Every finding on record at Laurel Heights Home for the Elderly

Based on observation, interview, and facility document and policy review, the facility failed to follow the planned menu for 50 of 152 residents who received meals from the facility. Specifically, the facility failed to ensure the correct portion size was served for residents who received ground or pureed diets for the lunch meal on 04/14/2026.Findings included: A facility policy titled Portion Control, dated 2023, indicated, Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. The policy revealed, 3.a. Portions that are too small result in the individual not receiving the nutrients needed. A facility Menu Plan Week II revealed lasagna was on the lunch menu for Tuesday, 04/14/2026. A facility Production Sheet for the Tuesday lunch meal indicated the serving size for pureed and ground lasagna was 6 ounces (oz). Observations of the lunch meal service on 04/14/2026 beginning at 10:11 AM revealed a 4 oz serving spoon was in containers of pureed and ground lasagna. Continued observations revealed [NAME] 4 used the 4 oz serving spoon to serve pureed and ground lasagna to residents throughout the meal service. During an interview on 04/14/2026 at 12:01 PM, [NAME] 4 revealed that she served a one-half cup (4 ounces) portion size of pureed lasagna and ground lasagna to residents. [NAME] 4 revealed she was aware that the production sheet provided serving size information. After reviewing the production sheet, [NAME] 4 stated that she should have served a 6 oz portion of the ground lasagna and pureed lasagna to residents. During an interview on 04/14/2026 at 12:05 PM, the Certified Dietary Manager (CDM) stated [NAME] 4 should have used a bigger serving spoon. The CDM stated that the cook should have double checked that the correct spoon was used. During an interview on 04/15/2026 at 2:38 PM, the Registered Dietitian (RD) stated her expectation was for staff to serve correct portion sizes so that residents met their nutritional needs. During an interview on 04/16/2026 at 8:50 AM, the Director of Nursing stated she expected staff to follow the menu and serve the appropriate portion sizes so that residents received adequate nutrition. During an interview on 04/16/2026 at 8:58 AM, the Administrator (ADM) stated she expected staff to follow standards of practice and the facility's policy for menus and portion sizes. The ADM stated residents needed to receive the right amount of food.

Based on facility policy review, record review, observation, a review of manufacturers' instructions, and interview, the facility failed to ensure a medication administration error rate of less than 5%. A total of 38 medication opportunities were observed with three errors, which resulted in a medication administration error rate of 7.89%. The deficiencies affected 2 (Resident 44 and Resident 38) of 5 residents reviewed during medication administration.Findings included: 1. A facility policy titled, Medication Administration (Standard of Care), last reviewed in May 2025, revealed the Purpose included To encourage Nurses and CMA's [certified medication aide's] to utilize sound principles and theory to the 'R's' of medication administration. The Policy included All Pharmacy/Nursing policies governing the ordering, procurement, distribution, administration, documentation, medication error, and emergence stock will be adhered to by the RN's [registered nurses], LPN's [licensed practical nurses], and CMA's assigned to administer medications. During an interview on 04/16/2026 at 12:08 PM, the Director of Nursing (DON) stated the R's of medication administration that were referred to in the facility policy titled Medication Administration (Standard of Care), were the rights of medication administration, which included the right medication, right resident, right route, right dose, and right time. An admission Record revealed the facility admitted Resident (R) 44 on 05/25/2011. According to the admission Record, the resident had a medical history that included a diagnosis of allergic rhinitis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2026, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had an active diagnosis of allergic rhinitis. Resident 44's Order Summary Report, with active orders as of 01/17/2026, contained an order, dated 02/11/2020, for fluticasone propionate (a corticosteroid) 50 micrograms (mcg) per spray, one spray in both nostrils two times a day for allergies. During an observation of medication administration on 04/15/2026 at 7:34 AM, CMA 1 prepared and administered eight medications to R44. CMA 1 did not administer the fluticasone propionate. CMA 1 then signed the resident's electronic medication administration record (eMAR) indicating that the medication was administered, including fluticasone propionate 50 mcg. During an interview on 04/15/2026 at 7:47 AM, CMA1 stated that when administering medications to a resident, she verified the resident and the resident's orders, which would include verifying the right medication, right dose, and right route. CMA 1 stated she pulled the medications from the cart and verified them against the physician's orders before administering them. CMA 1 reviewed R 44's eMAR and verified that the resident's fluticasone propionate 50 mcg was documented as administered and confirmed the medication was not administered to the resident. CMA 1 stated she overlooked R 44's order for fluticasone propionate and stated that she was nervous. During an interview on 04/16/2026 at 8:44 AM, Nurse Manager (NM) 3 stated that staff members who administered medications were educated at least annually on the rights of medication administration, which included ensuring the right dose, right drug, right route, right time, and the right resident when verifying medication orders. NM 3 stated that if staff did not implement the rights of medication administration, it could result in a medication error. During an interview on 04/16/2026 at 8:56 AM, the Director of Nursing (DON) stated that staff members who administered medications were educated on the rights of medication administration, which included ensuring the right dose, right drug, right route, right time, and the right resident when verifying medication orders. The DON stated that the rights of medication administration were important to resident safety, and a negative impact, such as a medication error, to the resident could occur if staff did not implement those rights. The DON stated that she expected staff to compare the medications in the medication cart to the resident's electronic medication administration record when pulling medications out of the cart to ensure the resident was receiving all of their medications as ordered. 2. A facility policy titled, Insulin Administration utilizing Insulin Pens, last reviewed June 2025, revealed, 1. Insulin administration will follow these guidelines, which included e. Insulin will only be administered using an insulin pen issued by [the facility's name]. A disposable safety needle will be used with the insulin pens for administration of insulin per OSHA [Occupational Safety and Health Administration] guidelines. The insulin pen will be primed and 2 units of insulin will be wasted prior to dose administration. An admission Record revealed the facility admitted Resident 38 on 01/18/2023. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2026, revealed R 38 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident 38's Order Summary Report, with active orders as of 02/14/2026, contained an order, dated 12/18/2025, for Humalog KwikPen Solution Pen-injector 100 units per milliliter (ml) solution (insulin lispro), inject two units subcutaneously in the morning for type 2 diabetes mellitus. Resident #38's Order Summary Report contained an order, dated 09/12/2025, for insulin glargine 100 units per ml solution via pen-injector, inject 39 units subcutaneously one time a day for type 2 diabetes mellitus. Humalog KwikPen (insulin lispro)'s Instruction for Use, revised 07/2023, revealed, Priming your Pen included Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The instructions revealed, Step 6: To prime you Pen, turn the Dose Knob to select 2 units. The instructions revealed, Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. The instructions revealed, Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. Lantus insulin glargine injection manufacturer instructions titled, How to use your Lantus SoloStar pen, revealed, Step 3. Perform a Safety Test, which included Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. The manufacturer instructions revealed, Always perform the safety test before each injection. During an observation of medication administration on 04/16/2026 at 8:31 AM, RN 2 gathered R 38's Humalog Kwik Pen and Lantus SoloStar pen injectors, several pen-injector needles, and several alcohol prep pads in a small caddy. RN 2 performed hand hygiene, donned clean gloves, and explained the procedure to the resident. RN 2 cleansed the top of Resident 38's Humalog Kwik Pen with alcohol and applied a needle to the tip of the pen. RN 2 dialed the dose selector on the Humalog Kwik Pen to 2 units, cleansed R 38's lower right abdomen, and administered the insulin lispro to the resident. RN 2 did not prime the needle of the pen-injector prior to selecting the dose and administering the medication to Resident 38. RN2 then cleansed the top of Resident 38's Lantus SoloStar pen with alcohol and applied a needle to the tip of the pen. RN 2 dialed the dose selector on the pen-injector to 39 units, cleansed Resident 38's lower right abdomen, and administered the insulin glargine to the resident. RN 2 did not prime the needle of the pen-injector prior to selecting the dose and administering the medication to R 38. During an interview on 04/16/2026 at 8:40 AM, RN 2 stated that after applying a needle to the pen-injector, she normally dialed a couple of units on the dose selector and wasted them before selecting the resident's insulin dose to ensure the resident received a proper dose of insulin. RN 2 stated that she did not want to waste insulin at the time of the observation. During an interview on 04/16/2026 at 8:44 AM, Nurse Manager (NM) 3 stated that nursing staff should prepare an insulin pen-injector by putting the needle on the pen-injector and priming the needle with two units of insulin before selecting the ordered dose. NM 3 stated that the purpose of priming the needle of the pen-injector was to ensure that the resident received the full dose as ordered. NM 3 stated that if nursing staff failed to prime the needle of the pen-injector prior to administration of the insulin, the resident may not receive the full ordered dose. During an interview on 04/16/2026 at 8:56 AM, the Director of Nursing (DON) stated that she expected nursing staff to prime the needle of a pen-injector when administering insulin by putting the needle on the pen-injector and priming the needle with two units of insulin before selecting the ordered dose. During an interview on 04/16/2026 at 9:19 AM, the Administrator (ADM) stated that she expected staff who administered medications to residents to follow facility protocols and best practices when administering medications.

Based on interview, record review, and a review of the facility visitation policy, it was determined the facility failed to protect the visitation rights for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a scheduled visit with family on 04/23/2021 and was visiting with two (2) family members when the facility screened two (2) additional family members to visit. Activities staff abruptly ended the visitation when they saw more than two (2) people visiting the resident. The findings include: A review of the facility visitation policy titled indoor visitation dated 03/29/2021 revealed the facility would allow indoor visitation and not restrict visitation without a clinical or safety reason. According to the policy, the number of visitors would be limited to two (2) visitors per resident. The visits would take place in designated visiting areas. A review of the medical record for Resident #1 revealed the facility admitted the resident on 05/15/2020 with diagnoses, which included major depressive disorder and anxiety. A review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of eleven (11) indicating the resident had moderately impaired cognition. Interview with Resident #1, on 05/06/2021 at 10:00 AM, revealed the resident was visiting with family on the his/her birthday on 04/23/2021. The resident said a facility staff member came in and removed the resident from the room. According to Resident #1, the resident only got to visit for a short while and the resident had not seen his/her family in a long time. Per the resident, he/she told the staff member that he/she wanted to talk to the family members and was removed from the room anyway. Further interview revealed the resident was upset over not being allowed to finish visiting with his/her family. An interview with Family Member (FM) #1 on 05/06/2021 at 3:15 PM revealed the family member had come to the facility with another family member to visit Resident #1 on 04/23/21 and was screened in to visit. According to FM #1, she brought presents and a cake to the resident for the resident's birthday. Further, interview with FM #1 revealed they had been visiting with Resident #1 when two additional family members came to the facility, were screened in by facility staff, and was visiting the Resident #1 in the dining room at the same time. Facility Activities Staff came into the visitation room, asked how the family members got in and why were there four (4) people visiting. The Activities Staff told the family member they would have to leave and removed Resident #1 from the room. According to FM #1, the Resident was upset over how the visit ended and the family member filed a complaint with the facility on 04/26/2021. An interview on 05/06/2021 at 12:59 PM, with Activities Staff #1, revealed on 04/23/2021, she and the Activities Director entered the room where family members were visiting with Resident #1. The Activities Staff stated there were four (4) family member in the room visiting and there was only supposed to be two (2) people visiting per the policy. According to Activities Staff, she asked the family how they got in the building, told them they were not allowed and would have to leave. She further stated that she and the Activities Director took Resident #1 out of the visitation room and returned the resident to the resident's room. An interview with the Activities Director, on 05/06/2021 at 4:06 PM, revealed she was informed that four (4) family members were in the facility visiting with Resident #1 on 04/23/2021. Further interview revealed since there was only supposed to be two (2) people at a time visiting, she went to ask the family to leave. According to the Activities Director, she did removed Resident #1 from the room because she thought the residents visiting time was up and that it was a safety issue for the resident to be visiting with four (4) family members. According to the Activities Director, she was unaware there was a problem with ending the visit and asking family to leave the facility until 04/26/2021 when she was questioned by the Administrator about the incident. An interview with the Administrator, on 05/07/2021 at 11:20 AM, revealed she was unaware of any problem with Resident #1's family visit on 04/23/2021 until the Social Worker informed her on 04/26/2021 that FM #1 had reported an abuse allegation. The Administrator stated Activities Staff had removed Resident #1 from the visitation room during a family visit. The Administrator stated facility staff had accidentally screened too many visitors to visit with Resident #1. After FM #1's reported the allegation, Activities Staff #1 was suspended and the allegation was reported to the required state agencies. The Administrator stated the incident was not handled professionally by Activities Staff and the resident's visit with family was cut short. According to the Administrator, staff should have notified her of the incident immediately and the situation could have been handled differently to avoid the resident and the family becoming upset. Further interview revealed Activities Staff #1 suspension was ongoing pending the outcome of a Department of Community Based Service investigation and the Activities Director had been counseled regarding notifying the Administrator of any incidents with visitation.

Based on observation, interview, and facility policy review it was determined the facility failed to distribute food in accordance with professional standards for food service safety. The findings include: Review of the facility policy titled In-Room Dining (Room Service), dated 2019, revealed, All foods should be covered and delivered as soon as possible after plating to maintain food quality and temperature. The facility also presented the policy titled Accuracy and Quality of Tray Line Services, dated 2019; however, it did not address covering of foods. Observation of the lunch tray line on 03/03/2020 at 10:00 AM revealed the resident meal trays were loaded with desserts and bread products that were not covered. Observation on 03/03/2020 at 11:07 AM of the meal cart on the Lower Basement (LB) level revealed meal trays delivered from the kitchen and served to residents with bread and dessert not covered. Observation on 03/03/2020 at 11:38 AM of the main floor dining room revealed meals were delivered to residents with the desserts and bread not covered. Observation on 03/03/2020 at 10:50 AM of meal trays on 2D level and Shepard's Cove revealed the meals were delivered to residents with the desserts and breads not covered. Interview on 03/03/2020 at 3:00 PM with the Dietary Manager revealed she had been the manager for several months. She stated dietary staff cover the residents' food to keep it warm. She further stated that staff put lids on the bowls and cups of liquids to keep them from spilling and agreed the lids also kept anything from falling into the food. She stated that they had always distributed the desserts and bread without covering them, but understood that not covering the dessert and bread could allow contaminants to fall into the food. Interview on 03/04/2020 at 10:30 AM with the Administrator revealed the Dietary Manager had informed her of the issue and was working with her vendor for a solution.

Based on observation, interview, record review, policy review, and review of the facility's investigation, it was determined that the facility failed to implement the plan of care for one (1) of thirty (30) sampled residents (Resident #130). The facility assessed Resident #130 to be at risk for falls and developed interventions that included placing the resident on the Guardian Angel Falls Program. However, review of the monitoring sheets for the Guardian Angel Falls Program revealed facility staff had failed to sign the Angel monitoring sheets as directed by the facility policy. The findings include: Review of the facility policy titled Guardian Angel Falls Program, revealed the goals of the program are to reduce the number of falls in the facility and to improve residents' quality of life. Further review revealed staff will check on the resident six (6) to eight (8) times per shift and sign the activity sheet that is left in the room. Review of the facility policy titled Care Plans-Comprehensive, dated 01/16/2019, revealed the comprehensive care plan is based on a thorough assessment and identifies the professional services that are responsible for each element of care. Review of Resident #130's medical record revealed the facility admitted the resident on 10/15/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status score of nine (9), which indicated the resident had moderately impaired cognition. Further review revealed the resident was assessed to require extensive assistance with ambulation. Additional review of the MDS revealed the resident had experienced falls since admission to the facility. Review of the comprehensive care plan revealed the facility identified the resident to be at risk for falls, and placed him/her on the Guardian Angel Falls Program. Review of a resident accident/incident report dated 11/18/2019 revealed the resident was placed on the Guardian Angel Falls Program after sustaining a non-injury fall. Review of the facility's Angel Sign Sheet revealed the following: for November 2019, there were seven (7) days that staff failed to initial and document per facility policy for the entire day; December 2019, eighteen (18) days staff failed to initial and document monitoring of the resident; January 2020, twelve (12) days staff failed to document and sign; and for February 2020, (7) seven days staff failed to initial and document. Interview with Resident #130 on 03/05/2020 at 1:29 PM revealed he/she is aware to call for staff when assistance is needed. Per Resident #130, he/she does not want to ask for help all the time. Resident #130 stated he/she was getting exercise to build strength and planned to return home soon. Per the resident, he/she did not get hurt from the fall and he/she is able to care for himself/herself. Interview with SRNA #4 on 03/05/2020 at 4:35 PM revealed staff should review the resident Kardex to determine the resident's care needs. SRNA #4 was knowledgeable of the Guardian Angel Falls Program and stated any staff member can check on the resident and sign the Angel sign-in sheet. Interview with SRNA #3 on 03/05/2020 at 4:43 PM revealed she had been trained to check on residents who are on the Guardian Angel Falls Program at least hourly if possible. SRNA #3 reported any staff member could check on the resident and document the check. SRNA #3 acknowledged that staff should look at the Kardex to determine resident's care needs. Interview with Registered Nurse (RN) #2 on 03/05/2020 at 4:50 PM revealed the expectation is that any staff member can check on residents who are on the Guardian Angel Falls Program and sign the sheet. SRNAs and nurses should review the care plan if there is any question about a resident's care needs. The RN stated no concerns had been identified with staff not signing the Guardian Angel check sheet. Interview with RN #3, Unit Manager, on 03/05/2020 at 5:04 PM revealed the expectation is that staff will follow the resident's plan of care when providing care. RN #3 makes rounds daily to monitor resident care and spot checks the sign sheets of Guardian Angel residents and had not identified any concern related to the sign sheets not being completed.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure services provided met professional standards of quality for one (1) of three (3) sampled residents (Resident #1). Interviews with therapy staff revealed Resident #1 experienced a change in condition on 05/14/19 at approximately 2:30 PM. Two therapy staff members stated they reported the resident's condition to the resident's primary nurse; however, the facility failed to assess the resident's condition until approximately 7:30 PM, five (5) hours later. The findings include: Review of the facility policy titled Fast facts sheet oxygen therapy, dated (MONTH) (YEAR), revealed the policy should serve as a guide in decision-making and critical thinking whenever the nurse was implementing, monitoring, and evaluating oxygen therapy. The policy stated all residents receiving oxygen must have their oxygen monitored and documented on the resident's Medication Administration Record [REDACTED]. In addition, according to the policy, oxygen concentrators did not have a battery backup system and must be plugged into red electrical outlets at all times. The facility had no policy related to conducting a nursing assessment, outside the requirements of the minimum data set assessment (MDS) requirements. Review of Resident #1's medical record revealed the facility admitted the resident on 04/25/19 with [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment dated [DATE] revealed the resident required extensive assistance of two (2) staff members with transfers and toileting, was usually able to make his/herself understood, and had a brief interview for mental status (BIMS) score of eight (8), indicating moderate cognitive impairment. Interview with Occupational Therapist (OT) #1 on 05/21/19 at 12:30 PM revealed on 05/14/19 at approximately 2:30 PM Resident #1 looked like (he/she) was short of breath. OT #1 also stated that the resident requested to hold my hand because he/she was so anxious and short of breath, which was new for the resident. Further interview revealed the resident was unable to participate in therapy that day due to shortness of breath, which was also new for the resident. The OT stated she reported the change in the resident's condition to Licensed Practical Nurse (LPN) #1 on 05/14/19; however, she did not observe the nurse conduct an assessment. Interview with Respiratory Therapist (RT) #1 on 05/21/19 at 1:15 PM revealed Resident #1 was short of breath, anxious, and requested to hold the RT's hand because he/she was scared due to shortness of breath. RT #1 stated this was new for Resident #1 and she reported the change in the resident's condition to the resident's primary nurse (LPN #1). The RT stated she administered a respiratory treatment to the resident, and the resident verbalized feeling better after the treatment. However, RT #1 did not observe LPN #1 assess the resident's condition after the change in the resident's condition was reported. Interview with LPN #1 on 05/21/19 at 4:35 PM revealed she was assigned to care for Resident #1 from 7:00 AM until 7:00 PM on 05/14/19. The LPN stated she recalled being notified that Resident #1 was having shortness of breath and was struggling; however, the LPN stated she did not assess Resident #1 because RT #1 had assessed the resident. Review of Resident #1's nursing documentation, completed by LPN #2, revealed on 05/14/19 at 7:45 PM the resident complained of shortness of air and was observed to have increased respirations and an oxygen saturation of eighty-five (85%) percent (normal oxygen saturation is 95-100%). Documentation also revealed a duo-neb (breathing) treatment was applied and the resident's daughter was at the bedside. Interview with Resident #1's family member (Daughter #2) on 05/21/19 at 12:05 PM revealed she was at the facility at approximately 7:30 PM on 05/14/19 when Resident #1 experienced a change in condition. She stated she informed LPN #2 that the resident was short of breath when she arrived at the facility. The resident's daughter stated the LPN administered a respiratory treatment; however, she did not assess the resident vital signs, which was concerning for the family member. Daughter #2 also stated LPN #2 entered the resident's room after the respiratory treatment was completed because Resident #1 didn't feel much better. The daughter stated LPN #2 then stated, No wonder (he/she) doesn't feel better, the oxygen tubing isn't connected to the concentrator, so (he/she) isn't getting any oxygen. Interview with State Registered Nurse Aide (SRNA) #1 on 05/22/19 at 9:35 AM revealed she was in Resident #1's room and acknowledged the resident's oxygen tubing was not connected to the oxygen concentrator as required on the evening of 05/14/19. SRNA #1 stated she witnessed LPN #2 inform the family member that the tubing was not connected to the machine and further stated, She's (LPN #2) the one that caught that it wasn't connected right. Interview with LPN #2 on 05/22/19 at 9:00 AM revealed she was assigned to care for Resident #1 on 05/14/19 from 7:00 PM to 7:00 AM. LPN #2 stated at approximately 7:30-7:45 PM, Resident #1's daughter informed her that Resident #1 wasn't breathing well. LPN #2 stated she assessed the resident's oxygen saturation reading to be eighty-four (84) percent so I gave her a breathing treatment. The nurse acknowledged she had not assessed the resident's blood pressure or heart rate before administering the respiratory treatment. LPN #2 stated that after the resident's respiratory treatment was completed, the resident's condition had not improved, the resident's blood pressure and heart rate were abnormally elevated (unable to recall exact readings), and she contacted the resident's physician. The LPN denied observing Resident #1's oxygen not properly connected as stated by the resident's family member and SRNA #1. A post-survey interview with Physician #1 on 05/23/19 at 10:00 AM revealed he expected nursing staff to conduct an assessment of a resident, which included evaluation of lung sounds, heart rate, respiratory rate, and blood pressure when a change in condition occurred to determine if the physician should be notified or whether medication could be administered. Physician #1 also stated if a resident's oxygen saturation reading was eighty-four (84%) or eighty-five (85%) he should have been notified, before an as-needed medication was provided to the resident. The physician also stated that he expected oxygen to be administered to residents as ordered. Interview with the Director of Nursing (DON) on 05/22/19 at 3:25 PM revealed she would not have expected LPN #1 to assess Resident #1 when the change in the resident's condition was identified by therapy staff because the respiratory therapist is the professional on lung sounds. The DON also stated LPN #2 did exactly what I would have done, give breathing treatment first. She stated oxygen was monitored by the nurses and documented on the resident's MAR. When questioned related to the resident's oxygen not being administered as ordered, the DON stated, You're taking the family's word. I am taking the staffs word on the oxygen.

Based on interview, record review, and review of facility policy, it was determined the facility failed to consult the physician for one (1) of three (3) residents (Resident #1) when there was a significant change in the resident's physical status. Interviews with Occupational Therapist (OT) #1 and Respiratory Therapist (RT) #1 on 05/21/19 revealed Resident #1 was definitely different, and was having increased anxiety and requested to hold their hand and was scared, due to shortness of breath, at approximately 2:30 PM on 05/14/19. The RT notified the nurse responsible for the resident's care and administered a breathing/respiratory treatment. The RT stated the resident's condition improved after the treatment was administered; however, nursing staff failed to notify the resident's physician of the change in the resident's condition. Approximately five (5) hours later, at 7:30 PM on 05/24/19, Resident #1 was short of air again. However, the facility failed to notify the resident's physician until after another breathing treatment was not effective. The findings include: Review of the facility policy titled Notification of a Change in the Resident's Condition, dated 03/16/17, revealed the policy's purpose was to ensure the timely notification of the resident, family, and physician when a change occurred in the resident's condition. The policy also stated the nurse assigned to the resident would execute timely notification of the resident, family, and physician in the event there were changes in the overall physical, mental, or psychosocial status due to clinical complications. The policy further stated clinical conditions that may justify immediate notification of the physician included respiratory distress, behavior and/or mood changes, and a decrease in the ability to tolerate physical activity, and a decrease in the resident's mobility. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission minimum data set assessment ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members with transfers and toileting. Further review revealed Resident #1 was usually able to make his/herself understood, and had a brief interview for mental status (BIMS) score of eight (8). Interview with OT #1 on 05/21/19 at 12:30 PM revealed on 05/14/19 at approximately 2:30 PM Resident #1 looked like (he/she) was short of breath. The OT also stated that the resident requested to hold my hand because he/she was so anxious and short of breath, which was new for the resident. Further interview with the OT revealed the resident was unable to participate in ambulation, due to shortness of breath, which was also new for the resident. OT #1 stated she reported the change in the resident's condition to Licensed Practical Nurse (LPN) #1 on 05/14/19. Interview with RT #1 on 05/21/19 at 1:15 PM revealed Resident #1 was short of breath, anxious, and requested to hold the RT's hand because he/she was scared due to shortness of breath. The RT stated this was new for Resident #1 so she reported the change in the resident's condition to the resident's primary nurse, LPN #1. The RT stated she administered a respiratory treatment to the resident, and the resident verbalized feeling better after the treatment was administered. Interview with LPN #1 on 05/21/19 at 4:35 PM revealed she was assigned to care for Resident #1 from 7:00 AM until 7:00 PM on 05/14/19. The LPN stated she recalled being notified that Resident #1 was having shortness of breath and was struggling. However, she acknowledged she did not assess Resident #1, evaluate the resident's vital signs, or notify the resident's physician because the resident calmed down after the respiratory treatment was administered. Review of Resident #1's nursing documentation, completed by LPN #2, revealed on 05/14/19 at 7:45 PM the resident complained of shortness of air, was observed to have increased respirations and an oxygen saturation of eighty-five (85%) percent. Documentation also revealed a duo-neb (respiratory) treatment was applied and the resident's daughter was at the bedside. Interview with LPN #2 on 05/22/19 at 9:00 AM revealed she was assigned to care for Resident #1 on 05/14/19 from 7:00 PM until 7:00 AM. LPN #2 stated at approximately 7:30 PM, Resident #1's daughter approached the nurses' desk and notified her that Resident #1 wasn't breathing well. LPN #2 stated she assessed the resident's oxygen saturation to be eighty-four (84) percent, so I gave (him/her) a breathing treatment (normal oxygen saturation is 95-100%). LPN #2 further stated that Resident #1's condition did not improve after the treatment and the resident's blood pressure and heart rate were abnormally elevated (unable to recall exact readings), so she contacted the resident's physician and the resident was transferred to the local hospital. Review of Resident #1's hospital record revealed the resident arrived at the hospital on [DATE] at 9:03 PM and was evaluated for complaints of respiratory distress. Continued review of the hospital record revealed the resident was admitted to the hospital on [DATE] at 10:45 PM with [DIAGNOSES REDACTED]. A post-survey interview conducted with Physician #1 on 05/23/19 at 10:00 AM revealed he expected nursing staff to assess residents when a change in condition occurred, which included evaluation of a resident's lung sounds, heart rate, respiratory rate, and blood pressure to determine whether he should be notified or whether a medication could be administered that was ordered as needed. Physician #1 also stated if a resident's oxygen saturation reading was eighty-four percent (84%) or eighty-five percent (85%), he should have been notified, before medication was administered to the resident. Interview with the Director of Nursing (DON) on 05/22/19 at 3:25 PM revealed physicians were notified as the nurse deemed necessary. The DON further stated whether a nurse contacted a physician when a resident had a change in condition was based on the nurse's judgment. The DON stated LPNs #1 and #2 done exactly what I would have done.

Based on observation, interview, facility policy review, and medical record review it was determined the facility failed to develop a Comprehensive Plan of Care for one (1) of thirty-one (31) sampled residents (Resident #81). Resident #81 was admitted to the facility with orders to utilize an orthopedic boot when out of bed. However, the facility failed to develop a Comprehensive Plan of Care for Resident #81 related to the orthopedic boot. The findings include: Based on the facility policy titled Assessment and Care Plan Policy, dated 02/20/16, revealed all residents would have a Comprehensive Plan of Care completed within twenty-one (21) days of admission to the facility. The policy also stated after reviewing the plan of care for accuracy, the Charge Nurse would then review the care plan for accuracy, sign the document, and implement any new interventions. Review of the medical record for Resident #81 revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #81's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating the resident was moderately cognitively impaired. Review of physician orders [REDACTED]. Observation and interview with Resident #81 on 01/08/19 at 9:30 AM revealed the resident was wearing the orthopedic boot on the right foot. The resident stated he/she had worn the orthopedic boot on the right foot when out of bed for standing or walking since being admitted to the facility on [DATE]. Review of Resident #81's Comprehensive Care Plan revised on 12/02/18, with focus of [DIAGNOSES REDACTED].#81 related to an orthopedic boot. In addition, review of the resident's Kardex (utilized by State Registered Nurse Aides when providing resident care) revealed no interventions for the boot were included on the care guide. Interview with State Registered Nurse Aide (SRNA) #1 on 01/10/19 at 10:10 AM revealed Resident #81 had worn the boot when transferring, standing, or walking since admission to the facility. SRNA #1 stated she had been told by nursing staff to ensure the resident utilized the boot when standing, walking, or transferring, but stated the Kardex did not list the boot as an intervention for Resident #81. Interview with Registered Nurse (RN) #1 on 01/10/19 at 9:25 AM revealed Resident #81 had used the boot on his/her right foot since admission to the facility for transferring, standing, or walking. RN #1 further stated the Comprehensive Plan of Care did not have the boot listed as an intervention to be utilized by the resident. Interview with the MDS Coordinator on 01/10/19 at 4:27 PM revealed when a resident was admitted to the facility the MDS Nurse would create a Comprehensive Plan of Care and the Kardex Report. The MDS Coordinator stated Resident #81's Comprehensive Plan of Care should have had interventions listed for the boot being utilized by the resident. The MDS Coordinator further revealed interventions regarding the boot had been overlooked when reviewing the Comprehensive Plan of Care. Interview with the Director of Nursing (DON) on 01/10/19 at 5:14 PM, revealed she randomly monitors the residents' Comprehensive Plan of Care by making rounds and observing residents and comparing the Comprehensive Plan of Care to the care being received by the resident. The DON stated Resident #81's Comprehensive Plan of Care should have had an intervention for the boot being utilized by the resident. The DON also revealed she had not identified any concerns with the Comprehensive Plan of Care being developed or implemented to reflect care being received by the residents.

Based on observation, interview, facility policy review, and medical record review it was determined the facility failed to review and revise a Comprehensive Plan of Care for one (1) of thirty-one (31) sampled residents (Resident #81) when the resident experienced a change in urinary functioning. The findings include: Review of the facility policy titled The Review and Signing of Care Plans after Each RAI Assessment, dated 02/22/16, revealed the purpose of the policy was to provide a mechanism of structure and process whereby residents' care plans would be reviewed, signed, and correlated with the clinical flow record. Further review revealed care plans would be updated as needed by the unit nurses and quarterly by the Resident Assessment Instrument (RAI) staff when quarterly assessments were done. Review of the medical record for Resident #81 revealed the facility admitted the resident on 10/05/18 with [DIAGNOSES REDACTED]. Review of Resident #81's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always continent of urine. Interview with Resident #81 on 01/08/19 at 9:30 AM revealed the resident self-toileted without assistance from staff. However, review of the Comprehensive Plan of Care for Resident #81 revealed the resident was frequently incontinent of bladder related to dribbling. Interventions initiated revealed the resident was to be checked for incontinence every two (2) hours and to be provided care after each incontinence episode. Interview with State Registered Nurse Aide (SRNA) #1 on 01/10/19 at 10:10 AM, revealed Resident #81 self-toileted and provided his/her own care after toileting. Interview with Registered Nurse (RN) #1 on 01/10/19 at 9:25 AM revealed Resident #81 did not require assistance with toileting. RN #1 further revealed the Comprehensive Plan of Care should have been revised to show the resident was continent of urine to correlate with the Quarterly MDS Assessment. Interview with the MDS Coordinator on 01/10/19 at 4:27 PM, revealed the Comprehensive Plan of Care for Resident #81 should have been revised when the resident's Quarterly MDS Assessment was completed on 11/21/18. The MDS Coordinator further revealed the Comprehensive Plan of Care should always correlate with the resident's MDS Assessment. The MDS Coordinator had not identified any concerns with Comprehensive Plans of Care being revised for residents as needed. Interview on 01/10/19 at 5:14 PM with the Director of Nursing (DON) revealed the MDS Coordinator and Nurses were responsible for revising the Comprehensive Plan of Care as needed. The DON further revealed the Comprehensive Plan of Care for Resident #81 should have been revised when his/her urinary status changed. The DON also revealed she monitored the Comprehensive Plan of Care for residents randomly and had not identified any concerns with revisions being done as needed.

Based on observation, interview, record review, facility policy review, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, it was determined the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for one (1) of thirty-one (31) residents. The facility failed to complete a Significant Change MDS assessment for Resident #81 after he/she experienced a significant change in condition. The findings include: Review of the facility policy titled, Assessment and Care Plan Procedure, dated 02/20/16, revealed whenever a significant change was noted in a resident's condition (either decline or improvement) the nurse in charge would notify the MDS Coordinator. Review of the facility policy titled Assessment and Care Plan Policy, dated 02/20/16, revealed all skilled nursing facility residents will have Significant Change in Status Assessment completed per Centers for Medicare and Medicaid Services regulations. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the MDS assessment dated (MONTH) (YEAR), revealed a Significant Change in Status Assessment would be appropriate if there were two (2) or more areas of decline or two (2) or more areas of improvement. This may include two changes within a particular domain such as two areas of Activities of Daily Living. Further review of the User's Manual revealed if a resident's decision-making skills improve or incontinence pattern improves a Significant Change in Status Assessment should be completed. Review of the medical record for Resident #81 revealed the facility admitted the resident on 10/05/18 with [DIAGNOSES REDACTED]. Review of Resident #81's MDS assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5) indicating the resident was severely cognitively impaired. Further review of the MDS assessment revealed the facility assessed the resident to require extensive physical assistance with two plus persons for bed mobility, transferring, and toilet use. In addition, the facility assessed Resident #81 to require extensive physical assistance of one person for eating, and the facility also assessed the resident to be frequently incontinent of urine. Review of Resident #81's MDS assessment dated [DATE], revealed the resident's BIMS score had increased to twelve (12) indicating the resident was moderately cognitively impaired. Further review of the MDS assessment revealed the facility assessed the resident to require only limited physical assistance of one person for bed mobility, transfers, and toilet use. In addition, the facility assessed Resident #81 to require only supervision with setup help only for eating, and the resident was always continent of urine. Interview with the MDS Coordinator on 01/10/19 at 4:27 PM revealed a Significant Change in Status MDS assessment should have been completed for Resident #81 on 11/21/18, instead of a Quarterly MDS assessment. The MDS Coordinator further revealed she was unsure why a Significant Change in Status MDS Assessment was not completed and that it was overlooked. The MDS Coordinator also revealed she had not identified any concerns with Significant Change in Status MDS Assessments being completed when a resident has a Significant Change in Status. Interview with the Director of Nursing (DON) on 01/10/19 at 5:14 PM revealed a Significant Change in Status MDS Assessment should have been completed for Resident #81 on 11/21/18 instead of a Quarterly MDS Assessment. The DON revealed she had not identified any concerns with Significant Change in Status MDS Assessments being completed when residents have a Significant Change in Status.

Based on observation, interview, and facility policy review it was determined that the facility failed to ensure the residents' environment remained free of accident hazards. Observations on 11/15/17 during the survey revealed cleaning supplies were stored in an unlocked area on the first floor accessible to residents. In addition, facility water temperatures exceeded 110 degrees Fahrenheit in three (3) resident rooms on the Louise Baker (LB) Unit. The findings include: 1. Review of the facility's policy titled Housekeeping Chemicals and Their Safe Use, dated October 2016, revealed staff were responsible to ensure the safe storage of all chemicals on their unit and would not allow residents to have access to chemicals. Further review of the policy revealed housekeeping staff were to keep cleaning products that were not in use in a locked cart. Observations during initial tour of the facility on 11/15/17 at 8:52 AM and during the environmental tour at 4:53 PM on the first floor Continued Care Rehabilitation Center (CCRC) Unit revealed the following items were observed stored in a closet with signage on the door stating Danger Hazardous Chemicals. However, the closet door was not locked or secured. The closet contained two (2) spray cans of glass cleaner, ten (10) cans of germicidal cleaner, one (1) spray bottle of bleach, one (1) bottle of floor cleaner, one (1) bottle of bathroom cleaner, two (2) boxes of hand sanitizer, one (1) gallon of heavy duty butyl degreaser, one (1) spray can of stainless steel cleaner, and five (5) boxes of hand cleanser. Interview with the Nurse Manager for the CCRC Unit on 11/16/17 at 11:34 AM revealed the housekeeping closet should have been locked and stated any resident could have gained access to the chemicals. The CCRC Manager stated she performed random rounds to ensure doors were locked/secured and had not identified any concerns. Interview with the Environmental Director on 11/16/17 at 5:39 PM revealed he was unaware of why or how long the closet had been unlocked, but stated it should be locked at all times. 2. Review of the facility's policy titled Water Temperature, revealed the facility would maintain water temperatures between 100 degrees Fahrenheit to 110 degrees Fahrenheit. Further review of the policy revealed water temperature checks would be conducted during second (2nd) shift for all nursing floors and units. Observations during the environmental tour with the facility's Maintenance Director on 11/15/17 at 4:16 PM, revealed the hot water temperature in resident room 2 at the sink was 120 degrees Fahrenheit, in resident room 16 at the sink the hot water temperature was 118 degrees Fahrenheit, and in resident room 22 the hot water temperature at the sink was 116.8 degrees Fahrenheit. Review of the facility's Daily Domestic Water Temperature Control Form, completed on 11/15/17, revealed the facility had documented water temperatures and no temperature was identified to have been in excess of 110 degrees Fahrenheit. However, review of the form revealed the form did not contain water temperature checks for rooms 2, 16, or 22. Interview conducted with the Maintenance Director on 11/16/17 at 5:28 PM, revealed the water system's mixing valve and circulating pump were not working properly and needed to be replaced. Further interview with the Maintenance Director revealed he had not identified any problems with water temperatures being too hot, and he stated that water temperatures throughout the facility were obtained and documented daily.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to ensure the environment was free of accident hazards. Observations during the survey revealed cleaning supplies, razors, and wound care supplies were stored in an unlocked area on the second floor accessible to residents. The findings include: Interview with the Environmental Supervisor on 10/05/16 at 2:00 PM revealed the facility did not have a policy to lock up housekeeping supplies, but it was facility practice to store housekeeping supplies and cleaners in a locked area. An interview with the facility Pharmacist on 10/05/16 at 2:05 PM revealed the facility did not have a policy for the storage of medical supplies, iodine swabs, peroxide, or bulk personal hygiene items such as razors. Observations of the second floor area near the medications room revealed the following items were observed stored in an area that was not locked or secured: 30 razors stored in an unlocked drawer; a 19-ounce spray can of germicidal cleaner, a 10-ounce spray can of industrial strength lubricant, two 16-ounce bottles of peroxide, and a pack of 11 iodine swabs stored on an open shelf; and one-half of a 4-pound carton of Epsom salts stored in an unlocked cabinet. An interview with the facility Pharmacist on 10/05/16 at 2:05 PM revealed the items had always been stored in the areas observed, the pharmacist was not aware of the razors being in the drawer, and the items were stored in a locked area on all other units of the facility. The Pharmacist further stated at some point in the past, the door to the area had been removed to make it easier to get the carts out of the medication room.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to provide care in accordance with each resident's written plan of care for three (3) of twenty-four (24) sampled residents (Residents #5, #6, and #14). Resident #5's Comprehensive Care Plan contained interventions that included an elbow pad on his/her left elbow when positioned on his/her left side when in bed. Observations revealed Resident #5 in bed and positioned on his/her left side without an elbow pad on. Resident #6 and Resident #14's Comprehensive Care Plan contained interventions that included for each resident to have heel protectors on when in bed. Observations of Resident #6 and Resident #14 revealed each resident in bed without heel protectors on. The findings include: Review of the facility's policy titled Care Plans-Comprehensive, dated 06/17/15, revealed the Comprehensive Care Plan aids in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Review of the medical record revealed the facility admitted Resident #5 on 09/14/16 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was unable to be interviewed, which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #5 required extensive assistance with bed mobility. Review of the Comprehensive Care Plan dated 09/27/16 revealed Resident #5 was to have an elbow pad to the left elbow when positioned on his/her left side. Observations on 10/03/16 at 2:25 PM, 3:08 PM, and 3:45 PM revealed Resident #5 was in bed on his/her left side without an elbow pad on the left elbow. Interview with State Registered Nurse Aide (SRNA) #1 on 10/05/16 at 1:25 PM revealed she checked the care plans daily and must have overlooked the elbow pad for Resident #5's left elbow. She further revealed the resident needed the elbow pad on to prevent skin breakdown. 2. Review of the medical record revealed the facility admitted Resident #6 on 09/16/16 with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #6 was unable to be interviewed, which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #6 was admitted to the facility with a Deep Tissue Injury (DTI) to both heels. Review of the Comprehensive Care Plan dated 09/27/16 revealed Resident #6 was to have heel protectors on when in bed. Observations on 10/03/16 at 3:05 PM, 3:55 PM, and 4:45 PM revealed Resident #6 was in bed without heel protectors on. Interview with SRNA #3 on 10/05/16 at 2:05 PM revealed she carried the care plans with her while providing care for her residents. She further revealed she just forgot to put the heel protectors on Resident #6. Interview further revealed the resident needed the heel protectors on to prevent skin breakdown. 3. Review of the medical record revealed the facility readmitted Resident #14 on 04/24/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #14 was unable to be interviewed which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #14 was totally dependent on staff for bed mobility. Review of the Comprehensive Care Plan dated 06/24/16 revealed Resident #14 was to have heel protectors on when in bed. Observations on 10/03/16 at 2:31 PM and 3:50 PM revealed Resident #14 was in bed without heel protectors on. Interview with SRNA #2 on 10/05/16 at 1:20 PM revealed she looked at the care plans daily before providing care for her residents. She further revealed she just forgot to put the heel protectors on Resident #14. Interview further revealed the resident needed the heel protectors on to prevent skin breakdown. Interview with the Unit Manager on 10/05/16 at 2:45 PM revealed she did random checks throughout the day to ensure the care plans were being followed. Interview further revealed the team leaders also completed rounds every two hours to ensure the care plans were being followed by the SRNAs. She further revealed she had not identified any concerns with the SRNAs not following the care plans.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure three (3) of twenty-four (24) sampled residents (Residents #5, #6, and #14) received the necessary treatment and services to prevent new sores from developing. Resident #5's Comprehensive Care Plan contained interventions that included an elbow pad on his/her left elbow when positioned on his/her left side when in bed. Observations revealed Resident #5 was in bed and positioned on his/her left side without an elbow pad on. Resident #6 and Resident #14's Comprehensive Care Plans contained interventions that included for each resident to have heel protectors on when in bed. Observations on Resident #6 and Resident #14 revealed each resident was in bed without heel protectors on. The findings include: Review of the facility policy titled Skin Care Program, dated 12/2011, revealed the facility would provide a structure whereby the standards for wound and skin care would be carried out in an organized fashion to ensure the highest level of care and quality outcomes. Further review of the policy revealed all residents who were at risk for skin breakdown will have preventative nursing interventions care planned. 1. Review of the medical record revealed the facility admitted Resident #5 on 09/14/16 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was unable to be interviewed, which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #5 required extensive assistance with bed mobility. Review of the Comprehensive Care Plan dated 09/27/16 revealed Resident #5 to have an elbow pad to the left elbow when positioned on his/her left side. Observations on 10/04/16 at 4:23 PM revealed the skin was intact on the left elbow. Observations on 10/03/16 at 2:25 PM, 3:08 PM, and 3:45 PM revealed Resident #5 in bed on his/her left side without an elbow pad on the left elbow. Interview with State Registered Nurse Aide (SRNA) #1 on 10/05/16 at 1:25 PM revealed she checked the care plans daily and must have overlooked the elbow pad for Resident #5's left elbow. She further revealed the resident needed the elbow pad on to prevent skin breakdown. 2. Review of the medical record revealed the facility admitted Resident #6 on 09/16/16 with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #6 was unable to be interviewed, which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #6 was admitted to the facility with a Deep Tissue Injury (DTI) to both heels. Review of the Comprehensive Care Plan dated 09/27/16 revealed Resident #6 to have heel protectors on when in bed. Observations on 10/03/16 at 3:05 PM, 3:55 PM, and 4:45 PM revealed Resident #6 in bed without heel protectors on. Observations on 10/05/16 at 8:20 AM, during a skin assessment, revealed redness around both heels, skin intact. Review of the care plan for treatment of [REDACTED]. Interview with SRNA #3 on 10/05/16 at 2:05 PM revealed she carried the care plans with her while providing care for her residents. She further revealed she just forgot to put the heel protectors on Resident #6. Interview further revealed the resident needed the heel protectors on to prevent skin breakdown. 3. Review of the medical record revealed the facility readmitted Resident #14 on 04/24/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #14 was unable to be interviewed which indicated he/she was severely cognitively impaired. Further review of the MDS revealed Resident #14 was totally dependent on staff for bed mobility. Review of the Comprehensive Care Plan dated 06/24/16 revealed Resident #14 was to have heel protectors on when in bed. Observations on 10/03/16 at 2:31 PM and 3:50 PM revealed Resident #14 was in bed without heel protectors on. Further observation on 10/03/16 at 3:50 PM revealed Resident #14's heels were intact. Interview with SRNA #2 on 10/05/16 at 1:20 PM revealed she looked at the care plans daily before providing care for her residents. She further revealed she just forgot to put the heel protectors on Resident #14. Interview further revealed the resident needed the heel protectors on to prevent skin breakdown. Interview with the Unit Manager on 10/05/16 at 2:45 PM revealed she did random checks throughout the day to ensure the care plans were being followed. Interview further revealed the team leaders also did rounds every two hours to ensure pressure sore prevention was in place. She further revealed she had not identified any concerns with the SRNAs not providing pressure sore prevention.

Based on observation, interview, and review of facility policy it was determined the facility failed to ensure pharmacy services were in place to ensure the labeling and storage of drugs and biologicals for two (2) of twenty-four (24) sampled residents (Resident #15 and Resident #17) and one (1) unsampled resident (Resident B). Observations of Resident #17 on 10/03/16 at 10:21 AM revealed two (2) cups containing unsecured medicines lying on the resident's bedside table without any staff present in the room. In addition, observation of Resident #15 on 10/03/16 at 10:40 AM revealed a cup containing unsecured medications sitting on the resident's overbed table. Further observation on 10/05/16 of the LB Medication room [ROOM NUMBER] drug cart revealed expired medications were available for resident use. The findings include: Review of the facility policy titled Best Practice Guidelines for Medication Administration, dated 2001, revealed it was facility policy to observe residents actually swallowing oral dosage forms of medication. 1. Observation of Resident #17 on 10/03/16 at 10:21 AM revealed Resident #17 was sitting in the recliner with one cup containing a pink liquid substance and one cup containing four tablet medications on the bedside table without any staff present in the room. Review of the Medication Administration Record [REDACTED]. The tablets were unable to be identified because Resident #17 was taking the medications. Review of Resident #17's medical record revealed the facility admitted Resident #17 on 08/01/13 with [DIAGNOSES REDACTED]. Review of Resident #17's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #17 to have a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #3's cognition was intact (meaning interviewable). Further review of the record revealed no evidence Resident #17 was assessed to self-administer medications. Interview with Resident #17 on 10/05/16 at 10:03 AM revealed the nurse was busy and left the room without ensuring the medications were administered. Interview with Medication Technician #1 on 10/05/16 at 10:04 AM revealed medication should never be left unattended because the resident could forget to take the medication or drop the medication on the floor, and a wandering resident could take it. Interview with Licensed Practical Nurse (LPN) #1 on 10/03/16 at 2:22 PM revealed she was responsible for administering Resident #17's 9:00 AM medications. Further interview revealed she left the room to get a blood pressure cuff. Additional interview revealed she should not have left medications unattended because someone else could have entered the room. Interview with Registered Nurse (RN) #1, who was also the Unit Manager, on 10/05/16 at 10:08 AM revealed there should not be medication left unattended. Further interview revealed she annually performed check-offs during medication pass and had not identified any problems or concerns with ensuring residents received their prescribed medications and/or medications being left unsecured. Interview with the Facility Pharmacist on 10/05/16 at 11:21 AM revealed she would expect the nurse to ensure the medication was administered prior to leaving the room. 2. A review of the medical record for Resident #15 revealed the facility admitted the resident on 01/25/11 with [DIAGNOSES REDACTED]. According to the most recent comprehensive MDS assessment dated [DATE] the resident was assessed to be cognitively intact with a BIMS score of 15. Additional review of the assessment revealed the resident was assessed to required extensive assistance with eating but had recently improved to be independent with eating. There was no evidence the resident had been assessed to self-administer medications by the facility. Observations during the initial tour on 10/03/16 at 10:40 AM revealed the resident was lying on the bed on his/her back with the head of the bed up. A medication cup with five unidentified pills was sitting on the resident's overbed table. When the resident was asked about the pills, the resident stated the nurse left the pills and the resident had not gotten around to taking the medications. According to the resident she wanted to wait until morning care was completed before taking the medications. The resident was observed to take the medications. An interview with LPN #1 on 10/03/16 at 10:42 AM revealed the nurse had passed medications to Resident #15; however, the nurse stated she left the medications in the room because the resident could self-administer medications and the resident must have fallen back asleep and did not take the medications. Interview with the Director of Nursing (DON) on 10/05/16 at 3:15 PM revealed the nurse should not have left the medications unattended and observed the resident take the medications to ensure the resident did not have any problems or need any assistance. 3. Interview with the facility Pharmacist on 10/05/16 at 11:20 AM revealed the facility did not have a policy concerning expired medications. Observation of the locked drug cart in the LB Medication room [ROOM NUMBER] on 10/05/16 at 10:30 AM revealed expired medications. Resident B had four (4) Loratadine (antihistamine) ten (10) milligram (mg) tablets that expired July 2016. Interview with Registered Nurse #2 on 10/05/16 at 2:30 PM revealed the night shift nurses were responsible to remove expired medications from the medication cart. Interview with the Unit Manager on the LB Hall on 10/05/16 at 2:45 PM revealed the pharmacist or the nurses who were administering the medications were responsible to check for expired medications and remove them from the medication cart. She further revealed she had not identified any concerns with expired medications. Interview with the Pharmacist on 10/05/16 at 11:20 AM revealed the Pharmacist spot checks the medication carts for expired medications. Further interview revealed it was also the responsibility of the staff administering the medications to check the expiration date of the medications and remove the expired medications. She had not identified any concerns with expired medications. Interview with the Director of Nursing (DON) on 10/05/16 at 3:15 PM revealed the nurses administering the medications were responsible to remove the expired medications from the medication carts. Further interview with the DON revealed she had not identified any concerns with expired medications.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to inform the family and physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (1) of three (3) sampled residents (Resident #1). Resident #1 sustained a fall and was involved in an incident on 02/07/16 that resulted in his/her left hand being injured as a result of Registered Nurse (RN) #1 hitting Resident #1 on the left hand multiple times. Resident #1 was noted to have bruising and cuts to his/her left hand as a result of the incident. An allegation of physical and verbal abuse was reported to the appropriate state agencies. The facility did not contact Resident #1's physician related to the fall, or the incident that caused injury to Resident #1's left hand. In addition, the facility failed to immediately notify Resident #1's family. The resident's family was notified on 02/08/16 while visiting Resident #1. However, the family was not notified that RN #1 had hit Resident #1 during the incident, or that an allegation of abuse had been made against RN #1. The facility's failure to ensure residents' physicians and families were notified, when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention, was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled Abuse, undated, revealed if appropriate an incident report would be filled out completely documenting the incident, the nature of the incident, and where and when the incident occurred. Continued review of the facility's policy revealed if appropriate the resident's physician would be contacted to report the resident's condition and treatment as indicated. Review of the facility's policy titled Reporting Incidents, undated, revealed incidents would be documented in the facility's incident report, documenting timely notification to the physician as well as in the nurse's notes. The policy stated all attempts to notify family members must be documented on the incident report. Review of facility's policy titled Behavior Management, undated, revealed changes in mental status with or without behaviors is considered a change in medical condition of the resident and must be reported to the physician. Review of the facility's policy titled Notification of Change in the Resident's Condition, undated, revealed the nurse assigned to the resident would execute timely notification of the resident's family and physician in the event a resident sustained [REDACTED]. Continued review of the facility's policy revealed the nurse assigned to the resident would execute timely notification to the resident's family and physician in the event a resident had a change in overall physical, mental, and psychosocial status due to clinical complications or a life threatening event. The policy stated the following may be examples of clinical conditions that may justify immediate notification of the physician: resident accidents with injury; behavior or mood changes; unusual episodes of behaviors such as confusion, combativeness, and agitation; and suspected resident abuse or neglect. Further review of the policy revealed the changes in a resident's condition requiring immediate notification and response from a physician were in part based on the clinical decision-making and professional judgment of the nurse. Observation of Resident #1 on 02/16/16 at 1:05 PM revealed Resident #1 sitting in the dayroom with activity staff. Continued observation of Resident #1 revealed Resident #1 had a brown bruised area to the top of his/her left hand. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with a newly implanted defibrillator with an incision and dressing to the resident's chest and with [DIAGNOSES REDACTED]. Review of Resident #1's Short Portable Mental Status Questionnaire (SPMSQ) dated 02/05/16 revealed the facility assessed Resident #1 to have a SPMSQ score of 8 which indicated Resident #1 had moderate intellectual impairment. Review of Resident #1's Mood/Behavior Symptom Log dated 02/07/16 revealed at 4:00 AM on the same date Resident #1 had gotten up several times on the side of the bed and had been assisted back to bed. Continued review of the behavior log revealed the Safety Attendant observed Resident #1 up at the door and tried to hold Resident #1 steady and Resident #1 punched the Safety Attendant. The behavior log further stated Resident #1 was wet with urine and four (4) staff members tried to take Resident #1 back to his/her room to change him/her. The behavior log further stated that Resident #1 became very violent, he/she punched, kicked, and squeezed staff's hands and would not let go. Resident #1's behavior log stated Resident #1 continued to fight with staff and Resident #1 had RN #1's hand and was squeezing so hard and would not let go. Further review of Resident #1's behavior log revealed RN #1 managed to get her hand free and Resident #1 was dried, clothed, and taken to the lobby. Review of the nurse's notes dated from 02/05/16 to 02/16/16 revealed no documentation related to Resident #1 sustaining a fall or being hit by RN #1 on 02/07/16. There was no documented evidence in the record that the physician or the family was notified of the behaviors, the fall, or the injury to the hand. Interview with Resident #1's family member on 02/16/16 at 7:00 PM revealed she was notified on 02/08/16 that Resident #1 got up in the middle of the night on 02/07/16 and became violent and staff had to get forceful with Resident #1 and had to hold the resident. Continued interview with Resident #1's family member revealed she was told that Resident #1 got the scratches on his/her hand from where the staff had to hold him/her. Resident #1's family member reported no one from the facility reported to her that RN #1 hit Resident #1. Further interview with Resident #1's family member revealed she had noticed Resident #1's left hand was bruised on approximately one-third of his/her hand and on the wrist, but no one from the facility had reported the injury or that anyone had hit Resident #1. Interview with RN #1 on 02/16/16 at 7:29 PM revealed she was working on 02/07/16 when Resident #1 became combative. RN #1 stated she did not fill out an incident report nor did she contact Resident #1's physician or family after the incident on 02/07/16. She stated that she did not report the incident to anyone because she did not want Resident #1 to be labeled as a combative resident. Continued interview with RN #1 on 02/19/16 at 11:02 AM revealed she was not aware that Resident #1 had fallen after he/she punched the Safety Attendant. Further interview with RN #1 revealed when she first observed Resident #1, the resident was standing. RN #1 reported the Safety Attendant had not reported to her that Resident #1 had sustained a fall on 02/07/16. Interview with Licensed Practical Nurse (LPN) #4 on 02/18/16 at 1:40 PM revealed she had notified Resident #1's responsible party of the incident on the morning of 02/08/16. LPN #4 stated that she reported to the responsible party that Resident #1 had been combative the day before and he/she had held the hands of a staff member and would not let go. Further interview with LPN #4 revealed she had not notified Resident #1's responsible party of the abuse allegation related to RN #1 because the resident's family go crazy if you tell them something like this. Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM revealed staff was required to notify the resident's physician and responsible party for changes of condition. The DON stated she would only have expected staff to contact Resident #1's physician after the incident on 02/07/16, if they thought the resident needed an order for [REDACTED].#1 sustained a fall on 02/07/16. Further interview with the DON revealed the fall should have been reported. Interview with the Administrator on 02/17/16 at 3:12 PM, revealed RN #1 should have filled out an incident report and made the physician and family notifications related to the incident that occurred on 02/07/16. Continued interview with the Administrator revealed she was not aware that an incident report had not been completed and that the physician had not been notified. The Administrator said she was not aware that Resident #1's family had not been notified of the entire incident. Continued interview with the Administrator on 02/19/16 at 12:22 PM, revealed the Safety Attendant had reported to her during the investigation that Resident #1 fell prior to the incident. The Administrator said a facility fall investigation should have been conducted after Resident #1's fall and notifications should have been made to his/her physician and family. Interview with Resident #1's physician on 02/18/16 at 1:50 PM revealed he had not been notified of the incident or fall that took place on 02/07/16. Resident #1's physician stated he would have expected to be notified of the incident and of the fall. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Administrator, Assistant Administrator, Director of Nursing, and Primary Charge Nurses on Abuse and Neglect, Dealing with Combative Resident Behavior, and Investigating Abuse. 9) Beginning on 02/19/16 and concluding on 02/22/16, in-services on Abuse and Neglect, and Dealing with Combative Resident Behaviors were held. These in-services were prepared by the Infection Preventionist/Nurse Educator, and given by the Administrator, Director of Nursing, and Primary Charge Nurses to all employees. The Dealing with Combative Resident Behavior section of the in-service covered the following objectives: Identify triggers and situations that could cause a resident to become combative; Review the role of staff in managing difficult behaviors; Identify methods to protect both the resident and staff from harm; Discuss scenarios involving combative residents and how the caregiver responds; and Review strategies to help prevent behaviors from escalating. The Abuse and Neglect section of the in-service covered the following objectives: Review the definition of abuse; Discuss the seven types of abuse; Identify the signs and symptoms of abuse; Discuss the SAFE acronym; and Review the requirements of reporting abuse. The Investigating Abuse section of the in-service consisted of watching a video (Resident Abuse: Prevention and Protection Volume XXVII) and review of the revised facility's Abuse Prevention Program. At the conclusion of the in-service, three post-tests were taken covering the three sections of the in-service. The post-tests were graded to ensure each attendee learned the concepts presented. At the conclusion of these in-services 99% of all employees had taken these in-services and passed their post-tests. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires will complete the education and in-service on Abuse and Neglect/Dealing with Combative Resident Behavior before going to work. 10) On 02/19/16 - 02/22/16 the following policies and procedures were reviewed by the Medical Director, Administrator, DON, Assistant Administrator, and Primary Charge Nurses to ensure each policy reflects the intent of the regulation: a) Abuse Prevention Program b) The following policies were reviewed with no revisions. Staff was reeducated (refer to action item #13): Reporting Incidents, Protecting a Resident During an Investigation, Falls Program, Assessment and Care Plan Policy, Assessment and Care Plan Procedure, Notification of a Change in Resident's Condition, Notification of the Director of Nursing or Nursing Administrative Representative who is on call, CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff, Behavior Management, Assessment of a Resident Who Has Sustained an Injury, Accident/Incident Monitoring Policy, The Review and Signing of Care Plan After Each RAI Assessment, The following policy is a new policy created after the IJ was identified. c) Certified Nursing Assistant (CNA) Resident Behavior Monitoring - This policy was created to provide structure in the monitoring of resident behavior. A CNA Resident Behavior Monitoring Log was created to be placed in the Clinical Flow Record for residents who have shown aggressive behaviors. The CNA Documentation will be monitored daily by the nurse who will make changes to the care plan as needed and notify the physician, pharmacy, and Social Services as needed. 11) On 02/23/16, in-services began on the policies and procedures as listed in Action Item #12 for all Nursing staff (including RNs, LPNs, CMAs, SRNAs, and Safety Attendants). The in-services were prepared and taught by the Director of Nursing. The in-services will conclude on Wednesday, 02/24/16. For the in-services, the policies and procedures were organized in sections as they related to deficient practices in the tags identified when the immediate jeopardy was received. Section II of the in-service covered notification. In Section II, the Director of Nursing reviewed the Notification of a Change in the Resident's Condition Policy, The Notification of the Director of Nursing or Nursing Administrative Representative Who Is on Call Policy, and the CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff Policy. For Section II, the DON focused on informing the resident, consulting with physician, and notifying the resident's legal representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Section III of the in-service covered Abuse. In Section III, the Director of Nursing reviewed the Protecting a Resident During an Investigation Policy, and the Abuse Policy covered in Action Item #11. For Section III, the DON focused on the resident's right to be free from all abuse, the facility's obligation to develop and implement an abuse prevention program, the facility's duty to prevent abuse, and the facility's duty to investigate abuse and prevent further abuse during an investigation. As part of the review on abuse, the Director of Nursing asked all attendees if they were aware of any new allegations of abuse. There were no new allegations of abuse reported. Any new allegations of abuse would be investigated immediately according to the facility's Abuse Prevention Program. The Director of Nursing also reminded the staff that abuse is to be reported immediately by reporting it to their immediate supervisor. If action is not taken they are to follow the chain of command by reporting immediately to the Director of Nursing and the Administrator. Section IV of the in-service covered falls and other incidents/accidents. In Section IV, the Director of Nursing reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, and the Falls Program. For Section IV, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment, the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. Section V of the in-service covered appropriate care plan revisions. (Reference Tag F280) In Section V, the Director of Nursing reviewed the Assessment and Care Plan Policy, the Assessment and Care Plan Procedure, and the Review and Signing of Care Plans After Each RAI Assessment Policy. For Section V, the Director of Nursing focused on periodically reviewing and revising the care plan and what types of actions require care plan revisions. The DON discussed that it was the nurses' responsibility to make the necessary care plan revisions and the importance of doing so timely. The DON reviewed that the nurse would make revisions after every accident/incident including but not limited to falls, skin tears, episodes of behavior, and other injuries. The DON reviewed that the MDS Nurse reviewed and revised care plans with every significant change and quarterly. Section VI of the in-service covered quality of care. (Reference Tag F309) In Section VI, the Director of Nursing again reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, the Falls Program, the CNA Resident Behavior Monitoring Policy and Log, and the Behavior Management Policy. For Section VI, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment (to be completed immediately), the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. For Section VI, the Director of Nursing also focused on identifying behaviors and making changes to the Care Plan and Clinical Flow Record to prepare staff to deal with resident behaviors effectively, and prevent them when possible. The DON reminded staff that when there is an incident of behavior that results in a fall or injury they still must follow the processes and complete all assessments mentioned above. At the conclusion of the in-service post-tests were taken by each nurse attending the in-service. The post-tests were graded to ensure that each nurse attendee learned the concepts presented. At the conclusion of the in-service 99% of the Nursing Department employees had attended the in-service. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires in the Nursing Department will complete the education and in-service on these policies and procedures before going to work. 12) Beginning on 02/24/16 The following QAPI audits will be utilized daily to ensure compliance with all of the above actions: Employee Knowledge of Abuse Policy QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nursing employees on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts. The audit will also include having every employee read and resign the revised Abuse Policy. As part of the audit each employee will be asked if they are aware of or have witnessed any abuse. Any issues identified as abuse will be thoroughly investigated as outlined in our Abuse Prevention Program. Reporting Incidents/Accidents, Falls, Notification of Physician/Family, CP Updates QAPI AUDIT: This audit will be performed daily by the Director of Nursing covering 100% of reportable Incidents/Accidents and Falls. This audit will include reviewing that all incident/accidents are reported correctly and that the appropriate assessments are completed, the appropriate notifications are made, and the appropriate revisions are made to the care plan. For the purpose of this audit, information will be gathered from the resident's medical record, incident/accident reports, board charting, completed assessments, and the care plan. Any issues identified will be corrected immediately by the Director of Nursing and reported to the Administrator. CNA/Ancillary Employee Knowledge of Reporting/Behaviors QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of SRNAs on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing staff and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with aggressive/combative resident behaviors. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Nurse Knowledge of Fall/Accident/Injury/Behavior QAPI Audit. This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nurses on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing nurses and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with Fall/Accident Injury/Behavior. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Falls QAPI Audit: This audit will be performed daily by the Director of Nursing covering 100% of all Resident Falls until the removal of the immediate jeopardy. This audit will gather information from the accident/incident report, completed assessments, root cause analysis, 72 Hour post fall assessment, and care plan. Any issues identified will be corrected immediately and reported to the Administrator. Body Mapping QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of Residents until the removal of the immediate jeopardy. This audit will include a daily Head to Toe Assessment of each resident utilizing the Body Mapping Diagram. Any issues identified will be corrected immediately and reported to the Administrator. Mood and Behavior Log QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of all Residents until the removal of the immediate jeopardy. This audit will include reviewing the resident's medical record and mood and behavior logs and ensuring the Care Plan and Clinical Flow Record reflect any necessary interventions. Any issues identified will be corrected immediately and reported to the Administrator. Quality Assurance Resident Interview - Staff Form QAPI Audit: This audit will be performed daily by the Social Service Workers who will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. The interview will include questions on resident rights, and abuse and neglect. Any report of abuse will be thoroughly investigated and reported immediately according to the Abuse Prevention Program. The Social Service workers will address every non-abuse negative comment or response by referring them to the appropriate department and continuing to follow up daily until negative responses are resolved. The Administrator

Based on observation, interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #1) from physical and verbal abuse. On 02/07/16 at approximately 4:00 AM, Resident #1 was observed standing in the doorway of his/her room and was approached by a Safety Attendant who touched Resident #1's elbow in an attempt to redirect the resident back into the room. Resident #1 punched the Safety Attendant causing the Safety Attendant to fall backward and causing Resident #1 to lose his/her balance and fall. The Safety Attendant summoned assistance and Registered Nurse (RN) #1, State Registered Nurse Aide (SRNA) #1, and SRNA #2 responded to assist the Safety Attendant. The staff was attempting to get Resident #1 to sit in a wheelchair but the resident refused. RN #1 then placed her leg behind Resident #1's leg and forced the resident to sit in the wheelchair. Staff then assisted Resident #1 back into his/her room. Resident #1 was standing with SRNA #1 to his/her right side and RN #1 to his/her left side to steady him/her while SRNA #2 attempted to change Resident #1's incontinence brief. Resident #1 began to squeeze SRNA #1 and RN #1's hands tightly. RN #1 began yelling and cursing and then started hitting Resident #1's left hand with her right hand multiple times. Resident #1 let go of RN #1's hand and then refused to sit down in the wheelchair again. RN #1 then pushed Resident #1 on the chest forcing the resident to sit down in the wheelchair. RN #1 then told the SRNAs to Get (Resident #1) the hell out of my face! The facility conducted an investigation and suspended RN #1 during the investigation. However, the facility concluded RN #1's actions toward Resident #1 were due to RN #1's fear of personal injury with no mention of verbal abuse. RN #1 was permitted to work for approximately three (3) hours after the alleged abuse occurred on 02/07/16. The facility allowed RN #1 to return to work and provide direct resident care on 02/11/16, 02/12/16, and 02/16/16. The facility's failure to ensure residents were protected from abuse was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled Abuse, undated, revealed residents had the right to be free from verbal, sexual, physical, and mental abuse. Further review of the policy revealed the facility did not permit any mistreatment or abuse of any resident. Continued review of the policy revealed any observation or allegation of abuse was to be reported immediately to a supervisor and then to the administrator. The policy stated abuse or potential abuse would be prevented while the investigation was in progress. Continued review of the facility's policy revealed if the alleged violation was verified, appropriate corrective action would be taken. The appropriate action to be taken could include but was not limited to termination of employment and criminal prosecution. The facility's policy defined physical abuse as doing something with the intention of causing physical pain or injury to a resident. According to the facility's policy, some examples of physical abuse would be hitting, scratching, biting, slapping, and punching. Further review of the policy revealed bruising, scratches, and cuts would be some examples of possible signs of physical abuse. The facility's policy defined psychological abuse as the threat of injury, unreasonable confinement and punishment, or verbal intimidation and humiliation that may result in mental anguish. The policy stated using insults, using demeaning language, yelling, screaming, and prohibiting free choice to be examples of psychological abuse. The policy did not define verbal abuse. Review of the facility's policy titled Behavior Management, undated, revealed changes in mental status with or without behaviors was considered a change in medical condition of the resident and must be reported to the physician. Further review of the policy revealed staff should approach residents with violent behaviors by using a pillow, blanket, or towels to cover their arms, chest, and face for protection. The policy stated staff was to defend themselves by blocking blows with covered arms crossed in front of them and should avoid grabbing at the resident or yelling loudly. Further review of the facility's policy revealed staff should not rush upon the resident too fast and should ask for permission to touch the resident. Observation of Resident #1 on 02/16/16 at 1:05 PM revealed Resident #1 sitting in the dayroom with activity staff. Continued observation of Resident #1 revealed Resident #1 had a brown bruised area to the top of his/her left hand. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed Resident #1 had been admitted to the facility with a newly implanted defibrillator with an incision and dressing to the resident's chest. Review of Resident #1's History and Physical from a local acute care hospital dated 01/31/16 revealed Resident #1 had been experiencing hallucinations at times. Review of Resident #1's Nursing Admission History and assessment dated [DATE] revealed Resident #1 was oriented to person with slow comprehension. Review of Resident #1's Short Portable Mental Status Questionnaire (SPMSQ) dated 02/05/16 revealed the facility had assessed Resident #1 to have a SPMSQ score of 8 which indicated Resident #1 had moderate intellectual impairment. Review of Resident #1's Admission Care Plan dated 02/05/16 revealed the facility had identified behavioral symptoms related to Resident #1 attempting to get out of bed without assistance and having episodes of restlessness. The interventions to address the behavioral symptoms included keeping the environment calm and relaxed and to encourage diversional activities. The Admission Care Plan further stated that Resident #1 had potential for loss of skin integrity and/or bruising related to loss of muscle mass, loss of adipose tissue, ageing process, and medication side effects with interventions to include: provide a safe environment, to educate staff or family in the correct way of handling/positioning residents to prevent skin tears, to protect resident from self-injury or injury during routine care. Continued review of Resident #1's Admission Care Plan revealed the facility had identified Resident #1 to have cognitive loss with interventions to include: staff to introduce self, approach in a calm manner, explain what you intend to do while providing care, and to anticipate needs and observe for non-verbal cues. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #2 notified the Administrator on 02/07/16 at approximately 8:00 AM of an allegation of abuse involving RN #1 and Resident #1. Review of the facility's investigation revealed SRNA #1, SRNA #2, and the Safety Attendant witnessed RN #1 punch Resident #1 while performing care on 02/07/16 at approximately 4:00 AM. The facility's investigation revealed RN #1 had been interviewed about the incident and she (RN #1) reported that she was afraid Resident #1 was going to break her hand because it was hurting so bad and bleeding. RN #1 stated she smacked Resident #1's hand so he/she would let go before he/she broke her hand. Continued review of the investigation revealed RN #1 stated she had thought of biting Resident #1's hand, but she did not bite the resident. RN #1 had reported this at shift change on 02/07/16. Continued review of the investigation revealed the facility had concluded that RN #1 had been a nurse for nineteen (19) years and had worked at the facility for seven and one-half (7 1/2) years. Further review of the facility's investigation revealed during RN #1's employment at the facility there had been no reports concerning abuse or inappropriate behavior toward residents or staff. The facility's investigation stated RN #1's actions toward Resident #1 were due to her fear of personal injury. Review of Resident #1's Mood/Behavior Symptom Log (MBSL) dated 02/07/16 revealed at 4:00 AM on the same date Resident #1 had gotten up several times on the side of the bed and had been assisted back into bed. Continued review of Resident #1's MBSL revealed the Safety Attendant observed Resident #1 up at the door and tried to hold Resident #1 steady and Resident #1 punched the Safety Attendant. The MBSL stated Resident #1 was wet with urine and four (4) staff members tried to take Resident #1 back to his/her room to change him/her. Continued review of Resident #1's MBSL revealed Resident #1 became very violent and punched, kicked, and squeezed staff's hands and would not let go. Resident #1's MBSL stated that Resident #1 continued to fight with staff and Resident #1 had RN #1's hand and was squeezing so hard and would not let go. Further review of Resident #1's MBSL revealed RN #1 managed to get her hand free and Resident #1 was dried, clothed, and taken to the lobby. Review of the head-to-toe skin assessment conducted on 02/07/16, after the incident occurred, revealed Resident #1 had new cuts noted to the back of his/her left hand around the thumb area and new cuts noted to his/her wrist area. The assessment also revealed Resident #1 had new bruising to the back of his/her left hand and wrist area. However, review of the nurse's notes revealed no documentation that RN #1 hit Resident #1. Review of the facility's staff assignment sheets for 02/11/16, 02/12/16, and 02/16/16 revealed RN #1 had worked as the Charge Nurse on the unit where Resident #1 resided. Interview with the facility's Safety Attendant on 02/16/16 at 6:05 PM revealed she was making rounds to check on residents on the morning of 02/07/16 and noticed Resident #1 standing in the doorway of his/her room at approximately 4:00 AM. Further interview with the Safety Attendant revealed she had approached Resident #1 and took him/her by the elbow and attempted to redirect Resident #1 back into his/her room. Continued interview with the Safety Attendant revealed Resident #1 turned and punched her in the neck, knocking her down, and then Resident #1 lost his/her balance and fell down. The Safety Attendant stated Resident #1 fell and attempted to get up. She stated she was able to talk Resident #1 into sitting down on the floor until she could get some help for the resident. Continued interview with the Safety Attendant revealed she yelled for help and RN #1 came to help her. The Safety Attendant stated she and RN #1 assisted Resident #1 up from the floor. Further interview with the Safety Attendant revealed at this time SRNA #1 and SRNA #2 had come to help them with Resident #1. The Safety Attendant stated she left Resident #1's room to get a blanket and draw sheet and when she returned to Resident #1's room, SRNA #1 had Resident #1's right hand and RN #1 had the resident's left hand to steady Resident #1 while other staff was performing care. Continued interview with the Safety Attendant revealed Resident #1 was squeezing SRNA #1's and RN #1's hand very tightly. The Safety Attendant stated she observed RN #1 tapping Resident #1's left hand with her right hand using a closed fist. The Safety Attendant reported she was unsure of how many times RN #1 had hit Resident #1. Further interview with the Safety Attendant revealed RN #1 had leaned down like she was going to bite Resident #1's hand. However, she was not sure that RN #1 actually bit Resident #1. Continued interview with the Safety Attendant revealed she did not witness RN #1 curse or push Resident #1 down in the wheelchair. However, the Safety Attendant did hear RN #1 tell the other staff to get Resident #1 out of the room. The Safety Attendant stated after the incident occurred, RN #1's hand and Resident #1's hand were bleeding. Continued interview with the Safety Attendant revealed she observed Resident #1's hand the following night on 02/08/16 and it appeared bruised on his/her knuckles. Interview with Registered Nurse (RN) #1 on 02/16/16 at 7:29 PM revealed she was in the medication room on the morning of 02/07/16 preparing medications and heard someone yell for help. RN #1 stated when she went into the hallway she observed the Safety Attendant standing near Resident #1. The Safety Attendant reported to RN #1 that Resident #1 had hit her in the neck after she had tried to redirect him/her back into his/her room. Continued interview with RN #1 revealed she had Resident #1's left hand and SRNA #1 had Resident #1's right hand while he/she was standing up to get Resident #1's incontinence brief changed. RN #1 stated Resident #1 began to squeeze her hand as hard as he/she could. Further interview with RN #1 revealed she attempted to talk to Resident #1 to try to get him/her to release her hand. RN #1 stated she tried to take her right hand and pry Resident #1's fingers away from her hand but she was unable to do so. Continued interview with RN #1 revealed when she was able to get her left hand free, Resident #1 grabbed her right hand. Further interview with RN #1 revealed she took her left hand and lightly smacked Resident #1's left hand trying to get Resident #1 to let go of her hand. RN #1 denied hitting Resident #1 with a closed fist. RN #1 stated she used an open hand and was smacking Resident #1 with the palm of her hand. RN #1 reported she thought about biting Resident #1, but denied actually biting Resident #1 or attempting to bite Resident #1. RN #1 denied pushing or forcing Resident #1 into a wheelchair and denied saying anything about getting Resident #1 discharged from the facility. She also denied causing any injury to Resident #1's hand during the incident. RN #1 stated she was trained that it was not acceptable to hit a resident under any circumstances, and did not believe her act of hitting Resident #1 was abuse. RN #1 stated she could not remember if she cursed at Resident #1 during the incident. Further interview with RN #1 revealed if this happened again she may respond in the same way, but she was not sure. Review of Resident #2's (Resident #1's roommate) medical record revealed the facility admitted Resident #2 on 01/07/16 with [DIAGNOSES REDACTED]. Review of Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #2 was cognitively intact and interviewable. Interview with Resident #2 on 02/16/16 at 7:05 PM revealed he/she was awakened on 02/07/16 but he/she was unsure of the time. Resident #2 stated he/she observed a nurse hit Resident #1. Continued interview with Resident #2 revealed he/she did not know the nurse, but he/she was scared when he/she observed his/her roommate being hit. Further interview with Resident #2 revealed he/she heard the nurse curse at Resident #1 and say, You won't do it again! Interview with SRNA #1 on 02/16/16 at 4:03 PM revealed she worked the night shift (7:00 PM to 7:00 AM) from 02/06/16 to 02/07/16 and heard a disturbance around 4:00 AM on the morning of 02/07/16. Further interview with SRNA # 1 revealed she observed RN #1 and the Safety Attendant near Resident #1's room. The Safety Attendant reported to her that Resident #1 had punched her in the throat. Continued interview with SRNA #1 revealed RN #1 attempted to get Resident #1 into a wheelchair. SRNA #1 stated when Resident #1 refused to sit in the wheelchair, RN #1 placed her leg behind Resident #1's leg in order to force Resident #1 down in the wheelchair. Continued interview with SRNA #1 revealed while staff was performing care for Resident #1, she was on one side of Resident #1 and RN #1 was on the other side of the resident and they were both holding Resident #1's hand in order to steady the resident while the resident stood and another staff person changed the resident's incontinence brief. Further interview with SRNA #1 revealed Resident #1 began to squeeze her hand and RN #1's hand at the same time while saying, I'm sorry, I don't mean it. SRNA #1 reported she did not believe Resident #1 was trying to hurt them on purpose. Continued interview with SRNA #1 revealed RN #1 began cursing at Resident #1 and then proceeded to punch Resident #1's hand three (3) or four (4) times with a closed fist. SRNA #1 stated that RN #1 leaned down toward Resident #1 like she was going to bite him/her. However, SRNA #1 stated she was not sure if RN #1 actually bit Resident #1. SRNA #1 stated that once Resident #1 had let go of RN #1's hand, RN #1 pushed Resident #1 on the chest area in order to force the resident back down in the wheelchair. SRNA #1 reported RN #1 told her and the other staff present to get (Resident #1) the hell out of my face! Interview with SRNA #2 on 02/16/16 at 4:29 PM revealed she had worked the night shift (7:00 PM to 7:00 AM) on 02/06/16 to 02/07/16. SRNA #2 stated that while she was doing her rounds to check on the residents she heard someone yell for help. Continued interview with SRNA #2 revealed when she went to Resident #1's room she observed Resident #1 standing in the doorway of his/her room. Further interview with SRNA #2 revealed when she got to Resident #1's room, RN #1 and the Safety Attendant were in the hallway in front of Resident #1's room. SRNA #2 stated that she had observed RN #1 place her leg behind Resident #1's leg and knock Resident #1's leg out from under him/her forcing Resident #1 down in the wheelchair when Resident #1 refused to sit down. Continued interview with SRNA #2 revealed once they got Resident #1 into his/her room they assisted him/her up in order to change his/her incontinence brief. SRNA #2 stated SRNA #1 was on one side of Resident #1 and RN #1 was on the other side to steady Resident #1 while she was changing the resident's incontinence brief. Further interview with SRNA #2 revealed Resident #1 began squeezing SRNA #1's hand and RN #1's hand. SRNA #2 stated RN #1 punched Resident #1's hand with her closed fist three (3) or four (4) times. SRNA #2 stated she observed RN #1 bend down toward Resident #1 like she was going to bite him/her, but did not actually see RN #1 bite Resident #1. Further interview with SRNA #2 revealed after Resident #1 let go of RN #1's hand RN #1 pushed Resident #1 on the chest forcing the resident to sit down in the wheelchair. Continued interview with SRNA #2 revealed RN #1 told her and other staff to get (Resident #1) the hell out of my face! She stated that RN #1 stated she was going to make sure that Resident #1 was discharged from the facility. SRNA #2 told RN #1 that Resident #1's hand was bleeding after the incident had occurred. Further interview with SRNA #2 revealed RN #1 stated the blood on Resident #1's hand was her (RN #1's) blood and did not assess the resident. Interview with SRNA #3 on 02/16/16 at 5:32 PM revealed she worked on 02/07/16, and heard SRNA #1 yell for her to come and assist with Resident #1. Continued interview with SRNA #3 revealed she assisted SRNA #1 in providing care for Resident #1's hand that was bleeding. SRNA #3 stated Resident #1's hand was bleeding from three (3) different places around his/her thumb and index finger. Continued interview with SRNA #3 revealed Resident #1 had dark places on top of his/her hand that went up to his/her wrist. SRNA #3 stated Resident #1's hand appeared very bruised and was purple in color on 02/08/16. Further interview with SRNA #3 revealed Resident #1 had complained to her that he/she was having some chest pain after the incident had occurred. SRNA #3 stated she reported Resident #1's chest pain to Licensed Practical Nurse (LPN) #1 on 02/07/16. Interview with Licensed Practical Nurse (LPN) #1 on 02/16/16 at 6:34 PM revealed SRNA #3 had not reported to her that Resident #1 had complained of chest pain after the incident occurred. Interview with LPN #2 on 02/17/16 at 11:36 AM revealed when she came in to work on the morning of 02/07/16 SRNA #1 and SRNA #2 reported what RN #1 had done to Resident #1. LPN #2 reported when she examined Resident #1's hand on the morning of 02/07/16, she observed cuts and bruising to his/her hand that she considered consistent with being punched by someone wearing rings. Further interview with LPN #2 revealed she had been trained that it was never acceptable to hit a resident under any circumstances. Continued interview with LPN #2 on 02/17/16 at 5:07 PM revealed on the morning of 02/07/16 she had observed Resident #1's left hand to be bruised from the knuckles up to the wrist. Further interview with LPN #2 revealed Resident #1's hand had a dark purple, almost black looking bruise to the top of it. Further interview with LPN #2 on 02/17/16 at 5:30 PM revealed the bruised area on Resident #1 (observed on 02/16/16) that had begun to fade was the same area where she had observed the bruising on 02/07/16 after the incident had occurred. Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM revealed she had been notified of the allegation of abuse on the morning of 02/07/16 and was on her way to the facility to assist with the investigation and had a family emergency. Continued interview with the DON revealed she and the Administrator had talked to RN #1 and discussed with her how she could have handled the situation differently. The DON reported RN #1 was suspended during the facility's investigation and the Administrator made the decision to permit RN #1 to return back to work. Further interview with the DON revealed she did not consider RN #1 hitting Resident #1 to be abuse because RN #1 had the right to protect herself and try to get away from a resident that was breaking her hand. The DON stated that it was not okay for staff to hit a resident. Interview with the Administrator on 02/17/16 at 3:12 PM revealed she had been notified of the allegation of abuse by LPN #2 at approximately 8:00 AM on 02/07/16. The Administrator reported she immediately contacted RN #1 and notified her that she was suspended from work until further notice. The Administrator stated that she observed Resident #1's left hand to be red on the knuckles and to have either cuts or abrasions present. Continued interview with the Administrator revealed she and the DON met and reviewed RN #1's employee file and had a discussion with RN #1 about how she could have handled the incident differently. The Administrator reported RN #1 told her that she had smacked Resident #1's hand during the incident, but didn't use the word hit. Continued interview with the Administrator revealed she, the DON, and the Unit Manager had conducted the investigation and that she had not unsubstantiated the abuse allegation, but had determined RN #1 had done what she had to do in order to protect herself. However, she stated that it was never acceptable to hit a resident. Continued interview with the Administrator revealed she had been the one who made the decision to allow RN #1 to come back to work. She stated the facility did not have any written criteria that must be met in order for an employee accused of abuse to return back to work. Interview with the Administrator on 02/17/16 at 5:01 PM revealed she did not make a determination of substantiated or unsubstantiated when concluding the facility's investigation. She stated the facility's policy was to wait until Adult Protective Services (APS) had concluded their investigation before determining if an employee named in an allegation would be permitted to return to work. However, the Administrator felt like it was taking too long for an APS investigation and decided to allow RN #1 to return to work before the APS investigation was completed. Further interview with the Administrator on 02/18/16 at 1:05 PM revealed RN #1 had received training on how to handle residents with Dementia on 02/23/11, during RN #1's previous employment at the facility. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Adminis

Based on interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to ensure an allegation of physical and verbal abuse was immediately reported to the administrator of the facility, failed to ensure allegations of abuse were thoroughly investigated, and failed to protect residents from further abuse for one (1) of three (3) sampled residents (Resident #1). On 02/07/16 at approximately 4:00 AM, Resident #1 punched a Safety Attendant in the throat when the Safety Attendant attempted to redirect the resident. Resident #1 and the Safety Attendant both fell to the floor during the incident; the Safety Attendant called out for assistance. Registered Nurse (RN) #1, State Registered Nurse Aide (SRNA) #1, and SRNA #2 responded to assist the Safety Attendant. While staff was assisting the resident, Resident #1 began to squeeze the hands of RN #1 and SRNA #1. RN #1 was observed by the other staff to yell, curse, and begin hitting Resident #1's hand with a closed fist, leaving scratches and bruises. Resident #1 let go of RN #1's hand, but refused to sit down in the wheelchair. At that time, RN #1 pushed Resident #1 on the chest forcing the resident to sit in the wheelchair. Review of Resident #1's Discharge Summary from a local acute care hospital dated 02/05/16 revealed Resident #1 had gotten his/her cardioverter-defibrillator generator replaced while at the hospital. RN #1 then told the SRNAs to get (Resident #1) the hell out of my face! The incident on 02/07/16 was witnessed by the Safety Attendant, SRNA #1, and SRNA #2. However, the staff failed to immediately report the incident to the Administrator. The abuse allegation was reported to the Administrator at approximately 8:00 AM on 02/07/16, approximately four (4) hours after the incident occurred. The facility initiated an investigation and RN #1 was notified that she was suspended from employment during the investigation. The facility failed to interview Resident #1's Roommate as part of the investigation, and failed to interview any other residents regarding RN #1. Furthermore, interview with the Administrator revealed she did not conclude the investigation to determine whether the allegation of abuse was substantiated or unsubstantiated, but allowed RN #1 to return to work. The facility failed to protect residents of the facility from potential abuse. The facility's failure to immediately report the allegation of physical and verbal abuse to the administrator, failure to conduct a thorough investigation into the incident that occurred on 02/07/16, and failure to protect residents from further abuse was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled Abuse, undated, revealed any observation or allegation of abuse was to be reported immediately to a supervisor and then to the administrator. Continued review of the facility's policy revealed the Administrator and Director of Nursing would do a thorough investigation by interviewing staff, family, and residents who were involved or may have knowledge of the incident. The policy stated further abuse or potential abuse would be prevented while the investigation was in progress, but it did not say how that would be accomplished. Further review of the policy revealed if appropriate an incident report would be filled out completely documenting the incident, the nature of the incident, and where and when the incident occurred. The policy stated if the alleged violation was verified, appropriate corrective action would be taken. The appropriate action to be taken could include but was not limited to termination of employment and criminal prosecution. Further review of the facility's policy revealed the definition of physical abuse was doing something with the intention of causing physical pain or injury to a resident. According to the facility's policy, some examples of physical abuse were hitting, scratching, biting, slapping, and punching. Further review of the policy revealed bruising, scratches, and cuts were some examples of possible signs of physical abuse. The policy defined psychological abuse as the threat of injury, unreasonable confinement and punishment, or verbal intimidation and humiliation that may result in mental anguish. The policy stated insults, using demeaning language, yelling, screaming, and prohibiting free choice were examples of psychological abuse. Review of the facility's policy titled Reporting Incidents, undated, revealed reportable occurrences which included physical abuse, verbal abuse, or other incidents that involve mistreatment, neglect, or abuse were to be reported immediately to the Administrator. Continued review of the policy revealed reportable occurrences included any aspect of resident care where potential or actual injury occurred. Review of a facility investigation dated 02/07/16 revealed Licensed Practical Nurse (LPN) #2 reported that RN #1 hit Resident #1 on 02/07/16 at approximately 4:00 AM. The investigation stated that SRNA #1 and SRNA #2 reported to LPN #2 that Resident #1 became aggressive and RN #1 punched the resident's hand to get the resident to let go of her. The facility's investigation revealed RN #1 was interviewed about the incident and reported that she (RN #1) was afraid Resident #1 was going to break her hand because it was hurting and bleeding. RN #1 reported she smacked Resident #1's hand so he/she would let go before Resident #1 broke her hand. Continued review of the facility's investigation revealed RN #1 reported she had thought of biting Resident #1's hand, but she did not bite the resident. RN #1 reported this at shift change on 02/07/16 to LPN #4. Further review of the facility's investigation revealed the facility concluded that during RN #1's employment at the facility there had been no reports concerning abuse or inappropriate behavior toward residents or staff and RN #1's actions toward Resident #1 were due to fear of personal injury. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with [DIAGNOSES REDACTED]. Review of Resident #1's History and Physical from a local acute care hospital dated 01/31/16 revealed Resident #1 had been experiencing hallucinations at times. Review of Resident #1's Nursing Admission History and assessment dated [DATE] revealed Resident #1 was oriented to person with slow comprehension. Review of Resident #1's Short Portable Mental Status Questionnaire (SPMSQ) dated 02/05/16 revealed the facility had assessed Resident #1 to have a SPMSQ score of 8 which indicated Resident #1 had moderate intellectual impairment. Review of Resident #1's Admission Care Plan dated 02/05/16 revealed the facility had identified behavioral symptoms related to Resident #1 attempting to get out of bed without assistance and to have episodes of restlessness. The interventions to address the behavioral symptoms included keeping the environment calm and relaxed and to encourage diversional activities. The Admission Care Plan further stated that Resident #1 had potential for loss of skin integrity and/or bruising related to loss of muscle mass, loss of adipose tissue, ageing process, and medication side effects with interventions to include providing a safe environment, to educate staff or family in the correct way of handling/positioning residents to prevent skin tears, and to protect the resident from self-injury or injury during routine care. Continued review of Resident #1's Admission Care Plan revealed the facility had identified Resident #1 to have cognitive loss. Interventions included: staff to introduce self, approach in a calm manner, explain what you intend to do while providing care, and anticipate needs and observe for non-verbal cues. Review of Resident #1's initial Body Mapping Diagram conducted upon admission on 02/05/16 revealed Resident #1 had an unmeasured bruise to the left hand around the base of his/her thumb. Review of Resident #1's Mood/Behavior Symptom Log (MBSL) dated 02/07/16 revealed at 4:00 AM on the same date Resident #1 had gotten up several times on the side of the bed and had been assisted back into bed. Continued review of Resident #1's MBSL revealed the Safety Attendant observed Resident #1 up at the door and tried to hold Resident #1 steady and Resident #1 punched the Safety Attendant. The MBSL stated Resident #1 was wet with urine and four (4) staff members tried to take Resident #1 back to his/her room to change Resident #1. Continued review of Resident #1's MBSL revealed Resident #1 became very violent and punched, kicked, and squeezed staff's hands and would not let go. Resident #1's MBSL stated Resident #1 continued to fight with staff and Resident #1 had RN #1's hand and was squeezing so hard and would not let go. Further review of Resident #1's MBSL revealed RN #1 managed to get her hand free and Resident #1 was dried, clothed, and taken to the lobby. Review of the head-to-toe skin assessment conducted on 02/07/16, after the incident occurred, revealed Resident #1 had new cuts noted to the back of his/her left hand around the thumb area, had new cuts noted to his/her wrist area, and had new bruising to the back of his/her left hand and wrist area. Review of the nurse's notes revealed no documentation that RN #1 hit Resident #1. Interview with SRNA #1 on 02/16/16 at 4:03 PM revealed she worked third shift (7:00 PM to 7:00 AM) from 02/06/16 to 02/07/16 and heard a disturbance around 4:00 AM on the morning of 02/07/16. Continued interview with SRNA #1 revealed while staff was performing care for Resident #1, she was on one side of Resident #1 and RN #1 was on the other side of Resident #1, they both were holding Resident #1's hand to steady the resident while they were standing. Further interview with SRNA #1 revealed Resident #1 began to squeeze her hand and RN #1's hand at the same time while saying, I'm sorry, I don't mean it. SRNA #1 reported she did not believe Resident #1 was trying to hurt them. Continued interview with SRNA #1 revealed RN #1 began cursing at Resident #1 and then proceeded to punch Resident #1's hand three (3) or four (4) times with a closed fist. SRNA #1 stated that RN #1 leaned down toward Resident #1 like she was going to bite the resident, but SRNA #1 stated she was not sure if RN #1 actually bit Resident #1. SRNA #1 stated that once Resident #1 had let go of RN #1's hand she pushed Resident #1 on the chest area, forcing the resident down in the wheelchair. SRNA #1 reported RN #1 cursed and told her and the others present to get Resident #1 out of the room. She stated she told RN #1 that Resident #1's hand was injured during the incident. Further interview with SRNA #1 revealed she had been trained to report abuse to her supervisor immediately, but she did not immediately report this incident due to being afraid of RN #1. SRNA #1 stated she reported the incident to RN #2 as RN #2 was coming in to work on 02/07/16. Interview with SRNA #2 on 02/16/16 at 4:29 PM revealed she worked the night shift (7:00 PM to 7:00 AM) from 02/06/16 to 02/07/16. SRNA #2 stated that while she was conducting rounds to check on the residents, she heard someone yell for help. Continued interview with SRNA #2 revealed when she went to Resident #1's room and observed Resident #1 standing in the doorway of his/her room. SRNA #2 stated that she observed RN #1 place her leg behind Resident #1's leg and push Resident #1's leg out from under him/her, causing the resident to fall into the wheelchair because the resident refused to sit in the wheelchair. Further interview with SRNA #2 revealed Resident #1 began squeezing SRNA #1's hand and RN #1's hand, while staff was providing incontinence care. SRNA #2 stated RN #1 punched Resident #1's hand with her closed fist three (3) or four (4) times. SRNA #2 stated she observed RN #1 bend down toward Resident #1 like she was going to bite the resident, but did not actually see RN #1 bite Resident #1. Further interview with SRNA #2 revealed after Resident #1 had released RN #1's hand, RN #1 pushed Resident #1 on the chest (resident recently had his/her cardioverter-defibrillator generator replaced while at the hospital) forcing Resident #1 to sit down in the wheelchair. Continued interview with SRNA #2 revealed she heard RN #1 curse and tell other staff to get Resident #1 out of her sight and that she was going to make sure that Resident #1 was discharged from the facility. SRNA #2 told RN #1 that Resident #1's hand was bleeding after the incident occurred. Continued interview with SRNA #2 revealed she had been trained to report abuse immediately to her supervisor and that it was never okay under any circumstances to hit a resident. SRNA #2 stated she did not report the allegation of abuse immediately after it occurred due to being intimidated by RN #1. Further interview with SRNA #2 revealed she did not report the alleged abuse to anyone until approximately 8:00 AM on 02/07/16 when she reported it to LPN #2. Interview with SRNA #3 on 02/16/16 at 5:32 PM revealed she worked on 02/07/16 and heard SRNA #1 yell for her to come and help SRNA #1 with Resident #1. SRNA #3 stated she did not see the incident and did not see RN #1 hit Resident #1, but she assisted SRNA #1 to clean Resident #1's hand that was bleeding. SRNA #3 stated Resident #1's hand was bleeding from three (3) different places around his/her thumb and index finger. Continued interview with SRNA #3 revealed Resident #1 had dark places on top of his/her hand that went up to his/her wrist. SRNA #3 stated Resident #1's hand appeared bruised and was purple in color on 02/08/16. SRNA #3 stated she had been trained to report abuse immediately. However, she did not think she should have reported the abuse allegation because she did not actually witness what occurred. Interview with the facility Safety Attendant on 02/16/16 at 6:05 PM revealed she was making rounds to check on residents on the morning of 02/07/16 and found Resident #1 standing at the door of his/her room. The Safety Attendant stated when she tried to redirect Resident #1, the resident punched her and they both fell to the floor. The Safety Attendant stated she called for assistance, and RN #1 came to assist her to get Resident #1 up from the floor. The Safety Attendant stated when she returned to Resident #1's room after getting supplies to change the resident's brief, SRNA #1 was holding Resident #1's right hand and RN #1 had his/her left hand to steady Resident #1 while other staff was performing care. The Safety Attendant stated Resident #1 was squeezing SRNA #1 and RN #1's hands very tightly. The Safety Attendant stated she observed RN #1 tapping Resident #1's left hand with her right hand using a closed fist. She stated she was unsure of how many times RN #1 hit Resident #1. The Safety Attendant further stated RN #1 leaned down like she was going to bite Resident #1's hand, but she did not know if RN #1 actually bit Resident #1. The Safety Attendant stated after the incident occurred, RN #1's hand and Resident #1's hand were bleeding. She stated she was trained to report abuse to her supervisor immediately, but did not report the incident because RN #1 had advised her that she (RN #1) was going to contact the facility Director of Nursing (DON) about the incident. Continued interview with the Safety Attendant on 02/18/16 at 1:50 PM revealed she had not considered reporting the abuse allegation to the charge nurse on call because she thought RN #1 would report it. Interview with Licensed Practical Nurse (LPN) #1 on 02/16/16 at 6:34 PM revealed SRNA #1 and SRNA #3 had come to her and requested some bandages on 02/07/16. LPN #1 stated she did not notice any injury to Resident #1's hand and did not ask SRNA #1 and SRNA #3 why they needed bandages. Further interview with LPN #1 revealed initially no one had reported an allegation of abuse to her and she was not aware that any abuse had occurred. LPN #1 reported that RN #1 told her that she had thought about biting Resident #1 during the incident, but had changed her mind. Further interview with LPN #1 revealed she had been trained to report abuse immediately. LPN #1 reported once she had been made aware of the allegation she did not report the abuse allegation to anyone because RN #1 had told her that she was going to contact the DON about the incident with her and Resident #1. Interview with Registered Nurse (RN) #1 on 02/16/16 at 7:29 PM revealed she was holding Resident #1's left hand and SRNA #1 was holding Resident #1's right hand while the resident was standing up to get Resident #1's incontinence brief changed. RN #1 stated Resident #1 began to squeeze her hand as hard as he/she could. Further interview with RN #1 revealed she attempted to talk to Resident #1 to try to get him/her to release her hand. RN #1 stated she tried to take her right hand and pry Resident #1's fingers away from her hand but was unable to do so. Continued interview with RN #1 revealed when she was able to get her left hand free, Resident #1 grabbed her right hand. RN #1 stated she took her left hand and lightly smacked Resident #1's left hand trying to get Resident #1 to let go of her hand. RN #1 denied hitting Resident #1 with a closed fist. RN #1 stated she used an open hand and was smacking Resident #1 with the palm of her hand. Further interview with RN #1 revealed she did not fill out an incident report or report the incident to anyone because she did not want Resident #1 to be labeled as a combative resident. RN #1 said she thought about biting Resident #1, but denied actually biting Resident #1 or attempting to bite Resident #1. RN #1 denied saying anything about getting Resident #1 discharged from the facility. Further interview with RN #1 revealed SRNA #1 and SRNA #2 had told her that Resident #1's hand was bleeding. RN #1 said she told SRNA #1 and SRNA #2 that the blood on Resident #1's hand was her blood and not Resident #1's blood. RN #1 denied causing any injury to Resident #1's hand during the incident. Further interview with RN #1 revealed she had been trained that it was not acceptable to hit a resident under any circumstance, but she did not see her hitting Resident #1 as abuse. RN #1 denied placing her leg behind Resident #1's leg in order to force Resident #1 into the wheelchair. Continued interview with RN #1 revealed she had not pushed Resident #1 on the chest in an attempt to get him/her to sit in the wheelchair. RN #1 said she could not remember if she cursed at Resident #1 during the incident. Further interview with RN #1 revealed if this happened again she wasn't sure that she wouldn't handle it the same way. RN #1 reported she did not get her hand examined after the incident. Interview with LPN #2 on 02/17/16 at 11:36 AM revealed she had come in to work on the morning of 02/07/16 and SRNA #1 and SRNA #2 reported to her that RN #1 had hit Resident #1. Continued interview with LPN #2 revealed she asked SRNA #1 and SRNA #2 if they had reported the abuse allegation to anyone, and the SRNAs reported they did not because they were afraid of retaliation from RN #1. Continued interview with LPN #2 revealed she told SRNAs #1 and #2 that they had to report the allegation immediately. LPN #2 immediately contacted the Administrator to ensure that she had been made aware of the allegation against RN #1. LPN #2 reported she checked Resident #1's hand after she ensured that the allegation had been reported. LPN #2 reported Resident #1 had cuts and bruising consistent with being cut and punched by someone wearing a ring. Further interview with LPN #2 revealed she had been trained that it was never acceptable to hit a resident under any circumstances. LPN #2 reported she felt like staff at the facility was intimidated by RN #1 and the Director of Nursing (DON). Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM revealed she was notified of the allegation by LPN #2 and was on her way to the facility to help assist with the investigation on 02/07/16 and had a family emergency. The DON reported that she was not present for the beginning of the investigation. Continued interview with the DON revealed she and the Administrator had talked to RN #1 and discussed with her how she could have handled the situation differently. Further interview with the DON revealed she was a hands-on DON and that she conducted rounds throughout the facility five (5) or six (6) times a day in order to ensure that residents in the facility were free from abuse. The DON stated RN #1 was suspended during the facility's investigation and the Administrator had made the decision to permit RN #1 to return to work. Further interview with the DON revealed she did not consider RN #1's hitting Resident #1 to be abuse because RN #1 had the right to protect herself and try to get away from a resident that was breaking her hand. The DON reported that it was not acceptable for staff to hit a resident; however, RN #1 had a right to protect herself. Further interview with the DON revealed she assisted in conducting the facility's abuse investigations by sitting in on interviews. The DON stated she would only interview facility residents if they had been involved in the allegation. Continued interview with the DON revealed staff was trained to leave a resident alone if they were being combative. The DON stated if a resident was in a safe environment, staff should walk away from a combative resident. She stated staff had been trained to report abuse immediately to their supervisor and if the supervisor was named in the allegation, staff should contact the on-call charge nurse to report the abuse. Continued interview with the DON revealed the abuse allegation should have been reported immediately. The DON reported that she observed a bruise on Resident #1's hand after the incident and was told Resident #1 had some small cuts on his/her hand. She stated that Resident #1 had bruising to his/her hand prior to the incident and also had some age spots present prior to the incident. Interview with the Administrator on 02/17/16 at 3:12 PM and 5:01 PM revealed she had been notified of the allegation of abuse by LPN #2 at approximately 8:00 AM on 02/07/16. The Administrator stated she immediately contacted RN #1 and notified her that she was suspended from work until further notice. Continued interview with the Administrator revealed she conducted interviews with staff that had been present during the incident. The Administrator reported that she observed Resident #1's left hand to be red on the knuckles and to have either cuts or abrasions present. She stated she interviewed Resident #1 and the resident's roommate (Resident #2) as part of the investigation; however, there was no documented evidence Resident #2 was interviewed. The Administrator stated that she should have talked to more residents and specifically asked them about RN #1 during the interviews. Continued interview with the Administrator on 02/17/16 at 3:12 PM revealed she and the DON met and reviewed RN #1's employee file and had a discussion with RN #1 about how she could have handled the incident differently. The Administrator stated that RN #1 told her that she had smacked Resident #1's hand during the incident, but she did not use the word hit. Continued interview with the Administrator revealed she, the DON, and Unit Manager conducted the investigation and determined that RN #1 had done what she had to do in order to protect herself, and neither substantiated nor unsubstantiated the allegation. The Administrator reported that it was never acceptable to hit a resident. Further interview with the Administrator revealed she conducted regular in-services related to reporting abuse and that the abuse allegation should have been reported immediately. Continued interview with the Administrator revealed she had been the one who had decided to allow RN #1 to come back to work. Further interview with the Administrator revealed the facility did not have any written criteria that must be met in order for an employee accused of abuse to return back to work, but the facility's policy stated the facility would wait for the results of the Adult Protective Services (APS) investigation before determining if an employee named in an allegation would be permitted to return to work. However, the Administrator stated she felt like it was taking too long for the APS investigation and decided to allow RN #1 to return to work before the APS investigation was completed. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follo

Based on interview, record review, facility policy review, and review of the facility's investigation it was determined that the facility failed to implement policies regarding reporting abuse and protection from abuse for (1) of three (3) sampled residents (Resident #1). On 02/07/16 at approximately 4:00 AM, an incident took place between Registered Nurse (RN) and Resident #1 that resulted in Resident #1 being physically and verbally abused. The incident on 02/07/16 was witnessed by the facility's Safety Attendant, State Registered Nurse Aide (SRNA) #1, and SRNA #2. However, the staff failed to immediately report the allegation of abuse according to the facility's policy. The abuse allegation was reported to the Administrator at approximately 8:00 AM on 02/07/16, approximately four (4) hours after the incident occurred. The facility initiated an investigation and suspended RN #1 during the investigation. However, interview with the Administrator on 02/17/16 revealed she did not make a determination to substantiate or unsubstantiate the allegation when concluding the facility's investigation. She stated the facility's policy was to wait until Adult Protective Services (APS) concluded their investigation before determining if an employee named in an allegation would be permitted to return to work. However, the Administrator stated she decided to allow RN #1 to return to work because it was taking too long for APS to conclude their investigation. The facility allowed RN #1 to return to work and provide care to the residents. The facility's failure to implement its policies related to abuse and permitting a staff member to return to work providing direct resident care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled Abuse, undated, revealed any observation or allegation of abuse was to be reported immediately to a supervisor and then to the administrator. The policy stated further abuse or potential abuse would be prevented while the investigation was in progress, but the policy did not specify how that would be accomplished. Further review of the facility policy revealed a thorough investigation of the incident would be conducted by the Administrator and the Director of Nursing by interviewing staff, family, and residents who were involved or may have knowledge of the incident. The policy stated if the alleged violation was verified appropriate corrective action would be taken. The appropriate action to be taken could include but was not limited to termination of employment and criminal prosecution. Continued review of the facility's policy revealed the definition of physical abuse was doing something with the intention of causing physical pain or injury to a resident. According to the facility's policy some examples of physical abuse were hitting, scratching, biting, slapping, and punching. Further review of the policy revealed bruising, scratches, and cuts were some examples of possible signs of physical abuse. The policy defined psychological abuse as the threat of injury, unreasonable confinement and punishment, or verbal intimidation and humiliation that may result in mental anguish. The facility's policy gave using insults, using demeaning language, yelling, screaming, and prohibiting free choice as examples of psychological abuse. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with [DIAGNOSES REDACTED]. Resident #1 had been admitted to the facility with a newly implanted defibrillator with an incision and dressing to the resident's chest. Review of the facility's investigation revealed an allegation of abuse was reported on 02/07/16 that RN #1 hit Resident #1. Further review of the investigation revealed the Administrator had been notified of the allegation by Licensed Practical Nurse (LPN) #2 on 02/07/16. Review of the investigation revealed State Registered Nurse Aide (SRNA) #1, SRNA #2, and the facility's Safety Attendant witnessed RN #1 hit Resident #1 on the hand multiple times. RN #1 was interviewed about the incident and reported she was afraid Resident #1 was going to break her hand so she smacked Resident #1's hand to get the resident to let go of her hand. Continued review of the investigation revealed RN #1 reported she had thought of biting Resident #1's hand, but she did not bite the resident. Further review of the facility's investigation revealed the facility concluded that RN #1 had been a nurse for nineteen (19) years and had worked at the facility for seven and one-half (7 1/2) years. The investigation stated during RN #1's employment at the facility there had been no reports concerning abuse or inappropriate behavior toward residents or staff. RN #1's actions toward Resident #1 were due to her fear of personal injury. The investigation did not conclude whether the abuse was substantiated or unsubstantiated. Furthermore, there was no evidence in the investigation that the facility interviewed other residents as part of their investigation. Interview with SRNA #1 on 02/16/16 at 4:03 PM reveled RN #1 attempted to get Resident #1 into a wheelchair and when Resident #1 refused to sit in the wheelchair, RN #1 placed her leg behind Resident #1's leg in order to force Resident #1 to sit down in the wheelchair. Further interview with SRNA #1 revealed Resident #1 began to squeeze her hand and RN #1's hand at the same time while they were providing care for Resident #1. SRNA #1 stated RN #1 began cursing at Resident #1 and then proceeded to punch Resident #1's hand three (3) or four (4) times with a closed fist. RN #1 pushed Resident #1 on the chest area in order to force him/her to sit back down in the wheelchair. SRNA #1 reported RN #1 cursed and told her and the other staff present to get Resident #1 out of the room. Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM revealed RN #1 was suspended during the facility's investigation. She stated the Administrator made the decision to permit RN #1 to return back to work. RN #1 was allowed to work unsupervised while she provided direct resident care. Interview with the Administrator on 02/17/16 at 3:12 PM and 5:01 PM revealed LPN #2 had notified her of the allegation of abuse at approximately 8:00 AM on 02/07/16. The Administrator stated she immediately contacted RN #1 and notified her that she was suspended from work until further notice and initiated an investigation. Continued interview with the Administrator revealed she, the DON, and Lower Level Unit Manager conducted the investigation. She stated that she did not substantiate the abuse allegation, but had determined RN #1 had done what she had to do in order to protect herself. Continued interview with the Administrator revealed she had been the one who decided to allow RN #1 to come back to work. Further interview with the Administrator revealed the facility did not have any written criteria that must be met in order for an employee accused of abuse to return to work, but the facility's practice was to wait for Adult Protective Services (APS) to complete their investigation before allowing an alleged perpetrator to return to work. The Administrator further stated she felt the APS investigation was taking too long and decided to allow RN #1 to return to work before the APS investigation was complete. She stated that during the investigation she interviewed Resident #1's roommate, but she did not document the interview and did not interview any other residents. Interview with the Administrator on 02/17/16 at 3:12 PM revealed she should have talked to more residents and specifically asked them about RN #1 during the interviews. She was unsure why she had not done this. A post-survey interview on 03/17/16 at 2:00 PM with the APS worker conducting the investigation revealed she had not completed her investigation yet. The APS worker stated she was concerned that the facility brought RN #1 back to work because the interviews with staff have been consistent that RN #1 struck the resident. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Administrator, Assistant Administrator, Director of Nursing, and Primary Charge Nurses on Abuse and Neglect, Dealing with Combative Resident Behavior, and Investigating Abuse. 9) Beginning on 02/19/16 and concluding on 02/22/16, in-services on Abuse and Neglect, and Dealing with Combative Resident Behaviors were held. These in-services were prepared by the Infection Preventionist/Nurse Educator, and given by the Administrator, Director of Nursing, and Primary Charge Nurses to all employees. The Dealing with Combative Resident Behavior section of the in-service covered the following objectives: Identify triggers and situations that could cause a resident to become combative; Review the role of staff in managing difficult behaviors; Identify methods to protect both the resident and staff from harm; Discuss scenarios involving combative residents and how the caregiver responds; and Review strategies to help prevent behaviors from escalating. The Abuse and Neglect section of the in-service covered the following objectives: Review the definition of abuse; Discuss the seven types of abuse; Identify the signs and symptoms of abuse; Discuss the SAFE acronym; and Review the requirements of reporting abuse. The Investigating Abuse section of the in-service consisted of watching a video (Resident Abuse: Prevention and Protection Volume XXVII) and review of the revised facility's Abuse Prevention Program. At the conclusion of the in-service, three post-tests were taken covering the three sections of the in-service. The post-tests were graded to ensure each attendee learned the concepts presented. At the conclusion of these in-services 99% of all employees had taken these in-services and passed their post-tests. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires will complete the education and in-service on Abuse and Neglect/Dealing with Combative Resident Behavior before going to work. 10) On 02/19/16 - 02/22/16 the following policies and procedures were reviewed by the Medical Director, Administrator, DON, Assistant Administrator, and Primary Charge Nurses to ensure each policy reflects the intent of the regulation: a) Abuse Prevention Program b) The following policies were reviewed with no revisions. Staff was reeducated (refer to action item #13): Reporting Incidents, Protecting a Resident During an Investigation, Falls Program, Assessment and Care Plan Policy, Assessment and Care Plan Procedure, Notification of a Change in Resident's Condition, Notification of the Director of Nursing or Nursing Administrative Representative who is on call, CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff, Behavior Management, Assessment of a Resident Who Has Sustained an Injury, Accident/Incident Monitoring Policy, The Review and Signing of Care Plan After Each RAI Assessment, The following policy is a new policy created after the IJ was identified. c) Certified Nursing Assistant (CNA) Resident Behavior Monitoring - This policy was created to provide structure in the monitoring of resident behavior. A CNA Resident Behavior Monitoring Log was created to be placed in the Clinical Flow Record for residents who have shown aggressive behaviors. The CNA Documentation will be monitored daily by the nurse who will make changes to the care plan as needed and notify the physician, pharmacy, and Social Services as needed. 11) On 02/23/16, in-services began on the policies and procedures as listed in Action Item #12 for all Nursing staff (including RNs, LPNs, CMAs, SRNAs, and Safety Attendants). The in-services were prepared and taught by the Director of Nursing. The in-services will conclude on Wednesday, 02/24/16. For the in-services, the policies and procedures were organized in sections as they related to deficient practices in the tags identified when the immediate jeopardy was received. Section II of the in-service covered notification. In Section II, the Director of Nursing reviewed the Notification of a Change in the Resident's Condition Policy, The Notification of the Director of Nursing or Nursing Administrative Representative Who Is on Call Policy, and the CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff Policy. For Section II, the DON focused on informing the resident, consulting with physician, and notifying the resident's legal representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Section III of the in-service covered Abuse. In Section III, the Director of Nursing reviewed the Protecting a Resident During an Investigation Policy, and the Abuse Policy covered in Action Item #11. For Section III, the DON focused on the resident's right to be free from all abuse, the facility's obligation to develop and implement an abuse prevention program, the facility's duty to prevent abuse, and the facility's duty to investigate abuse and prevent further abuse during an investigation. As part of the review on abuse, the Director of Nursing asked all attendees if they were aware of any new allegations of abuse. There were no new allegations of abuse reported. Any new allegations of abuse would be investigated immediately according to the facility's Abuse Prevention Program. The Director of Nursing also reminded the staff that abuse is to be reported immediately by reporting it to their immediate supervisor. If action is not taken they are to follow the chain of command by reporting immediately to the Director of Nursing and the Administrator. Section IV of the in-service covered falls and other incidents/accidents. In Section IV, the Director of Nursing reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, and the Falls Program. For Section IV, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment, the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. Section V of the in-service covered appropriate care plan revisions. (Reference Tag F280) In Section V, the Director of Nursing reviewed the Assessment and Care Plan Policy, the Assessment and Care Plan Procedure, and the Review and Signing of Care Plans After Each RAI Assessment Policy. For Section V, the Director of Nursing focused on periodically reviewing and revising the care plan and what types of actions require care plan revisions. The DON discussed that it was the nurses' responsibility to make the necessary care plan revisions and the importance of doing so timely. The DON reviewed that the nurse would make revisions after every accident/incident including but not limited to falls, skin tears, episodes of behavior, and other injuries. The DON reviewed that the MDS Nurse reviewed and revised care plans with every significant change and quarterly. Section VI of the in-service covered quality of care. (Reference Tag F309) In Section VI, the Director of Nursing again reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, the Falls Program, the CNA Resident Behavior Monitoring Policy and Log, and the Behavior Management Policy. For Section VI, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment (to be completed immediately), the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. For Section VI, the Director of Nursing also focused on identifying behaviors and making changes to the Care Plan and Clinical Flow Record to prepare staff to deal with resident behaviors effectively, and prevent them when possible. The DON reminded staff that when there is an incident of behavior that results in a fall or injury they still must follow the processes and complete all assessments mentioned above. At the conclusion of the in-service post-tests were taken by each nurse attending the in-service. The post-tests were graded to ensure that each nurse attendee learned the concepts presented. At the conclusion of the in-service 99% of the Nursing Department employees had attended the in-service. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires in the Nursing Department will complete the education and in-service on these policies and procedures before going to work. 12) Beginning on 02/24/16 The following QAPI audits will be utilized daily to ensure compliance with all of the above actions: Employee Knowledge of Abuse Policy QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nursing employees on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts. The audit will also include having every employee read and resign the revised Abuse Policy. As part of the audit each employee will be asked if they are aware of or have witnessed any abuse. Any issues identified as abuse will be thoroughly investigated as outlined in our Abuse Prevention Program. Reporting Incidents/Accidents, Falls, Notification of Physician/Family, CP Updates QAPI AUDIT: This audit will be performed daily by the Director of Nursing covering 100% of reportable Incidents/Accidents and Falls. This audit will include reviewing that all incident/accidents are reported correctly and that the appropriate assessments are completed, the appropriate notifications are made, and the appropriate revisions are made to the care plan. For the purpose of this audit, information will be gathered from the resident's medical record, incident/accident reports, board charting, completed assessments, and the care plan. Any issues identified will be corrected immediately by the Director of Nursing and reported to the Administrator. CNA/Ancillary Employee Knowledge of Reporting/Behaviors QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of SRNAs on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing staff and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with aggressive/combative resident behaviors. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Nurse Knowledge of Fall/Accident/Injury/Behavior QAPI Audit. This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nurses on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing nurses and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with Fall/Accident Injury/Behavior. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Falls QAPI Audit: This audit will be performed daily by the Director of Nursing covering 100% of all Resident Falls until the removal of the immediate jeopardy. This audit will gather information from the accident/incident report, completed assessments, root cause analysis, 72 Hour post fall assessment, and care plan. Any issues identified will be corrected immediately and reported to the Administrator. Body Mapping QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of Residents until the removal of the immediate jeopardy. This audit will include a daily Head to Toe Assessment of each resident utilizing the Body Mapping Diagram. Any issues identified will be corrected immediately and reported to the Administrator. Mood and Behavior Log QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of all Residents until the removal of the immediate jeopardy. This audit will include reviewing the resident's medical record and mood and behavior logs and ensuring the Care Plan and Clinical Flow Record reflect any necessary interventions. Any issues identified will be corrected immediately and reported to the Administrator. Quality Assurance Resident Interview - Staff Form QAPI Audit: This audit will be performed daily by the Social Service Workers who will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. The interview will include questions on resident rights, and abuse and neglect. Any report of abuse will be thoroughly investigated and reported immediately according to the Abuse Prevention Program. The Social Service workers will address every non-abuse negative comment or response by referring them to the appropriate department and continuing to follow up daily until negative responses are resolved. The Administrator will compile a daily report and summary of all of the above QAPI audits to be reviewed by the QAPI Committee including the Medical Director who will review the daily report and all action taken to address and remove the Immediate Jeopardy. The Medical Director will review daily all incident reports/accidents/falls, review of all allegations of abuse, review of all QAPI Audits. **The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1) Review of the revised facility investigation (undated) revealed the State Survey Agency (SSA) substantiated abuse and the facility terminated RN #1's employment with the facility effective 02/19/16. Review of a facility statement, Employee Counseling Form, dated 02/19/15, revealed the facility contacted RN #1 on 02/19/16 and notified her that her employment with the facility was terminated effective 02/19/16 and that her written counseling would be mailed. She was also notified the abuse would be reported to the Kentucky Board of Nursing (KBN). Continued review of the facility statement revealed the Facility Administrator, Assistant Administrator, Director of Nursing, and Human Resources Director were present at the time the phone call was made to RN #1. Review of a mailing label dated 02/19/16 revealed the Employee Counseling Form had been mailed to RN #1 on 02/19/16. Review of a KBN facility complaint form dated 02/19/16 revealed the facility filed a complaint regarding RN #1 to the KBN via the internet. Review of a mailing label dated 02/20/16 revealed the facility mailed the required documentation to the KBN to complete the complaint process. 2) Review of an Employee Counseling Form dated 02/19/16 for SRNA #1, SRNA #2, and the Safety Attendant revealed the staff

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined that the facility failed to provide services in accordance with the plan of care for one (1) of three (3) sampled residents (Resident #1) related to Resident #1's psychosocial well-being, behavioral symptoms, and skin integrity. Review of Resident #1's admission care plan dated 02/05/16 revealed the facility developed interventions for Resident #1 related to behavioral symptoms, potential loss of skin integrity/bruising, and cognitive loss. The interventions included keeping a calm environment, providing a safe environment, educating staff and family on the correct way to handle the resident, and approaching him/her in a calm manner. The facility's investigation dated 02/07/16 revealed Resident #1 was found standing at the door of his/her room and when redirected the resident became aggressive and punched the Safety Attendant. Registered Nurse (RN) #1 then forced the resident into a wheelchair and took the resident into the room to provide incontinence care. Staff was holding the resident's hands to steady him/her when Resident #1 began squeezing the staff members' hands. RN #1 began yelling and hitting the resident. The staff failed to provide a calm environment as outlined in the resident's care plan. Further review of the investigation revealed Resident #1 was assessed to have one scratch observed to the left hand. However, an assessment after the incident revealed Resident #1 had new cuts noted to the back of his/her left hand around the thumb area, had new cuts noted to his/her wrist area, and had new bruising to the back of his/her left hand and wrist area. The facility's failure to ensure services were provided according to the care plan was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled The Review and Signing of Care Plans after each RAI (Resident Assessment Instrument) Assessment, dated April 2013, revealed the purpose of the policy was to provide a mechanism of structure and process whereby resident care plans will be reviewed, signed, and correlated with the clinical flow record. Review of the facility's policy titled Behavior Management, undated, revealed staff should approach residents with violent behaviors by using a pillow, blanket, or towels to cover their arms, chest, and face for protection. The policy stated staff was to defend themselves by blocking blows with covered arms crossed in front of them and should avoid grabbing at the resident or yelling loudly. Further review of the policy revealed staff should not rush upon the resident too fast and should ask for permission to touch the resident. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed Resident #1 had been admitted to the facility with a newly implanted defibrillator with an incision and dressing to the resident's chest. Review of Resident #1's History and Physical from a local acute care hospital dated 01/31/16 revealed Resident #1 had been experiencing hallucinations at times. Review of Resident #1's Nursing Admission History and assessment dated [DATE] revealed Resident #1 was oriented to person with slow comprehension. Review of Resident #1's Short Portable Mental Status Questionnaire (SPMSQ) dated 02/05/16 revealed the facility assessed Resident #1 to have a SPMSQ score of 8 which indicated Resident #1 had moderate intellectual impairment. Review of Resident #1's Admission Care Plan dated 02/05/16, revealed the facility had identified behavioral symptoms, potential for loss of skin integrity and/or bruising, and cognitive loss as problem areas and developed the following interventions to address the concerns: keep the environment calm and relaxed, encourage diversional activities, provide a safe environment, educate staff or family in the correct way to handle/position the resident to prevent skin tears, approach in a calm manner, staff to introduce themselves, explain what you intend to do while providing care, and observe for non-verbal cues. Review of Resident #1's Mood/Behavior Symptom Log dated 02/07/16 revealed at 4:00 AM on 02/07/16 Resident #1 had gotten up several times on the side of the bed and had been assisted back into bed. Continued review of Resident #1's behavior log revealed the Safety Attendant observed Resident #1 up at the door and tried to hold Resident #1 steady; while doing this, Resident #1 punched the Safety Attendant. The Log stated Resident #1 was wet with urine and four (4) staff members tried to take the resident back to his/her room to change him/her. Continued review of Resident #1's behavior log revealed Resident #1 became very violent and punched, kicked, and squeezed staff's hands and would not let go. Resident #1's behavior log stated Resident #1 continued to fight with staff and he/she had RN #1's hand and was squeezing so hard and would not let go. The log stated that RN #1 managed to get her hand free; Resident #1 was dried, clothed, and taken to the lobby. Review of the head-to-toe skin assessment conducted on 02/07/16 after the incident occurred revealed Resident #1 had new cuts noted to the back of his/her left hand around the thumb area, had new cuts noted to his/her wrist area, and had new bruising to the back of his/her left hand and wrist area. Interview with the Safety Attendant on 02/16/16 at 6:05 PM, revealed she was making rounds to check on residents on the morning of 02/07/16 and noticed Resident #1 standing in the doorway of his/her room. Further interview with the Safety Attendant revealed she had approached Resident #1 and took him/her by the elbow and attempted to redirect Resident #1 back into his/her room. Continued interview with the Safety Attendant revealed Resident #1 turned and punched her in the neck, knocking her down, and then Resident #1 lost his/her balance and fell down. The Safety Attendant stated Resident #1 fell and had attempted to get up. She stated she was able to talk Resident #1 into sitting down on the floor until she could get some help for him/her. Continued interview with the Safety Attendant revealed she yelled for help and RN #1 came to help her. The Safety Attendant stated she and RN #1 helped get Resident #1 up from the floor. Further interview with the Safety Attendant revealed at this time SRNA #1 and SRNA #2 came to help them with Resident #1. The Safety Attendant stated she left Resident #1's room to get a blanket and draw sheet. She stated when she returned to Resident #1's room SRNA #1 had Resident #1's right hand and RN #1 had his/her left hand to steady him/her while other staff was performing care. Continued interview with the Safety Attendant revealed Resident #1 was squeezing SRNA #1's and RN #1's hand very tightly. The Safety Attendant stated she observed RN #1 tapping Resident #1's left hand with her right hand using a closed fist. Further interview with the Safety Attendant revealed she heard RN #1 tell the other staff to get Resident #1 out of the room. Interview with the Safety Attendant on 02/18/16 at 1:50 PM revealed she was trained how to approach a combative resident and should have approached the resident slowly, but was unaware that Resident #1 had combative behaviors. Interview with SRNA #1 on 02/16/16 at 4:03 PM revealed she had worked the night shift (7:00 PM to 7:00 AM) on 02/06/16 to 02/07/16 and heard a disturbance around 4:00 AM on the morning of 02/07/16. Further interview with SRNA #1 revealed she observed RN #1 and the Safety Attendant near Resident #1's room. The Safety Attendant reported to her that Resident #1 had punched her in the throat. SRNA #1 stated RN #1 had attempted to get Resident #1 into a wheelchair. When Resident #1 refused to sit in the wheelchair RN #1 placed her leg behind Resident #1's leg in order to make Resident #1 sit down in the wheelchair. Continued interview with SRNA #1 revealed while they were performing care on Resident #1, she was on one side of the resident and RN #1 was on the other side of Resident #1 both holding his/her hand in order to steady him/her while he/she was standing. Further interview with SRNA #1 revealed Resident #1 began to squeeze her hand and RN #1's hand at the same time while saying, I'm sorry, I don't mean it. SRNA #1 reported she did not believe Resident #1 was trying to hurt them on purpose. Continued interview with SRNA #1 revealed RN #1 began cursing at Resident #1 and then proceeded to punch Resident #1's hand three (3) or four (4) times with a closed fist. She stated that RN #1 leaned down toward Resident #1 like she was going to bite him/her. However, SRNA #1 stated she was not sure if RN #1 actually bit Resident #1. SRNA #1 stated that once Resident #1 had let go of RN #1's hand she pushed Resident #1 on the chest area in order to make him/her sit back down in the wheelchair. SRNA #1 reported RN #1 cursed and told her and the other staff present to get Resident #1 out of the room. Interview with SRNA #2 on 02/16/16 at 4:29 PM revealed she had worked the night shift (7:00 PM to 7:00 AM) on 02/06/16 to 02/07/16. SRNA #2 stated that while she was doing her rounds to check on the resident she heard someone yell for help. Continued interview with SRNA #2 revealed when she went to Resident #1's room she observed Resident #1 standing in the doorway of his/her room. SRNA #2 stated that she had observed RN #1 place her leg behind Resident #1's leg and knock Resident #1's leg out from under him/her when Resident #1 refused to sit down in the wheelchair. Continued interview with SRNA #2 revealed once they got Resident #1 into his/her room they assisted him/her up in order to change his/her incontinence brief. SRNA #2 stated SRNA #1 was on one side of Resident #1 and RN #1 was on the other side to steady the resident while she was changing his/her incontinence brief. Further interview with SRNA #2 revealed Resident #1 began squeezing SRNA #1's hand and RN #1's hand. SRNA #2 stated RN #1 punched Resident #1's hand with her closed fist three (3) or four (4) times. SRNA #2 stated she observed RN #1 bend down toward Resident #1 like she was going to bite him/her, but did not actually see RN #1 bite Resident #1. Further interview with SRNA #2 revealed after Resident #1 let go of RN #1's hand RN #1 pushed Resident #1 on the chest causing him/her to sit down in the wheelchair. Continued interview with SRNA #2 revealed she heard RN #1 curse and tell other staff to get Resident #1 out of her sight and that she was going to make sure that Resident #1 was discharged from the facility. Interview with SRNA #2 on 02/18/16 at 2:07 PM revealed she had observed RN #1 place her leg behind Resident #1's leg in order to force Resident #1 to sit in the wheelchair. Interview with Registered Nurse (RN) #1 on 02/16/16 at 7:29 PM revealed she was in the medication room on the morning of 02/07/16 preparing medications and heard someone yell for help. RN #1 stated when she went into the hallway she observed the Safety Attendant standing near Resident #1. The Safety Attendant reported to RN #1 that Resident #1 had hit her in the neck after she had tried to redirect him/her back into his/her room. Continued interview with RN #1 revealed she had Resident #1's left hand and SRNA #1 had Resident #1's right hand while he/she was standing up to get his/her incontinence brief changed. RN #1 stated Resident #1 began to squeeze her hand as hard as he/she could. Further interview with RN #1 revealed she attempted to talk to Resident #1 to try to get him/her to release her hand. RN #1 stated she tried to take her right hand and pry Resident #1's fingers away from her hand but she was unable to do so. Continued interview with RN #1 revealed when she was able to get her left hand free Resident #1 grabbed her right hand. Further interview with RN #1 revealed she took her left hand and lightly smacked Resident #1's left hand trying to get Resident #1 to let go of her hand. RN #1 denied hitting Resident #1 with a closed fist. She stated she used an open hand and was smacking Resident #1 with the palm of her hand. RN #1 stated she thought about biting Resident #1, but denied actually biting Resident #1 or attempting to bite him/her. During further interview, RN #1 denied pushing or forcing Resident #1 into a wheelchair and denied saying anything about getting Resident #1 discharged from the facility. RN #1 denied causing any injury to Resident #1's hand during the incident. RN #1 stated she did what she thought was right to take care of the resident. Interview with Certified Medication Aide (CMA) #1 on 02/16/16 at 12:03 PM revealed she had been trained that it was never acceptable to hit a resident for any reason. Continued interview with CMA #1 revealed she had cared for Resident #1 in the past and had never had any problems getting Resident #1 to calm down by just talking to the resident. Interview with RN #3 on 02/17/16 at 5:12 PM revealed she was the admitting nurse for Resident #1 when he/she was admitted to the facility on [DATE]. Continued interview with RN #3 revealed Resident #1's family had reported to her that Resident #1 had hallucinations in the past. Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM revealed she and the Administrator had talked to RN #1 and discussed with her how she could have handled the situation differently. The DON also reported that she could not remember if Resident #1 was taking any medications that may have increased his/her hallucinations or dementia related behaviors. Further interview with the DON revealed staff was trained to leave a resident alone if they were being combative. Interview with the Administrator on 02/17/16 at 3:12 PM and on 02/18/16 at 1:05 PM revealed she and the DON met and reviewed RN #1's employee file and had a discussion with RN #1 about how she could have handled the incident differently. The Administrator reported RN #1 told her that she had smacked Resident #1's hand during the incident. The Administrator reported that it was never acceptable to hit a resident. She stated RN #1 had not received the facility's training on how to deal with combative residents since she had been rehired on 11/05/15. Continued interview with the Administrator revealed RN #1 had received training on how to handle residents with Dementia on 02/23/11 during RN #1's previous employment at the facility. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Administrator, Assistant Administrator, Director of Nursing, and Primary Charge Nurses on Abuse and Neglect, Dealing with Combative Resident Behavior, and Investigating Abuse. 9) Beginning on 02/19/16 and concluding on 02/22/16, in-services on Abuse and Neglect, and Dealing with Combative Resident Behaviors were held. These in-services were prepared by the Infection Preventionist/Nurse Educator, and given by the Administrator, Director of Nursing, and Primary Charge Nurses to all employees. The Dealing with Combative Resident Behavior section of the in-service covered the following objectives: Identify triggers and situations that could cause a resident to become combative; Review the role of staff in managing difficult behaviors; Identify methods to protect both the resident and staff from harm; Discuss scenarios involving combative residents and how the caregiver responds; and Review strategies to help prevent behaviors from escalating. The Abuse and Neglect section of the in-service covered the following objectives: Review the definition of abuse; Discuss the seven types of abuse; Identify the signs and symptoms of abuse; Discuss the SAFE acronym; and Review the requirements of reporting abuse. The Investigating Abuse section of the in-service consisted of watching a video (Resident Abuse: Prevention and Protection Volume XXVII) and review of the revised facility's Abuse Prevention Program. At the conclusion of the in-service, three post-tests were taken covering the three sections of the in-service. The post-tests were graded to ensure each attendee learned the concepts presented. At the conclusion of these in-services 99% of all employees had taken these in-services and passed their post-tests. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires will complete the education and in-service on Abuse and Neglect/Dealing with Combative Resident Behavior before going to work. 10) On 02/19/16 - 02/22/16 the following policies and procedures were reviewed by the Medical Director, Administrator, DON, Assistant Administrator, and Primary Charge Nurses to ensure each policy reflects the intent of the regulation: a) Abuse Prevention Program b) The following policies were reviewed with no revisions. Staff was reeducated (refer to action item #13): Reporting Incidents, Protecting a Resident During an Investigation, Falls Program, Assessment and Care Plan Policy, Assessment and Care Plan Procedure, Notification of a Change in Resident's Condition, Notification of the Director of Nursing or Nursing Administrative Representative who is on call, CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff, Behavior Management, Assessment of a Resident Who Has Sustained an Injury, Accident/Incident Monitoring Policy, The Review and Signing of Care Plan After Each RAI Assessment, The following policy is a new policy created after the IJ was identified. c) Certified Nursing Assistant (CNA) Resident Behavior Monitoring - This policy was created to provide structure in the monitoring of resident behavior. A CNA Resident Behavior Monitoring Log was created to be placed in the Clinical Flow Record for residents who have shown aggressive behaviors. The CNA Documentation will be monitored daily by the nurse who will make changes to the care plan as needed and notify the physician, pharmacy, and Social Services as needed. 11) On 02/23/16, in-services began on the policies and procedures as listed in Action Item #12 for all Nursing staff (including RNs, LPNs, CMAs, SRNAs, and Safety Attendants). The in-services were prepared and taught by the Director of Nursing. The in-services will conclude on Wednesday, 02/24/16. For the in-services, the policies and procedures were organized in sections as they related to deficient practices in the tags identified when the immediate jeopardy was received. Section II of the in-service covered notification. In Section II, the Director of Nursing reviewed the Notification of a Change in the Resident's Condition Policy, The Notification of the Director of Nursing or Nursing Administrative Representative Who Is on Call Policy, and the CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff Policy. For Section II, the DON focused on informing the resident, consulting with physician, and notifying the resident's legal representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Section III of the in-service covered Abuse. In Section III, the Director of Nursing reviewed the Protecting a Resident During an Investigation Policy, and the Abuse Policy covered in Action Item #11. For Section III, the DON focused on the resident's right to be free from all abuse, the facility's obligation to develop and implement an abuse prevention program, the facility's duty to prevent abuse, and the facility's duty to investigate abuse and prevent further abuse during an investigation. As part of the review on abuse, the Director of Nursing asked all attendees if they were aware of any new allegations of abuse. There were no new allegations of abuse reported. Any new allegations of abuse would be investigated immediately according to the facility's Abuse Prevention Program. The Director of Nursing also reminded the staff that abuse is to be reported immediately by reporting it to their immediate supervisor. If action is not taken they are to follow the chain of command by reporting immediately to the Director of Nursing and the Administrator. Section IV of the in-service covered falls and other incidents/accidents. In Section IV, the Director of Nursing reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, and the Falls Program. For Section IV, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment, the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. Section V of the in-service covered appropriate care plan revisions. (Reference Tag F280) In Section V, the Director of Nursing reviewed the Assessment and Care Plan Policy, the Assessment and Care Plan Procedure, and the Review and Signing of Care Plans After Each RAI Assessment Policy. For Section V, the Director of Nursing focused on periodically reviewing and revising the care plan and what types of actions require care plan revisions. The DON discussed that it was the nurses' responsibility to make the necessary care plan revisions and the importance of doing so timely. The DON reviewed that the nurse would make revisions after every accident/incident including but not limited to falls, skin tears, episodes of behavior, and other injuries. The DON reviewed that the MDS Nurse reviewed and revised care plans with every significant change and quarterly. Section VI of the in-service covered quality of care. (Reference Tag F309) In Section VI, the Director of Nursing again reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, the Falls Program, the CNA Resident Behavior Monitoring Policy and Log, and the Behavior Management Policy. For Section VI, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment (to be completed immediately), the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. For Section VI, the Director of Nursing also focused on identifying behaviors and making changes to the Care Plan and Clinical Flow Record to prepare staff to deal with resident behaviors effectively, and prevent them when possible. The DON reminded staff that when there is an incident of behavior that results in a fall or injury they still must follow the processes and complete all assessments mentioned above. At the conclusion of the in-service post-tests were taken by each nurse attending the in-service. The post-tests were graded to ensure that each nurse attendee learned the concepts presented. At the conclusion of the in-service 99% of the Nursing Department employees had attended the in-service. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires in the Nursing Department will complete the education and in-service on these policies and procedures before going to work. 12) Beginning on 02/24/16

Based on interview, record review, facility policy review, and review of the facility's investigation it was determined that the facility failed to assess one (1) of three (3) sampled residents (Resident #1) after the resident sustained [REDACTED].#1. Resident #1 was admitted to the facility on [DATE] with a newly implanted defibrillator with an incision and dressing to the resident's chest. On 02/07/16, Resident #1 sustained a fall after striking a Safety Attendant. The Safety Attendant yelled for help and RN #1 responded. While providing care to the resident, the resident was squeezing the staff's hand; RN #1 hit Resident #1's hand multiple times when the resident would not let go of her hand. RN #1 then pushed on the resident's chest, pushing the resident into a wheelchair. The resident sustained [REDACTED]. Even though staff reported the resident had fallen and had injuries, the facility failed to assess Resident #1's injuries to his/her hand and to determine if the resident had sustained other injuries. The facility's failure to ensure residents were assessed for injury after falls and after abusive incidents that resulted in resident injury was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's policy titled Falls Prevention Program, undated, revealed a physical evaluation would be conducted after a fall to include an immediate head-to-toe assessment; if possible, blood pressure and pulse should be obtained lying, sitting, and standing, and vital signs of the resident should be obtained the next time the resident performs the activity that resulted in the fall. Review of the facility's policy titled Fall/Accident Risk (Detection, Prevention, and Management), undated, revealed when a resident falls a nurse would perform the Initial Post Fall Assessment, document the assessment on the Post Fall Initial Assessment Form, review the resident's care plan for new interventions, and notify the DON. Review of the facility's policy titled, Prevention Protocol for High Risk Falls, undated revealed residents who have a score of 10 or greater on the Fall Risk Assessment were to be evaluated after each fall by conducting another resident and environment assessment. Review of the facility's policy titled Reporting Incidents, undated, revealed the purpose of the policy was to ensure reportable occurances were recorded and reported. The policy stated examples of reportable occurences included physical abuse and verbal abuse and required an incident report to be completed. The policy further stated that some incidents (such as falls) required an incident report to be completed, but was not necessarily a reportable incident. Review of Resident #1's medical record revealed the facility admitted Resident #1 on 02/05/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Short Portable Mental Status Questionnaire (SPMSQ) dated 02/05/16 revealed the facility had assessed Resident #1 to have a SPMSQ score of 8 which indicated Resident #1 had moderate intellectual impairment. Review of Resident #1's Admission Care Plan dated 02/05/16 revealed the facility had identified that Resident #1 attempted to get out of bed without assistance and had episodes of restlessness. Further review of Resident #1's care plan revealed Resident #1 had the potential for loss of skin integrity and/or bruising related to loss of muscle mass, loss of adipose tissue, ageing process, and medication side effects. The facility also identified concerns with the resident's psychosocial well-being/being in a new environment. Review of Resident #1's Body Mapping Diagram (skin assessment) dated 02/05/16 revealed Resident #1 had a bruise on his/her left thumb around the first knuckle upon admission to the facility. Continued review of the Body Mapping Diagram revealed the facility had assessed the bruise to be caused by an accident outside of the facility. Interview with the Safety Attendant on 02/19/16 at 11:17 AM revealed on 02/07/16 Resident #1 was standing in the doorway of his/her bedroom. When the Safety Attendant attempted to redirect the resident, Resident #1 struck the Safety Attendant and they both fell on the floor. The Safety Attendant yelled for help and RN #1, SRNA #1, and SRNA #2 responded and assisted Resident #1 up from the floor. The Safety Attendant stated she reported to RN #1 that Resident #1 had fallen. Interview with SRNA #1 on 02/16/16 at 4:03 PM and 4:29 PM revealed RN #1 had punched Resident #1 on the hand three or four times. SRNA #1 reported to RN #1 that Resident #1's hand was injured and bleeding. Continued interview with SRNA #1 revealed she also notified Licensed Practical Nurse (LPN) #1 of Resident #1's hand injury. Continued interview with SRNA #1 revealed RN #1 had attempted to get Resident #1 into a wheelchair. She stated when Resident #1 refused to sit in the wheelchair RN #1 placed her leg behind Resident #1's leg in order to make the resident sit down in the wheelchair. Further interview with SRNA #1 revealed Resident #1 began to squeeze her hand and RN #1's hand at the same time while saying, I'm sorry, I don't mean it. SRNA #1 reported she did not believe Resident #1 was trying to hurt them on purpose. Continued interview with SRNA #1 revealed RN #1 began cursing at Resident #1 and then proceeded to punch Resident #1's hand three (3) or four (4) times with a closed fist. Interview with SRNA #2 on 02/16/16 at 4:29 PM revealed she had observed RN #1 place her leg behind Resident #1's leg and knock Resident #1's leg out from under him/her when Resident #1 had refused to sit down in the wheelchair. Further interview revealed while care was being provided for the resident, Resident #1 began squeezing SRNA #1's hand and RN #1's hand. SRNA #2 stated RN #1 punched Resident #1's hand with her closed fist three (3) or four (4) times. Further interview with SRNA #2 revealed after Resident #1 let go of RN #1's hand RN #1 pushed Resident #1 on the chest causing him/her to sit down in the wheelchair. SRNA #2 told RN #1 that Resident #1's hand was bleeding after the incident had occurred. Interview with SRNA #3 on 02/16/16 at 5:32 PM revealed on 02/07/16 she assisted SRNA #1 in cleaning up Resident #1's hand that was bleeding. SRNA #3 stated Resident #1's hand was bleeding from three (3) different places around his/her thumb and index finger. Further interview with SRNA #3 revealed Resident #1 had complained to her that he/she was having chest pain after the incident occurred. SRNA #3 stated she had reported Resident #1's chest pain to LPN #1. Review of the nurse's notes dated 02/05/16 revealed no documented evidence RN #1 or LPN #1 assessed Resident #1 after the resident fell or assessed the injuries to the resident's hand. Review of a Mood/Behavior Symptom Log (MBSL) dated 02/07/16 revealed RN #1 documented that Resident #1 had gotten out of bed several times and had punched the Safety Attendant. The Log further stated that when four (4) staff members attempted to provide incontinence care for the resident the resident became very violent, and kicked and squeezed staff's hands and would not let go. According to RN #1's documentation, she managed to get her hand free and Resident #1 was dried, clothed, and taken to the lobby. Further review revealed the resident's injuries were not mentioned. Interview with Licensed Practical Nurse (LPN) #1 on 02/16/16 at 6:34 PM revealed the only thing that staff reported to her about the incident was that Resident #1 had hit the Safety Attendant in the throat. Continued interview with LPN #1 revealed SRNA #1 and SRNA #3 requested some bandages, but LPN #1 stated she did not ask the SRNAs why they needed bandages. She stated she did not assess Resident #1 or notice any injury to Resident #1's hand at that time. Continued interview with LPN #1 revealed no one reported that Resident #1 had complained of chest pain after the incident. Interview with Registered Nurse (RN) #1 on 02/16/16 at 7:29 PM revealed SRNA #1 and SRNA #2 told her that Resident #1's hand was bleeding. RN #1 said she told SRNA #1 and SRNA #2 that the blood on Resident #1's hand was her blood and not Resident #1's blood. RN #1 stated she did not assess the resident. RN #1 denied causing any injury to Resident #1's hand during the incident. Continued interview with RN #1 on 02/19/16 at 11:02 AM revealed the Safety Attendant did not report that Resident #1 had fallen. Further interview with RN #1 revealed she observed a small scratch on Resident #1's hand. However, she did not assess Resident #1's hand because she was unsure if the scratch had been a result of the scuffle. RN #1 stated she did not assess Resident #1 for injuries after the incident. Interview with the Director of Nursing (DON) on 02/17/16 at 2:02 PM and on 02/19/16 at 11:29 AM revealed she observed a bruise on Resident #1's hand after the incident and was told Resident #1 had some small cuts on his/her hand. The DON stated Resident #1 had bruising to his/her hand prior to the incident and also had some age spots present prior to the incident. Further interview with the DON on 02/19/16 at 11:29 AM revealed she was not aware that Resident #1 had sustained a fall on 02/07/16. Continued interview with the DON revealed if RN #1 was aware that Resident #1 had fallen she should have assessed him/her and completed the facility's fall packet. She stated a nurse should have assessed Resident #1 for any injuries and treated any injuries present. Interview with the Administrator on 02/17/16 at 3:12 PM and on 02/19/16 at 12:22 PM, revealed she observed Resident #1's left hand to be red on the knuckles and to have either cuts or abrasions present after the incident with RN #1. The Administrator stated the Safety Attendant reported to her that Resident #1 had fallen prior to the incident. According to the Administrator, Resident #1 should have been assessed after he/she fell and after he/she was involved in the incident with RN #1. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Administrator, Assistant Administrator, Director of Nursing, and Primary Charge Nurses on Abuse and Neglect, Dealing with Combative Resident Behavior, and Investigating Abuse. 9) Beginning on 02/19/16 and concluding on 02/22/16, in-services on Abuse and Neglect, and Dealing with Combative Resident Behaviors were held. These in-services were prepared by the Infection Preventionist/Nurse Educator, and given by the Administrator, Director of Nursing, and Primary Charge Nurses to all employees. The Dealing with Combative Resident Behavior section of the in-service covered the following objectives: Identify triggers and situations that could cause a resident to become combative; Review the role of staff in managing difficult behaviors; Identify methods to protect both the resident and staff from harm; Discuss scenarios involving combative residents and how the caregiver responds; and Review strategies to help prevent behaviors from escalating. The Abuse and Neglect section of the in-service covered the following objectives: Review the definition of abuse; Discuss the seven types of abuse; Identify the signs and symptoms of abuse; Discuss the SAFE acronym; and Review the requirements of reporting abuse. The Investigating Abuse section of the in-service consisted of watching a video (Resident Abuse: Prevention and Protection Volume XXVII) and review of the revised facility's Abuse Prevention Program. At the conclusion of the in-service, three post-tests were taken covering the three sections of the in-service. The post-tests were graded to ensure each attendee learned the concepts presented. At the conclusion of these in-services 99% of all employees had taken these in-services and passed their post-tests. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires will complete the education and in-service on Abuse and Neglect/Dealing with Combative Resident Behavior before going to work. 10) On 02/19/16 - 02/22/16 the following policies and procedures were reviewed by the Medical Director, Administrator, DON, Assistant Administrator, and Primary Charge Nurses to ensure each policy reflects the intent of the regulation: a) Abuse Prevention Program b) The following policies were reviewed with no revisions. Staff was reeducated (refer to action item #13): Reporting Incidents, Protecting a Resident During an Investigation, Falls Program, Assessment and Care Plan Policy, Assessment and Care Plan Procedure, Notification of a Change in Resident's Condition, Notification of the Director of Nursing or Nursing Administrative Representative who is on call, CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff, Behavior Management, Assessment of a Resident Who Has Sustained an Injury, Accident/Incident Monitoring Policy, The Review and Signing of Care Plan After Each RAI Assessment, The following policy is a new policy created after the IJ was identified. c) Certified Nursing Assistant (CNA) Resident Behavior Monitoring - This policy was created to provide structure in the monitoring of resident behavior. A CNA Resident Behavior Monitoring Log was created to be placed in the Clinical Flow Record for residents who have shown aggressive behaviors. The CNA Documentation will be monitored daily by the nurse who will make changes to the care plan as needed and notify the physician, pharmacy, and Social Services as needed. 11) On 02/23/16, in-services began on the policies and procedures as listed in Action Item #12 for all Nursing staff (including RNs, LPNs, CMAs, SRNAs, and Safety Attendants). The in-services were prepared and taught by the Director of Nursing. The in-services will conclude on Wednesday, 02/24/16. For the in-services, the policies and procedures were organized in sections as they related to deficient practices in the tags identified when the immediate jeopardy was received. Section II of the in-service covered notification. In Section II, the Director of Nursing reviewed the Notification of a Change in the Resident's Condition Policy, The Notification of the Director of Nursing or Nursing Administrative Representative Who Is on Call Policy, and the CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff Policy. For Section II, the DON focused on informing the resident, consulting with physician, and notifying the resident's legal representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Section III of the in-service covered Abuse. In Section III, the Director of Nursing reviewed the Protecting a Resident During an Investigation Policy, and the Abuse Policy covered in Action Item #11. For Section III, the DON focused on the resident's right to be free from all abuse, the facility's obligation to develop and implement an abuse prevention program, the facility's duty to prevent abuse, and the facility's duty to investigate abuse and prevent further abuse during an investigation. As part of the review on abuse, the Director of Nursing asked all attendees if they were aware of any new allegations of abuse. There were no new allegations of abuse reported. Any new allegations of abuse would be investigated immediately according to the facility's Abuse Prevention Program. The Director of Nursing also reminded the staff that abuse is to be reported immediately by reporting it to their immediate supervisor. If action is not taken they are to follow the chain of command by reporting immediately to the Director of Nursing and the Administrator. Section IV of the in-service covered falls and other incidents/accidents. In Section IV, the Director of Nursing reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, and the Falls Program. For Section IV, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment, the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. Section V of the in-service covered appropriate care plan revisions. (Reference Tag F280) In Section V, the Director of Nursing reviewed the Assessment and Care Plan Policy, the Assessment and Care Plan Procedure, and the Review and Signing of Care Plans After Each RAI Assessment Policy. For Section V, the Director of Nursing focused on periodically reviewing and revising the care plan and what types of actions require care plan revisions. The DON discussed that it was the nurses' responsibility to make the necessary care plan revisions and the importance of doing so timely. The DON reviewed that the nurse would make revisions after every accident/incident including but not limited to falls, skin tears, episodes of behavior, and other injuries. The DON reviewed that the MDS Nurse reviewed and revised care plans with every significant change and quarterly. Section VI of the in-service covered quality of care. (Reference Tag F309) In Section VI, the Director of Nursing again reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, the Falls Program, the CNA Resident Behavior Monitoring Policy and Log, and the Behavior Management Policy. For Section VI, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment (to be completed immediately), the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. For Section VI, the Director of Nursing also focused on identifying behaviors and making changes to the Care Plan and Clinical Flow Record to prepare staff to deal with resident behaviors effectively, and prevent them when possible. The DON reminded staff that when there is an incident of behavior that results in a fall or injury they still must follow the processes and complete all assessments mentioned above. At the conclusion of the in-service post-tests were taken by each nurse attending the in-service. The post-tests were graded to ensure that each nurse attendee learned the concepts presented. At the conclusion of the in-service 99% of the Nursing Department employees had attended the in-service. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires in the Nursing Department will complete the education and in-service on these policies and procedures before going to work. 12) Beginning on 02/24/16 The following QAPI audits will be utilized daily to ensure compliance with all of the above actions: Employee Knowledge of Abuse Policy QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nursing employees on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts. The audit will also include having every employee read and resign the revised Abuse Policy. As part of the audit each employee will be asked if they are aware of or have witnessed any abuse. Any issues identified as abuse will be thoroughly investigated as outlined in our Abuse Prevention Program. Reporting Incidents/Accidents, Falls, Notification of Physician/Family, CP Updates QAPI AUDIT: This audit will be performed daily by the Director of Nursing covering 100% of reportable Incidents/Accidents and Falls. This audit will include reviewing that all incident/accidents are reported correctly and that the appropriate assessments are completed, the appropriate notifications are made, and the appropriate revisions are made to the care plan. For the purpose of this audit, information will be gathered from the resident's medical record, incident/accident reports, board charting, completed assessments, and the care plan. Any issues identified will be corrected immediately by the Director of Nursing and reported to the Administrator. CNA/Ancillary Employee Knowledge of Reporting/Behaviors QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of SRNAs on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing staff and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with aggressive/combative resident behaviors. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Nurse Knowledge of Fall/Accident/Injury/Behavior QAPI Audit. This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nurses on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing nurses and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with Fall/Accident Injury/Behavior. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Falls QAPI Audit: This audit will be performed daily by the Director of Nursing covering 100% of all Resident Falls until the removal of the immediate jeopardy. This audit will gather information from the accident/incident report, completed assessments, root cause analysis, 72 Hour post fall assessment, and care plan. Any issues identified will be corrected immediately and reported to the Administrator. Body Mapping QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of Residents until the removal of the immediate jeopardy. This audit will include a daily Head to Toe Assessment of each resident utilizing the Body Mapping Diagram. Any issues identified will be corrected immediately and reported to the Administrator. Mood and Behavior Log QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of all Residents until the removal of the immediate jeopardy. This audit will include reviewing the resident's medical record and mood and behavior logs and ensuring the Care Plan and Clinical Flow Record reflect any necessary interventions. Any issues identified will be corrected immediately and reported to the Administrator. Quality Assurance Resident Interview - Staff Form QAPI Audit: This audit will be perf

Based on interview, record review, facility policy review, and review of the facility's investigation it was determined that the facility failed to be administered in a manner that maintained the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to ensure residents were protected from abuse. The Administrator received an allegation of abuse on 02/07/16. The allegation of abuse was made that Registered Nurse (RN) #1 hit Resident #1 on the left hand multiple times in an attempt to get Resident #1 to let go of her hand. She also cursed at Resident #1. RN #1 admitted to hitting Resident #1 on the hand on 02/07/16 and there were witnesses to the incident. However, the facility investigated the allegation and concluded that RN #1 hit Resident #1 due to her fear of personal injury. The facility did not investigate the alleged verbal abuse between RN #1 and Resident #1. The facility's policy stated they would wait for the Adult Protective Services (APS) investigation findings before determining if an employee named in an abuse allegation would be permitted to return to the facility to provide resident care. However, interview with the Administrator revealed she allowed RN #1 to return to work due to the length of time it was taking APS to complete their investigation. During this time, the Administrator failed to implement any actions to ensure that residents in the facility were free from abuse and/or further potential abuse, as RN #1 was allowed to provide care. The facility Administrator's failure to ensure residents were protected from abuse or protected from further abuse was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 02/07/16 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), and 42 CFR 483.25 Quality of Care (F309). The facility was notified of the Immediate Jeopardy on 02/19/16. An acceptable Allegation of Compliance was received on 02/26/16 which alleged removal of the Immediate Jeopardy on 02/25/16. A partial extended survey was conducted on 03/01-02/16. The State Survey Agency determined Immediate Jeopardy was removed on 02/25/16 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, F226), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes. The findings include: Review of the facility's Administrator job description, undated, revealed the Administrator must be able to successfully carry out the mission of the nursing facility and every task the Administrator performs affects resident care. Continued review of the Administrator's job description revealed the Administrator must have the knowledge base needed to deal with the changing resident population, new federal regulations, and increased demands for professionalism. Further review of the Administrator's job description revealed some of the essential functions of the Administrator were to plan, implement, and evaluate the following: nursing services to maximize the resident's health potential, social service programs to meet the resident's psychological needs, social needs, and resident rights, medical services to meet the resident's medical care needs, and medical records program for resident care to meet documentation requirements. Further review of the facility Administrator's job description stated the Administrator should train, evaluate, and retrain individuals to provide resident care and services. Continued review of the facility Administrator job description revealed the Administrator should plan, implement, and evaluate the following: an overall safety program which will ensure the health, welfare, and safety of residents, and policies and procedures to maintain compliance with laws and regulations. Continued review of the job description revealed the Administrator should observe, monitor, and evaluate outcomes of all programs, policies, and procedures of the facility to ensure effectiveness and should implement, monitor, and ensure the integration of residents' rights with all aspects of the facility's operations. The facility Administrator's job description stated the Administrator should be able to perform the following cognitive tasks: use good judgment, analyze, and investigate. Review of the facility's policy titled Abuse, undated, revealed any observation or allegation of abuse was to be reported immediately to a supervisor and then to the administrator. The policy stated if the alleged violation was verified, appropriate corrective action would be taken. The appropriate action to be taken could include but was not limited to termination of employment and criminal prosecution. Continued review of the policy revealed the definition of physical abuse was doing something with the intention of causing physical pain or injury to a resident. According to the facility's policy, some examples of physical abuse were hitting, scratching, biting, slapping, and punching. Further review of the policy revealed bruising, scratches, and cuts were some examples of possible signs of physical abuse. The facility's policy defined psychological abuse as the threat of injury, unreasonable confinement and punishment, or verbal intimidation and humiliation that may result in mental anguish. The policy gave using insults, using demeaning language, yelling, screaming, and prohibiting free choice as examples of psychological abuse. The facility policy stated if the alleged violation is verified, appropriate corrective action must be taken. Continued review of the facility abuse policy revealed the policy did not address when an employee named in an abuse allegation would be permitted to return to work and provide direct resident care. However, interview with the Facility Administrator on 02/17/16 at 5:01 PM revealed it was the facility's practice to wait for the Adult Protective Services (APS) investigation findings before determining if an employee would be permitted to return back to work at the facility. Interview with the Administrator on 02/17/16 at 3:12 PM revealed she had been notified of the allegation of abuse by LPN #2 at approximately 8:00 AM on 02/07/16. She stated she conducted interviews with staff that had been present during the incident. The Administrator stated that she observed Resident #1's left hand to be red on the knuckles and to have either cuts or abrasions present. Further interview with the Administrator revealed the only residents that had been interviewed during the facility's investigation were Resident #1 and his/her roommate. The Administrator reported that she should have talked to more residents and specifically asked them about RN #1 during the interviews. Continued interview with the Administrator revealed she and the DON met and reviewed RN #1's employee file and had a discussion with RN #1 about how she could have handled the incident differently. The Administrator reported RN #1 told her that she had smacked Resident #1's hand during the incident, but RN #1 did not use the word hit. Continued interview with the Administrator revealed she, the DON, and the Unit Manager conducted the investigation and that she had not unsubstantiated the abuse allegation, but had determined RN #1 had done what she had to do in order to protect herself. She stated that it was never acceptable to hit a resident. Further interview with the Administrator revealed she conducted regular in-services related to reporting abuse and that the abuse allegation should have been reported immediately according to the facility's policy. Continued interview with the Administrator revealed she had been the one who decided to allow RN #1 to come back to work. She stated the facility did not have any written criteria that must be met in order for an employee accused of abuse to return to work, but the facility's practice was for staff to not be permitted to return to work until Adult Protective Services (APS) completed an investigation. The Administrator stated she felt APS was taking too long to complete the investigation and allowed RN #1 to return to work. The Administrator reported that at the time of the interview, RN #1 had not received any disciplinary action as a result of her actions. Further interview with the Administrator revealed she and the DON met and reviewed RN #1's employee file and had a discussion with RN #1 about how she could have handled the incident differently. Continued interview with the Administrator revealed RN #1 had not received any additional training on how to handle combative residents before she had returned to work. A post-survey interview on 03/17/16 at 2:00 PM with the APS worker conducting the investigation revealed she had not completed her investigation yet. The APS worker stated she was concerned that the facility brought RN #1 back to work because the interviews with staff have been consistent that RN #1 struck the resident. *The facility implemented the following actions to remove Immediate Jeopardy. 1) On 02/19/16, the Administrator concluded the facility's investigation. As a result of the completed investigation, RN #1 was terminated. On 02/19/16, RN #1 was contacted by phone and informed that her employment would be terminated effective immediately due to the substantiation of the alleged abuse. RN #1 was informed her counseling would be mailed and the abuse would be reported to the Kentucky Board of Nursing. On 02/19/16, the Administrator filed a complaint online with the Kentucky Board of Nursing and mailed the supporting documentation to the Kentucky Board of Nursing on 02/20/16. 2) On 02/19/16, the three (3) other employees involved in the incident with Resident #1 received written counseling for failure to follow the Abuse Policy and report any allegation of abuse immediately. 3) On 02/19/16, the Administrator notified Resident #1's responsible party by phone of the conclusion of the investigation and of the State Survey Agency (SSA) findings of Immediate Jeopardy. 4) On 02/19/16 the following actions were taken to assess and protect Resident #1 related to the IJ: a) The Assistant Administrator notified Resident #1's Physician of the SSA's findings, requesting the physician to come and assess and examine the resident. The physician assessed Resident #1 on 02/20/16. b) The Director of Nursing and Primary Charge Nurse interviewed Resident #1 to make sure the resident felt safe and to inform the resident that RN #1 no longer worked for the facility. c) On 02/18/16, the care plan for Resident #1 was updated by the Director of Nursing and Primary Charge Nurse to reflect the fall which occurred and the behavior which led to the incident of substantiated abuse. On 02/22/16, the care plan for Resident #1 was reviewed again by the Minimum Data Set (MDS) Coordinator to see if any additional updates were necessary following the physician's visit. d) On 02/19/16, Resident #1 was reassessed using the Department of Nursing Body Mapping Diagram. No new injuries were identified. 5) On 02/19/16 - 02/24/16 the following actions were taken to assess all facility residents for any physical signs and symptoms of abuse and to check for appropriate notification and care plan revisions: a) On 02/19/16, all residents were reassessed utilizing the Department of Nursing Body Mapping Diagram. All assessments were completed and signed by the nurse performing the assessment. Assessment included documenting skin condition and measuring all abnormalities noted and looking for any warning signs of potential abuse. No suspicious injuries were identified and there were no findings of potential abuse. b) On 02/19/16 - 02/24/16 all incident reports (including falls) from 01/01/16 - 02/24/16 were reviewed by the Director of Nursing and Primary Charge Nurses utilizing the Reporting Incidents/Accidents, Falls, Notification of Physician/Family, Care Plan Updates, Quality Assurance, and Performance Improvement (QAPI) Audit, with a focus on ensuring that there was proper notification to nursing administration, physician, and the responsible party. There were no new notification issues identified. c) On 02/19/16 - 02/24/16 all residents' care plans were updated to reflect reassessment of skin, results of the Department of Nursing Body Mapping Diagram, results of the Incidents/Accidents, Falls, Notification of Physician/Family and CP Updates Audit. d) Beginning on 02/19/16 and concluding on 02/20/16, a mood and behavior audit was performed by the Director of Nursing and Primary Charge Nurses utilizing the new Mood and Behavior Log QAPI Audit. They reviewed the Mood and Behavior Log for all residents and identified residents with aggressive/combative behavior. For each resident with aggressive/combative behavior the care plan and clinical flow record were reviewed and revised when necessary to reflect appropriate interventions. 6) On 02/16/16 - 02/19/16 every alert and interviewable resident in the facility (identified as having a BIMS score of 8-15) was interviewed and surveyed by the Social Service Workers utilizing the Quality Assurance Resident Interview - Staff Form. The interview included questions on resident rights, and abuse and neglect. There were no reports of allegations of abuse. Effective 02/24/16, the Social Service Workers will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. 7) On 02/19/16 - 02/22/16 the Abuse Prevention Program was reviewed and revised with a focus on but not limited to: a) Investigative Protocol Revised Section V to include: Collecting and preserving physical and documentation evidence; An interview with the person reporting alleged abuse; Interviews with any witnesses that may have knowledge of the alleged abuse; An interview with the alleged resident; Interviews with staff who have worked with the accused to determine if they ever witnessed any mistreatment by the accused; An interview with the accused staff member allegedly responsible for mistreatment or abuse; Interviews with other residents to determine if they have been abused or mistreated; Interviews with other staff who have contact with the resident; Interviews with staff who worked previous shifts to determine if they were aware of any injury or incident; Review of incident reports regarding the resident to ensure timely notification of physician and family of incident of alleged abuse; and Review of care plan to ensure accident/injury is documented as well as necessary interventions. b) Protecting a Resident During an Investigation revised to include: All staff alleged of resident abuse will be suspended immediately, exit the workplace, and be advised that they are not permitted on the facility's premises until the investigation is completed by Social Services (Adult Protection) and the Office of Inspector General. An assessment will be conducted by the Primary Charge Nurse in collaboration with the assigned Nurse. This will include a physical assessment, interview of the resident for fear, anxiety, and/or depression. Appropriate interventions and treatments will be addressed. Social Service Staff will follow up in a few days and interview the resident for fear, depression, and anxiety. c) Administrator Conclusion of Investigation revised to include: The Investigative Report submitted to Social Services (Adult Protection), Office of Inspector General, Police Department (if applicable), and other state agencies as required will contain a conclusion and any corrective actions taken as a result of the investigation. 8) On 02/19/16 at 10:00PM, the Infection Preventionist/Nurse Educator in-serviced the Administrator, Assistant Administrator, Director of Nursing, and Primary Charge Nurses on Abuse and Neglect, Dealing with Combative Resident Behavior, and Investigating Abuse. 9) Beginning on 02/19/16 and concluding on 02/22/16, in-services on Abuse and Neglect, and Dealing with Combative Resident Behaviors were held. These in-services were prepared by the Infection Preventionist/Nurse Educator, and given by the Administrator, Director of Nursing, and Primary Charge Nurses to all employees. The Dealing with Combative Resident Behavior section of the in-service covered the following objectives: Identify triggers and situations that could cause a resident to become combative; Review the role of staff in managing difficult behaviors; Identify methods to protect both the resident and staff from harm; Discuss scenarios involving combative residents and how the caregiver responds; and Review strategies to help prevent behaviors from escalating. The Abuse and Neglect section of the in-service covered the following objectives: Review the definition of abuse; Discuss the seven types of abuse; Identify the signs and symptoms of abuse; Discuss the SAFE acronym; and Review the requirements of reporting abuse. The Investigating Abuse section of the in-service consisted of watching a video (Resident Abuse: Prevention and Protection Volume XXVII) and review of the revised facility's Abuse Prevention Program. At the conclusion of the in-service, three post-tests were taken covering the three sections of the in-service. The post-tests were graded to ensure each attendee learned the concepts presented. At the conclusion of these in-services 99% of all employees had taken these in-services and passed their post-tests. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires will complete the education and in-service on Abuse and Neglect/Dealing with Combative Resident Behavior before going to work. 10) On 02/19/16 - 02/22/16 the following policies and procedures were reviewed by the Medical Director, Administrator, DON, Assistant Administrator, and Primary Charge Nurses to ensure each policy reflects the intent of the regulation: a) Abuse Prevention Program b) The following policies were reviewed with no revisions. Staff was reeducated (refer to action item #13): Reporting Incidents, Protecting a Resident During an Investigation, Falls Program, Assessment and Care Plan Policy, Assessment and Care Plan Procedure, Notification of a Change in Resident's Condition, Notification of the Director of Nursing or Nursing Administrative Representative who is on call, CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff, Behavior Management, Assessment of a Resident Who Has Sustained an Injury, Accident/Incident Monitoring Policy, The Review and Signing of Care Plan After Each RAI Assessment, The following policy is a new policy created after the IJ was identified. c) Certified Nursing Assistant (CNA) Resident Behavior Monitoring - This policy was created to provide structure in the monitoring of resident behavior. A CNA Resident Behavior Monitoring Log was created to be placed in the Clinical Flow Record for residents who have shown aggressive behaviors. The CNA Documentation will be monitored daily by the nurse who will make changes to the care plan as needed and notify the physician, pharmacy, and Social Services as needed. 11) On 02/23/16, in-services began on the policies and procedures as listed in Action Item #12 for all Nursing staff (including RNs, LPNs, CMAs, SRNAs, and Safety Attendants). The in-services were prepared and taught by the Director of Nursing. The in-services will conclude on Wednesday, 02/24/16. For the in-services, the policies and procedures were organized in sections as they related to deficient practices in the tags identified when the immediate jeopardy was received. Section II of the in-service covered notification. In Section II, the Director of Nursing reviewed the Notification of a Change in the Resident's Condition Policy, The Notification of the Director of Nursing or Nursing Administrative Representative Who Is on Call Policy, and the CNA Reporting Changes in Condition and Interruption to Direct Care to Licensed Nursing Staff Policy. For Section II, the DON focused on informing the resident, consulting with physician, and notifying the resident's legal representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharge the resident from the facility. Section III of the in-service covered Abuse. In Section III, the Director of Nursing reviewed the Protecting a Resident During an Investigation Policy, and the Abuse Policy covered in Action Item #11. For Section III, the DON focused on the resident's right to be free from all abuse, the facility's obligation to develop and implement an abuse prevention program, the facility's duty to prevent abuse, and the facility's duty to investigate abuse and prevent further abuse during an investigation. As part of the review on abuse, the Director of Nursing asked all attendees if they were aware of any new allegations of abuse. There were no new allegations of abuse reported. Any new allegations of abuse would be investigated immediately according to the facility's Abuse Prevention Program. The Director of Nursing also reminded the staff that abuse is to be reported immediately by reporting it to their immediate supervisor. If action is not taken they are to follow the chain of command by reporting immediately to the Director of Nursing and the Administrator. Section IV of the in-service covered falls and other incidents/accidents. In Section IV, the Director of Nursing reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, and the Falls Program. For Section IV, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment, the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. Section V of the in-service covered appropriate care plan revisions. (Reference Tag F280) In Section V, the Director of Nursing reviewed the Assessment and Care Plan Policy, the Assessment and Care Plan Procedure, and the Review and Signing of Care Plans After Each RAI Assessment Policy. For Section V, the Director of Nursing focused on periodically reviewing and revising the care plan and what types of actions require care plan revisions. The DON discussed that it was the nurses' responsibility to make the necessary care plan revisions and the importance of doing so timely. The DON reviewed that the nurse would make revisions after every accident/incident including but not limited to falls, skin tears, episodes of behavior, and other injuries. The DON reviewed that the MDS Nurse reviewed and revised care plans with every significant change and quarterly. Section VI of the in-service covered quality of care. (Reference Tag F309) In Section VI, the Director of Nursing again reviewed the Reporting Incidents Policy, the Accident/Incident Monitoring Policy, the Falls Program, the CNA Resident Behavior Monitoring Policy and Log, and the Behavior Management Policy. For Section VI, the DON focused on staff assessment of the resident after a fall or other incident/accident. The DON reviewed the Quick Reference for Processing a Fall and step by step requirements the nurse is to complete when there is a fall or other accident/incident. The DON also discussed and reviewed the completion and routing of incident reports. The DON reviewed completing the Initial Assessment (to be completed immediately), the actual Incident Report, the Root Cause Analysis, the 72 Hour Post Fall/Potential Injury Assessment, and Head to Toe Assessments utilizing the Body Mapping Diagram. For Section VI, the Director of Nursing also focused on identifying behaviors and making changes to the Care Plan and Clinical Flow Record to prepare staff to deal with resident behaviors effectively, and prevent them when possible. The DON reminded staff that when there is an incident of behavior that results in a fall or injury they still must follow the processes and complete all assessments mentioned above. At the conclusion of the in-service post-tests were taken by each nurse attending the in-service. The post-tests were graded to ensure that each nurse attendee learned the concepts presented. At the conclusion of the in-service 99% of the Nursing Department employees had attended the in-service. Any employee who was on a leave of absence or vacation will not be permitted to return to work in the resident care area before they complete these in-services. Also, all new hires in the Nursing Department will complete the education and in-service on these policies and procedures before going to work. 12) Beginning on 02/24/16 The following QAPI audits will be utilized daily to ensure compliance with all of the above actions: Employee Knowledge of Abuse Policy QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nursing employees on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts. The audit will also include having every employee read and resign the revised Abuse Policy. As part of the audit each employee will be asked if they are aware of or have witnessed any abuse. Any issues identified as abuse will be thoroughly investigated as outlined in our Abuse Prevention Program. Reporting Incidents/Accidents, Falls, Notification of Physician/Family, CP Updates QAPI AUDIT: This audit will be performed daily by the Director of Nursing covering 100% of reportable Incidents/Accidents and Falls. This audit will include reviewing that all incident/accidents are reported correctly and that the appropriate assessments are completed, the appropriate notifications are made, and the appropriate revisions are made to the care plan. For the purpose of this audit, information will be gathered from the resident's medical record, incident/accident reports, board charting, completed assessments, and the care plan. Any issues identified will be corrected immediately by the Director of Nursing and reported to the Administrator. CNA/Ancillary Employee Knowledge of Reporting/Behaviors QAPI Audit: This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of SRNAs on all units and on all shifts until the removal of the immediate jeopardy. This audit will also be performed daily by each Department Head covering greater than 90% of their employees on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing staff and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with aggressive/combative resident behaviors. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Nurse Knowledge of Fall/Accident/Injury/Behavior QAPI Audit. This audit will be performed daily by the Infection Preventionist/Nurse Educator covering greater than 95% of nurses on all units and on all shifts until the removal of the immediate jeopardy. This audit includes interviewing nurses and testing their knowledge and comprehension regarding recognizing, preventing, reporting, and dealing with Fall/Accident Injury/Behavior. Any issues identified will be addressed through immediate reeducation and reported to the Administrator. Falls QAPI Audit: This audit will be performed daily by the Director of Nursing covering 100% of all Resident Falls until the removal of the immediate jeopardy. This audit will gather information from the accident/incident report, completed assessments, root cause analysis, 72 Hour post fall assessment, and care plan. Any issues identified will be corrected immediately and reported to the Administrator. Body Mapping QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of Residents until the removal of the immediate jeopardy. This audit will include a daily Head to Toe Assessment of each resident utilizing the Body Mapping Diagram. Any issues identified will be corrected immediately and reported to the Administrator. Mood and Behavior Log QAPI Audit: This audit will be performed daily by the Director of Nursing and Primary Charge Nurses on 100% of all Residents until the removal of the immediate jeopardy. This audit will include reviewing the resident's medical record and mood and behavior logs and ensuring the Care Plan and Clinical Flow Record reflect any necessary interventions. Any issues identified will be corrected immediately and reported to the Administrator. Quality Assurance Resident Interview - Staff Form QAPI Audit: This audit will be performed daily by the Social Service Workers who will interview 25% of interviewable residents (identified as having a BIMS score of 8-15) on each unit every day until the removal of the immediate jeopardy. The interview will include questions on resident rights, and abuse and neglect. Any report of abuse will be thoroughly investigated and reported immediately according to the Abuse Prevention Program. The Social Service workers will address every non-abuse negative comment or response by referring them to the appropriate department and continuing to follow up daily until negative responses are resolved. The Administrator will compile a daily report and summary of all of the above QAPI audits to be reviewed by the QAPI Committee including the Medical Director who will review the daily report and all action taken to address and remove the Immediate Jeopardy. The Medical Director will review daily all incident reports/accidents/falls, review of all allegations of abuse, review of all QAPI Audits. **The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1) Review of the revised facility investigation (undated) revealed the State Survey Agency (SSA) substantiated abuse and the facility terminated RN #1's employment with the facility effective 02/19/16. Review of a facility statement, Employee Counseling Form, dated 02/19/15, revealed the facility contacted RN #1 on 02/19/16 and notified her that her employment with the facility was terminated effective 02/19/16 and that her written counseling would be mailed. She was also notified the abuse would be reported to the Kentucky Board of Nursing (KBN). Continued review of the facility statement revealed the Facility Administrator, Assistant Administrator, Director of Nursing, and Human Resources Director were present at the time the phone call was made to RN #1. Review of a mailing label dated 02/19/16 revealed the Employee Counseling Form had been mailed to RN #1 on 02/19/16. Review of a KBN facility complaint form dated 02/19/16 revealed the facility filed a complaint regarding RN #1 to the KBN via the internet. Review of a mailing label dated 02/20/16 revealed the facility mailed the required documentation to the KBN to complet