hospital, and were understanding of the resident's severe neurological damage and grim prognosis. The resident's parents were amenable to brain death exams and withdrawal of care. The hospital conducted brain death exams and the record further revealed the resident's death was declared at 1:14 PM on [DATE]. Observation of the facility's Video surveillance from [DATE], revealed there was no time stamping on the video, but the video identified the number of seconds into minutes the video was running. Residents #1, #2, and #3 were seated in the common living area on the Sunshine Lane Cottage on [DATE]. Resident #1 had a tray table attached to his/her wheelchair. Resident #2 was seated next to Resident #1 and Resident #3 was in a wheelchair, and just behind Resident #1. There was a play pit and a bookcase between the Staff Station and the common living area where Residents #1, #2, and #3 were watching television. The residents were facing the television, and their backs were toward the Staff Station. Resident #1 was thrashing from side to side and twisting his/her torso to his/her right side. Licensed Practical Nurse (LPN) #2 entered the camera view, and began backing Resident #3 away from Residents #1 and #2 in the common living area. Resident #1 continued to have pronounced movement of his/her upper torso, but LPN #2 had her back turned to the resident, while she was working at a small rolling caddy that was positioned near the wall and just outside Room B4. Further observation of the facility's Video Surveillance, revealed just as LPN #2 began to enter Room B4 with Resident #3, Resident #1 lowered his/her head to the tray table on his/her wheelchair and did not show any further movements for the remainder of the video. LPN #3 exited Room B4 after LPN #2 entered Room B4. As LPN #3 exited Room B4, she did not look toward the common living area where Residents #1 and #2 were still seated, but walked away from the common living area and down the hall toward the side two (2) exit doors, and entered room (B5). LPN #2 exited Room B4, did not look toward the common living area, but proceeded to the staff station, sanitized her hands, and continued down Side 2 hallway and also entered Room B5. LPN #1 appeared in camera view, and came from Hallway Side 1, disappeared briefly and then was next seen in front of Resident #1, lifting the resident's head from the lap tray. She turned Resident #1's wheelchair around and headed swiftly toward Hallway #1 and Room B2 (Resident #1's room). LPN #2 and LPN #3 were seen exiting room B5 and moved rapidly past the Staff Station and followed LPN #1 in to Room B2. Additional staff from outside the unit could be seen entering the Cottage and going into Room B2. Review of the facility's Investigation, dated [DATE], and signed by the Vice President (VP) of Clinical Services, revealed a timeline of the events leading up to when Resident #1 was discovered by LPN #1 with his/[MEDICAL CONDITION] on [DATE]. The VP of Clinical Services and the Clinical Quality Assurance Performance Improvement (QAPI) Specialist's names were listed at the bottom of the narrative account. Interview, on [DATE] at 3:21 PM with the Clinical QAPI Specialist, revealed she and the VP of Clinical Services viewed the footage and recorded the following timeline found in the investigation as the video did not incorporate time stamping of the activities documented by the video coverage. Per the written Investigation: 12:50 PM-Resident #1 was positioned in the wheelchair, in the common area, left of the television (TV) in front of the bookcase. The resident can be visualized twisting his/her body to the right in what appears to be a motion to look behind him/her. He/she appears to be rocking side to side, feet are kicking and both arms moving up and down playfully as he/she appears to be looking over his/her right shoulder. 12:52 PM- Resident #1 lowers his/her head, chin to chest and appears to slump over onto the wheelchair lap tray. No staff members can be visualized in the common area. 12:52.58 PM-LPN #3 exits B4 and walks down the hallway toward Team 2 Exit Doors and enters B5 walking away from the common area where residents are watching TV. LPN #3 does not appear to look back at the residents watching TV. 12:59.30- LPN #2 exits B4, walks toward Staff Station, uses hand sanitizer at Staff Station, then walks into B5, walking away from the common area where residents are watching TV. LPN #2 does not appear to look back at the residents watching TV. 1:00 PM- LPN #1 enters the frame from Team 1 hallway and walks towards Resident #1 in front of the TV, pauses to say his/her name and gain his/her attention. Stops in front of the resident, raises his/her head, turns with him/her and wheels the resident quickly toward Room B2, across the common area by the Staff Station to Team 1 hallway, then goes out of the frame. LPN #2 was observed exiting B5 and moved quickly toward B2 following LPN #1. LPN #3 also exits B5 and follows the group to B2. Further review of the facility's Investigation, revealed video coverage confirmed at 12:52 PM Resident #1 lowered his/her chin to chest and had no other movement. LPN #1 reported in interview with the facility's investigators, that she approached Resident #1 and found him/her unresponsive at 1:00 PM which was also confirmed on video. The investigation further revealed staff interviewed confirmed Resident #1 was attached to the pulse oximeter at the time he/she was in his/her wheelchair in the common area of the cottage where he/she lived. Review of the Home of the Innocents Skilled Nursing Facility (SNF) Follow-up Question Report, dated [DATE], revealed on [DATE] at 7:40 AM, Resident #1's oxygen saturation was measured at ninety-seven percent (97%); method of delivery was [MEDICAL CONDITION]; percentage of oxygen being delivered was twenty-one percent (21%). The entry was documented by Respiratory Therapist (RT) #1. Review of the pulse oximetry data, downloaded from the pulse oximeter in use for Resident #1 on [DATE], revealed the data captured measured the resident's SPO2 (an estimate of the amount of oxygen in the blood) readings beginning on [DATE] at 12:35.56. According to the data with readings every two (2) seconds, the resident's SPO2 was measuring in the range from ninety-five percent to ninety-eight percent (95%-98%) which was within the acceptable range according to the physician's orders [REDACTED]. At 12:39.26 the resident's SPO2 was ninety-seven percent (97%), but at 12:39.28 the reading changed to zero percent (0%). Additional data was recorded in the last column of the document at 12:39.28 that read, (Pulse Ox) Sensor off Patient. Interview with the RTM, on [DATE] at 12:15 PM, revealed the pulse oximeter used on [DATE] for Resident #1 was given to him on [DATE] by the VP of Clinical Services so he could test it for proper function. He stated the device was working properly as per the tests he performed on [DATE]. Per interview, he also retrieved/downloaded and printed the oximetry readings related to Resident #1's SPO2 and pulse rate on [DATE]. He stated the pulse oximeter was not sent away for any additional evaluation after the incident with Resident #1 because according to his evaluation of the device it was functioning properly. Further interview with the RTM, revealed respiratory therapists assigned to cottages were responsible for checking the resident's pulse oximeter for proper function each shift, which was every twelve (12) hours, and they were to document the results in the Clinical record under Point of Care. He stated their documentation included a notation that the pulse oximeter was turned on, and the resident's blood oxygen level and heart rate were visible on the pulse oximeter screen. He further stated the RTMs had not been required to check the status of the alarm, like function or loudness, because that was not a manufacturer's recommendation. Review of the untitled document provided by the Respiratory Therapy Manager (RTM), dated [DATE], revealed on [DATE] he validated the pulse-oximetry (pulse ox) serial number M 6, was functioning properly by testing it with a Masimo Tester plugged in to the cable of the oximeter. Per the document, this validation was also witnessed by the Clinical Quality Assurance Performance Improvement (QAPI) Specialist. Review of the Sunshine Census Acuity for [DATE], revealed the resident Census for the cottage was fourteen (14). Seven (7) of the fourteen (14) residents had a [MEDICAL CONDITION]; eight (8) residents were monitored by pulse oximetry; all fourteen (14) residents on the census had a feeding tube; and one (1) resident was under droplet isolation precautions. Three (3) Licensed Practical Nurses (LPNs) and one State Registered Nursing Assistant (SRNA) staffed the cottage on [DATE] from 7:00 AM-7:00 PM. Interview on [DATE] at 3:58 PM, with Respiratory Therapist (RT) #10, revealed she provided Resident #1's [MEDICAL CONDITION] care on [DATE] at approximately 9:00 AM. She stated between the RT and the nurses on duty, the resident was assessed for the need for suctioning every two (2) hours, and as needed. She further stated she did not identify any abnormalities with Resident #1's [MEDICAL CONDITION], or reasons for concern [MEDICAL CONDITION]. Per interview, she secured the resident'[MEDICAL CONDITION] using the Velcro-like closure on the collar. RT #10 stated she had heard through the grapevine that Resident #1 had previously pulled out his/[MEDICAL CONDITION] to the incident on [DATE], but she had not personally seen that happen. Interview on [DATE] at 5:28 PM, with State Registered Nurse Aide (SRNA) #1, revealed she had taken care of Resident #1 many times. She stated about one (1) to (2) months ago, while she was bathing Resident #1 in the shower room, he/she was pulling on the HME device connected to [MEDICAL CONDITION] the resident'[MEDICAL CONDITION] came out. However, she stated a licensed nurse, (LPN) #4, was in the shower room and replaced the resident's trach. Further interview revealed she was assigned to Resident #1 on [DATE] on the shift in which the resident'[MEDICAL CONDITION] dislodged. She stated when she gave Resident #1 his/her bath on [DATE] at 8:30 AM, the resident'[MEDICAL CONDITION] in place. She further stated the RT [MEDICAL CONDITION] just after she bathed the resident on that date. Per interview, after the resident was dressed for the day, she took him/her to the common living area in his/her wheelchair. SRNA #1 stated she had secured the resident's pulse oximeter probe (device that measures heart rate and oxygen levels) by taping it to his/her toe and by donning the resident's sock and high top tennis shoe as per the interventions on the resident's Kardex care plan that she used as a reference for providing resident care. She further stated the sock, shoe, and a strap on the wheelchair pedal helped to keep Resident #1's pulse oximeter in place. Further interview revealed SRNA #1 saw Resident #1 about twenty (20) minutes before the incident because she went to the common living area to get Resident #4 to assist him/her to bed for rest. She stated at that time Resident #1 did not look like he/she was in any distress, and was his/her usual self, bouncing around in the wheelchair while watching television. Per interview, the resident bounced using his/her entire body, was very active, and the bouncing action would make the resident's wheelchair rock. SRNA #1 further stated she was about to leave Resident #4's room about 1:00 PM when she heard LPN #1 yell out that she needed help and Resident #1 was blue! Interview, on [DATE] at 6:11 PM, with LPN #1, who was Resident #1's assigned nurse on [DATE], revealed Resident #1 had a Heat Moisture Exchanger (HME) attached to his/her [MEDICAL CONDITION]. She stated the HME was a device that provided moisture to the air the resident breathed through [MEDICAL CONDITION]. She further stated the resident did not like the HME, and would often swat at it or grab at the HME, pull it off, and throw it on the floor. Further interview revealed the resident also had a pulse oximeter monitor on his/her toe and the nurses relied on the pulse oximeter equipment for monitoring the resident's blood oxygen levels and heart rate. She stated if the pulse oximeter came off or if the resident's oxygen saturation level decreased, the pulse oximeter would sound an alarm. Continued interview revealed Resident #1 spent most of the morning in the common living area on [DATE], and she saw the resident seated in his/her wheelchair in front of the television when she went to lunch about 12:00 noon. Per interview, there were two (2) other residents in the common living area with Resident #1 at that time. LPN #1 stated she could not recall if there was a staff person in the common living area when she left for lunch, but when she returned around 12:30 PM, she did not see any staff members in the common living area with the three (3) residents who were still in front of the television. Continued interview with LPN #1, revealed from 12:30 PM-to just before 1:00 PM, on [DATE], she was in the medication room behind the nurse's station reviewing Resident #1's treatment orders and preparing his/her feeding and medications. LPN #1 stated at approximately 1:00 PM, she left the medication room with a couple of syringes of medication, and walked toward the common living area. She further stated as she was walking toward Resident #1, she could see the resident was bent over with his/her head on the lap tray on the wheelchair and she thought that was odd because Resident #1 did not typically take daytime naps. LPN #1 stated she went to the resident and lifted his/her head and noted the resident's skin color was gray and his/[MEDICAL CONDITION] was out. She stated the collar was still flush against the resident's neck, and [MEDICAL CONDITION] still attached to the collar and laying against the resident's neck, slightly below the stoma (trach opening). Per interview, she briefly attempted to reinsert [MEDICAL CONDITION], but within a few seconds she realized that was not working, so she yelled for help and started wheeling the resident to his/her room. LPN #1 stated other nurses responded to her call for help, and a Code Blue was called with the RT on duty as well as the Nursing Supervisor responding. Per interview, staff tilted the resident's wheelchair back to get a better view of the resident'[MEDICAL CONDITION], but were still unable to get [MEDICAL CONDITION] in. She stated, at that point she went numb, and was not exactly sure who replaced the resident's trach, but the resident was transferred to his/her bed, and staff started providing CPR. Per interview, EMS (Emergency Medical Services) staff arrived and the resident was transferred to the local hospital emergency department. Further interview with LPN #1, revealed management including the Vice President of Clinical Services, Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) told her they reviewed the video coverage of the incident, and they thought when Resident #1 turned his/her head to look back toward the nurse's station, [MEDICAL CONDITION] just slipped out. However, LPN #1 stated, in her opinion, the resident may have been pulling at the HME on the trach, because he/she had that behavior, and when [MEDICAL CONDITION] out, the resident may have been looking back in panic. LPN #1 further stated Resident #1 had awareness of the people who were around him/her and was able to have conversations with people when using the I-pad as a communication device. Per interview, she thought the staff on duty on [DATE] did all they could, but administration had not listened to their concerns about the need for additional help in monitoring the residents when they were seated in the common living area of the facility, especially at heavy care times during the shift. Continued interview with LPN #1, on [DATE] at 12:48 PM, revealed when she was in the Medication Room behind the nurse's station, she would be able to hear the pulse oximeter alarms go off in the resident rooms across the hall from the medication room door. However, she stated she was not able to hear a resident's pulse oximeter alarm go off if the resident was in the common living area of the Sunshine Lane Cottage. LPN #1 stated if Resident #1's alarm went off on [DATE] between 12:30 PM and 1:00 PM, she did not hear it sound. Per interview, if other staff at the Cottage heard Resident #1's device alarm go off, they would tell her, but because Resident #1's alarm went off so frequently, the staff could have had alarm fatigue. LPN #1 stated if Resident #1 got excited about something he/she was watching on television, he/she would shake side-to-side in his/her chair, and that might make the pulse oximeter alarm sound. Further, if the resident had an increased heart rate when he/she became excited, that might activate the alarm. Additional interview with LPN #1, revealed the facility implemented Cottage Safety Monitoring (CSM) about a year or so ago. She stated CSM was intended for the common living area in the cottage. Per interview, the Nursing Supervisors passed out a piece of paper with time slots listed in thirty (30) minute increments of time and staff on duty was to sign up to cover the monitoring continuously from 7:00 AM to midnight, daily. However, she stated the facility did not create a new position specifically for CSM, and therefore staff already on duty was to monitor in the CSM role in addition to other resident care assignments. LPN #1 stated staff on the Sunshine Lane Cottage Unit had not followed through with the monitoring assignments since probably [DATE], as it was not feasible for direct care staff to do the monitoring with other duties assigned. Further interview revealed at least one-fourth (,[DATE]) to one third (,[DATE]) of the direct care staff had voiced concerns to management that the CSM process could not work with the numbers of staff and the ac (TRUNCATED)

Based on interview, record review and review of facility Policy, it was determined the facility failed to develop and implement a baseline care plan that included necessary instructions to provide effective person-centered care for one (1) of four (4) sampled residents (Resident #1). On 10/31/19, Resident #1 was admitted to the facility for respite care and the resident's Baseline Care Plan and Kardex (Guide used by the Certified Nursing Assistants (CNAs) as a reference for providing care), was developed with interventions for two (2) caregivers to provide care when warranted to assure safety. The Baseline Care Plan was not developed to specify how many staff was required for providing incontinence care, leaving it to the interpretation of the staff member caring for the resident. Although Certified Nursing Aide (CNA) #2 received information during shift report on 11/01/19, related to the resident attempting to jump out of the Veil bed (an enclosure bed with a mesh tent connected to the bed frame which limits the person's ability to get out of bed), CNA #2 did not review Resident #1's Baseline Care Plan or Kardex and on that date attempted to provide incontinence care to the resident independently. While CNA #2 was reaching for a clean brief at the foot of Resident #1's bed, the resident fell to the floor. Resident #1 was transferred to the Hospital Emergency Department on 11/01/19, and admitted to the Hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Refer to F-689) The findings include: Review of the facility Management of Information: Resident Care Plan, Policy, revised February 2018, revealed a person-centered Baseline Care Plan (BCP) shall be initiated on admission and developed within forty-eight (48) hours. The BCP shall include the minimum healthcare information necessary to properly care for a resident immediately upon admission. It shall address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, including, but not limited to the following: resident and/or guardian's goals and objectives for care delivery during the stay; initial goals, services and treatments based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review, of Resident #1's closed medical record revealed the facility admitted the resident on 10/31/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Interdisciplinary Admission Assessment, dated 10/31/19, signed by Licensed Practical Nurse (LPN) #1, revealed the resident was admitted for respite care. Review of Section F, titled Mood and Behavior Patterns & Psychosocial Well-Being, revealed the resident would have fidgeting behavior. Section G, of the assessment, titled Communication/Hearing Patterns, revealed the resident's verbal communication efforts included humming and babble type sounds, but the resident could not use phrases or sentences as means of expression. Further, the resident demonstrated very limited ability to understand the communication of others. Review of Section I, titled Activities of Daily Living, revealed Resident #1 was very dependent on staff for all activities of daily living, was to be in a Pedicraft bed with two (2) rails up when in the bed, and required a seat belt when in the wheelchair. Per the assessment, the resident had not sustained a fall or fracture during the past one hundred eighty (180) days prior to this admission. Review of Resident #1's Baseline Care Plan, dated 11/01/19, revealed the resident was at risk for injury due to an inability to protect self from injury, self-mobility in bed or on mat, had no preservation skills, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal revealed the resident would remain free from injury through the next review date. Interventions included caregivers to monitor for behavioral symptoms including resisting care, and pinching and hitting others, that placed the resident and others at risk for injury or abuse; and use two (2) caregivers to provide care when warranted to assure safety. However, the Baseline Care Plan was not developed with individualized interventions related to how many staff was required to perform incontinence care. Review of the Kardex, dated 11/01/19, revealed the Behavior Monitoring Section included interventions to monitor for behavioral symptoms including resisting care and pinching or hitting others that placed the resident and others at risk for injury or abuse; and use two (2) people to provide care when warranted to assure safety. Review of the Nurse's Note, dated 11/01/19, time stamped 19:39 (7:39 PM), revealed LPN #1 was called to Resident #1's room by CNA #2, and the resident was found in his/her bed with blood on the sheet and on his/her face. The Nursing Supervisor and the Medical Director were both called to the resident's room. The Medical Director assessed the resident and noted additional blood on the resident's neck, nose, mouth, and lips. According to the Note, the resident's front teeth were not normal. Per the Note, the Physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Hospital Emergency Department (ED) Note, dated 11/01/19, revealed the resident was evaluated on 11/01/19, beginning at 5:14 PM. Per the Note, the resident's visit diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the resident received Computerized Tomography (CT) scanning of his/her head, and x-rays. These diagnostic tests revealed Resident #1's top four (4) teeth were completely intruded, and one (1) of the embedded teeth appeared to be just at the right maxillary sinus wall/floor without actually protruding into the maxillary sinus. The tests also revealed a Maxillary Fracture. Continued review of the Note, revealed the resident was picking at the scabs at his/her mouth during the ED visit, and the family was not comfortable taking the resident home. Additional review of the Note, revealed the Physician on duty admitted Resident #1 to the hospital for further management of his/her dental injury. Review of the Hospital Discharge Summary, dated 11/06/19, revealed on 11/05/19, Resident #1 underwent a surgical procedure to extract the four (4) embedded teeth, and the resident was discharged home to the care of his/her parents on 11/06/19. Interview, on 12/11/19 at 6:45 PM, with Family Member #1, revealed Resident #1 had many respite care visits to the facility prior to the most recent admission, and he and Resident #1's mother provided a binder on admission with details about the resident. He stated any caregiver could pick up the binder and know how to care for the resident. Further interview with Family Member #1, revealed he and Resident #1's mother always tried to tell staff what to expect from the resident and always notified staff he/she scooted around in bed. Family Member #1 stated the facility should have known the resident was active when in bed because he shared that information with the admitting nurse on 10/31/19. However, he stated he did not see the nurse writing down the information and the nurse did not communicate well with him or Resident #1's mother during the admission process. Interview, on 12/11/19 at 8:12 AM, with CNA #1, revealed she was assigned to Resident #1 on 11/01/19 during the day shift . She stated the night shift CNA reported Resident #1 was a new admit for respite care, and was active and able to move around in the bed. Per interview, during the course of the day shift, Resident #1 pulled out his/her Gastric tube when she was bathing the resident and also grabbed her neck during the bath, so she received assistance from CNA #3 for completing the bath. Further interview revealed Resident #1 tried to jump out of the bed a few times, and she reported the resident's behavior to CNA #2 at shift change. Per interview, when she was providing report, CNA #2's response was she knew about Resident #1's tendencies because she had worked with the resident during his/her previous admissions. CNA #1 stated in addition to receiving shift change report, the CNAs were to review the Kardex which served as the CNA Care Plan for each of their assigned residents. Interview, on 12/11/19 at 1:45 PM, with CNA #2, revealed CNAs were to review the Kardex at the beginning of the shift as it served as a guide for caring for the residents, but she did not take time to review the Kardex prior to entering Resident #1's room to provide care on 11/01/19. Per interview, this was because she had reviewed the resident's Kardex during his/her previous respite care admissions. She stated she did receive shift change report from CNA #1 and was told the resident had acted up, during his/her shower and pulled out his/her Gastric tube, and also tried to jump out of bed. Continued interview revealed Resident #1 was in his/her bed when her shift began, and she didn't think she needed help with providing incontinence care to the resident as the resident seemed calm as she approached the bed. Per interview, she unzipped the netting over the Veil bed and checked Resident #1's brief, then lowered the padded rail, and reached for the clean brief at the foot of the bed. She stated at that point the resident fell to the floor. Per interview, she called for help, but no one came, so she picked the resident up off the floor herself and placed him/her back in bed. Further interview with CNA #2, revealed she went to the nurse's station and informed LPN #1 that Resident #1's mouth was bleeding and the nurse entered the resident's room, and asked her what happened. CNA #2 stated she felt confused, and did not tell the nurse about the fall. Per interview, she did not admit to the resident sustaining a fall on 11/01/19, until she was interviewed by administrative staff during a phone call on 11/05/19. Interview, on 12/11/19 at 3:12 PM, with LPN #1, revealed she admitted Resident #1 on 10/31/19, and his/her parents were there on admission and brought a binder with information about the resident. She stated the binder had tips for how to care for the resident such as a list of the resident's likes and dislikes, and it also included information about the way the resident was cared for at home. LPN #1 stated she couldn't remember if she opened the book during this admission, but she did remember some information about the resident being quick. Per interview, she also remembered the resident's mother telling her the resident was on the go all the time, and that staff would need to watch the resident for grabbing at his/her Gastric tube. LPN #1 stated she did not remember the family telling her about the resident's activity level when he/she was lying in bed. Continued interview with LPN #1, revealed the Vice President (VP) of Clinical Services created the Baseline Care Plan for newly admitted residents from the Interdisciplinary Admission Assessment completed by the admitting nurse and from other pertinent information in the record. Further interview revealed she remembered telling CNA #1 on 11/01/19, that she should probably have another care giver help her with bathing Resident #1, and for transferring the resident because he/she exceeded the weight limit for a one (1) person transfer. However, LPN #1 stated she did not have a conversation with CNA #2 about Resident #1 during the afternoon shift change, nor did she ensure CNA #2 reviewed the Baseline Care Plan/Kardex prior to caring for Resident #1. Additional interview with LPN #1, revealed on 11/01/19 about 4:00 PM, CNA #2 approached the nurse's station and asked her if Resident #1 had been to the dental clinic that day because the resident's mouth was bleeding. LPN #1 stated she immediately went to the resident's room and noted the resident was lying on his/her left side in a fetal position and there was blood on the bed, blood all over the resident's head and a pool of blood on the sheet under his/her head. Per interview, the Physician immediately assessed the resident and the resident was transferred to the Hospital Emergency Department. LPN #2 stated CNA #2 did not inform her the resident had sustained a fall and the cause of the injury was unknown at the time the resident was transferred to the Hospital. LPN #1 further stated, In a perfect world the CNAs should review the Baseline Care Plan or Kardex which served as a Care Plan for the CNAs, but that did not always happen. Additional interview revealed CNA #2 should have ensured she had another caregiver assisting with incontinence care for Resident #1 for safety. Interview, on 12/12/19 at 8:56 AM, with the Medical Social Services Manager, revealed when the social services staff made the pre-admission phone contact with Resident #1's mother, and she did not report any changes to the resident's status since his/her previous respite stay at the facility. The Medical Social Services Manager stated she could not remember the binder Resident #1's family brought to the facility, but stated the facility actually encouraged the residents' families to create the informational binders, as this information was helpful in developing the Baseline Care Plans. Interview, on 12/11/19 at 4:10 PM, with the VP of Clinical Services, revealed she initiated the Baseline Care Plan from the pre-admission assessment data collected by the social services staff, and tried to include information about the resident's likes and dislikes, any adaptive equipment used in the home, the type of bed the resident had at home, and other available information as she started the care planning process. Per interview, if any new or unusual information was provided to social services from parents or guardians, she would review that information and determine if a new intervention should be added to the care plan. She stated this same process would be used to formulate a care plan for a resident admitted for respite care. Further, when completing the Interdisciplinary Admission Assessment for a new admission, the nurse would be obligated to include any pertinent information the parents or guardians provided during the admission. Continued interview with the VP of Clinical Services, revealed the CNAs should review the Baseline Care Plan/Kardex on file for each resident before providing care. Per interview, staff would get to know most of the residents very well over time, but it was critically important to review the Baseline Care Plan/Kardex when providing care for a newly admitted resident. The VP of Clinical Services stated CNA #2 had worked at the facility for at least one (1) year, and she thought CNA #2 as well as other direct care staff knew Resident #1 very well due to his/her previous admissions for respite care. She further stated CNA #2 as well as other staff members were aware Resident #1 was very active, even in bed, and should know when two (2) staff would be required during direct care. Post Survey Interview, on 01/03/19 at 10:26 AM with the Vice President (VP) of Clinical Services revealed the care plan from Resident #1's previous respite care stays was reactivated on 11/01/19, and the care plan component that included the intervention for using two (2) care givers when warranted to provide care and assure safety was originally initiated on 07/17/18 during one of the resident's previous stays, and remained a care intervention. The VP of Clinical Services stated she created Resident #1's Baseline Care Plan and it was in affect at the time of Resident #1's fall. Post survey interview, on 01/03/19 at 10:26 AM, with the Clinical Quality Assurance Performance Improvement (QAPI) Specialist, revealed Resident #1's Baseline Care Plan did include an intervention to use two (2) care givers when warranted to provide care and assure safety. Per interview, the as warranted verbiage on Resident #1's Baseline Care Plan referred to the type of care being provided at the time. She explained for example, the resident may not need two (2) staff to administer medication. Per interview, Resident #1's Baseline Care Plan did not specify the quantity of caregivers needed to provide incontinence care. The Clinical QAPI specialist stated if CNA #2 had been informed the resident was very active in report, such as attempting to jump out of bed, the CNA felt should have asked for assistance. She stated all staff had been trained to offer assistance to co-workers when asked to do so, and all staff had been trained to review the Baseline Care Plan/Kardex prior to providing care to residents. Interview, on 12/11/19 at 10:17 AM and on 12/12/19 at 2:38 PM, with the Director of Nursing (DON), revealed the information from the binder brought in by the family would have been useful in developing Resident #1's Baseline Care Plan; however, she did not know if this binder was reviewed by staff. Further interview revealed it was her expectation CNAs review the Baseline Care Plan/Kardex prior to providing care to residents, and this would be especially important prior to providing care for a new admission. When questioned if the Baseline Care Plan/Kardex should have included specific instructions for two (2) staff to provide incontinence care, she stated she did not have any concerns with the development of the Baseline Care Plan, but did state the verbiage on Resident #1's Baseline Care Plan and Kardex, stating two care givers when warranted, would be up to the interpretation of the person reading the care plan. Further interview revealed CNA #2 informed her the resident was calm at the time she approached him/her to change his/her brief on 11/01/19, prior to the resident sustaining the fall, and therefore CNA #2 did not think she needed to ask for assistance with incontinence care. Interview, on 01/03/19 at 9:50 AM, with the Administrator, revealed the facility was still in the seven (7) day window for assessment of Resident #1 when the fall incident occurred. However, he stated the staff had been gathering information about Resident #1's activity level/behavior since his/her admission on 10/31/19. Per interview, the resident's Baseline Care Plan should have been developed and implemented to include two (2) caregivers for any care provided based on the resident's behaviors.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of four (4) sampled residents (Resident #1). Resident #1 was admitted to the facility for respite care on 10/31/19, and on 11/01/19 the resident's Baseline Care Plan and Kardex (Guide used by the Certified Nursing Assistants as a reference for providing care) was developed with interventions for two (2) caregivers to provide care when warranted to assure safety. Resident #1 displayed behaviors on 11/01/19, during first shift including pulling out his/her Gastric tube and the resident required two (2) staff to assist with a bath due to behaviors. Resident #1 also tried to jump out of the Veil bed, which had a mesh netting over the top half of the bed that was enclosed via a zipper type closure. Certified Nursing Assistant (CNA) #1 reported these behaviors to CNA #2 during shift change, on 11/01/19. However, on 11/01/19, CNA #2 attempted to provide incontinence care to Resident #1 independently, and while reaching for a clean brief that was at the foot of the resident's bed, the resident fell to the floor. CNA #2 picked up the resident and placed him/her back on the bed, and then went to get help. Licensed Practical Nurse (LPN) #1 entered the resident's room and noted blood all over the resident's head and a pool of blood on the sheet under his/her head; however, CNA #2 did not initially admit to the resident sustaining a fall. Resident #1 was transferred to the Hospital Emergency Department (ED) and admitted to the Hospital on 11/01/19 with diagnoses including Intrusion of Teeth, Dental Injury, Facial Trauma, and Maxillary Fracture requiring a surgical procedure to extract the four (4) embedded teeth. Per the facility Investigation, the cause of the injury was unknown until CNA #2 admitted on [DATE], the resident fell from the bed during care on 11/01/19. (Refer to F-655) The findings include: Interview with the Administrator, on 12/10/19 at 8:25 AM, revealed the facility did not have a policy related to falls, but did utilize the Unusual Occurrence Reporting Policy. Review of the facility's Unusual Occurrence Reporting Policy, revised March 2018, revealed an unusual occurrence is any episode that harms or has the potential to harm a service recipient. The Policy listed examples of unusual occurrences, including when a service recipient has sustained a fall. Further review of the Policy, revealed unusual occurrence training was provided to employees during orientation, and team members shall understand how to respond to and report unusual occurrences as appropriate to their position. Review of Resident #1's closed clinical record revealed the facility admitted the resident on 10/31/19 with diagnoses including [CONDITION(S)], Autistic Disorder, Dysphagia, Gastrostomy Status, Personal History of Self-Harm, and Unspecified Convulsions. Review of the Interdisciplinary Admission Assessment, dated 10/31/19, revealed Resident #1 was admitted for respite care and Licensed Practical Nurse (LPN) #1 signed the admission assessment. Review of Section F of the assessment, titled Mood and Behavior Patterns & Psychosocial Well-Being, revealed the resident demonstrated fidgeting behavior. Section G, of the assessment, titled Communication/Hearing Patterns, revealed the resident's verbal communication efforts included humming and babble type sounds, and he/she could not use phrases or sentences as means of expression. In addition, the assessment revealed the resident demonstrated very limited ability to understand the communication of others. Review of Section I, titled Activities of Daily Living, revealed Resident #1 was very dependent on staff for all activities of daily living, was to be in a Pedicraft bed with two (2) rails up when in the bed, and required a seat belt when in the wheelchair. The admission assessment also revealed the resident had not fallen, nor had a fracture during the past one hundred eighty (180) days prior to this admission. Post-survey interview, on 01/03/19 at 10:26 AM, with the Clinical Quality Assurance Performance Improvement (QAPI) Specialist, revealed section I of the Interdisciplinary Admission Assessment served as the facility's falls risk assessment as it included information in providing staff with interventions needed in caring for the resident to prevent falls. Review of the Baseline Care Plan, dated 11/01/19, revealed the resident was at risk for injury due to an inability to protect self from injury, self-mobility in bed or on mat, had no preservation skills, and had a history of high risk behavior that placed child and others at risk. The goal stated the resident would remain free from injury through the next review date. The interventions included caregivers to monitor for behavioral symptoms including resisting care, and pinching and hitting others, that placed the resident and others at risk for injury or abuse; and Use two (2) caregivers to provide care when warranted to assure safety. (Refer to F-655) Post Survey interview, on 01/03/19 at 10:26 AM with the Vice President (VP) of Clinical Services, revealed the Baseline Care Plan dated 11/01/19, to include the intervention for using two (2) care givers when warranted to provide care and assure safety, was in place from the resident's previous respite care stay, and re-activated upon admission. Review of the Kardex, dated 11/01/19, revealed the Behavior Monitoring Section included approaches to monitor for behavioral symptoms including resisting care and pinching or hitting others that placed the resident and others at risk for injury or abuse; and Use two (2) people to provide care when warranted to assure safety. Review of the Usual Occurrence Report, dated 11/01/19, completed by the Nursing Supervisor, revealed the time of the actual occurrence was unknown, but he was called to Resident #1's room at 1541 (3:41 PM). The Nursing Supervisor further documented the resident was found in bed with his/her face down, head turned to side, and blood was found on the sheets. The Medical Director was called to the room, and the assessment revealed the resident had no scratches or bruises, but had a bloody mouth with a few front teeth missing. Per the Report, a full skin assessment was completed and the Physician ordered transfer of the resident to a local Hospital ED for further evaluation. Review of the Nurse's Note, dated 11/01/19, time stamped 19:39 (7:39 PM), revealed LPN #1 was called to Resident #1's room by CNA #2. Per the Note, the resident was found in his/her bed with blood on the sheet and on his/her face. LPN #1 then directed staff to call the Nursing Supervisor, and he came to Resident #1's room, as well as the Medical Director. Per the Note, the Medical Director assessed the resident and found additional blood on the resident's neck, nose, mouth, and lips. Further review of the Note, revealed the resident's front teeth were not normal, and the Physician gave an order for the facility to transfer the resident to an acute care Emergency Department (ED) for evaluation. Review of the Hospital Emergency Department (ED) Note, dated 11/01/19, revealed Resident #1 was evaluated on 11/01/19, beginning at 5:14 PM, with visit diagnoses including Intrusion of Teeth, Dental Injury, and Facial Trauma. Computerized Tomography (CT) scanning and x-rays revealed Resident #1's top four (4) teeth were completely intruded, and one of the embedded teeth appeared to be just at the right maxillary sinus wall/floor without actually protruding into the maxillary sinus. Tests also revealed a Maxillary Fracture. Further review revealed the resident was picking at the scabs at his/her mouth during the ED visit, and the family was not comfortable taking the resident home. The Physician on duty admitted Resident #1 to the Hospital for further management of the dental injury. Review of Resident #1's Hospital Discharge Summary, dated 11/06/19, revealed the resident had a surgical procedure to extract the four (4) embedded teeth. Per the Summary, the resident was discharged home to the care of his/her parents on 11/06/19. Review of the facility's Investigation, initiated on 11/01/19, signed by the Director of Nursing (DON), and the Clinical QAPI Specialist, revealed on 11/01/19, the Nursing Supervisor and the Medical Director were notified at 3:41 PM, that Resident #1 had sustained an injury. Per the Investigation, the Medical Director immediately examined the resident and identified bleeding was coming from the resident's mouth and teeth appeared to be missing. The Medical Director determined the resident needed to be evaluated in the Hospital ED and CNA #2 accompanied the resident to the Hospital. Skin assessments were conducted on all residents. Further review revealed the Information Technology (IT) Department retrieved video footage from the hallway outside the resident's room for the date of 11/01/19. Interviews were conducted with staff who had provided care to Resident #1 or were observed on video to be in or around the resident's room between the time the resident was taken back to his/her room at 12:26 PM and the time of the report of the incident. During video review and multiple staff member interviews, it was determined CNA #1, CNA #2, and CNA #3, were the last staff members to be in the resident's room prior to discovery of the injury, and these three (3) staff members were interviewed. CNA #1, CNA #2, and CNA #3 denied being aware of the cause of injury to Resident #1 and on 11/01/19, all three (3) staff members were placed on leave. Review of the Statement obtained by the facility from CNA #2, on 11/01/19 at 8:29 PM, revealed she received report from CNA #1 at 3:00 PM, and was informed the resident had pulled out his/her Gastric Tube earlier in the day. Per the Statement, CNA #2 and CNA #3 spoke at the nurses's station before entering Resident #1's room. CNA #2 took Resident #3's temperature and changed his/her brief around 3:20 PM-3:30 PM. Afterwards CNA #3 left the room and CNA #2 went to check Resident #1 and saw blood. Per the Statement, CNA #2 ran to the nurse to inform her of the blood. Continued review of the Investigation, revealed on Monday, 11/04/19, CNA #1, CNA #2 and CNA #3 were asked to come to the facility to be interviewed by the DON, Medical Social Services and Clinical (QAPI) Specialist, and the Statements obtained from CNA #1, CNA #2 and CNA #3 were consistent with those obtained on 11/01/19. Further review of the Investigation, revealed the DON received a Red e App message (internal messaging system) on 11/05/19 at 8:46 PM from CNA #2, stating she wanted to explain the truth and she had been confused and traumatized from the minute the accident occurred. A three (3) way phone call was initiated at 9:02 PM with CNA #2, DON and the Medical Services Manager. During this call CNA #2 stated she lowered the resident's bed rail and unzipped the bed to check the resident's brief and determined the resident was wet. CNA #2 saw a brief at the end of the bed and placed one hand on the resident and reached with the right hand to get the brief. At this point the resident fell off the bed on to the floor, landing on his/her face and belly. CNA #2 picked the resident up and put him/her in bed and went to find a nurse. Interview, on 12/10/19 at 8:25 AM, and at 9:45 AM, with the Administrator, revealed Resident #1 had a brief stay for respite care. However, the facility transferred the resident to a local Hospital ED due to an injury sustained at the facility on the afternoon of 11/01/19. Further interview revealed the facility had preserved the bed Resident #1 was in when the incident occurred, and asked if the surveyor would like to see the bed. Observation, on 12/10/19 at 9:50 AM, revealed the bed was stored in the basement of the facility. There was a mesh netting over the top half of the bed that was enclosed via a zipper type closure. The white fabric covered mattress pad had a brown/red stain near the head of the bed which was approximately four (4) x five (5) inches in size with uneven edges. There was also a smaller brown/red stain on one of the padded side rails near the head of the bed. The Administrator stated the facility did not preserve the sheets that were on the bed at the time of the incident, and he thought they had been washed. Interview, on 12/11/19 at 8:12 AM, with CNA #1, revealed she was the assigned caregiver for Resident #1 for the day shift (11/01/19). Per interview, the night shift CNA reported Resident #1 was a new admit for respite care, and was active and able to move around in the bed. CNA #1 stated during the course of the day shift, Resident #1 pulled out his/her Gastric tube when she was bathing the resident, and also grabbed her neck while she was bathing him/her so she received assistance from CNA #3 for completing the bath. Per interview, the resident also tried to jump out of the bed a few times, and she reported the resident's behavior to CNA #2 at shift change. CNA #1 further stated when she was providing report, CNA #2's response was she knew about Resident #1's tendencies because she had worked with the resident during his/her previous admissions. CNA #1 stated in addition to getting shift change report, the CNAs were supposed to review the Kardex for each of their assigned residents to learn of any changes in care. Phone interview, on 12/11/19 at 1:45 PM, with CNA #2, revealed on 11/01/19, she received the change of shift report from CNA #1, who told her Resident #1 had acted up, during his/her shower and pulled out his/her Gastric tube. Further, CNA #1 told her the resident had also tried to jump out of bed. CNA #2 stated Resident #1 was in his/her bed when she started her shift, and entered the resident's room to provide care for both Residents #1 and Resident #3. CNA #2 stated CNA #3 followed her into the room, and while she was taking Resident #3's vital signs, CNA #3 started talking to her about being upset related to something CNA #2 had said earlier. CNA #2 stated she apologized and then went to the other side of the room to check on Resident #1, and CNA #3 left the room. Further phone interview with CNA #2, revealed the Kardex was the guide the CNAs used as a reference in providing care, but she did not take time to review the Kardex prior to entering Resident #1's room because she thought she could provide care for Resident #1 independently. CNA# 2 stated she checked on Resident #1 by unzipping the mesh cover over the resident's bed. Per interview, the resident's brief needed to be changed, so she lowered the bed rail, and reached for a clean brief that was at the foot of Resident #1's bed. She stated she thought she tried to stay in front of the resident at the middle portion of the bed, but the resident slid on the bed, and fell to the floor. Per interview, she yelled for help, but did not think about pressing the call light near the resident's bed. CNA #2 further stated when no one responded, she picked up the resident and placed him/her back on the bed. Per interview, she went to the nurse's station and informed LPN #1 that Resident #1's mouth and the nurse immediately went to the resident's room and asked her what happened. CNA #2 stated she felt confused, and was not able tell the nurse about the fall. She further stated the nurse told her to call the Nursing Supervisor, and have him come to the room. Further phone interview with CNA #2, revealed she sent a text to the Director of Nursing (DON) on 11/04/19 (Per the investigation, CNA #2 sent the text to the DON on 11/05/19), and in the text she explained that just after the resident fell , she felt very confused. Per interview, she was very scared, and stated My mind was being still. She stated that was the reason she could not tell the DON or others who interviewed her on 11/01/19, exactly what happened. When the Surveyor questioned if she should have ensured another staff member was assisting her in providing incontinence care to Resident #1 on 11/01/19, CNA #2 responded she did not think she needed someone to help her provide incontinence care because the resident looked calm when she went to his/her bedside to provide care. Interview, on 12/10/19 at 2:30 PM, with LPN #1, revealed she was sitting at the nurses' station, and happened to be on the phone with Resident #1's mother who had called in to see how the resident's day had gone. LPN #1 stated at that point, she told Resident #1's mother the resident had been having a good day. However, she stated during the call, CNA #2 approached the nurse's station and asked her if Resident #1 had been to the dental clinic that day because the resident's mouth was bleeding. LPN #1 stated she immediately went to the resident's room. Per interview, Resident #1 was lying on his/her left side in a fetal position in bed, and she saw blood on the bed. LPN #1 stated she unzipped only the top portion of the netting closest to the head of the bed because she knew the resident was very active. She stated she saw blood all over the resident's head and a pool of blood on the sheet under his/her head; however, did not notice any blood on the floor at that time. Further interview with LPN #1, revealed she immediately sent CNA #2 to have someone contact the Nursing Supervisor and the Physician while she stayed with the resident. She stated the Nursing Supervisor and the Physician came to the resident's room, and the Physician could not see the resident's top front teeth, and gave an order to transfer the resident to the hospital emergency room . Per interview, prior to the injury, Resident #1's front teeth were easy to see. Further interview revealed CNA #2 did not inform her the resident fell from the bed and she did not have a chance to question CNA #2 about what happened because the Nursing Supervisor directed the CNA to ride with the resident to the Hospital ED and stay with him/her until the resident's parents arrived. Additional interview with LPN #1, revealed she remembered telling CNA #1 during day shift, she should probably have another care giver help her with bathing the resident, and for transferring the resident because he/she exceeded the weight limit for a one (1) person transfer. However, LPN stated she did not have a conversation with CNA #2 about Resident #1 during the afternoon shift change. LPN #1 stated, in retrospect, it would have been best to provide a shift report to CNA #2, or at least ensure that CNA #1 gave CNA #2 a detailed report on Resident #1. LPN #1 stated, In a perfect world the CNAs should review the Kardex which served as a Care Plan for the CNAs, but that did not always happen. Per interview, CNA #2 should have ensured she had another caregiver assisting with incontinence care for Resident #1 for safety, as the resident was very active. Per interview, it was ultimately the licensed nurse's responsibility to instruct CNAs on how to provide safe resident care. Interview, on 12/12/19 at 10:43 AM, with the Medical Director, revealed she was in the facility and was called to assess Resident #1 on 11/01/19. She stated when she entered Resident #1's room, there was blood noted on the bed. Per interview, she could not see the resident's mouth easily as there was a lot of blood around his/her mouth. She stated she could not palpate the resident's top front teeth, so she gave an order for the facility to transfer the resident to the hospital for evaluation of the injury. The Medical Director stated she spoke with the Hospital ED Physician later that day and learned Resident 1's teeth had been pushed into his/her gums, and the Hospital was in the process of obtaining a Computerized Tomography (CT) scan. Per interview, the ED Physician informed her the Oral-Maxillo Surgeon was consulted, and was evaluating the resident for any hairline fractures of the facial bones. The Medical Director further stated she thought the fall was the result of a lapse in judgement on CNA #2's part for not ensuring two (2) staff provided care. Per interview, the resident was in a veiled bed because he/she did move about when in the bed. Interview, on 12/10/19 at 11:00 AM, with the Vice President (VP) of Clinical Services, revealed the Nursing Supervisor and the Medical Director were called to Resident #1's room on 11/01/19, once it was apparent the resident had bleeding with a mouth injury. Per interview, the Medical Director assessed the resident, but the resident's top front teeth were not visible, and when staff searched the bed, they could not find the resident's teeth. Per interview, CNA #2 did not immediately reveal Resident #1 fell from the bed when she was attempting to change the resident's brief. Continued interview revealed Resident #1 was transferred to an acute care Hospital for evaluation, and the facility notified the resident's parents who met the resident at the hospital. Further interview revealed the facility continued to investigate the incident, but it was not clear what caused the injury to the resident's face and mouth until 11/05/19 when CNA #2 told the DON and the Medical Social Services Manager what caused the injury to the resident's face and mouth. The VP of Clinical Services stated, during the interview with the DON and the Medical Social Services Manager, on 11/05/19 at 9:01 PM, CNA #2 told them when she was reaching for a clean brief at the foot of the resident's bed, the resident fell from the bed to the floor. Interview, on 12/11/19 at 6:45 PM, with Family member #1, revealed Resident #1 had received respite care at the facility in the past and each time, he and the resident's mother left a binder with details about the resident including tips for communicating with the resident. Per interview, any caregiver could pick up the binder and know how to care for the resident. Further, he tried to tell the staff what to expect from the resident, and always requested a veil bed. Per interview, the resident had a sleep safe bed at home because the resident scooted around in the bed and if the resident saw something of interest he/she would try to reach for it. Family Member #1 stated he told the admitting nurse (LPN #1) about the resident's scooting behavior, but he did not see the nurse writing down the information. He followed up by saying, Honestly, we were not very enthused about the nurse. When the surveyor asked Family Member #1 to clarify the statement, he stated the nurse who admitted Resident #1 did not communicate well with them. Additional interview with Family Member #1, revealed the facility staff notified him and Resident #1's mother just after the incident occurred, and he and the resident's mother met the resident at the hospital. Family Member #1 stated the ED Physician told them Resident #1's top front teeth had been shoved into his/her gums, were completely invisible, and were almost touching the resident's sinus cavity. Additional interview revealed Resident #1's teeth could not be saved, and he thought the resident also sustained a fracture to a bone at or near the roof of his/her mouth. Family Member #1 stated the injury had changed Resident #1's appearance and his/her life, forever. Interview, on 12/11/19 at 11:17 AM, on 12/12/19 at 2:38 PM, and post survey interview on 01/03/19 at 11:00 AM, with the DON, revealed pending the outcome of the investigation related to Resident #1's injury, the facility initially suspended CNAs #1, #2 and #3. She stated it was initially unclear how the incident happened because CNA #2 was not forthcoming with information when interviewed by Administrative staff on 11/01/19. Per interview, on 11/01/19, CNA #2 was interviewed by the Administrator, Medical Social Services Coordinator, and DON and per her interview, she found the resident in bed with bleeding, and wondered if he/she had a dental procedure that day. Per interview, CNA's account did not change until she was interviewed by the DON and Medical Social Services Manager on the evening of 11/05/19, and then she admitted the resident sustained a fall from the bed causing the injury. Additional interview revealed the Kardex was the guide used by the CNAs to provide care, and it incorporated information from the Baseline Care Plan. She stated the verbiage on Resident #1's Kardex, two care givers when warranted, would be up to the interpretation of the person reading the care plan. The DON stated CNA #2 should have checked the resident's Kardex prior to providing care and also should have ensured she received a detailed report on the resident as he/she was a new admit and had behaviors. The DON further stated she did not think staff adequately communicated with each other during the afternoon shift change report when CNA #2 came on shift on 11/01/19. Per interview, CNA #2 told her in the interview on 11/05/19, Resident #1 looked calm when she entered his/her room on 11/01/19 to provide care, and therefore she did not think she would need a second caregiver while changing the resident's brief. Per interview, it was the responsibility of the licensed nurse to ensure staff checked the Kardex, and received a detailed report at shift change. Further, it was the nurse's responsibility to give CNAs guidance on how to provide safe resident care. Interview, on 12/12/19 at 3:05 PM, with the Staff Development Coordinator, revealed after Resident #1's fall, she met with the DON and the Quality Assurance (QA) Specialist and it was identified there needed to be staff training related to the importance of walking rounds, staff communication, reporting of adverse events, and on a resident's right to receive safe care. She further stated the training began on 11/06/19, and staff members working on all cottages received the training. Interview, on 12/12/19 at 3:55 PM, and post survey interview on 01/03/20 at 9:28 AM, with the Administrator, revealed newly hired employees received training for safe resident care practices. Per interview, during the course of the investigation of the incident involving Resident #1, it was identified CNA #2 should have reviewed Resident #1's Kardex as well as identified the need for two (2) staff to provide incontinence care for the resident. Further interview revealed CNA #2 should have been forthcoming and reported that the resident sustained a fall immediately after the event on 11/01/19. Per interview, the facility staff did not receive CNA #2's statement that the resident fell from the bed while she was providing care until the evening of 11/05/19 during the arranged three (3) way call with the DON and the Medical Social Services Manager. Continued interview revealed CNA #2 might have been distracted just before going to Resident #1's bedside on 11/01/19, because during the investigation it was identified CNA #3 approached CNA #2 in Resident #1's room, and told CNA #2, that she (CNA #3) was upset with her. He further stated that might have caused a distraction, as CNA #2 might have been upset by CNA #3's comments. Further interview revealed after the incident, the facility looked for ways to implement corrective action, and staff in-service education was provided.

Based on interview, record review, review of facility policies, and review of the facility's investigations and security video, it was determined the facility failed to have an effective system to protect one (1) of five (5) sampled residents, Resident #2, from abuse. Record review and staff interviews revealed the facility was aware of Resident #1's sexually acting out behaviors at the facility and at school. Per staff interviews, staff was to have close supervision of Resident #1 while on the unit and one (1) to one (1) supervision when off the unit; however, Resident #1 and Resident #2 were in the unit's activity area without staff supervision. Interview and review of the facility's security video revealed, on 12/10/17, Resident #1 pulled Resident #2's pants and brief down, and put his/her hand down Resident #2 pants and put his/her face into Resident #2's genital area. Resident #2 was unable to call out for assistance. Per interview with the Director of Nursing (DON) and the Vice President of Clinical Services, the facility had not assigned supervision for the activity area of the unit where Resident #1 and Resident #2 were stationed. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/26/18, and it was determined to exist on 12/10/17. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 02/09/18, alleging removal of the IJ on 02/05/18. The State Survey Agency validated the IJ was removed on 02/05/18, prior to exit on 02/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Resident Focused Services: Protecting Residents/Clients/Patients from Abuse and Neglect, revised (MONTH) (YEAR), revealed the facility was to protect all residents from abuse and neglect. Further review revealed the facility was to ensure the safety of the residents under the care of the facility. Review of the facility's policy, Protecting Residents/Clients from Abuse/Neglect: Managing Allegations of Abuse/Neglect, revised (MONTH) (YEAR), revealed the facility was to do everything within the facilities control to prevent abuse to the residents. Review of the facility's policy, Assessment: Child Abuse/Neglect Identification Criteria, revised (MONTH) 2013, revealed criteria was to be utilized as potential indicators of abuse/neglect, which included family health history of being abused as a child, history of abuse of or by a sibling, and history of the child in foster home placement for abuse/neglect. Further review revealed the child health history was to review which included excessive or public masturbation. Review of the facility's Attestation of Commitment, dated (YEAR), revealed the number one commitment of the facility's staff was to keep the child resident safe. Review of the facility's Residents' Rights Packet, not dated, revealed all residents were to be free of mental and physical abuse, and chemical and physical restraints. Review of the facility's security video, on 01/22/18 at 2:20 PM, with the DON and Vice President of Clinical Services, revealed the DON and Vice President of Clinical Services identified Resident #1 and #2 in the video on 12/10/17. Resident #1 and #2 were in the activity area of the unit by themselves. Resident #1 moved Resident #2's belt and unfastened the left and right side of the resident's brief and pulled down Resident #2's pants to expose the lower portion of abdomen. Resident #1 attempted multiple different angles to put a hand into Resident #2's pants. Resident #1 was self-gratifying using his/her left hand while pulling down Resident #2's pants. Resident #1 also peered physically into Resident #2's brief and placed his/her face directly into Resident #2's genital area. The DON and Vice President of Clinical Services identified nineteen (19) minutes of the security video recorded and seventeen (17) minutes revealed staff could not be seen providing supervision. The DON and Vice President of Clinical Services revealed the facility did not assign supervision in the activity area of the unit. Review of a facility investigation, dated 12/14/17, revealed on 12/10/17 Certified Nursing Assistant (CNA) #2 observed Resident #1 with his/her hand in Resident #2's pants in the community area of the unit. When questioned what he/she was doing, Resident #1 quickly jerked his/her hand away and returned to his/her room. The facility reviewed the video which showed Resident #1 attempting to undo Resident #2's pants/brief and put his/her hand down Resident #2's pants. Resident #1 admitted to touching Resident #2's private area and was placed under one (1) to one (1) supervision. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/08/15, with the [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Staff Assessment for Mental Status was conducted and determined the resident was severely impaired. The facility assessed Resident #2 was totally dependent on staff for all self-care needs. Interview with Resident #1, on 01/18/18 at 3:40 PM, revealed Resident #1 placed his/her hand into Resident #2's pants. Resident #1 stated he/she looked around the unit where he/she and Resident #2 were so he/she would not get into trouble. Resident #1 stated it was wrong what he/she had done. Review of Resident #1's clinical record revealed the facility admitted the resident on 02/18/16, with the [DIAGNOSES REDACTED]. Review of Resident #1's initial History and Physical, dated 02/18/16, revealed Resident #1 was removed from the biological family in (MONTH) (YEAR) for sexual abuse by a brother with maternal indifference as well as maternal substance abuse, and maternal incarceration. Resident #1 was placed in foster care and the foster family refused to continue care for Resident #1. Review of a quarterly MDS, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview of Mental Status (BIMS) score of eleven (11) out of fifteen (15) and determined the resident was interviewable. The facility assessed the resident displayed behaviors such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, and/or screaming and disruptive sounds. Review of a quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of six (6) out of fifteen (15) and determined the resident not interviewable. The facility assessed the resident displayed behaviors as described above. Review of Resident #1's Nursing Note, dated 05/22/17, revealed Resident #1 was masturbating in the common area of the unit. The CNA instructed Resident #1 the behavior was not allowed in the public area of the unit and should be done in the privacy of his/her room. Resident #1 verbalized understanding of the instruction. Review of Resident #1's Nursing Note, dated 06/11/17, revealed while visiting another unit in the facility, Resident #1 pulled up his/her shirt and shook his/her chest toward a female resident. Staff redirected Resident #1 and sent him/her back to the assigned unit with notification of the supervisor. Review of Resident #1's Nursing Note, dated 07/03/17 at 5:00 PM, revealed Resident #1 expressed to a resident he/she loved them while on the facility phone. Review of a facility's investigation revealed Social Services interviewed Resident #1, on 10/26/17, and Resident #1 admitted to being involved in sexual inappropriate behaviors at school. Resident #1 stated a second student instructed Resident #1 to pull his/her pants down and Resident #1 told a third student to lick his/her private area, and at that time, the second student pushed the third student's head down into Resident #1's lap. The Social Service Director interviewed the School Principal, on 10/27/17, and the school reported Resident #1 had an incident prior to the 10/26/17 incident, toward the same peer at school. Resident #1 kissed the same peer on cheek without peer consent. Interview with the DON, on 01/24/18 at 12:35 PM, revealed Resident #1's school informed the facility their investigation deemed the resident participated in the incident and was not a victim. Interview with the Education Coordinator, on 01/19/18 at 11:12 AM, revealed the school counselor notified her of the incident at school on 10/26/17. She stated she agreed with the upper management that Resident #1 required better supervision at school and was a danger to other students. She stated after the (MONTH) (YEAR) school incident, Resident #1 was to be supervised by staff when on the unit, and have one (1) on one (1) supervision when off the unit. She further stated Resident #1 knew right from wrong. Review of Resident #1's Social Services Note, dated 10/26/17 at 9:03 PM, revealed Resident #1 was restricted to unit activities. Review of Resident #1's Quarterly Care Plan Evaluation Note, dated 11/10/17, revealed Resident #1 had behavioral issues at school and a facility meeting was held on 11/09/17, with the decision to move Resident #1 to a new school. The Activity Director documented Resident #1 was to be closely monitored when around other residents due to the recent inappropriate behavior, and activities were one (1) to one (1) interaction. As an additional precaution, during planned swimming activities, Resident #1 was to be with male residents only. Review of Resident #1's Quarterly Care Plan Evaluation Note, by the MDS Coordinator, dated 11/16/17, revealed Resident #1 made statements toward same sexed residents in regard to loving them, and was noted to have significant behavioral issues which were sexual in nature at school in (MONTH) (YEAR). Interview with the Social Services Coordinator, on 01/19/18 at 10:49 AM, revealed the facility made the decision to move Resident #1 to a new school and to continue counseling by the Psychology Practicum Student for appropriate boundaries, appropriate and inappropriate behaviors, and hoped that would address the issues with Resident #1. She further stated the facility had not foreseen any issues regarding Resident #1's school incident and risks in the facility. Interview with the Social Services Manager, on 01/25/18 at 3:50 PM, revealed Resident #1 had Internet privileges taken away at the facility and at school prior to the school incident in (MONTH) (YEAR), because Resident #1 had viewed pornographic videos. Interview with Nursing Supervisor #1, on 01/18/18 at 3:29 PM, revealed staff and Administration had previous knowledge of Resident #1's behaviors before the (MONTH) (YEAR) school incident, including masturbating in public areas of unit. She stated staff redirected Resident #1 to go to the privacy of his/her room. According to the Supervisor, the supervisors and Administration had discussed Resident #1's behaviors, which included the (MONTH) (YEAR) school incident. She stated she had no concerns for the other residents on the unit in regards to Resident #1 behaviors. She stated the facility did not meet to discuss interventions to put in place within the facility after the (MONTH) (YEAR) school incident with the exception of close monitoring, and staff accompany Resident #1 outside of the unit. She stated the facility did not think what happened in school in (MONTH) (YEAR) would happen in the facility. Interview with CNA #7, on 01/27/18 at 8:17 PM, revealed Resident #1 was brought to other units to visit with peers of the same age. CNA #7 stated before the 10/26/17 school incident, she was instructed to have Resident #1 within eyesight to keep close supervision, and the resident was not to be alone with other residents. CNA #7 stated nursing staff was unable to keep constant supervision of Resident #1 because staff had to provide care to other residents on the unit. Review of Resident #1's Nursing Note, dated 12/11/17 at 8:25 AM, revealed CNA #2 notified Licensed Practical Nurse (LPN #1) with concerns that Resident #2 was the victim of a sexual assault by Resident #1 in the back of the unit (which occurred on 12/10/17). CNA #2 reported she found Resident #2 with his/her pants and diaper pulled down with exposed pubic hair, and Resident #1's hand was in Resident #2's genital area. The CNA told Resident #1 not to touch Resident #2 and Resident #1 went to his/her room. LPN #1 noted she went to Resident #1's room and asked if Resident #1 touched Resident #2 and Resident #1 stated yes, after reminded of the presence of security tapes. LPN #1 instructed Resident #1 to stay away from Resident #2 for the day. LPN #1 noted Resident #2 was kept in the sunroom area of the unit and she kept an eye on him/her and notified the supervisor. Resident #1 was placed on one (1) to one (1) supervision with supervisor notification. Interview with CNA #2, on 01/19/18 at 9:12 AM, via telephone, revealed when she came back from break on 12/10/17, she noticed Resident #1 with his/her hand in Resident #2's pants. When she asked Resident #1 what he/she was doing, the resident said he/she was fixing Resident #2's pants and immediately left the area. According to CNA #2, Resident's #2 pants and brief were pulled down low enough to see pubic hair. Resident #2 clothes were readjusted and she reported the incident to LPN #1. Interview with LPN #1, on 01/18/18 at 2:50 PM and on 01/19/18 at 2:35 PM, revealed she was in charge of Resident #1's care on 12/10/17. She stated CNA #2 reported Resident #1's hand was in Resident #2's pants. Resident #1 admitted to putting his/her hand down Resident #2's pants. LPN #1 stated she instructed Resident #1 to stay away from Resident #2, and stay in his/her room. LPN #1 noted Resident #2's brief was pulled down, and pubic hair was exposed. Continued interview with LPN #1, on 01/19/18 at 2:35 PM, revealed LPN #1 stated Resident #1 had previous behaviors before the 12/10/17 incident with Resident #2. LPN #1 stated Resident #1 had an incident at school in (MONTH) (YEAR), which involved another student and inappropriate behaviors. LPN #1 stated she spoke to the Social Services Coordinator, the DON, and to the Vice President with concerns for the welfare of the residents on the same unit. She stated she had concerns because the residents in the same unit could not move away from Resident #1 or call for help. LPN #1 stated she had not received orders, instructions, or a revised care plan to address behaviors for Resident #1 before or after the 10/26/17 school incident. LPN #1 stated she was not surprised the incident on 12/10/17 occurred, as no interventions were put in place after the (MONTH) (YEAR) school incident, except to move Resident #1 to a new school. LPN #1 stated Resident#1 was not placed with a sitter or CNA after the 10/26/17 school incident. According to LPN #1, the facility instructed staff to have close supervision of Resident #1; however, staff was unable to closely supervise Resident #1 in the unit because staff was responsible for seven (7) other residents. Interview with CNA #3, on 01/21/18 at 7:38 PM, revealed staff was responsible for their assigned residents, which included supervision. CNA #3 stated when staff was in resident rooms providing care, they were unable to supervise the other residents who were in the common area. Interview with CNA #5, on 01/22/18 at 1:15 PM, revealed staff was not assigned to supervise residents in the activity area of the unit. CNA #5 stated the facility instructed staff to have close supervision of Resident #1 after the 10/26/17 school incident. CNA #5 stated close supervision was not possible because staff was responsible for seven (7) other residents on the assigned teams. CNA #5 stated staff discussed concerns regarding Resident #1's higher functioning, mobility, behavior, and the safety of other residents with Supervisors and Administration. Interview with LPN #3, on 01/22/18 at 1:45 PM, revealed the facility instructed staff to closely monitor Resident #1, and keep the resident in eyesight at all times because of the incident at school on 10/26/17. LPN #3 stated staff was unable to care for Resident #1 adequately concerning mental health needs. LPN #3 stated residents who were abused could be emotionally and physically scarred for life. LPN #3 stated the facility was responsible for the safety of the residents. Interview with LPN #4, on 01/22/18 at 2:00 PM, revealed Resident #1 also touched staff inappropriately and the facility knew about the behaviors. LPN #4 stated the facility had group discussions with supervisors present concerning the safety of the other residents, and Resident #1 after the incident at school in (MONTH) (YEAR), and the facility told staff the facility was working on the discharge of Resident #1. LPN #4 stated the facility instructed staff to monitor Resident #1 closely to protect the other residents on the unit; however, she stated staff could not monitor residents who were mobile because staff had responsibilities to the other residents who were not mobile and dependent on care. Continued interview with Nursing Supervisor #1, on 01/23/18 at 1:50 PM, revealed she spoke to the DON and Vice President of Clinical Services regarding Resident #1 and the (MONTH) (YEAR) school incident. She further stated staff, supervisors, and Administration were not trained to handle residents with behaviors and a history of sexual abuse. She stated the facility had minimal exposure to residents who could walk, talk, and interact. She further stated she knew the facility had not done a good job protecting Resident #2 and the facility missed the possibility of an incident occurring in the facility. Interview with Registered Nurse (RN) #4, on 02/09/18 at 8:36 AM revealed higher functioning residents required constant supervision but staff on the units were unable to provide supervision when providing care in resident rooms. RN #4 stated the facility had not trained staff in behavioral care needs for residents who were higher functioning. She stated it was the responsibility of the facility to protect all residents. Interview with the Medical Director, on 01/23/18 at 11:55 AM, revealed Resident #1 had typical teenage behaviors in regard to self-gratification and was redirected to his/her room when that occurred in the open unit. The Medical Director stated she determined Resident #1 understood the participation in the school incident in (MONTH) (YEAR) was a bad decision. The Director stated the facility had heightened the awareness concerning Resident #1 after the school incident and she deemed the school incident as an isolated occurrence, and the facility discussed Resident #1 care, concerns, and family dynamics often. Interview with the Assistant Medical Director, on 01/22/18 at 11:48 AM, revealed Resident #1 had known inappropriate behaviors before the (MONTH) (YEAR) school incident. She stated she never thought Resident #1 would be a sexual predator and had not considered Resident #1 a risk to other residents. She further stated if she had thought Resident #1 had potential to be a predator, she would have had Resident #1 on one (1) to one (1) supervision. She stated the facility discussed Resident #1's (MONTH) (YEAR) school incident during the quarterly care plan meeting in (MONTH) (YEAR). Continued interview with the Assistant Medical Director, on 01/23/18 at 2:20 PM, revealed the facility was aware of Resident #1's incident at school and the behaviors that occurred in the facility. He stated Resident #1 had normal behaviors to masturbate and had done that behavior in the open unit at times. He stated the facility was aware of Resident #1's past abuse history and the facility focused on protecting Resident #1 rather than protecting other residents from Resident #1. The Assistant Director stated the facility had not looked closely into Resident #1's incident at school on 10/26/17, and with the background social history, failed to evaluate how it affected the resident's behavior in the facility. He further stated it was the facility's responsibility to ensure all residents were safe. Interview with the DON, on 01/24/18 at 12:35 PM, revealed the facility did not have steps in place to monitor residents with behaviors. The DON revealed previous behaviors of masturbating in the open unit, inappropriate sexual comments, and inappropriate behavior with residents, and Resident #1's previous sexual abuse by the family, were known by the facility before (MONTH) (YEAR) and before the 12/10/17 incident in the facility. She stated the facility was not capable to provide one (1) to one (1) supervision. According to the DON, the facility failed to anticipate or understand the behaviors of Resident #1, which led to the failure to protect Resident #2 from abuse. Interview with the Vice President of Clinical Services, on 01/24/18 at 1:30 PM, revealed the facility did not have prior knowledge of the possibility of Resident #1 abuse to Resident #2 was going to happen and she did not feel the facility was able to prevent the incident. She stated Resident #1 was curious about the body and did not have boundaries due to not having boundaries at home. She stated the unit's activity area was not assigned to staff to monitor and supervise; however, staff was always on the unit providing supervision. She stated the facility had numerous residents who were sexually abused in their history and this had not put the residents in a higher category to become an abuser. She further stated to protect residents from abuse was difficult and she did not feel the facility failed to protect the residents from abuse based on what the facility knew of Resident #1. Continued interview with the Social Services Manager, on 01/25/18 at 3:50 PM, revealed Administration was aware of Resident #1's behaviors, which included self-gratification in a public area, pornographic material, and anger toward other residents such as yelling and throwing objects, inappropriate comments, inappropriate touching towards female staff, and touching other residents. She stated the facility was responsible for the safety of all residents and when Resident #1 was outside of the assigned unit after the 10/26/17 school incident, the facility had a staff person with Resident #1 for supervision. She further stated she and the Administration instructed staff on the unit to provide close supervision of Resident #1, and staff was to supervise Resident #1 as part of the staffs' assigned duty. However, review of Resident #1's Care Plan, dated 08/21/17 and 11/20/17, revealed Resident #1 was not care planned for inappropriate behaviors. In addition, the Care Plan, dated 11/20/17, did not address the school incident of 10/26/17. Further review of Resident #1's Care Plan, dated 01/19/18, revealed Resident #1 displayed impulsive and inappropriate behaviors with inappropriate touching of peers, and self-regulated behaviors; however, the 12/10/17 incident was not added to the care plan with client centered interventions and goals. In addition, the care plan did not address supervision of Resident #1. Interview with Child Protection Services (CPS) Case Worker, on 01/29/18 at 9:29 AM, revealed the facility was notified of Resident #1's abuse history. The Case Worker stated the facility had been notified Resident #1's foster family had requested Resident #1 be removed from the home after Resident #1 had exposed his/her genitals to the family. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) supervision at all times beginning 12/10/17. 2. Resident #2 was evaluated by the Medical Social Services Coordinator (MSSC) on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. In addition, the MSSC regularly reviewed nursing documentation for Resident #2 including Nursing Narrative Notes, and Behavior and Response to Care Notes in order to assess changes in Resident #2's behavior and evidence of psychosocial harm. 3. Resident #2 was moved to a different unit, Ocean Avenue, on 12/15/17. 4. Resident #1 was discharged from the facility on 01/22/18, at the request of his/her mother who regained custody of Resident #1. 5. The Vice President of Clinical Services reviewed Interdisciplinary Progress Notes, Behavior and Response to Care Notes, and Skin Observation Notes on 01/24/18 and 01/25/18 for each resident on Maple Way, where the abuse occurred, for (MONTH) (YEAR), to determine if any physical or psychosocial signs or symptoms of abuse were documented on other residents and if additional residents might have been impacted or were at risk from Resident #1. 6. A root cause analysis was facilitated by the Vice President of Quality Improvement and Compliance and completed by facility team members including the Senior Vice President (SVP), Vice President of Clinical Services (VPCS), Director of Nursing (DON), Medical Director, Vice President of Therapy Services (VPTS), Medical Social Services Manager (MSSM), Medical Social Services Coordinator (MSSC), Health Information Management Coordinator (HIMC), Staff Development Coordinator (SDC), Respiratory Therapy Manager (RTM), Education Coordinator, Registered Nurse (RN) Clinical Supervisor, Child Development Coordinator and the facility's Administrative Assistant on 01/26/18 and 01/30/18. The Five Why's Methodology was used to determine why the facility failed to protect a resident from abuse. 7. Training on the Immediate Jeopardy, and on recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was developed on 01/26/18 by leadership, including SVP, VPCS, DON, MSSM, MSSC, and VPTS. 8. Training was implemented on 01/26/18 by leadership team members including SVP, VPCS, DON, MSSM, MSSC, HIMC, SDC, RTM, RN Clinical Supervisors and VPTS. Training was required for all team members prior to providing care. 9. Trainings occurred several times a day on 01/26/18, 01/27/18, 01/28/18, 01/29/18, 01/30/18, 01/31/18, 02/01/18, 02/02/18, 02/03/18, and 02/04/18. A leadership team member was stationed at the time clock to notify team members to report for training prior to going on units to provide care through 01/30/18 and a notice was posted at the time clock by the Director of Nursing to alert team members about required training. A notice was distributed by an electronic team member notification application, and by email listing dates and times of retraining. 10. All resident Care Plans and Kardexes were updated by MSSC, MSSM, and the VPCS. Updates occurred on 01/27/18, 01/30/18, 01/31/18, 02/02/18, and 02/03/18 to reflect residents' histories of abuse or neglect, any known high-risk behaviors, and subsequent level of intervention and supervision required. 11. Resident #2's care plan was updated by the MSSC and the VPCS on 01/27/18, to include monitoring of symptoms including changes in behavior, withdrawal, aggressive or disruptive behavior, symptoms of anxiety or depression, changes in sleep patterns, and crying. 12. Resident #2 was referred to a Psychologist for an intensive follow up evaluation and assessed on 01/29/18. 13. As a result of the root-cause analysis conducted on 01/30/18 by the interdisciplinary care team, the team further discussed every resident in an effort to evaluate and determine known histories of abuse or neglect and/or high-risk behaviors that could place each resident or other residents at risk for injury, abuse, or neglect. Further discussion resulted in the need for additional supervision and it was determined Cottage Safety Monitors (CSM) would be utilized to provide additional supervision. 14. The VPCS created a new procedure titled, Resident Supervision, which included a plan to implement CSM's and Safety Circles on 01/31/18. An email describing the new procedure and expectations was sent to all staff on 02/01/18. CSM's would be utilized during waking hours on cottages where additional supervision was required to monitor residents and mitigate the risk of injury, abuse, or neglect. CSM's will provide structured, age appropriate activities when possible to engage residents while providing appropriate oversight and supervision. CSM's will identify themselves to team members assigned to the unit. 15. The VPCS and the Clinical Quality Improvement Specialist created a new procedure, Behavior Management, that outlined an improved process for behavioral and mental health services and management. The procedure included emphasis on recognizing and communicating when residents have high-risk behavior or behavioral symptoms. The VPCS sent an email describing the new procedure and team member expectations to all staff on 02/03/18, with a read receipt that acknowledges each team member's acceptance of the responsibility for knowing and understanding high-risk behaviors of residents as well as monitoring for, prohibiting, and preventing negative outcomes. 16. Training on Immediate Jeopardy, recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was attended by team members in the following departments: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, the facility's Administrative Team, Restorative Aides, Physical Therapy, Speech Therapy, Occupational Therapy, Respiratory Therapy, Receptionists, Training, Dietary, Finance, Maintenance, Information Technology, Environmental Services, Laundry, Materials Management and Quality Improvement and Compliance. Twenty-one (21) individuals had yet to complete training but were arranged to be trained prior to any care delivery. Contracted agency personnel and students had been trained and will be trained prior to any provision of care. Refer to training dates listed in #9. 17. Resident room placement and resident dynamics on each unit was evaluated to determine where CSM's would be required. 18. CSM's will follow the expectations outlined in the procedure titled, Managing Allegations of Abuse or Neglect, for removing the offending resident or individual and immediately reporting to a leadership team member if an inappropriate incident occurred. CSM's were responsible for ensuring continuous coverage by designating the CSM role to another available team member. CSM's were also responsible for ensuring that mobile residents were in the community area, in their room without a roommate present, or in bed. 19. A red Safety Circle was placed on the back of the wheelchair of residents that were mobile, those with the functional ability to reach out to others with either upper or lower extremities, and those with known high-risk behaviors requiring a 3-foot circle of safety around their wheelchair at all times. 20. Training was incorporated into the facility's Employee Orientation and included Abuse, Neglect & Exploitation Training: Prohibiting/Preventing, Identifying, Recognizing, Reporting and Understanding & Responding to Behaviors, resident supervision strategies including utilization of CSM's and Red Safety Circles, and attestation of the expectation that caregivers were responsible for knowing and understanding the information included in the residents' plan of care prior to providing care or supervision. 21. Ongoing monitoring of compliance included frequent and comprehensive knowledge checks. Knowledge Checks conducted by the facility's leadership team were done as face-to-face interviews or completing a knowledge check in writing along with a face-to-face question and answer session. Knowledge Checks were to be done at least weekly for one (1) year. Knowledge Checks included a set of competency-based questions verifying team members understanding and ability to (TRUNCATED)

Based on interview, record review, review of the facility's policies and the facility's investigation, it was determined the facility failed to have an effective system to ensure policies and procedures were implemented to prevent abuse of a resident for one (1) of five (5) sampled residents, Resident #2. Staff interview and record review revealed the facility was aware of Resident #1's sexual behaviors at the facility and at school but failed to ensure Resident #1 was closely supervised. On 12/10/17, Certified Nursing Assistant (CNA) #2 observed Resident #1 with his/her hand in Resident #2's pants in the community area of the unit. Per the facility's own investigation, staff delayed reporting the abuse to the supervisor, which caused delay in reporting to Administration. However, the facility failed to conduct in-servicing of staff after the incident on 12/10/17. In addition, the facility failed to identify the root cause of the abuse through their investigation. The facility's failure to have an effective system in place to ensure the facility's abuse policy was implemented has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/26/18, and it was determined to exist on 12/10/17. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 02/09/18, alleging removal of the IJ on 02/05/18. The State Survey Agency validated the IJ was removed on 02/05/18, prior to exit on 02/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Protecting Residents/Clients from Abuse/Neglect: Managing Allegations of Abuse/Neglect, revised (MONTH) (YEAR), revealed the facility was to do all within the facility control to prevent abuse. The facility was to carry out the procedures to prevent abuse, which included the seven (7) components of screening, training, prevention, identification, investigation, protection, and reporting/response. The facility and staff were to have emphasized training, empowerment, prevention, intervention, and the reporting of abuse. Any witness of abuse was to provide protection to the resident immediately, report immediately to the supervisor, and complete an incident report. The Supervisors were to begin the investigation and ensure descriptive documentation was entered into the residents' medical record. The Vice President or Director was to complete an internal investigation, which was to include interviews of all persons involved, review staffing assignments, review documentation, and review the summary findings. Review of the facility's policy, Critical Incident/Adverse Event Review, and Reporting Requirements, revised (MONTH) (YEAR), revealed the facility was to ensure appropriate measures were taken to identify, evaluate, respond to critical or adverse events, and the follow the procedure to ensure these were completed. The Vice President of Quality Improvement (QI) was to review each incident for initiation of an investigation, statements obtained, ensure the review was independent with an evaluation of a root cause, address ongoing monitoring, and to determine the effectiveness of the facility action. Review of the facility's training packet, Resident Rights (YEAR), revealed staff was to receive ongoing training for reporting allegations and recognizing signs of abuse and neglect. Further review revealed residents were to be immediately protected, and the incident immediately reported. Review of the facility's job titled, Certified Nursing Assistant (CNA), dated (MONTH) (YEAR), revealed the CNA was to report concerns including suspected abuse to the supervisors or administrative team while having had protected the residents at all times. Review of the facility's job titled, Staff Nurse (Registered Nurse (RN) and Licensed Practical Nurse (LPN)), dated (MONTH) (YEAR), revealed the nurses were to report all concerns, which included suspected abuse to the supervisors or to the administrative team with protection provided to the residents at all times. Review of the facility's job titled, Medical Social Services Manager, dated (MONTH) (YEAR), revealed the social service personnel were responsible to train all new employees and facility staff regarding Resident Rights that included abuse, neglect, and reporting. Review of the facility's investigation, dated 12/14/17, revealed CNA #2 observed Resident #1 with one hand down Resident #2 pants while the residents were in the community area of the unit before an activity, on 12/10/17. When CNA #2 asked Resident #1 what he/she was doing, the resident quickly jerked his/her and away and left the area and went to his/her room. Resident #2's pants were pulled down low enough to where pubic hair was visible. The CNA informed the nurse, she informed the Clinical Supervisor, and the Supervisor informed the Director of Nursing (DON). The facility determined during the investigation, staff failed to timely report the incident to the Clinical Supervisor causing a delay in reporting to facility Administrators. In addition, Resident #1 was allowed to return to an activity on the unit with Resident #2 and other residents. Interview with RN #1, on 01/19/18 at 9:00 AM, revealed she worked on another unit on 12/10/17, but was on Resident #1 and #2's unit with another resident after the incident occurred. RN #1 stated CNA #2 reported questionable behaviors between the two residents. RN #1 instructed the CNA to report to the nurse on the unit. RN #1 stated she did not report the incident, and she did not follow up to ensure the CNA had reported the behavior. RN #1 stated she guessed she should have had followed up to ensure the CNA had reported the behavior since the CNA had originally reported to her. Interview with CNA #2, on 01/19/18 at 9:12 AM, via telephone, revealed when she came back from break on 12/10/17, she noticed Resident #1 with his/her hand in Resident #2's pants. CNA #2 stated she informed RN #1 of the incident and they went to check on Resident #2. According to CNA #2, when she and RN #1 checked on Resident #2, they noted the resident's pants and brief were pulled down low enough to see pubic hair. They readjusted Resident #2 clothes and RN #1 told her to report the incident to LPN #1. After she reported to LPN #1, CNA #2 stated she went about her normal duties. Interview with LPN #1, on 01/19/18 at 2:35 PM, revealed she was Resident #1's nurse on 12/10/17. She stated CNA #2 reported Resident #1's hand was in Resident #2's pants. At the time CNA #2 notified her, she was in another residents' room providing care. When LPN #1 finished that task, she went to Residents #1's room and the resident admitted to putting a hand down Resident #2's pants. LPN #1 stated she instructed Resident #1 to stay away from Resident #2 and to stay in his/her room. LPN #1 stated it was approximately thirty (30) minutes before she remembered to notify the house supervisor. Interview with Nursing Supervisor #1, on 01/18/18 at 2:30 PM, revealed she was notified of the abuse by LPN #1 and when she arrived on the unit, a music activity was completing. She stated Resident #1 was at the activity with activity staff and unit staff supervising the activity, but staff was not one (1) to one (1) with Resident #1. Interview also revealed Resident #2 was present and was crying; however, that was not an unusual behavior for that resident. Per interview, LPN #1 delayed notification of the abuse. Interview with the DON, on 01/19/18 at 2:11 PM and on 01/24/18 at 12:35 PM, revealed staff delayed reporting the incident on 12/10/17 to the supervisor. She stated Resident #1 was allowed to return to the activity on the unit on 12/10/17 after the incident occurred and not with one (1) to one (1) staff and Resident #2 was not moved to safety. In addition, per interview, the facility did not inform all staff of the 12/10/17 incident because the facility wanted to keep the incident low keyed for the benefit of Resident #1. Further interview with the DON, on 01/26/18 at 3:10 PM, revealed the facility did not determine a root cause of the abuse incident on 12/10/17. She stated the facility discussed the 12/10/17 incident, prior issues, reviewed nursing notes, and looked for triggers, but the facility did not identify any noted concerns. She stated the facility did not identify what could have been put into place to prevent the abuse because the facility did not feel Resident #1 was at risk for abusive behavior. Interview with the Vice President of Clinical Services, on 01/26/18 at 3:10 PM, revealed after review of the incident on the unit, medical and social history, and the events and noted behaviors of Resident #1, a root cause was not identified. She stated other residents were not capable of similar behavior so the facility had not put any pieces in place to prevent abuse. Interview with the Senior Vice President, on 01/23/18 at 2:20 PM, revealed a root cause was not identified for the 12/10/17 incident. He revealed the facility was focused on the protection of Resident #1 and not so much on Resident #1's behaviors and the protection of other residents. He stated the facility was more focused on staff to resident abuse and not resident-to-resident abuse. According to the Senior Vice President, he was aware of Resident #1's behaviors, school incident, and psychosocial history, but had not identified potential issues as well as interventions to prevent the 12/10/17 incident. Additional interview with the DON, on 02/09/18 at 3:00 PM, revealed the DON had no formal training to conduct investigations. She stated through the years she learned from the previous Administrator and the Vice President of Clinical Services on what needed to be reviewed and completed for an investigation. She stated the regulations guided her through the investigations. She stated she was lead investigator for the 12/10/17 incident. Further interview with the Vice President of Clinical Services, on 02/09/18 at 2:30 PM, revealed she had not been trained to complete investigations and learned how to do investigations by following the regulations, guidance from the previous Administrator, and by the in-services provided by the State. She stated she reviewed the DON findings and interviews and assisted with the investigation. She stated the facility had not had an incident of abuse in the facility to follow to ensure this one was investigated correctly. In addition, staff interviews revealed no staff in-service education on abuse was conducted after the incident on 12/10/17. Interview with RN #1, on 01/19/18 at 9:00 AM, revealed the facility did not complete an in-service after 12/10/17, for abuse but she attended the in-services before the incident, which included abuse. Interview with LPN #1, on 01/19/18 at 2:35 PM, revealed she did not receive additional training after 12/10/17; however, the DON counseled her on proper procedure regarding reporting abuse. Interview with LPN #3, on 01/22/18 at 1:45 PM, revealed the facility did not complete in-services for abuse after 12/10/17. Interview with the Social Service Manager, on 01/25/18 at 4:46 PM, revealed staff involved with the 12/10/17 incident had issues with proper procedure, and were counseled; however, it reflected an issue and the facility needed to complete a full facility in-service on abuse but failed to complete that task. She stated the facility had initially not considered the error in reporting a facility wide issue. Continued interview with the DON, on 01/24/18 at 12:35 PM, revealed the annual facility in-service, including Abuse Prohibition, was completed on 12/04/17, and therefore the facility decided an in-service so close to the completion of the annual was not needed. She stated she did not evaluate staff's knowledge of abuse other than those directly involved with the 12/10/17 incident. She stated it was the facility's responsibility to ensure all staff was appropriately trained and knowledgeable in regards of abuse to assure all staff was competent in their job roles to protect the residents. Interview with the Senior Vice President, on 01/23/18 at 2:20 PM, revealed he was responsible for all aspects of the facility. He stated staff was recently trained in abuse prevention and well aware of what needed to be done. However, he did not audit staff's knowledge after the training. He stated he was aware the facility had not completed an abuse in-service after the incident, as he was involved in the decision. Interview with the Vice President of Clinical Services, on 01/19/18 at 2:11 PM, revealed the facility did not complete Abuse/Neglect training after the 12/10/17 incident, as decided by her, the DON, and the Senior Vice President in order to keep the embarrassment to Resident #1 at a minimum. She stated the annual facility abuse training was completed relatively close to the incident and therefore another training was not needed, and the parties involved were counseled individually. She further stated she did not feel the facility failed to protect Resident #2 against abuse. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) supervision at all times beginning 12/10/17. 2. Resident #2 was evaluated by the Medical Social Services Coordinator (MSSC) on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. In addition, the MSSC regularly reviewed nursing documentation for Resident #2 including Nursing Narrative Notes, and Behavior and Response to Care Notes in order to assess changes in Resident #2's behavior and evidence of psychosocial harm. 3. Resident #2 was moved to a different unit, Ocean Avenue, on 12/15/17. 4. Resident #1 was discharged from the facility on 01/22/18, at the request of his/her mother who regained custody of Resident #1. 5. The Vice President of Clinical Services reviewed Interdisciplinary Progress Notes, Behavior and Response to Care Notes, and Skin Observation Notes on 01/24/18 and 01/25/18 for each resident on Maple Way, where the abuse occurred, for (MONTH) (YEAR), to determine if any physical or psychosocial signs or symptoms of abuse were documented on other residents and if additional residents might have been impacted or were at risk from Resident #1. 6. A root cause analysis was facilitated by the Vice President of Quality Improvement and Compliance and completed by facility team members including the Senior Vice President (SVP), Vice President of Clinical Services (VPCS), Director of Nursing (DON), Medical Director, Vice President of Therapy Services (VPTS), Medical Social Services Manager (MSSM), Medical Social Services Coordinator (MSSC), Health Information Management Coordinator (HIMC), Staff Development Coordinator (SDC), Respiratory Therapy Manager (RTM), Education Coordinator, Registered Nurse (RN) Clinical Supervisor, Child Development Coordinator and the facility's Administrative Assistant on 01/26/18 and 01/30/18. The Five Why's Methodology was used to determine why the facility failed to protect a resident from abuse. 7. Training on the Immediate Jeopardy, and on recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was developed on 01/26/18 by leadership, including SVP, VPCS, DON, MSSM, MSSC, and VPTS. 8. Training was implemented on 01/26/18 by leadership team members including SVP, VPCS, DON, MSSM, MSSC, HIMC, SDC, RTM, RN Clinical Supervisors and VPTS. Training was required for all team members prior to providing care. 9. Trainings occurred several times a day on 01/26/18, 01/27/18, 01/28/18, 01/29/18, 01/30/18, 01/31/18, 02/01/18, 02/02/18, 02/03/18, and 02/04/18. A leadership team member was stationed at the time clock to notify team members to report for training prior to going on units to provide care through 01/30/18 and a notice was posted at the time clock by the Director of Nursing to alert team members about required training. A notice was distributed by an electronic team member notification application, and by email listing dates and times of retraining. 10. All resident Care Plans and Kardexes were updated by MSSC, MSSM, and the VPCS. Updates occurred on 01/27/18, 01/30/18, 01/31/18, 02/02/18, and 02/03/18 to reflect residents' histories of abuse or neglect, any known high-risk behaviors, and subsequent level of intervention and supervision required. 11. Resident #2's care plan was updated by the MSSC and the VPCS on 01/27/18, to include monitoring of symptoms including changes in behavior, withdrawal, aggressive or disruptive behavior, symptoms of anxiety or depression, changes in sleep patterns, and crying. 12. Resident #2 was referred to a Psychologist for an intensive follow up evaluation and assessed on 01/29/18. 13. As a result of the root-cause analysis conducted on 01/30/18 by the interdisciplinary care team, the team further discussed every resident in an effort to evaluate and determine known histories of abuse or neglect and/or high-risk behaviors that could place each resident or other residents at risk for injury, abuse, or neglect. Further discussion resulted in the need for additional supervision and it was determined Cottage Safety Monitors (CSM) would be utilized to provide additional supervision. 14. The VPCS created a new procedure titled, Resident Supervision, which included a plan to implement CSM's and Safety Circles on 01/31/18. An email describing the new procedure and expectations was sent to all staff on 02/01/18. CSM's would be utilized during waking hours on cottages where additional supervision was required to monitor residents and mitigate the risk of injury, abuse, or neglect. CSM's will provide structured, age appropriate activities when possible to engage residents while providing appropriate oversight and supervision. CSM's will identify themselves to team members assigned to the unit. 15. The VPCS and the Clinical Quality Improvement Specialist created a new procedure, Behavior Management, that outlined an improved process for behavioral and mental health services and management. The procedure included emphasis on recognizing and communicating when residents have high-risk behavior or behavioral symptoms. The VPCS sent an email describing the new procedure and team member expectations to all staff on 02/03/18, with a read receipt that acknowledges each team member's acceptance of the responsibility for knowing and understanding high-risk behaviors of residents as well as monitoring for, prohibiting, and preventing negative outcomes. 16. Training on Immediate Jeopardy, recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was attended by team members in the following departments: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, the facility's Administrative Team, Restorative Aides, Physical Therapy, Speech Therapy, Occupational Therapy, Respiratory Therapy, Receptionists, Training, Dietary, Finance, Maintenance, Information Technology, Environmental Services, Laundry, Materials Management and Quality Improvement and Compliance. Twenty-one (21) individuals had yet to complete training but were arranged to be trained prior to any care delivery. Contracted agency personnel and students had been trained and will be trained prior to any provision of care. Refer to training dates listed in #9. 17. Resident room placement and resident dynamics on each unit was evaluated to determine where CSM's would be required. 18. CSM's will follow the expectations outlined in the procedure titled, Managing Allegations of Abuse or Neglect, for removing the offending resident or individual and immediately reporting to a leadership team member if an inappropriate incident occurred. CSM's were responsible for ensuring continuous coverage by designating the CSM role to another available team member. CSM's were also responsible for ensuring that mobile residents were in the community area, in their room without a roommate present, or in bed. 19. A red Safety Circle was placed on the back of the wheelchair of residents that were mobile, those with the functional ability to reach out to others with either upper or lower extremities, and those with known high-risk behaviors requiring a 3-foot circle of safety around their wheelchair at all times. 20. Training was incorporated into the facility's Employee Orientation and included Abuse, Neglect & Exploitation Training: Prohibiting/Preventing, Identifying, Recognizing, Reporting and Understanding & Responding to Behaviors, resident supervision strategies including utilization of CSM's and Red Safety Circles, and attestation of the expectation that caregivers were responsible for knowing and understanding the information included in the residents' plan of care prior to providing care or supervision. 21. Ongoing monitoring of compliance included frequent and comprehensive knowledge checks. Knowledge Checks conducted by the facility's leadership team were done as face-to-face interviews or completing a knowledge check in writing along with a face-to-face question and answer session. Knowledge Checks were to be done at least weekly for one (1) year. Knowledge Checks included a set of competency-based questions verifying team members understanding and ability to implement aspects of Abuse, Neglect and Exploitation training, resident supervision including utilization of CSM's and Red Safety Circles, and location of and information included in residents' plan of care. Outcome measures for weekly knowledge checks would be tabulated and reported quarterly to the Quality Improvement Committee for review and compliance. The SSA validated the facility implemented the following actions: 1. Interview with Certified Nursing Assistant (CNA) #9, on 02/09/18 at 11:39 AM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring following the incident. She revealed she participated in monitoring Resident #1 for two (2) days. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring by members of staff and he/she was monitored at all times. A company was contracted to come in and sit with Resident #1 until his/her discharge on 01/22/18. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed RN Clinical Supervisors made daily assignment sheets to ensure Resident #1 had one (1) to one (1) supervision at all times. She revealed staff monitored Resident #1 for two (2) days and then a company came in to offer one (1) to one (1) services. 2. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she evaluated Resident #2 on the day of the incident, 12/10/17. She stated Resident #2 appeared happy and was smiling, and displayed normal behavior. She revealed she continued to check on Resident #2 on 12/12/17, 12/13/17, and 12/14/17, with no change in behavior noted. She stated she evaluated Resident #2 several times each week following the incident. She stated she and the VPCS reviewed clinical notes to look for behavioral changes or any unusual occurrences. She revealed no concerns were found. Review of Resident #2's Social Services Notes, dated 01/30/18, by the MSSC, revealed the MSSC documented her evaluations of the resident on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. The MSSC documented she reviewed Resident #2's Nursing Notes, and Behavior and Response Notes and found no concerns. 3. Observation, on 02/09/18 at 11:20 AM, revealed Resident #2 was in his/her room seated in wheelchair on Ocean Avenue Cottage with CNA #11 reading him/her a book. Review of Resident #2's clinical record revealed he/she was transferred to Ocean Avenue Cottage on 12/15/17. 4. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was discharged on [DATE] into the custody of his/her mother. Review of Resident #1's discharge summary revealed he/she was discharged from the facility on 01/22/18. 5. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed it was a standard practice that all residents received a full assessment every twelve (12) hours and received baths every day. She revealed she reviewed all nursing notes, including every twelve hours (12) assessments, behavior notes, and skin notes for every resident on Maple Way Cottage. She revealed she discovered no concerns. Review of Resident #4 and #5's nursing notes, assessments, behavior notes, and skin notes revealed no concerns. 6. Interview with the Vice President of Quality Improvement and Corporate Compliance, on 02/09/18 at 3:00 PM, revealed she facilitated the root cause analysis with the SVP and VPCS. She revealed she utilized the Five Why's methodology, which was a tool where the team named a negative outcome and continuously asked the question, why, in order to determine the root cause. She revealed she reviewed what the team determined had been the root cause. Interview with the SVP, on 02/09/18 at 5:15 PM, revealed he was involved in two (2) root cause analysis meetings. He stated the team went through the Five Why's to determine the root cause. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she and a team of managers met on two (2) separate occasions to determine the root-cause that led to Resident #1 sexually assaulting Resident #2. She revealed they used the Five Why's tool to dig deeper to determine where the facility failed. Review of the facilities Root Cause Analysis and Action Plan revealed utilization of the Five Why's in order to determine the systemic root cause. The action plan included Barriers, Interventions, Outcome Monitoring, Person(s) Responsible, and Implementation Dates. The facility determined the root cause was limitation with personnel resources and budgetary/financial constraints that did not adequately support the evolving needs of the pediatric long-term care population. 7. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she reviewed the regulation and revised the attestation statement. She stated she created a training outline for all educators to ensure all training provided to staff was consistent. The training outline went over how to spot abuse, how to report abuse, supervision, and immediate jeopardy. Interview with the DON, on 02/09/18 at 4:00 PM, revealed as a team, they looked at what training was lacking and discovered that more emphasis needed to be placed on behavioral health. She stated the team developed training that included information on abuse, resident behaviors, when to report abuse, and awareness of a change in the resident population. 8. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she played a role in educating nurses, CNAs, and therapists. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed she worked to ensure no staff worked until they were retrained. She stated she educated staff using the script that was given to all educators to ensure consistent training. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she initiated reeducation along with the management team beginning 01/26/18. Interview with the Health Information Manager, on 02/09/18 at 3:35 PM, revealed he participated in training development. He utilized a script and discussed abuse, responding to abuse, protecting the resident, and the importance of notifying a leadership member immediately. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she gave several trainings to staff members across multiple disciplines. 9. Observation, on 02/09/18 at 11:13 AM, revealed next to the computer utilized for clocking in and out was a sign indicating mandatory abuse/neglect training must be attended prior to working with the residents. Interview with RN #4, on 02/09/18 at 11:50 AM, revealed when she came to work following the incident, a charge nurse was waiting at the time clock and told her she had to attend a mandatory in-service. She stated she received education on signs of abuse, reporting abuse, the new Cottage Safety Monitor program, and the red dot safety circle program. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed the night of 01/26/18, a supervisor was posted at the time clock to alert staff of mandatory training. For employees who were not in the building, the electronic cell phone notifications, as well as emails, were sent to alert staff on mandatory training required prior to providing care. Interview with Nursing Supervisor #4, on 02/09/18 at 2:58 PM, revealed she attended multiple in-services, trainings, and received multiple emails relating to abuse and neglect as well as behavior monitoring following the incident. Interview with the Cook, on 02/09/18 at 11:40 AM, revealed she was unable to clock in for her shift until after she received education on abuse. She revealed she received training on reporting abuse and she had to sign a form acknowledging understanding of the training. Interview with the MSSM, on 02/09/18 at 6:10 PM, revealed she stood at the time clock for third shift on 01/27/18, to ensure all staff clocking in on third shift was trained on abuse prohibition and prevention prior to working that night. She stated other staff members stood by the time clock on all shifts until it was assured all staff were trained before working with residents. Review of a screenshot of the electronic team member notification cell phone application revealed the DON sent out a notification to staff listing dates and times available for mandatory training. 10. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she and the MSSC reviewed all the resident's care plans and included in the care plans, residents who had a known history of abuse or neglect. In addition, she revealed residents with known behaviors care plans were updated to include the Safety Circle intervention. Review of thirty-four (34) resident care plans and Kardexes revealed they were updated to include a known history of being a victim of abuse or neglect. A new intervention was implemented for all residents with a known history to monitor, document, and report symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, fractures, and unexplained bruising or injuries through the next review date. 11. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed all residents with a history of abuse, neglect, or behaviors had their care plans updated, including Resident #2. Review of Resident #2's clinical record revealed a care plan focus of Altered Family Process related to the resident's [DIAGNOSES REDACTED]. The care plan revealed Resident #2 had a known previous history of being a victim of sexual abuse and neglect. An intervention was initiated on 01/26/18, to continually monitor for psychosocial harm due to recent incident of abuse and document and report symptoms immediately to RN Clinical Supervisor or the facility's Leadership. It further included to monitor for symptoms including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, and crying. An intervention was initiated on 01/27/18, to monitor, document, and report symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, fractures, and unexplained bruising or injuries through next review date. Resident #2's care plan revealed an additional focus area of Risk for Injury related to inability to protect self from injury, self-mobility in bed or on mat, and has no self-preservation skills. An intervention was initiated on 02/03/18, to monitor for behavioral symptoms such as self-mobility in wheelchair without sa (TRUNCATED)

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure care plans were reviewed and revised for two (2) of five (5) sampled residents, Resident #1 and #2. The facility was aware of Resident #1's inappropriate sexual behaviors that occurred on the unit and at school; however, did not update the care plan with interventions to address the behaviors. On 12/10/17, Resident #1 put his/her hands down Resident #2's pants while sitting in the community area of the unit. Resident #1 was also diagnosed and treated for [REDACTED]. In addition, after the incident on 12/10/17, Resident #2's care plan was not updated to monitor for possible effects from the event. The facility's failure to have an effective system in place to ensure resident care plans were updated for treatment of [REDACTED]. Immediate Jeopardy (IJ) was identified on 01/26/18, and it was determined to exist on 12/10/17. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 02/09/18, alleging removal of the IJ on 02/05/18. The State Survey Agency validated the IJ was removed on 02/05/18, prior to exit on 02/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Resident Care Plan, revised (MONTH) 2010, revealed all residents were to have an ongoing, interdisciplinary, and comprehensive care plan, which focused on the treatment of [REDACTED]. The resident care plan was to include medical orders, Minimum Data Set (MDS) assessments, Care Area Assessments (CAA), and problems with measurable goals. Further review revealed all care plans were to be revised as needed, and evaluated quarterly by the Interdisciplinary Care Plan Team. Review of the facility's policy, Assessment: Child Abuse/Neglect Identification Criteria, revised (MONTH) 2013, revealed the criteria utilized as potential indicators of abuse/neglect, included family health history of being abused as a child, history of abuse of or by a sibling, and history of child the in foster home placement for abuse/neglect. Review of the facility's job title, Medical Social Services Manager, dated (MONTH) (YEAR), revealed social services were to complete and revise the residents' care plan for the bio-psychosocial care needs of the resident. Review of the facility's investigation, dated 12/14/17, revealed on 12/10/17 Certified Nursing Assistant (CNA) #2 observed Resident #1 with his/her hand in Resident #2's pants in the community area of the unit. When questioned what he/she was doing, Resident #1 quickly jerked his/her hand away and returned to his/her room. The facility reviewed the video which showed Resident #1 attempting to undo Resident #2's pants/brief and put his/her hand down Resident #2's pants. Resident #1 admitted to touching Resident #2's private area and was placed under one (1) to one (1) supervision. Review of Resident #1's clinical record revealed the facility admitted the resident on 02/18/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Initial History and Physical, dated 02/18/16, revealed Resident #1 was removed from the biological family in (MONTH) (YEAR) for sexual abuse by a brother with maternal indifference. Resident #1's mother had substance abuse addiction and was placed in jail. Resident #1 was placed in foster care and the foster family refused to continue care for Resident #1. Further review of Resident #1's clinical record revealed five (5) documented incidents of inappropriate sexual and/or aggressive behavior prior to the incident on 12/10/17; however the resident's care plan was not revised to address these behaviors. Review of Resident #1's Nursing Note, dated 05/22/17, revealed Resident #1 was masturbating in the common area of the unit. Review of Resident #1's Nursing Note, dated 06/11/17, revealed while visiting another unit in the facility, Resident #1 pulled up his/her shirt and shook his/her chest toward a female resident. Resident #1 was redirected and sent back to his/her unit and the supervisor was notified. Review of Resident #1's Nursing note, dated 07/03/17, revealed Resident #1 threw a box of gloves towards another resident on the unit and the nurse heard Resident #1 express love to a resident of the same sex while on the facility phone. Review Resident #1's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) and determined the resident interviewable. The facility assessed Resident #1 displayed behavioral symptoms, which were not directed towards others. Further review revealed the resident received antianxiety and antidepressant medications. However, review of Resident #1's Care Plan, dated 08/21/17, revealed the facility failed to revise the care plan to address the resident's behaviors. Continued review of the clinical record revealed Nursing Notes, dated 10/15/17, which stated Resident #1 remarked a staff member on the unit had big boobs, was hot, and asked the nurse to express the observation to the other staff member on the unit. Supervisor #5 was notified. Review of Social Services Interview with Resident #1, dated 10/26/17, revealed a second student instructed Resident #1 to pull his/her pants down to which Resident #1 complied. Resident #1 told a third student to lick his/her genital area, and at that time, the second student pushed the third students head down into Resident #1's genital area. Resident #1 asked staff if he/she was in trouble because the resident did not want to lose phone privileges. Review of a Social Service Director's Note, dated 10/27/17, revealed school reported Resident #1 had a previous incident at school prior to the 10/26/17 incident, toward the same peer at school where Resident #1 kissed the peer on the cheek without consent. However, review of Resident #1's Care Plan revealed the facility failed to revise the care plan to address the resident's behaviors on 10/26/17. Review of Resident #2's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of six (6) out of fifteen (15) and determined the resident not interviewable. The facility assessed Resident #1 exhibited behaviors directed towards others. Further review revealed the resident had [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Care Plan Evaluation Review by the MDS Coordinator, dated 11/16/17, revealed the resident used markers to mark on self, was coded on the MDS as behavioral, but not directed toward other persons. Resident #1 made statements to other same sexed residents concerning loving them, and was noted to have significant behavioral issues that were sexual in nature at school in October. The MDS coordinator stated the behaviors at school required Resident #1 to switch schools. However, review of Resident #1's Care Plan, dated 11/20/17, revealed the facility failed to revise the care plan to address the resident's behaviors. Further review revealed the plan was also not revised for the problems of Anxiety and Depression. Review of Resident #1's Nursing Note, dated 12/11/17 at 8:25 AM, revealed CNA #2 notified Licensed Practical Nurse (LPN #1) with concerns that Resident #2 was the victim of a sexual assault by Resident #1 in the back of the unit (which occurred on 12/10/17). CNA #2 reported she found Resident #2 with his/her pants and diaper pulled down with exposed pubic hair, and Resident #1's hand was in Resident #2's genital area. However, review of Resident #1's Care Plan revealed the facility failed to revise the care plan after the 12/10/17 incident. In addition, review of Resident #2's Care Plan, dated 12/19/17, revealed the facility failed to revise the care plan to reflect the 12/10/17 sexual assault by a resident. Interview with the Social Service Manager, on 01/25/18 at 3:50 PM, revealed she was responsible for initiating and revising resident behavioral care plans. She stated she thought Resident #1 was care planned for the all behaviors he/she exhibited and did not know why the care plan for behavior management was not completed. Interview with the CNA #3 on 01/21/18 at 7:38 PM and CNA #7 on 01/27/18/ at 8:17 PM, revealed the CNAs utilized bedside treatment cards for instructions on how to care for residents, in addition to report from staff. Per interview, the nurses were responsible to update the bedside treatment cards. If the care plans were not up to date, then the information on the treatment cards were not up to date. Interview with LPN #3, on 01/22/18 at 1:45 PM, revealed nurses were not able to update care plans. He stated the facility instructed nurses to report any update needs or changes to the supervisors. LPN #3 stated staff received updated emails once a month for all residents whose care plan had been reviewed and or changed and numerous residents were included in the email and it was difficult to review at times due to the length of the emails. LPN #3 revealed he updated the bedside treatment cards when notified of care plan changes. He stated if care plans were not correct, staff was not able to care for the residents to the highest potential. Interview with LPN #4, on 01/22/18 at 2:00 PM, revealed care plans were updated by the care plan team and she was unable to access the care plan to revise for resident needs. She stated an email was sent out with the updated care plans to be reviewed and then she updated the bedside treatment cards. She stated if care plans were not accurate, she was unable to care for the residents to the best of her ability. Interview with LPN #5, on 01/27/18 at 8:03 PM, revealed in order to make revisions to the care plan, staff was to notify the supervisors and the supervisors notified the Vice President of Clinical Services. He stated he did not have access to the care plans, which were in the computer, and staff was not to write on the care plans in the resident charts. He stated he received most of the information regarding care of residents in shift report. Interview with Nursing Supervisor #3, on 01/21/18 at 7:30 PM, revealed care plans were updated monthly and quarterly by the Vice President of Clinical Services. She stated supervisors were assigned residents to review, which included the resident's chart for orders, nursing documentation, medications, and any noted changes to the care. She stated all gathered information was sent to Vice President of Clinical Services for review. She further stated she did not do care plan auditing to evaluate if the care plans were correct. Interview with Nursing Supervisor #1, on 01/23/18 at 1:50 PM, revealed nursing supervisors were assigned resident charts to review weekly or monthly, and were to complete a thorough review of the chart. She stated any new orders, treatments, and medications were to be reported to the Vice President of Clinical Services, as well as any concerns in nursing notes found in the chart. She stated all information gathered was discussed during care plan review meetings, which occurred weekly, monthly, or quarterly. The Supervisor stated she was unable to add or revise care plans for residents, as the facility did not want supervisors to complete care plans. She stated she was unsure of the reason Resident #1 and #2's care plan were not updated because she would have updated the care plans for behaviors and on the incidents that occurred. Interview with the Director of Nursing (DON), on 01/24/18 at 1:35 PM, revealed the Vice President of Clinical Services was responsible for all resident care plans. She stated Social Services could initiate and revise behavior care plans. However, the facility did not want care plans to be managed by numerous individuals, so only the Vice President of Clinical Services was to access, initiate, and revise resident care plans. The DON stated she did not know why Resident #1's care plan did not include the behaviors the resident exhibited. She further stated care plans communicated to the staff the care needs of the residents. Interview with the Vice President of Clinical Services, on 01/24/18 at 1:30 PM, revealed she was responsible for resident care plans, which included the initial care plan and revision. She stated the care plan team was responsible for their respective areas, and she was responsible for nursing care plan areas. She stated care plans were updated with changes in treatment, medical orders, changes in diagnosis, and an event or changes in behavior. The Vice President of Clinical Services stated the supervisors reviewed the resident charts and reported the findings to her. She stated for other departments, the care plan team determined what would be added or deleted from the care plans. She stated staff was updated monthly or as needed by email for changes in the care plan. She revealed Resident #1's and #2's care plan were not revised, which was her responsibility to do; however, she stated she did not know why she did not update the care plans. She stated staff needed updated care plans in order to care for residents. Interview with the Senior Vice President, on 01/23/18 at 2:20 PM, revealed he attended care plan meetings for residents to review the care plan process and make recommendations. He stated he had over site of the Vice President of Clinical Services who was responsible for resident care plans. He stated he was unaware the care plan for Resident #1 and #2 were not accurate or up to date with care needs, services, and the incident of 12/10/17. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) supervision at all times beginning 12/10/17. 2. Resident #2 was evaluated by the Medical Social Services Coordinator (MSSC) on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. In addition, the MSSC regularly reviewed nursing documentation for Resident #2 including Nursing Narrative Notes, and Behavior and Response to Care Notes in order to assess changes in Resident #2's behavior and evidence of psychosocial harm. 3. Resident #2 was moved to a different unit, Ocean Avenue, on 12/15/17. 4. Resident #1 was discharged from the facility on 01/22/18, at the request of his/her mother who regained custody of Resident #1. 5. The Vice President of Clinical Services reviewed Interdisciplinary Progress Notes, Behavior and Response to Care Notes, and Skin Observation Notes on 01/24/18 and 01/25/18 for each resident on Maple Way, where the abuse occurred, for (MONTH) (YEAR), to determine if any physical or psychosocial signs or symptoms of abuse were documented on other residents and if additional residents might have been impacted or were at risk from Resident #1. 6. A root cause analysis was facilitated by the Vice President of Quality Improvement and Compliance and completed by facility team members including the Senior Vice President (SVP), Vice President of Clinical Services (VPCS), Director of Nursing (DON), Medical Director, Vice President of Therapy Services (VPTS), Medical Social Services Manager (MSSM), Medical Social Services Coordinator (MSSC), Health Information Management Coordinator (HIMC), Staff Development Coordinator (SDC), Respiratory Therapy Manager (RTM), Education Coordinator, Registered Nurse (RN) Clinical Supervisor, Child Development Coordinator and the facility's Administrative Assistant on 01/26/18 and 01/30/18. The Five Why's Methodology was used to determine why the facility failed to protect a resident from abuse. 7. Training on the Immediate Jeopardy, and on recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was developed on 01/26/18 by leadership, including SVP, VPCS, DON, MSSM, MSSC, and VPTS. 8. Training was implemented on 01/26/18 by leadership team members including SVP, VPCS, DON, MSSM, MSSC, HIMC, SDC, RTM, RN Clinical Supervisors and VPTS. Training was required for all team members prior to providing care. 9. Trainings occurred several times a day on 01/26/18, 01/27/18, 01/28/18, 01/29/18, 01/30/18, 01/31/18, 02/01/18, 02/02/18, 02/03/18, and 02/04/18. A leadership team member was stationed at the time clock to notify team members to report for training prior to going on units to provide care through 01/30/18 and a notice was posted at the time clock by the Director of Nursing to alert team members about required training. A notice was distributed by an electronic team member notification application, and by email listing dates and times of retraining. 10. All resident Care Plans and Kardexes were updated by MSSC, MSSM, and the VPCS. Updates occurred on 01/27/18, 01/30/18, 01/31/18, 02/02/18, and 02/03/18 to reflect residents' histories of abuse or neglect, any known high-risk behaviors, and subsequent level of intervention and supervision required. 11. Resident #2's care plan was updated by the MSSC and the VPCS on 01/27/18, to include monitoring of symptoms including changes in behavior, withdrawal, aggressive or disruptive behavior, symptoms of anxiety or depression, changes in sleep patterns, and crying. 12. Resident #2 was referred to a Psychologist for an intensive follow up evaluation and assessed on 01/29/18. 13. As a result of the root-cause analysis conducted on 01/30/18 by the interdisciplinary care team, the team further discussed every resident in an effort to evaluate and determine known histories of abuse or neglect and/or high-risk behaviors that could place each resident or other residents at risk for injury, abuse, or neglect. Further discussion resulted in the need for additional supervision and it was determined Cottage Safety Monitors (CSM) would be utilized to provide additional supervision. 14. The VPCS created a new procedure titled, Resident Supervision, which included a plan to implement CSM's and Safety Circles on 01/31/18. An email describing the new procedure and expectations was sent to all staff on 02/01/18. CSM's would be utilized during waking hours on cottages where additional supervision was required to monitor residents and mitigate the risk of injury, abuse, or neglect. CSM's will provide structured, age appropriate activities when possible to engage residents while providing appropriate oversight and supervision. CSM's will identify themselves to team members assigned to the unit. 15. The VPCS and the Clinical Quality Improvement Specialist created a new procedure, Behavior Management, that outlined an improved process for behavioral and mental health services and management. The procedure included emphasis on recognizing and communicating when residents have high-risk behavior or behavioral symptoms. The VPCS sent an email describing the new procedure and team member expectations to all staff on 02/03/18, with a read receipt that acknowledges each team member's acceptance of the responsibility for knowing and understanding high-risk behaviors of residents as well as monitoring for, prohibiting, and preventing negative outcomes. 16. Training on Immediate Jeopardy, recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was attended by team members in the following departments: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, the facility's Administrative Team, Restorative Aides, Physical Therapy, Speech Therapy, Occupational Therapy, Respiratory Therapy, Receptionists, Training, Dietary, Finance, Maintenance, Information Technology, Environmental Services, Laundry, Materials Management and Quality Improvement and Compliance. Twenty-one (21) individuals had yet to complete training but were arranged to be trained prior to any care delivery. Contracted agency personnel and students had been trained and will be trained prior to any provision of care. Refer to training dates listed in #9. 17. Resident room placement and resident dynamics on each unit was evaluated to determine where CSM's would be required. 18. CSM's will follow the expectations outlined in the procedure titled, Managing Allegations of Abuse or Neglect, for removing the offending resident or individual and immediately reporting to a leadership team member if an inappropriate incident occurred. CSM's were responsible for ensuring continuous coverage by designating the CSM role to another available team member. CSM's were also responsible for ensuring that mobile residents were in the community area, in their room without a roommate present, or in bed. 19. A red Safety Circle was placed on the back of the wheelchair of residents that were mobile, those with the functional ability to reach out to others with either upper or lower extremities, and those with known high-risk behaviors requiring a 3-foot circle of safety around their wheelchair at all times. 20. Training was incorporated into the facility's Employee Orientation and included Abuse, Neglect & Exploitation Training: Prohibiting/Preventing, Identifying, Recognizing, Reporting and Understanding & Responding to Behaviors, resident supervision strategies including utilization of CSM's and Red Safety Circles, and attestation of the expectation that caregivers were responsible for knowing and understanding the information included in the residents' plan of care prior to providing care or supervision. 21. Ongoing monitoring of compliance included frequent and comprehensive knowledge checks. Knowledge Checks conducted by the facility's leadership team were done as face-to-face interviews or completing a knowledge check in writing along with a face-to-face question and answer session. Knowledge Checks were to be done at least weekly for one (1) year. Knowledge Checks included a set of competency-based questions verifying team members understanding and ability to implement aspects of Abuse, Neglect and Exploitation training, resident supervision including utilization of CSM's and Red Safety Circles, and location of and information included in residents' plan of care. Outcome measures for weekly knowledge checks would be tabulated and reported quarterly to the Quality Improvement Committee for review and compliance. The SSA validated the facility implemented the following actions: 1. Interview with Certified Nursing Assistant (CNA) #9, on 02/09/18 at 11:39 AM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring following the incident. She revealed she participated in monitoring Resident #1 for two (2) days. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring by members of staff and he/she was monitored at all times. A company was contracted to come in and sit with Resident #1 until his/her discharge on 01/22/18. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed RN Clinical Supervisors made daily assignment sheets to ensure Resident #1 had one (1) to one (1) supervision at all times. She revealed staff monitored Resident #1 for two (2) days and then a company came in to offer one (1) to one (1) services. 2. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she evaluated Resident #2 on the day of the incident, 12/10/17. She stated Resident #2 appeared happy and was smiling, and displayed normal behavior. She revealed she continued to check on Resident #2 on 12/12/17, 12/13/17, and 12/14/17, with no change in behavior noted. She stated she evaluated Resident #2 several times each week following the incident. She stated she and the VPCS reviewed clinical notes to look for behavioral changes or any unusual occurrences. She revealed no concerns were found. Review of Resident #2's Social Services Notes, dated 01/30/18, by the MSSC, revealed the MSSC documented her evaluations of the resident on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. The MSSC documented she reviewed Resident #2's Nursing Notes, and Behavior and Response Notes and found no concerns. 3. Observation, on 02/09/18 at 11:20 AM, revealed Resident #2 was in his/her room seated in wheelchair on Ocean Avenue Cottage with CNA #11 reading him/her a book. Review of Resident #2's clinical record revealed he/she was transferred to Ocean Avenue Cottage on 12/15/17. 4. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was discharged on [DATE] into the custody of his/her mother. Review of Resident #1's discharge summary revealed he/she was discharged from the facility on 01/22/18. 5. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed it was a standard practice that all residents received a full assessment every twelve (12) hours and received baths every day. She revealed she reviewed all nursing notes, including every twelve hours (12) assessments, behavior notes, and skin notes for every resident on Maple Way Cottage. She revealed she discovered no concerns. Review of Resident #4 and #5's nursing notes, assessments, behavior notes, and skin notes revealed no concerns. 6. Interview with the Vice President of Quality Improvement and Corporate Compliance, on 02/09/18 at 3:00 PM, revealed she facilitated the root cause analysis with the SVP and VPCS. She revealed she utilized the Five Why's methodology, which was a tool where the team named a negative outcome and continuously asked the question, why, in order to determine the root cause. She revealed she reviewed what the team determined had been the root cause. Interview with the SVP, on 02/09/18 at 5:15 PM, revealed he was involved in two (2) root cause analysis meetings. He stated the team went through the Five Why's to determine the root cause. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she and a team of managers met on two (2) separate occasions to determine the root-cause that led to Resident #1 sexually assaulting Resident #2. She revealed they used the Five Why's tool to dig deeper to determine where the facility failed. Review of the facilities Root Cause Analysis and Action Plan revealed utilization of the Five Why's in order to determine the systemic root cause. The action plan included Barriers, Interventions, Outcome Monitoring, Person(s) Responsible, and Implementation Dates. The facility determined the root cause was limitation with personnel resources and budgetary/financial constraints that did not adequately support the evolving needs of the pediatric long-term care population. 7. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she reviewed the regulation and revised the attestation statement. She stated she created a training outline for all educators to ensure all training provided to staff was consistent. The training outline went over how to spot abuse, how to report abuse, supervision, and immediate jeopardy. Interview with the DON, on 02/09/18 at 4:00 PM, revealed as a team, they looked at what training was lacking and discovered that more emphasis needed to be placed on behavioral health. She stated the team developed training that included information on abuse, resident behaviors, when to report abuse, and awareness of a change in the resident population. 8. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she played a role in educating nurses, CNAs, and therapists. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed she worked to ensure no staff worked until they were retrained. She stated she educated staff using the script that was given to all educators to ensure consistent training. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she initiated reeducation along with the management team beginning 01/26/18. Interview with the Health Information Manager, on 02/09/18 at 3:35 PM, revealed he participated in training development. He utilized a script and discussed abuse, responding to abuse, protecting the resident, and the importance of notifying a leadership member immediately. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she gave several trainings to staff members across multiple disciplines. 9. Observation, on 02/09/18 at 11:13 AM, revealed next to the computer utilized for clocking in and out was a sign indicating mandatory abuse/neglect training must be attended prior to working with the residents. Interview with RN #4, on 02/09/18 at 11:50 AM, revealed when she came to work following the incident, a charge nurse was waiting at the time clock and told her she had to attend a mandatory in-service. She stated she received education on signs of abuse, reporting abuse, the new Cottage Safety Monitor program, and the red dot safety circle program. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed the night of 01/26/18, a supervisor was posted at the time clock to alert staff of mandatory training. For employees who were not in the building, the electronic cell phone notifications, as well as emails, were sent to alert staff on mandatory training required prior to providing care. Interview with Nursing Supervisor #4, on 02/09/18 at 2:58 PM, revealed she attended multiple in-services, trainings, and received multiple emails relating to abuse and neglect as well as behavior monitoring following the incident. Interview with the Cook, on 02/09/18 at 11:40 AM, revealed she was unable to clock in for her shift until after she received education on abuse. She revealed she received training on reporting abuse and she had to sign a form acknowledging understanding of the training. Interview with the MSSM, on 02/09/18 at 6:10 PM, revealed she stood at the time clock for third shift on 01/27/18, to ensure all staff clocking in on third shift was trained on abuse prohibition and prevention prior to working that night. She stated other staff members stood by the time clock on all shifts until it was assured all staff were trained before working with residents. Review of a screenshot of the electronic team member notification cell phone application revealed the DON sent out a notification to staff listing dates and times available for mandatory training. 10. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she and the MSSC reviewed all the resident's care plans and included in the care plans, residents who had a known history of abuse or neglect. In addition, she revealed residents with known behaviors care plans were updated to include the Safety Circle intervention. Review of thirty-four (34) resident care plans and Kardexes revealed they were updated to include a known history of being a victim of abuse or neglect. A new intervention was implemented for all residents with a known history to monitor, document, and report symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, fractures, and unexplained bruising or injuries through the next review date. 11. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed all residents with a history of abuse, neglect, or behaviors had their care plans updated, including Resident #2. Review of Resident #2's clinical record revealed a care plan focus of Altered Family Process related to the resident's [DIAGNOSES REDACTED]. The care plan revealed Resident #2 had a known previous history of being a victim of sexual abuse and neglect. An intervention was initiated on 01/26/18, to continually monitor for psychosocial har (TRUNCATED)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure staff was trained to meet the behavioral health needs for one (1) of five (5) sampled residents, Resident #1. Record review and staff interviews revealed Resident #1's exhibited sexual behaviors at the facility and at school. Interviews revealed staff was not trained to address these behaviors. On 12/10/17, Resident #1 pulled Resident #2's pants and brief down, and put his/her hand down Resident #2 pants and put his/her face into Resident #2's genital area. The facility's failure to have an effective system in place to ensure staff was trained to meet the behavioral health needs of residents has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 01/26/18, and it was determined to exist on 12/10/17. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 02/09/18, alleging removal of the IJ on 02/05/18. The State Survey Agency validated the IJ was removed on 02/05/18, prior to exit on 02/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Behavior Management, revised (MONTH) (YEAR), revealed staff was to be trained to apply behavior management interventions. Review of Resident #1's clinical record revealed the facility admitted the resident on 02/18/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Notes, from 05/22/17 through 10/26/17 revealed five (5) entries related to sexual and/or aggressive behavior towards staff and/or residents. Review of the clinical record revealed this was not addressed through the resident's care plan and interviews with staff revealed they were not comfortable handling this type of behavior. Review of Resident #1's Nursing Note, dated 12/11/17 at 8:25 AM, revealed Certified Nursing Assistant (CNA) #2 notified Licensed Practical Nurse (LPN #1) with concerns that Resident #2 was the victim of a sexual assault by Resident #1 in the back of the unit (which occurred on 12/10/17). CNA #2 reported she found Resident #2 with his/her pants and diaper pulled down with exposed pubic hair, and Resident #1's hand was in Resident #2's genital area. Interview with CNA #7, on 01/27/18 at 8:17 PM, revealed the facility did not train her on the behavioral care and services for the residents. Interview with LPN #1, on 01/19/18 at 2:35 PM, revealed the facility had not instructed or educated her on behavior needs of residents. Interview with LPN #4, on 01/22/18 at 2:00 PM, revealed the facility did not provide instruction or in-services on care for Resident #1's behaviors. Interview with LPN #3, on 01/22/18 at 1:45 PM, revealed the facility was not a behavior facility and he had not been trained by the facility to care for residents with behaviors. He stated the facility did not provide in-services regarding residents with sexual behaviors and abuse histories. LPN #3 stated he had a mental health background and identified staff had not been prepared to take care of residents with psychological care needs. Interview with LPN #5, on 01/27/18 at 8:03 PM, revealed staff was verbally instructed on what type of behaviors to monitor and report for Resident #1. He further stated the facility did not provide behavior or mental health care as an in-service for staff who cared for the residents. He stated the facility needed to do more training on resident behaviors because the facility had admitted more residents with behavior issues. Interview with Nursing Supervisor #4, on 01/23/18 at 2:40 PM, revealed staff and supervisors needed behavioral and mental health in-services to provide care for the residents. She stated the facility management was told staff was not educated to provide behavior management and care. She further stated she used her nursing experience and knowledge as a mother to handle the behaviors of residents in the facility. Interview with the Social Service Manager, on 01/25/18 at 3:50 PM, revealed she spoke with staff on the resident's unit in an informal setting on the topic of what behaviors were to be monitored and reported after the 10/26/17 incident. She stated open discussion on a unit did not qualify as an in-service to staff for behavioral health care. Interview with Nursing Supervisor #1, on 01/28/18 at 1:50 PM, revealed staff needed education and in-services on behavioral care. She stated the facility admitted more and more residents who were able to ambulate, converse, and who had a history of [REDACTED]. The Supervisor stated staff had requested education for behavior and mental health care, but this had yet to occur. She further stated staff was not able to handle residents with behaviors. Interview with the Director of Nursing (DON), on 01/24/18 at 12:35 PM, revealed facility management had requested to be trained on the management of residents and behaviors for the medically fragile children in the facility so that nursing staff could be trained. However, per interview, the requests were not fulfilled. She further stated the facility determined Resident #1 was not appropriate for the facility due to his/her higher functioning and behaviors. Interview with the Senior Vice President, on 01/23/18 at 2:40 PM, revealed he was to assure all residents were safe and all needs were met for care and services in the facility. He stated most of the staff did not have backgrounds in mental or behavioral health care and the facility had done a poor job providing behavioral health care. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) supervision at all times beginning 12/10/17. 2. Resident #2 was evaluated by the Medical Social Services Coordinator (MSSC) on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. In addition, the MSSC regularly reviewed nursing documentation for Resident #2 including Nursing Narrative Notes, and Behavior and Response to Care Notes in order to assess changes in Resident #2's behavior and evidence of psychosocial harm. 3. Resident #2 was moved to a different unit, Ocean Avenue, on 12/15/17. 4. Resident #1 was discharged from the facility on 01/22/18, at the request of his/her mother who regained custody of Resident #1. 5. The Vice President of Clinical Services reviewed Interdisciplinary Progress Notes, Behavior and Response to Care Notes, and Skin Observation Notes on 01/24/18 and 01/25/18 for each resident on Maple Way, where the abuse occurred, for (MONTH) (YEAR), to determine if any physical or psychosocial signs or symptoms of abuse were documented on other residents and if additional residents might have been impacted or were at risk from Resident #1. 6. A root cause analysis was facilitated by the Vice President of Quality Improvement and Compliance and completed by facility team members including the Senior Vice President (SVP), Vice President of Clinical Services (VPCS), Director of Nursing (DON), Medical Director, Vice President of Therapy Services (VPTS), Medical Social Services Manager (MSSM), Medical Social Services Coordinator (MSSC), Health Information Management Coordinator (HIMC), Staff Development Coordinator (SDC), Respiratory Therapy Manager (RTM), Education Coordinator, Registered Nurse (RN) Clinical Supervisor, Child Development Coordinator and the facility's Administrative Assistant on 01/26/18 and 01/30/18. The Five Why's Methodology was used to determine why the facility failed to protect a resident from abuse. 7. Training on the Immediate Jeopardy, and on recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was developed on 01/26/18 by leadership, including SVP, VPCS, DON, MSSM, MSSC, and VPTS. 8. Training was implemented on 01/26/18 by leadership team members including SVP, VPCS, DON, MSSM, MSSC, HIMC, SDC, RTM, RN Clinical Supervisors and VPTS. Training was required for all team members prior to providing care. 9. Trainings occurred several times a day on 01/26/18, 01/27/18, 01/28/18, 01/29/18, 01/30/18, 01/31/18, 02/01/18, 02/02/18, 02/03/18, and 02/04/18. A leadership team member was stationed at the time clock to notify team members to report for training prior to going on units to provide care through 01/30/18 and a notice was posted at the time clock by the Director of Nursing to alert team members about required training. A notice was distributed by an electronic team member notification application, and by email listing dates and times of retraining. 10. All resident Care Plans and Kardexes were updated by MSSC, MSSM, and the VPCS. Updates occurred on 01/27/18, 01/30/18, 01/31/18, 02/02/18, and 02/03/18 to reflect residents' histories of abuse or neglect, any known high-risk behaviors, and subsequent level of intervention and supervision required. 11. Resident #2's care plan was updated by the MSSC and the VPCS on 01/27/18, to include monitoring of symptoms including changes in behavior, withdrawal, aggressive or disruptive behavior, symptoms of anxiety or depression, changes in sleep patterns, and crying. 12. Resident #2 was referred to a Psychologist for an intensive follow up evaluation and assessed on 01/29/18. 13. As a result of the root-cause analysis conducted on 01/30/18 by the interdisciplinary care team, the team further discussed every resident in an effort to evaluate and determine known histories of abuse or neglect and/or high-risk behaviors that could place each resident or other residents at risk for injury, abuse, or neglect. Further discussion resulted in the need for additional supervision and it was determined Cottage Safety Monitors (CSM) would be utilized to provide additional supervision. 14. The VPCS created a new procedure titled, Resident Supervision, which included a plan to implement CSM's and Safety Circles on 01/31/18. An email describing the new procedure and expectations was sent to all staff on 02/01/18. CSM's would be utilized during waking hours on cottages where additional supervision was required to monitor residents and mitigate the risk of injury, abuse, or neglect. CSM's will provide structured, age appropriate activities when possible to engage residents while providing appropriate oversight and supervision. CSM's will identify themselves to team members assigned to the unit. 15. The VPCS and the Clinical Quality Improvement Specialist created a new procedure, Behavior Management, that outlined an improved process for behavioral and mental health services and management. The procedure included emphasis on recognizing and communicating when residents have high-risk behavior or behavioral symptoms. The VPCS sent an email describing the new procedure and team member expectations to all staff on 02/03/18, with a read receipt that acknowledges each team member's acceptance of the responsibility for knowing and understanding high-risk behaviors of residents as well as monitoring for, prohibiting, and preventing negative outcomes. 16. Training on Immediate Jeopardy, recognizing, reporting, monitoring for, and responding to incidents of suspected abuse was attended by team members in the following departments: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, the facility's Administrative Team, Restorative Aides, Physical Therapy, Speech Therapy, Occupational Therapy, Respiratory Therapy, Receptionists, Training, Dietary, Finance, Maintenance, Information Technology, Environmental Services, Laundry, Materials Management and Quality Improvement and Compliance. Twenty-one (21) individuals had yet to complete training but were arranged to be trained prior to any care delivery. Contracted agency personnel and students had been trained and will be trained prior to any provision of care. Refer to training dates listed in #9. 17. Resident room placement and resident dynamics on each unit was evaluated to determine where CSM's would be required. 18. CSM's will follow the expectations outlined in the procedure titled, Managing Allegations of Abuse or Neglect, for removing the offending resident or individual and immediately reporting to a leadership team member if an inappropriate incident occurred. CSM's were responsible for ensuring continuous coverage by designating the CSM role to another available team member. CSM's were also responsible for ensuring that mobile residents were in the community area, in their room without a roommate present, or in bed. 19. A red Safety Circle was placed on the back of the wheelchair of residents that were mobile, those with the functional ability to reach out to others with either upper or lower extremities, and those with known high-risk behaviors requiring a 3-foot circle of safety around their wheelchair at all times. 20. Training was incorporated into the facility's Employee Orientation and included Abuse, Neglect & Exploitation Training: Prohibiting/Preventing, Identifying, Recognizing, Reporting and Understanding & Responding to Behaviors, resident supervision strategies including utilization of CSM's and Red Safety Circles, and attestation of the expectation that caregivers were responsible for knowing and understanding the information included in the residents' plan of care prior to providing care or supervision. 21. Ongoing monitoring of compliance included frequent and comprehensive knowledge checks. Knowledge Checks conducted by the facility's leadership team were done as face-to-face interviews or completing a knowledge check in writing along with a face-to-face question and answer session. Knowledge Checks were to be done at least weekly for one (1) year. Knowledge Checks included a set of competency-based questions verifying team members understanding and ability to implement aspects of Abuse, Neglect and Exploitation training, resident supervision including utilization of CSM's and Red Safety Circles, and location of and information included in residents' plan of care. Outcome measures for weekly knowledge checks would be tabulated and reported quarterly to the Quality Improvement Committee for review and compliance. The SSA validated the facility implemented the following actions: 1. Interview with Certified Nursing Assistant (CNA) #9, on 02/09/18 at 11:39 AM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring following the incident. She revealed she participated in monitoring Resident #1 for two (2) days. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was immediately placed on one (1) to one (1) monitoring by members of staff and he/she was monitored at all times. A company was contracted to come in and sit with Resident #1 until his/her discharge on 01/22/18. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed RN Clinical Supervisors made daily assignment sheets to ensure Resident #1 had one (1) to one (1) supervision at all times. She revealed staff monitored Resident #1 for two (2) days and then a company came in to offer one (1) to one (1) services. 2. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she evaluated Resident #2 on the day of the incident, 12/10/17. She stated Resident #2 appeared happy and was smiling, and displayed normal behavior. She revealed she continued to check on Resident #2 on 12/12/17, 12/13/17, and 12/14/17, with no change in behavior noted. She stated she evaluated Resident #2 several times each week following the incident. She stated she and the VPCS reviewed clinical notes to look for behavioral changes or any unusual occurrences. She revealed no concerns were found. Review of Resident #2's Social Services Notes, dated 01/30/18, by the MSSC, revealed the MSSC documented her evaluations of the resident on 12/10/17, 12/12/17, 12/13/17, and 12/14/17. The MSSC documented she reviewed Resident #2's Nursing Notes, and Behavior and Response Notes and found no concerns. 3. Observation, on 02/09/18 at 11:20 AM, revealed Resident #2 was in his/her room seated in wheelchair on Ocean Avenue Cottage with CNA #11 reading him/her a book. Review of Resident #2's clinical record revealed he/she was transferred to Ocean Avenue Cottage on 12/15/17. 4. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed Resident #1 was discharged on [DATE] into the custody of his/her mother. Review of Resident #1's discharge summary revealed he/she was discharged from the facility on 01/22/18. 5. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed it was a standard practice that all residents received a full assessment every twelve (12) hours and received baths every day. She revealed she reviewed all nursing notes, including every twelve hours (12) assessments, behavior notes, and skin notes for every resident on Maple Way Cottage. She revealed she discovered no concerns. Review of Resident #4 and #5's nursing notes, assessments, behavior notes, and skin notes revealed no concerns. 6. Interview with the Vice President of Quality Improvement and Corporate Compliance, on 02/09/18 at 3:00 PM, revealed she facilitated the root cause analysis with the SVP and VPCS. She revealed she utilized the Five Why's methodology, which was a tool where the team named a negative outcome and continuously asked the question, why, in order to determine the root cause. She revealed she reviewed what the team determined had been the root cause. Interview with the SVP, on 02/09/18 at 5:15 PM, revealed he was involved in two (2) root cause analysis meetings. He stated the team went through the Five Why's to determine the root cause. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she and a team of managers met on two (2) separate occasions to determine the root-cause that led to Resident #1 sexually assaulting Resident #2. She revealed they used the Five Why's tool to dig deeper to determine where the facility failed. Review of the facilities Root Cause Analysis and Action Plan revealed utilization of the Five Why's in order to determine the systemic root cause. The action plan included Barriers, Interventions, Outcome Monitoring, Person(s) Responsible, and Implementation Dates. The facility determined the root cause was limitation with personnel resources and budgetary/financial constraints that did not adequately support the evolving needs of the pediatric long-term care population. 7. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she reviewed the regulation and revised the attestation statement. She stated she created a training outline for all educators to ensure all training provided to staff was consistent. The training outline went over how to spot abuse, how to report abuse, supervision, and immediate jeopardy. Interview with the DON, on 02/09/18 at 4:00 PM, revealed as a team, they looked at what training was lacking and discovered that more emphasis needed to be placed on behavioral health. She stated the team developed training that included information on abuse, resident behaviors, when to report abuse, and awareness of a change in the resident population. 8. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she played a role in educating nurses, CNAs, and therapists. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed she worked to ensure no staff worked until they were retrained. She stated she educated staff using the script that was given to all educators to ensure consistent training. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she initiated reeducation along with the management team beginning 01/26/18. Interview with the Health Information Manager, on 02/09/18 at 3:35 PM, revealed he participated in training development. He utilized a script and discussed abuse, responding to abuse, protecting the resident, and the importance of notifying a leadership member immediately. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed she gave several trainings to staff members across multiple disciplines. 9. Observation, on 02/09/18 at 11:13 AM, revealed next to the computer utilized for clocking in and out was a sign indicating mandatory abuse/neglect training must be attended prior to working with the residents. Interview with RN #4, on 02/09/18 at 11:50 AM, revealed when she came to work following the incident, a charge nurse was waiting at the time clock and told her she had to attend a mandatory in-service. She stated she received education on signs of abuse, reporting abuse, the new Cottage Safety Monitor program, and the red dot safety circle program. Interview with the SDC, on 02/09/18 at 2:18 PM, revealed the night of 01/26/18, a supervisor was posted at the time clock to alert staff of mandatory training. For employees who were not in the building, the electronic cell phone notifications, as well as emails, were sent to alert staff on mandatory training required prior to providing care. Interview with Nursing Supervisor #4, on 02/09/18 at 2:58 PM, revealed she attended multiple in-services, trainings, and received multiple emails relating to abuse and neglect as well as behavior monitoring following the incident. Interview with the Cook, on 02/09/18 at 11:40 AM, revealed she was unable to clock in for her shift until after she received education on abuse. She revealed she received training on reporting abuse and she had to sign a form acknowledging understanding of the training. Interview with the MSSM, on 02/09/18 at 6:10 PM, revealed she stood at the time clock for third shift on 01/27/18, to ensure all staff clocking in on third shift was trained on abuse prohibition and prevention prior to working that night. She stated other staff members stood by the time clock on all shifts until it was assured all staff were trained before working with residents. Review of a screenshot of the electronic team member notification cell phone application revealed the DON sent out a notification to staff listing dates and times available for mandatory training. 10. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she and the MSSC reviewed all the resident's care plans and included in the care plans, residents who had a known history of abuse or neglect. In addition, she revealed residents with known behaviors care plans were updated to include the Safety Circle intervention. Review of thirty-four (34) resident care plans and Kardexes revealed they were updated to include a known history of being a victim of abuse or neglect. A new intervention was implemented for all residents with a known history to monitor, document, and report symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, fractures, and unexplained bruising or injuries through the next review date. 11. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed all residents with a history of abuse, neglect, or behaviors had their care plans updated, including Resident #2. Review of Resident #2's clinical record revealed a care plan focus of Altered Family Process related to the resident's [DIAGNOSES REDACTED]. The care plan revealed Resident #2 had a known previous history of being a victim of sexual abuse and neglect. An intervention was initiated on 01/26/18, to continually monitor for psychosocial harm due to recent incident of abuse and document and report symptoms immediately to RN Clinical Supervisor or the facility's Leadership. It further included to monitor for symptoms including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, and crying. An intervention was initiated on 01/27/18, to monitor, document, and report symptoms of abuse and neglect including changes in behavior, aggressive or disruptive behavior, withdrawal, symptoms of anxiety or depression, changes in sleep patterns, fractures, and unexplained bruising or injuries through next review date. Resident #2's care plan revealed an additional focus area of Risk for Injury related to inability to protect self from injury, self-mobility in bed or on mat, and has no self-preservation skills. An intervention was initiated on 02/03/18, to monitor for behavioral symptoms such as self-mobility in wheelchair without safety awareness of others, resisting care, destroying equipment or property, pinching or pulling at care givers, entering other resident's rooms or unauthorized spaces, and sexual self-stimulation in public areas that places residents or others at risk for injury or abuse. 12. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she emailed the Psychologist to examine Resident #2 for signs of psychosocial harm. Interview with the MSSC, on 02/09/18 at 4:30 PM, revealed the Psychologist arrived on the Ocean Avenue Cottage on Monday 01/29/18 and visited with Resident #2 for over an hour and reported she saw no signs or symptoms of psychological harm. Review of email correspondence between the MSSM and the Psychologist revealed Resident #2 was seen by the Psychologist on 01/29/18. 13. Observation, on 02/09/18 at 11:20 AM, revealed CNA #11 was reading to Resident #2. CNA #11 had been the Cottage Safety Monitor for that shift according to the schedule hanging at the nurse's station. The cottage contained two (2) residents at the time. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she looked at every resident and identified residents who had specific behaviors that potentially posed a threat to other residents. She revealed based on the behaviors, the VPCS and the interdisciplinary team decided that more supervision was required at certain times of the day and developed the Cottage Safety Monitor (CSM) role. Interview with the MSSM, on 02/09/18 at 2:11 PM, revealed she and the MSSC reviewed the clinical records for residents who had a history of [REDACTED]. 14. Interview with CNA #9, on 02/09/18 at 11:39 AM, revealed she was educated at three (3) separate trainings about Cottage Safety Monitors. Interview with RN #4, on 02/09/18 at 11:50 AM, revealed she received education on the new Cottage Safety Monitor program. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she emailed all staff members on 02/01/18, about the role of CSM's and the expectations of staff. Review of a procedure titled, Resident Supervision, revealed CSM's would be utilized during waking hours on units where additional supervision was required to monitor residents and mitigate risk of injury, abuse, or neglect. It included CSM's were required to provide age appropriate activities to engage residents while providing appropriate oversight and supervision. 15. Interview with the VPCS, on 02/09/18 at 3:28 PM, revealed she emailed all staff members on 02/03/18, and attached the new Behavior Management procedure and requested all staff attach a read receipt once it had been read. The VCPS stated she received all staff members read receipts for staff who had worked since it was sent. Interview with Nursing Supervisor #4, on 02/09/18 at 2:58 PM, revealed she received multiple emails related to behavior monitoring following the 12/10/17 incident. Interview with the Activities Coordinator, on 02/09/18 at 3:30 PM, revealed she received several emails on behavior management and abuse as well as two (2) trainings and multiple face-to-face communications with management staff. Review of a procedure entitled, Behavior Management, dated 01/2018, revealed the procedure included behavioral interventions, therapeutic holding guidelines, assessment requirements, and care plan formulation. An email was sent to all staff on 02/03/18, with the Behavior Management procedure and Safety Circle Room List attachments. The email stated all staff must respond with a read receipt to acknowledge they have read the Behavior Management procedure. 16. Interview with CNA #10, on 02/09/18 at 11:20 AM, revealed she received training following the incident and was given papers stating the different types of abuse, instructions on what to do if she witnessed abuse, and at the end, she revealed she signed off that she received the training. Interview with the Restorative Aide, on 02/09/18 at 11:30 AM, revealed a sign for mandatory training on abuse was posted where she clocked in. During the abuse training, she learned about the new Safety Circle program, which required a three (3) foot space surrounding residents in order to prevent resident-to-resident abuse. She stated residents' wheelchairs contain a red safety circle if they were considered a risk. Interview with the facility's Administrative Assistant, on 02/09/18 at 11:32 AM, revealed she received education on abuse on 01/29/18. She revealed the educator presented the information and then quizzed staff and they acted out scenarios. During the course of the teaching, several staff had questions about the reporting process, which the educators answered. She stated after receiving the education, she felt encouraged on what to do if she witnessed abuse. Interview with CNA #9, on 02/09/18 at 11:39 AM, revealed she was educated at three (3) separate trainings about abuse recognition, abuse reporting, Safety Circles, and Cottage Safety Monitors. Interview with the Cook, on 02/09/18 at 11:40 AM, revealed she was unable to clock in for her shift until after she received education on abuse. She revealed she received training on reporting abuse and she had to sign a form acknowledging understanding of the training. Interview with LPN #7, on 02/09/18 at 11:45 AM, revealed she was trained on abuse and neglect. If she suspected something was wrong, she stated she was supposed to ensure the resident was safe and then report it immediately. She stated if nothing were done, she would report it to Child Protective Services or the Ombudsman Interview with RN #4, on 02/09/18 at 11:50 AM, revealed when she came to work following the incident, a charge nurse was waiting at the time clock and told her she had to attend a mandatory in-service. She stated she received education on signs of abuse, reporting abuse, the new Cottage Safety Monitor program, and the red dot safety circle program. Interview with the Environmental Services, on 02/09/18 at 12:18 PM, revealed she went to a mandatory meeting related to abuse and neglect, how to recognize abuse, and the reporting requirement. She revealed she would report to the nurse on the unit immediately if she witnessed abuse. Interview with CNA #11, on 02/09/18 at 12:20 PM, revealed training was provided on Tuesday night, 01/30/18, relating to abuse. The training discussed signs of abuse, reporting abuse, safety circles, and ensuring the resident was safe prior to reporting. Interview with Nursing Supervisor #4, on 02/09/18 at 2:58 PM, revealed she attended multiple in-services, trainings, and received multiple emails relating to abuse and neglect as well as behavior monitoring following the incident. Interview with the Activities Coordinator, on 02/09/18 at 3:30 PM, revealed she received several emails on behavior management and abuse as well as two (2) trainings and multiple face-to-face communications with management staff. She sta (TRUNCATED)