Every finding on record at Lake Barkley Health & Rehabilitation

Based on observation, interview, and review of the facility's Certified Nursing Assistant (CNA) job description and policy, the facility failed to have sufficient nursing staff 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. Observation and interview revealed an average call light response time of 15 - 20 minutes for three of 50 sampled residents, (Resident (R)15, R42, and R196). The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), undated, revealed the facility was to provide care, treatment, and services to residents as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Review of the facility policy titled, Answering the Call Light, undated, revealed the facility was to maintain a functional call light system and should make all reasonable efforts to ensure timely responses to the resident's requests and needs. Review of the facility policy titled, Staffing, dated 10/01/2021, revealed the facility was to provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the residents' care plans and the facility assessment. Review of the facility's job description titled, Certified Nursing Assistant, revised 03/2024, revealed the Certified Nursing Assistant's (CNA) personal nursing care responsibilities included ensuring (residents') call lights were within reach of residents and were answered promptly. During the Resident Council meeting held on 04/23/2025 at 1:18 PM, the residents unanimously stated most staff treated residents with dignity; however, certain staff were not friendly and could be mean or hateful. The residents stated sometimes they had to wait up to two hours for help after turning on their call lights. They further stated it was not uncommon to have to wait of 20-30 minutes to get help. Review of the residents who attended and actively participated in the Resident Council meeting medical records revealed Minimum Data Set (MDS) Assessments with Assessment Reference Dates (ARDs) ranging from 01/23/2025 to 03/28/2025 and Brief Interview for Mental Status (BIMS) scores ranging from 13 to 15, indicating intact cognitive function. 1. Record review revealed the facility admitted R42 on 03/28/2025, with diagnoses to include displaced trimalleolar fracture of left lower extremity, history of falls, and essential hypertension. Review of the MDS Assessment with an Assessment Reference Date (ARD) of 04/11/2025, revealed the facility assessed R42 to have a BIMS score of 15 out of 15, indicating intact cognitive function. Observation on 04/23/2025 at 5:18 PM revealed the call light R42 on as the State Survey Agency (SSA) Surveyor passed the resident's room. Observation at 5:22 PM, revealed Licensed Practical Nurse (LPN) 2 walked passed R42's room where the call light was on, and at 5:25 PM, LPN 2 and Registered Nurse (RN) 1 also walked past the resident's room where the call light was still on. Observation at 5:26 PM, revealed the Housekeeping Supervisor walked past R42's room where the call light remained on. Continued observation revealed at 5:31 PM, RN 1 knocked on R42's door and entered the room stating, you had your light on?. In interview on 04/23/2025 at 5:35 PM, R42 stated she was unsure how long she had waited after turning her call light on. She stated the reason the call light was on was because she needed help to get to the bathroom. 2. Review of the medical record facesheet for R15 revealed the facility admitted the resident on 03/05/2021, with diagnoses that included respiratory failure, generalized anxiety disorder, primary osteoarthritis, and hypothyroidism. Review of the MDS Assessment with an ARD of 03/13/2025, revealed the facility assessed R15 to have a BIMS score of nine out of 15, which indicated moderate cognitive impairment. In interview on 04/22/2025 at 1:00 PM, R15 stated her only complaint was that the wash cloths and bed pads were always locked up and she had to go find staff to get them when she needed them. She stated that made her feel in-human. R15 said, I'm an adult and shouldn't have to ask for a wash cloths when I want or need one. It's like they work with a skeleton crew. She stated when she turned her call light on, she had to wait for an hour for someone to come help her. R42 said it is always like that, because staff said it was because the facility was shorthanded. She reported there were usually only two or three aides for a day for the entire building, and the building was big and spread out. R42 stated the facility had new owners, had done a lot of cut backs, and fired some staff about six months ago. She further stated the staff were so overworked, working over 12 hours per day. 3. Review of the medical record facesheet for R196 revealed that the facility admitted the resident on 04/18/2025, with diagnoses that included stage 3A chronic kidney disease, type 2 diabetes, peripheral vascular disease, and moderate vascular dementia. Observation of R196 on 04/22/2025 at 2:55 PM, revealed resident lying on his right side on the bed, with yellow stains appearing to be dried urine on his briefs and bed pads and dried red stains by his foot wound which appeared to be blood on his bed sheets. In interview, at the time of observation, R196 stated his right leg was numb because no on had been in to help him change positions. The SSA Surveyor encouraged R196 to use his call light to request help, and the resident proceeded to press the call light button at that time. Further observation revealed staff responded to R196's call light 20 minutes later when the SSA Surveyor stepped into the hallway to find a staff member to help the resident. In interview on 04/23/2025 at 4:50 PM, CNA 2 stated she believed there was not enough staff to take care of the residents as they should be taken care of. In interview on 04/23/2025 at 5:00 PM, CNA 3 stated in her opinion there was no way there was enough staff to properly take care of the residents. In interview on 04/23/25 at 5:05 PM, the Housekeeping Supervisor stated when the (resident) census was down staff was decreased and residents had to wait longer for help. In interview with CNA 11 on 04/24/2025 at 9:35 AM, she stated anyone could answer a resident's call light and the lights should be answered within three minutes but no longer than 10 minutes. She said even if she was busy, she would stop and acknowledge the light and let the resident know that she would be right back to assist them. CNA 11 further stated a resident could try to get up alone and fall or even choke if their call light was not answered timely. In interview with CNA 12 on 04/24/25 at 10:00 AM, she stated anyone could answer a call light. She stated it should never take more than 10 minutes to answer a resident's call light and definitely should not be 20 minutes or an hour. CNA 12 said anything could happen to a resident during that the waiting time. She further stated she did not think the facility had enough staff, but she always got her job done and did not have to work over to finish it. In interview on 04/24/2025 at 6:23 PM, the Director of Nursing stated if someone walked by and saw a resident's call light on they should stop and respond. The DON said if the staff responding to the light could not take care of the resident's need, they should find someone that could. She stated 15-20 minutes response times were unacceptable. The DON reported elderly people's skin was frail, and they did not need to be left on the bed pan for too long. She stated there could be a lot of negative outcomes for not answering call lights in a timely manner. The DON further stated, You don't know why they (the residents) are calling and that can lead to lots of bad outcomes. She stated she stressed recognize and respond (to call lights). The DON explained that neglect was a big problem and never acceptable to her at all. She said staff are to be checking and changing residents more often. She stated that she expects her staff to conduct themselves professionally and respect other staff members. In interview on 04/24/2025 at 7:00 PM, the Administrator stated it was his expectation for answering call lights was as fast as they come on they should be answered. He stated the importance of answering call lights was discussed in morning meetings and said he answers call lights himself. The Administrator stated a 15-20 minute response time was unacceptable, and said, call lights are my biggest pet peeve. He stated he expected his staff to change residents and make sure they were dry, and did not expect his residents to be lying in urine and feces. The Administrator further stated a negative outcome for not answering call lights timely was a resident could fall, or have a crisis going on, and needed to be changed timely to prevent bed sores and urinary tract infections. 52041

Based on observation, interview, facility policy review, and review of manufacturer's instructions, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or labeled with currently accepted professional principles, including the expiration date when applicable. Observation of a medication storage room revealed two Tuberculin vials stored in the refrigerator were opened but not labeled with a date as to calculate its discard date. Observation also revealed two vials of Tuberculin dated with a date that was beyond the 30 day manufacturer's required discard date. Additionally, observation revealed 60 COVID-19 test kits stored beyond the manufacturer's expiration date. The findings include: Review of the facility policy titled, Medication Storage, undated, revealed medications stored must be labeled accordingly and the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. Observation on 04/23/2025 at 1:00 PM, of the medication storage room, revealed two multi-dose vials of house stock Aplisol tuberculin (used to detect tuberculosis infection) that was opened; however, not dated. Continued review revealed two additional multi-dose vials of house stock Aplisol tuberculin, one dated 03/15/2025 and the other 03/18/2025, which was past the manufacturer's 30 day required discard date. Further review revealed nine boxes of four (equaling 36 tests) Pilot COVID-19 at home test kits with an expiration date of 04/14/2025 and 24 Cordx COVID-19 ag at home test kits with an expiration date of 04/01/2025. During interview with Registered Nurse (RN) 1 on 04/23/2025 at 1:20 PM, she stated she was an agency nurse. RN 1 stated the tuberculin vials should be labeled with a date and initial immediately after opening. RN 1 reported a resident could have an adverse reaction (from the tuberculin that was undated or past the discard date) and the medication might not even be good anymore. She said the expired medications and test kits would need to be discarded based on the manufacturer's expiration date. The RN stated she did not know the recommendation from the manufacturer regarding how long a tuberculin vial was good for once it was opened. She stated she did not know who was responsible for monitoring the medication room for expired items. RN 1 further stated if the COVID tests were used, they could give a false result. During interview with Licensed Practical Nurse (LPN) 1, she stated the tuberculin vials should have been dated, timed and initialed as soon as they were opened and were only good for 30 days. She said residents could have an adverse reaction and the medication might not be as effective if it was used. LPN 1 reported the nurse who had been responsible for monitoring the medications had quit about two weeks ago. The LPN stated she did not know who was responsible for monitoring the medications now. She said staff should check expiration dates prior to using any medication or COVID test. LPN 1 further stated the COVID tests should have been discarded once they expired. During interview with the Director of Nursing (DON) on 04/24/2025 at 6:23 PM, she stated it was her first week working at the facility. She stated she would be responsible for checking expiration dates. The DON said she expected her staff to check expiration dates and dispose of any medication or test that was expired and dispose of those expired. She reported by using expired medications or COVID tests could result in a resident having a reaction or it could lead to a false test result, which might result in the result receiving treatment for something they did not actually have. The DON further stated expiration dates were there for a reason and should be followed. During interview with the Administrator on 04/24/2025 at 6:59 PM, he stated he expected staff to check expiration dates, date the medication vials once opened and discard the medication once it was past the deadline dates. He said something possibly could have happened to the residents (if the expired products were used). The Administrator explained the medication might not have been at full strength and might have became contaminated. He stated the COVID tests also needed to be monitored for their expiration dates. The Administrator reported if staff used an outdated test, it might not give an accurate indication of the results. He further stated his staff needed to be re-educated on the importance of expiration dates and when to discard medications.

Based on observation, interview, record review and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 sampled residents, (Resident (R)10). During observation on 04/24/2025 at 3:33 PM, Licensed Practical Nurse (LPN) 5 was observed to blow her nose; however, failed to perform hand hygiene after doing that. The LPN was then observed to touch R10's packaged medications and administer them to the resident. The findings include: Review of the facility policy titled, Hand Hygiene, undated, revealed it was to promote a simple and effective method for preventing the spread of infection. Per policy review, it included specific guidance for all staff to follow hand hygiene procedures after personal care activities that included blowing of the nose. Observation of LPN 5 on 04/24/2025 at 3:33 PM, revealed the LPN blew her nose at the medication cart, and tossed the used tissue into the waste can. Continued observation revealed LPN 5 then proceeded to touch the computer keyboard, open the medication drawer, and remove packaged medications from the drawer. Further observation revealed LPN 5 proceed to open the packaged medications to prepare to administer the medications to R10. In interview on 04/24/2025 at 3:40 PM, LPN 5 was asked by the State Survey Agency (SSA) Surveyor if she had hand sanitized her hands after blowing her nose. LPN 5 stated she had not sanitized her hands; however, probably should have and said was having allergies. The LPN further stated hand hygiene was important to stop the spread of germs. In interview on 04/24/2025 at 5:23 PM, the Director of Nursing (DON) stated she expected the nurse (LPN 5) to have performed hand hygiene after blowing her nose. The DON further stated the nurse should have performed the hand hygiene prior to touching anything to prevent potential contamination of everything, including the resident. She additionally stated the nurse should have performed hand hygiene to also prevent the spread of infection. In interview with the Administrator on 04/24/2025 at 6:46 PM, he stated he expected staff to appropriately perform hand hygiene to prevent the spread of germs.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure survey results were posted in a place readily accessible, where individuals wishing to examine the survey results did not have to ask to see them. The facility's failure affected 8 residents who attended the resident council meeting (Resident (R)4, R11, R12, R24, R31, R32, R36, and R38) and had the potential to affect all residents residing in the facility, as well as family/representatives, and visitors of the facility who had the right to review the facility's survey history. Observation revealed the facility's survey binder was not located in a readily accessible place and interview revealed the binder had been stored in the Administrator's office. The findings include: Review of the facility policy titled, Resident Rights, undated, revealed each resident had a right to examine the results of the most recent survey of the facility conducted by Federal or State Surveyors and any plan of correction in effect with respect to the facility. Observation on 04/22/2025 at 11:45 AM, revealed a wall pocket located in the facility's entrance, which was labeled Survey Results. Per observation of the wall pocket, no survey book/binder was present in it. Continued observation revealed a sign located in the main entrance that noted, State Law KRS 216.457 required state inspection reports of the facility to be made available to upon request and to ask a representative of the facility. Further observation of the main entrance area, as well as other areas throughout the facility, revealed no visual evidence the required survey reports were present and/or accessible for independent review. A Resident Council meeting was conducted on 04/23/2025 at 1:18 PM, with residents who regularly attend the Resident Council meetings. During the meeting, interview with the residents who were present (R4, R11, R12, R24, R31, R32, R36, and R38) revealed none of the resident knew where the facility's survey book (results of the facility's surveys) was located. Observation on 04/23/25 at 8:40 AM, revealed the survey results wall pocket remained empty. Observation on 04/23/25 at 2:45 PM, revealed the survey binder was located in its labeled location at the front door. In interview with the Administrator, at the time of observation, he said the binder had been stored in his office since he began working in his current position. The Administrator stated he had been reviewing the previous survey results and had forgotten to replace the binder in its designated area. He further stated the binder had been replaced when it was brought to his attention that the binder was not in its designated location. During interview on 04/24/2025 at 1:10 PM, Licensed Practical Nurse (LPN) 1, LPN 5, and Certified Nursing Assistant (CNA) 4 stated the survey book was kept in the Director of Nursing's (DON) office. SRNA 9 said however, the survey book was to in the main entrance. In interview with the DON on 04/24/2025 at 6:23 PM, she stated it was her first week working as the facility's DON and she was new to long term care. She further stated she assumed the survey binder should be available. In interview with the facility's Administrator on 04/24/2025 at 7:00 PM, he stated the survey binder would be kept at the front door in it designated spot in the future.

Based on interview, record review, review of the facility's investigation, and facility policy review, it was determined the facility failed to protect one (1) of three (3) sampled residents from mental abuse (Resident #1). On 05/18/2020, the Director of Nursing (DON) instructed three (3) staff to hold Resident #1's arms, legs, and feet, while she inserted an indwelling urinary catheter, after the resident refused the catheter. Resident #1 was crying, kicking, and begging staff not to insert the catheter. The resident stated he/she felt like he/she was being molested, as the resident has a history of abuse. In addition, staff involved failed to protect residents from abuse when they failed to report the allegation to the Administrator until 05/26/2020. After the Administrator received the allegation, he failed to recognize the incident as abuse; failed to remove the alleged perpetrators from resident care; and, report to the appropriate State agencies. The facility's failure to ensure the resident was free from abuse has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 06/10/2020 and determined to exist on 05/18/2020. The facility was notified of the Immediate Jeopardy on 06/10/2020. An acceptable Allegation of Compliance (AoC) was received on 06/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 06/19/2020, as alleged. The Scope and Severity was lowered to a D for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at F600, F607, F609 and F610; and 42 CFR 483.70 Administration at F835; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, titled Abuse Protocol, last revised January 2016, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment, and involuntary seclusion. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes biting, slapping, pinching, kicking and pushing, It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. All employees will report to their immediate supervisor any incidents of abuse, neglect or exploitation. The Executive Director will direct the investigation and may appoint other staff members to investigate all complaints. The investigation will include the details of the event and review of all circumstances surrounding the incident. For protection during the investigation, any individual suspected of resident abuse will be placed on administrative leave without pay. While on administrative leave, any employee being investigated for possible abuse is banned from returning to the facility. Review of the facility's policy, titled, Resident Rights, effective date 11/28/2016, revealed the resident has the right to request, refuse, and/or discontinue treatment. Record review revealed the facility admitted Resident #1 on 03/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Annual Minimum Data Set (MDS) assessment, dated 03/17/2020, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was interviewable. Review of an Electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was electronically signed by the DON, but it was not signed by the Physician as of 06/01/2020 (date the survey was initiated). Interview with Resident #1's Physician/facility Medical Director, on 06/02/2020 at 9:56 AM, revealed she and the DON had a conversation about things they might try for the resident due to the resident's refusal of incontinent care and having skin breakdown but she did not recall giving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #1, on 06/01/2020 at 1:37 PM, and on 06/10/2020 at 4:13 PM, revealed on 05/18/2020, he/she told the DON that he/she did not want a catheter and the DON told him/her if (he/she) did not get the catheter, (he/she) would be sent farther away from family. The resident stated when the DON was putting in the catheter (process when a catheter [tubing] is inserted into the bladder through the urethra) he/she was fighting and kicking and the DON told the Aides to hold him/her down. Resident #1 stated that he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated when the catheter was being put in he/she felt like (he/she) was being molested. Resident #1 further stated he/she felt like he/she was abused. The resident also stated that the DON told him/her, that (he/she) didn't love (himself/herself). Further interview on 06/25/2020 at 10:30 AM, revealed Resident #1 reported that the DON told him/her that she (the DON) would not leave the room after she inserted the catheter until she received a hug from the resident. Resident #1 stated the DON asked him/her again, so he/she (Resident #1) hugged the DON so that she would leave. The resident stated the Advanced Practice Registered Nurse (ARNP) and Physician told him/her that they had not ordered the catheter. Interview with the DON, on 06/01/2020 at 4:15 PM, revealed Resident #1 was non-compliant and she had talked with the physician on 06/02/2020 about a bariatric bedpan and bariatric bedside commode for the resident to use to encourage compliance and to help with healing the resident's wounds. The DON stated she told the resident if the interventions (bariatric bedpan and bedside commode) did not work, the physician had ordered an indwelling catheter to be used as a temporary measure, if the wound got worse. However, the physician did not recall giving the order, and according to documentation in the resident's record, the wound measured the same as when it was identified on 04/28/2020. Further interview with the DON revealed the resident continued to refuse bed incontinent care, and the use of the bedpan and bedside commode. She stated staff were having to give the resident a complete bed bath every morning. The DON stated on 05/18/2020, the wound had become larger and the steps put into place were not working so she told the resident that the third step was a temporary measure and that they needed to place the catheter on a short-term basis. She stated, If the resident had not of agreed, I would not have done it. The DON stated she had the aides hold the resident's large thighs apart as she assembled her equipment. She stated the resident was very shy and when she went to clean the perineal area, the resident put his/her hand down in the area. According to the DON, the resident was very animated and dramatic, very loud and with high anxiety. Further interview revealed she then told the Aides to get the resident's hands so that he/she did not contaminate the sterile field, so the resident's legs and arms were held by the Aides. The DON stated she asked the resident to take a deep breath and the catheter was inserted with a large amount of urine returned. She stated the staff then released the resident's legs/wrists. She stated, if the resident had told her to stop, she would have. The DON reported she thought the staff in the room were very uncomfortable because of all the excitement and anxiety in the room. Interview with Licensed Practical Nurse (LPN) #1, on 06/01/2020 at 2:35 PM, and 06/25/2020 at 10:01 AM, revealed she was in and out of the room during Resident #1's catheter insertion gathering supplies. LPN #1 stated when the resident came into the room, the resident stated he/she did not want the catheter, but the resident got up from the wheelchair using the sit-to-stand lift to transfer to the bed. LPN #1 stated the resident was crying and the DON talked to the resident about the importance of having a catheter in relation to his/her wound and told the resident there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Nurse Aide (NA) #1, on 06/01/2020 at 2:51 PM, and 06/08/2020 at 8:14 AM and review of his/her written statement, dated 05/26/2020 revealed he and SRNA #1 went to the resident's room with LPN #1 and the DON to assist in the placement of a urinary catheter. NA #1 stated the resident started crying stating that he/she did not want the catheter and the DON stated to the resident, If you do not get this catheter, I will find you somewhere else to go., and the resident stated he/she still did not want the catheter. NA #1 stated the DON told the resident it was a doctor's order and that he/she didn't have a choice. Further interview revealed LPN #1 spread the resident's legs so the DON could insert the catheter and the resident started screaming that he/she felt like he/she was being molested. NA #1 stated the DON then grabbed the catheter and told him and SRNA #1 to hold the resident's arms and legs to keep them down while she inserted the catheter. The DON then inserted the catheter and inflated the catheter balloon via the syringe. NA #1 further stated the resident asked the DON to please leave my room at which time the DON turned to the resident and stated, I'm not leaving until you give me a hug. The resident again begged the DON to leave his/her room, but eventually hugged the DON so that she (the DON) would leave the room. NA #1 stated he reported the abuse allegation to Registered Nurse (RN) #1 after the incident. An additional interview with NA #1, on 06/10/2020 at 5:33 PM, revealed Corporate staff met with him on 06/08/2020 and wanted him to change his story for the image of the company. According to NA #1, they were trying to get him not to use the word abuse. NA #1 stated Resident #1 has been quieter since the incident, and was less talkative. Interview with SRNA #1, on 06/02/2020 at 8:04 AM, and review of her written statement, dated 05/26/2020 revealed she, Aide #1, LPN #1 and the DON were in Resident #1's room. SRNA #1 stated the resident did not want the catheter and was told by the DON if he/she didn't get it they would find him/her somewhere else to go. She stated the staff assisted the resident onto the bed and started providing incontinent care when the resident started crying and fighting, and stated he/she felt like he/she was being raped. SRNA #1 stated the DON told her and NA #1 to hold the resident's legs and arms down. Then the DON told her and Aide #1 to hold the resident's arms and legs while she inserted the catheter. The SRNA stated the resident was begging them to to stop and the DON went on and inserted the catheter. She stated that after the DON got the catheter in, she told the resident to give her a hug or she was not leaving the room. SRNA #1 stated she stepped out of the room because she was upset and crying herself, and was not in the room to see the hug. The SRNA further stated, The patient has the right to refuse and (she) considered it abuse. She stated she and NA #1 reported to RN #1 that the DON had them to hold the resident's arms and legs down. Interview with SRNA #2, on 06/02/2020 at 10:50 AM, revealed she was at the foot of the bed during the incident. She stated the resident was refusing the catheter and was crying and the DON told the resident he/she would either have to get a catheter or go somewhere else. She stated when the resident started kicking, the DON instructed her to hold the resident's feet to keep him/her from kicking. She stated she did not report the abuse to a supervisor. Interview with RN #1, on 06/08/2020 at 8:25 AM, revealed SRNA #1 and NA #1 told her they held the resident down and the resident was threatened to be sent far away from family if he/she did not let the DON insert the catheter. RN #1 stated she heard the resident screaming from down the hall. RN #1 stated the Aides also stated that the DON had promised the resident a milkshake after the catheterization and the Aide left to go get it. RN #1 stated she did not report the abuse to the Complaint Coordinator/former Administrator even though she felt it was abuse. Further interview with RN #1, on 06/10/2020 at 4:59 PM, revealed the facility had been trying to cover up the situation and the former Administrator had been trying to get staff to change their stories. Interview with the Admission/Marketing person, on 06/04/2020 at 11:54 AM, revealed on 05/26/2020, she went by Resident #1's room and asked the resident how things were going. She stated the resident went on to tell her that he/she had been catheterized and it caused him/her to have back spasms and that staff held his/her legs down to get the catheter. Further interview revealed the resident stated he/she did not want to be sent away farther from his/her family. The Admissions/Marketing person stated they went to get the SSD so that the resident could repeat what she had been told. She stated that she and the SSD reported to the former Administrator what the resident had revealed to them about the event. Interview with the Social Services Director (SSD), on 06/03/2020 at 4:22 PM, revealed on 05/26/2020 she was sitting in her office and the Admission/Marketing person came and asked her to go to Resident #1's room, as the resident wanted to talk to her. The SSD stated when she walked in the room the resident was crying. She stated the resident told her that he/she had been given a catheter last week that he/she did not want. She stated the resident said he/she had been sitting up in the three-hundred (300) area when an Aide came up to get him/her as instructed by the DON. She stated the resident told her that when they got to the resident's room, the DON, LPN #1, NA #1 and SRNA #1 were already in the room. At this time, the resident was told they would be putting a catheter in at which time the resident became upset and began to cry. She stated the resident also reported that the DON told both Aides to hold his/her arms and legs down so she could insert the catheter. The SSD stated the resident told her that the DON said if he/she did not let them put the catheter in he/she would be moved where it would be harder for him/her to see his/her Mother and Grandkids. The SSD stated the resident was alert and oriented, but did not always make the best choices for his/her health. She stated she and the Admission/Marketing person both went to the Administrator's office on 05/26/2020 at 11:15 AM and reported the incident to him. Interview with the former Administrator/Abuse Coordinator, on 06/08/2020 at 10:23 AM, revealed he was made aware of the allegation on 05/26/2020 by the SSD and Admissions/Marketing person. He stated he was told that Resident #1 complained of a treatment she received by the DON, the insertion of a catheter on a temporary basis to allow a worsening Moisture Associated Skin Damage (MASD) area to heal that was a result of the resident's non-compliance with care. He stated the resident said that he/she did not want a catheter and was told it was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Former Administrator stated the resident reported that the DON said she would ship him/her to another facility if he/she did not comply and the resident was catheterized. He stated he immediately began an investigation and determined the incident was not abuse. He stated the DON was not suspended because it was a treatment related to the resident's refusals. He stated the DON continued the investigation and he did not see a willful intent. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. On 06/10/2020 - 06/11/2020, an investigation of the complaint of alleged abuse was conducted by the Regional Client Operations Consultant. The investigation showed that the Administrator failed to utilize the abuse protocol for the report of alleged abuse by failing to suspend the employees involved in the situation, reporting to the State agencies as required, conducting a thorough investigation, and reporting the results. 2. The Director of Nursing was terminated on 06/10/2020 and the Administrator was terminated on 06/11/2020, based on investigation findings. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. LPN #1 was suspended on 06/10/2020. The Regional Client Operations Consultant immediately took the role of Acting Administrator. 3. Staff were interviewed with questionnaires on 06/12/2020 and 06/14/2020 to ascertain if they had witnessed any abuse. No further allegations were reported. 4. Staff were educated regarding Abuse and Resident Rights on 06/11/2020 and 06/12/2020 by the former Administrator and the Interim Administrator as well as the Regional Nurse Consultant and the Assistant Director of Nursing (ADON). The education included resident rights to be free from abuse, how the abuse policy is to be implemented to prevent abuse and protect residents, immediate staff intervention upon any allegation of abuse including separating the accused/suspending and reporting to required authorities in a timely manner. 5. The Medical Director was informed of the allegation on 06/10/2020 and was involved ongoing. The Medical Director actively participated in the weekly care plan meeting with the resident on 06/12/2020 regarding ongoing efforts to gain his/her cooperation with a toileting plan and skin healing efforts. The Medical Director actively participated in the focused Quality Assurance Performance Improvement (QAPI) meeting which occurred on 06/12/2020 to review and approve the Allegation of Compliance and QAPI plan. On 06/15/2020, the Acting Administrator communicated with the Medical Director and the Medical Director had a telehealth visit with the resident. On 06/16/2020, the Acting Administrator had further communication with the Medical Director and facility administration for an update on the AOC efforts. On 06/18/2020, the Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visits with the resident post survey findings. The Medical Director completed an assessment of the resident on 06/18/2020 including Diagnosis/Assessment Plan, History of Present illness, Physical Examination, Medical History, Review of Systems, Social/Family History and Summary including follow up on Mental Health status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, on this date, the Medical Director participated in the weekly care plan with the resident, as well as participated in the focused Performance Improvement meeting on survey response, AOC and review of education efforts; and, audit results giving input and approval of steps taken for compliance. 6. Resident #1 had a routine head to toe assessment performed on 05/19/2020 by the Charge Nurse. There were no abnormalities noted resulting from the catheterization. Resident #1 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements of the macerated area on 05/19/2020 had increased to 13 cm x 4.5 cm. (This areas was first noted on 04/28/2020 and treatment orders were obtained). Head to toe skin assessments completed by the Charge Nurse on 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020. The resident continue with macerated area and no other new skin findings. 7. The resident was seen by the Mental Health Nurse Practitioner on 06/04/2020 and an evaluation was completed. Per mental health notes, the resident stated he/she was ok and did not require any changes in his/her medications. The resident had a follow up visit with the Mental Health Nurse Practitioner on 06/12/2020. The Mental Health NP notes stated the resident denied any depression and anxiety. Trauma Screening Questionnaire assessment completed post four (4) weeks since event. Resident showed that he/she has been coping well. On 06/16/2020, the resident was seen by the Psychiatric Nurse Practitioner. The session lasted fifty-three (53) minutes and discussion was about the resident's past relationships as well as the incident of the catheterization. The resident stated that he/she feels safe. 8. The resident was seen by the physician's Nurse Practitioner on 05/26/2020. A review of systems noted no concerns and head to toe assessment noted no acute distress or abnormal findings. The resident was also seen by the nurse practitioner on 05/27/2020 regarding a failed GDR (gradual dose reduction) of [MEDICATION(S)]. Review of the systems noted no acute distress or abnormal findings. Resident was seen again on 06/10/2020. Follow up visit 06/18/2020 by the NP and the MD. Progress note stated the resident was pleasant and cooperative, mood has gotten better, with no signs of anxiety. 9. The Social Services Director had follow up visits with Resident #1. The Social Service Director reported the resident had been in good spirits. Social Services visits a minimum of weekly and has told the resident she is available anytime to talk or just hang out. The resident was receptive to this. This visit occurred on 06/09/2020. Other follow up visits occurred on 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/16/2020 and 06/18/2020. 10. The Resident Council met on 06/12/20 and again on 06/18/2020 to review resident rights, reporting concerns they may have immediately to the nurse, department manager, Administrator, or Regional Consultants. 11. Residents with a BIMS (Brief Interview for Mental Status) score of eight (8) or higher were interviewed by staff using the Quality Improvement Survey (QIS) questions to verify there was no reported abuse. 12. Residents with a BIMS score below eight (8) had an Emotional Change Assessment completed by the MDS Coordinator and the SSD on 06/12/2020, as well as a head-to-toe assessment, which was completed on 06/22/2020 by the Regional Nurse Consultant with no physical indicators of abuse. 13. On 06/12/2020, twenty-one (21) residents were interviewed with the Resident QIS Surveyor Questions for abuse and had no concerns. Eight (8) residents plus Resident #1 who were referred to in the complaint, expressed concerns. All eight of the residents were interview by the Acting Administrator. Four (4) residents had concerns with SRNA #1 being loud in the hallway and using a loud tone. This SRNA is no longer employed at the facility. Unsampled Resident #2 had concerns about not being able to enter the nutrition room. The reasons why that was not allowed (Infection Control) was discussed with the resident and the resident stated understanding. Another resident reported that a SRNA expressed frustration when it was pointed out to her that linen was left on the floor. The issue was investigated, disciplinary action given and the SRNA was re-educated. One resident had concerns regarding the timing of his/her medication administration. He/She wanted his/her medication exactly on time and not five (5) minutes after the hour. The Administrator explained the process and will have the nurse make every effort to give the medications as close as possible to the time due. The Administrator will follow up. Resident #1's concerns with the catheter have been addressed. Any resident concerns were investigated by the Administrator and were resolved. 14. The Acting Administrator, Regional Nurse Consultant, and ADON provided education to all current staff members and management team on the policy of abuse and resident rights on 06/11/2020 through 06/12/2020. Education included the definition of abuse, types of abuse, as well as the steps to follow when there was an incident of abuse. The abuse policy was reviewed with the staff with specific focus: when a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff member is also to report to the Administrator. The person(s) involved in the alleged abuse will be suspended during the investigation by the Abuse Coordinator (Administrator). The Administrator will report the allegation to the appropriate state and federal agencies as well as to the Regional [NAME] Operations Consultant. OIG (Office of Inspector General/State Survey Agency) reports will be submitted in a timely manner to meet the initial reporting regulations. The allegation will be thoroughly investigated by the Administrator and appropriate management team members. The resident and any staff member that reports abuse will be protected from retaliation. Upon the completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will assure that Consulting Staff were contacted immediately upon notification of any allegation of abuse so that reporting regulations will be met and conducted timely. A full reporting of findings will follow within twenty-four (24) hours of initial reporting to members of the Management Consulting group including Operations, Nursing Consulting and Risk Management for evaluation of thoroughness of investigation, proper actions taken for protection of residents and reporting guidelines met and appropriate actions taken, according to findings of the investigation. The Regional Client Operations Consultant and Nursing Consultants will follow up on such reports and conduct chart reviews and assure follow up is completed monthly, or more often as deemed necessary and the consultant will visit the facility. After the education was presented the staff were asked specific questions and to verbalize their understanding of their responsibility in response to any future signs/symptoms or allegations of abuse. Scenarios were presented and open-ended questions about their required response to those situations were asked. The scenarios included walking past a room and hearing a staff member speaking harshly to a resident, or a resident to resident altercation or even physical/emotional, concerned interactions between a resident and a family member. The education did not end until each staff member could detail the requirements of separating the accused, protecting the resident, notifying the Abuse Coordinator immediately after separating the accused so that the person could be informed that they were suspended or could no longer be at the facility or have any resident contact until completion of the investigation, reporting requirements and deadlines. The staff member was to verbalize what to do if the supervisor/Abuse Coordinator did not appear to respond appropriately and according to the regulations, facility policy and procedure. Included was the updated phone contact information for the Regional Client Operations Consultant and contact information for the Vice President of Operations. The VP of Operations for Care Centers Management Consulting (CCMC) is the supervisor for the Regional Client Operations Consultant and acting Administrator presently for CCMC. The VP of Operations contact information has been added to the Abuse Coordinator contact listing by the time clock and Administrator's office posting locations in the event the Administrator doesn't answer after hours timely or respond appropriately and to enable the reporter's need to elevate concern. In the event any staff member is not comfortable in reporting to the Administrator, they are educated to call a Regional Client Operations Consultant, the Vice President of Client Operations, or call the Management Consulting Company on the hotline number. These contact numbers are posted at the time clock and outside the Administrator's office for ease of access for residents/employees or family members. The call is kept confidential and may be made anonymously. 15. On 06/10/2020, the VP of Client Operations educated the Regional Client Operations Consultant to assure the knowledge of the abuse policy which included types of abuse and the steps involved in the procedure including timely reporting requirements and immediate protection of the resident. 16. On 06/11/2020, the Director of Nursing Consultant educated the Regional Nurse Consultant on the knowledge of the abuse policy and staff education. 17. On 06/12/2020, the Acting Administrator educated the Department Managers on the abuse policy. In addition, department managers were re-educated on the hiring process (screening of applicants prior to job offer; reference checks, Human Resources will complete a criminal background check and check the abuse registry), monitoring for staff frustration and burn out for intervention as appropriate, and if a staff member reports to them as department manager they are to follow the steps: ensure resident is safe, if staff member is on duty, to remove them away from the direct care area, and notification of the Administrator. This education was repeated for all department managers by the Acting Administrator on 06/18/2020. 18. All newly hired staff and management will be educated on the abuse policy and procedure upon hire and then again during the general orientation period by the Social Services Director or ADON. In the event of the use of agency staff, the abuse policy will be included in the contract staff facility orientation materials. The agency staff will review and then sign that the policies were reviewed prior to their assigned shift. 19. The Social Services Director and ADON will perform weekly random assessments for allegations of abuse using the Resident QIS Surveyor Questions for Abuse for residents with BIMS score of eight (8) and above and the Emotional Change Assessment for those resident with a BIMS score less than eight (8). Any concerns will be immediately reported to the Administrator. The Administrator will immediately follow up with the resident following the abuse policy. A minimum of five (5) residents will be interviewed and assessed weekly. The residents with a BIMS score of less than eight (8) will also have a head to toe assessment along with the emotional change assessment to ensure there are no physical signs of abuse. 20. Staff will be interviewed weekly utilizing the QIS Surveyor Questions for Abuse by the ADON and Nurse Consultant. Any concerns will be immediately reported to the Administrator who will immediately follow up according to the facility's abuse policy. A minimum of five (5) staff members will be interviewed weekly, ongoing. 21. Focused Quality Assurance Performance Improvement (QAPI) meetings will be held weekly to review the action plan. The meetings will occur weekly x four (4) weeks. One-hundred percent (100%) compliance refers to every grievance or allegation is followed up per policy, which is resident safety, suspension, immediate reporting, thorough investigation, and reporting of results. Members of the QAPI committee include the Administrator, ADON, Medical Director, Regional Nurse Consultant, SSD and the MDS Coordinator. If guidelines are maintained during these four (4) weeks, the meetings will move to monthly. The members of the monthly QAPI committee consists of the Administrator, Medical Director, DON, ADON, Dietary Manager, Director of Housekeeping/Laundry, Medical Records Coordinator, SSD, Activities Director, BOM, HR Manager, Director of Maintenance, Rehabilitation Manager, MDS Coordinator and Pharmacy Consultant. 22. All monitors will be ongoing and reviewed at each

Based on interview, record review, and review of the facility's Abuse Policy, it was determined the facility failed to implement their abuse policy for a reported abuse allegation for one (1) of three (3) sampled residents (Resident #1). On 05/18/2020, it was alleged the Director of Nursing (DON) abused Resident #1 when he/she instructed State Registered Nurse Aide (SRNA) #1, Nurse Aide (NA) #1, and SRNA #2, to hold the resident's arms, legs, and feet, to insert an indwelling urinary catheter while the resident was crying, kicking, and begging the staff not to insert it. The resident, who has a history of sexual abuse, stated it made him/her feel like he/she was being molested. Registered Nurse (RN) #1 failed to report the allegation to the Administrator when she was made aware on 05/18/2020, per facility policy. On 05/26/2020, the Social Service Director (SSD) and Admission staff were made aware of the allegation by the resident and reported the incident to the former Administrator/Abuse Coordinator. However, the former Administrator failed to implement the facility's policy when he failed to identify the allegation as abuse; report the incident to the appropriate State agencies, and place the alleged perpetrators on Administrative leave while the investigation was completed. The facility's failure to implement its abuse policy has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 06/10/2020 and determined to exist on 05/18/2020. The facility was notified of the Immediate Jeopardy on 06/10/2020. An acceptable Allegation of Compliance (AoC) was received on 06/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 06/19/2020, as alleged. The Scope and Severity was lowered to a D for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at F600, F607, F609 and F610; and 42 CFR 483.70 Administration at F835; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Protocol, last revised January 2016, revealed the facility has a zero tolerance policy for abuse. The facility will attempt to identify and will investigate any reported violation or allegation of same. All employees will report to their immediate supervisor any incidents of abuse upon suspicion. If the supervisor or person in charge is involved with the alleged abuse, the Executive Director is to be notified immediately. Review of Statutes require the immediate notification to the appropriate agencies of any suspected event(s) of abuse. Record review revealed the facility admitted Resident #1 on 03/13/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with NA #1 on 06/01/2020 at 2:51 PM, and SRNA #1 on 06/02/2020 at 8:14 AM revealed Resident #1 refused the indwelling catheter prior to the procedure. The Aides stated Resident #1 was crying, kicking, and begging staff not to insert the catheter; and, the DON instructed them to hold the resident's arms and legs and she inserted the catheter. SRNA #1 and NA #1 stated they reported the incident to Registered Nurse (RN) #1 after it happened. Interview with RN #1, on 06/08/2020 at 8:25 AM, revealed SRNA #1 and NA #1 told her the DON instructed them to hold the resident down (Resident #1) and threatened to send the resident far away from family if he/she did not let them insert the urinary catheter. The RN stated she heard the resident screaming from down the hallway. RN #1 further stated she considered it abuse but she did not report it, per facility policy, because the DON was standing there when the Aides reported it. Interview with the SSD, on 06/03/2020 at 4:22 PM, and the Admission Marketing person on 06/04/2020 at 11:54 AM, revealed on 05/26/2020 the resident told them he/she had been given a catheter last week that he/she did not want. The SSD stated the resident said he/she was crying and kicking; and the DON told him/her if he/she did not get the catheter he/she would be moved to a facility farther away where it would be harder for him/her to see his/her Mother and grandchildren. The SSD further stated the resident reported to them, that the DON told both staff (SRNA and NA) to hold his/her arms and legs down so she could insert the catheter. The SSD and the Admission/Marketing person stated they both went to the former Administrator's office on 05/26/2020 at 11:15 AM and reported the incident to the Abuse Coordinator. Review of the facility's investigation, dated 05/26/2020, revealed the former Administrator determined the incident was an attempt to get a non-compliant resident to agree to a treatment regimen. Further review of the investigation revealed there was no documented evidence the former Administrator identified the allegation was abuse, ensured the appropriate State Agencies were notified of the alleged abuse, and the DON was placed on Administrative leave, while the investigation was completed; per facility policy. Interview with the former Administrator/Abuse Coordinator, on 06/08/2020 at 10:23 AM, revealed he was made aware of the allegation on Tuesday, 05/26/2020 by the SSD and the Admissions/Marketing person. He stated they told him the resident stated that the DON had the staff hold him/her down to insert a catheter that the resident had refused, and was screaming and crying. The former Administrator stated he began an investigation at that time; however, he did not report the allegation to the appropriate State agencies and suspend the DON, per facility policy; because he determined it was not abuse and it was a treatment related to the resident's refusals. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. On 06/10/2020 - 06/11/2020, an investigation of the complaint of alleged abuse was conducted by the Regional Client Operations Consultant. The investigation showed that the Administrator failed to utilize the abuse protocol for the report of alleged abuse by failing to suspend the employees involved in the situation, reporting to the State agencies as required, conducting a thorough investigation, and reporting the results. 2. The Director of Nursing was terminated on 06/10/2020 and the Administrator was terminated on 06/11/2020, based on investigation findings. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. LPN #1 was suspended on 06/10/2020. The Regional Client Operations Consultant immediately took the role of Acting Administrator. 3. Staff were interviewed with questionnaires on 06/12/2020 and 06/14/2020 to ascertain if they had witnessed any abuse. No further allegations were reported. 4. Staff were educated regarding Abuse and Resident Rights on 06/11/2020 and 06/12/2020 by the former Administrator and the Interim Administrator as well as the Regional Nurse Consultant and the Assistant Director of Nursing (ADON). The education included resident rights to be free from abuse, how the abuse policy is to be implemented to prevent abuse and protect residents, immediate staff intervention upon any allegation of abuse including separating the accused/suspending and reporting to required authorities in a timely manner. 5. The Medical Director was informed of the allegation on 06/10/2020 and was involved ongoing. The Medical Director actively participated in the weekly care plan meeting with the resident on 06/12/2020 regarding ongoing efforts to gain his/her cooperation with a toileting plan and skin healing efforts. The Medical Director actively participated in the focused Quality Assurance Performance Improvement (QAPI) meeting which occurred on 06/12/2020 to review and approve the Allegation of Compliance and QAPI plan. On 06/15/2020, the Acting Administrator communicated with the Medical Director and the Medical Director had a telehealth visit with the resident. On 06/16/2020, the Acting Administrator had further communication with the Medical Director and facility administration for an update on the AOC efforts. On 06/18/2020, the Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visits with the resident post survey findings. The Medical Director completed an assessment of the resident on 06/18/2020 including Diagnosis/Assessment Plan, History of Present illness, Physical Examination, Medical History, Review of Systems, Social/Family History and Summary including follow up on Mental Health status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, on this date, the Medical Director participated in the weekly care plan with the resident, as well as participated in the focused Performance Improvement meeting on survey response, AOC and review of education efforts; and, audit results giving input and approval of steps taken for compliance. 6. Resident #1 had a routine head to toe assessment performed on 05/19/2020 by the Charge Nurse. There were no abnormalities noted resulting from the catheterization. Resident #1 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements of the macerated area on 05/19/2020 had increased to 13 cm x 4.5 cm. (This areas was first noted on 04/28/2020 and treatment orders were obtained). Head to toe skin assessments completed by the Charge Nurse on 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020. The resident continue with macerated area and no other new skin findings. 7. The resident was seen by the Mental Health Nurse Practitioner on 06/04/2020 and an evaluation was completed. Per mental health notes, the resident stated he/she was ok and did not require any changes in his/her medications. The resident had a follow up visit with the Mental Health Nurse Practitioner on 06/12/2020. The Mental Health NP notes stated the resident denied any depression and anxiety. Trauma Screening Questionnaire assessment completed post four (4) weeks since event. Resident showed that he/she has been coping well. On 06/16/2020, the resident was seen by the Psychiatric Nurse Practitioner. The session lasted fifty-three (53) minutes and discussion was about the resident's past relationships as well as the incident of the catheterization. The resident stated that he/she feels safe. 8. The resident was seen by the physician's Nurse Practitioner on 05/26/2020. A review of systems noted no concerns and head to toe assessment noted no acute distress or abnormal findings. The resident was also seen by the nurse practitioner on 05/27/2020 regarding a failed GDR (gradual dose reduction) of [MEDICATION(S)]. Review of the systems noted no acute distress or abnormal findings. Resident was seen again on 06/10/2020. Follow up visit 06/18/2020 by the NP and the MD. Progress note stated the resident was pleasant and cooperative, mood has gotten better, with no signs of anxiety. 9. The Social Services Director had follow up visits with Resident #1. The Social Service Director reported the resident had been in good spirits. Social Services visits a minimum of weekly and has told the resident she is available anytime to talk or just hang out. The resident was receptive to this. This visit occurred on 06/09/2020. Other follow up visits occurred on 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/16/2020 and 06/18/2020. 10. The Resident Council met on 06/12/20 and again on 06/18/2020 to review resident rights, reporting concerns they may have immediately to the nurse, department manager, Administrator, or Regional Consultants. 11. Residents with a BIMS (Brief Interview for Mental Status) score of eight (8) or higher were interviewed by staff using the Quality Improvement Survey (QIS) questions to verify there was no reported abuse. 12. Residents with a BIMS score below eight (8) had an Emotional Change Assessment completed by the MDS Coordinator and the SSD on 06/12/2020, as well as a head-to-toe assessment, which was completed on 06/22/2020 by the Regional Nurse Consultant with no physical indicators of abuse. 13. On 06/12/2020, twenty-one (21) residents were interviewed with the Resident QIS Surveyor Questions for abuse and had no concerns. Eight (8) residents plus Resident #1 who were referred to in the complaint, expressed concerns. All eight of the residents were interview by the Acting Administrator. Four (4) residents had concerns with SRNA #1 being loud in the hallway and using a loud tone. This SRNA is no longer employed at the facility. Unsampled Resident #2 had concerns about not being able to enter the nutrition room. The reasons why that was not allowed (Infection Control) was discussed with the resident and the resident stated understanding. Another resident reported that a SRNA expressed frustration when it was pointed out to her that linen was left on the floor. The issue was investigated, disciplinary action given and the SRNA was re-educated. One resident had concerns regarding the timing of his/her medication administration. He/She wanted his/her medication exactly on time and not five (5) minutes after the hour. The Administrator explained the process and will have the nurse make every effort to give the medications as close as possible to the time due. The Administrator will follow up. Resident #1's concerns with the catheter have been addressed. Any resident concerns were investigated by the Administrator and were resolved. 14. The Acting Administrator, Regional Nurse Consultant, and ADON provided education to all current staff members and management team on the policy of abuse and resident rights on 06/11/2020 through 06/12/2020. Education included the definition of abuse, types of abuse, as well as the steps to follow when there was an incident of abuse. The abuse policy was reviewed with the staff with specific focus: when a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff member is also to report to the Administrator. The person(s) involved in the alleged abuse will be suspended during the investigation by the Abuse Coordinator (Administrator). The Administrator will report the allegation to the appropriate state and federal agencies as well as to the Regional [NAME] Operations Consultant. OIG (Office of Inspector General/State Survey Agency) reports will be submitted in a timely manner to meet the initial reporting regulations. The allegation will be thoroughly investigated by the Administrator and appropriate management team members. The resident and any staff member that reports abuse will be protected from retaliation. Upon the completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will assure that Consulting Staff were contacted immediately upon notification of any allegation of abuse so that reporting regulations will be met and conducted timely. A full reporting of findings will follow within twenty-four (24) hours of initial reporting to members of the Management Consulting group including Operations, Nursing Consulting and Risk Management for evaluation of thoroughness of investigation, proper actions taken for protection of residents and reporting guidelines met and appropriate actions taken, according to findings of the investigation. The Regional Client Operations Consultant and Nursing Consultants will follow up on such reports and conduct chart reviews and assure follow up is completed monthly, or more often as deemed necessary and the consultant will visit the facility. After the education was presented the staff were asked specific questions and to verbalize their understanding of their responsibility in response to any future signs/symptoms or allegations of abuse. Scenarios were presented and open-ended questions about their required response to those situations were asked. The scenarios included walking past a room and hearing a staff member speaking harshly to a resident, or a resident to resident altercation or even physical/emotional, concerned interactions between a resident and a family member. The education did not end until each staff member could detail the requirements of separating the accused, protecting the resident, notifying the Abuse Coordinator immediately after separating the accused so that the person could be informed that they were suspended or could no longer be at the facility or have any resident contact until completion of the investigation, reporting requirements and deadlines. The staff member was to verbalize what to do if the supervisor/Abuse Coordinator did not appear to respond appropriately and according to the regulations, facility policy and procedure. Included was the updated phone contact information for the Regional Client Operations Consultant and contact information for the Vice President of Operations. The VP of Operations for Care Centers Management Consulting (CCMC) is the supervisor for the Regional Client Operations Consultant and acting Administrator presently for CCMC. The VP of Operations contact information has been added to the Abuse Coordinator contact listing by the time clock and Administrator's office posting locations in the event the Administrator doesn't answer after hours timely or respond appropriately and to enable the reporter's need to elevate concern. In the event any staff member is not comfortable in reporting to the Administrator, they are educated to call a Regional Client Operations Consultant, the Vice President of Client Operations, or call the Management Consulting Company on the hotline number. These contact numbers are posted at the time clock and outside the Administrator's office for ease of access for residents/employees or family members. The call is kept confidential and may be made anonymously. 15. On 06/10/2020, the VP of Client Operations educated the Regional Client Operations Consultant to assure the knowledge of the abuse policy which included types of abuse and the steps involved in the procedure including timely reporting requirements and immediate protection of the resident. 16. On 06/11/2020, the Director of Nursing Consultant educated the Regional Nurse Consultant on the knowledge of the abuse policy and staff education. 17. On 06/12/2020, the Acting Administrator educated the Department Managers on the abuse policy. In addition, department managers were re-educated on the hiring process (screening of applicants prior to job offer; reference checks, Human Resources will complete a criminal background check and check the abuse registry), monitoring for staff frustration and burn out for intervention as appropriate, and if a staff member reports to them as department manager they are to follow the steps: ensure resident is safe, if staff member is on duty, to remove them away from the direct care area, and notification of the Administrator. This education was repeated for all department managers by the Acting Administrator on 06/18/2020. 18. All newly hired staff and management will be educated on the abuse policy and procedure upon hire and then again during the general orientation period by the Social Services Director or ADON. In the event of the use of agency staff, the abuse policy will be included in the contract staff facility orientation materials. The agency staff will review and then sign that the policies were reviewed prior to their assigned shift. 19. The Social Services Director and ADON will perform weekly random assessments for allegations of abuse using the Resident QIS Surveyor Questions for Abuse for residents with BIMS score of eight (8) and above and the Emotional Change Assessment for those resident with a BIMS score less than eight (8). Any concerns will be immediately reported to the Administrator. The Administrator will immediately follow up with the resident following the abuse policy. A minimum of five (5) residents will be interviewed and assessed weekly. The residents with a BIMS score of less than eight (8) will also have a head to toe assessment along with the emotional change assessment to ensure there are no physical signs of abuse. 20. Staff will be interviewed weekly utilizing the QIS Surveyor Questions for Abuse by the ADON and Nurse Consultant. Any concerns will be immediately reported to the Administrator who will immediately follow up according to the facility's abuse policy. A minimum of five (5) staff members will be interviewed weekly, ongoing. 21. Focused Quality Assurance Performance Improvement (QAPI) meetings will be held weekly to review the action plan. The meetings will occur weekly x four (4) weeks. One-hundred percent (100%) compliance refers to every grievance or allegation is followed up per policy, which is resident safety, suspension, immediate reporting, thorough investigation, and reporting of results. Members of the QAPI committee include the Administrator, ADON, Medical Director, Regional Nurse Consultant, SSD and the MDS Coordinator. If guidelines are maintained during these four (4) weeks, the meetings will move to monthly. The members of the monthly QAPI committee consists of the Administrator, Medical Director, DON, ADON, Dietary Manager, Director of Housekeeping/Laundry, Medical Records Coordinator, SSD, Activities Director, BOM, HR Manager, Director of Maintenance, Rehabilitation Manager, MDS Coordinator and Pharmacy Consultant. 22. All monitors will be ongoing and reviewed at each Quality Assurance Performance Improvement Meeting. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the investigation completed on 06/11/2020, revealed the allegation of abuse was identified and a thorough investigation was completed. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed that a new investigation of the complaint was completed and substantiated on 06/10/2020 through 06/11/2020 and determined abuse had occurred. 2. Review of the personnel files revealed the DON was terminated on 06/10/2020; and, the Administrator was terminated on 06/11/20, after the investigation was completed. Further review of the personnel files revealed SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. Interview with the Administrator on 06/24/2020 at 9:00 AM revealed the DON was terminated on 06/10/2020 by the former Administrator. The former Administrator was terminated on 06/11/2020 after a thorough investigation was completed. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. 3. Review of the questionnaires used to interview all staff, dated 06/17/2020, revealed the interviews were conducted with no concerns identified. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed they had been interviewed with questionnaires related to their knowledge of abuse in the facility and it was determined there was no additional knowledge about abuse allegations. 4. Review of Sign-in sheets dated 06/11/2020 and 06/12/2020 revealed all facility staff was educated on Abuse and Resident Rights. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed the staff were educated on Abuse and Resident Rights. The staff stated the education included all residents having the right to be free from abuse, and how the abuse policy is to be implemented to prevent abuse and protect residents. The staff revealed there should be immediate staff intervention when there is an allegation of abuse to include separating the accused and suspending the alleged perpetrators if they are at work. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed she was educated by the Vice President of Client Operations on 06/10/2020. Interview with the Regional Nurse Consultant on 06/25/2020 at 11:58 AM revealed she was educated by the RN of Nursing Consulting on 06/11/2020. 5. Interview with the Medical Director on 06/24/2020 at 10:17 AM, revealed she was notified of the abuse allegation on 06/10/2020 and participated in the weekly care plan meeting with the resident on 06/12/2020. She stated she also actively participated in the QAPI meeting which occurred on 06/12/2020 and reviewed and approved the AOC and QAPI plan. The Medical Director reported she had a telehealth visit with Resident #1 on 06/15/2020 and 06/16/2020; and, spoke with the Acting Administrator about the updated AOC. The Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visit with the resident, and post survey findings on 06/18/2020. The document was reviewed by the surveyor to verify the content. The Medical Director also stated she did a complete assessment on the resident and that document was verified and reviewed. The Medical Director reported she gave further input regarding the AOC to the facility's Acting Administrator on 06/19/2020 and participated with the Administrator in a meeting to discuss the survey response, AOC and review the education and audit results and she gave her approval. 6. Review of a head to toe skin assessments, dated 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020, revealed they were completed by the Charge Nurse. The resident continues to have the macerated area with no other new findings. Interview with Charge Nurse #1 on 06/24/2020 at 10:10 AM revealed he performed a head to toe assessment on Resident #1 on 05/19/2020. He stated he found no abnormalities related to the catheterization. 7. Review of the Mental Health Nurse Practitioner Progress Note, dated 06/04/2020 revealed an evaluation was completed and Resident #1 stated he/she had no concerns. There were no changes to the resident's medication at that time. Review of follow-up notes dated 06/12/2020 revealed the resident denied depression and anxiety. Review of a Trauma Screening assessment dated [DATE], revealed the resident had been coping well. Review of the Psychiatric Nurse Practitioner's Note, dated 06/16/2020, revealed Resident #1 was seen by the Psychiatric Nurse Practitioner and the resident was able to talk about past relationships as well as the incident with the catheter. The resident reported to the NP that he/she felt safe. On 06/24/2020, attempts were made to contact Nurse Practitioner (NP) #1 at 12:19 PM, and NP #2 at 12:22 PM, by phone with messages left to return the call with no further contact. 8. Review of the Electronic Nurse Practitioner Assessment Notes revealed Resident #1 was seen by the Physician's Nurse Practitioner on 05/26/2020 and again on 05/27/2020. Further review revealed the resident was in no acute distress. On 05/27/2020, it was determined the resident had a failed Gradual Dose Reduction (GDR) for the medication [MEDICATION(S)], therefore the medication was adjusted. The resident had been upset and crying because he/she had missed a smoke break. On 06/24/2020 at 12:22 PM an attempt was made to interview the Physician's NP regarding the visit on 05/26/2020 and 05/27/2020, but was unable to reach the NP. 9. Review of the SSD Progress Notes, dated 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/09/2020, 06/16/2020 and 06/18/2020 revealed the SSD spoke with the resident. Interview with the SSD, on 06/25/2020 at 8:35 AM, revealed she had been making frequent follow-up visits with Resident #1 and made notations in the progress notes. 10. Review of the Resident Council Meeting minutes revealed meetings were held on 06/12/2020 and 06/18/2020 with Resident Rights, resident right to refuse, and the abuse protocol discussed with the residents. Further review revealed the staff members in attendance included the Activities Director, Interim Administrator and the ADON. Interviews on 06/24/2020 with the Administrator at 9:00 AM and ADON at 4:25 PM; and, on 06/25/2020 with the Activities Director at 9:03 AM revealed they attended the Resident Council Meetings. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM and Unsampled Resident #B at 2:57 PM revealed they attended the meetings and talked about the abuse policy and resident rights. 11. Review of QIS Abuse Questionnaire revealed residents with a BIMS score of eight (8) and higher completed a questionnaire provided by staff on 06/12/2020 by the MDS Coordinator to assess for complaints of abuse. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM, Unsampled Resident #B at 2:57 PM, Unsampled Resident #C at 2:51 PM, and Unsampled Resident #D at 2:48 PM, revealed staff asked them questions related any abuse or mistreatment. The residents stated they had no concerns with abuse. 12. Review of the Emotional Change Assessment forms for residents with a BIMS score of less than eight (8) dated 06/12/2020, revealed the MDS Coordinator and the Social Services Director (SSD) assessed the non-interviewable residents for possible abuse related to changes in emotions. Interviews on 06/25/2020 with the MDS Coordinator at 11:40 AM and the SSD at 8:35 AM revealed they completed the Emotional Change Assessments and none of the resident had any indications of physical/emotional abuse. 13. Review of the QIS Questionnaires revealed twenty-one residents were interviewed using the questionnaires. Eight of the residents plus Resident #1 had concerns that were investigated by the Acting Administrator and addressed. Interviews with the Acting Administrator on 06/25/2020 at 2:30 PM revealed twenty-one (21) residents were interviewed using the QIS Surveyor questionnaires. and all concerns identified were investigated by the Acting Administrator to the residents' satisfaction. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM revealed that linens were being left on the floor; the issue was resolved; Unsampled Resident #B at 2:57 PM revealed that the resident wanted to have personal access to the snack room but now understood that was an Infection Control Risk; Unsampled Resident #C at 2:51 PM wanted medication given at the exact time it was ordered and was informed that they would pass the medications as close to the time as possible. Interview with Unsampled Resident #D at 2:48 PM revealed the resident had a concern with a SRNA, who was loud. This SRNA is no longer employed by the facility. 14. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director o [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure staff reported an allegation of abuse to the Administrator timely; and, the Administrator failed to report to the appropriate State agencies, for one (1) of three (3) sampled residents (Resident #1). On 05/18/2020, staff reported to Registered Nurse (RN) #1, that the Director of Nursing (DON) had two (2) staff hold Resident #1 down while she inserted an indwelling urinary catheter that the resident had refused. The staff reported to the RN that they felt the incident was abuse. The resident was crying, yelling, and begging the staff not to insert the catheter. After the incident, the resident begged the DON to leave his/her room. However, the DON would not leave the room until the resident gave her a hug. RN #1 failed to report the allegation to the former Administrator. In addition, the Social Services Director (SSD) and Admission staff reported the allegation to the former Administrator after they became aware of the allegation from the resident, on 05/26/2020. However, the former Administrator failed to report the allegation to the appropriative State agencies. The facility's failure to report an allegation of abuse has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 06/10/2020 and determined to exist on 05/18/2020. The facility was notified of the Immediate Jeopardy on 06/10/2020. An acceptable Allegation of Compliance (AoC) was received on 06/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 06/19/2020, as alleged. The Scope and Severity was lowered to a D for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at F600, F607, F609 and F610; and 42 CFR 483.70 Administration at F835; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Protocol, last revised January 2016, revealed State Statues require the immediate notification to the State Agency of any suspected event(s) of abuse. The definition of immediate is without delay, therefore, it is imperative that suspected events of abuse be reported upon suspicion. The report should not be delayed pending the results of the investigation process. All employees will report to their immediate supervisor any incidents of abuse, neglect or exploitation upon suspicion. The report should not be delayed pending the results of the investigation process. Record review revealed the facility admitted Resident #1 on 03/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews with State Registered Nurse Aide (SRNA) #1 on 06/02/2020 at 8:04 AM and Nurse Aide (NA) #1, on 06/01/2020 at 2:51 PM; and, review of their written statements, dated 05/26/2020, revealed the DON told them to hold Resident #1's arms and legs, while she inserted an indwelling urinary catheter. SRNA #1 and NA #1 stated the resident was crying, kicking, and begging staff not to insert the catheter. SRNA #1 and NA #1 stated they reported to RN #1 right after the incident that they were told by the DON to hold the resident down while she inserted the urinary catheter and that the resident was fighting, crying and telling them to stop. SRNA #1 and NA #1 revealed they felt like the resident was abused. Interview with RN #1, on 06/08/2020 at 8:25 AM, revealed SRNA #1 and NA #1 told her they held the resident down while he/she was crying and screaming and the DON threatened to send the resident far away from family if he/she did not get catheter. RN #1 stated she overheard the resident screaming from down the hallway. However, RN #1 stated she did not report this because the DON was standing within three (3) feet of them while having the conversation with SRNA #1 and NA #1. Interview with the Admission Marketing person on 06/04/2020 at 11:54 AM, and the SSD, on 06/03/2020 at 4:22 PM, revealed on 05/26/2020 (eight{8} days after the incident) the resident said the DON had inserted a urinary catheter that he/she did not want. Further interview revealed the resident told her that he/she was crying and kicking; and the DON told him/her if he/she did not get the catheter he/she would be moved to a facility farther away where it would be harder for him/her to see his/her Mother and grandchildren. Further interview revealed the DON then told both Aides to hold the resident's arms and legs down so she could insert the catheter. The SSD and the Admission/Marketing person stated they went to the former Administrator's office and reported the incident to the Abuse Coordinator/former Administrator, on 05/26/2020 at 11:15 AM. Review of the facility's investigation conducted by the former Administrator/Abuse Coordinator, initiated 05/26/2020 and completed 05/27/2020, revealed no documented evidence the allegation of abuse was reported to the appropriate State Agencies. Interview with the Abuse Coordinator/former Administrator, on 06/08/2020 at 10:23 AM, revealed the SSD and the Admissions/Marketing person told him Resident #1 reported staff held him/her down while the DON inserted an indwelling urinary catheter on Tuesday, 05/26/2020. He stated they told him the resident reported that he/she had refused the catheter; and, that he/she was crying, begging and kicking to get them to stop, but the DON inserted it anyway. The former Administrator stated he initiated the investigation immediately; however, he did not report the allegation to the appropriate State agencies because he did not think it was abuse, because it was a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. On 06/10/2020 - 06/11/2020, an investigation of the complaint of alleged abuse was conducted by the Regional Client Operations Consultant. The investigation showed that the Administrator failed to utilize the abuse protocol for the report of alleged abuse by failing to suspend the employees involved in the situation, reporting to the State agencies as required, conducting a thorough investigation, and reporting the results. 2. The Director of Nursing was terminated on 06/10/2020 and the Administrator was terminated on 06/11/2020, based on investigation findings. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. LPN #1 was suspended on 06/10/2020. The Regional Client Operations Consultant immediately took the role of Acting Administrator. 3. Staff were interviewed with questionnaires on 06/12/2020 and 06/14/2020 to ascertain if they had witnessed any abuse. No further allegations were reported. 4. Staff were educated regarding Abuse and Resident Rights on 06/11/2020 and 06/12/2020 by the former Administrator and the Interim Administrator as well as the Regional Nurse Consultant and the Assistant Director of Nursing (ADON). The education included resident rights to be free from abuse, how the abuse policy is to be implemented to prevent abuse and protect residents, immediate staff intervention upon any allegation of abuse including separating the accused/suspending and reporting to required authorities in a timely manner. 5. The Medical Director was informed of the allegation on 06/10/2020 and was involved ongoing. The Medical Director actively participated in the weekly care plan meeting with the resident on 06/12/2020 regarding ongoing efforts to gain his/her cooperation with a toileting plan and skin healing efforts. The Medical Director actively participated in the focused Quality Assurance Performance Improvement (QAPI) meeting which occurred on 06/12/2020 to review and approve the Allegation of Compliance and QAPI plan. On 06/15/2020, the Acting Administrator communicated with the Medical Director and the Medical Director had a telehealth visit with the resident. On 06/16/2020, the Acting Administrator had further communication with the Medical Director and facility administration for an update on the AOC efforts. On 06/18/2020, the Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visits with the resident post survey findings. The Medical Director completed an assessment of the resident on 06/18/2020 including Diagnosis/Assessment Plan, History of Present illness, Physical Examination, Medical History, Review of Systems, Social/Family History and Summary including follow up on Mental Health status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, on this date, the Medical Director participated in the weekly care plan with the resident, as well as participated in the focused Performance Improvement meeting on survey response, AOC and review of education efforts; and, audit results giving input and approval of steps taken for compliance. 6. Resident #1 had a routine head to toe assessment performed on 05/19/2020 by the Charge Nurse. There were no abnormalities noted resulting from the catheterization. Resident #1 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements of the macerated area on 05/19/2020 had increased to 13 cm x 4.5 cm. (This areas was first noted on 04/28/2020 and treatment orders were obtained). Head to toe skin assessments completed by the Charge Nurse on 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020. The resident continue with macerated area and no other new skin findings. 7. The resident was seen by the Mental Health Nurse Practitioner on 06/04/2020 and an evaluation was completed. Per mental health notes, the resident stated he/she was ok and did not require any changes in his/her medications. The resident had a follow up visit with the Mental Health Nurse Practitioner on 06/12/2020. The Mental Health NP notes stated the resident denied any depression and anxiety. Trauma Screening Questionnaire assessment completed post four (4) weeks since event. Resident showed that he/she has been coping well. On 06/16/2020, the resident was seen by the Psychiatric Nurse Practitioner. The session lasted fifty-three (53) minutes and discussion was about the resident's past relationships as well as the incident of the catheterization. The resident stated that he/she feels safe. 8. The resident was seen by the physician's Nurse Practitioner on 05/26/2020. A review of systems noted no concerns and head to toe assessment noted no acute distress or abnormal findings. The resident was also seen by the nurse practitioner on 05/27/2020 regarding a failed GDR (gradual dose reduction) of [MEDICATION(S)]. Review of the systems noted no acute distress or abnormal findings. Resident was seen again on 06/10/2020. Follow up visit 06/18/2020 by the NP and the MD. Progress note stated the resident was pleasant and cooperative, mood has gotten better, with no signs of anxiety. 9. The Social Services Director had follow up visits with Resident #1. The Social Service Director reported the resident had been in good spirits. Social Services visits a minimum of weekly and has told the resident she is available anytime to talk or just hang out. The resident was receptive to this. This visit occurred on 06/09/2020. Other follow up visits occurred on 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/16/2020 and 06/18/2020. 10. The Resident Council met on 06/12/20 and again on 06/18/2020 to review resident rights, reporting concerns they may have immediately to the nurse, department manager, Administrator, or Regional Consultants. 11. Residents with a BIMS (Brief Interview for Mental Status) score of eight (8) or higher were interviewed by staff using the Quality Improvement Survey (QIS) questions to verify there was no reported abuse. 12. Residents with a BIMS score below eight (8) had an Emotional Change Assessment completed by the MDS Coordinator and the SSD on 06/12/2020, as well as a head-to-toe assessment, which was completed on 06/22/2020 by the Regional Nurse Consultant with no physical indicators of abuse. 13. On 06/12/2020, twenty-one (21) residents were interviewed with the Resident QIS Surveyor Questions for abuse and had no concerns. Eight (8) residents plus Resident #1 who were referred to in the complaint, expressed concerns. All eight of the residents were interview by the Acting Administrator. Four (4) residents had concerns with SRNA #1 being loud in the hallway and using a loud tone. This SRNA is no longer employed at the facility. Unsampled Resident #2 had concerns about not being able to enter the nutrition room. The reasons why that was not allowed (Infection Control) was discussed with the resident and the resident stated understanding. Another resident reported that a SRNA expressed frustration when it was pointed out to her that linen was left on the floor. The issue was investigated, disciplinary action given and the SRNA was re-educated. One resident had concerns regarding the timing of his/her medication administration. He/She wanted his/her medication exactly on time and not five (5) minutes after the hour. The Administrator explained the process and will have the nurse make every effort to give the medications as close as possible to the time due. The Administrator will follow up. Resident #1's concerns with the catheter have been addressed. Any resident concerns were investigated by the Administrator and were resolved. 14. The Acting Administrator, Regional Nurse Consultant, and ADON provided education to all current staff members and management team on the policy of abuse and resident rights on 06/11/2020 through 06/12/2020. Education included the definition of abuse, types of abuse, as well as the steps to follow when there was an incident of abuse. The abuse policy was reviewed with the staff with specific focus: when a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff member is also to report to the Administrator. The person(s) involved in the alleged abuse will be suspended during the investigation by the Abuse Coordinator (Administrator). The Administrator will report the allegation to the appropriate state and federal agencies as well as to the Regional [NAME] Operations Consultant. OIG (Office of Inspector General/State Survey Agency) reports will be submitted in a timely manner to meet the initial reporting regulations. The allegation will be thoroughly investigated by the Administrator and appropriate management team members. The resident and any staff member that reports abuse will be protected from retaliation. Upon the completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will assure that Consulting Staff were contacted immediately upon notification of any allegation of abuse so that reporting regulations will be met and conducted timely. A full reporting of findings will follow within twenty-four (24) hours of initial reporting to members of the Management Consulting group including Operations, Nursing Consulting and Risk Management for evaluation of thoroughness of investigation, proper actions taken for protection of residents and reporting guidelines met and appropriate actions taken, according to findings of the investigation. The Regional Client Operations Consultant and Nursing Consultants will follow up on such reports and conduct chart reviews and assure follow up is completed monthly, or more often as deemed necessary and the consultant will visit the facility. After the education was presented the staff were asked specific questions and to verbalize their understanding of their responsibility in response to any future signs/symptoms or allegations of abuse. Scenarios were presented and open-ended questions about their required response to those situations were asked. The scenarios included walking past a room and hearing a staff member speaking harshly to a resident, or a resident to resident altercation or even physical/emotional, concerned interactions between a resident and a family member. The education did not end until each staff member could detail the requirements of separating the accused, protecting the resident, notifying the Abuse Coordinator immediately after separating the accused so that the person could be informed that they were suspended or could no longer be at the facility or have any resident contact until completion of the investigation, reporting requirements and deadlines. The staff member was to verbalize what to do if the supervisor/Abuse Coordinator did not appear to respond appropriately and according to the regulations, facility policy and procedure. Included was the updated phone contact information for the Regional Client Operations Consultant and contact information for the Vice President of Operations. The VP of Operations for Care Centers Management Consulting (CCMC) is the supervisor for the Regional Client Operations Consultant and acting Administrator presently for CCMC. The VP of Operations contact information has been added to the Abuse Coordinator contact listing by the time clock and Administrator's office posting locations in the event the Administrator doesn't answer after hours timely or respond appropriately and to enable the reporter's need to elevate concern. In the event any staff member is not comfortable in reporting to the Administrator, they are educated to call a Regional Client Operations Consultant, the Vice President of Client Operations, or call the Management Consulting Company on the hotline number. These contact numbers are posted at the time clock and outside the Administrator's office for ease of access for residents/employees or family members. The call is kept confidential and may be made anonymously. 15. On 06/10/2020, the VP of Client Operations educated the Regional Client Operations Consultant to assure the knowledge of the abuse policy which included types of abuse and the steps involved in the procedure including timely reporting requirements and immediate protection of the resident. 16. On 06/11/2020, the Director of Nursing Consultant educated the Regional Nurse Consultant on the knowledge of the abuse policy and staff education. 17. On 06/12/2020, the Acting Administrator educated the Department Managers on the abuse policy. In addition, department managers were re-educated on the hiring process (screening of applicants prior to job offer; reference checks, Human Resources will complete a criminal background check and check the abuse registry), monitoring for staff frustration and burn out for intervention as appropriate, and if a staff member reports to them as department manager they are to follow the steps: ensure resident is safe, if staff member is on duty, to remove them away from the direct care area, and notification of the Administrator. This education was repeated for all department managers by the Acting Administrator on 06/18/2020. 18. All newly hired staff and management will be educated on the abuse policy and procedure upon hire and then again during the general orientation period by the Social Services Director or ADON. In the event of the use of agency staff, the abuse policy will be included in the contract staff facility orientation materials. The agency staff will review and then sign that the policies were reviewed prior to their assigned shift. 19. The Social Services Director and ADON will perform weekly random assessments for allegations of abuse using the Resident QIS Surveyor Questions for Abuse for residents with BIMS score of eight (8) and above and the Emotional Change Assessment for those resident with a BIMS score less than eight (8). Any concerns will be immediately reported to the Administrator. The Administrator will immediately follow up with the resident following the abuse policy. A minimum of five (5) residents will be interviewed and assessed weekly. The residents with a BIMS score of less than eight (8) will also have a head to toe assessment along with the emotional change assessment to ensure there are no physical signs of abuse. 20. Staff will be interviewed weekly utilizing the QIS Surveyor Questions for Abuse by the ADON and Nurse Consultant. Any concerns will be immediately reported to the Administrator who will immediately follow up according to the facility's abuse policy. A minimum of five (5) staff members will be interviewed weekly, ongoing. 21. Focused Quality Assurance Performance Improvement (QAPI) meetings will be held weekly to review the action plan. The meetings will occur weekly x four (4) weeks. One-hundred percent (100%) compliance refers to every grievance or allegation is followed up per policy, which is resident safety, suspension, immediate reporting, thorough investigation, and reporting of results. Members of the QAPI committee include the Administrator, ADON, Medical Director, Regional Nurse Consultant, SSD and the MDS Coordinator. If guidelines are maintained during these four (4) weeks, the meetings will move to monthly. The members of the monthly QAPI committee consists of the Administrator, Medical Director, DON, ADON, Dietary Manager, Director of Housekeeping/Laundry, Medical Records Coordinator, SSD, Activities Director, BOM, HR Manager, Director of Maintenance, Rehabilitation Manager, MDS Coordinator and Pharmacy Consultant. 22. All monitors will be ongoing and reviewed at each Quality Assurance Performance Improvement Meeting. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the investigation completed on 06/11/2020, revealed the allegation of abuse was identified and a thorough investigation was completed. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed that a new investigation of the complaint was completed and substantiated on 06/10/2020 through 06/11/2020 and determined abuse had occurred. 2. Review of the personnel files revealed the DON was terminated on 06/10/2020; and, the Administrator was terminated on 06/11/20, after the investigation was completed. Further review of the personnel files revealed SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. Interview with the Administrator on 06/24/2020 at 9:00 AM revealed the DON was terminated on 06/10/2020 by the former Administrator. The former Administrator was terminated on 06/11/2020 after a thorough investigation was completed. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. 3. Review of the questionnaires used to interview all staff, dated 06/17/2020, revealed the interviews were conducted with no concerns identified. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed they had been interviewed with questionnaires related to their knowledge of abuse in the facility and it was determined there was no additional knowledge about abuse allegations. 4. Review of Sign-in sheets dated 06/11/2020 and 06/12/2020 revealed all facility staff was educated on Abuse and Resident Rights. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed the staff were educated on Abuse and Resident Rights. The staff stated the education included all residents having the right to be free from abuse, and how the abuse policy is to be implemented to prevent abuse and protect residents. The staff revealed there should be immediate staff intervention when there is an allegation of abuse to include separating the accused and suspending the alleged perpetrators if they are at work. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed she was educated by the Vice President of Client Operations on 06/10/2020. Interview with the Regional Nurse Consultant on 06/25/2020 at 11:58 AM revealed she was educated by the RN of Nursing Consulting on 06/11/2020. 5. Interview with the Medical Director on 06/24/2020 at 10:17 AM, revealed she was notified of the abuse allegation on 06/10/2020 and participated in the weekly care plan meeting with the resident on 06/12/2020. She stated she also actively participated in the QAPI meeting which occurred on 06/12/2020 and reviewed and approved the AOC and QAPI plan. The Medical Director reported she had a telehealth visit with Resident #1 on 06/15/2020 and 06/16/2020; and, spoke with the Acting Administrator about the updated AOC. The Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visit with the resident, and post survey findings on 06/18/2020. The document was reviewed by the surveyor to verify the content. The Medical Director also stated she did a complete assessment on the resident and that document was verified and reviewed. The Medical Director reported she gave further input regarding the AOC to the facility's Acting Administrator on 06/19/2020 and participated with the Administrator in a meeting to discuss the survey response, AOC and review the education and audit results and she gave her approval. 6. Review of a head to toe skin assessments, dated 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020, revealed they were completed by the Charge Nurse. The resident continues to have the macerated area with no other new findings. Interview with Charge Nurse #1 on 06/24/2020 at 10:10 AM revealed he performed a head to toe assessment on Resident #1 on 05/19/2020. He stated he found no abnormalities related to the catheterization. 7. Review of the Mental Health Nurse Practitioner Progress Note, dated 06/04/2020 revealed an evaluation was completed and Resident #1 stated he/she had no concerns. There were no changes to the resident's medication at that time. Review of follow-up notes dated 06/12/2020 revealed the resident denied depression and anxiety. Review of a Trauma Screening assessment dated [DATE], revealed the resident had been coping well. Review of the Psychiatric Nurse Practitioner's Note, dated 06/16/2020, revealed Resident #1 was seen by the Psychiatric Nurse Practitioner and the resident was able to talk about past relationships as well as the incident with the catheter. The resident reported to the NP that he/she felt safe. On 06/24/2020, attempts were made to contact Nurse Practitioner (NP) #1 at 12:19 PM, and NP #2 at 12:22 PM, by phone with messages left to return the call with no further contact. 8. Review of the Electronic Nurse Practitioner Assessment Notes revealed Resident #1 was seen by the Physician's Nurse Practitioner on 05/26/2020 and again on 05/27/2020. Further review revealed the resident was in no acute distress. On 05/27/2020, it was determined the resident had a failed Gradual Dose Reduction (GDR) for the medication [MEDICATION(S)], therefore the medication was adjusted. The resident had been upset and crying because he/she had missed a smoke break. On 06/24/2020 at 12:22 PM an attempt was made to interview the Physician's NP regarding the visit on 05/26/2020 and 05/27/2020, but was unable to reach the NP. 9. Review of the SSD Progress Notes, dated 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/09/2020, 06/16/2020 and 06/18/2020 revealed the SSD spoke with the resident. Interview with the SSD, on 06/25/2020 at 8:35 AM, revealed she had been making frequent follow-up visits with Resident #1 and made notations in the progress notes. 10. Review of the Resident Council Meeting minutes revealed meetings were held on 06/12/2020 and 06/18/2020 with Resident Rights, resident right to refuse, and the abuse protocol discussed with the residents. Further review revealed the staff members in attendance included the Activities Director, Interim Administrator and the ADON. Interviews on 06/24/2020 with the Administrator at 9:00 AM and ADON at 4:25 PM; and, on 06/25/2020 with the Activities Director at 9:03 AM revealed they attended the Resident Council Meetings. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM and Unsampled Resident #B at 2:57 PM revealed they attended the meetings and talked about the abuse policy and resident rights. 11. Review of QIS Abuse Questionnaire revealed residents with a BIMS score of eight (8) and higher completed a questionnaire provided by staff on 06/12/2020 by the MDS Coordinator to assess for complaints of abuse. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM, Unsampled Resident #B at 2:57 PM, Unsampled Resident #C at 2:51 PM, and Unsampled Resident #D at 2:48 PM, revealed staff asked them questions related any abuse or mistreatment. The residents stated they had no concerns with abuse. 12. Review of the Emotional Change Assessment forms for residents with a BIMS score of less than eight (8) dated 06/12/2020, revealed the MDS Coordinator and the Social Services Director (SSD) assessed the non-interviewable residents for possible abuse related to changes in emotions. Interviews on 06/25/2020 with the MDS Coordinator at 11:40 AM and the SSD at 8:35 AM revealed they completed the Emotional Change Assessments and none of the resident had any indications of physical/emotional abuse. 13. Review of the QIS Questionnaires revealed twenty-one residents were interviewed using the questionnaires. Eight of the residents plus Resident #1 had concerns that were investigated by the Acting Administrator and addressed. Interviews with the Acting Administrator on 06/25/2020 at 2:30 PM revealed twenty-one (21) residents were interviewed using the QIS Surveyor questionnaires. and all concerns identified were investigated by the Acting Administrator to the residents' satisfaction. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM revealed that linens were being left on the floor; the issue was resolved; Unsampled Resident #B at 2:57 PM revealed that the resident wanted to have personal access to the snack room but now understood that was an Infection Control Risk; Unsampled Resident #C at 2:51 PM wanted medication given at the exact time it was ordered and was informed that they would pass the medications as close to the time as possible. Interview with Unsampled Resident #D at 2:48 PM revealed the resident had a concern with a SRNA, who was loud. This SRNA is no longer employed by the facility. 14. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Market [TRUNCATED]

Based on interview, record review and review of facility policy, it was determined the facility failed to identify an allegation of abuse and prevent further potential abuse while the investigation was in progress for one (1) of three (3) sampled residents (Resident #1). On 05/26/2020, the former Administrator was made aware the Director of Nursing (DON) instructed two (2) staff to hold Resident #1 down while she inserted an indwelling urinary catheter. During this process, the resident was crying, yelling, and begging the staff not to insert the catheter. The resident stated he/she felt like he/she was being molested. However, the former Administrator failed to identify it as an allegation of abuse, and failed to suspend the DON while the investigation was in progress. The facility's failure to identify an allegation of abuse, conduct a thorough investigation, and protect residents from further abuse, as the alleged perpetrators were not suspended has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 06/10/2020 and determined to exist on 05/18/2020. The facility was notified of the Immediate Jeopardy on 06/10/2020. An acceptable Allegation of Compliance (AoC) was received on 06/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 06/19/2020, as alleged. The Scope and Severity was lowered to a D for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at F600, F607, F609 and F610; and 42 CFR 483.70 Administration at F835; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Protocol, last revised January 2016, revealed the Executive Director will direct the investigation and may appoint other staff members to investigate all complaints. The investigation will include the details of the event and review of all circumstances surrounding the incident. For protection during the investigation, any individual suspected of resident abuse will be placed on administrative leave without pay. While on administrative leave, any employee being investigated for possible abuse is banned from returning to the facility. Record review revealed the facility admitted Resident #1 on 03/13/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Admission/Marketing person, on 06/04/2020 at 11:54 AM, and the Social Services Director (SSD), on 06/03/2020 at 4:22 PM revealed Resident #1 reported the DON inserted a urinary catheter after he/she refused it. Further interview revealed the resident stated he/she was crying and fighting but the DON inserted the catheter anyway by having staff hold his/her arms and legs. The resident also informed them he/she did not want to be sent farther away from his/her family, as the DON had told him/her she would have him/her moved far away, so he/she would not be [NAME] to see his/her Mother and grandchildren. Review of the facility's investigation, dated 05/26/2020 and concluded on 05/27/2020, revealed there was no documented evidence the former Administrator identified the allegation as abuse or that the alleged perpetrators were placed on Administrative leave while the investigation was completed, as per policy. Further review of the investigation revealed State Registered Nurse (SRNA) #1's and Nurse Aide (NA) #1's (who were both in room at time of alleged abuse) written statements were not included in the investigation. Further review revealed the DON (alleged perpetrator) was allowed to participate in the acquisition of information for the investigation. Interview with the former Administrator/Abuse Coordinator, on 06/08/2020 at 10:23 AM, revealed he was made aware of the allegation on Tuesday, 05/26/2020 by the SSD and the Admissions/Marketing person and he began the investigation at that time. He stated he did not place the DON on Administrative leave because he did not identify the allegation as abuse, but as a treatment related to the resident's refusals. He stated he did not think the staff were trying to hurt the resident. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. On 06/10/2020 - 06/11/2020, an investigation of the complaint of alleged abuse was conducted by the Regional Client Operations Consultant. The investigation showed that the Administrator failed to utilize the abuse protocol for the report of alleged abuse by failing to suspend the employees involved in the situation, reporting to the State agencies as required, conducting a thorough investigation, and reporting the results. 2. The Director of Nursing was terminated on 06/10/2020 and the Administrator was terminated on 06/11/2020, based on investigation findings. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. LPN #1 was suspended on 06/10/2020. The Regional Client Operations Consultant immediately took the role of Acting Administrator. 3. Staff were interviewed with questionnaires on 06/12/2020 and 06/14/2020 to ascertain if they had witnessed any abuse. No further allegations were reported. 4. Staff were educated regarding Abuse and Resident Rights on 06/11/2020 and 06/12/2020 by the former Administrator and the Interim Administrator as well as the Regional Nurse Consultant and the Assistant Director of Nursing (ADON). The education included resident rights to be free from abuse, how the abuse policy is to be implemented to prevent abuse and protect residents, immediate staff intervention upon any allegation of abuse including separating the accused/suspending and reporting to required authorities in a timely manner. 5. The Medical Director was informed of the allegation on 06/10/2020 and was involved ongoing. The Medical Director actively participated in the weekly care plan meeting with the resident on 06/12/2020 regarding ongoing efforts to gain his/her cooperation with a toileting plan and skin healing efforts. The Medical Director actively participated in the focused Quality Assurance Performance Improvement (QAPI) meeting which occurred on 06/12/2020 to review and approve the Allegation of Compliance and QAPI plan. On 06/15/2020, the Acting Administrator communicated with the Medical Director and the Medical Director had a telehealth visit with the resident. On 06/16/2020, the Acting Administrator had further communication with the Medical Director and facility administration for an update on the AOC efforts. On 06/18/2020, the Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visits with the resident post survey findings. The Medical Director completed an assessment of the resident on 06/18/2020 including Diagnosis/Assessment Plan, History of Present illness, Physical Examination, Medical History, Review of Systems, Social/Family History and Summary including follow up on Mental Health status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, on this date, the Medical Director participated in the weekly care plan with the resident, as well as participated in the focused Performance Improvement meeting on survey response, AOC and review of education efforts; and, audit results giving input and approval of steps taken for compliance. 6. Resident #1 had a routine head to toe assessment performed on 05/19/2020 by the Charge Nurse. There were no abnormalities noted resulting from the catheterization. Resident #1 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements of the macerated area on 05/19/2020 had increased to 13 cm x 4.5 cm. (This areas was first noted on 04/28/2020 and treatment orders were obtained). Head to toe skin assessments completed by the Charge Nurse on 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020. The resident continue with macerated area and no other new skin findings. 7. The resident was seen by the Mental Health Nurse Practitioner on 06/04/2020 and an evaluation was completed. Per mental health notes, the resident stated he/she was ok and did not require any changes in his/her medications. The resident had a follow up visit with the Mental Health Nurse Practitioner on 06/12/2020. The Mental Health NP notes stated the resident denied any depression and anxiety. Trauma Screening Questionnaire assessment completed post four (4) weeks since event. Resident showed that he/she has been coping well. On 06/16/2020, the resident was seen by the Psychiatric Nurse Practitioner. The session lasted fifty-three (53) minutes and discussion was about the resident's past relationships as well as the incident of the catheterization. The resident stated that he/she feels safe. 8. The resident was seen by the physician's Nurse Practitioner on 05/26/2020. A review of systems noted no concerns and head to toe assessment noted no acute distress or abnormal findings. The resident was also seen by the nurse practitioner on 05/27/2020 regarding a failed GDR (gradual dose reduction) of [MEDICATION(S)]. Review of the systems noted no acute distress or abnormal findings. Resident was seen again on 06/10/2020. Follow up visit 06/18/2020 by the NP and the MD. Progress note stated the resident was pleasant and cooperative, mood has gotten better, with no signs of anxiety. 9. The Social Services Director had follow up visits with Resident #1. The Social Service Director reported the resident had been in good spirits. Social Services visits a minimum of weekly and has told the resident she is available anytime to talk or just hang out. The resident was receptive to this. This visit occurred on 06/09/2020. Other follow up visits occurred on 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/16/2020 and 06/18/2020. 10. The Resident Council met on 06/12/20 and again on 06/18/2020 to review resident rights, reporting concerns they may have immediately to the nurse, department manager, Administrator, or Regional Consultants. 11. Residents with a BIMS (Brief Interview for Mental Status) score of eight (8) or higher were interviewed by staff using the Quality Improvement Survey (QIS) questions to verify there was no reported abuse. 12. Residents with a BIMS score below eight (8) had an Emotional Change Assessment completed by the MDS Coordinator and the SSD on 06/12/2020, as well as a head-to-toe assessment, which was completed on 06/22/2020 by the Regional Nurse Consultant with no physical indicators of abuse. 13. On 06/12/2020, twenty-one (21) residents were interviewed with the Resident QIS Surveyor Questions for abuse and had no concerns. Eight (8) residents plus Resident #1 who were referred to in the complaint, expressed concerns. All eight of the residents were interview by the Acting Administrator. Four (4) residents had concerns with SRNA #1 being loud in the hallway and using a loud tone. This SRNA is no longer employed at the facility. Unsampled Resident #2 had concerns about not being able to enter the nutrition room. The reasons why that was not allowed (Infection Control) was discussed with the resident and the resident stated understanding. Another resident reported that a SRNA expressed frustration when it was pointed out to her that linen was left on the floor. The issue was investigated, disciplinary action given and the SRNA was re-educated. One resident had concerns regarding the timing of his/her medication administration. He/She wanted his/her medication exactly on time and not five (5) minutes after the hour. The Administrator explained the process and will have the nurse make every effort to give the medications as close as possible to the time due. The Administrator will follow up. Resident #1's concerns with the catheter have been addressed. Any resident concerns were investigated by the Administrator and were resolved. 14. The Acting Administrator, Regional Nurse Consultant, and ADON provided education to all current staff members and management team on the policy of abuse and resident rights on 06/11/2020 through 06/12/2020. Education included the definition of abuse, types of abuse, as well as the steps to follow when there was an incident of abuse. The abuse policy was reviewed with the staff with specific focus: when a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff member is also to report to the Administrator. The person(s) involved in the alleged abuse will be suspended during the investigation by the Abuse Coordinator (Administrator). The Administrator will report the allegation to the appropriate state and federal agencies as well as to the Regional [NAME] Operations Consultant. OIG (Office of Inspector General/State Survey Agency) reports will be submitted in a timely manner to meet the initial reporting regulations. The allegation will be thoroughly investigated by the Administrator and appropriate management team members. The resident and any staff member that reports abuse will be protected from retaliation. Upon the completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will assure that Consulting Staff were contacted immediately upon notification of any allegation of abuse so that reporting regulations will be met and conducted timely. A full reporting of findings will follow within twenty-four (24) hours of initial reporting to members of the Management Consulting group including Operations, Nursing Consulting and Risk Management for evaluation of thoroughness of investigation, proper actions taken for protection of residents and reporting guidelines met and appropriate actions taken, according to findings of the investigation. The Regional Client Operations Consultant and Nursing Consultants will follow up on such reports and conduct chart reviews and assure follow up is completed monthly, or more often as deemed necessary and the consultant will visit the facility. After the education was presented the staff were asked specific questions and to verbalize their understanding of their responsibility in response to any future signs/symptoms or allegations of abuse. Scenarios were presented and open-ended questions about their required response to those situations were asked. The scenarios included walking past a room and hearing a staff member speaking harshly to a resident, or a resident to resident altercation or even physical/emotional, concerned interactions between a resident and a family member. The education did not end until each staff member could detail the requirements of separating the accused, protecting the resident, notifying the Abuse Coordinator immediately after separating the accused so that the person could be informed that they were suspended or could no longer be at the facility or have any resident contact until completion of the investigation, reporting requirements and deadlines. The staff member was to verbalize what to do if the supervisor/Abuse Coordinator did not appear to respond appropriately and according to the regulations, facility policy and procedure. Included was the updated phone contact information for the Regional Client Operations Consultant and contact information for the Vice President of Operations. The VP of Operations for Care Centers Management Consulting (CCMC) is the supervisor for the Regional Client Operations Consultant and acting Administrator presently for CCMC. The VP of Operations contact information has been added to the Abuse Coordinator contact listing by the time clock and Administrator's office posting locations in the event the Administrator doesn't answer after hours timely or respond appropriately and to enable the reporter's need to elevate concern. In the event any staff member is not comfortable in reporting to the Administrator, they are educated to call a Regional Client Operations Consultant, the Vice President of Client Operations, or call the Management Consulting Company on the hotline number. These contact numbers are posted at the time clock and outside the Administrator's office for ease of access for residents/employees or family members. The call is kept confidential and may be made anonymously. 15. On 06/10/2020, the VP of Client Operations educated the Regional Client Operations Consultant to assure the knowledge of the abuse policy which included types of abuse and the steps involved in the procedure including timely reporting requirements and immediate protection of the resident. 16. On 06/11/2020, the Director of Nursing Consultant educated the Regional Nurse Consultant on the knowledge of the abuse policy and staff education. 17. On 06/12/2020, the Acting Administrator educated the Department Managers on the abuse policy. In addition, department managers were re-educated on the hiring process (screening of applicants prior to job offer; reference checks, Human Resources will complete a criminal background check and check the abuse registry), monitoring for staff frustration and burn out for intervention as appropriate, and if a staff member reports to them as department manager they are to follow the steps: ensure resident is safe, if staff member is on duty, to remove them away from the direct care area, and notification of the Administrator. This education was repeated for all department managers by the Acting Administrator on 06/18/2020. 18. All newly hired staff and management will be educated on the abuse policy and procedure upon hire and then again during the general orientation period by the Social Services Director or ADON. In the event of the use of agency staff, the abuse policy will be included in the contract staff facility orientation materials. The agency staff will review and then sign that the policies were reviewed prior to their assigned shift. 19. The Social Services Director and ADON will perform weekly random assessments for allegations of abuse using the Resident QIS Surveyor Questions for Abuse for residents with BIMS score of eight (8) and above and the Emotional Change Assessment for those resident with a BIMS score less than eight (8). Any concerns will be immediately reported to the Administrator. The Administrator will immediately follow up with the resident following the abuse policy. A minimum of five (5) residents will be interviewed and assessed weekly. The residents with a BIMS score of less than eight (8) will also have a head to toe assessment along with the emotional change assessment to ensure there are no physical signs of abuse. 20. Staff will be interviewed weekly utilizing the QIS Surveyor Questions for Abuse by the ADON and Nurse Consultant. Any concerns will be immediately reported to the Administrator who will immediately follow up according to the facility's abuse policy. A minimum of five (5) staff members will be interviewed weekly, ongoing. 21. Focused Quality Assurance Performance Improvement (QAPI) meetings will be held weekly to review the action plan. The meetings will occur weekly x four (4) weeks. One-hundred percent (100%) compliance refers to every grievance or allegation is followed up per policy, which is resident safety, suspension, immediate reporting, thorough investigation, and reporting of results. Members of the QAPI committee include the Administrator, ADON, Medical Director, Regional Nurse Consultant, SSD and the MDS Coordinator. If guidelines are maintained during these four (4) weeks, the meetings will move to monthly. The members of the monthly QAPI committee consists of the Administrator, Medical Director, DON, ADON, Dietary Manager, Director of Housekeeping/Laundry, Medical Records Coordinator, SSD, Activities Director, BOM, HR Manager, Director of Maintenance, Rehabilitation Manager, MDS Coordinator and Pharmacy Consultant. 22. All monitors will be ongoing and reviewed at each Quality Assurance Performance Improvement Meeting. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the investigation completed on 06/11/2020, revealed the allegation of abuse was identified and a thorough investigation was completed. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed that a new investigation of the complaint was completed and substantiated on 06/10/2020 through 06/11/2020 and determined abuse had occurred. 2. Review of the personnel files revealed the DON was terminated on 06/10/2020; and, the Administrator was terminated on 06/11/20, after the investigation was completed. Further review of the personnel files revealed SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. Interview with the Administrator on 06/24/2020 at 9:00 AM revealed the DON was terminated on 06/10/2020 by the former Administrator. The former Administrator was terminated on 06/11/2020 after a thorough investigation was completed. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. 3. Review of the questionnaires used to interview all staff, dated 06/17/2020, revealed the interviews were conducted with no concerns identified. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed they had been interviewed with questionnaires related to their knowledge of abuse in the facility and it was determined there was no additional knowledge about abuse allegations. 4. Review of Sign-in sheets dated 06/11/2020 and 06/12/2020 revealed all facility staff was educated on Abuse and Resident Rights. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed the staff were educated on Abuse and Resident Rights. The staff stated the education included all residents having the right to be free from abuse, and how the abuse policy is to be implemented to prevent abuse and protect residents. The staff revealed there should be immediate staff intervention when there is an allegation of abuse to include separating the accused and suspending the alleged perpetrators if they are at work. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed she was educated by the Vice President of Client Operations on 06/10/2020. Interview with the Regional Nurse Consultant on 06/25/2020 at 11:58 AM revealed she was educated by the RN of Nursing Consulting on 06/11/2020. 5. Interview with the Medical Director on 06/24/2020 at 10:17 AM, revealed she was notified of the abuse allegation on 06/10/2020 and participated in the weekly care plan meeting with the resident on 06/12/2020. She stated she also actively participated in the QAPI meeting which occurred on 06/12/2020 and reviewed and approved the AOC and QAPI plan. The Medical Director reported she had a telehealth visit with Resident #1 on 06/15/2020 and 06/16/2020; and, spoke with the Acting Administrator about the updated AOC. The Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visit with the resident, and post survey findings on 06/18/2020. The document was reviewed by the surveyor to verify the content. The Medical Director also stated she did a complete assessment on the resident and that document was verified and reviewed. The Medical Director reported she gave further input regarding the AOC to the facility's Acting Administrator on 06/19/2020 and participated with the Administrator in a meeting to discuss the survey response, AOC and review the education and audit results and she gave her approval. 6. Review of a head to toe skin assessments, dated 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020, revealed they were completed by the Charge Nurse. The resident continues to have the macerated area with no other new findings. Interview with Charge Nurse #1 on 06/24/2020 at 10:10 AM revealed he performed a head to toe assessment on Resident #1 on 05/19/2020. He stated he found no abnormalities related to the catheterization. 7. Review of the Mental Health Nurse Practitioner Progress Note, dated 06/04/2020 revealed an evaluation was completed and Resident #1 stated he/she had no concerns. There were no changes to the resident's medication at that time. Review of follow-up notes dated 06/12/2020 revealed the resident denied depression and anxiety. Review of a Trauma Screening assessment dated [DATE], revealed the resident had been coping well. Review of the Psychiatric Nurse Practitioner's Note, dated 06/16/2020, revealed Resident #1 was seen by the Psychiatric Nurse Practitioner and the resident was able to talk about past relationships as well as the incident with the catheter. The resident reported to the NP that he/she felt safe. On 06/24/2020, attempts were made to contact Nurse Practitioner (NP) #1 at 12:19 PM, and NP #2 at 12:22 PM, by phone with messages left to return the call with no further contact. 8. Review of the Electronic Nurse Practitioner Assessment Notes revealed Resident #1 was seen by the Physician's Nurse Practitioner on 05/26/2020 and again on 05/27/2020. Further review revealed the resident was in no acute distress. On 05/27/2020, it was determined the resident had a failed Gradual Dose Reduction (GDR) for the medication [MEDICATION(S)], therefore the medication was adjusted. The resident had been upset and crying because he/she had missed a smoke break. On 06/24/2020 at 12:22 PM an attempt was made to interview the Physician's NP regarding the visit on 05/26/2020 and 05/27/2020, but was unable to reach the NP. 9. Review of the SSD Progress Notes, dated 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/09/2020, 06/16/2020 and 06/18/2020 revealed the SSD spoke with the resident. Interview with the SSD, on 06/25/2020 at 8:35 AM, revealed she had been making frequent follow-up visits with Resident #1 and made notations in the progress notes. 10. Review of the Resident Council Meeting minutes revealed meetings were held on 06/12/2020 and 06/18/2020 with Resident Rights, resident right to refuse, and the abuse protocol discussed with the residents. Further review revealed the staff members in attendance included the Activities Director, Interim Administrator and the ADON. Interviews on 06/24/2020 with the Administrator at 9:00 AM and ADON at 4:25 PM; and, on 06/25/2020 with the Activities Director at 9:03 AM revealed they attended the Resident Council Meetings. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM and Unsampled Resident #B at 2:57 PM revealed they attended the meetings and talked about the abuse policy and resident rights. 11. Review of QIS Abuse Questionnaire revealed residents with a BIMS score of eight (8) and higher completed a questionnaire provided by staff on 06/12/2020 by the MDS Coordinator to assess for complaints of abuse. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM, Unsampled Resident #B at 2:57 PM, Unsampled Resident #C at 2:51 PM, and Unsampled Resident #D at 2:48 PM, revealed staff asked them questions related any abuse or mistreatment. The residents stated they had no concerns with abuse. 12. Review of the Emotional Change Assessment forms for residents with a BIMS score of less than eight (8) dated 06/12/2020, revealed the MDS Coordinator and the Social Services Director (SSD) assessed the non-interviewable residents for possible abuse related to changes in emotions. Interviews on 06/25/2020 with the MDS Coordinator at 11:40 AM and the SSD at 8:35 AM revealed they completed the Emotional Change Assessments and none of the resident had any indications of physical/emotional abuse. 13. Review of the QIS Questionnaires revealed twenty-one residents were interviewed using the questionnaires. Eight of the residents plus Resident #1 had concerns that were investigated by the Acting Administrator and addressed. Interviews with the Acting Administrator on 06/25/2020 at 2:30 PM revealed twenty-one (21) residents were interviewed using the QIS Surveyor questionnaires. and all concerns identified were investigated by the Acting Administrator to the residents' satisfaction. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM revealed that linens were being left on the floor; the issue was resolved; Unsampled Resident #B at 2:57 PM revealed that the resident wanted to have personal access to the snack room but now understood that was an Infection Control Risk; Unsampled Resident #C at 2:51 PM wanted medication given at the exact time it was ordered and was informed that they would pass the medications as close to the time as possible. Interview with Unsampled Resident #D at 2:48 PM revealed the resident had a concern with a SRNA, who was loud. This SRNA is no longer employed by the facility. 14. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM, revealed the staff were educated on the facility's abuse policy and Resident Rights. The staff were able to articulate the proper places to find information regarding to whom to report any abuse allegations and to the Hotline, as necessary. In addition, the staff revealed they had to answer questions when asked about the abuse policy and reporting as well as questions regarding Resident Rights. Observations 06/25/2020 at 1:30 PM revealed signage located at the time clock and outside the Administrator's door with telephone numbers listed to contact for reporting allegations. 15. Review of a signed statement from the VP of Client Operations and interview with the Regional Client Operations Consultant on 06/24/2020 at 9:00 AM revealed that she was educated on the abuse protocol to include different types of abuse, assuring the facility's Abuse Coordinator and staff timely and properly report abuse and, the immediate suspension of staff named in an abuse allegation. 16. Interview with the Regional Nurse Consultant, on 06/25/2020 at 11:58 AM, revealed that she was educated on the abuse policy and procedure by the Director of Nursing Consultant on 06/11/2020. 17. R [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility's administration failed to have an effective system in place to ensure resources were effectively utilized to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of three sampled residents (Resident #1). On 05/26/2020, the former Administrator was made aware the Director of Nursing (DON) instructed staff to hold the resident's arms, legs, and feet, while she catheterized (process to insert a urinary indwelling catheter via the urethra) Resident #1 even though the resident refused the catheter and was screaming, crying, and kicking while the catheter was inserted. The Administrator failed to identify the allegation as abuse, suspend the staff involved, and report to the appropriate state agencies, per facility policy and the Facility Executive Director's job Duties. The facility's failure to have an effective system in place to ensure the facility implemented its policy and procedures related to abuse has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 06/10/2020 and determined to exist on 05/18/2020. The facility was notified of the Immediate Jeopardy on 06/10/2020. An acceptable Allegation of Compliance (AoC) was received on 06/23/2020. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 06/19/2020. The Scope and Severity was lowered to a D for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at F600, F607, F609 and F610; and 42 CFR 483.70 Administration at F835; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Executive Director's job duties revealed he/she accepts seven (7) day/week, twenty-four (24) hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility. Consistently demonstrates loyalty and commitment to the facility staff as well as establishes standards, goals, policies and procedures. The Executive Director (ED) is to assure resident safety at all times and learn and abide by Residents' Rights, rules and regulations. The ED ensures that all residents' right to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to file complaints, are well established and maintained at all times. Also ensures that resident preferences are followed when providing care and service. Must perform duties in compliance with established policies and procedures. Review of the facility's policy, titled Abuse Protocol, last revised January 2016, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment, and involuntary seclusion. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes biting, slapping, pinching, kicking and pushing, It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. All employees will report to their immediate supervisor any incidents of abuse, neglect or exploitation. The Executive Director will direct the investigation and may appoint other staff members to investigate all complaints. The investigation will include the details of the event and review of all circumstances surrounding the incident. For protection during the investigation, any individual suspected of resident abuse will be placed on administrative leave without pay. While on administrative leave, any employee being investigated for possible abuse is banned from returning to the facility. Interview with the Admission/Marketing person, on 06/04/2020 at 11:54 AM, and the Social Services Director (SSD), on 06/03/2020 at 4:22 PM revealed Resident #1 reported on 05/26/2020, the DON inserted a urinary catheter after he/she refused it. Further interview revealed the resident stated he/she was crying and fighting, but the DON inserted the catheter anyway by having staff hold his/her arms and legs. The resident also informed them the DON stated if he/she did not get the catheter he/she would be sent away and he/she did not want to be sent farther away from his/her family. The Admission/Marketing person and the SSD stated they reported this information to the Administrator on 05/26/2020. Review of the facility's investigation, dated 05/26/2020 and concluded on 05/27/2020, revealed Resident #1 alleged the Director of Nursing (DON) catheterized the resident without the resident's permission while the resident was crying and fighting but the catheter was inserted despite the resident's refusal. Further review of the investigation revealed there was no documented evidence the Administrator identified the allegation as abuse, placed the alleged perpetrators on administration leave, and reported the allegation to appropriate State agencies. In addition, the former Administrator instructed the DON (one of alleged perpetrators) to educate staff on refusal of care on 05/26/2020. Interview with the former Administrator/Abuse Coordinator, on 06/08/2020 at 10:23 AM, revealed he was made aware of the allegation on 05/26/2020 by the SSD and Admissions/Marketing person. He stated he was told Resident #1 complained that the DON inserted a catheter even though the resident had refused the catheter. The DON told the resident it was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he immediately began an investigation and he determined the incident was not abuse and the DON was not suspended because it was a treatment related to the resident's refusals. He stated the DON continued the investigation and he did not see a willful intent. However, according to the facility's policy, for the residents' protection during the investigation, any individual suspected of resident abuse will be placed on administrative leave without pay. The facility's administration allowed the DON to work and also participate in the investigation. Interview (Post Survey) with the Regional Client Operations Consultant, on 07/09/2020 at 11:40 AM, revealed she was the person responsible to oversee the former Administrator's job performance. She stated the former Administrator, when learning of the abuse allegation, should have suspended anyone involved in the allegation pending the outcome of the investigation and reported the incident. She stated he should have followed the Abuse Protocol and the facility's policies/procedures. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. On 06/10/2020 - 06/11/2020, an investigation of the complaint of alleged abuse was conducted by the Regional Client Operations Consultant. The investigation showed that the Administrator failed to utilize the abuse protocol for the report of alleged abuse by failing to suspend the employees involved in the situation, reporting to the State agencies as required, conducting a thorough investigation, and reporting the results. 2. The Director of Nursing was terminated on 06/10/2020 and the Administrator was terminated on 06/11/2020, based on investigation findings. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. LPN #1 was suspended on 06/10/2020. The Regional Client Operations Consultant immediately took the role of Acting Administrator. 3. Staff were interviewed with questionnaires on 06/12/2020 and 06/14/2020 to ascertain if they had witnessed any abuse. No further allegations were reported. 4. Staff were educated regarding Abuse and Resident Rights on 06/11/2020 and 06/12/2020 by the former Administrator and the Interim Administrator as well as the Regional Nurse Consultant and the Assistant Director of Nursing (ADON). The education included resident rights to be free from abuse, how the abuse policy is to be implemented to prevent abuse and protect residents, immediate staff intervention upon any allegation of abuse including separating the accused/suspending and reporting to required authorities in a timely manner. 5. The Medical Director was informed of the allegation on 06/10/2020 and was involved ongoing. The Medical Director actively participated in the weekly care plan meeting with the resident on 06/12/2020 regarding ongoing efforts to gain his/her cooperation with a toileting plan and skin healing efforts. The Medical Director actively participated in the focused Quality Assurance Performance Improvement (QAPI) meeting which occurred on 06/12/2020 to review and approve the Allegation of Compliance and QAPI plan. On 06/15/2020, the Acting Administrator communicated with the Medical Director and the Medical Director had a telehealth visit with the resident. On 06/16/2020, the Acting Administrator had further communication with the Medical Director and facility administration for an update on the AOC efforts. On 06/18/2020, the Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visits with the resident post survey findings. The Medical Director completed an assessment of the resident on 06/18/2020 including Diagnosis/Assessment Plan, History of Present illness, Physical Examination, Medical History, Review of Systems, Social/Family History and Summary including follow up on Mental Health status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, on this date, the Medical Director participated in the weekly care plan with the resident, as well as participated in the focused Performance Improvement meeting on survey response, AOC and review of education efforts; and, audit results giving input and approval of steps taken for compliance. 6. Resident #1 had a routine head to toe assessment performed on 05/19/2020 by the Charge Nurse. There were no abnormalities noted resulting from the catheterization. Resident #1 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements of the macerated area on 05/19/2020 had increased to 13 cm x 4.5 cm. (This areas was first noted on 04/28/2020 and treatment orders were obtained). Head to toe skin assessments completed by the Charge Nurse on 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020. The resident continue with macerated area and no other new skin findings. 7. The resident was seen by the Mental Health Nurse Practitioner on 06/04/2020 and an evaluation was completed. Per mental health notes, the resident stated he/she was ok and did not require any changes in his/her medications. The resident had a follow up visit with the Mental Health Nurse Practitioner on 06/12/2020. The Mental Health NP notes stated the resident denied any depression and anxiety. Trauma Screening Questionnaire assessment completed post four (4) weeks since event. Resident showed that he/she has been coping well. On 06/16/2020, the resident was seen by the Psychiatric Nurse Practitioner. The session lasted fifty-three (53) minutes and discussion was about the resident's past relationships as well as the incident of the catheterization. The resident stated that he/she feels safe. 8. The resident was seen by the physician's Nurse Practitioner on 05/26/2020. A review of systems noted no concerns and head to toe assessment noted no acute distress or abnormal findings. The resident was also seen by the nurse practitioner on 05/27/2020 regarding a failed GDR (gradual dose reduction) of [MEDICATION(S)]. Review of the systems noted no acute distress or abnormal findings. Resident was seen again on 06/10/2020. Follow up visit 06/18/2020 by the NP and the MD. Progress note stated the resident was pleasant and cooperative, mood has gotten better, with no signs of anxiety. 9. The Social Services Director had follow up visits with Resident #1. The Social Service Director reported the resident had been in good spirits. Social Services visits a minimum of weekly and has told the resident she is available anytime to talk or just hang out. The resident was receptive to this. This visit occurred on 06/09/2020. Other follow up visits occurred on 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/16/2020 and 06/18/2020. 10. The Resident Council met on 06/12/20 and again on 06/18/2020 to review resident rights, reporting concerns they may have immediately to the nurse, department manager, Administrator, or Regional Consultants. 11. Residents with a BIMS (Brief Interview for Mental Status) score of eight (8) or higher were interviewed by staff using the Quality Improvement Survey (QIS) questions to verify there was no reported abuse. 12. Residents with a BIMS score below eight (8) had an Emotional Change Assessment completed by the MDS Coordinator and the SSD on 06/12/2020, as well as a head-to-toe assessment, which was completed on 06/22/2020 by the Regional Nurse Consultant with no physical indicators of abuse. 13. On 06/12/2020, twenty-one (21) residents were interviewed with the Resident QIS Surveyor Questions for abuse and had no concerns. Eight (8) residents plus Resident #1 who were referred to in the complaint, expressed concerns. All eight of the residents were interview by the Acting Administrator. Four (4) residents had concerns with SRNA #1 being loud in the hallway and using a loud tone. This SRNA is no longer employed at the facility. Unsampled Resident #2 had concerns about not being able to enter the nutrition room. The reasons why that was not allowed (Infection Control) was discussed with the resident and the resident stated understanding. Another resident reported that a SRNA expressed frustration when it was pointed out to her that linen was left on the floor. The issue was investigated, disciplinary action given and the SRNA was re-educated. One resident had concerns regarding the timing of his/her medication administration. He/She wanted his/her medication exactly on time and not five (5) minutes after the hour. The Administrator explained the process and will have the nurse make every effort to give the medications as close as possible to the time due. The Administrator will follow up. Resident #1's concerns with the catheter have been addressed. Any resident concerns were investigated by the Administrator and were resolved. 14. The Acting Administrator, Regional Nurse Consultant, and ADON provided education to all current staff members and management team on the policy of abuse and resident rights on 06/11/2020 through 06/12/2020. Education included the definition of abuse, types of abuse, as well as the steps to follow when there was an incident of abuse. The abuse policy was reviewed with the staff with specific focus: when a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff member is also to report to the Administrator. The person(s) involved in the alleged abuse will be suspended during the investigation by the Abuse Coordinator (Administrator). The Administrator will report the allegation to the appropriate state and federal agencies as well as to the Regional [NAME] Operations Consultant. OIG (Office of Inspector General/State Survey Agency) reports will be submitted in a timely manner to meet the initial reporting regulations. The allegation will be thoroughly investigated by the Administrator and appropriate management team members. The resident and any staff member that reports abuse will be protected from retaliation. Upon the completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will assure that Consulting Staff were contacted immediately upon notification of any allegation of abuse so that reporting regulations will be met and conducted timely. A full reporting of findings will follow within twenty-four (24) hours of initial reporting to members of the Management Consulting group including Operations, Nursing Consulting and Risk Management for evaluation of thoroughness of investigation, proper actions taken for protection of residents and reporting guidelines met and appropriate actions taken, according to findings of the investigation. The Regional Client Operations Consultant and Nursing Consultants will follow up on such reports and conduct chart reviews and assure follow up is completed monthly, or more often as deemed necessary and the consultant will visit the facility. After the education was presented the staff were asked specific questions and to verbalize their understanding of their responsibility in response to any future signs/symptoms or allegations of abuse. Scenarios were presented and open-ended questions about their required response to those situations were asked. The scenarios included walking past a room and hearing a staff member speaking harshly to a resident, or a resident to resident altercation or even physical/emotional, concerned interactions between a resident and a family member. The education did not end until each staff member could detail the requirements of separating the accused, protecting the resident, notifying the Abuse Coordinator immediately after separating the accused so that the person could be informed that they were suspended or could no longer be at the facility or have any resident contact until completion of the investigation, reporting requirements and deadlines. The staff member was to verbalize what to do if the supervisor/Abuse Coordinator did not appear to respond appropriately and according to the regulations, facility policy and procedure. Included was the updated phone contact information for the Regional Client Operations Consultant and contact information for the Vice President of Operations. The VP of Operations for Care Centers Management Consulting (CCMC) is the supervisor for the Regional Client Operations Consultant and acting Administrator presently for CCMC. The VP of Operations contact information has been added to the Abuse Coordinator contact listing by the time clock and Administrator's office posting locations in the event the Administrator doesn't answer after hours timely or respond appropriately and to enable the reporter's need to elevate concern. In the event any staff member is not comfortable in reporting to the Administrator, they are educated to call a Regional Client Operations Consultant, the Vice President of Client Operations, or call the Management Consulting Company on the hotline number. These contact numbers are posted at the time clock and outside the Administrator's office for ease of access for residents/employees or family members. The call is kept confidential and may be made anonymously. 15. On 06/10/2020, the VP of Client Operations educated the Regional Client Operations Consultant to assure the knowledge of the abuse policy which included types of abuse and the steps involved in the procedure including timely reporting requirements and immediate protection of the resident. 16. On 06/11/2020, the Director of Nursing Consultant educated the Regional Nurse Consultant on the knowledge of the abuse policy and staff education. 17. On 06/12/2020, the Acting Administrator educated the Department Managers on the abuse policy. In addition, department managers were re-educated on the hiring process (screening of applicants prior to job offer; reference checks, Human Resources will complete a criminal background check and check the abuse registry), monitoring for staff frustration and burn out for intervention as appropriate, and if a staff member reports to them as department manager they are to follow the steps: ensure resident is safe, if staff member is on duty, to remove them away from the direct care area, and notification of the Administrator. This education was repeated for all department managers by the Acting Administrator on 06/18/2020. 18. All newly hired staff and management will be educated on the abuse policy and procedure upon hire and then again during the general orientation period by the Social Services Director or ADON. In the event of the use of agency staff, the abuse policy will be included in the contract staff facility orientation materials. The agency staff will review and then sign that the policies were reviewed prior to their assigned shift. 19. The Social Services Director and ADON will perform weekly random assessments for allegations of abuse using the Resident QIS Surveyor Questions for Abuse for residents with BIMS score of eight (8) and above and the Emotional Change Assessment for those resident with a BIMS score less than eight (8). Any concerns will be immediately reported to the Administrator. The Administrator will immediately follow up with the resident following the abuse policy. A minimum of five (5) residents will be interviewed and assessed weekly. The residents with a BIMS score of less than eight (8) will also have a head to toe assessment along with the emotional change assessment to ensure there are no physical signs of abuse. 20. Staff will be interviewed weekly utilizing the QIS Surveyor Questions for Abuse by the ADON and Nurse Consultant. Any concerns will be immediately reported to the Administrator who will immediately follow up according to the facility's abuse policy. A minimum of five (5) staff members will be interviewed weekly, ongoing. 21. Focused Quality Assurance Performance Improvement (QAPI) meetings will be held weekly to review the action plan. The meetings will occur weekly x four (4) weeks. One-hundred percent (100%) compliance refers to every grievance or allegation is followed up per policy, which is resident safety, suspension, immediate reporting, thorough investigation, and reporting of results. Members of the QAPI committee include the Administrator, ADON, Medical Director, Regional Nurse Consultant, SSD and the MDS Coordinator. If guidelines are maintained during these four (4) weeks, the meetings will move to monthly. The members of the monthly QAPI committee consists of the Administrator, Medical Director, DON, ADON, Dietary Manager, Director of Housekeeping/Laundry, Medical Records Coordinator, SSD, Activities Director, BOM, HR Manager, Director of Maintenance, Rehabilitation Manager, MDS Coordinator and Pharmacy Consultant. 22. All monitors will be ongoing and reviewed at each Quality Assurance Performance Improvement Meeting. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the investigation completed on 06/11/2020, revealed the allegation of abuse was identified and a thorough investigation was completed. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed that a new investigation of the complaint was completed and substantiated on 06/10/2020 through 06/11/2020 and determined abuse had occurred. 2. Review of the personnel files revealed the DON was terminated on 06/10/2020; and, the Administrator was terminated on 06/11/20, after the investigation was completed. Further review of the personnel files revealed SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. Interview with the Administrator on 06/24/2020 at 9:00 AM revealed the DON was terminated on 06/10/2020 by the former Administrator. The former Administrator was terminated on 06/11/2020 after a thorough investigation was completed. SRNA #1 and Aide #1 were suspended on 06/10/2020 and terminated on 06/11/2020. 3. Review of the questionnaires used to interview all staff, dated 06/17/2020, revealed the interviews were conducted with no concerns identified. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed they had been interviewed with questionnaires related to their knowledge of abuse in the facility and it was determined there was no additional knowledge about abuse allegations. 4. Review of Sign-in sheets dated 06/11/2020 and 06/12/2020 revealed all facility staff was educated on Abuse and Resident Rights. Interviews on 06/24/2020 with KMA #1 at 4:06 PM, KMA #2 at 4:25 PM, the ADON at 4:25 PM, SRNA #3 at 4:39 PM, Housekeeper #1 at 5:47 PM, and on 06/25/2020 with Maintenance at 8:28 AM, SSD at 8:35 AM, Admission/Marketing at 8:58 AM, Director of Activities at 9:03 AM, LPN #2 at 9:49 AM, LPN #1 at 10:01 AM, RN #2 at 10:53 AM, SRNA #4 at 11:31 AM, Human Resources Clerk at 11:35 AM, MDS Coordinator at 11:40 AM, RN #3 at 11:49 AM, Housekeeping Supervisor at 11:56 AM, Business Office Manager at 12:06 PM, Dietary Aide #1 at 12:08 PM, SRNA #5 at 12:18 PM, RN #1 at 12:26 PM, Laundry staff at 12:40 PM and SRNA #6 at 12:43 PM revealed the staff were educated on Abuse and Resident Rights. The staff stated the education included all residents having the right to be free from abuse, and how the abuse policy is to be implemented to prevent abuse and protect residents. The staff revealed there should be immediate staff intervention when there is an allegation of abuse to include separating the accused and suspending the alleged perpetrators if they are at work. Interview with the Interim Administrator on 06/24/2020 at 9:00 AM revealed she was educated by the Vice President of Client Operations on 06/10/2020. Interview with the Regional Nurse Consultant on 06/25/2020 at 11:58 AM revealed she was educated by the RN of Nursing Consulting on 06/11/2020. 5. Interview with the Medical Director on 06/24/2020 at 10:17 AM, revealed she was notified of the abuse allegation on 06/10/2020 and participated in the weekly care plan meeting with the resident on 06/12/2020. She stated she also actively participated in the QAPI meeting which occurred on 06/12/2020 and reviewed and approved the AOC and QAPI plan. The Medical Director reported she had a telehealth visit with Resident #1 on 06/15/2020 and 06/16/2020; and, spoke with the Acting Administrator about the updated AOC. The Medical Director provided a written statement regarding the Nurse Practitioner's and her evaluations and visit with the resident, and post survey findings on 06/18/2020. The document was reviewed by the surveyor to verify the content. The Medical Director also stated she did a complete assessment on the resident and that document was verified and reviewed. The Medical Director reported she gave further input regarding the AOC to the facility's Acting Administrator on 06/19/2020 and participated with the Administrator in a meeting to discuss the survey response, AOC and review the education and audit results and she gave her approval. 6. Review of a head to toe skin assessments, dated 05/25/2020, 06/02/2020, 06/09/2020 and 06/16/2020, revealed they were completed by the Charge Nurse. The resident continues to have the macerated area with no other new findings. Interview with Charge Nurse #1 on 06/24/2020 at 10:10 AM revealed he performed a head to toe assessment on Resident #1 on 05/19/2020. He stated he found no abnormalities related to the catheterization. 7. Review of the Mental Health Nurse Practitioner Progress Note, dated 06/04/2020 revealed an evaluation was completed and Resident #1 stated he/she had no concerns. There were no changes to the resident's medication at that time. Review of follow-up notes dated 06/12/2020 revealed the resident denied depression and anxiety. Review of a Trauma Screening assessment dated [DATE], revealed the resident had been coping well. Review of the Psychiatric Nurse Practitioner's Note, dated 06/16/2020, revealed Resident #1 was seen by the Psychiatric Nurse Practitioner and the resident was able to talk about past relationships as well as the incident with the catheter. The resident reported to the NP that he/she felt safe. On 06/24/2020, attempts were made to contact Nurse Practitioner (NP) #1 at 12:19 PM, and NP #2 at 12:22 PM, by phone with messages left to return the call with no further contact. 8. Review of the Electronic Nurse Practitioner Assessment Notes revealed Resident #1 was seen by the Physician's Nurse Practitioner on 05/26/2020 and again on 05/27/2020. Further review revealed the resident was in no acute distress. On 05/27/2020, it was determined the resident had a failed Gradual Dose Reduction (GDR) for the medication [MEDICATION(S)], therefore the medication was adjusted. The resident had been upset and crying because he/she had missed a smoke break. On 06/24/2020 at 12:22 PM an attempt was made to interview the Physician's NP regarding the visit on 05/26/2020 and 05/27/2020, but was unable to reach the NP. 9. Review of the SSD Progress Notes, dated 06/03/2020, 06/04/2020, 06/05/2020, 06/08/2020, 06/09/2020, 06/16/2020 and 06/18/2020 revealed the SSD spoke with the resident. Interview with the SSD, on 06/25/2020 at 8:35 AM, revealed she had been making frequent follow-up visits with Resident #1 and made notations in the progress notes. 10. Review of the Resident Council Meeting minutes revealed meetings were held on 06/12/2020 and 06/18/2020 with Resident Rights, resident right to refuse, and the abuse protocol discussed with the residents. Further review revealed the staff members in attendance included the Activities Director, Interim Administrator and the ADON. Interviews on 06/24/2020 with the Administrator at 9:00 AM and ADON at 4:25 PM; and, on 06/25/2020 with the Activities Director at 9:03 AM revealed they attended the Resident Council Meetings. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM and Unsampled Resident #B at 2:57 PM revealed they attended the meetings and talked about the abuse policy and resident rights. 11. Review of QIS Abuse Questionnaire revealed residents with a BIMS score of eight (8) and higher completed a questionnaire provided by staff on 06/12/2020 by the MDS Coordinator to assess for complaints of abuse. Interviews on 06/25/2020 with Unsampled Resident #A at 2:54 PM, Unsampled Resident #B at 2:57 PM, Unsampled Resident #C at 2:51 PM, and Unsampled Resident #D at 2:48 PM, revealed staff asked them questions related any abuse or mistreatment. The residents stated they had no concerns with abuse. 12. Review of the Emotional Change Assessment forms for residents with a BIMS score of less than eight (8) dated 06/12/2020, revealed the MDS Coordinator and the Social Services Director (SSD) assessed the non-interviewable residents for possible abuse related to changes in emotions. Interviews on 06/25/2020 with the MDS Coordinator at 11:40 AM and the SSD at 8:35 AM revealed they completed the Emotional Change Assessments and none of the resident had any indications of physical/emotional abuse. 13. Review of the QIS Questionnaires revealed twenty-one residents were interviewed using the questionnaires. Eight of the residents plus Resident #1 had concerns that were investigated by the Acting Administrator and addressed. Interviews with the Acting Administrator on 06/25/2020 at 2:30 PM revealed twenty-one (21) residents were interviewed using the QIS Surveyor questionnaires. and all concerns ident [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) was able to exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. On 05/18/2020, staff failed to honor Resident #1's right to refuse treatment when staff held the resident's arms, legs, and feet to insert an indwelling urinary catheter. Resident #1 was screaming, crying, kicking, and begging staff not to insert the catheter during the procedure. The Director of Nursing (DON) told the resident if he/she did not let them insert the catheter, he/she would be sent away. The resident stated he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/26/2020 (eight {8} days later), Resident #1 reported the incident to the Social Service Director (SSD). The resident was crying and stated she did not want to be sent away from his/her family. The findings include: Review of the facility's policy titled, Resident Rights, last revised November 2018, revealed a resident has the right to refuse treatment. Record review revealed the facility admitted Resident #1 on 03/13/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Annual Minimum Data Set (MDS) assessment, dated 03/17/2020 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of an Electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Electronic Interdisciplinary Progress Note entered by the DON, dated 05/18/2020 at 4:05 PM, revealed The resident continues with incontinence of bowel and bladder, contaminating resident's wounds. Provided bedside commode and resident refuses to use. Indwelling catheter inserted this shift with resident's authorization. 16 French 30 ml bulb to bedside drainage, tubing free of kinks, below level of the bladder to facilitate drainage. Clear yellow urine return with insertion. Resident is very uncomfortable at times with care or treatment provision in perineal area, states 'Sometimes it makes me feel uncomfortable.' and informed resident that when (he/she) feels that way to let staff know. Resident agreed. Interview with Resident #1, on 06/01/2020 at 1:37 PM, revealed when he/she was made aware staff were going to insert an indwelling urinary catheter (process to insert a catheter into the bladder, via the urethra) to drain urine, he/she refused. Resident #1 stated the DON told him/her if he/she did not allow them to insert the catheter, he/she would have to be sent away. The resident further stated he/she was crying, kicking, and begging the staff not to insert the catheter. Resident #1 stated the DON had State Registered Nurse Aide (SRNA) #1 and Nurse Aide (NA) #1 hold his/her hands and legs while she inserted the catheter. Further interview with Resident #1, on 06/10/2020 at 4:13 PM, revealed it made him/her feel like he/she was being molested when the DON had the staff hold him/her down for the catheterization (cath) process, as the resident stated he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Licensed Practical Nurse (LPN) #1, on 06/01/2020 at 2:35 PM, revealed the DON talked with Resident #1 about the importance of using the catheter related to the resident's wound and that there was an order from the Physician to cath the resident. LPN #1 stated the resident did not want a catheter and was crying. Interviews on 06/02/2020 with SRNA #1 at 8:04 AM, and SRNA #2 at 10:50 AM; and, an interview with NA #1 on 06/01/2020 at 2:51 PM, revealed the resident refused the catheter prior to and during the insertion of the catheter. The Aides stated the DON told Resident #1 that if he/she did not get the catheter he/she would have to find somewhere else to go. The Aides stated the resident was crying, kicking, and begging the staff not to insert the catheter, and the DON told them to hold the resident's arms, legs, and feet while she inserted the catheter. Interview with the DON, on 06/01/2020 at 4:15 PM, revealed she told Resident #1 that she needed to put the catheter in short-term. The DON stated, If the resident had not of wanted the catheter, I would not have done it. The DON stated the resident was very shy and when she went to clean the vaginal area to insert the catheter, the resident put his/her hand down toward the perineal area and she had the staff hold the resident's arms in addition to his/her legs to hold them open. She stated Resident #1 was very animated, dramatic, and loud with high anxiety; and, the staff in the room felt very uncomfortable because of all the excitement and anxiety. Interview with the SSD, on 06/03/2020 at 4:22 PM, revealed on 05/26/2020 she was sitting in her office and the Admission/Marketing person came and asked her to go to Resident #1's room, as the resident wanted to talk to her. The SSD stated when she walked in the room the resident was crying. She stated the resident told her that he/she had been given a catheter last week that he/she did not want. The SSD stated the resident told her that the DON said if he/she did not let them put in the catheter he/she would be moved where it would be harder for the resident to see his/her Mother and Grandkids. She stated the resident told her the DON told both Aides to hold his/her arms and legs down so she could insert the catheter. Interview with the former Administrator, on 06/08/2020 at 10:23 AM, revealed Resident #1 had the right to refuse care, but that the resident was encouraged to comply.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1), who entered the facility without an indwelling catheter, was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary. On 05/18/2020, the Director of Nursing (DON) inserted an indwelling urinary catheter without Resident #1's consent; and, a valid reason for the catheter and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no evidence Resident #1's risks and benefits of the use of the catheter or the resident's right to decline the catheter were assessed and discussed with the resident; and, there was no documented evidence of the Physician's valid clinical indication to support the use of the indwelling catheter. The Physician stated she recalled having a conversation with the DON on things to try, but she did not recall giving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Review of the facility's policy, titled Orders for Services, last revised February 2020, revealed products, service, treatment, and care are provided in accordance with the most current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional documentation will be collected from the prescriber if further information is needed to determine medical necessity of the care, service, or treatment. Interview (Post Survey) with the Assistant Director of of Nursing (ADON), on 07/01/2020 at 12:17 PM, revealed there was no policy to address the facility's process to determine a resident's need for a catheter. Record review revealed the facility admitted Resident #1 on 03/13/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Annual Minimum Data Set (MDS) assessment, dated 03/17/2020 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was interviewable. The MDS also revealed the facility assessed the resident to require extensive assist of two (2) for bowel/bladder, was always incontinent, and had Moisture Associated Skin Damage (MASD). Review of Resident #1's Comprehensive Care Plan revealed a plan of care for Resident often refuses to allow staff to care for the resident by refusing showers, incontinent care and wound care and to go to wound care clinic, with an effective date of 02/02/2020. Further review revealed interventions to encourage resident to allow staff to care for him/her, be aware that the resident will not call for assistance when he/she needs to be toileted and resident prefers to be incontinent, offer to take the resident to the toilet every two (2) hours and as needed (prn), and educate the resident on the importance of allowing staff to provide incontinent care and showers. Review of an electronic documented wound assessment, dated 04/28/2020, revealed Resident #1 was identified to have MASD to the left posterior thigh that measured thirteen (13) by four point five (4.5) centimeters (cm) with no description of the wound. Further review of the Interdisciplinary Progress Notes (IPN) and Wound Assessments revealed there were no further wound assessments of the MASD conducted until documentation in an IPN, dated 05/19/2020 (day after catheter insertion), which revealed the area of MASD still measured thirteen (13) cm by four point five (4.5) cm. Review of an Electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the order revealed the order was electronically signed by the DON, but was not signed by the Physician as of 06/01/2020 (day the survey was initiated). Review of Resident #1's medical record revealed there was no documented evidence that the risks and benefits of the use of the catheter or the resident's right to decline the catheter were assessed and discussed with the resident. In addition, there was no documented evidence of the Physician's valid clinical indication to support the use of the indwelling catheter. Review of a Interdisciplinary Progress Note (IPN), dated 05/18/2020, revealed, Resident continues with incontinence of bowel and bladder, contaminating resident's wounds. Provided bedside commode (BSC) and resident refuses to use. Indwelling catheter inserted this shift with resident's authorization. 16 french 30 cc bulb to bedside drainage (BSD), tubing free of kinks, below level of the bladder to facilitate drainage. Clear yellow urine return with insertion. Resident is very uncomfortable at times with care or treatment provision in perineal area, states sometimes it makes me feel uncomfortable, writer informed resident that when (he/she) feels that way to let staff know, resident agreed. However, interviews with Resident #1 on 06/01/2020 at 1:37 PM, State Registered Nurse Aide (SRNA) #1 on 06/02/2020 at 8:04 AM, SRNA #2 on 06/02/2020 at 10:50 AM, and Nurse Aide (NA) #1 on 06/01/2020 at 2:51 PM, revealed on 05/18/2020, the resident stated he/she did not want the catheter and the DON instructed SRNA #1, SRNA #2 and NA #1 to hold the resident's arms, legs, and feet, while the resident was screaming, crying, and kicking stating he/she did not want the catheter. Interview with Resident #1's Physician/facility Medical Director, on 06/02/2020 at 9:56 AM, revealed she did not recall giving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DON, on 06/04/2020 at 12:05 PM, revealed she talked to the physician about a plan of action that included using the bedpan and bedside commode in relation to Resident #1's wounds. The DON stated she and the Physician discussed trying to use other means such as the bedside commode and bariatric bedpan prior to using a catheter. She stated the resident refused to use the bariatric bedpan and bedside commode so she initiated the catheter. She stated she did not write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the order was signed by the DON and dated 05/18/2020. Interview (Post Survey) with the ADON, on 07/01/2020 at 12:17 PM, revealed prior to the insertion of a urinary catheter, there should be a catheter assessment, a care plan meeting, and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, record review, and facility policy review, it was determined the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of three (3) sampled resident (Resident #1). On 03/02/2020, the Psychologist evaluated Resident #1 and was informed, by the resident that he/she had a history of sexual abuse. However, the Social Worker, who scheduled the appointment, had no system in place to ensure she followed up and obtained the results of the evaluation. On 05/26/2020, Resident #1 reported that the Director of Nursing (DON) had staff hold him/her down to perform a urinary indwelling catheter procedure. During this process, the resident was screaming, kicking and begging the staff not to do it. Resident #1 stated it made him/her feel like he/she was being molested. However, the facility failed to provide Social Service follow up to ensure the resident's mental and psychosocial well being. The findings include: Interview with the Administrator, on 06/25/2020 revealed the facility only had a job description for the Director of Social Services with an overview of the position as; accepting twenty-four seven (24/7) responsibility for planning, organizing, directing, implementing and evaluating Social Services and admissions within accepted professional standards and current regulations. The Director of Social Services must also develop a thorough working knowledge of all state, federal and consultant's guidelines in order to improve and or maintain the individual resident's physical, cognitive and psychosocial status. They also serve as the Grievance Official and will assist residents with grievances. Record review revealed the facility admitted Resident #1 on 03/13/2019 with diagnoses which included Anxiety Disorder, and Major Depressive Disorder. Review of an Annual Minimum Data Set (MDS) assessment, dated 03/17/2020, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of a telephone order dated 02/17/2020 at 12:22 PM, revealed an order for a psychologist referral to evaluate and treat as indicated. However, review of Resident #1's medical record revealed there was no documented evidence the resident saw the Psychologist in March 2020. After the State Survey Agency requested documentation of the psychologist's evaluation, the facility obtained the report, from the psychologist, as they had not followed up to get the report. Review of the Psychotherapy Intake Note, dated 03/02/2020, revealed, The patient reports a history of sexual abuse. Interview with the Social Services Director (SSD), on 06/04/2020 at 11:42 AM, revealed Resident #1 had an appointment with the Psychologist on 03/02/2020. The SSD stated the facility discovered on 06/01/2020, after the report was requested by the State Survey Agency (Surveyor), that they had never received the resident's Psychologist's visit note so she contacted the Psychologist to get a copy of the note. She stated she was not aware the resident stated he/she had a history of sexual abuse during this visit and if she had been aware she would have provided the information to the MDS Nurse for care planning; and, the nurses/physician as well for information purposes. She further stated she had no system in place to ensure she received information related to Psychologists/Psychiatrist visits In addition, review of a facility investigation, dated 05/26/2020 and concluded on 05/27/2020, revealed Resident #1 alleged to the SSD that the Director of Nursing (DON) inserted a catheter without the resident's permission while the resident was crying and fighting. However, review of the Interdisciplinary Progress Notes dated 05/26/2020 through 06/02/2020 revealed there was no documented evidence the SSD followed up with Resident #1 related to how he/she was coping after the incident. Further interview with the SSD on 06/03/2020 at 4:22 PM, revealed on 05/26/2020 she entered Resident #1's room, and the resident was crying. She stated the resident told her that he/she had been given a catheter last week that he/she did not want. The SSD stated the resident reported that staff held his/her arms and legs down to insert the catheter, while he/she was crying and fighting to stop them. Interview (Post survey) with the Acting Administrator on 07/01/2020 at 4:21 PM, revealed she expected the SSD to follow up with a resident with a concern.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents' (Resident#1) medical record was complete. Resident #1 had a Psychologist Visit on 03/02/2020, however, there was no documented evidence in the medical record of the visit, and the outcome of the visit. The findings include: Review of the facility's policy titled, General Policies, last revised August 2012, revealed the purpose is to establish a uniform set of guidelines in the implementation and maintenance of Resident information that ensures compliance with current local, state, and federal regulations. Clinical records shall be maintained uniformly for all residents without regard to race, color, national origin, age, sex, religion, or disability. The Clinical Records Clerk is directly responsible for the maintenance, preservation, completion, etc., of all paper portions of the clinical records as well as scanning required resident documentation into the electronic health record (EHR). Record review revealed the facility admitted Resident #1 on 03/13/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a telephone order dated 02/17/2020 at 12:22 PM, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of Resident #1's medical record revealed there was no documented evidence the resident saw the Psychologist in March 2020; or, of the outcome of the visit. Interview with the SSD (Social Services Director) on 06/04/2020 at 11:42 AM revealed the facility discovered on 06/01/2020 after requested by the State Survey Agency (Surveyor), that they had never received the resident's Psychologist's visit note. The SSD then contacted the Psychologist to get a copy of the note. Review of the Psychotherapy Intake Note, dated 03/02/2020, revealed the resident was seen by the Psychologist on 03/02/2020 and one of the things identified was the resident reported a history of sexual abuse. Interview with the Psychologist, on 06/09/2020 at 1:12 PM, revealed during the appointment with Resident #1, the resident revealed to him that he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychologist stated it was his policy to e-mail the progress notes/reports through a secure server through Canada. He further stated he was working on another solution because it sometimes would take a while to get the progress notes to the facility. Interview with the SSD, on 06/04/2020 at 3:10 PM, revealed after a resident was seen by the Psychiatrist or Psychologist, the Progress Notes were sent to her; and the notes were then sent to Medical Records and scanned into the medical record. She stated Resident #1 had a face-to-face appointment with the Psychologist on 03/02/2020. The SSD stated there was a delay in receiving the documents and she had no system to ensure the evaluation notes were received. She stated the notes should have been in the medical record and the information that the resident stated he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the former Administrator, on 06/05/2020 at 8:35 AM, revealed he expected the notes to be available and followed through. He stated he was aware there was a delay in getting psychiatry/psychologist progress notes and the SSD was working on a new process that would make sure that all notes were received in a timely manner.

Based on observation, interview, and review of the facility policy it was determined the facility failed to ensure infection control practices were maintained in the kitchen. On 02/11/2020, during the lunch and supper tray line, observations revealed a kitchen employee left the tray line and returned without changing gloves and performing hand hygiene. Further observation revealed a kitchen employee plated food and on three (3) occasions returned the food to the steam table pan. The findings include: Review of the facility policy, Use of Disposable Gloves for Food Handling, dated 03/27/2012, revealed gloves are to be discarded when damaged, torn, or soiled, or when interruptions occur. Review of the facility policy, Infection Control, dated 03/25/2012, did not reveal any guidance regarding plating of food. Observation of the tray line for the lunch meal on 02/11/2020 at 1:09 PM revealed the dietary cook shuffling through meal tickets with gloved hands to retrieve a ticket and then proceeding to plate the lunch meals. Further observation at 1:50 PM revealed the cook left the tray line to pick up a pan, went to the deep fryer, and placed food out of the fryer into the pan. The cook then returned to the tray line, set the pan on the steam table, and proceeded to plate the lunch without changing gloves and performing hand hygiene. Observation of the tray line for the supper meal on 02/11/2020 at 6:09 PM revealed the kitchen employee plated a chicken breast onto a bun and then took the chicken breast off the bun and put it back into the pan on the steam table. Further observation at 6:18 PM revealed the worker again placed a chicken breast on a bun and then removed it and returned it to the steam table pan. At 6:14 PM, observation revealed the kitchen worker served up broccoli into a bowl and then poured the broccoli back into the steam table pan. The worker was attempting to plate meals for residents as they were coming into the dining room. Interview with the Dietary Manager (DM) on 02/12/2020 at 3:36 PM revealed she had been in the position for five (5) months. She stated that once a kitchen employee who is working the tray line and plating the food leaves the tray, they should remove gloves, wash hands, and don clean gloves. She also stated the dietary cook should have removed gloves, washed hands, and donned clean gloves after leaving the tray to get the pan and bring new food to the steam table. The DM also stated that once the food is served from the steam table on to a plate it is not to be returned to the steam table. Interview with the Director of Nursing (DON) on 0[DATE]20 at 5:03 PM revealed she also serves as the infection control nurse for the facility. She stated infection control in the kitchen is paramount. She further stated that if a worker leaves the tray they should remove gloves, wash hands, and put on clean gloves to resume plating food. She also stated you would never put food back into the steam table pans after being plated.

Based on observation and interview it was determined that the facility failed to ensure a homelike environment for one (1) of eighteen (18) sampled residents (Resident #44). A chair was observed in Resident #44's room that was torn with the inside padding protruding out of the upholstery. The findings include: Interview with the Administrator on 02/12/2020 at 4:45 PM revealed that to his knowledge the facility did not have a policy addressing a homelike environment. Record review revealed the facility admitted Resident #44 on 06/07/2016 with [DIAGNOSES REDACTED]. Review of Resident #44's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not done due to the resident being marked as rarely or never understood. Staff stated that the resident's cognition was severely impaired and Section C1000 was marked as never/rarely made decisions. Further review of the MDS revealed the resident required total assistance for all activities of daily living. Observation of Resident #44 on 02/11/2020 at 11:08 AM revealed the resident was resting in a low bed. The resident had his/her eyes open but did not respond to questions. An upholstered chair was observed in the corner of the resident's room. The arms of the chair were cushioned. The material on the arms of the chair was torn and the inside padding was protruding. Observation of Resident #44 on 02/12/2020 at 3:15 PM revealed the resident up in a geri-chair with eyes open. An interview was attempted but the resident was unable to answer any questions. Interview on 0[DATE]20 at 3:50 PM with the Housekeeping Director revealed the chair should not have been left in the resident's room. The Housekeeping Director stated, Oh no, that needs to go. The Housekeeping Director along with the Maintenance Director took the chair out of the room. Interview on 0[DATE]20 at 5:22 PM with the Director of Nursing (DON) revealed the facility tries to provide a homelike environment and many residents have brought their own furniture into the facility. She stated that she made rounds multiple times a day and had not noticed any furniture that was torn. Per the DON, she stated that she doubted the torn chair belonged to the resident as a lot of chairs had been left by discharged residents or families. She further revealed that they were trying to replace furniture as it was feasible. She stated that Resident #44 was totally dependent on staff for all activities of daily living and she had no concerns with the chair being a hazard to Resident #44; however, she did see that it could be a concern with other residents.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents (Resident #27) received respiratory care consistent with professional standards of practice. Resident #27 was observed to have their oxygen concentrator set to deliver three (3) liters per minute (LPM) during observation on 02/11/2020 and 0[DATE]20. Review of the physician order revealed the resident's oxygen was ordered for two (2) LPM. Further observation on 0[DATE]20 revealed the resident's oxygen tubing, attached to the resident's portable oxygen cylinder, was dated [DATE]. The findings include: Review of the facility policy, Oxygen Therapy/Administration, dated December 2019, revealed all disposable supplies should be discarded every fourteen (14) days. Observation of Resident #27 during the initial tour on 02/11/2020 at approximately 9:30 AM revealed the resident lying in bed and wearing oxygen via nasal cannula. Further observation of the oxygen concentrator revealed the setting was at three (3) LPM. Observation at 12:08 PM revealed the oxygen concentrator setting was at three (3) LPM. Observation of Resident #27 on 0[DATE]20 at 9:25 AM revealed the oxygen concentrator was set on three (3) LPM. Review of the medical record revealed the facility admitted Resident #27 on 06/29/2018 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 12/07/2019, revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident had moderate cognitive impairment. Review of the physician orders, dated [DATE]20 through 0[DATE]20, revealed an order dated 11/04/2019 for oxygen at two (2) LPM by nasal cannula. Further review of the physician orders revealed an order dated 11/04/2019 for oxygen cannula tubing to be changed every two (2) weeks on Friday during the night shift. Review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Continued review of the MARs did not reveal a task for changing the oxygen tubing every two (2) weeks. Review of the comprehensive care plan for Resident #27 revealed an intervention for oxygen at two (2) LPM by nasal cannula dated 11/19/2019 to the problem area of Activities of Daily Living. Interview with Registered Nurse (RN) #1 on 0[DATE]20 at 9:54 AM revealed nursing staff sign off the task on the MAR for oxygen. She stated that when they sign this task off they are assessing the respiratory status of the resident by auscultating breath sounds, checking the resident's oxygen saturation, and ensuring the oxygen is being delivered at the correct setting. The RN then accompanied the surveyor to the room of Resident #27 and observed the oxygen concentrator setting. She stated it was on three (3) LPM and needed to be set on two (2) LPM per the physician orders. The RN then adjusted the concentrator setting to two (2) LPM. The RN then observed the oxygen tubing on the portable oxygen tank on the wheelchair of the resident and stated the tubing was dated [DATE]. She removed the tubing immediately and stated the tubing is changed by the oxygen company contracted by the facility every couple of weeks. The resident then stated that the oxygen company had been in his/her room on 02/12/2020 and changed the tubing on the concentrator. Interview with the Director of Nursing on 0[DATE]20 at 5:08 PM revealed when Nursing signs the MAR for oxygen therapy they are signing that the oxygen is being delivered at the correct setting and that the tubing and concentrator/oxygen tank are clean.

Based on observation, interview, and review of the facility policy it was determined the facility failed to ensure proper storage and labeling of medications on two (2) of four (4) medication carts. Observation on 0[DATE]20 revealed an opened, undated [MEDICATION NAME] pen on Medication Cart 2 and an opened and undated Basaglar insulin pen on a treatment cart. Both medications were available for use. The findings include: Review of the facility policy, Insulin Vials (Dating and Storage), dated September 2019, revealed insulin would be stored in packaging and maintained in the refrigerator until opened. Once the insulin was opened, the insulin was to be dated with the opening date. Observation of the medication cart for Hall 200 on 0[DATE]20 at 2:30 PM revealed an opened [MEDICATION NAME] pen which was not dated as to when opened. Observation of a treatment cart on 0[DATE]20 at 2:30 PM revealed an opened Basaglar insulin pen, also without a date as to when opened. Interview with Registered Nurse (RN) #1 on 0[DATE]20 at 2:30 PM revealed she had not administered insulin from the [MEDICATION NAME] pen on Medication Cart 2. She stated the pens should be dated when opened and placed on the cart. Interview with Licensed Practical Nurse (LPN) #1 on 0[DATE]20 at 2:30 PM revealed she had opened the Basaglar insulin pen that morning and had failed to date the pen. Interview with the Director of Nursing (DON) on 0[DATE]20 at 5:17 PM revealed an insulin pen should have the information showing the type of insulin, resident's name, and date opened on the pen.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure resident food preferences were honored for one (1) of eighteen (18) sampled residents (Resident #99) related to food dislikes and food/drink requests. The findings include: Review of the facility policy titled Diet History and Food Preferences, dated 02/11/2014, revealed, Food preferences will be noted on the tray ticket and honored at meal services when possible. Furthermore, the policy revealed that the Director of Food and Nutrition Services (or designee) and/or Registered Dietician or Dietetic Technician Registered will gather a diet history with food and beverage preferences within [AGE] hours for all admissions. The policy referred the reader to an attached form. The attached form was titled Diet History and Food Preferences. Record review revealed the facility admitted Resident #99 on 01/28/2020 with [DIAGNOSES REDACTED]. Interview with Resident #99 on 02/11/2020 at 3:59 PM revealed that he/she had notified staff of his/her dislike of eggs; however, the resident stated he/she was still receiving eggs on his/her tray every morning. In addition, Resident #99 stated he/she had requested orange juice on his/her tray for meals but the resident stated he/she was not receiving the orange juice. Further review of Resident #99's record revealed a physician's order for the resident to receive a regular diet with thin liquids. Record review revealed no noted contraindication for the resident to receive orange juice. Interview with the Dietary Manager (DM) on 02/12/2020 at 3:46 PM revealed she was aware of Resident #99's food preferences and of the resident's dislike of eggs. The Dietary Manager stated she was also aware of the resident's request to receive orange juice with meals. The Dietary Manager stated she had identified the above information when she obtained Resident #99's preferences on 01/29/2020, the day following his/her admitted . However, the Dietary Manager was unable to produce the Diet History and Food Preferences form. The DM revealed that she was aware that Resident #99 had received eggs on his/her tray on 02/12/2020. However, the DM stated she was unable to correct the meal ticket and was only able to add to the comments. In addition, the DM stated she did not know whom to contact to correct Resident #99's computerized meal ticket. Interview with the Administrator on 02/12/2020 at 4:00 PM and with the DM at 4:59 PM revealed the Administrator supplied the contact person for revising the computerized meal ticket for Resident #99 and the DM stated Resident #99's meal ticket had been revised to include the resident's food dislikes and requests. However, observation on 0[DATE]20 at 8:35 AM of Resident #99's breakfast tray revealed the resident's tray card was incorrect. The card directed staff to provide the resident with 1/4 cup scrambled eggs and the tray card failed to include the resident's preference for orange juice. Interview with the DM on 0[DATE]20 at 9:13 AM revealed Resident #99's tray card was incorrect because she did not reprint the ticket after it was corrected. The DM stated the meal tickets were printed approximately one (1) week in advance. The DM stated she ensured meal tickets were correct by checking them, as she is present for most meals; however, she stated neither she nor the cook had corrected Resident #99's tray card for 0[DATE]20.

Based on observation, interview, record review, and policy review, the facility failed to ensure accurate record documentation for one (1) of eighteen (18) sampled residents (Resident #7) related to the application of splints. Facility staff had documented that bilateral hand splints were applied to Resident #7's hands daily; however, staff interviews revealed the splints were not applied as documented. In addition, the order to place Resident #7's hand splints on hold was not transcribed to the Medication Administration Record [REDACTED] The findings include: Review of the facility policy titled Documentation and Charting, effective date September 2008, revealed that documentation of the record should be accurate and complete. Review of the facility policy titled Electronic Telephone/Verbal Orders, effective date July 2016, revealed orders were to be entered into the electronic medical record after receiving. Observations on 02/11/2020 at 12:27 PM and 02/12/2020 at 2:27 PM revealed the resident had bilateral wrist contractures and the resident was not wearing splints. Review of the record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed a Minimum Data Set (MDS) assessment dated [DATE] that assessed the resident to have severely impaired cognitive skills and to require extensive assistance from staff for activities of daily living. Review of the physician orders revealed bilateral hand splints were ordered on [DATE] and were to be applied for one to two hours daily. Review of the MAR for month of February 2020 revealed License Practical Nurse (LPN) #1 had documented that the splints were applied as ordered on [DATE], 02/02/2020, [DATE]20, 02/08/2020, 02/09/2020, and 02/10/2020. Further review of the physician's orders, dated 02/01/2020, revealed an order to hold the splints because the resident was not tolerating the splint application. However, further review of the MAR indicated [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #2 on 02/12/2020 at 3:05 PM revealed that she had never seen the resident wearing the splints on his/her hands. Interview with LPN #1 on 0[DATE]20 at 11:46 AM revealed that she had not applied the splints to Resident #7's hands. The LPN further stated that she should not have signed the Medication Record to show the splints had been applied. The LPN stated that she was not aware of an order to hold the splints. Interview with the Director of Nursing (DON) on 02/12/2020 at 2:00 PM, revealed that she had notified the physician that the resident was having issues with the splints, and received an order from the physician to place the splints on hold. Further interview with the DON on [DATE]20 at 8:43 AM revealed newly received physician's orders should be noted by the nurse on duty and acted on. The DON stated she did not know why the nurse did not transcribe the order to hold the splints onto the MAR.

Based on observations, interview, record review, and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of infections for one (1) of eighteen (18) sampled residents (Resident #17). Observation on 02/11/2020 revealed while assisting Resident #17 with dinner, facility staff directly touched the resident's food with ungloved hands. The findings include: Review of the facility policy titled Feeding the Dependent Resident, with an implementation date of September 19[AGE] and a reviewed/revised date of August 2012, revealed a procedure to feed slowly with fork or spoon filled only half full. Record review revealed the facility admitted Resident #17 on 05/21/2018 with [DIAGNOSES REDACTED]. Review of Resident #17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Further review of the MDS revealed Resident #17 required the assistance of one staff person with eating. Observation during the evening meal on 02/11/2020 at 6:27 PM revealed State Registered Nurse Aide (SRNA) #5 was assisting Resident #17 with his/her meal. The SRNA was observed to pick up and handle the resident's food (grilled chicken sandwich) with her bare hands. At 6:30 PM, SRNA #5 was observed to pick up the resident's waffle fries with her bare ungloved hands. Interview with SRNA #5 on 0[DATE]20 at 3:21 PM revealed that education and in-services were provided by the facility related to infection control and feeding of residents. Per SRNA #5, she has touched residents' food before with bare hands and remembered touching Resident #17's grilled chicken sandwich and waffle fries on 02/11/2020. SRNA #5 stated that she should not have touched the food and that it is a break in infection control practice/policy. Review of SRNA #5's annual competency evaluation dated [DATE] revealed SRNA #5 met expectations regarding eating and infection control measures. The competency evaluation was signed by SRNA #5. The Director of Nursing (DON) signed the competency evaluation acknowledging that SRNA #5 was competent in performing the skills as defined. Interview with SRNA #2 on 0[DATE]20 at 9:47 AM revealed that training and education was provided to staff upon hire and routinely throughout the year related to feeding of residents and infection control practices. Per SRNA #2, she utilizes eating utensils when assisting residents with eating and does not touch residents' food with her hands. Interview with SRNA #1 on 0[DATE]20 at 10:33 AM revealed that she was educated to utilize gloves if she needed to touch resident food. Per SRNA #1, she utilized utensils when assisting a resident with eating and would not touch a resident's food without gloves. Interview with the Director of Nursing (DON)/Infection Control Nurse on 0[DATE]20 at 4:43 PM revealed that she had not identified any concerns regarding staff touching resident food when assisting residents with eating. The DON stated touching resident food with bare hands is not acceptable. The DON stated if staff touched a resident's food with their bare hands it would be an infection control issue. The DON stated the facility had not provided staff education related to food handling.

Based on observation, interview and record review, it was determined the facility failed to implement the comprehensive care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned he/she required a mechanical lift for transfers with the resident Kardex specifying use a mechanical lift to transfer the resident with the assist of two (2). However, on 06/04/19 one (1) staff transferred the resident using the mechanical lift and the lift tipped over causing the resident to sustain Bilateral Femur Fractures which required surgery. The findings include: Review of a educational presentation provided by the facility revealed a Plan of Care was to be developed upon admission and updated as required for all residents. The Care Plan provides a profile of the needs of the individual, and the roles of each in meeting their needs to achieve the goal of care. A Kardex provides a quick profile of each resident, their basic physician orders, ADL needs and abilities, special services/appointments as well as other care needs. Any change to resident condition, orders or needs will be added to Care Plan and Kardex and updated accordingly. Record review revealed the facility admitted Resident #1 on 02/28/11 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 07/16/18, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's Comprehensive Care Plan for Activities of Daily Living (ADL), dated 07/30/18, revealed an intervention For transfers, I require a mechanical lift. Review of Resident #1's Kardex, not dated revealed the resident required the use of a mechanical lift to transfer the resident with the assist of two (2). However, review of the facility investigation and incident report dated 06/04/19 and interview with Resident #1 on 06/11/19 at 12:19 PM, revealed Resident #1 was transferred using a mechanical lift by one (1) staff member (State Registered Nurse {SRNA} #1) instead of two (2) per care plan/kardex on 06/04/19 at 11:10 AM. Further review of the investigation and review of a Nurse's Notes dated 06/04/19 at 12:00 and 4:00 PM, revealed the mechanical lift tipped over causing the resident to fall to the floor. The resident was transferred to the hospital and it was determined the resident had sustained bilateral femur fractures that required surgical intervention. Unsuccessful attempts to reach SRNA #1 were completed on 06/12/19 at 8:55 AM, 10:04 AM and 11:16 AM. Interviews on 06/12/19 with SRNA #2 at 9:04 AM, SRNA/Restorative Aide #1 at 9:19 AM, and Registered Nurse (RN) #1, Charge Nurse, on 06/12/19 at 10:06 AM revealed two (2) staff should always be used when transferring a resident with a mechanical lift. SRNA #2 stated the resident's needs are posted in the Kardex Book and on the inside of the resident's closet door. Interview with the Director of Nursing (DON), on 06/12/19 at 12:47 PM, revealed the incident happened on 06/04/19 and she was not in the facility but did hear about it from the nurse. She stated she was told that it was a fall during a transfer. She revealed she expected staff to follow the Care Plan and the Kardex. **The facility implemented the following actions to correct the deficient practice 1. On 06/04/19, the facility initiated an investigation related to the fall on 06/04/19. 2. On 06/04/19, the Maintenance Man checked the mechanical lift device for malfunctions with none identified. 3. On 06/04/19, SRNA #1 was suspended by the Assistant Director of Nursing (ADON) after the incident on 06/04/19 and was terminated on 06/07/19. 4. On 06/04/19, re-education was provided by the ADON to SRNA/Restorative #1 on the use of the lift and implementation of care plan/kardex with return demonstration of the use of lift. The all Nursing staff were educated by SRNA/Restorative #1 on the proper use of a mechanical lift. The staff were also educated on the importance of following the Care Plan and the Kardex in terms of transfers of residents. Staff also had to perform return demonstrations on the use of the mechanical lift. Staff were educated on 06/04/19 and other staff were required to have education prior to working again. 5. Starting on 06/05/19, lift audits were conducted by the Charge Nurse, five (5) days a week on five percent (5%) or ten (10) residents each shift to check the functionality of the lift device and to ascertain the proper use of the mechanical lift while transferring actual residents by the . **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility investigation revealed the Administrator and ADON initiated an investigation of the incident on 06/04/19 and determined SRNA #1 had transferred Resident #1 without the assistance of another staff member. 2. Interview with the Administrator, on 06/11/19 at 1:54 PM, revealed that the lift was taken out of service after the incident on 06/04/19 in order to be inspected for malfunctions by the Maintenance Man. When no problems were noted, the mechanical lift was placed back into service. Interview with the Maintenance Man, on 06/11/19 at 2:03 PM, revealed he does a monthly check on the mechanical lifts and that the lift involved in the fall was taken out of service after the fall on 06/04/19 in order to inspect it for malfunctions. No malfunctions were found and the lift was put back into operation. 3. Interview with the ADON, on 06/12/19 at 12:33 PM, revealed she arrived at the facility shortly after the fall. She stated re-education was provided at that time by the ADON to the SRNA/Restorative #1. She revealed she escorted SRNA #1 to the time clock at which time the SRNA was suspended pending the outcome of the investigation, The SRNA never returned to work and was terminated on 06/07/19. 4. Review of Inservice Sign In Sheet dated 06/04/19 revealed all nursing staff was educated by SRNA/Restorative #1 and required to provide return demonstration on the use of the lift. Interviews on 06/12/19 with SRNA #2 at 9:04 AM, SRNA/Restorative #1 on 06/12/19 at 9:19 AM, Housekeeping/Laundry Supervisor/SRNA at 9:33 AM, RN #1 at 10:06 AM, SRNA #3 at 10:25 AM, the ADON at 12:33 PM, the DON at 12:47 PM, SRNA #4 at 2:29 PM, and SRNA #5 at 2:33 PM revealed they were all educated on the use of the mechanical lift to include having to have two staff when using the mechanical lift and the need to follow the Care Plan and Kardex in reference to mechanical lifts. The staff stated they had to perform return demonstration of the use of the lift for the educator. Interview with the ADON, on 06/12/19 at 12:33 PM, revealed she re-educated SRNA/Restorative #1 on the proper use of the lift and following the care plan/kardex in regards to transfers on 06/04/19. She stated staff also had to perform return demonstrations on the use of the mechanical lift. Interview with the DON, on 06/12/19 at 2:15 PM, revealed staff was educated on following the Care Plans and the Kardex by SRNA/Restorative #1, starting on 06/04/19. 6. Review of the mechanical lift audits revealed the audits were conducted 06/05/19 through 06/12/19 on five percent (5%) or ten (10) residents on each shift by the Charge Nurse with no concerns identified.

Based on observation, interview, record review, a review of facility policy, and review of the Hospital Discharge Summary it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #1). The facility failed to ensure Resident #1 was transferred by two (2) staff per facility policy. One staff transferred the resident with a mechanical lift which resulted in the lift turning over and the resident sustaining Bilateral Femur Fractures which required surgery. The findings include: Review of a facility policy titled, Use of Manual or Battery-powered Resident lifts, last revised on (MONTH) (YEAR)5, revealed all planned lifting and transfers of residents shall be done using a lift. Safe use of the lift shall always be in accordance with manufacturer's instructions and shall include, but not limited to, the following safety guides: Nursing staff will complete competency on mechanical lift use upon hire and annually. A minimum of two (2) staff members are required to use the lift for transferring a resident. Have sufficient staff available for the procedure. A minimum of two people can perform the lift, however, certain residents may require an additional person. Record review revealed the facility admitted Resident #1 on 02/28/11 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 07/16/18, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's Lift Assessment, dated 08/01/17, revealed the resident with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Activities of Daily Living (ADL's), dated 07/30/18, revealed an intervention that indicated, For transfers, I require a mechanical lift. Review of Resident #1's Kardex, not dated revealed the resident required the use of a mechanical lift to transfer the resident with the assist of two (2). Review of Resident #1's Nurse's Note, dated 06/04/19 at 1200 PM, revealed Registered Nurse (RN) #1 was called to the resident's room where she observed the resident lying on the floor sitting with the lift tipped over on him/her at 11:10 AM. The resident was up in the lift being transferred from the bed to chair and the lift tipped over. Further review of the note revealed the resident complained of bilateral hip pain and was noted to be calling out in pain. The physician was notified at 11:30 AM and an order was obtained to send the resident out for evaluation and treatment to the hospital. Emergency Medical Services (EMS) were called and arrived at 11:45 AM and the resident was transported by ambulance. At 4:00 PM, the hospital was called to check on the resident status. The hospital reported the resident was being admitted with bilateral Closed Intertrochanteric Fracture of bilateral femurs with surgery scheduled for 06/05/19. Review of the Hospital Discharge Summary revealed Resident #1 had surgery on 06/05/19 for Open Reduction Internal Fixation (ORIF) to right knee and a Titanium Trochanteric Fixation (TFN) to the left femur. The resident was returned to the Long Term Care (LTC) facility on 06/07/19. Review of the facility investigation and incident report revealed Resident #1 was being transferred using a mechanical lift by one (1) staff member (SRNA #1) on 06/04/19 at 11:10 AM. Further review revealed the mechanical lift tipped over causing the resident to fall to the floor. The resident complained of bilateral left pain and required transfer to the emergency room at his/her request. Upon examination there, it was determined the resident had sustained bilateral femur fractures that required surgical intervention. Interview with Resident #1, on 06/11/19 at 12:19 PM, revealed he/she was transferred by one (1) staff via the mechanical lift. Resident #1 stated his/her pain level was a ten (10) of ten (10) with ten being the worse at the time of the interview. Unsuccessful attempts to reach State Registered Nurse Aide (SRNA) #1 were completed on 06/12/19 at 8:55 AM, 10:04 AM and 11:16 AM. Interview with SRNA #2, on 06/12/19 at 9:04 AM, revealed she was working the day of the fall but she was not assigned to Resident #1. She stated at the time of the fall, she was caring for another resident on the four-hundred (400) hall and SRNA #1 came running out of Resident #1's room. SRNA #2 revealed when she entered the room, the resident was noted to be on the floor with the mechanical lift tipped over. She stated two (2) staff should always be used when transferring a resident with a mechanical lift and the resident's needs are posted in the Kardex Book and on the inside of the resident's closet door. She stated after she saw the resident in the floor, she called for help STAT. She stated the resident was crying in pain and the physician was notified and an order was received to send the resident to the emergency room for evaluation. Interview with SRNA/Restorative Aide #1, on 06/12/19 at 9:19 AM, revealed she had responded to the fall after the resident was on the floor and saw the resident was on the floor by the dresser, the lift was still attached to the residents lift pad, and the lift was lying on its side. She stated the resident complained of leg pain. She stated there should be two (2) staff when using a mechanical lift and the three (3) aides back where usually help each other. Interview with Registered Nurse (RN) #1, Charge Nurse, on 06/12/19 at 10:06 AM revealed she was called to Resident #1's room and when she entered there were several people already in there. RN #1 stated Resident #1 was sitting on the floor, and the lift was turned over. She revealed the resident was assessed and was complaining of leg pain. She stated SRNA #1 told him/her the lift flipped over but she was not aware at the time that SRNA #1 was using the lift by herself during the transfer. RN #1 stated the lift should always be used with two (2) staff minimum. Interview with the Director of Nursing (DON), on 06/12/19 at 12:47 PM, revealed the incident happened on 06/04/19 and she was not in the facility but did hear about it from the nurse. She stated she was told that it was a fall during a transfer. She stated she expected staff to follow the Care Plan, Kardex, and facility policy related to using two (2) staff to transfer resident with mechanical lift. **The facility implemented the following actions to correct the deficient practice 1. On 06/04/19, the facility initiated an investigation related to the fall on 06/04/19. 2. On 06/04/19, the Maintenance Man checked the mechanical lift device for malfunctions with none identified. 3. On 06/04/19, SRNA #1 was suspended by the Assistant Director of Nursing (ADON) after the incident on 06/04/19 and was terminated on 06/07/19. 4. On 06/04/19, re-education was provided by the ADON to SRNA/Restorative #1 on the use of the lift and implementation of care plan/kardex with return demonstration of the use of lift. The all Nursing staff were educated by SRNA/Restorative #1 on the proper use of a mechanical lift. The staff were also educated on the importance of following the Care Plan and the Kardex in terms of transfers of residents. Staff also had to perform return demonstrations on the use of the mechanical lift. Staff were educated on 06/04/19 and other staff were required to have education prior to working again. 5. Starting on 06/05/19, lift audits were conducted by the Charge Nurse, five (5) days a week on five percent (5%) or ten (10) residents each shift to check the functionality of the lift device and to ascertain the proper use of the mechanical lift while transferring actual residents by the . **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility investigation revealed the Administrator and ADON initiated an investigation of the incident on 06/04/19 and determined SRNA #1 had transferred Resident #1 without the assistance of another staff member. 2. Interview with the Administrator, on 06/11/19 at 1:54 PM, revealed that the lift was taken out of service after the incident on 06/04/19 in order to be inspected for malfunctions by the Maintenance Man. When no problems were noted, the mechanical lift was placed back into service. Interview with the Maintenance Man, on 06/11/19 at 2:03 PM, revealed he does a monthly check on the mechanical lifts and that the lift involved in the fall was taken out of service after the fall on 06/04/19 in order to inspect it for malfunctions. No malfunctions were found and the lift was put back into operation. 3. Interview with the ADON, on 06/12/19 at 12:33 PM, revealed she arrived at the facility shortly after the fall. She stated re-education was provided at that time by the ADON to the SRNA/Restorative #1. She revealed she escorted SRNA #1 to the time clock at which time the SRNA was suspended pending the outcome of the investigation, The SRNA never returned to work and was terminated on 06/07/19. 4. Review of Inservice Sign In Sheet dated 06/04/19 revealed all nursing staff was educated by SRNA/Restorative #1 and required to provide return demonstration on the use of the lift. Interviews on 06/12/19 with SRNA #2 at 9:04 AM, SRNA/Restorative #1 on 06/12/19 at 9:19 AM, Housekeeping/Laundry Supervisor/SRNA at 9:33 AM, RN #1 at 10:06 AM, SRNA #3 at 10:25 AM, the ADON at 12:33 PM, the DON at 12:47 PM, SRNA #4 at 2:29 PM, and SRNA #5 at 2:33 PM revealed they were all educated on the use of the mechanical lift to include having to have two staff when using the mechanical lift and the need to follow the Care Plan and Kardex in reference to mechanical lifts. The staff stated they had to perform return demonstration of the use of the lift for the educator. Interview with the ADON, on 06/12/19 at 12:33 PM, revealed she re-educated SRNA/Restorative #1 on the proper use of the lift and following the care plan/kardex in regards to transfers on 06/04/19. She stated staff also had to perform return demonstrations on the use of the mechanical lift. Interview with the DON, on 06/12/19 at 2:15 PM, revealed staff was educated on following the Care Plans and the Kardex by SRNA/Restorative #1, starting on 06/04/19. 6. Review of the mechanical lift audits revealed the audits were conducted 06/05/19 through 06/12/19 on five percent (5%) or ten (10) residents on each shift by the Charge Nurse with no concerns identified.