Every finding on record at Lee County Care & Rehabilitation Center

Based on observations, interviews, and record review conducted from 12/16/2025 - 12/18/2025, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Multiple ongoing environmental concerns were identified that had the potential to negatively impact the health, safety, and quality of life of residents, staff, and the public. These issues were noted throughout resident rooms and common areas. These findings demonstrated a failure to routinely monitor, identify, and address environmental concerns to maintain the facility in safe and good repair. Review of the facility's policy titled Resident Rights, last revised 01/31/2025, revealed all residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. However, observations, interviews, and record review revealed the facility did not consistently maintain the physical environment in accordance with this policy.Review of the facility's maintenance request logs revealed multiple environmental concerns identified during the survey, including damaged wall surfaces, broken or deteriorated tiles, rusted fixtures, and other structural concerns in resident rooms and common areas, were not consistently documented in the maintenance tracking system prior to surveyor observation. Maintenance requests for several of these concerns were entered into the log on or after 12/17/2025 and 12/18/2025, following identification during the survey. This indicated the facility did not have an effective system in place to routinely identify, document, and track maintenance concerns to ensure the physical environment was maintained in safe and good repair.Observation on 12/17/2025 at 3:35 PM in the C Wing shower room revealed environmental conditions that were not maintained in a safe and sanitary manner. Two cracked tiles were observed at the corner of the shower. A black, mold-like substance was observed underneath the blue cushion of a resident mobile shower chair. In addition, a wad of hair, debris, and loose hair were observed underneath the blue cushion and on the surface beneath the cushion of the mobile shower bed.Observation on 12/17/2025 at 3:55 PM in the B Wing shower room revealed a rusted air vent located within the shower area, two broken tiles noted on the corner of the shower entrance, and multiple floor tiles observed separating from the corner wall. Additionally, a mobile shower chair stored in the shower room was observed with a mold-like substance present on its surface and wheel wells. Observations during a facility tour conducted on 12/18/2025 beginning at 8:56 AM revealed multiple areas within resident use and common areas that were not maintained in a safe, functional, and sanitary manner. In the dining room, six ceiling tiles were observed with brown staining, black substance was noted on ceiling tiles located directly outside of the kitchen area, and multiple drop ceiling clips exhibited visible rust. A section of baseboard was missing from a dining room wall. On the ramp leading to the dining room, ceiling tiles were observed to be sagging, including two tiles with brown staining and one tile with a broken corner. The door frame leading to the nurses' station on B Wing was observed to be rusted, and paint was noted to be scratched and missing from the wall between resident rooms B12 and B13. The door to resident room B10 was missing a section of paneling and paint. Additional observations included a scuffed and rusted door frame leading to the utility room on B Hall, a scuffed and rusted door frame leading to the restroom in resident room B2, and a scuffed and rusted door frame leading to resident room A4. A four-inch area of paint was observed to be chipped off the wall outside of resident room A5. In addition, the light panel at the C Wing nurses' station was observed to be broken, and the wall corner guard located across from the C Wing nurses' station was observed to be broken and separated from the wall. These conditions demonstrated a lack of routine environmental monitoring and maintenance, resulting in multiple deteriorated surfaces and fixtures present thought-out resident-use and common areas. Interview with Resident (R21) on 12/16/2025 at approximately 11:11 AM stated he had a hole in the ceiling of his room that had been present for several weeks and stated no one had come to assess or repair it. R21 further stated he had observed brown stains on the ceiling in the dining room and noticed cracked tiles and broken ceiling tiles in the shower room. He further stated that since residing at the facility, no one had addressed the rust present around the entryway to his room or in the bathroom. R21 stated he would like these concerns repaired and indicated that if he were able to do so himself at home, the repairs would have already been completed.Interview with State Registered Nurse Aide (SRNA) 1 on 12/17/2025 at 11:30 AM stated she had been employed by the facility for approximately one month and stated that the door paneling to resident room B10 had been missing for the duration of her employment. SRNA 1 further stated that she had not reported the missing paneling to supervisory or maintenance staff for repair, although she acknowledged that it should have been reported. SRNA 1 stated the facility serves as the residents' home and that maintaining the physical environment in good repair was important to promote resident safety and comfort.Interview with the District Manager for housekeeping services on 12/17/2025 at 4:00 PM stated mobile shower chairs and mobile shower beds were expected to be cleaned by either nursing staff or housekeeping staff after each resident use to promote resident safety and reduce the risk of infection transmission. The District Manager further stated that damaged wall tiles and deteriorated surfaces within resident shower areas were hazardous, as broken or sharp edges could result in residents sustaining cuts or other injuries during use of the bathing area.Interview with the Housekeeping Supervisor on 12/17/2025 at 4:06 PM stated neither she nor her housekeeping staff routinely cleaned mobile shower devices after each use. The Housekeeping Supervisor acknowledged that ensuring resident safety was important and further stated that the wheel wells of the mobile shower chair were not routinely cleaned. She indicated that failure to remove mold-like substances from shower equipment could potentially place residents at risk for respiratory issues and other health concerns. Interview with Housekeeper 2 on 12/18/2025 at 9:25 AM stated she had observed multiple environmental concerns within resident rooms and common areas, including brown stains and broken ceiling tiles, scuffed flooring, and rust present on door frames leading to resident rooms. Housekeeper 2 stated that she had not reported these concerns to the maintenance department but should have. She further stated she did not routinely report environmental concerns she considered to be cosmetic in nature. Housekeeper 2 stated it was important to report all environmental concerns, so residents did not feel like they lived in a broken facility. Interview with the Maintenance Director on 12/18/2025 at approximately 3:00 PM stated he conducted facility rounds on a weekly basis to identify areas in need of repair and maintenance; however, he stated that he relied on all facility staff to report environmental concerns as they were identified. The Maintenance Director stated that he was not aware of a hole in the wall of resident room [ROOM NUMBER] on the B Wing at the time of interview. He further stated the maintenance department consisted of one Maintenance Director, one full-time maintenance employee, and one additional staff member who assisted as needed. The Maintenance Director stated that during the week of the survey, more maintenance work was completed than at any other time since he assumed the role due to having additional staff onsite to help.Interview with the Regional Plant Operations Manager on 12/18/2025 at 3:05 PM stated the facility needed to establish a plan to ensure the physical environment was maintained in good repair. He further stated that maintaining the physical environment was important to ensure resident safety and comfort.Interview with the Administrator on 12/18/2025 at 3:20 PM stated it was her expectation that environmental concerns and items in need of repair were identified and corrected in a timely manner. The Administrator stated all staff were expected to report environmental issues to the maintenance department to ensure repairs were completed and resident safety was maintained.Interview with State Registered Nurse Aide (SRNA) 2 on 12/18/2025 at 3:30 PM, stated she was aware of environmental concerns within the facility, including cracked tiles in resident shower areas and a rusted air vent located in the shower room, but had not reported them to anyone. SRNA 2 stated these areas had been present for an extended period and had not been repaired. SRNA 2 further stated she had utilized the mobile shower chair during resident care and acknowledged that she had not ever cleaned the wheel wells of the mobile shower chair after use. She stated environmental conditions, and equipment should be maintained in a clean and safe condition, as residents rely on staff to ensure bathing areas and equipment do not pose a safety or health concern.

Based on observation, interview, and review of facility's policy, the facility failed to protect resident rights to privacy related to electronic medical records (EMRs). The computer located on top of the medication cart, contained confidential resident information and was observed to be left open and viewable to visitors, residents, and staff in the hallway on 12/16/2025 at 10:34AM,10:40AM and at 11:05AM. The findings include: Review of the facility admission packet under title Resident Records, Duties of facilities effective June 20, 2005, section 7 revealed all residents' shall be provided with confidential treatment of their medical and personal records. Review of the facility admission packet under title Federal- Resident Rights -privacy and confidentiality revealed the resident has the right to personal privacy and confidentiality of his/her personal and medical records, and the right to refuse the release of personal and medical records in accordance with state laws. This included privacy and confidentiality in his /her accommodations, medical treatment, written and telephone communications, personal care, visits and meetings with family and residents' groupsObservation of the medication/treatment cart located at the B Wing nurses' station, on 12/16/2025 at 10:34AM, 10:40AM and at 11:05AM, revealed the computer was left open with residents' information in public view. Residents and staff were observed in the hallway during all three observations. Further observation of the computer screen revealed a resident picture in the upper left-hand corner. On 12/16/2025 at 10:42AM the Director of Nursing (DON) was walking down the hall and saw the computer left open with residents' information in clear view of anyone in the hall. The DON stated in an interview that it was a violation of privacy, and that the computer screen should be minimized before staff walked away from the medication cart.During an interview on 12/16/2025 at 10:45AM RN 1 stated leaving the computer open with resident information visible to anyone was a violation of the resident's privacy. On 12/16/20025 at 11:05AM RN1 was observed to prepare medication for a resident and RN1 walked away from the B Wing medication cart with the computer screen open and resident information in full view of anyone one in the hallway.During an interview on 12/17/2025 at 11:40 AM, the Administrator, stated the computer screen should be minimized or closed for resident privacy before staff walk away from the medication cart.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was accurate, person-centered, and reflective of the resident's assessed needs and preferences for one of 27 sampled residents (R21). Review of R21's behavioral care plan revealed it was updated to include the statement I have a history of refusing showers and medications at times; however, the care plan did not include any corresponding interventions to address the identified behaviors. Interview with R21 revealed he did not refuse showers. Additionally, interview with the Medical Records Nurse revealed R21 did not have a history of refusing medications and stated this information should not have been included in the care plan. This resulted in a care plan that contained inaccurate information and failed to provide individualized interventions to guide staff in meeting the resident's needs.Review of the facility's policy titled Resident Assessment, last reviewed on 01/31/2025, revealed the facility was responsible for conducting comprehensive, accurate, and standardized assessments of each resident using multiple sources of information, including resident interview, medical record review, observations, and input from interdisciplinary staff, to ensure assessment data accurately reflected the resident's status. The policy further required if assessment data was conflicting, inaccurate, or requires clarification, the Minimum Data Set Coordinator was responsible for verifying the information with the resident and appropriate staff and correcting the documentation accordingly. Additionally, the policy required any identified inaccuracies be clarified and corrected through appropriate documentation to ensure the resident's care plan accurately reflected the resident's needs, preferences, and behaviors.Review of the facility's policy titled Resident Rights, last reviewed 01/31/2025, revealed all residents have the right to be treated with respect and dignity and to receive care in a manner and environment that promotes maintenance or enhancement of quality of life. The policy further stated residents have the right to participate in decisions regarding their care and care planning and to review their care plan, including the right to be informed of and participate in decisions affecting their treatment. Additionally, the policy emphasized respect for the resident's individuality and self-determination, requiring that care planning accurately reflected the resident's preferences, needs, and choices.Review of the facility's policy titled Behavioral Health, last reviewed 09/13/2024, revealed the facility was responsible for providing necessary behavioral health care and services in accordance with each resident's comprehensive assessment and plan of care to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further stated behavioral health care was to be based on a comprehensive resident assessment, and person-centered approaches must be implemented according to the resident's interests, preferences, and choices. Additionally, the policy required staff remain alert to the effectiveness and accuracy of care plan interventions, and the care plan be reviewed and revised as necessary to reflect the resident's current status and needs.Review of the facility's policy titled Quality Assurance/Performance Improvement (QAPI) Program Policy, last reviewed on 2/3/2025, revealed the facility was responsible for conducting an ongoing, systematic Quality Assurance and Performance Improvement program designed to monitor, evaluate, and improve the quality and appropriateness of resident care. The policy stated QAPI activities were to examine both processes and outcomes, identify problem areas, and implement corrective actions when care practices place resident outcomes at risk. The policy further required the QAPI Committee to review identified concerns, conduct audits and assessments, and develop improvement plans when care processes, including care planning and assessment accuracy, fail to meet standards or negatively affect resident care.Review of the facility's Abuse, Neglect and Misappropriation of Property policy, last reviewed 1/31/25, revealed the facility was responsible for the ongoing identification, assessment, care planning, and monitoring of residents' needs and behaviors to prevent harm, neglect, and unmet psychosocial needs. The policy stated residents were to be monitored for changes in condition, care planning was to include appropriate interventions based on identified needs, and residents' physical, mental, and psychosocial well-being were to be addressed through assessment, care planning, and ongoing monitoring. The policy further required identified resident needs and behaviors be addressed through appropriate interventions to ensure residents received care and services consistent with their assessed needs.Review of the facility's policy titled Comprehensive Care Plans, last reviewed on 1/31/2025, revealed the facility was responsible for developing and implementing a comprehensive, person-centered care plan for each resident based on a thorough assessment of the resident's medical, nursing, mental, and psychosocial needs. The policy required the Interdisciplinary Team to develop and maintained a care plan that incorporated identified problem areas and associated risk factors, including measurable objectives, and to ensure the care plan was revised as necessary when changes occur. The policy further stated residents and/or their representatives were encouraged to participate in the development and review of the care plan, and the comprehensive care plan was designed to address identified problems through individualized interventions to assist in preventing or reducing declines in the resident's physical and psychosocial well-being.Review of Resident 21's behavioral care plan, start date 11/20/2025, revealed it had been updated to include the statement the resident has a history of refusing showers and medications at times. Further review revealed the care plan did not include any identified interventions, approaches, or strategies to address the identified behaviors. The care plan lacked documentation supporting the inclusion of these behaviors and did not reflect individualized, person-centered interventions related to bathing or medication administration. The inclusion of unsupported behavioral concerns without corresponding interventions indicated the care plan was not based on an accurate and comprehensive assessment of the resident's needs and did not demonstrate an individualized approach to care planning.Review of Resident 21's Nurse Aide Care Plan revealed an entry dated 12/15/2025 indicating leave and return; however, the documentation did not include any clarification regarding the purpose of the leave, the duration, or specific instructions identifying when or how the information was to be applied to the resident's care. Further review revealed the entry lacked accompanying guidance or direction for nursing staff or nurse aides to ensure continuity and consistency of care following the resident's return. Additionally, the entry was not signed or initialed by the individual who entered the information. The absence of clear instructions and staff authentication indicated the Nurse Aide Care Plan did not provide sufficient, individualized guidance to direct staff in meeting the resident's care needs.Review of R21's Resident Face Sheet revealed R21 was admitted to the facility on [DATE] following a hospital stay with diagnosis including cerebral infarction with left sided hemiplegia (damage to the right side of the brain, causing paralysis on the body's left side.)Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.The MDS Nurse 1 stated in interview on 12/17/2025 at 2:45 PM upon review of Resident 21's care plan, the resident did not have any interventions in place related to a behavioral concern of refusing showers or medications. MDS Nurse 1 stated if a behavior was identified and entered onto a care plan, corresponding interventions should be implemented immediately to address the behavior. MDS Nurse 1 further stated she reviewed the care plan at the time of the interview and was unable to locate any interventions addressing refusal of showers or medications, indicating the care plan did not provide guidance to staff regarding the identified behavior.Interview with MDS Nurse 2 on 12/17/2025 at 2:45 PM stated the resident did not have a documented history of refusing showers or medications and no interventions addressing refusal of showers or medications were present on the care plan. MDS Nurse 2 stated when behaviors were added to a care plan, it was expected that individualized interventions were developed to ensure staff have clear direction on how to meet the resident's needs. MDS Nurse 2 further stated staff received routine training, including pre- and post-testing, to promote understanding of care planning expectations; however, the resident's care plan did not reflect interventions aligned with those expectations.The Medical Records Nurse stated in interview on 12/17/2025 at 3:15 PM she was responsible for entering the behavioral information onto Resident 21's care plan. The Medical Records Nurse stated when a behavioral concern was identified, the care plan should be updated immediately with person-centered interventions to guide staff in addressing the behavior; however, she stated she had forgotten to update the care plan with interventions for R21's behaviors. The Medical Records Nurse further acknowledged that although the behavioral concern had been added to the care plan, corresponding interventions were not entered at that time. She additionally stated a care plan entry had previously been made indicating the resident refused medications; however, upon later review, it was determined the resident did not have a history of refusing medications, and the care plan was subsequently updated to remove the incorrect behavior from R21's care plan.Interview with the Administrator on 12/17/2025 at 3:50 PM stated it was her expectation when a behavior was identified and added to a resident's care plan, the care plan would be updated immediately to include appropriate interventions. The Administrator further stated nurse aides were expected to reference the Nurse Aide Care Plan for direction regarding resident care and this document was intended to guide nurse aides in how care was to be provided to the resident. (The Nurse Aide Care Plan was used by nurse aides for day-to-day care direction, whereas the comprehensive care plan reflected the resident's overall care needs and required nursing interventions.)State Registered Nurse Aide (SRNA) 3 stated in interview on 12/18/2025 at 10:13 AM she had worked at the facility for more than three years; however, she did not understand what the notation leave and return on Resident 21's Nurse Aide Care Plan meant. SRNA #3 stated she would need to ask a nurse for clarification regarding the instruction.Registered Nurse (RN) 2 stated in interview on 12/18/2025 at 10:15 AM the leave and return notation on the Nurse Aide Care Plan should have included clearer instructions for staff, like when the directive applied, what services it applied to, and how it was expected to be used by nurse aides. RN 2 further stated the entry should have been signed or otherwise identified by the individual who entered it so staff would know who to contact for clarification if additional information was needed.During an interview with State Registered Nurse Aide (SRNA) 4 on 12/18/2025 at 10:20 AM she stated she did not understand what the leave and return notation on Resident 21's Nurse Aide Care Plan meant. SRNA #4 stated the entry should have been signed or initialed by the individual who added it to the care plan so nursing assistants would know who to ask for clarification.R21 stated in interview on 12/18/2025 at 12:35 PM that he has never refused showers or medications. R21 further stated when personal care services were not provided in a timely manner, he felt unclean and uncomfortable, which made him more likely to request hygiene care rather than refuse it. R21 stated due to these feelings, he would not refuse showers and did not understand why the facility would have care planned for refusals or behaviors he has not demonstrated.The Director of Nursing (DON) stated in interview on 12/18/2025 at 2:04 PM it was her expectation that when a behavior was entered into a resident's care plan, nursing staff update the care plan at that time to include appropriate interventions. The DON stated nursing staff were responsible for ensuring the care plan accurately reflected the resident's current needs and provided clear guidance for staff.

Based on observation, record review, and interview, the facility failed to ensure one out of 27 sampled resident's (R21) basic hygiene needs were met by not providing routine nail care as needed. The failure to provide routine nail care resulted in long unclean nails, placing the resident at risk for discomfort, skin integrity issues, and infection.Review of the facility's policy titled Resident Rights, last revised 01/31/2025, revealed all residents would be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Additionally, the stakeholders would respect the resident's individuality and value their input by providing a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility.Review of the facility's policy titled Abuse, Neglect, and Misappropriation of Property, last revised 09/15/2023, revealed neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of R21's Resident Face Sheet revealed R21 was admitted to the facility on [DATE] following a hospital stay with diagnosis including cerebral infarction with left sided hemiplegia (damage to the right side of the brain, causing paralysis on the body's left side.), dysphagia (difficulty swallowing), and chronic respiratory conditions.Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.Review of R21's Behavioral Care Plan, problem start date 11/20/2025, revealed R21 had a history of self-inflicted scratching and bruising to the left side of his nose, with nursing interventions documented to address hygiene and reduce the risk of complications. Observations conducted on 12/16/2025 through 12/18/2025 revealed R21's fingernails were long and visibly soiled on each day. R21's nails extended beyond the fingertips and contained dark debris underneath all fingernails. The condition of R21's fingernails remained unchanged throughout the observation period.During an interview conducted with R21 on 12/16/2025 at 11:11 AM, R21 stated his fingernails had not been cut in over a month. R21 reported he had asked facility staff on multiple occasions to trim his fingernails but felt his requests were ignored. R21 further stated if he were able to trim his fingernails himself, he would do so. R21 expressed not having his fingernails trimmed in the manner he preferred made him feel dirty.During an interview conducted with State Registered Nurse Aide (SRNA) 4 on 12/18/2025 at 10:05 AM, SRNA 4 stated she did not bring R21's shower documentation sheet with her during the resident's shower care and therefore did not document the observations related to R21's skin or nail care. SRNA 4 stated nail care was typically addressed during the shower routine; however, she did not verify whether R21 was a diabetic prior to initiating the shower. SRNA 4 stated if a resident was a diabetic, nail care must be completed by a licensed nurse and documented accordingly. SRNA 4 further stated she did not complete R21's shower documentation sheet at the time of care, explaining she became sidetracked and left the form incomplete along with other residents' documentation. Additionally, SRNA 4 stated documenting observations during shower care was intended to alert licensed nursing staff to residents' additional care needs, including nail care.During an interview conducted with Registered Nurse (RN) 2 on 12/18/2025 at 10:15 AM, RN 2 stated shower documentation sheets were intended to be reviewed to identify residents who require nail care. RN2 stated that SRNA's were expected to complete the shower documentation sheets and provide them to licensed nurses for review so that any additional care needs, including nail care, could be addressed. RN2 further stated SRNA's should verify whether a resident was diabetic prior to providing nail care, as nail care for diabetic residents must be completed by a licensed nurse, with podiatry providing toenail care as indicated. RN2 stated that completion and review of the shower documentation sheets was essential, as there was no designated location within the Electronic Health Record (EHR) to document nail care. Additionally, RN2 sated that failure to identify and follow up on nail care needs may result in routine hygiene care not being provided as intended.During an interview conducted with Director of Nursing (DON) on 12/18/2025 at 2:04 PM, the DON stated trimming residents' nails was a responsibility of the nursing staff and part of providing routine personal care. The DON stated it was her expectation that nursing staff listen to residents when they communicate care needs or requests and take appropriate action to address those needs. The DON further stated that if R21 had been requesting nail care, his nails should have been trimmed.During an interview conducted with the Administrator on 12/18/2025 at 2:30 PM, the Administrator stated the shower documentation sheets were not the only method for staff to communicate residents' care needs and that staff could also verbally communicate identified needs to licensed nursing staff. The Administrator stated it was her expectation that staff communicate resident care needs through appropriate channels and follow through to ensure those needs were addressed. The Administrator did not identify any additional system used to track or ensure follow-up of verbally communicated care needs.

Based on observation, interview, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 27 sampled residents, (Resident (R)59). The findings include:Review of the policy titled Infection Control Infection Prevention Measure, undated, section 3.2 Needleless Connectors, revealed Needless connectors were to be vigorously scrubbed with an antiseptic wipe before accessing. Needless connectors must be swabbed between each entry into the connector, including attaching syringes of flush solution or attaching the administration set. On 12/16/2025 at 11:05AM Registered Nurse (RN) 1was observed to administer intravenous (IV) Vancomycin (an antibiotic) to resident (R) 59. RN1 did not place a barrier on the bed before laying the tubing from the IV with open ports on R59's bedsheets. Further observation revealed that RN1 did not wipe the ends of the port from R59s wrist with an alcohol swab or the end of the IV tubing before connecting them to administer R59's medication. During an interview, on 12/16/2025 at 11:10AM, RN1 stated it was not necessary to wipe the IV tubing ports as the bed had the resident's flora and cleanliness was not an issue. During an interview on 12/17/2025 at 11:34AM the Staffing Procurement Registered Nurse (SPRN) stated IV tubing should not have been placed on R59's bed without a barrier underneath as it could become contaminated. The SPRN further stated that she would have expected the tubing to have been put on a clean surface. The Administrator stated in an interview on 12/17/2025 at 11:40AM she expected RN1 to have used a barrier under R59s IV tubing and that the IV ports were required to be wiped with an alcohol swab prior to being connected. During an interview on 12/17/2025 at 11:45AM with the Director of Nursing (DON), the DON stated she expected RN1 to have used a barrier to lay the IV tubing on and to have wiped the IV ports before connecting. The DON further stated the facility did not have competency training for regular IV administration such as antibiotics.

Based on observation, interview, and record review it was determined the facility failed to ensure supplies available for use were not expired in one (1) of three (3) medication rooms. Observation of the Seasons Unit's medication room on 08/01/19, revealed sixty (60) blue top serum vacutainer vials with the expiration date of 04/10/19 available for resident use. The findings include: Interview with the Director of Nursing (DON) on 08/01/19 at 4:15 PM, revealed the facility did not have a policy related to the storage of laboratory supplies. Observation of the Seasons Unit's medication room on 08/01/19 at 12:57 PM, revealed a bin sitting on the counter, which contained sixty (60) blue top vacutainer vials utilized for blood collection with an expiration date of 04/10/19. Review of a Medication Room Audit tool, dated (YEAR) and 2019, revealed audits were performed in (MONTH) and (MONTH) of each year. Further review of the audit tool revealed the (MONTH) 2019 audit had comments that all discontinued and expired medications and supplies were discarded. Interview with Licensed Practical Nurse (LPN) #1 on 08/01/19 at 1:10 PM, revealed the vacutainer vials were used when the facility had to obtain a laboratory specimen. She further stated she could not remember the last time the facility had to perform a venipuncture to obtain a blood specimen. She added the facility's contract laboratory utilizes their own vials and does not use the facility's. The LPN then stated she was not sure who was responsible to audit the medication room for expired supplies. Interview with Registered Nurse (RN) #1, the Seasons Unit Manager, on 08/01/19 at 3:48 PM, revealed the medication room was audited two (2) times per year for expired/damaged items. She stated this usually occurred in the spring and fall of the year. She then added the expired laboratory vacutainer vials should have been discarded due to the possibility of incorrect results if an expired vacutainer was used. Interview with the DON on 08/01/19 at 4:15 PM, revealed that two (2) times a year a big cleaning and audit for expired supplies occurred. She further stated it was the responsibility of the staff to check before using any supply to ensure it was not expired.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-three sampled (23) residents (Resident #68 and Resident #92) received the necessary care and services to maintain grooming and hygiene. Observation of incontinence care for Resident #68 on 05/23/18, revealed staff failed to provide the resident with incontinence care every two (2) hours as required. In addition, after providing Resident #68 with incontinence care, staff were observed to place the resident back onto the urine-soiled mattress without cleaning the mattress. Observation of Resident #92 on 05/23/18, revealed the resident was in bed and observed to have soiled feet; however, the resident had been provided a bed bath approximately 20 minutes earlier. The findings include: 1. Review of the facility's policy titled, Perineal Care Male or Female, with a revision date of 12/03/15, revealed the policy did not address how often incontinence care should be provided, or the cleaning of the mattress if it has been soiled during an incontinence episode. Review of the medical record for Resident #68 revealed the facility admitted the resident on 11/21/17, with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS) assessment completed by the facility for Resident #68 dated 04/06/18, revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident was incontinent of bowel and bladder. Review of Resident #68's comprehensive care plan dated 05/10/18, revealed interventions to provide incontinence care every two (2) hours and as needed, and to keep the resident's skin clean and dry. Observation of incontinence care for Resident #68 on 05/23/18 at 9:30 AM, revealed State Registered Nursing Assistant (SRNA) #3 and SRNA #4 washed/sanitized their hands and donned gloves. SRNA #3 then removed the resident's brief, which was observed to be saturated with urine. The resident's gown, drawsheet, and mattress were also observed to be saturated with urine. Continued observation revealed SRNA #3 provided incontinence care for Resident #68, applied a clean brief and gown to the resident, and changed the drawsheet on the bed. However, the SRNAs failed to clean or dry the mattress, and Resident #68 was placed onto the urine-soaked mattress. Interview conducted with SRNA #3 and SRNA #4 on 05/23/18 at 9:40 AM, revealed Resident #68 had not been provided incontinence care since approximately 6:00 AM. The SRNAs stated they had been busy and had not had time to change the resident within the two-hour timeframe the resident was assessed to require. The SRNAs stated they should have also cleaned and dried the mattress prior to placing Resident #68 back onto it. Interview conducted with License Practical Nurse (LPN) #2 on 05/24/18 at 3:44 PM, revealed she made rounds every two (2) hours to ensure residents received the care they required. The LPN stated that Resident #68 was to receive incontinence care every two (2) hours and as needed, and that staff should not have placed the resident onto the mattress until it had been cleaned and dried. Interview conducted with the Director of Nursing (DON) on 05/24/18 at 4:15 PM, revealed she made rounds daily and provided random spot checks to ensure care was being provided as required. The DON stated she had not identified any concerns related to residents not receiving timely incontinence care, or staff not properly cleaning/drying mattresses that become soiled. 2. Review of the facility's policy titled, Shower/Tub bath Competency, with a revision date of 08/24/17, revealed staff were required to assist residents into the shower and to provide assistance as needed to complete the bath or shower. Review of the medical record for Resident #92 revealed the facility admitted the resident on 07/15/15, with [DIAGNOSES REDACTED]. Review of a significant change MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3) which indicated the resident was severely cognitively impaired. The MDS also revealed the resident required extensive assistance of two (2) persons for personal hygiene and bathing. Observation of Resident #92 on 05/23/18, at 11:54 AM, revealed the resident was observed to be in bed with his/her feet uncovered with a dark buildup of dirt on the soles of his/her feet. However, review of Resident #92's bathing sheet dated 05/23/18, and interview with SRNA #1 on 05/24/18 at 8:30 AM revealed Resident #92 had been given a bed bath on 05/23/18 at approximately 11:30 AM. Continued interview with SRNA #1 on 05/24/18 at 8:30 AM, revealed she always washed Resident #92's feet when providing the resident with a bed bath. However, she had not been aware that Resident #92's feet remained soiled after having provided the bed bath to the resident on 05/23/18. Interview conducted with LPN #2 on 05/24/18 at 3:44 PM, revealed she made rounds every two (2) hours to ensure residents were receiving the care they had been assessed to require. LPN #2 stated she had identified no concerns with residents not receiving appropriate care during bathing. Interview conducted with the Director of Nursing (DON) on 05/24/18 at 4:15 PM, revealed she made rounds daily and provided random spot checks to ensure care was being provided as required by the resident. The DON stated the SRNAs were required to check the care plan daily and as needed to obtain the care required by the residents. The DON stated Resident #92's feet should not have remained soiled on 05/23/18 after receiving a bed bath.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care was provided in accordance with the resident's written plan of care for four (4) of twenty-two (22) sampled residents (Residents #3, #6, #8, and #16). Review of a fall investigation for Resident #8 dated 12/20/16, at 12:10 PM, revealed the resident fell from his/her wheelchair in the dining room. Review of Resident #8's comprehensive care plan revealed the resident was supposed to be wearing shoes and a personal alarm. However, a review of the facility's investigation revealed Resident #8 was not wearing shoes/socks nor was there any evidence the resident had a personal alarm on at the time of the fall. Review of the comprehensive care plans for Resident #3 and Resident #6 revealed the staff was required to provide good perineal care with every incontinence episode. However, observation of incontinence care for Resident #3 on 03/07/17 revealed staff cleansed the resident's perineal area from back to front. Observation of incontinence care for Resident #6 on 03/07/17 revealed staff was observed to use water and no soap or any other cleansing agent to cleanse feces from the resident's perineal area. In addition, Resident #16's comprehensive care plan revealed the resident would receive oxygen as ordered by the physician. Review of the physician's orders [REDACTED]. However, observation of Resident #16 on 03/06/17 and 03/09/17 revealed Resident #16 was wearing oxygen at two (2) LPM. The findings include: A review of the care plan policy titled Care Planning, dated 06/01/15, revealed it was the intent of the facility to provide an individualized comprehensive plan of care for each resident incorporating goals and objectives that lead to the resident's highest obtainable level of independence. 1. Review of the medical record for Resident #8 revealed the resident was admitted by the facility on 11/13/14, with [DIAGNOSES REDACTED]. Review of the comprehensive care plan for Resident #8 dated 11/13/16 revealed the resident should wear shoes when in a wheelchair and should have a personal alarm. Review of a significant change Minimum Data Set (MDS) assessment completed by the facility for Resident #8 dated 12/20/16 revealed the resident had been assessed to have moderately impaired decision-making ability. The MDS also revealed Resident #8 was assessed to require the extensive assistance of two (2) persons to assist the resident with ambulation and had sustained one (1) fall with injury. Review of a fall investigation for Resident #8 dated 12/20/16, at 12:10 PM, revealed another resident alerted staff that Resident #8 fell . The investigation revealed the resident fell from a wheelchair and sustained an abrasion to the forehead and the left hand. Further review of the investigation revealed Resident #8 was not wearing shoes/socks, and the investigation did not address whether or not the resident had on a personal alarm or whether it was sounding. Interview conducted with Licensed Practical Nurse (LPN) #4 on 03/09/17, at 5:00 PM, revealed she responded to Resident #8 in the dining room on 12/20/16. The LPN stated another resident reported Resident #8's fall, but she could not remember who the resident was that alerted her. LPN #4 could not recall whether the resident was wearing a personal alarm or whether an alarm was sounding. LPN #4 stated the resident was not wearing shoes but sometimes the resident took his/her shoes off. The LPN stated she was required to review residents' care plans at the beginning of every shift. Interview conducted with LPN #5, who was the Unit Manager for the C Wing, on 03/09/17 at 5:30 PM, revealed she reviewed all fall investigations for the C Wing. The LPN stated Resident #8 should have had on shoes at the time of the resident's fall on 12/20/16, and also should have had a personal alarm on at the time. The LPN stated she was not sure if the resident had been wearing a personal alarm at the time of the resident's fall. The LPN stated she should have questioned whether or not the alarm was on the resident and did not know why she did not question it. The LPN stated she made rounds frequently to ensure staff provided care as directed in their comprehensive plans of care. Interview conducted with the Director of Nursing (DON) on 03/09/17, at 6:05 PM, revealed she, as well as Unit Managers, made rounds daily to ensure staff was providing care as directed by their comprehensive plans of care. The DON stated fall investigations were reviewed Monday through Friday in the daily clinical meeting and she had not identified any concerns with residents' comprehensive plans of care not being followed. 2. Review of the facility's policy titled Perineal Care Male or Female, dated 12/03/15, revealed the female resident's perineum should be cleaned by wiping from front to back. Medical record review for Resident #3 revealed the facility admitted the resident on 07/11/16 with a [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was frequently incontinent of bladder and bowel and required extensive assistance with personal hygiene. Further review of the MDS revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which revealed the resident was severely cognitively impaired and not interviewable. Review of the Comprehensive Care Plan updated 10/27/16 revealed Resident #3 would receive good perineal care with every incontinence episode. Observation of Resident #3 during incontinence care on 03/07/17 at 3:20 PM revealed State Registered Nurse Aide (SRNA) #1 cleansed the resident's perineal area by wiping the resident's perineum from back to front. Interview with SRNA #1 conducted by phone on 03/09/17 at 5:48 PM revealed she was taught to clean a female perineum by wiping from front to back; however, she cleansed Resident #3 by wiping from back to front because she was nervous with the surveyor observing. Interview with the Director of Nursing (DON) on 03/09/17 at 7:15 PM revealed SRNA #1 should have cleansed Resident #3's perineum by wiping from front to back. The DON stated she monitored perineal care and conducted skill checks, education classes annually, random audits, and on-the-spot education. The DON revealed she had not identified any concerns with incontinence care. 3. Review of the facility's policy titled Perineal Care Male or Female, dated 12/03/15, revealed staff was required to cleanse residents using mild soap or other authorized cleansing agents. Medical record review for Resident #6 revealed the facility readmitted the resident on 09/15/16 with a [DIAGNOSES REDACTED]. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was incontinent of bladder and bowel and required extensive assistance for personal hygiene. Further review of the MDS revealed Resident #6 had a Brief Interview for Mental Status score of seven (7) which indicated the resident was severely cognitively impaired. Review of Resident #6's Comprehensive Care Plan updated 02/20/17 revealed the resident should receive good peri-care with each incontinence episode. Observation of Resident #6 during incontinence care on 03/07/17 at 8:55 AM revealed State Registered Nurse Aide (SRNA) #2 did not use soap or any cleansing agents during incontinence care after the resident had a bowel movement. Interview with SRNA #2 on 03/07/17 at 9:00 AM revealed she had only dampened her washcloth with water and had not applied any soap to the cloth. Interview with the Director of Nursing on 03/09/17 at 7:15 PM revealed that all residents should be cleansed with soap and water during perineal care. The DON stated she monitored perineal care and conducted skill checks, education classes annually, random audits, and on-the-spot education. The DON further revealed she had not identified any concerns with soap or other cleansing agents not being used during perineal care. 4. Review of the medical record for Resident #16 revealed the facility readmitted Resident #16 on 03/01/17 with [DIAGNOSES REDACTED]. Review of Resident #16's admission care plan revealed the Resident was at risk for respiratory complications and would receive medications as ordered. Review of the February 2017 physician's orders [REDACTED]. Observations of Resident #16 on 03/06/17 at 11:50 AM and on 03/09/17 at 2:06 PM, 2:21 PM, 2:33 PM, and at 3:24 PM revealed Resident #16 was wearing oxygen at two (2) LPM, instead of three (3) LPM as ordered. Interview with SRNA #3 on 03/09/17 at 2:41 PM revealed SRNA's were not allowed to adjust oxygen and was not aware of Resident #16's ordered oxygen flow rate. Interview with SRNA #4 on 03/09/17 at 2:44 PM revealed she was trained not to adjust residents' oxygen. Interview with Licensed Practical Nurse (LPN) #3 on 03/09/17 at 2:48 PM revealed Resident #16's oxygen was ordered at three (3) LPM and did not know why the oxygen flow rate was on two (2) LPM. Interview with the Director of Nursing on 03/09/17 at 7:49 PM revealed all nursing staff should be following care plan interventions, and was not aware that Resident #16's care plan intervention related to oxygen therapy was not being followed. Further interview with the DON revealed Resident #16's oxygen should have been on three (3) LPM as ordered. Additional interview with the DON revealed she monitored oxygen therapy with the Interdisciplinary Team (IDT) meetings and during random rounds to ensure oxygen was delivered at the correct liter flow rate and she had not identified any problems.

Based on observations, interview, and facility policy review it was determined the facility failed to serve food in accordance with professional standards for food service safety for one hundred two (102) trays served. On 03/06/17 during tray line of the supper meal service, Dietary Aide #1 was observed to adjust her clothing around her waist area and failed to wash/sanitize her hands prior to continuing to serve food. The findings include: Review of the facility policy, Handwashing and Glove Use, with a revision date of 02/01/14, revealed dietary staff would wash their hands following any contact with an unsanitary surface, i.e., touching hair, sneezing, opening doors, etc. Observation on 03/06/17 at 4:58 PM and 5:00 PM, while tray line was already in progress during the evening meal, revealed Dietary Aide #1 was observed to touch her clothing around her waist and failed to wash and sanitize her hands on two (2) occasions. Interview with Dietary Aide #1 on 03/09/17 at 10:00 AM revealed she was trained to wash/sanitize her hands after touching any unsanitary surface because of contamination. Further interview revealed she should have washed/sanitized her hands but she did not because she was nervous. Interview with the Dietary Manager on 03/09/17 at 4:00 PM revealed Dietary Aide #1 should have washed her hands after touching the clothing around her waist. Further interview revealed she monitored meal service and had not identified any concerns. Interview with the Registered Dietitian on 03/08/17 at 3:30 PM revealed Dietary Aide #1 should have washed her hands because of cross-contamination. Further interview revealed she monitored meal service and had not identified any concerns.

Based on interview, record review, and facility policy review it was determined that the facility failed to ensure medication administration records were accurate for nine (9) of twenty-two (22) sampled residents (Residents #3, #5, #6, #7, #9, #11, #12, #15, and #18). The findings include: Interview with the facility Administrator on 03/09/17 at 8:10 PM revealed the facility did not have a written policy related to the accuracy of medication administration records or accuracy of other medical records. Review of a facility policy titled Medication Administration, dated May 2016, revealed the individual who administered a medication dose was required to record the administration on the resident's Medication Administration Record [REDACTED]. Continued review of the facility policy revealed staff was required to initial the resident's MAR indicated [REDACTED]. Further review of the facility's policy revealed when as needed (PRN) medications were administered the date and time of administration, dose, and route of administration were required to be documented. 1. Review of Resident #5's medical record revealed the facility admitted Resident #5 on 05/12/16 with [DIAGNOSES REDACTED]. Review of Resident #5's Physician's Order dated 11/29/16 revealed Resident #5's physician ordered [MEDICATION NAME] (antifungal cream) 2% to be applied topically to affected area(s) every twelve (12) hours. Further review of Resident #5's Physician's Orders revealed the resident's physician ordered liquid protein (protein supplement) thirty (30) milliliters (ml) by mouth twice daily for the resident on 11/29/16. Review of Resident #5's February Medication Administration Record [REDACTED]. Continued review of Resident #5's MAR indicated [REDACTED]. 2. Review of Resident #7's medical record revealed the facility admitted Resident #7 on 08/11/16 with a [DIAGNOSES REDACTED].#7's Physician's Order dated 11/17/16 revealed the resident's physician ordered two (2) ounces of fortified nutritional shake to be given three (3) times a day for weight loss. Review of Resident #7's February MAR indicated [REDACTED]. 3. Review of Resident #11's medical record revealed the facility admitted Resident #11 on 11/04/09 with [DIAGNOSES REDACTED]. Review of Resident #11's Physician's Order dated 02/04/17 revealed Resident #11 was ordered [MEDICATION NAME] alcohol drops (eye drops) one (1) drop to be instilled into both eyes twice daily. Review of Resident #11's February MAR indicated [REDACTED]. 4. Review of Resident #12's medical record revealed the facility admitted Resident #12 on 11/19/14 with [DIAGNOSES REDACTED]. Review of Resident #12's February 2017 Physician's Order revealed Resident #12's physician ordered [MEDICATION NAME] sulfate ([MEDICATION NAME][MEDICATION NAME]) one (1) puff to be inhaled orally every six (6) hours, [MEDICATION NAME] (treats diabetic nerve pain and [MEDICAL CONDITION]) 600 milligrams (mg) one (1) tablet orally three (3) times daily, and [MEDICATION NAME](fast acting insulin) 100 units per milliliter, ten (10) units before each meal. Review of Resident #12's February MAR indicated [REDACTED]. Review of Resident #12's March MAR indicated [REDACTED]. 5. Review of Resident #18's medical record revealed the facility admitted Resident #18 on 08/11/16 with a [DIAGNOSES REDACTED].#18's Physician's Orders dated 12/28/16 revealed Resident #18 was ordered [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 5/325 mg, one (1) tablet every six (6) hours as needed. Review of Resident #18's Controlled Medication Sign Out sheet for February 2017 and March 2017 revealed LPN #1 had signed out one (1) tablet of [MEDICATION NAME]-[MEDICATION NAME] tablet for Resident #18 on 02/02/17, 02/03/17, 02/04/17, 02/05/17, 02/09/17, 02/10/17, 02/11/17, 02/12/17, 02/16/17, 02/17/17, 02/18/17, 02/19/17, 02/24/17, 02/25/17, 02/26/17, 02/27/17, 03/03/17, 03/04/17, and 03/05/17. However, review of Resident #18's February and March MAR indicated [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 03/09/17 at 7:21 PM revealed she remembered signing out Resident #18's [MEDICATION NAME]-[MEDICATION NAME] tablets as documented on the Controlled Medication Sign Out sheet. Continued interview with LPN #1 revealed she had administered all of the medication that she signed out to Resident #18 but must have gotten busy passing medications and forgot to document that the medication was administered on Resident #18's MAR. 6. Review of physician's orders for Resident #9 dated 05/24/16 revealed orders for the resident to receive [MEDICATION NAME] 5 mg twice daily (medication for hypertension); [MEDICATION NAME] 0.2 mg twice daily (medication for hypertension); [MEDICATION NAME] Sodium 100 mg twice daily (medication for constipation); [MEDICATION NAME] 25 mg twice daily (medication for hypertension); Travoprost 0.004% one drop to affected eyes daily (for [MEDICAL CONDITION]); [MEDICATION NAME] 25 mg every night (antidepressant); and [MEDICATION NAME] 15 mg every night (antidepressant). Review of the most recent quarterly MDS for Resident #9 dated 12/06/16 revealed the facility had assessed the resident to have a BIMS score of ten (10) and was therefore interviewable. Review of Resident #9's MAR indicated [REDACTED]. Observation of Resident #9's medications on 03/06/17 at 4:00 PM revealed all medications ordered by Resident #9's physician were available in the medication cart for Resident #9. Interview conducted with Resident #9 on 03/06/17 at 5:55 PM revealed the resident had always received his/her medications as they were ordered by the physician and had never missed a dose of medication. Attempts to reach LPN #3, the nurse who was assigned to provide care for Resident #9 on 03/05/17, were unsuccessful. 7. Review of the medical record for Resident #15 revealed the facility admitted the resident on 05/04/16, with [DIAGNOSES REDACTED]. Review of the most recent significant change MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14), which indicated the resident had intact cognition and was interviewable. Review of physician's orders for Resident #15 dated 01/25/17 revealed the resident was to receive Carvedilol 6.25 mg twice daily (for hypertension); Calcium 600 mg with Vitamin D3 200 mg twice daily (calcium supplement); Vitamin C 500 mg twice daily (vitamin supplement); [MEDICATION NAME] 300 mg three times daily (for nerve pain); Floraster 250 mg twice daily ([MEDICATION NAME]); and [MEDICATION NAME] 10 mg three (3) times daily (for anxiety). Review of Resident #15's MAR indicated [REDACTED]. Observation of Resident #15's medications on 03/09/17 at 1:05 PM revealed all medications ordered by Resident #15's physician were available in the medication cart for Resident #15. Interview conducted with Resident #15 on 03/09/17 at 1:40 PM revealed he/she had received the medications that were ordered on [DATE] at 9:00 PM and always received his/her medications as ordered by the physician. Interview conducted with Kentucky Medication Aide (KMA) #1 on 03/09/17 at 7:05 PM revealed she was responsible for administering the medications to Resident #15 on 02/12/17, at 9:00 PM, and was required to document on the MAR indicated [REDACTED]. The KMA stated she administered Resident #15's medication but forgot to document that she administered the medications. 8. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 07/11/16 with [DIAGNOSES REDACTED]. Review of physician's orders for Resident #3 dated 02/22/17 revealed an order for [REDACTED]. Review of the narcotic record for Resident #3 revealed [MEDICATION NAME] 32.4 mg had been signed out on 03/07/17 at 2:00 PM by Registered Nurse (RN) #1. However, review of Resident #3's MAR for March 2017 revealed no documentation that staff administered [MEDICATION NAME] to Resident #3 on 03/07/17 at 2:00 PM. Interview with RN #1 on 03/09/17 at 7:05 PM revealed she administered [MEDICATION NAME] 32.4 mg tablet to Resident #3. RN #1 further revealed she should have signed off on the MAR, but made a mistake and overlooked it. 9. Review of Resident #6's medical record revealed the facility readmitted Resident #6 on 09/15/16 with [DIAGNOSES REDACTED]. Review of physician's orders for Resident #6 dated 01/12/17 revealed an order for [REDACTED]. Review of the narcotic record for Resident #6 revealed [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg had been signed out on 02/09/17 at 6:00 PM by Kentucky Medication Aide (KMA) #2. However, review of Resident #6's MAR indicated [REDACTED]. During an interview with KMA #2 on 03/09/17 at 6:45 PM, the KMA stated as far as I know (the resident) got (his/her) medications. The KMA stated that she was aware she had to document that medications were administered on the resident's MAR, but probably overlooked it. Interview with the Director of Nursing (DON) on 03/09/17 at 7:29 PM revealed all medications administered should be documented on the resident's Medication Administration Record [REDACTED]. The DON reported she checked the MAR indicated [REDACTED]. Interview with the Administrator on 03/09/17 at 8:10 PM revealed nurses were required to print omission reports in order to identify any documentation concerns with the MARs. Continued interview with the Administrator revealed she was not aware of any issues with the residents' MARs.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents (Residents #3 and #6) received appropriate incontinence care. Observation of incontinence care for Resident #3 on 03/07/17 revealed State Registered Nurse Aide (SRNA) #1 cleansed the resident's perineal area from bottom to top, which was not in accordance with the facility's policy. In addition, observation of incontinence care for Resident #6 revealed SRNA #2 cleansed the resident without using soap or any cleansing agent, which was also not in accordance with the facility's policy. The findings include: Review of the facility's policy titled Perineal Care Male or Female, dated 12/03/15, revealed staff should clean the female perineal area from front to back. The policy further revealed that perineal care was required to be completed using soap or another authorized cleansing agent. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 07/11/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was severely cognitively impaired and not interviewable. Further review of the MDS revealed the resident was frequently incontinent of bladder and always incontinent of bowel. Observation of incontinence care on 03/07/17 at 3:20 PM revealed SRNA #1 washed Resident #3's perineal area from back to front with perianal wash and a dampened washcloth, rotating the washcloth with each swipe. 2. Review of Resident #6's medical record revealed the facility readmitted the resident on 09/15/16 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was severely, cognitively impaired and not interviewable. Further review of the MDS revealed the resident was incontinent of bladder and bowel. Observation of incontinence care on 03/07/17 at 8:55 AM revealed SRNA #2 washed Resident #6's perineal area with a washcloth dampened with water only. Interview with SRNA #1 on 03/09/17 at 5:48 PM revealed she was taught to wash or sanitize her hands any time her gloves were soiled or any time before touching anything clean after touching something soiled. SRNA #1 revealed she was nervous and forgot to wash her hands after cleaning Resident #3 and Resident #6 and before touching the residents' clothes and linens. Interview with SRNA #2 on 03/09/17 at 5:20 PM revealed she was taught to wash or sanitize her hands any time she took her gloves off. SRNA #2 further revealed she should have washed her hands before she touched Resident #3's and Resident #6's linens after cleaning the residents. SRNA #2 revealed she was just nervous and knew that she did not follow proper procedure. Interview with the Director of Nursing (DON) on 03/09/17 at 7:15 PM revealed staff should wash their hands before putting on clean gloves or more frequently if needed. The DON further revealed she monitored handwashing by training and in-services at least once a year or more often if needed. The DON revealed she had not identified any concerns with handwashing.

Based on observation, interview, record review, review of the facility's policy, and review of the facility investigation the facility failed to ensure each resident received adequate supervision to prevent falls and to ensure the resident environment remained as free from accident hazards as possible for two (2) of twenty-two (22) sampled residents (Residents #8 and #15). Resident #8 sustained a fall on 12/20/16 at 12:10 PM and there was no evidence the resident was wearing shoes or a personal alarm, as required by the resident's care plan, when the resident fell . Observation on 03/09/17 at 1:40 PM of Resident #15's bedroom revealed two (2) yellow pills and one (1) white pill in a plastic medication cup on the resident's bed. Resident #15 was not in the room and the medications were unattended. The findings include: Review of the facility's policy titled, Falls, with a revision date of 06/01/15, revealed if a resident sustained [REDACTED]. The policy revealed the Interdisciplinary Team (IDT) would determine the root cause of the fall, if possible, and would update the care plan. The policy further stated the Director of Nursing (DON) would review falls for the month at the monthly Quality Assurance meeting. Review of the facility's policy titled Medication Administration, dated May 2016, revealed residents were always observed after administration to ensure the entire dose was completely ingested. 1. A review of Resident #8's medical record revealed the resident was admitted by the facility on 11/13/14, with [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set (MDS) assessment for Resident #8 dated 12/20/16 revealed the resident had moderately impaired decision-making ability. The MDS also revealed Resident #8 required the extensive assistance of two (2) persons to assist the resident with ambulation. According to the MDS, Resident #8 had sustained one (1) fall with injury. A review of Resident #8's comprehensive care plan dated 11/13/16 revealed the resident was required to have shoes on when in the wheelchair and required a personal alarm (a device used to alert staff when a resident attempts to get up unassisted). A review of a fall investigation dated 12/20/16, at 12:10 PM, revealed Resident #8 fell from his/her wheelchair in the dining room. The investigation revealed staff was alerted to the fall by another resident. The investigation also revealed Resident #8 sustained an abrasion which measured 4.2 centimeters in length and 0.4 centimeters in width to the top of the left hand and another abrasion that measured 2.0 centimeters to the right side of the resident's forehead. The investigation revealed Resident #8 was not wearing shoes/socks; however, the investigation did not address whether the resident was wearing a personal alarm or whether it was sounding at the time of the resident's fall. An interview conducted with Licensed Practical Nurse (LPN) #4 on 03/09/17 at 5:00 PM revealed she responded to Resident #8's fall in the dining room on 12/20/16. The LPN stated she could not remember who the resident was that alerted her, nor could she recall if the personal alarm was on the resident or if it was sounding. The LPN stated Resident #8 did not have on shoes and should have. The LPN stated Resident #8 would sometimes take his/her shoes off, but she could not recall if the resident's shoes were on in the dining room. The LPN stated she should have documented where the resident's shoes were and if the resident had a personal alarm on and if it was sounding. An interview conducted with LPN #5, who was the Unit Manager for the C Wing, on 03/09/17 at 5:30 PM revealed she reviewed all fall investigations for the C Wing. The LPN stated Resident #8 should have had on shoes at the time of the resident's fall on 12/20/16 and also should have had a personal alarm on at the time. The LPN stated she should have questioned whether or not the alarm was on the resident, and did not know why she did not. An interview conducted with the Director of Nursing (DON) on 03/09/17 at 6:05 PM revealed she made rounds daily, as well as Unit Managers, to ensure residents were being provided with care as directed in their comprehensive plans of care. The DON stated fall investigations were reviewed Monday through Friday in the daily clinical meeting. The DON revealed a fall investigation was required to be completed with any fall. The DON stated she had not identified any concerns with fall investigations not being thorough nor not being completed with every fall. 2. Review of the medical record for Resident #15 revealed the facility admitted the resident on 05/04/16, with [DIAGNOSES REDACTED]. Review of a significant change in condition MDS assessment for Resident #15 dated 12/28/16 revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident's cognition was intact. Review of physician's orders [REDACTED]. Review of Resident #15's Medication Administration Record (MAR) revealed the resident received the Neurontin and BuSpar medications on 03/09/17 at 1:00 PM. Observation of Resident #15's bedroom on 03/09/17, at 1:40 PM, revealed two (2) yellow pills and one (1) white pill were in a plastic medication cup on the resident's bed. Resident #15 was not in the room. Review of a list of wandering residents in the facility revealed the facility had two (2) residents who had been assessed by the facility to be wanderers on the C Wing of the facility. Interview conducted with Kentucky Medication Aide (KMA) #2 on 03/09/17, at 1:42 PM, revealed the two (2) yellow pills were Neurontin and the white pill was BuSpar. The KMA stated she had given the medication cup to Resident #15 and left the room. The KMA stated she did not stay to ensure the resident had taken the medication prior to the resident leaving the room to smoke. The KMA stated she had been trained to stay and observe to ensure the resident ingested the medication and should not have left until the resident had taken the medication. Interview conducted with Resident #15 on 03/09/17, at 1:50 PM, revealed staff gave him/her medications. The resident placed the medications on his/her bed and left the room to go smoke. The resident stated he/she planned to take the medication as soon as the smoke break was over. Interview with the DON on 03/09/17 at 7:10 PM, revealed staff was required to observe residents to ensure medication was ingested by the resident. The DON stated KMA #2 should not have left the room prior to the resident ingesting the medication. The DON stated she had not identified any concerns with residents not being monitored to ensure medication was ingested.

Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #16) received proper care and treatment related to oxygen administration. Resident #16 had a physician's order dated 03/01/17, for oxygen to be administered at three (3) liters per minute (LPM) via nasal cannula; however, observations revealed Resident #16 was wearing oxygen at two (2) LPM on 3/06/17 and 03/09/17, instead of three (3) LPM as ordered. The findings include: Review of the facility policy, Medication Administration, dated May 2016, revealed the facility's policy was to administer medications in accordance with written orders of the prescriber. A review of the medical record for Resident #16 revealed the facility readmitted Resident #16 on 03/01/17 with [DIAGNOSES REDACTED]. Review of Resident #16's admission care plan revealed the resident was at risk for respiratory complications and would receive medications as ordered. Review of the February 2017 Physician's Orders for Resident #16 revealed the physician ordered oxygen to be administered at three (3) LPM. Observations of Resident #16 on 03/06/17 at 11:50 AM and 03/09/17 at 2:06 PM, 2:21 PM, 2:33 PM, and 3:24 PM revealed Resident #16 was wearing oxygen at two (2) LPM, instead of three (3) LPM as ordered via nasal cannula. Interview with State Registered Nurse Aide (SRNA) #3 on 03/09/17 at 2:41 PM revealed SRNAs were not allowed to adjust oxygen and was not aware of Resident #16's ordered oxygen flow rate. Interview with SRNA #4 on 03/09/17 at 2:44 PM revealed she was not trained on oxygen administration and did not adjust oxygen. Interview with Licensed Practical Nurse (LPN) #3 on 03/09/17 at 2:48 PM revealed Resident #16's oxygen was ordered at three (3) LPM. Further interview with LPN #3 revealed she had made rounds and did not identify Resident #16's oxygen flow rate was on two (2) LPM. Additional interview with LPN #3 revealed nurses were responsible for ensuring that residents requiring the use of oxygen were wearing oxygen as ordered by the physician. Interview with the Director of Nursing on 03/09/17 at 7:49 PM revealed she made rounds daily to ensure residents were receiving oxygen as directed by their physicians; however, the DON had not identified any concerns with staff not administering residents' oxygen as ordered by their physicians.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of infection for two (2) of twenty-two (22) sampled residents (Residents #3 and #6). Observation of incontinence care for Residents #3 and #6 on 03/07/17 revealed State Registered Nurse Aide (SRNA) #1 and SRNA #2 provided incontinent care for the residents, and then adjusted the residents' linens and clothing without washing or sanitizing their hands. The findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors and all employees should wash/sanitize hands before and after direct contact with residents. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 07/11/16 with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was severely cognitively impaired and not interviewable. Further review of the MDS revealed the resident was frequently incontinent of bladder and always incontinent of bowel. Observation of incontinence care on 03/07/17 at 3:20 PM revealed SRNA #1 and SRNA #2 washed Resident #3's perineal area. SRNA #1 and SRNA #2 applied clean gloves without washing or sanitizing their hands and assisted Resident #3 with getting dressed and adjusted the resident's linens. 2. Review of Resident #6's medical record revealed the facility readmitted the resident on 09/15/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was severely cognitively impaired and not interviewable. Further review of the MDS revealed the resident was incontinent of bladder and bowel. Observation of incontinence care on 03/07/17 at 8:55 AM revealed SRNA #1 and SRNA #2 provided incontinence care for Resident #6, removed their soiled gloves, and applied clean gloves without washing or sanitizing hands. The SRNAs assisted the resident with getting dressed and adjusted the resident's bed linens. Interview with SRNA #1 on 03/09/17 at 5:48 PM revealed she was taught to wash or sanitize her hands when she changed her gloves. However, SRNA #1 stated she was nervous and forgot to wash her hands after cleaning Resident #3 and Resident #6 and before touching the residents' clothing and linens. Interview with SRNA #2 on 03/09/17 at 5:20 PM revealed she was aware she was required to wash or sanitize her hands when she removed her gloves. SRNA #2 further revealed she should have washed her hands before she touched Resident #3 and Resident #6's linens after cleaning the residents. Interview with the Director of Nursing (DON) on 03/09/17 at 7:15 PM revealed staff should wash their hands before putting on clean gloves or more frequently if needed. The DON further revealed she monitored handwashing and provided training and in-services at least once a year or more often if needed. The DON revealed she had not identified any concerns with handwashing.

Based on interview, record review, review of the facility policy, and review of nursing standards of practice, it was determined the facility failed to provide services that met professional standards of practice for one (1) of three (3) sampled residents (Resident #1). Interviews and a review of facility documentation revealed facility staff failed to accurately document the administration of narcotic antianxiety medication for Resident #1. The findings include: Review of the facility policy titled Medication Administration, dated December 2012, revealed medications are prescribed in accordance with manufacturers' specifications and with good nursing principles and practices. The policy further revealed the individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. Continued review of the policy revealed when an as needed medication (PRN) was administered, the following documentation was provided: date and time of the administration and dose; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time the results were noted; and the signature of the person recording the administration. Review of standards of practice from the American Nurses Association's Nursing: Scope and Standards of Practice, 3rd Edition revealed the registered nurse documents nursing practice in a manner that supports quality and performance improvement initiatives. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/18/16 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed the resident was transferred out of the facility for an evaluation at a hospital on [DATE]. Review of Resident #1's Physician Orders, dated November 2016, revealed the resident had a physician's order for Klonopin (a narcotic antianxiety medication) 0.5 milligrams (mg) to be given by mouth twice a day as needed for anxiety. Review of Resident #1's Narcotic Medication Record, for Klonopin 0.5 mg, revealed facility staff signed the medication out for the resident on the following days: 09/04/16, 09/16/16 through 09/21/16, 09/24/16, 09/29/16 through 10/05/16, and 10/07/16 through 11/01/16. Review of Resident #1's MARs, dated September 2016, October 2016, and November 2016, revealed facility staff documented on the resident's MARs that Klonopin 0.5 mg had been administered on the following dates: 09/04/16, 09/18/16, 09/19/16, and 09/21/16. There was no evidence on the MAR that the resident received the Klonopin on 09/16/16, 09/17/16, 09/20/16, 09/24/16, 09/29/16 through 10/05/16, and 10/07/16 through 11/01/16. Review of Resident #1's nurse's notes, dated September 2016, October 2016, and November 2016, revealed no documented evidence Klonopin had been administered to the resident, a reason for the administration of the Klonopin, or a follow-up for the effectiveness of the medication. Interviews on 11/09/16 with Registered Nurse (RN) #1 at 2:30 PM, Licensed Practical Nurse (LPN) #1 at 3:50 PM, and RN #2 at 4:05 PM revealed Resident #1 was administered the Klonopin almost every night because the resident requested the medication due to anxiety. The interviews further revealed the administration of the medication should have been documented on the MAR with the reason the medication was administered. Continued interviews revealed a follow-up of the medication's effectiveness should have been documented in the nurse's notes or on the MAR. The nursing staff revealed medication administration time was a busy time and the nurses did not always remember to document when an as needed dose of a narcotic was administered. Interview on 11/09/16 at 4:00 PM with the Director of Nursing (DON) and at 5:18 PM with the Administrator revealed the nursing staff should have documented on the MAR that Resident #1 was administered the Klonopin, the reason the resident was receiving the medication, and a follow-up to the medication's effectiveness.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure clinical records were maintained as complete and accurate for each resident, in accordance with accepted professional standards and practices, for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's Narcotic Medication Record revealed facility staff had signed out doses of Klonopin (an anti-anxiety controlled substance) on various dates/times. However, review of Resident #1's Medication Administration Record (MAR) revealed facility staff had failed to document the medications, that had been signed out on the resident's Narcotic Medication Record, as administered on the resident's MAR as required. The findings include: Review of the facility policy titled Medication Administration, dated December 2012, revealed medications are prescribed in accordance with manufacturers' specifications and with good nursing principles and practices. The policy further revealed the individual who administers the medication dose, records the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. Continued review of the policy revealed when an as needed medication (PRN) was administered the following documentation was provided: date and time of the administration and dose; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time the results were noted; and the signature of the person recording the administration. Interview on 11/28/16 at 12:43 PM with the Administrator revealed the facility did not have a policy about maintaining an accurate medical record. Review of the medical record for Resident #1 revealed the facility admitted the resident on 08/18/16 with [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed the resident was transferred out of the facility for an evaluation at a hospital on [DATE]. Review of Resident #1's Physician Orders, dated November 2016, revealed the resident had a physician's order for Klonopin (a narcotic antianxiety medication) 0.5 milligrams (mg) to be given by mouth twice a day as needed for anxiety. Review of Resident #1's Narcotic Medication Record revealed facility staff signed out Klonopin 0.5 mg for the resident on the following days: 09/04/16, 09/16/16 through 09/21/16, 09/24/16, 09/29/16 through 10/05/16, and 10/07/16 through 11/01/16. Review of Resident #1's MARs, dated September 2016, October 2016, and November 2016, revealed facility staff documented on the resident's MARs that Klonopin 0.5 mg had been administered on the following dates: 09/04/16, 09/18/16, 09/19/16, and 09/21/16. There was no evidence on the MAR that the resident received the Klonopin on 09/16/16, 09/17/16, 09/20/16, 09/24/16, 09/29/16 through 10/05/16, and 10/07/16 through 11/01/16. Review of Resident #1's nurse's notes, dated September 2016, October 2016 and November 2016, revealed no documented evidence Klonopin had been administered to the resident, a reason for the administration of the Klonopin, or a follow-up for the effectiveness of the medication. Interviews on 11/09/16 with Registered Nurse (RN) #1 at 2:30 PM, Licensed Practical Nurse (LPN) #1 at 3:50 PM, and RN #2 at 4:05 PM revealed Resident #1 requested the Klonopin due to anxiety and was administered the medication almost every night. The interviews further revealed the administration of the medication should have been documented on the MAR with the reason the medication was administered. Continued interviews revealed a follow-up of the medication's effectiveness should have been documented in the nurse's notes or on the MAR. The nursing staff revealed medication administration time was a busy time and the nurses did not always remember to document that the narcotic PRNs were administered. Interview on 11/09/16 at 4:00 PM with the Director of Nursing (DON) and at 5:18 PM with the Administrator revealed the nursing staff should have documented that Resident #1 was administered the Klonopin on the MAR, the reason the resident was receiving the medication, and a follow-up to the medication's effectiveness.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly interior. Observations on 03/23/16 and on 03/24/16 revealed the floor in two (2) of three (3) shower rooms had a brown substance on the floor. The findings include: Review of the facility's policy titled Bath and Shower Cleaning, (undated) revealed the shower chair, room, and the tub will be disinfected between residents to prevent cross-contamination of bacteria and to prevent infections. Observations during the environmental tour on 03/23/16 at 2:55 PM revealed a brown substance on the floor of the shower stall of the Seasons Hall shower room. Additional observation on 03/24/16 at 10:43 AM revealed a dried brown substance on the floor of the C Wing shower room. Interview with State Registered Nurse Aide (SRNA) #4 on 03/23/16 at 2:56 PM revealed the brown substance on the floor of the Seasons Hall shower room was feces. SRNA #4 revealed SRNAs were responsible for cleaning the shower room after showering each resident. Further interview with SRNA #4 on 03/23/16 at 3:53 PM revealed, I must have overlooked it when cleaning up. Interview with Registered Nurse (RN) #1 on 03/24/16 at 10:00 AM revealed the SRNAs were responsible to clean the shower room after each use. Further interview with RN #1 revealed nurses were responsible to ensure the shower rooms were cleaned after all showers were given. Interview with Licensed Practical Nurse (LPN) #1 on 03/24/16 at 10:43 AM revealed her observation of the C Wing shower room revealed a dried brown substance on the floor. LPN #1 revealed the SRNA assigned to each resident was responsible to clean up after each shower. Further interview revealed no one was assigned to monitor the SRNAs to ensure the shower rooms were cleaned after each use. Interview with the facility's Administrator on 03/24/16 at 6:45 PM revealed the SRNAs were responsible for cleaning the shower after each use. Further interview with the Administrator revealed the nurses monitored the shower rooms to ensure they were cleaned after each use. Additional interview revealed she had not identified any problems with shower rooms not being cleaned.

Based on observation, interview, and record review, it was determined the facility failed to honor resident choices regarding food and drink likes and dislikes for one (1) of twenty-one (21) sampled residents (Resident #4). Observations on 03/22/16 during the evening meal service revealed Resident #4 received items on his/her meal tray that were listed as foods the resident disliked. The findings include: Review of the facility's policy and procedure titled Electronic Tray Cards, not dated, revealed each resident would have a diet tray card that must identify the resident's food preferences and the resident's likes, dislikes, and allergies [REDACTED]. Record review revealed the facility admitted Resident #4 on 01/21/16 with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #4 was not interviewable. Observation on 03/22/16 at 5:20 PM revealed Resident #4 was served the evening meal tray. Further observation revealed Resident #4 received mixed vegetables, which included peas, carrots, and corn. Additionally, observation of Resident #4's meal tray card revealed the resident had peas, carrots, and corn listed as his/her dislikes. Interview with Resident #4 on 03/22/16 at 5:22 PM revealed the mixed vegetables were not his/her favorite thing to eat. Interview with State Registered Nursing Assistant (SRNA) #1 on 03/23/16 at 2:50 PM revealed that although she was trained to observe the meal cards when serving the meals to the residents, it was not her usual practice. SRNA #1 stated she usually just relied on the resident to tell her if they disliked something on their tray. Interview with the Administrator on 03/23/16 at 1:55 PM revealed she expected all staff to follow the policy and procedures. The Administrator stated the staff was trained to honor the residents' preferences, likes, and dislikes. Further interview revealed this had not been a concern in the past.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assure services were arranged by the facility to meet professional standards of quality for one (1) of twenty (20) sampled residents (Resident #13). The facility failed to assure Resident #13, a newly admitted resident of the facility, received necessary care to assure toenail care was provided. The findings include: Interview with the facility Director of Nursing on 04/02/15 at 6:56 PM revealed the facility does not have a written policy related to developing initial care plans for residents. Observations made on 03/31/15 at 10:08 AM and on 04/02/15 at 6:55 PM revealed Resident #13 to have long untrimmed toenails. Review of Resident #13's medical record revealed the facility admitted the resident on 03/26/15, with [DIAGNOSES REDACTED]. Further review of the record revealed the admission Minimum Data Set (MDS) assessment was not complete due to the resident's admitted and the MDS was not required to be complete yet. Review of the Nursing Admission Information assessment, dated 03/26/15, revealed Resident #13 required assistance related to personal hygiene. Continued review of the nursing admission assessment under the Foot Care section revealed the facility assessed the resident to have no issues or concerns related to Resident #13's toenails. Further review of the nursing admission assessment revealed no indication of Resident #13 having long untrimmed toenails on the full body skin assessment. Review of Resident #13's Interim Comprehensive Care Plan dated 03/26/15, and Nurse Assistant Care Plan dated March 2015, revealed the facility did not develop a care plan with interventions to address toenail care. Interview with Registered Nurse (RN) #1 on 04/02/15 at 6:35 PM revealed she was the nurse who admitted Resident #13 to the facility and that when admitting residents to the facility she checks skin, fingernails, and toenails on the admission assessment. Continued interview with RN #1 revealed Resident #13 had been admitted to the facility at shift change and she should have made note of his/her long toenails on the admission assessment. RN #1 stated, "I just missed it. I develop the CNA (certified nursing assistant) care plan and should have developed a care plan for nail care." Interview with the Seasons Unit Clinical Coordinator on 04/02/15 at 6:30 PM revealed that an intervention to address Resident #13's toenail care should have been on the Nurse Aide Care Plan. Continued interview with the Unit Clinical Coordinator revealed the nurse who admitted Resident #13 was responsible for developing the care plan. Further interview with the Unit Clinical Coordinator revealed resident care plans were reviewed in the facility's morning meetings (Quality Assurance) and she made rounds in order to ensure residents were receiving the care required. The Unit Clinical Coordinator revealed nail care was to be provided once a week on all residents. Interview with the facility Director of Nursing (DON) on 04/02/15 at 7:00 PM revealed nail care was to be provided for residents once a week and the admitting nurse was responsible for developing a care plan related to nail care. Continued interview with the DON revealed they go over resident care plans in their morning meeting (Quality Assurance) and had not identified any concerns with Resident #13's care plan. Further interview with the DON revealed she conducted daily rounds to ensure residents were being cared for and she was not aware of the condition of Resident #13's toenails.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that one (1) of twenty (20) sampled residents (Resident #13) received the necessary services to maintain good personal hygiene related to long untrimmed toenails. The facility failed to assure Resident #13 received necessary assistance to assure nail care was completed. Observations of Resident #13 made on 03/31/15 at 10:08 AM and 04/02/15 at 6:55 PM revealed Resident #13 to have long untrimmed toenails. The findings include: Review of facility policy titled "Nails-Cleaning and Trimming," dated December 2010 revealed the nursing staff would provide observation and care of nails for all residents daily and as necessary. Observations made on 03/31/15 at 10:08 AM and on 04/02/15 at 6:55 PM revealed Resident #13 to have long untrimmed toenails. Review of Resident #13's medical record revealed the facility admitted the resident on 03/26/15, with [DIAGNOSES REDACTED]. Review of the Nursing Admission Information assessment dated [DATE] revealed Resident #13 to need assistance related to personal hygiene. Continued review of the nursing admission assessment under the Foot Care section revealed the facility assessed the resident to have no issues or concerns related to Resident #13's toenails. Further review of nursing admission assessment revealed no indication of Resident #13 having long untrimmed toenails on the full body skin assessment. Review of Resident #13's Interim Comprehensive Care Plan dated 03/26/15 and Nurse Assistant Care Plan dated March 2015 revealed the facility did not develop a care plan with interventions to address toenail care for Resident #13. Interview with the Seasons Unit Clinical Coordinator on 04/02/15 at 6:30 PM revealed she should have included an intervention on Resident #13's Nurse Aide Care Plan to address toenail care. Continued interview with the Unit Clinical Coordinator revealed the nurse who admitted Resident #13 was responsible for developing the care plan. Further interview with the Unit Clinical Coordinator revealed resident care plans were reviewed in their morning meeting (Quality Assurance) and she made rounds in order to ensure residents were receiving the care required. The Unit Clinical Coordinator revealed nail care was to be provided once a week on all residents. Interview with Registered Nurse (RN) #1 on 04/02/15 at 6:35 PM revealed she was the nurse who admitted Resident #13 to the facility and that when admitting residents to the facility she checks skin, fingernails, and toenails on the admission assessment. Continued interview with RN #1 revealed Resident #13 had been admitted to the facility at shift change and she should have made note of his/her long toenails on the admission assessment. RN #1 stated, "I just missed it. I develop the CNA (certified nursing assistant) care plan and should have developed a care plan for nail care." Interview with the facility Director of Nursing (DON) on 04/02/15 at 7:00 PM revealed nail care was to be provided for residents once a week and the admitting nurse was responsible for developing a care plan related to nail care. Continued interview with the DON revealed they go over resident care plans in their morning meeting (Quality Assurance) and had not identified any concerns with Resident #13's care plan. Further interview with the DON revealed she conducted daily rounds to ensure residents were being cared for and she was not aware of the condition of Resident #13's toenails.

Based on observations, interviews, record reviews, and review of the facility's policies, the National Federation of Licensed Practical Nurses publication entitled "Nursing Practice Standards for the Licensed Practical/Vocational Nurse," a Fall Risk Evaluation, an Accident/Incident Report, and the emergency room Physician's assessment, it was determined the facility failed to ensure services provided for one (1) of nineteen (19) sampled residents (Resident #19) met professional standards of care. The facility admitted Resident #19 on 01/15/14, at approximately 12:00 PM, from an acute care facility. Review of the History and Physical from the acute care facility, dated 01/11/14, revealed the resident required the assistance of two people to ambulate. However, review of an Accident/Incident Report dated 01/16/14, revealed on 01/15/14 at approximately 1:45 PM to 2:00 PM (approximately two hours after the resident's admission to the facility) two staff persons assisted the resident to the bathroom and left him/her alone in the bathroom. The resident sustained [REDACTED]. Review of the Emergency Department Physician's Report dated 01/15/14, revealed Resident #19 sustained a contusion and hematoma to the head as a result of the fall. Interview with Licensed Practical Nurse (LPN) #2 revealed even though she was made aware Resident #19 required the assistance of two for ambulation, she failed to develop an initial care plan to address the resident's needs until after the resident sustained [REDACTED]. The findings include: Review of the facility's policy titled, "Admission Assessment and Follow Up: Role of the Nurse," with a revision date of December 2012, revealed the purpose of the assessment was to identify the resident's needs and to initiate a care plan based on the assessment. The policy revealed the nurse would also conduct a fall risk assessment at the time the admission assessment was conducted. Review of the facility's policy titled, "Fall Policy," dated April 2012, revealed the facility would conduct a fall risk assessment at the time of the resident's admission to the facility and appropriate care plan interventions would be implemented as indicated by the assessment. Review of the National Federation of Licensed Practical Nurses publication, dated October 2003, entitled "Nursing Practice Standards for the Licensed Practical/Vocational Nurse," section "Practice," revealed "The Licensed Practical/Vocational Nurse" ..."4. Shall know and utilize the nursing process in planning, implementing and evaluating health services and nursing care for the individual patient or group," and "Planning: The planning of nursing includes: 1) assessment/data collection of health status of the individual patient, the family and community groups. 2) reporting information gained from assessment/data collection." Review of the closed record for Resident #19 revealed Licensed Practical Nurse (LPN) #2 admitted the resident on 01/15/14, at approximately 12:00 PM, with [DIAGNOSES REDACTED]. Review of the History and Physical report from the acute care hospital dated 01/11/14, revealed two staff persons were to assist Resident #19 to ambulate. The facility assessed the resident to be alert. Review of a Fall Risk Evaluation dated 01/15/14, completed prior to the resident's fall, revealed the facility assessed Resident #19 to have a score of 17 (a score of greater than 10 indicated the resident was at risk for falls). Review of an Accident/Incident Report dated 01/15/14, revealed LPN #2 and Resident #19's family member entered the resident's bathroom at 2:00 PM and found the resident lying on his/her right side on the floor. Review of the Emergency Department physician's assessment dated [DATE], at 3:20 PM, revealed Resident #19 sustained a hematoma and contusion to the right side of the head as a result of the fall at the facility. Interview conducted with State Registered Nurse Aide (SRNA) #17 on 02/05/14, at 2:15 PM, revealed SRNA #18 had told her Resident #19 required the assistance of two to ambulate and had asked her assistance to take Resident #19 to the bathroom. SRNA #17 stated she and SRNA #18 assisted Resident #19 to the bathroom, the resident asked for privacy, and the SRNA closed the door and left the room. According to SRNA #17, she thought SRNA #18 remained outside the resident's bathroom door. SRNA #17 stated she should have also stayed outside the resident's door to assist SRNA #18 to take the resident back to bed from the bathroom, but she had been assigned to another unit in the facility and returned to the unit to complete her assignments. Interview conducted with SRNA #18 on 02/05/14, at 2:53 PM, revealed she had been assigned to provide direct care to Resident #19 on 01/15/14. SRNA #18 stated she had been told by LPN #2 that Resident #18 required the assistance of two persons to ambulate. The SRNA stated after they were inside the bathroom, the resident asked for privacy; she and SRNA #17 closed the bathroom door and left the room. The SRNA stated she should have stayed in the resident's room outside the bathroom door but had been in a "hurry" because it was near the end of her shift and she had been "busy" assisting other residents back to bed. In addition, SRNA #18 stated she had not looked for an initial Plan of Care for Resident #19 prior to assisting the resident to the bathroom. Interview conducted with Licensed Practical Nurse (LPN) #2 on 02/05/14, at 3:00 PM, revealed she had provided care to Resident #19 upon the resident's admission to the facility on [DATE]. LPN #2 stated she had been informed by staff from the acute care facility that the resident had a history of [REDACTED]. In addition, LPN #2 stated that based on her initial assessment of Resident #19 she had determined the resident was a fall risk. She stated although she had not developed the resident's initial care plan until after the resident sustained [REDACTED].#18 that Resident #19 required the assistance of two persons for ambulation. LPN #2 stated although Resident #19 had asked for privacy in the bathroom, SRNAs #17 and #18 should have remained outside the resident's bathroom door. Interview with Resident #19 on 02/05/14, at 4:25 PM, revealed the resident could not remember anything about the fall. The resident stated it was just a "big blur." Interview conducted with the Director of Nursing (DON) on 02/06/14, at 2:35 PM, revealed staff should have developed an initial plan of care and should have put the plan into place upon the resident's admission to the facility. According to the DON, facility staff was aware Resident #19 was at risk for falls and should not have left the resident unattended in the bathroom.

The facility failed to ensure the environment remained as free of accident hazards as possible for one (1) of nineteen (19) sampled residents (Resident #19). The facility admitted Resident #19 on 01/15/14 from an acute care facility. Prior to the resident's arrival to the facility on [DATE], acute care staff informed facility staff Resident #19 required the assistance of two persons to ambulate. In addition, review of the Nurse Aide Care Plan for Resident #19 revealed upon admission the facility assessed the resident to require two staff persons to provide assistance to the resident for transfers and two staff persons were to assist the resident to reposition every two hours, or on a "PRN" (as needed) basis. However, on 01/15/14, two staff persons assisted Resident #19 to the bathroom at approximately 1:45 PM to 2:00 PM. They left the resident unattended in the bathroom, and at approximately 2:00 PM, observed the resident lying on the floor of the bathroom. The facility transferred Resident #19 to the Emergency Department on 01/15/14 at 2:30 PM. Resident #19 sustained a hematoma and contusion to the head as a result of the fall. The findings include: Review of the facility's policy titled, "Fall Policy," dated April 2012, revealed the facility would conduct a fall risk assessment at the time of the resident's admission to the facility and appropriate care plan interventions would be implemented as indicated by the assessment. Review of Resident #19's closed medical record revealed the facility admitted Resident #19 from an acute care facility on 01/15/14 at approximately 12:00 PM. Further review revealed Resident #19's [DIAGNOSES REDACTED]. Prior to the resident's arrival to the facility on [DATE], acute care staff informed facility staff that Resident #19 required the assistance of two persons to ambulate. The resident was assessed to be alert. Review of the acute care facility's History and Physical report, dated 01/11/14, revealed two staff persons were required to assist Resident #19 to ambulate. Review of instructions on the facility's Fall Risk Evaluation tool revealed a score greater than 10 indicated a resident was at risk for falls. Review of the Fall Risk Evaluation, dated 01/15/14 (no time was documented), revealed the facility assessed Resident #19 to have a Fall Risk Evaluation score of 17. Review of an Accident/Incident Report, dated 01/15/14 at 2:00 PM, revealed LPN #2 and Resident #19's family member entered the resident's bathroom and observed the resident lying on his/her right side on the bathroom floor. The Accident/Incident Report revealed LPN #2 observed a large hematoma to the right side of the resident's head. The report stated the resident was transported by ambulance to an acute care hospital on [DATE], at 2:30 PM, for further evaluation and treatment. Review of the Emergency Department physician's documentation, dated 01/15/14, at 3:20 PM, revealed Resident #19 had a hematoma and contusion to the right side of the head which was a result of a fall the resident had at the facility. Interview with Resident #19 on 02/05/14, at 4:25 PM, revealed the resident could not remember anything about the fall. The resident stated he/she could not remember what happened and stated it was just a "big blur." Interview with State Registered Nurse Aide (SRNA) #17 on 02/05/14, at 2:15 PM, revealed SRNA #18 had requested her assistance to take Resident #19 to the bathroom. SRNA #17 stated SRNA #18 had told her Resident #19 required the assistance of two to ambulate and both she and SRNA #18 assisted Resident #19 to the bathroom. Continued interview with SRNA #17 revealed after they reached the bathroom, Resident #19 asked for privacy, and she closed the door and left the resident's room. According to SRNA #17 she should have assisted SRNA #18 to take the resident back to the bed but she had been assigned to another unit in the facility and returned to the unit to complete her assignments. Interview with SRNA #18 on 02/05/14, at 2:53 PM, revealed she had been assigned to provide direct care to Resident #19 on 01/15/14. SRNA #18 stated she had been told by LPN #2 that Resident #18 required the assistance of two persons to ambulate. She asked SRNA #17 to assist her to walk Resident #19 to the bathroom. According to SRNA #18, after they were inside the bathroom, the resident asked for privacy and both she and SRNA #17 closed the bathroom door and left the room. The SRNA stated she should have stayed in the resident's room outside the bathroom door but had been in a "hurry" because it was near the end of her shift and she had been "busy" assisting other residents back to bed. SRNA #18 stated she felt Resident #19 would be all right alone in the bathroom. Licensed Practical Nurse (LPN) #2 stated in an interview conducted on 02/05/14, at 3:00 PM, that she had been assigned to provide care to Resident #19 at the time of the resident's admission to the facility on [DATE]. LPN #2 stated she was informed by staff from the acute care facility that the resident had a history of [REDACTED]. In addition, LPN #2 stated that based on her initial assessment of Resident #19 she had determined the resident was a fall risk and had informed SRNA #18 that Resident #19 required the assistance of two persons for ambulation. LPN #2 stated although Resident #19 had asked for privacy in the bathroom, SRNAs #17 and #18 should have remained outside the resident's bathroom door to assist the resident back to his/her bed. The Director of Nursing (DON) stated in interview conducted on 02/06/14 at 2:35 PM that facility staff should have remained outside the resident's bathroom door after they had assisted Resident #19 to the bathroom. According to the DON, facility staff was aware Resident #19 was at risk for falls and should not have left the resident unattended in the bathroom.

Based on interview, record review, and review of the facility's investigation and policy and procedures it was determined the facility failed to have an effective system to ensure all allegations of abuse were reported immediately to the Administrator of the facility, failed to protect residents after an allegation of abuse, and failed to ensure all alleged violations were thoroughly investigated for six of twenty-nine sampled residents (Resident #1, #4, #19, #29, #30, and #31). On 02/17/13 at approximately 7:35 AM, staff observed Resident #1 sitting in a wheelchair located in the dining room next to the Nurses' station, crying in pain, and requesting to go to bed. Licensed Practical Nurse (LPN) #1 refused to allow staff to take Resident #1 to bed and stated the resident would remain seated in the wheelchair until the resident quit "crying," "hollering," and/or "whining." LPN #1 placed a radio near Resident #1's head and turned up the volume. According to interviews, staff attempted to report the alleged abuse to the Social Worker/Abuse Coordinator, in accordance with facility policy; however, staff was unable to contact the Social Worker/Abuse Coordinator and left a voice mail message on the Social Worker/Abuse Coordinator's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, Director of Nursing (DON), and Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. According to the facility investigation, dated 02/22/13, after the investigation was completed the facility unsubstantiated that abuse occurred. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. (Refer to F223.) In addition, on the morning of 03/24/13, at approximately 12:00 AM, Resident #4 reported to Registered Nurse (RN) #8 that RN #8 was mean to the resident; that the resident did not want RN #8 to provide care for the resident anymore; and, asked RN #8 to not come back into the resident's room. RN #8 documented the incident in Resident #4's medical record and reported the incident to the oncoming Nurse (RN #4) at 7:00 AM. RN #4 reported the incident to the Weekend Manager on 03/24/13, and the Weekend Manager contacted the DON to report the incident. However, the DON did not initiate an investigation of the incident and did not notify the Administrator of the incident. On 03/27/13, the facility's Cooperate Nurse Consultant learned of the incident through review of Resident #4's medical record. The DON and Administrator #2 interviewed RN #8 about the incident prior to the start of her shift on 03/27/13. However, the DON and Administrator #2 allowed RN #8 to continue to provide direct care to residents in the facility during her scheduled twelve (12) hour shift on 03/27/13 and, as a result, failed to ensure residents in the facility were protected from further potential abuse while the facility's investigation was in progress. In addition, the facility failed to ensure four (4) other potential allegations of abuse were thoroughly investigated and reported to the appropriate State Agencies; alleged verbal abuse involving Resident #19; Resident #29 expressing fear of State Registered Nurse Aide (SRNA) #14; Resident #30 being sprayed with cold water and having a towel wrapped around his/her neck; and, Resident #31 being handled roughly by staff while being placed in a chair. The facility's failure to immediately report an allegation of abuse, failure to protect residents during the course of an investigation of abuse, and failure to thoroughly investigate an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Two Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The findings include: 1. Review of the facility's abuse policy, dated 01/2012, revealed it was "the intent of the facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident's property or reasonable suspicion of criminal act or intent." The policy stated "any report or suspicion of an incident was to be reported immediately to the charge nurse", and the Administrator, Director of Nursing and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report". Further review revealed "any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate". The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process". The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse". Based on a review of the facility's investigation, dated 02/22/13, and interviews with Housekeeper #1 on 02/28/13 at 12:17 PM and again on 03/04/13 at 11:37 AM, with Housekeeper #2 on 03/01/13 at 11:47 AM, with SRNA #3 on 03/01/13 at 12:29 PM, with Kentucky Medication Aide (KMA) #1 on 03/01/13 at 12:01 PM, and review of a witness statement provided by SRNA #2 (unable to be reached for interview), LPN #1 was observed to abuse Resident #1. However, no action was immediately taken by the staff who witnessed the abuse to protect residents in the facility or notify appropriate facility personnel until approximately 11:30 AM, when Housekeeper #1 attempted to notify the Social Worker/Abuse Coordinator, as directed in the facility's policy, via phone, but was unable to reach her, and left a message describing what she had witnessed. Housekeeper #1 and Housekeeper #2 stated they did not immediately report the abuse due to being "nervous," "scared," and "did not know what to do," since the abuse had been committed by the Charge Nurse. Housekeeper #1 stated after leaving the voice message for the Abuse Coordinator, she observed the Staff Development Coordinator in the facility and immediately reported what she had witnessed to her. An interview conducted with the Staff Development Coordinator/Nurse Manager on 02/28/13 at 5:35 PM, on 03/04/13 at 11:07 AM, and again on 03/05/13 at 4:45 PM revealed she was at the facility on 02/17/13 and was approached by Housekeepers #1 and #2 at approximately 11:40 AM, reporting the incident they witnessed concerning Resident #1 and LPN #1. The Staff Development Coordinator/Nurse Manager stated she proceeded to talk with other staff related to the incident and had staff fill out witness statements, but took no action to protect residents in the facility from further abuse by the LPN. The Staff Development Coordinator/Nurse Manager stated she did not have the authority to remove LPN #1 (Charge Nurse) from patient care, stating only the Administrator, Social Worker/Abuse Coordinator, or Director of Nursing had that authority. The Staff Development Coordinator/Nurse Manager stated she also attempted to contact the Social Worker/Abuse Coordinator, time unknown, but was unable to reach her and left a voice message. The Staff Development Coordinator/Nurse Manager stated she was unable to notify the DON of the alleged abuse due to not having access to her "current" phone number. According to the Staff Development Coordinator/Nurse Manager, LPN #1 continued to be in charge of resident care and remained on the floor with residents until 12:30 PM (five hours after the abuse was observed) when the Staff Development Coordinator/Nurse Manager contacted the facility's Nurse Consultant via telephone and was instructed to suspend LPN #1, the Charge Nurse. However, review of the facility's policy revealed residents would "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process". Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM revealed once she discovered and listened to the voice messages from Housekeeper #1 and the Staff Development Coordinator/Nurse Manager on 02/17/13 (time unknown) she went to the facility to assist with the investigation. According to the Social Worker/Abuse Coordinator staff was required to report any allegations of abuse to the Abuse Coordinator (herself), the Administrator, the DON, or the Charge Nurse. However, the facility had no specific detailed reporting procedure such as an "on call" system, to ensure staff was able to report abuse as the facility policy directs. The Social Worker/Abuse Coordinator stated there was no written order of whom to report abuse to, and staff would have to go through the individuals listed in the policy until one was reached. The Social Worker/Abuse Coordinator further stated she was allowed to remove alleged perpetrators from resident care and she was unaware if another Nurse had the authority to remove alleged perpetrators from direct care after an allegation of abuse had been alleged. Interview further revealed when an allegation of abuse was made she, the DON, and the Administrator, performed the investigation. According to the Social Worker/Abuse Coordinator depending on who got to the facility first, the others would just "see who did what" and assist with the investigation. The Social Worker/Abuse Coordinator stated the Administrator was ultimately responsible for the decision to determine if a staff member had committed an abusive act toward a resident, and made decisions regarding all disciplinary action. Review of the facility's policy revealed only the "Administrator and/or Director of Nursing and/or Social Worker" would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse". Administrator #1 stated in an interview conducted on 02/28/13 at 5:20 PM that his investigation of the alleged abuse consisted of reviewing witness statements, information that had been obtained, consulting with his regional staff, and interviewing LPN #1, the Charge Nurse. According to Administrator #1 when he interviewed LPN #1, she did confirm Resident #1 was crying and yelling at the Nurses' station and she (the Charge Nurse) instructed staff to leave the resident up in the chair, but explained that it was to "observe the resident." Administrator #1 also acknowledged he had been aware of the staff interviews and witness statements describing the LPN's (Charge Nurse) intentions to "teach" (Resident #1) "a lesson." Additionally, the Abuse Coordinator had reported that although she had been unable to get specifics of the alleged incident from Resident #1 due to (his/her) impaired cognition, an alert and oriented resident had reported witnessing LPN #1 being inappropriate and rude to another resident previously. However, after considering all the information that had been obtained during the investigation, he had concluded that staff "might have misinterpreted" the LPN's actions, and stated he was unable to come to a "firm" conclusion or determine if LPN #1 had abused Resident #1, and therefore unsubstantiated the allegation, and took no further disciplinary action against LPN #1 in regard to the alleged abuse to Resident #1. Review of the facility's abuse policy revealed the Administrator/designee would "make all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them". At the time of the investigation, LPN #1, the Charge Nurse, was no longer employed by the facility, and attempts to interview her were unsuccessful. 2. Review of the medical record revealed the facility admitted Resident #29 on 03/18/10 with [DIAGNOSES REDACTED]. A list of residents assessed by the facility to be alert, oriented and interviewable was provided on 04/02/13. According to the list, the facility had assessed Resident #29 to be alert, oriented, and interviewable. Resident #29 was observed sitting in a wheelchair in the facility dining room on 04/05/13 at 5:50 PM. Interview conducted on 04/05/13, at 5:50 PM with Resident #29 revealed he/she was afraid of a staff person (SRNA #14). The resident stated SRNA #14 had touched his/her breast when the SRNA hugged the resident approximately 2-3 months ago, and would come into the resident's room without knocking when the resident was "disrobed." Resident #29 stated he/she reported the incident that occurred 2-3 months ago to the facility's Social Worker/Abuse Coordinator at the time the incident occurred. The resident stated SRNA #14 had been moved to another area in the facility after he/she reported the incident to the Social Worker/Abuse Coordinator. Interview conducted with the Social Worker/Abuse Coordinator on 04/05/13, at 6:50 PM, revealed Resident #29 reported to her on 03/01/13 that SRNA #14 had touched the resident's breast and, although Resident #29 reportedly did not feel SRNA #14's action was abuse, the resident felt the his actions were "inappropriate". According to the Social Worker/Abuse Coordinator, she had the responsibility to investigate allegations of abuse, to report the allegation to the appropriate state agencies, and to provide administrative staff a report of her findings. The Social Worker/Abuse Coordinator stated on 03/01/13, she and Administrator #1 talked with Resident #29 regarding the reported incident and informed Resident #29 that SRNA #14 would be reassigned to another area in the facility. The Social Worker/Abuse Coordinator stated she obtained verbal statements from Resident #29; Resident #29's daughter; and SRNA #14; and a written statement from a staff Nurse that had been assigned to the Seasons unit at the time the resident reported the incident. The Social Worker/Abuse Coordinator stated as a result of the allegation made by Resident #29, SRNA #14 was reassigned to another unit of the facility and was permitted to continue to provide direct care to residents. In addition, the Social Worker/Abuse Coordinator stated she had not considered the incident to be possible abuse; did not conduct further investigation of the allegation; and did not report the incident to the appropriate state agencies. However, review of the facility's policy on abuse revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process". According to the Social Worker/Abuse Coordinator, as part of her responsibilities of abuse investigations, she was responsible to remove the alleged perpetrator from resident care and to provide administrative staff the results of her investigation. Administrator #1 was no longer employed as Administrator of the facility and an interview could not be obtained with Administrator #1. Interview conducted on 04/05/13, at 6:05 PM, with the Vice President of Operations revealed he was also currently acting as the facility's Administrator. The Vice President of Operations stated although he was not aware of the incident involving Resident #29, he would attempt to locate the facility's investigation. Continued interview with the Vice President of Operations on 04/05/13 at 7:30 PM revealed SRNA #14 had continued to work at the facility and was working on 04/05/13 when Resident #29 reported the incident to the surveyor. According to the Vice President of Operations, the facility's investigation of the incident consisted of the interviews that had been obtained by the Social Worker/Abuse Coordinator. The Vice President of Operations stated effective 04/05/13 SRNA #14 had been suspended from employment pending further investigation of the incident. The Vice President of Operations stated he did recall Administrator #1 telling him SRNA #14 had been moved to another area of the facility to work due to a resident telling staff he/she did not want SRNA #14 providing their care. However, the Vice President of Operations stated he could not recall the resident's name and did not ask additional questions related to that resident's concern. 3. A review of a facility's investigation revealed on 03/24/13, Resident #30 alleged that SRNA #13 had repeatedly sprayed cold water on the resident during a shower and had wrapped a sheet around the resident's neck too tight following the shower on 03/22/13 from 8:00 PM to 9:00 PM. According to investigation witness statements and an investigation was started on 03/24/13 by the facility's Social Worker/Abuse Coordinator. However, review of the facility's policy on abuse revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident". Additional review on 04/09/13 revealed the facility had not completed the investigation and had failed to report the allegation to the appropriate State Agencies until 04/09/13, sixteen (16) days after the alleged incident was reported. In addition, there was no evidence the alleged perpetrator had been suspended. However, the facility's policy revealed the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process". According to the initial report of the allegation dated 04/09/13, revealed that SRNA #13 was not on duty, the facility had attempted to contact SRNA #13, and SRNA #13 would be suspended and not allowed to work until the investigation had cleared the SRNA of the allegation. A review of the facility's investigation log revealed no entry regarding Resident #30. An interview conducted with the facility Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed, on 04/08/13, the Social Worker/Abuse Coordinator informed the Administrator of the allegation of abuse that had occurred on 03/22/13 and involved Resident #30. According to the Social Worker/Abuse Coordinator, it was the Social Worker/Abuse Coordinator's responsibility to report the allegation to the Administrator and the Director of Nursing. In addition, the Social Worker/Abuse Coordinator stated, the facility's investigation of the allegation that had reportedly occurred on 03/22/13 had not been completed. Interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 was aware the Social Worker/Abuse Coordinator was talking with Resident #30 on 03/24/13, however; was not aware of an abuse allegation. According to Administrator #2 he was not aware of the allegation of abuse had not been thoroughly investigated and reported as required until the investigation file was found on 04/08/13. 4. Interview with facility Administrator #2 on 03/28/13 at 1:50 PM revealed there had been an allegation of abuse that he planned to report to the appropriate State Agencies. Administrator #2 stated the incident occurred on 03/24/13, was reported on 03/27/13, and the facility was in the process of conducting an investigation. According to Administrator #2, a resident said a Nurse was mean to her/him, but "no abuse occurred." Administrator #2 further stated the DON was aware of the allegation on 03/24/13, the date of the alleged abuse, and confirmed an investigation of the incident had not been initiated on 03/24/13 by the facility. Review of an investigation conducted by the facility dated 04/01/13 revealed on 03/24/13 Resident #4 alleged RN #8 was mean to the resident and the resident did not want the Nurse to provide care for her/him. According to the investigation Resident #8 was interviewed on 03/28/13, and reported no one was mean to her/him. The investigation also revealed the resident reported "one of the women" was mean to her, and stated it was RN #8; however, documentation in the report revealed the resident stated he/she "didn't really mean it". Further review of the investigation revealed RN #8 verified Resident #4 had told her that she was mean to the resident on 03/24/13. Based on the facility's investigation the facility unsubstantiated abuse based on the "resident's moderately impaired cognitive ability". Review of Resident #4's medical record revealed on 02/01/13 the facility assessed the resident's cognition level as moderately impaired when a significant change in status Minimum Data Set (MDS) assessment had been completed. Interview with Resident #4 on 03/29/13 at 4:00 PM, revealed the resident did not remember the date but stated "a few days ago", he/she needed to go to the restroom during the night and turned the call light on to alert staff. Resident #4 stated he/she could not wait and went to the restroom alone. According to Resident #4, RN #8 came in and started telling the resident not to get up unassisted and to wait for help. Resident #4 stated RN #8 was being loud and the resident did not like it. The resident stated he/she told the RN she was being mean; that the resident did not want the RN to provide care for him/her; and, not to come back into the resident's room. Resident #4 stated that later in the morning, he/she told RN #8 that he/she was sorry and the resident did not think the RN was mean. Interview with RN #8 on 03/28/13 at 8:07 PM revealed on 03/24/13, around midnight, Resident #4 rang the call light and the RN went into the room. The RN found the resident in the restroom and instructed the resident to wait for assistance before getting up. According to the RN, the resident became angry and upset and yelled at the RN "don't fuss, don't quarrel". RN #8 further stated she went into Resident #8's room again between 2:00 AM and 4:00 AM when the resident's call light was sounding and the resident told the RN he/she did not want the RN to take care of her/him anymore, and stated they could not get along and the resident did not want the Nurse coming in the resident's room anymore. RN #8 further stated around 6:00 AM on 03/24/13 Resident #4 told her she could provide care for her and the resident did not think the RN was mean. Further interview revealed the RN had informed "in a casual way" RN #9 on B wing of what the resident stated and SRNA #14 and #15 were also aware of Resident #4 being upset with RN #8. However, according to RN #8 she did not inform the DON or Administrator of the incident. Further interview revealed on 03/27/13 around 6:00 PM the DON called and asked the RN to come in early for work. RN #8 stated when she arrived, the DON asked her about the incident on 03/24/13. RN #8 stated she explained the incident and the DON informed her it should have been reported to the DON and Administrator as an allegation of abuse. RN #8 stated after speaking with the DON on 03/27/13 she went out on the floor and worked her twelve (12) hours scheduled shift. Interview with RN #9 on 03/29/13 at 8:02 PM revealed he did remember RN #8 coming to B wing on the morning of 03/24/13 crying. However, he did not remember anything related to Resident #4. Interview with SRNA #14 on 03/29/13 at 4:45 PM revealed on 03/24/13 between 3:00 AM and 4:00 AM, RN #8 informed her about the incident with Resident #4. According to SRNA #14 she did not hear the exchange between RN #8 and the resident. SRNA #14 stated she should have reported the incident to another Nurse but it "didn't enter" her "mind to do that". Interview with SRNA #15 on 03/29/13 at 2:34 PM revealed on the morning of 03/24/13 the SRNA came to work at 5:00 AM and RN #8 informed her about the incident between the RN and Resident #4. SRNA #15 stated she did not report the information to the DON or Administrator as she had been instructed to. Interview with RN #4 on 03/29/13 at 7:35 PM revealed she worked on the morning of 03/24/13. According to RN #4, RN #8 informed her during change of shift of the incident between the RN and Resident #8. RN #4 stated RN #8 informed her she had documented the incident in the resident's Nurse's Notes and did not know what else to do about it. RN #4 further stated around 9:00 AM on 03/24/13 she reported the incident to the Weekend Manager "because it was charted in the Nurse's Notes"; in case there was a "need to open an investigation". RN #4 went on to state if it had not been charted she "wouldn't have been so concerned" about reporting it. Further interview revealed RN #4 did not report the incident to the DON or Administrator because she "didn't see any immediate harm". RN #4 stated she "didn't feel abuse" occurred, since the resident was "fine, everything was fine", and since RN #8 did not go back into Resident #4's room. Interview with the Weekend Manager, who was the Dietary Manager, on 03/28/13 at 6:41 PM, revealed she was the Manager on Duty on Sunday 03/24/13. When she came in that morning she went to each Nurse's station to talk with Nurses. According to the Weekend Manager, RN #4 informed her of the incident that transpired between RN #8 and Resident #4 during the early morning. The Weekend Manager stated she called the DON around 10:00 AM on 03/24/13 to inform her of the incident. The Weekend Manager stated the DON told her the way the "situation" was handled was fine since Resident #4 told RN #8 she did not think the RN was mean. The Weekend Manager stated she did not pursue an investigation after speaking with the DON, nor did she report the incident to the Administrator. Interview with the DON on 04/02/13 at 8:45 PM revealed she was aware of the incident between Resident #4 and RN #8 that had occurred on 03/24/13. She stated the Weekend Manager had informed her of the situation on 03/24/13 and she did not give the Weekend Manager any further instructions. However, the DON did not initiate an investigation nor did she notify the Administrator. The DON stated on 03/27/13, the Corporate Nurse Consultant contacted her regarding the incident after she had read it in the Nurse's Notes. The DON stated, at that time, she called RN #8 and asked her to come to the facility for interview. The DON further stated she and Administrator #2 allowed the RN to continue working on 03/27/13 after interviewing her and prior to the finishing the investigation that was initiated on 03/27/13. The DON stated after she and Administrator #2 interviewed RN #8, they determined abuse had not occurred. Interview with the Cooperate Nurse Consultant on 03/28/13 at 7:45 PM revealed on 03/27/13 she was training another corporate staff member while performing audits of resident medical records. According to the Corporate Nurse Consultant, the trainee was reviewing Resident #4's chart and discovered Nurses' Notes from 03/24/13 regarding the incident between the resident and RN #8. Further interview revealed she called the DON, who was in the building, to question if she was aware of the incident. The DON informed her she was, but had forgotten to investigate it and report it to anyone else. The Cooperate Nurse Consultant stated on 03/27/13 she called the Chief Nurse Executive to inform her of the findings. The Chief Nurse Executive informed her to interview RN #8 and obtain a statement. Interview further revealed, after the interview had been conducted, she did not conduct a follow-up to ensure an investigation had been initiated and residents were protected. The Cooperate Nurse Consultant stated she was not aware RN #8 was permitted to work the shift on the evening of 03/27/13. Interview with the Chief Nurse Executive on 03/29/13 at 3:25 PM revealed she did receive a call on 03/27/13 concerning the incident between RN #8 and Resident #4. She instructed the Cooperate Nurse Consultant to obtain a statement from the RN and that she would notify the Cooperate Regional Controller, who was in charge while the Vice President of Operations was away. Further interview revealed she did notify the Corporate Regional Controller who stated "this is not good", and stated she would notify the Administrator. According to the Chief Nurse Executive, even though she thought they needed to suspend the Nurse, she provided no additional input into the investigation. Interview with the Cooperate Regional Controller on 03/29/13 at 2:15 PM revealed she was notified on 03/27/13 by the Chief Nurse Executive of the incident between Resident #4 and RN #8. She further stated she informed the Chief Nurse Executive that she would notify the Administrator. Further interview revealed she was not aware RN #8 was permitted to work on the evening of 03/27/13 because, at that point, the investigation had just been initiated. Interview with Administrator #2 on 03/28/13 at 2:00 PM; 6:40 PM; and on 03/29/13 at 10:25 AM and 4:11 PM, revealed he became aware of the incident on 03/27/13 at approximately 5:40 PM and went to speak with the DON regarding the incident. According to Administrator #2 the DON informed him she had forgotten to notify him of the allegation and failed to initiate an investigation into the incident. Administrator #2 further stated on 03/27/13 when the DON acknowledged the incident and reported she had forgotten to conduct an investigation; the DON called RN #8 into the office to question her regarding the incident. Administrator #2 stated although he sat in during the interview, he was "half paying attention". Administrator #2 further stated he was aware the RN was permitted to work after being interviewed on 03/27/13 while the investigation was in progress. However, review of the facility's abuse policy revealed the resident was to "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process." The Administrator and/or Director of Nursing and/or Social Worker would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse". Further interview with Administrator #2 revealed he "did not think it (the allegation) was reportable", he stated "in my heart of hearts I have gotten to know the little girl (RN #8) while I've been here, I just didn't feel it was true and reportable". He stated as of 03/29/13 RN #8 was on suspension and the decision to let her work on 03/27/13 was "probably a bad decision", "with the facility the way it is". Further interview revealed Administrator #2 had not interviewed the DON regarding the incident, but was aware the DON had "just forgotten" to do anything with the information she received on 03/24/13. 5. A review of the facility's investigation of an allegation of verbal abuse of Resident #19 that was alleged to have occurred on 04/04/13 at 9:00 AM, revealed SRNA #1 and SRNA #8 were assisting a Laboratory Technician to obtain a blood specimen from Reside

Based on interview, record review, and review of the facility's investigation and policy and procedures it was determined the facility failed to have an effective system to ensure all allegations of abuse were reported immediately to the Administrator of the facility, failed to protect residents after an allegation of abuse, and failed to ensure all alleged violations were thoroughly investigated for six of twenty-nine sampled residents (Resident #1, #4, #19, #29, #30, and #31). On 02/17/13 at approximately 7:35 AM, staff observed Resident #1 sitting in a wheelchair located in the dining room next to the Nurses' station, crying in pain, and requesting to go to bed. Licensed Practical Nurse (LPN) #1 refused to allow staff to take Resident #1 to bed and stated the resident would remain seated in the wheelchair until the resident quit "crying," "hollering," and/or "whining." LPN #1 placed a radio near Resident #1's head and turned up the volume. According to interviews, staff attempted to report the alleged abuse to the Social Worker/Abuse Coordinator, in accordance with facility policy; however, staff was unable to contact the Social Worker/Abuse Coordinator and left a voice mail message on the Social Worker/Abuse Coordinator's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, Director of Nursing (DON), and Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. According to the facility investigation, dated 02/22/13, after the investigation was completed the facility unsubstantiated that abuse occurred. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. (Refer to F223.) In addition, on the morning of 03/24/13, at approximately 12:00 AM, Resident #4 reported to Registered Nurse (RN) #8 that RN #8 was mean to the resident; that the resident did not want RN #8 to provide care for the resident anymore; and, asked RN #8 to not come back into the resident's room. RN #8 documented the incident in Resident #4's medical record and reported the incident to the oncoming Nurse (RN #4) at 7:00 AM. RN #4 reported the incident to the Weekend Manager on 03/24/13, and the Weekend Manager contacted the DON to report the incident. However, the DON did not initiate an investigation of the incident and did not notify the Administrator of the incident. On 03/27/13, the facility's Cooperate Nurse Consultant learned of the incident through review of Resident #4's medical record. The DON and Administrator #2 interviewed RN #8 about the incident prior to the start of her shift on 03/27/13. However, the DON and Administrator #2 allowed RN #8 to continue to provide direct care to residents in the facility during her scheduled twelve (12) hour shift on 03/27/13 and, as a result, failed to ensure residents in the facility were protected from further potential abuse while the facility's investigation was in progress. In addition, the facility failed to ensure four (4) other potential allegations of abuse were thoroughly investigated and reported to the appropriate State Agencies; alleged verbal abuse involving Resident #19; Resident #29 expressing fear of State Registered Nurse Aide (SRNA) #14; Resident #30 being sprayed with cold water and having a towel wrapped around his/her neck; and, Resident #31 being handled roughly by staff while being placed in a chair. The facility's failure to immediately report an allegation of abuse, failure to protect residents during the course of an investigation of abuse, and failure to thoroughly investigate an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/17/13 with the facility alleging removal of the Immediate Jeopardy on 04/17/13. The State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 04/22-04/23/13, as alleged in the acceptable AOC, with remaining noncompliance at 42 CFR 483.13 Resident Behavior and Facility Practices F225- S/S "E", while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's abuse policy, dated 01/2012, revealed it was "the intent of the facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident's property or reasonable suspicion of criminal act or intent." The policy stated "any report or suspicion of an incident was to be reported immediately to the charge nurse", and the Administrator, Director of Nursing and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." Further review revealed "any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate." The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." Based on a review of the facility's investigation, dated 02/22/13, and interviews with Housekeeper #1 on 02/28/13 at 12:17 PM and again on 03/04/13 at 11:37 AM, with Housekeeper #2 on 03/01/13 at 11:47 AM, with SRNA #3 on 03/01/13 at 12:29 PM, with Kentucky Medication Aide (KMA) #1 on 03/01/13 at 12:01 PM, and review of a witness statement provided by SRNA #2 (unable to be reached for interview), LPN #1 was observed to abuse Resident #1. However, no action was immediately taken by the staff who witnessed the abuse to protect residents in the facility or notify appropriate facility personnel until approximately 11:30 AM, when Housekeeper #1 attempted to notify the Social Worker/Abuse Coordinator, as directed in the facility's policy, via phone, but was unable to reach her, and left a message describing what she had witnessed. Housekeeper #1 and Housekeeper #2 stated they did not immediately report the abuse due to being "nervous," "scared," and "did not know what to do," since the abuse had been committed by the Charge Nurse. Housekeeper #1 stated after leaving the voice message for the Abuse Coordinator, she observed the Staff Development Coordinator in the facility and immediately reported what she had witnessed to her. An interview conducted with the Staff Development Coordinator/Nurse Manager on 02/28/13 at 5:35 PM, on 03/04/13 at 11:07 AM, and again on 03/05/13 at 4:45 PM revealed she was at the facility on 02/17/13 and was approached by Housekeepers #1 and #2 at approximately 11:40 AM, reporting the incident they witnessed concerning Resident #1 and LPN #1. The Staff Development Coordinator/Nurse Manager stated she proceeded to talk with other staff related to the incident and had staff fill out witness statements, but took no action to protect residents in the facility from further abuse by the LPN. The Staff Development Coordinator/Nurse Manager stated she did not have the authority to remove LPN #1 (Charge Nurse) from patient care, stating only the Administrator, Social Worker/Abuse Coordinator, or Director of Nursing had that authority. The Staff Development Coordinator/Nurse Manager stated she also attempted to contact the Social Worker/Abuse Coordinator, time unknown, but was unable to reach her and left a voice message. The Staff Development Coordinator/Nurse Manager stated she was unable to notify the DON of the alleged abuse due to not having access to her "current" phone number. According to the Staff Development Coordinator/Nurse Manager, LPN #1 continued to be in charge of resident care and remained on the floor with residents until 12:30 PM (five hours after the abuse was observed) when the Staff Development Coordinator/Nurse Manager contacted the facility's Nurse Consultant via telephone and was instructed to suspend LPN #1, the Charge Nurse. However, review of the facility's policy revealed residents would "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process." Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM revealed once she discovered and listened to the voice messages from Housekeeper #1 and the Staff Development Coordinator/Nurse Manager on 02/17/13 (time unknown) she went to the facility to assist with the investigation. According to the Social Worker/Abuse Coordinator staff was required to report any allegations of abuse to the Abuse Coordinator (herself), the Administrator, the DON, or the Charge Nurse. However, the facility had no specific detailed reporting procedure such as an "on call" system, to ensure staff was able to report abuse as the facility policy directs. The Social Worker/Abuse Coordinator stated there was no written order of whom to report abuse to, and staff would have to go through the individuals listed in the policy until one was reached. The Social Worker/Abuse Coordinator further stated she was allowed to remove alleged perpetrators from resident care and she was unaware if another Nurse had the authority to remove alleged perpetrators from direct care after an allegation of abuse had been alleged. Interview further revealed when an allegation of abuse was made she, the DON, and the Administrator, performed the investigation. According to the Social Worker/Abuse Coordinator depending on who got to the facility first, the others would just "see who did what" and assist with the investigation. The Social Worker/Abuse Coordinator stated the Administrator was ultimately responsible for the decision to determine if a staff member had committed an abusive act toward a resident, and made decisions regarding all disciplinary action. Review of the facility's policy revealed only the "Administrator and/or Director of Nursing and/or Social Worker" would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." Administrator #1 stated in an interview conducted on 02/28/13 at 5:20 PM that his investigation of the alleged abuse consisted of reviewing witness statements, information that had been obtained, consulting with his regional staff, and interviewing LPN #1, the Charge Nurse. According to Administrator #1 when he interviewed LPN #1, she did confirm Resident #1 was crying and yelling at the Nurses' station and she (the Charge Nurse) instructed staff to leave the resident up in the chair, but explained that it was to "observe the resident." Administrator #1 also acknowledged he had been aware of the staff interviews and witness statements describing the LPN's (Charge Nurse) intentions to "teach" (Resident #1) "a lesson." Additionally, the Abuse Coordinator had reported that although she had been unable to get specifics of the alleged incident from Resident #1 due to (his/her) impaired cognition, an alert and oriented resident had reported witnessing LPN #1 being inappropriate and rude to another resident previously. However, after considering all the information that had been obtained during the investigation, he had concluded that staff "might have misinterpreted" the LPN's actions, and stated he was unable to come to a "firm" conclusion or determine if LPN #1 had abused Resident #1, and therefore unsubstantiated the allegation, and took no further disciplinary action against LPN #1 in regard to the alleged abuse to Resident #1. Review of the facility's abuse policy revealed the Administrator/designee would "make all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them." At the time of the investigation, LPN #1, the Charge Nurse, was no longer employed by the facility, and attempts to interview her were unsuccessful. 2. Review of the medical record revealed the facility admitted Resident #29 on 03/18/10 with [DIAGNOSES REDACTED]. A list of residents assessed by the facility to be alert, oriented and interviewable was provided on 04/02/13. According to the list, the facility had assessed Resident #29 to be alert, oriented, and interviewable. Resident #29 was observed sitting in a wheelchair in the facility dining room on 04/05/13 at 5:50 PM. Interview conducted on 04/05/13, at 5:50 PM with Resident #29 revealed he/she was afraid of a staff person (SRNA #14). The resident stated SRNA #14 had touched his/her breast when the SRNA hugged the resident approximately 2-3 months ago, and would come into the resident's room without knocking when the resident was "disrobed." Resident #29 stated he/she reported the incident that occurred 2-3 months ago to the facility's Social Worker/Abuse Coordinator at the time the incident occurred. The resident stated SRNA #14 had been moved to another area in the facility after he/she reported the incident to the Social Worker/Abuse Coordinator. Interview conducted with the Social Worker/Abuse Coordinator on 04/05/13, at 6:50 PM, revealed Resident #29 reported to her on 03/01/13 that SRNA #14 had touched the resident's breast and, although Resident #29 reportedly did not feel SRNA #14's action was abuse, the resident felt the his actions were "inappropriate." According to the Social Worker/Abuse Coordinator, she had the responsibility to investigate allegations of abuse, to report the allegation to the appropriate state agencies, and to provide administrative staff a report of her findings. The Social Worker/Abuse Coordinator stated on 03/01/13, she and Administrator #1 talked with Resident #29 regarding the reported incident and informed Resident #29 that SRNA #14 would be reassigned to another area in the facility. The Social Worker/Abuse Coordinator stated she obtained verbal statements from Resident #29; Resident #29's daughter; and SRNA #14; and a written statement from a staff Nurse that had been assigned to the Seasons unit at the time the resident reported the incident. The Social Worker/Abuse Coordinator stated as a result of the allegation made by Resident #29, SRNA #14 was reassigned to another unit of the facility and was permitted to continue to provide direct care to residents. In addition, the Social Worker/Abuse Coordinator stated she had not considered the incident to be possible abuse; did not conduct further investigation of the allegation; and did not report the incident to the appropriate state agencies. However, review of the facility's policy on abuse revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." According to the Social Worker/Abuse Coordinator, as part of her responsibilities of abuse investigations, she was responsible to remove the alleged perpetrator from resident care and to provide administrative staff the results of her investigation. Administrator #1 was no longer employed as Administrator of the facility and an interview could not be obtained with Administrator #1. Interview conducted on 04/05/13, at 6:05 PM, with the Vice President of Operations revealed he was also currently acting as the facility's Administrator. The Vice President of Operations stated although he was not aware of the incident involving Resident #29, he would attempt to locate the facility's investigation. Continued interview with the Vice President of Operations on 04/05/13 at 7:30 PM revealed SRNA #14 had continued to work at the facility and was working on 04/05/13 when Resident #29 reported the incident to the surveyor. According to the Vice President of Operations, the facility's investigation of the incident consisted of the interviews that had been obtained by the Social Worker/Abuse Coordinator. The Vice President of Operations stated effective 04/05/13 SRNA #14 had been suspended from employment pending further investigation of the incident. The Vice President of Operations stated he did recall Administrator #1 telling him SRNA #14 had been moved to another area of the facility to work due to a resident telling staff he/she did not want SRNA #14 providing their care. However, the Vice President of Operations stated he could not recall the resident's name and did not ask additional questions related to that resident's concern. 3. A review of a facility's investigation revealed on 03/24/13, Resident #30 alleged that SRNA #13 had repeatedly sprayed cold water on the resident during a shower and had wrapped a sheet around the resident's neck too tight following the shower on 03/22/13 from 8:00 PM to 9:00 PM. According to investigation witness statements and an investigation was started on 03/24/13 by the facility's Social Worker/Abuse Coordinator. However, review of the facility's policy on abuse revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident." Additional review on 04/09/13 revealed the facility had not completed the investigation and had failed to report the allegation to the appropriate State Agencies until 04/09/13, sixteen (16) days after the alleged incident was reported. In addition, there was no evidence the alleged perpetrator had been suspended. However, the facility's policy revealed the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." According to the initial report of the allegation dated 04/09/13, revealed that SRNA #13 was not on duty, the facility had attempted to contact SRNA #13, and SRNA #13 would be suspended and not allowed to work until the investigation had cleared the SRNA of the allegation. A review of the facility's investigation log revealed no entry regarding Resident #30. An interview conducted with the facility Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed, on 04/08/13, the Social Worker/Abuse Coordinator informed the Administrator of the allegation of abuse that had occurred on 03/22/13 and involved Resident #30. According to the Social Worker/Abuse Coordinator, it was the Social Worker/Abuse Coordinator's responsibility to report the allegation to the Administrator and the Director of Nursing. In addition, the Social Worker/Abuse Coordinator stated, the facility's investigation of the allegation that had reportedly occurred on 03/22/13 had not been completed. Interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 was aware the Social Worker/Abuse Coordinator was talking with Resident #30 on 03/24/13, however; was not aware of an abuse allegation. According to Administrator #2 he was not aware of the allegation of abuse had not been thoroughly investigated and reported as required until the investigation file was found on 04/08/13. 4. Interview with facility Administrator #2 on 03/28/13 at 1:50 PM revealed there had been an allegation of abuse that he planned to report to the appropriate State Agencies. Administrator #2 stated the incident occurred on 03/24/13, was reported on 03/27/13, and the facility was in the process of conducting an investigation. According to Administrator #2, a resident said a Nurse was mean to her/him, but "no abuse occurred." Administrator #2 further stated the DON was aware of the allegation on 03/24/13, the date of the alleged abuse, and confirmed an investigation of the incident had not been initiated on 03/24/13 by the facility. Review of an investigation conducted by the facility dated 04/01/13 revealed on 03/24/13 Resident #4 alleged RN #8 was mean to the resident and the resident did not want the Nurse to provide care for her/him. According to the investigation Resident #8 was interviewed on 03/28/13, and reported no one was mean to her/him. The investigation also revealed the resident reported "one of the women" was mean to her, and stated it was RN #8; however, documentation in the report revealed the resident stated he/she "didn't really mean it." Further review of the investigation revealed RN #8 verified Resident #4 had told her that she was mean to the resident on 03/24/13. Based on the facility's investigation the facility unsubstantiated abuse based on the "resident's moderately impaired cognitive ability." Review of Resident #4's medical record revealed on 02/01/13 the facility assessed the resident's cognition level as moderately impaired when a significant change in status Minimum Data Set (MDS) assessment had been completed. Interview with Resident #4 on 03/29/13 at 4:00 PM, revealed the resident did not remember the date but stated "a few days ago", he/she needed to go to the restroom during the night and turned the call light on to alert staff. Resident #4 stated he/she could not wait and went to the restroom alone. According to Resident #4, RN #8 came in and started telling the resident not to get up unassisted and to wait for help. Resident #4 stated RN #8 was being loud and the resident did not like it. The resident stated he/she told the RN she was being mean; that the resident did not want the RN to provide care for him/her; and, not to come back into the resident's room. Resident #4 stated that later in the morning, he/she told RN #8 that he/she was sorry and the resident did not think the RN was mean. Interview with RN #8 on 03/28/13 at 8:07 PM revealed on 03/24/13, around midnight, Resident #4 rang the call light and the RN went into the room. The RN found the resident in the restroom and instructed the resident to wait for assistance before getting up. According to the RN, the resident became angry and upset and yelled at the RN "don't fuss, don't quarrel." RN #8 further stated she went into Resident #8's room again between 2:00 AM and 4:00 AM when the resident's call light was sounding and the resident told the RN he/she did not want the RN to take care of her/him anymore, and stated they could not get along and the resident did not want the Nurse coming in the resident's room anymore. RN #8 further stated around 6:00 AM on 03/24/13 Resident #4 told her she could provide care for her and the resident did not think the RN was mean. Further interview revealed the RN had informed "in a casual way" RN #9 on B wing of what the resident stated and SRNA #14 and #15 were also aware of Resident #4 being upset with RN #8. However, according to RN #8 she did not inform the DON or Administrator of the incident. Further interview revealed on 03/27/13 around 6:00 PM the DON called and asked the RN to come in early for work. RN #8 stated when she arrived, the DON asked her about the incident on 03/24/13. RN #8 stated she explained the incident and the DON informed her it should have been reported to the DON and Administrator as an allegation of abuse. RN #8 stated after speaking with the DON on 03/27/13 she went out on the floor and worked her twelve (12) hours scheduled shift. Interview with RN #9 on 03/29/13 at 8:02 PM revealed he did remember RN #8 coming to B wing on the morning of 03/24/13 crying. However, he did not remember anything related to Resident #4. Interview with SRNA #14 on 03/29/13 at 4:45 PM revealed on 03/24/13 between 3:00 AM and 4:00 AM, RN #8 informed her about the incident with Resident #4. According to SRNA #14 she did not hear the exchange between RN #8 and the resident. SRNA #14 stated she should have reported the incident to another Nurse but it "didn't enter" her "mind to do that." Interview with SRNA #15 on 03/29/13 at 2:34 PM revealed on the morning of 03/24/13 the SRNA came to work at 5:00 AM and RN #8 informed her about the incident between the RN and Resident #4. SRNA #15 stated she did not report the information to the DON or Administrator as she had been instructed to. Interview with RN #4 on 03/29/13 at 7:35 PM revealed she worked on the morning of 03/24/13. According to RN #4, RN #8 informed her during change of shift of the incident between the RN and Resident #8. RN #4 stated RN #8 informed her she had documented the incident in the resident's Nurse's Notes and did not know what else to do about it. RN #4 further stated around 9:00 AM on 03/24/13 she reported the incident to the Weekend Manager "because it was charted in the Nurse's Notes"; in case there was a "need to open an investigation." RN #4 went on to state if it had not been charted she "wouldn't have been so concerned" about reporting it. Further interview revealed RN #4 did not report the incident to the DON or Administrator because she "didn't see any immediate harm." RN #4 stated she "didn't feel abuse" occurred, since the resident was "fine, everything was fine", and since RN #8 did not go back into Resident #4's room. Interview with the Weekend Manager, who was the Dietary Manager, on 03/28/13 at 6:41 PM, revealed she was the Manager on Duty on Sunday 03/24/13. When she came in that morning she went to each Nurse's station to talk with Nurses. According to the Weekend Manager, RN #4 informed her of the incident that transpired between RN #8 and Resident #4 during the early morning. The Weekend Manager stated she called the DON around 10:00 AM on 03/24/13 to inform her of the incident. The Weekend Manager stated the DON told her the way the "situation" was handled was fine since Resident #4 told RN #8 she did not think the RN was mean. The Weekend Manager stated she did not pursue an investigation after speaking with the DON, nor did she report the incident to the Administrator. Interview with the DON on 04/02/13 at 8:45 PM revealed she was aware of the incident between Resident #4 and RN #8 that had occurred on 03/24/13. She stated the Weekend Manager had informed her of the situation on 03/24/13 and she did not give the Weekend Manager any further instructions. However, the DON did not initiate an investigation nor did she notify the Administrator. The DON stated on 03/27/13, the Corporate Nurse Consultant contacted her regarding the incident after she had read it in the Nurse's Notes. The DON stated, at that time, she called RN #8 and asked her to come to the facility for interview. The DON further stated she and Administrator #2 allowed the RN to continue working on 03/27/13 after interviewing her and prior to the finishing the investigation that was initiated on 03/27/13. The DON stated after she and Administrator #2 interviewed RN #8, they determined abuse had not occurred. Interview with the Cooperate Nurse Consultant on 03/28/13 at 7:45 PM revealed on 03/27/13 she was training another corporate staff member while performing audits of resident medical records. According to the Corporate Nurse Consultant, the trainee was reviewing Resident #4's chart and discovered Nurses' Notes from 03/24/13 regarding the incident between the resident and RN #8. Further interview revealed she called the DON, who was in the building, to question if she was aware of the incident. The DON informed her she was, but had forgotten to investigate it and report it to anyone else. The Cooperate Nurse Consultant stated on 03/27/13 she called the Chief Nurse Executive to inform her of the findings. The Chief Nurse Executive informed her to interview RN #8 and obtain a statement. Interview further revealed, after the interview had been conducted, she did not conduct a follow-up to ensure an investigation had been initiated and residents were protected. The Cooperate Nurse Consultant stated she was not aware RN #8 was permitted to work the shift on the evening of 03/27/13. Interview with the Chief Nurse Executive on 03/29/13 at 3:25 PM revealed she did receive a call on 03/27/13 concerning the incident between RN #8 and Resident #4. She instructed the Cooperate Nurse Consultant to obtain a statement from the RN and that she would notify the Cooperate Regional Controller, who was in charge while the Vice President of Operations was away. Further interview revealed she did notify the Corporate Regional Controller who stated "this is not good", and stated she would notify the Administrator. According to the Chief Nurse Executive, even though she thought they needed to suspend the Nurse, she provided no additional input into the investigation. Interview with the Cooperate Regional Controller on 03/29/13 at 2:15 PM revealed she was notified on 03/27/13 by the Chief Nurse Executive of the incident between Resident #4 and RN #8. She further stated she informed the Chief Nurse Executive that she would notify the Administrator. Further interview revealed she was not aware RN #8 was permitted to work on the evening of 03/27/13 because, at that point, the investigation had just been initiated. Interview with Administrator #2 on 03/28/13 at 2:00 PM; 6:40 PM; and on 03/29/13 at 10:25 AM and 4:11 PM, revealed he became aware of the incident on 03/27/13 at approximately 5:40 PM and went to speak with the DON regarding the incident. According to Administrator #2 the DON informed him she had forgotten to notify him of the allegation and failed to initiate an investigation into the incident. Administrator #2 further stated on 03/27/13 when the DON acknowledged the incident and reported she had forgotten to conduct an investigation; the DON called RN #8 into the office to question her regarding the incident. Administrator #2 stated although he sat in during the interview, he was "half paying attention." Administrator #2 further stated he was aware the RN was permitted to work after being interviewed on 03/27/13 while the investigation was in progress. However, review of the facility's abuse policy revealed the resident was to "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process." The Administrator and/or Director of Nursing and/or Social Worker would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." Further interview with Administrator #2 revealed he "did not think it (the allegation) was reportable", he stated "in my heart of hearts I have gotten to know the little girl (RN #8) while I've been here, I just didn't feel it was true and reportable." He stated as of 03/29/13 RN #8 was on suspension and the decision to let her work on

Based on interview, record review, and a review of the facility's policy and procedures and investigations, it was determined the facility failed to have an effective system to ensure policy and procedures related to abuse were implemented for six of twenty-nine residents (Residents #1, #4, #19, #29, #30, and #31). The facility failed to ensure a suspicion of an incident of abuse was reported immediately, failed to ensure that a thorough investigation was conducted for an alleged incident of abuse involving a staff member, and failed to ensure residents were protected following a report of abuse and during the investigation process. Facility staff failed to ensure an allegation of abuse was reported timely. On 02/17/13, facility staff witnessed Licensed Practical Nurse (LPN) #1, the Charge Nurse, verbally abuse Resident #1 at approximately 7:35 AM. Staff attempted, between 11:30 AM and 12:00 PM, to contact the facility's Social Worker/Abuse Coordinator to report the allegation per the facility's policy. The Social Worker/Abuse Coordinator was unavailable and staff left a voice message on the Social Worker/Abuse Coordinator's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. After receipt of the report of alleged abuse, the facility failed to ensure residents were protected from potential further abuse. The facility's policies and procedures stated the Administrator and/or Director of Nursing (DON) and/or Social Worker were the staff that could make any immediate decisions related to the removal of the alleged abuser from direct care giving. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, the DON, and the Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. After completion of the facility's investigation, Administrator #1 reported as a result of the investigation, interviews, and a review of the witness statements, he could not come to a "firm" conclusion that abuse had occurred and the allegation of abuse was determined to be unsubstantiated by the facility. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. (Refer to F223 and F225.) In addition, interview and record review revealed the facility failed to immediately initiate an investigation, failed to ensure residents were protected from further potential abuse during an investigation, and failed to notify the Administrator and appropriate State Agencies for allegations of potential abuse involving Residents #19, #29, #30, and #31. (Refer to F225.) The facility's failure to have an effective system in place to ensure the development and implementation of policies and procedures to protect residents from abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Two Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's abuse policy, dated 01/2012, revealed, "any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing, and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." Further review revealed, "any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate." The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident;" the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them;" and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 1. A review of the facility's investigation revealed on 02/17/13, staff reported Resident #1 was "crying," and wanted to be put to bed. However, based on documentation, staff reported LPN #1 (who was the Charge Nurse) would not allow staff to put the resident to bed due to the resident "yelling" and "crying." The investigation further revealed the LPN was "immediately" suspended on 02/17/13 pending the outcome of the investigation. Further, during the investigation, other residents were interviewed, and one resident reported he/she had overheard LPN #1 say negative things about another resident at the facility. According to the investigation, dated 02/22/13, the facility did not substantiate that the abuse occurred. During the course of the investigation, attempts were made to contact LPN #1 for interview. However, LPN #1 was no longer employed by the facility and attempts to contact the LPN were unsuccessful. A review of LPN #1's employee file revealed the LPN was terminated from employment by the facility on 02/25/13 for falsification of documentation. Interview with the Staff Development Coordinator/Unit Manager on 02/28/13 at 5:35 PM and again on 03/04/13 at 11:07 AM revealed she came to the facility on [DATE] at approximately 11:00 AM to do a "weekend check." At approximately 11:30 AM-11:40 AM, Housekeepers #1 and #2 came to her and stated they felt a "little uneasy" and "uncomfortable" with what they had witnessed between LPN #1 and Resident #1. The Staff Development Coordinator/Unit Manager stated the housekeepers informed her Resident #1 asked to be put to bed and the LPN refused to allow staff to put the resident to bed and that they had attempted to contact the Social Worker/Abuse Coordinator prior to notifying her in accordance with facility policy. The Staff Development Coordinator/Unit Manager stated after the housekeepers spoke with her she went out on the floor, started an investigation, talked to individuals on the unit, and had the staff fill out written statements. She stated she spoke with State Registered Nurse Aides and an Activities Worker and had them fill out witness statements. The Staff Development Coordinator/Unit Manager stated LPN #1 remained on the nursing unit at the nurses' station during the time she initiated the investigation. She stated she did not remove LPN #1 from the floor immediately because she was trying to determine if it was "appropriate" for her to "pull the LPN from the floor." Between 11:30 AM and 12:30 PM she attempted to call the Social Worker/Abuse Coordinator, for further guidance, per the facility policy; however, she was unable to contact her via phone. According to the Staff Development Coordinator/Unit Manager, she then contacted the Facility's Nurse Consultant for further direction, and informed LPN #1 that she was being sent home pending the final investigation. She further stated she did not know if she could remove staff from the floor, and the allegation had to be "justifiable" to remove facility staff from the floor. Further interview revealed she was not sure what was being reported by the housekeepers was abuse. However, review of the facility's policy revealed "any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing, and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." In addition, the policy stated the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." However, interview and record review revealed these procedures were not implemented. Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM confirmed she had received a voice mail message from one of the facility housekeepers and the Staff Development Coordinator/Nurse Manager on 02/17/13. She stated she came to the facility the same day and assisted with the investigation. Further interview with the Social Worker/Abuse Coordinator on 03/04/13, at 1:25 PM, revealed staff had been trained to report allegations of abuse to her, the DON or the Administrator. The Social Worker/Abuse Coordinator further stated she was not sure if a nurse could remove a staff member from direct resident care in the event an allegation of abuse had been made and staff could not reach Administrative staff. Review of staff training records revealed the last abuse training provided by the facility was in December 2012. Interview with Administrator #1 on 02/28/13 at 5:20 PM, revealed LPN #1 did not have a history of abuse and staff may have "misinterpreted" the LPN since she was "loud" by nature. Administrator #1 stated they could not come to a "firm" conclusion related to abuse, at the conclusion of the investigation, and the facility was not able to substantiate that abuse occurred. Interview with Administrator #1 on 03/05/13 at 4:25 PM revealed he was not aware the facility policy instructed staff to seek guidance from him, the DON, or the Social Worker/Abuse Coordinator prior to the removal of the alleged perpetrator after an allegation of abuse was made. Per interview, he was not aware the facility's abuse policy did not instruct staff to immediately remove the alleged perpetrator from direct resident care. However, review of the facility's policy revealed only the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." Interview with the facility's Vice President of Operations, Chief Nurse Executive, and the Nurse Consultant on 03/04/13 at 5:05 PM, revealed the facility's abuse policy had been developed at the corporate level and they were not aware the policy indicated only the "Administrator and/or DON and/or Social Worker" would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact following an allegation of suspected abuse." 2. Interview with Resident #29 on 04/05/13 at 5:50 PM, revealed the resident reported he/she was "afraid" of SRNA #14 because he had touched the resident's breast while hugging the resident two to three months ago. Resident #29 stated SRNA #14 was moved to another area in the facility to work after he/she reported the incident to the facility's Social Worker/Abuse Coordinator. Interview with the Social Worker/Abuse Coordinator on 04/05/13, at 3:30 PM, revealed she also acted as the facility's Abuse Coordinator, was responsible to assist with investigations related to abuse/neglect, and to provide staff education/in-service related to abuse/neglect as indicated. The Social Worker/Abuse Coordinator stated in accordance with facility policy allegations of alleged abuse were to be immediately investigated and reported to the appropriate state agencies. The Social Worker/Abuse Coordinator further stated she had received training from the facility regarding the facility's abuse policies/procedures when she was hired by the facility on 06/20/11, as well as when the policy, which included reporting, investigation, and resident protection of abuse allegations, was revised in March 2013. Further interview conducted with the Social Worker/Abuse Coordinator on 04/05/13, at 6:50 PM confirmed Resident #29 reported SRNA #14 touched the resident's breast on 03/01/13. According to the Social Worker/Abuse Coordinator, she and Administrator #1 talked with the resident about the incident and the resident stated he/she felt the touching incident was inappropriate. The Social Worker/Abuse Coordinator further stated Resident #29 told her he/she did not feel the incident was abuse. According to the Social Worker/Abuse Coordinator, SRNA #14 was moved to another unit in the facility following the report by Resident #29 and was allowed to continue to provide direct care for residents. Although the Social Worker/Abuse Coordinator stated she did obtain statements from Resident #29, the resident's daughter, SRNA #14, and a staff nurse assigned to the Seasons Unit, she did not further investigate the alleged incident. The Social Worker/Abuse Coordinator also stated since the resident stated she did not feel the incident was abuse, she did not report the alleged incident to the State Agencies. An additional interview conducted on 04/09/13, at 11:09 AM, with the Social Worker/Abuse Coordinator revealed she was no longer employed by the facility effective 04/08/13 due to illness. During this interview, the Social Worker/Abuse Coordinator stated she routinely reported all allegations to the DON or Administrator; and they would direct her on the procedures to follow when an allegation of abuse was reported, including investigation, protection, and reporting. The Social Worker/Abuse Coordinator stated she had missed doing "some things" during the investigation of the incident reported by Resident #29. Interview conducted on 04/05/13, at 6:05 PM, with the Vice President of Operations revealed he was currently acting as the facility's Administrator, and was not aware of the incident involving Resident #29. Further interview with the Vice President of Operations on 04/05/13 at 7:30 PM, revealed SRNA #14 continued to work at the facility in the provision of direct care after Resident #29 had reported the incident and was still providing direct resident care on 04/05/13. However, the Vice President of Operations stated SRNA #14 was suspended from employment after he was informed of the alleged incident on 04/05/13. The Vice President of Operations also confirmed no further investigation had been conducted by the facility of the alleged incident and he could provide no evidence the allegation had been reported to the state agencies as directed by the facility's abuse policy. 3. Review of the facility's investigation, initiated by the facility's Social Worker/Abuse Coordinator on 03/24/13, revealed Resident #30 reported on 03/24/13, that on 03/22/13, from 8:00 PM to 9:00 PM, SRNA #13 had sprayed cold water on the resident while in the shower and had wrapped a sheet too tight around the resident's neck. Continued review revealed the investigation was not completed and the allegation was not reported to the appropriate state agencies until 04/09/13, (sixteen days after the incident was reported). It could not be determined by a review of documentation if the facility had protected residents from further potential abuse while the investigation was being conducted, or if the facility allowed SRNA #13 to continue to provide resident care at the facility. According to the initial report, dated 04/09/13, the facility had attempted to contact SRNA #13 to inform the SRNA that she would be suspended and not allowed to work until the investigation had been completed. An interview conducted with the facility's Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed the Social Worker/Abuse Coordinator had informed Administrator #2 on 04/08/13, of the abuse allegation involving Resident #30 that occurred on 03/22/13. According to the Social Worker/Abuse Coordinator the investigation of the allegation had not been completed. Interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 was not aware the allegation of abuse had not been thoroughly investigated and reported as required until the Social Worker/Abuse Coordinator had reported on 04/08/13 that the investigation was not complete. At the time of the interview, Administrator #2 could provide no documentation that any action had taken to ensure residents were protected during the facility's investigation or that the allegation had been reported to the appropriate State Agencies. According to Administrator #2, the allegations were logged in an abuse investigation log at the end of each day. However, review of the facility's investigation log revealed no entry regarding Resident #30. 4. A review of the facility's investigation dated 04/01/13 revealed on 03/27/13, the Administrator was informed that Resident #4 had made an allegation of abuse on 03/24/13, three days prior. According to the investigation, Resident #4 was interviewed on 03/28/13 and reported that "no one had been mean to (her/him)". When the facility questioned the resident if he/she had alleged someone was mean to him/her the resident stated he/she had "told one of the women that." According to the facility's investigation, the resident "didn't really mean it." The Social Worker/Abuse Coordinator asked the resident if the woman was RN #8 and the resident stated, "Yeah my little nurse." Further review of the investigation revealed RN #8 stated Resident #4 did make the statement on 03/24/13 that she was mean to the resident. RN #8 reported she had told the resident to use the call light for assistance instead of getting up on her own. All residents assessed by the facility to be interviewable were interviewed in regards to their treatment. The investigation concluded the allegation of abuse was unsubstantiated based on Resident #4's moderately impaired cognitive ability. Interview with RN #8 on 03/28/13 at 8:07 PM revealed on the morning of 03/24/13 Resident #4 alleged the RN was mean to the resident and Resident #4 did not want RN #8 to come into the resident's room again or provide care for the resident. RN #8 stated she documented the incident in the nurse's notes, and only thought Resident #4 was upset the morning of 03/24/13. However, RN #8 stated she should have told another nurse; removed herself from the floor; and called the Administrator and DON. RN #8 stated the incident "didn't seem like an allegation of abuse." Interview with the DON on 04/02/13 at 8:45 PM revealed she was informed of the allegation against RN #8 on 03/24/13 by the Weekend Manager. She stated she did not give the Weekend Manager any further instructions. The DON stated on 03/25/13 she interviewed Resident #4; got "side tracked with something else"; and did not notify the Administrator or interview RN #8. The DON stated on 03/27/13, the Corporate Nurse Consultant questioned her related to a nurse's note found in Resident #4's medical record related to the incident. The DON stated she called RN #8 and had her come in to work early on the evening of 03/27/13 to obtain an interview. After interviewing the nurse, the DON and Administrator #2 allowed RN #8 to work her scheduled 12-hour shift. The DON stated since RN #8 and Resident #4 denied the allegation, she and Administrator #2 decided abuse did not occur. However, the DON acknowledged the facility's investigation had not been finished at the time of the interview. Interview with Administrator #2 on 03/28/13 at 2:00 PM; 6:40 PM; and on 03/29/13 at 10:25 AM and 4:11 PM revealed he became aware of the incident on 03/27/13, at approximately 5:40 PM, and spoke to the DON regarding the incident. Administrator #2 stated the DON informed him she had forgotten to inform him of the allegation of abuse and failed to initiate an investigation related to the allegation. Further, Administrator #2 stated he sat in during the interview between the DON and RN #8; however, he was "half paying attention." Administrator #2 initially stated in interview that he was not aware RN #8 had been permitted to work on 03/27/13 and that he "didn't ask (DON) why she didn't remove" the alleged perpetrator. Continued interview with Administrator #2 revealed he was aware RN #8 had been permitted to work after the interview had been conducted on 03/27/13 while the investigation was in progress. Interview further revealed Administrator #2 "did not think it was reportable" and stated, "In my heart of hearts I have gotten to know the little girl while I've been here, I just didn't feel it was true and reportable." Further interview revealed Administrator #2 had not interviewed the DON regarding the incident and stated the DON had just forgotten to do anything with the information she received on 03/24/13. Administrator #2 stated RN #8 should have reported the incident to another Charge Nurse on 03/24/13; that he should have been notified of the incident; and, that RN #8 should have been sent home on 03/24/13 following the incident. Continued interview with Administrator #2 on 03/29/13 at 4:11 PM revealed he did "concur" with the DON on 03/27/13 related to allowing RN #8 to work her shift after the resident stated he/she did not want RN #8 to take care of her. Per interview, he and the DON agreed RN #8 could continue to provide resident care. Administrator #2 further stated in "hindsight" with the facility "the way it is" right now allowing the RN to continue to work during the investigation was "probably a bad decision". 5. Review of the facility's investigation revealed SRNA #1 and SRNA #8 reported to the facility's Social Worker/Abuse Coordinator that on 04/04/13, they overheard a Lab Technician tell Resident #19 "It's going to hurt you worse than it will me because I have a needle stuck in your arm". Even though the investigation revealed the incident had been reported immediately to the facility's Social Worker/Abuse Coordinator on 04/04/13, the facility failed to ensure the allegation was immediately reported to the required state agencies until 04/06/13 (two days after the incident was reported). Interview on 04/09/13 at 2:55 PM with the Corporate Nurse Executive who had completed the investigation of the allegation revealed she initially had not considered the allegation reportable. However, the Corporate Nurse Executive stated as a part of the facility's ongoing audits, the allegation was determined to be an allegation of verbal abuse and was reported to the appropriate State Agencies late, on 04/06/13. The Corporate Nurse Executive stated the allegation being reported "late was better than not reporting" the allegation. 6. An interview conducted with the facility's Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed the Social Worker/Abuse Coordinator had informed Administrator #2 on 04/08/13 of an abuse allegation involving Resident #31 but she could not recall the date of the allegation. An interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 could not recall the allegation regarding Resident #31 that was reported on 04/08/13 and an investigation of the allegation had not been initiated. Continued interview with Administrator #2 on 04/09/13 at 5:00 PM revealed Administrator #2 had discussed the allegation reported by the Social Worker/Abuse Coordinator on 04/08/13 with staff and learned there was an allegation that Resident #31 may have been sat down in a chair too hard by facility staff around 3/17-19/13, but no witness statements or investigation could be found. Review of the facility's investigation log revealed no entry regarding the alleged incident involving Resident #31, which was reported on 04/08/13.

Based on interview, record review, and a review of the facility's policy and procedures and investigations, it was determined the facility failed to have an effective system to ensure policy and procedures related to abuse were implemented for six of twenty-nine residents (Residents #1, #4, #19, #29, #30, and #31). The facility failed to ensure a suspicion of an incident of abuse was reported immediately, failed to ensure that a thorough investigation was conducted for an alleged incident of abuse involving a staff member, and failed to ensure residents were protected following a report of abuse and during the investigation process. Facility staff failed to ensure an allegation of abuse was reported timely. On 02/17/13, facility staff witnessed Licensed Practical Nurse (LPN) #1, the Charge Nurse, verbally abuse Resident #1 at approximately 7:35 AM. Staff attempted, between 11:30 AM and 12:00 PM, to contact the facility's Social Worker/Abuse Coordinator to report the allegation per the facility's policy. The Social Worker/Abuse Coordinator was unavailable and staff left a voice message on the Social Worker/Abuse Coordinator's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. After receipt of the report of alleged abuse, the facility failed to ensure residents were protected from potential further abuse. The facility's policies and procedures stated the Administrator and/or Director of Nursing (DON) and/or Social Worker were the staff that could make any immediate decisions related to the removal of the alleged abuser from direct care giving. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, the DON, and the Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. After completion of the facility's investigation, Administrator #1 reported as a result of the investigation, interviews, and a review of the witness statements, he could not come to a "firm" conclusion that abuse had occurred and the allegation of abuse was determined to be unsubstantiated by the facility. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. (Refer to F223 and F225.) In addition, interview and record review revealed the facility failed to immediately initiate an investigation, failed to ensure residents were protected from further potential abuse during an investigation, and failed to notify the Administrator and appropriate State Agencies for allegations of potential abuse involving Residents #4, #19, #29, #30, and #31. (Refer to F225.) The facility's failure to have an effective system in place to ensure the development and implementation of policies and procedures to protect residents from abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy with Substandard Quality of Care was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/17/13 with the facility alleging removal of the Immediate Jeopardy on 04/17/13. The State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 04/22-04/23/13, as alleged in the acceptable AOC, with remaining noncompliance at 42 CFR 483.13 Resident Behavior and Facility Practices F226 - S/S "E", while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's abuse policy, dated 01/2012, revealed, "any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing, and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." Further review revealed, "any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate." The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident;" the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them;" and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 1. A review of the facility's investigation revealed on 02/17/13, staff reported Resident #1 was "crying," and wanted to be put to bed. However, based on documentation, staff reported LPN #1 (who was the Charge Nurse) would not allow staff to put the resident to bed due to the resident "yelling" and "crying." The investigation further revealed the LPN was "immediately" suspended on 02/17/13 pending the outcome of the investigation. Further, during the investigation, other residents were interviewed, and one resident reported he/she had overheard LPN #1 say negative things about another resident at the facility. According to the investigation, dated 02/22/13, the facility did not substantiate that the abuse occurred. During the course of the investigation, attempts were made to contact LPN #1 for interview. However, LPN #1 was no longer employed by the facility and attempts to contact the LPN were unsuccessful. A review of LPN #1's employee file revealed the LPN was terminated from employment by the facility on 02/25/13 for falsification of documentation. Interview with the Staff Development Coordinator/Unit Manager on 02/28/13 at 5:35 PM and again on 03/04/13 at 11:07 AM revealed she came to the facility on [DATE] at approximately 11:00 AM to do a "weekend check." At approximately 11:30 AM-11:40 AM, Housekeepers #1 and #2 came to her and stated they felt a "little uneasy" and "uncomfortable" with what they had witnessed between LPN #1 and Resident #1. The Staff Development Coordinator/Unit Manager stated the housekeepers informed her Resident #1 asked to be put to bed and the LPN refused to allow staff to put the resident to bed and that they had attempted to contact the Social Worker/Abuse Coordinator prior to notifying her in accordance with facility policy. The Staff Development Coordinator/Unit Manager stated after the housekeepers spoke with her she went out on the floor, started an investigation, talked to individuals on the unit, and had the staff fill out written statements. She stated she spoke with State Registered Nurse Aides and an Activities Worker and had them fill out witness statements. The Staff Development Coordinator/Unit Manager stated LPN #1 remained on the nursing unit at the nurses' station during the time she initiated the investigation. She stated she did not remove LPN #1 from the floor immediately because she was trying to determine if it was "appropriate" for her to "pull the LPN from the floor." Between 11:30 AM and 12:30 PM she attempted to call the Social Worker/Abuse Coordinator, for further guidance, per the facility policy; however, she was unable to contact her via phone. According to the Staff Development Coordinator/Unit Manager, she then contacted the Facility's Nurse Consultant for further direction, and informed LPN #1 that she was being sent home pending the final investigation. She further stated she did not know if she could remove staff from the floor, and the allegation had to be "justifiable" to remove facility staff from the floor. Further interview revealed she was not sure what was being reported by the housekeepers was abuse. However, review of the facility's policy revealed "any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing, and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." In addition, the policy stated the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process." However, interview and record review revealed these procedures were not implemented. Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM confirmed she had received a voice mail message from one of the facility housekeepers and the Staff Development Coordinator/Nurse Manager on 02/17/13. She stated she came to the facility the same day and assisted with the investigation. Further interview with the Social Worker/Abuse Coordinator on 03/04/13, at 1:25 PM, revealed staff had been trained to report allegations of abuse to her, the DON or the Administrator. The Social Worker/Abuse Coordinator further stated she was not sure if a nurse could remove a staff member from direct resident care in the event an allegation of abuse had been made and staff could not reach Administrative staff. Review of staff training records revealed the last abuse training provided by the facility was in December 2012. Interview with Administrator #1 on 02/28/13 at 5:20 PM, revealed LPN #1 did not have a history of abuse and staff may have "misinterpreted" the LPN since she was "loud" by nature. Administrator #1 stated they could not come to a "firm" conclusion related to abuse, at the conclusion of the investigation, and the facility was not able to substantiate that abuse occurred. Interview with Administrator #1 on 03/05/13 at 4:25 PM revealed he was not aware the facility policy instructed staff to seek guidance from him, the DON, or the Social Worker/Abuse Coordinator prior to the removal of the alleged perpetrator after an allegation of abuse was made. Per interview, he was not aware the facility's abuse policy did not instruct staff to immediately remove the alleged perpetrator from direct resident care. However, review of the facility's policy revealed only the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." Interview with the facility's Vice President of Operations, Chief Nurse Executive, and the Nurse Consultant on 03/04/13 at 5:05 PM, revealed the facility's abuse policy had been developed at the corporate level and they were not aware the policy indicated only the "Administrator and/or DON and/or Social Worker" would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact following an allegation of suspected abuse." 2. Interview with Resident #29 on 04/05/13 at 5:50 PM, revealed the resident reported he/she was "afraid" of SRNA #14 because he had touched the resident's breast while hugging the resident two to three months ago. Resident #29 stated SRNA #14 was moved to another area in the facility to work after he/she reported the incident to the facility's Social Worker/Abuse Coordinator. Interview with the Social Worker/Abuse Coordinator on 04/05/13, at 3:30 PM, revealed she also acted as the facility's Abuse Coordinator, was responsible to assist with investigations related to abuse/neglect, and to provide staff education/in-service related to abuse/neglect as indicated. The Social Worker/Abuse Coordinator stated in accordance with facility policy allegations of alleged abuse were to be immediately investigated and reported to the appropriate state agencies. The Social Worker/Abuse Coordinator further stated she had received training from the facility regarding the facility's abuse policies/procedures when she was hired by the facility on 06/20/11, as well as when the policy, which included reporting, investigation, and resident protection of abuse allegations, was revised in March 2013. Further interview conducted with the Social Worker/Abuse Coordinator on 04/05/13, at 6:50 PM confirmed Resident #29 reported SRNA #14 touched the resident's breast on 03/01/13. According to the Social Worker/Abuse Coordinator, she and Administrator #1 talked with the resident about the incident and the resident stated he/she felt the touching incident was inappropriate. The Social Worker/Abuse Coordinator further stated Resident #29 told her he/she did not feel the incident was abuse. According to the Social Worker/Abuse Coordinator, SRNA #14 was moved to another unit in the facility following the report by Resident #29 and was allowed to continue to provide direct care for residents. Although the Social Worker/Abuse Coordinator stated she did obtain statements from Resident #29, the resident's daughter, SRNA #14, and a staff nurse assigned to the Seasons Unit, she did not further investigate the alleged incident. The Social Worker/Abuse Coordinator also stated since the resident stated she did not feel the incident was abuse, she did not report the alleged incident to the State Agencies. An additional interview conducted on 04/09/13, at 11:09 AM, with the Social Worker/Abuse Coordinator revealed she was no longer employed by the facility effective 04/08/13 due to illness. During this interview, the Social Worker/Abuse Coordinator stated she routinely reported all allegations to the DON or Administrator; and they would direct her on the procedures to follow when an allegation of abuse was reported, including investigation, protection, and reporting. The Social Worker/Abuse Coordinator stated she had missed doing "some things" during the investigation of the incident reported by Resident #29. Interview conducted on 04/05/13, at 6:05 PM, with the Vice President of Operations revealed he was currently acting as the facility's Administrator, and was not aware of the incident involving Resident #29. Further interview with the Vice President of Operations on 04/05/13 at 7:30 PM, revealed SRNA #14 continued to work at the facility in the provision of direct care after Resident #29 had reported the incident and was still providing direct resident care on 04/05/13. However, the Vice President of Operations stated SRNA #14 was suspended from employment after he was informed of the alleged incident on 04/05/13. The Vice President of Operations also confirmed no further investigation had been conducted by the facility of the alleged incident and he could provide no evidence the allegation had been reported to the state agencies as directed by the facility's abuse policy. 3. Review of the facility's investigation, initiated by the facility's Social Worker/Abuse Coordinator on 03/24/13, revealed Resident #30 reported on 03/24/13, that on 03/22/13, from 8:00 PM to 9:00 PM, SRNA #13 had sprayed cold water on the resident while in the shower and had wrapped a sheet too tight around the resident's neck. Continued review revealed the investigation was not completed and the allegation was not reported to the appropriate state agencies until 04/09/13, (sixteen days after the incident was reported). It could not be determined by a review of documentation if the facility had protected residents from further potential abuse while the investigation was being conducted, or if the facility allowed SRNA #13 to continue to provide resident care at the facility. According to the initial report, dated 04/09/13, the facility had attempted to contact SRNA #13 to inform the SRNA that she would be suspended and not allowed to work until the investigation had been completed. An interview conducted with the facility's Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed the Social Worker/Abuse Coordinator had informed Administrator #2 on 04/08/13, of the abuse allegation involving Resident #30 that occurred on 03/22/13. According to the Social Worker/Abuse Coordinator the investigation of the allegation had not been completed. Interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 was not aware the allegation of abuse had not been thoroughly investigated and reported as required until the Social Worker/Abuse Coordinator had reported on 04/08/13 that the investigation was not complete. At the time of the interview, Administrator #2 could provide no documentation that any action had taken to ensure residents were protected during the facility's investigation or that the allegation had been reported to the appropriate State Agencies. According to Administrator #2, the allegations were logged in an abuse investigation log at the end of each day. However, review of the facility's investigation log revealed no entry regarding Resident #30. 4. A review of the facility's investigation dated 04/01/13 revealed on 03/27/13, the Administrator was informed that Resident #4 had made an allegation of abuse on 03/24/13, three days prior. According to the investigation, Resident #4 was interviewed on 03/28/13 and reported that "no one had been mean to (her/him)". When the facility questioned the resident if he/she had alleged someone was mean to him/her the resident stated he/she had "told one of the women that." According to the facility's investigation, the resident "didn't really mean it." The Social Worker/Abuse Coordinator asked the resident if the woman was RN #8 and the resident stated, "Yeah my little nurse." Further review of the investigation revealed RN #8 stated Resident #4 did make the statement on 03/24/13 that she was mean to the resident. RN #8 reported she had told the resident to use the call light for assistance instead of getting up on her own. All residents assessed by the facility to be interviewable were interviewed in regards to their treatment. The investigation concluded the allegation of abuse was unsubstantiated based on Resident #4's moderately impaired cognitive ability. Interview with RN #8 on 03/28/13 at 8:07 PM revealed on the morning of 03/24/13 Resident #4 alleged the RN was mean to the resident and Resident #4 did not want RN #8 to come into the resident's room again or provide care for the resident. RN #8 stated she documented the incident in the nurse's notes, and only thought Resident #4 was upset the morning of 03/24/13. However, RN #8 stated she should have told another nurse; removed herself from the floor; and called the Administrator and DON. RN #8 stated the incident "didn't seem like an allegation of abuse." Interview with the DON on 04/02/13 at 8:45 PM revealed she was informed of the allegation against RN #8 on 03/24/13 by the Weekend Manager. She stated she did not give the Weekend Manager any further instructions. The DON stated on 03/25/13 she interviewed Resident #4; got "side tracked with something else"; and did not notify the Administrator or interview RN #8. The DON stated on 03/27/13, the Corporate Nurse Consultant questioned her related to a nurse's note found in Resident #4's medical record related to the incident. The DON stated she called RN #8 and had her come in to work early on the evening of 03/27/13 to obtain an interview. After interviewing the nurse, the DON and Administrator #2 allowed RN #8 to work her scheduled 12-hour shift. The DON stated since RN #8 and Resident #4 denied the allegation, she and Administrator #2 decided abuse did not occur. However, the DON acknowledged the facility's investigation had not been finished at the time of the interview. Interview with Administrator #2 on 03/28/13 at 2:00 PM; 6:40 PM; and on 03/29/13 at 10:25 AM and 4:11 PM revealed he became aware of the incident on 03/27/13, at approximately 5:40 PM, and spoke to the DON regarding the incident. Administrator #2 stated the DON informed him she had forgotten to inform him of the allegation of abuse and failed to initiate an investigation related to the allegation. Further, Administrator #2 stated he sat in during the interview between the DON and RN #8; however, he was "half paying attention." Administrator #2 initially stated in interview that he was not aware RN #8 had been permitted to work on 03/27/13 and that he "didn't ask (DON) why she didn't remove" the alleged perpetrator. Continued interview with Administrator #2 revealed he was aware RN #8 had been permitted to work after the interview had been conducted on 03/27/13 while the investigation was in progress. Interview further revealed Administrator #2 "did not think it was reportable" and stated, "In my heart of hearts I have gotten to know the little girl while I've been here, I just didn't feel it was true and reportable." Further interview revealed Administrator #2 had not interviewed the DON regarding the incident and stated the DON had just forgotten to do anything with the information she received on 03/24/13. Administrator #2 stated RN #8 should have reported the incident to another Charge Nurse on 03/24/13; that he should have been notified of the incident; and, that RN #8 should have been sent home on 03/24/13 following the incident. Continued interview with Administrator #2 on 03/29/13 at 4:11 PM revealed he did "concur" with the DON on 03/27/13 related to allowing RN #8 to work her shift after the resident stated he/she did not want RN #8 to take care of her. Per interview, he and the DON agreed RN #8 could continue to provide resident care. Administrator #2 further stated in "hindsight" with the facility "the way it is" right now allowing the RN to continue to work during the investigation was "probably a bad decision". 5. Review of the facility's investigation revealed SRNA #1 and SRNA #8 reported to the facility's Social Worker/Abuse Coordinator that on 04/04/13, they overheard a Lab Technician tell Resident #19 "It's going to hurt you worse than it will me because I have a needle stuck in your arm". Even though the investigation revealed the incident had been reported immediately to the facility's Social Worker/Abuse Coordinator on 04/04/13, the facility failed to ensure the allegation was immediately reported to the required state agencies until 04/06/13 (two days after the incident was reported). Interview on 04/09/13 at 2:55 PM with the Corporate Nurse Executive who had completed the investigation of the allegation revealed she initially had not considered the allegation reportable. However, the Corporate Nurse Executive stated as a part of the facility's ongoing audits, the allegation was determined to be an allegation of verbal abuse and was reported to the appropriate State Agencies late, on 04/06/13. The Corporate Nurse Executive stated the allegation being reported "late was better than not reporting" the allegation. 6. An interview conducted with the facility's Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM, revealed the Social Worker/Abuse Coordinator had informed Administrator #2 on 04/08/13 of an abuse allegation involving Resident #31 but she could not recall the date of the allegation. An interview with Administrator #2 on 04/09/13 at 3:03 PM revealed Administrator #2 could not recall the allegation regarding Resident #31 that was reported on 04/08/13 and an investigation of the allegation had not been initiated. Continued interview with Administrator #2 on 04/09/13 at 5:00 PM revealed Administrator #2 had discussed the allegation reported by the Social Worker/Abuse Coordinator on 04/08/13 with staff and learned there was an allegation that Resident #31 may have been sat down in a chair too hard by facility staff around 3/17-19/13, but no witness statements or investigation could be found. Review of the facility's investigation log revealed no entry regarding the alleged incident involving Resident #31, which was reported on 04/08/13. ---The facility provided an acceptable (AOC) on 04/17/13, which alleged the removal of Immediate Jeopardy on 04/17/13 based on the following: The allegation of abuse against Resident #31 was reported to appropriate State Agencies on 04/09/13 by Administrator #2. The Interim Social Services Director (SSD) completed an interview with Resident #31 and the resident's daughter on 04/09/13. The facility suspended the alleged perpetrator on 04/09/13. Other employees were interviewed by the Vice President of Human Resources and the Regional Human Resources Director on 04/10/13 to identify if any other staff had observed the alleged perpetrator be rude or rough with any other residents. All residents with a BIMS score of seven or above were interviewed by Regional Staff regarding any concerns with rough or rude treatment and no concerns were identified. The allegation of abuse against Resident #19 was reported to the appropriate State Agencies by the Chief Nurse Executive on 04/06/13. A body audit on Resident #19 was completed by the Regional Nurse Consultant on 04/04/13. Statements were obtained from the lab technician, the alleged perpetrator, on 04/08/13. Statements were obtained on 04/04/13 from two staff members who were present during the alleged abuse. The supervisor of the lab technician was notified by the Chief Nurse Executive on 04/04/13 that the facility would no longer utilize the lab technician. The allegation of abuse against Resident #30 was reported to the appropriate State Agencies on 04/09/13 by Administrator #2. The Administrator and the Interim Social Services Director interviewed Resident #30 on 04/10/13 regarding the alleged abuse incident. Statements were obtained on 04/10/13 from the two staff who was the alleged perpetrators. The two alleged perpetrators were suspended on 04/10/13. An interview was completed by the Chief Operating Officer on 04/09/13 with the Nurse who provided care for Resident #30 on the evening of the alleged incident. Interviews were completed by Regional Staff on 04/09/13 with other residents who reside on the same unit as Resident #30, regarding staff treatment during care, with no concerns identified. The allegation of abuse against Resident #29 was reported to the appropriate State Agencies on 04/05/13 by the Chief Nurse Executive. Administrator #2 and the Interim Social Services Director interviewed Resident #29 on 04/05/13 regarding the alleged abuse. The Regional Nurse completed a body audit on Resident #29 on 04/05/13 with no injuries identified. The alleged perpetrator was interviewed by the Vice President of Human Resources and the Chief Operating Officer along with a statement obtained. The alleged perpetrator was suspended on 04/05/13 along with Administrator #1, who was the facility ' s Administrator at the time of the occurrence, Resident ' s with a BIMS score over 7 was interviewed by Department Managers on 04/05/13 and Regional Staff on 04/05/13 regarding other incidents of inappropriate treatments, with no concerns identified. The allegation of abuse by Resident #4 was reported to the appropriate State Agencies on 03/30/13 by Administrator #2 and a final report was submitted on 04/03/13 to the appropriate State Agencies, which unsubstantiated abuse regarding Resident #4. The second allegation of abuse by Resident #4 was submitted to the appropriate State Agencies on 04/09/13. The staff member who was the alleged abuser was suspended during the investigation. A third allegation by Resident #4 was submitted on 04/09/13 regarding a review of an incident report dated 03/28/13 for bruises. The investigation was in progress. All staff including Department Directors and Regional Staff received education regarding abuse, completed by an Independent Contractor by 04/06/13, with completion of a posttest. All staff were re-educated by the Department Directors and Regional Team on 04/12/13. Staff not scheduled, on leave or who work as needed, will be re-educated upon returning to work. The Independent Contractor was secured on 04/07/13 to remain onsite at the facility daily until 04/13/13 to provide continued oversight and education related to abuse, to include investigation, reporting, and protection. The Independent Contractor will provide one on one education with Administrator #2, Director of Nursing, and the Interim Social Services Director regarding protection, reporting, and investigation of allegations of abuse by 04/12/13. The Independent Contractor initiated continued abuse education regarding identifying, reporting, and ensuring resident safety on 04/11/13. All staff scheduled to work will receive this re-education by 04/12/13. Staff not scheduled to work during that time frame, who work as needed, or who are on leave of absence will receive the education upon returning to work, by Administrator #2, Director of Nursing, Assistant Director of Nursing, Unit Manager, Social Services Director, Staff Development Coordinator, or Regional Staff. On 04/12/13 thirty-four (34) interviews were conducted by the Department Managers (Staffing Coordinator, Dietary Manager, Housekeeping Director) for residents with a Brief Interview for Mental Status (BIMS) score of seven (7) or above to determine their feelings of safety and identify any allegations of mistreatment or abuse. There were no concerns voiced. A body audit was complete for eighty-one (81) residents, there were an additional nine (9) residents who refused a body audit therefore the audit was not performed on those nine (9), by Administrative Nurses (MDS Coordinators, DON, Staff Development Coordinator), on 04/12/13 and regional nurses (Signature Care Consultants, Internal Audit Director -RN from the Corporate office, Director of Medical Review -RN from the corporate office) for residents with a BIMS score below 7 to ensure that no physical signs and symptoms of abuse were present. Results of body audits did not reflect any physical injuries. On 04/12/13 Department Managers (Dietary Manager, Staffing Coordinator) also met with license nurse and Certified Nurse Assistant (C.N.A.) (State Registered Nurse Aides) assigned to residents with a BIMS of seven (7) or less, thirty-six (36) residents, to interview for any noted change of behavior or any signs of fear. All above interviews were placed in a binder called the AOC binder located In the Administrator's office. Administrator #2, Director of Nursing, Interim Social Services Director, Department Managers (MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Rehabilitation Manager) or Regional staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) conducted 20 interviews daily which were initiated on 04/13/13 with residents who have a BIMS score of 7 or above, to ensure residents feel protected without any evidence of abuse, neglect, or misappropriation. Findings of signs and symptoms of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. The Department Managers ( MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assist

Based on interview, record review, and review of the facility's investigation and policy and procedures it was determined the facility failed to be administered in a manner that maintained the highest physical well-being for six of twenty-nine sampled residents (Residents #1, #4, #19, #29, #30, and #31). The facility failed to have an effective system in place to ensure policies and procedures were developed/implemented to ensure staff immediately reported allegations of abuse to Administration and to the appropriate State Agencies; failed to ensure all residents were protected from abuse during facility investigations; and failed to ensure thorough investigations had been conducted related to abuse allegations. (Refer to F223, F225, F226, and F520.) The Administration's failure to ensure facility policies/procedures related to abuse prevention were developed and implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Two Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.75 Administration (F490 and F520), with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's abuse policy, dated 01/2012, revealed it was "the intent of the facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident's property or reasonable suspicion of criminal act or intent." The policy stated, "Any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." Further review revealed, "Any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate." The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process". The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 1. Interview and review of the facility's investigation, dated 02/22/13, revealed on the morning of 02/17/13, after the morning meal, staff observed Resident #1 at the nurses' station crying, wanting to go to bed. Staff reported LPN #1, the Charge Nurse, would not allow staff to assist the resident to bed due to the resident "yelling," "whining," and "crying." One staff member reported LPN #1 made the comment that she was going to teach the resident a lesson. Interviews revealed staff did not immediately take action to protect residents in the facility or notify appropriate facility personnel until approximately 11:30 AM, and LPN #1 continued to be in charge of resident care and remained on the floor with residents until 12:30 PM (five hours after the abuse had occurred). Further review revealed LPN #1 was "immediately" suspended pending the outcome of the investigation. During the facility's investigation, LPN #1 was interviewed and stated she wanted Resident #1 to stay at the nurses' station to be monitored for the resident's behavior. Facility staff interviewed other residents on the unit and one other resident reported he/she had overheard the LPN say negative things about another resident. The investigation further stated based on the investigation abuse could not be substantiated. Interview with Administrator #1 on 02/28/13 at 5:20 PM revealed his investigation of the alleged abuse consisted of reviewing witness statements, information that had been obtained, consulting with his regional staff, and interviewing LPN #1, the Charge Nurse. Administrator #1 acknowledged he had been aware of the staff interviews and witness statements describing the LPN's (Charge Nurse) intentions to "teach" (Resident #1) "a lesson" and he was aware an alert and oriented resident had reported witnessing LPN #1 be inappropriate and rude to another resident previously. However, he had concluded that staff "might have misinterpreted" the LPN's actions, and stated he was unable to come to a "firm" conclusion or determine if LPN #1 had abused Resident #1. Therefore, the allegation of abuse was unsubstantiated, and no further disciplinary action was taken against the LPN concerning the alleged abuse to Resident #1. However, review of the facility's policy revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them." Further interview with Administrator #1 on 03/05/13 at 4:25 PM revealed he was not aware the facility's policy did not instruct staff to immediately remove the alleged perpetrator from direct resident care. However, the policy stated only the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 2. A review of the facility's first AOC, alleging removal of jeopardy on 03/06/13, revealed all staff, including the Administrator, the DON, Social Worker/Abuse Coordinator were re-educated beginning 03/04/13, on the revisions of the abuse policy. The AOC further stated that the Chief Nurse Executive reviewed all incidents and investigations that occurred from June 2012 through the present time, with no concerns. However, during an interview with Resident #29 on 04/05/13, the resident stated he/she had reported an allegation of abuse to the facility's Social Worker/Abuse Coordinator approximately two to three months prior when the incident occurred. Resident #29 alleged that a male staff member touched her breast inappropriately and the resident was afraid of the staff person. An interview with the Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM revealed the allegation was not reported to the appropriate State Agencies and the alleged perpetrator continued to provide direct care because the facility felt it was not abuse, even though a complete investigation had not been conducted. There was no evidence the facility identified as part of their review of past investigations as stated in the AOC that this investigation was not thorough, the abuse allegation was not reported, and the resident was not protected. Administrator #1, who was the Administrator on record during this time, was no longer employed as Administrator of the facility and was not available for interview. Interview on 04/05/13 at 6:05 PM, with the Vice President of Operations who was also acting as the facility's Administrator, revealed he was not aware of the incident involving Resident #29. However, further interview on 04/05/13 at 7:30 PM, revealed he did recall Administrator #1 telling him about the incident; however, he could not recall the resident's name and did not ask additional questions related to that resident's concern. 3. Interview and review of the facility's investigation dated 04/01/13 revealed on 03/27/13 the Administrator was notified of an allegation of abuse involving RN #8 and Resident #4 that occurred on 03/24/13. A review of a facility's investigation dated 04/01/13, revealed on 03/24/13, Resident #4 alleged RN #8 was "mean" to the resident and the resident did not want RN #8 to provide further care for the resident and did not want RN #8 to come back to Resident #4's room. The facility interviewed Resident #4, the RN, and all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher. Based on this information, the facility unsubstantiated that abuse occurred based on Resident #4's "moderately impaired cognitive ability." Interview with the DON on 04/02/13 at 8:45 PM revealed she became aware of the allegation on 03/24/13; however, did not notify the Administrator, or initiate an investigation until 03/27/13, three days later, when the Corporate Nurse Consultant questioned her regarding the incident. Interview with Administrator #2 on 03/28/13 at 2:00 PM, 6:40 PM, and on 03/29/13 at 10:25 AM, and 4:11 PM revealed he became aware of the incident on 03/27/13 around 5:40 PM. Administrator #2 stated the DON informed him she had forgotten to start an investigation related to the incident and forgot to inform him of the allegation of abuse. Further interview revealed Administrator #2 "did not think it was reportable." He stated, "In my heart of hearts I have gotten to know the little girl while I've been here. I just didn't feel it was true and reportable," even before the investigation had been complete. 4. A review of the facility's second AOC, dated 04/05/13, alleging removal of jeopardy on 04/05/13, revealed facility staff, including the facility Administrator, DON, and Social Worker/Abuse Coordinator, had been retrained on abuse protocols that included investigation, reporting, and protection of residents. In addition, according to the AOC, an abuse investigation log was to be maintained by the Administrator to track/trend all allegations of abuse. However, interview with the facility's Social Worker/Abuse Coordinator on 04/09/13 revealed four other allegations of resident abuse involving Residents #19, #29, #30, and #31 had been reported to facility staff and there was no evidence the abuse allegations had been reported to the appropriate State Agencies, had been thoroughly investigated, or that facility residents had been protected from further potential abuse. In addition, review of the facility's abuse log revealed no entry for the abuse allegations involving Residents #19, #29, #30, and #31. An interview with Administrator #2 on 04/09/13 at 5:45 PM, revealed the abuse log was not effective to identify facility failures to investigate, report, and protect Residents #19, #29, #30, and #31 when an allegation was reported. Administrator #2 stated he was not aware of these allegations of abuse.

Based on interview, record review, and review of the facility's investigation and policy and procedures it was determined the facility failed to be administered in a manner that maintained the highest physical well-being for six of twenty-nine sampled residents (Residents #1, #4, #19, #29, #30, and #31). The facility failed to have an effective system in place to ensure policies and procedures were developed/implemented to ensure staff immediately reported allegations of abuse to Administration and to the appropriate State Agencies; failed to ensure all residents were protected from abuse during facility investigations; and failed to ensure thorough investigations had been conducted related to abuse allegations. (Refer to F223, F225, F226, and F520.) The Administration's failure to ensure facility policies/procedures related to abuse prevention were developed and implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.75 Administration (F490 and F520), with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13 and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/17/13 with the facility alleging removal of the Immediate Jeopardy on 04/17/13. The State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 04/22-04/23/13, as alleged in the acceptable AOC, with remaining noncompliance at 42 CFR 483.13 Resident Behavior and Facility Practices (F223 - S/S "D" and F225 and F226 - S/S "E") and 42 CFR 483.75 Administration (F490 and F520 - S/S "E") while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's abuse policy, dated 01/2012, revealed it was "the intent of the facility to immediately report and thoroughly investigate allegations of mistreatment, neglect, abuse, misappropriation of resident's property or reasonable suspicion of criminal act or intent." The policy stated, "Any report or suspicion of an incident was to be reported immediately to the charge nurse," and the Administrator, Director of Nursing and Abuse Coordinator, as appropriate, were to be "notified immediately by the charge nurse who receives the report." Further review revealed, "Any report or suspicion of an incident of abuse was to be immediately reported to the charge nurse and/or Abuse Coordinator, as appropriate." The policy also revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them"; and that the resident was to "receive measures to ensure his or her immediate safety and wellbeing following the incident and during the investigation process". The policy further stated the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 1. Interview and review of the facility's investigation, dated 02/22/13, revealed on the morning of 02/17/13, after the morning meal, staff observed Resident #1 at the nurses' station crying, wanting to go to bed. Staff reported LPN #1, the Charge Nurse, would not allow staff to assist the resident to bed due to the resident "yelling," "whining," and "crying." One staff member reported LPN #1 made the comment that she was going to teach the resident a lesson. Interviews revealed staff did not immediately take action to protect residents in the facility or notify appropriate facility personnel until approximately 11:30 AM, and LPN #1 continued to be in charge of resident care and remained on the floor with residents until 12:30 PM (five hours after the abuse had occurred). Further review revealed LPN #1 was "immediately" suspended pending the outcome of the investigation. During the facility's investigation, LPN #1 was interviewed and stated she wanted Resident #1 to stay at the nurses' station to be monitored for the resident's behavior. Facility staff interviewed other residents on the unit and one other resident reported he/she had overheard the LPN say negative things about another resident. The investigation further stated based on the investigation abuse could not be substantiated. Interview with Administrator #1 on 02/28/13 at 5:20 PM revealed his investigation of the alleged abuse consisted of reviewing witness statements, information that had been obtained, consulting with his regional staff, and interviewing LPN #1, the Charge Nurse. Administrator #1 acknowledged he had been aware of the staff interviews and witness statements describing the LPN's (Charge Nurse) intentions to "teach" (Resident #1) "a lesson" and he was aware an alert and oriented resident had reported witnessing LPN #1 be inappropriate and rude to another resident previously. However, he had concluded that staff "might have misinterpreted" the LPN's actions, and stated he was unable to come to a "firm" conclusion or determine if LPN #1 had abused Resident #1. Therefore, the allegation of abuse was unsubstantiated, and no further disciplinary action was taken against the LPN concerning the alleged abuse to Resident #1. However, review of the facility's policy revealed a thorough investigation was to be "initiated immediately for all alleged incidents of abuse involving staff members, residents, family, and/or visitors who had potential knowledge of the incident"; the Administrator/designee would make "all reasonable efforts to investigate and address alleged reports, concerns, and grievances presented to them." Further interview with Administrator #1 on 03/05/13 at 4:25 PM revealed he was not aware the facility's policy did not instruct staff to immediately remove the alleged perpetrator from direct resident care. However, the policy stated only the Administrator and/or DON and/or Social Worker would "make any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." 2. A review of the facility's first AOC, alleging removal of jeopardy on 03/06/13, revealed all staff, including the Administrator, the DON, Social Worker/Abuse Coordinator were re-educated beginning 03/04/13, on the revisions of the abuse policy. The AOC further stated that the Chief Nurse Executive reviewed all incidents and investigations that occurred from June 2012 through the present time, with no concerns. However, during an interview with Resident #29 on 04/05/13, the resident stated he/she had reported an allegation of abuse to the facility's Social Worker/Abuse Coordinator approximately two to three months prior when the incident occurred. Resident #29 alleged that a male staff member touched her breast inappropriately and the resident was afraid of the staff person. An interview with the Social Worker/Abuse Coordinator on 04/09/13 at 11:09 AM revealed the allegation was not reported to the appropriate State Agencies and the alleged perpetrator continued to provide direct care because the facility felt it was not abuse, even though a complete investigation had not been conducted. There was no evidence the facility identified as part of their review of past investigations as stated in the AOC that this investigation was not thorough, the abuse allegation was not reported, and the resident was not protected. Administrator #1, who was the Administrator on record during this time, was no longer employed as Administrator of the facility and was not available for interview. Interview on 04/05/13 at 6:05 PM, with the Vice President of Operations who was also acting as the facility's Administrator, revealed he was not aware of the incident involving Resident #29. However, further interview on 04/05/13 at 7:30 PM, revealed he did recall Administrator #1 telling him about the incident; however, he could not recall the resident's name and did not ask additional questions related to that resident's concern. 3. Interview and review of the facility's investigation dated 04/01/13 revealed on 03/27/13 the Administrator was notified of an allegation of abuse involving RN #8 and Resident #4 that occurred on 03/24/13. A review of a facility's investigation dated 04/01/13, revealed on 03/24/13, Resident #4 alleged RN #8 was "mean" to the resident and the resident did not want RN #8 to provide further care for the resident and did not want RN #8 to come back to Resident #4's room. The facility interviewed Resident #4, the RN, and all residents with a Brief Interview for Mental Status (BIMS) score of 8 or higher. Based on this information, the facility unsubstantiated that abuse occurred based on Resident #4's "moderately impaired cognitive ability." Interview with the DON on 04/02/13 at 8:45 PM revealed she became aware of the allegation on 03/24/13; however, did not notify the Administrator, or initiate an investigation until 03/27/13, three days later, when the Corporate Nurse Consultant questioned her regarding the incident. Interview with Administrator #2 on 03/28/13 at 2:00 PM, 6:40 PM, and on 03/29/13 at 10:25 AM, and 4:11 PM revealed he became aware of the incident on 03/27/13 around 5:40 PM. Administrator #2 stated the DON informed him she had forgotten to start an investigation related to the incident and forgot to inform him of the allegation of abuse. Further interview revealed Administrator #2 "did not think it was reportable." He stated, "In my heart of hearts I have gotten to know the little girl while I've been here. I just didn't feel it was true and reportable," even before the investigation had been complete. 4. A review of the facility's second AOC, dated 04/05/13, alleging removal of jeopardy on 04/05/13, revealed facility staff, including the facility Administrator, DON, and Social Worker/Abuse Coordinator, had been retrained on abuse protocols that included investigation, reporting, and protection of residents. In addition, according to the AOC, an abuse investigation log was to be maintained by the Administrator to track/trend all allegations of abuse. However, interview with the facility's Social Worker/Abuse Coordinator on 04/09/13 revealed four other allegations of resident abuse involving Residents #19, #29, #30, and #31 had been reported to facility staff and there was no evidence the abuse allegations had been reported to the appropriate State Agencies, had been thoroughly investigated, or that facility residents had been protected from further potential abuse. In addition, review of the facility's abuse log revealed no entry for the abuse allegations involving Residents #19, #29, #30, and #31. An interview with Administrator #2 on 04/09/13 at 5:45 PM, revealed the abuse log was not effective to identify facility failures to investigate, report, and protect Residents #19, #29, #30, and #31 when an allegation was reported. Administrator #2 stated he was not aware of these allegations of abuse. ---The facility provided an acceptable (AOC) on 04/17/13, which alleged the removal of Immediate Jeopardy on 04/17/13 based on the following: On 04/11/13 and 04/12/13, the Chief Operating Officer performed a document search of the Administrator's office and computer for any files related to allegations of abuse, misappropriation, or neglect. There were six files identified, which had not been reported to appropriate State Agencies and had not been thoroughly investigated, in which the initial reports were submitted on 04/11/13 and 04/12/13 to the appropriate State Agencies. The Administrator of record during the time of the alleged abuse allegations, Administrator #1, has been suspended by the Chief Operating Officer on 04/05/13. An investigation has been initiated. All staff including Department Directors and Regional Staff received education regarding abuse, completed by an Independent Contractor by 04/06/13, with completion of a post-test. All staff were re-educated by the Department Directors and Regional Team on 04/12/13. Staff not scheduled, on leave or who work as needed will be re-educated upon returning to work. The Independent Contractor was secured on 04/07/13 to remain onsite at the facility daily until 04/13/13 to provide continued oversight and education related to abuse, to include investigation, reporting, and protection. The Independent Contractor will provide one on one education with Administrator #2, Director of Nursing, and the Interim Social Services Director regarding protection, reporting, and investigation of allegations of abuse by 04/12/13. The Chief Operating Officer and Chief Nursing Executive completed a review of all allegations of abuse by 04/10/13 to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. The Administrator will continue to report any allegations of abuse, neglect, or misappropriation as identified. The Chief Operating Officer or Regional Vice President of Operations will complete a daily review of abuse allegations, grievance reports, incident reports, and daily resident interviews to ensure appropriate protection, reporting, and investigations of abuse allegations. The Chief Nurse Executive or Regional Clinical Consultant will complete a daily onsite visit to review skin assessments to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. Daily reviews will continue until the removal of Immediate Jeopardy. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse investigations daily to ensure that the resident is protected, the perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log that will include documentation of the following: ensured protection of residents, perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and thorough investigation is completed. The Administrator and one of the following: Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will review the abuse investigation to ensure protection of the resident, that the perpetrator was removed from the resident care area, reports to the Inspector General were filed timely, and a thorough investigation has been completed. This will occur daily until removal of Immediate Jeopardy. ---Based on observation, interview, record review, and review of the facility's Allegation of Compliance (AOC), the State Survey Agency validated the AOC as follows: Interview with the Chief Operating Officer, on 04/23/13 at 2:12 PM, revealed he performed a search of the Administrator's office on 04/11/13 and 04/12/13 and identified six (6) files that had not been thoroughly investigated nor reported, that were submitted to the appropriate State Agencies on 04/11/13 and 04/12/13. Interview with the Chief Operating Officer, on 04/23/13 at 2:12 PM, and a review of a statement written by the Chief Operating Officer dated 04/22/13 revealed he suspended the Administrator of record on 04/05/13, Administrator #1. Interview with on 04/23/13 at 11:32 AM with the Regional Nurse Consultant; at 11:53 AM with the Chief Nurse Executive; at 1:46 PM with the Clinical Regional Nurse Consultant; at 2:12 PM with the Chief Operating Officer; at 2:38 PM with Administrator #2; at 10:35 AM with the Director of Admissions; at 12:09 PM with the Quality of Life Director; at 12:21 PM with the Director of Nursing; at 12:38 PM with the Interim Social Services Director; at 12:45 PM with the Rehabilitation Service Manager; at 12:57 PM with the Central Supply and Staffing Manager; at 1:04 PM with the Dietary Manager; at 1:16 PM with the Housekeeping Manager; at 1:23 PM with the Staff Development Coordinator; and at 1:40 PM with the Director of Maintenance confirmed they had received training on abuse by the Independent Contractor on 04/06/13 and had completed a post test. The above Regional Staff and Department Directors verified they had also assisted with education of the remaining staff on 04/12/13. Review of post-test and interviews on 04/23/13 at 10:35 AM with State Registered Nurse Aide (SRNA) #8; at 10:53 AM with Housekeeper #4; at 11:03 AM with Registered Nurse #5; at 11:16 AM with Housekeeper #5; at 11:27 AM with Licensed Practical Nurse #4; at 11:37 AM with SRNA #5; at 11:45 AM with Dietary Aide #1; at 11:54 AM with Dietary Aide #2; at 12:05 PM with SRNA #7; at 12:12 PM with Registered Nurse #4; at 12:20 PM with SRNA #12; at 12:28 PM with SRNA #9; at 12:38 PM with SRNA #1; at 12:49 PM with Certified Medication Aide #1; at 12:56 PM with Certified Medication Aide #6; at 1:09 PM with SRNA #1; at 1:17 PM with Maintenance Worker #1; at 1:41 PM with Laundry Worker #1; and at 1:54 PM with Activity Assistant #1 confirmed they were re-educated by Department Directors and/or Regional Staff. Record review and interview on 04/23/13 at 2:38 PM with Administrator #2; at 12:21 PM with the DON; and at 12:38 PM with the Interim Social Services Director revealed the Independent Contractor did provide them with one on one education related to protection, reporting, and investigation of allegations of abuse prior to 04/12/13. Interview with the Chief Operating Officer on 04/23/13 at 2:12 PM and the Chief Nurse Executive at 11:53 AM revealed, by 04/10/13, they had completed a review of all allegations of abuse received by the facility and no concerns were identified. Further interview with the Chief Operating Officer revealed he had assisted in completing daily reviews, seven (7) days a week, of abuse allegations, grievance reports, incident reports, and daily resident interviews with no concerns identified. Interview with the Chief Nurse Executive on 04/23/13 at 11:53 AM and the Regional Nurse Consultant at 11:32 AM revealed they were reviewing all daily skin assessments onsite. Record review and interview on 04/23/13 at 2:38 PM with Administrator #2; at 12:21 PM with the Director of Nursing; and at 12:38 PM with the Interim Social Services Director revealed they were meeting on numerous occasions daily to review any abuse investigations that were reported. The Administrator stated he utilized an abuse investigation log daily to keep track of all abuse allegations to ensure they were investigated, the residents were protected, and that the allegations had been reported timely to the appropriate State Agencies. Interview with the Chief Nurse Executive on 04/22/13 at 2:15 PM revealed she assists in reviewing the abuse investigation log on a daily, seven (7) days a week, basis. ---During a complaint investigation (KY ) conducted in conjunction with the revisit, an additional example of noncompliance was identified. Interview, review of the facility investigation and review of the facility's Abuse, Neglect and Misappropriation Policy, revealed the facility failed to be administered in a manner that maintained the highest physical well-being for Resident #32. The facility failed to have an effective system in place to ensure policies and procedures were developed/implemented to ensure allegations of abuse were reported to the State Survey Agency in a timely manner. (Refer to F225 and F226.) A review of the facility's Abuse, Neglect and Misappropriation policy, revised March 2013 and effective April 2013, revealed, "all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with officials in accordance with State law through established guidelines." A review of the facility's investigation report revealed on 04/17/13, at approximately 10:50 AM, Licensed Practical Nurse (LPN) #5 reported to the facility's Administration that Kentucky Medication Aide (KMA) #6 reported an allegation that had been made against her (KMA #6). According to the facility's investigation, while KMA #6 was providing care to Resident #32 that morning (04/17/13), the resident told KMA #6 that she was pulling the resident's hair and trying to "kill" the resident. According to documentation on the report, the alleged perpetrator (KMA #6) was immediately suspended and an investigation was initiated. The report further revealed the allegation was reported to the State Survey Agency on 04/18/13 at 5:52 PM (a timeframe of 31 hours after the allegation had been reported to the administration of the facility). Interview on 04/22/13 at 2:15 PM with the Chief Nurse Executive (CNE) revealed the regulatory guidelines indicated reporting of an allegation of abuse "ought not to exceed 24 hours," and had interpreted the statement to mean the facility could have more time to report if necessary. The interview further revealed the CNE thought the time frame was in "business hours" and the facility was a "24-hour business." Administrator #2 acknowledged in interview on 04/22/13 at 1:58 PM that the facility had not reported the incident until 04/18/13 at 5:52 PM even though the facility staff had reported the incident to Administration at approximately 10:50 AM on 04/17/13. According to the Administrator, he thought the facility had until midnight the day after an incident had been reported to make the report and stated he thought the "24-hour timeframe" was from midnight on the day the incident occurred to midnight the day after the incident occurred.

Based on interview, record review, and review of facility policy and procedures and investigations, it was determined the facility failed to maintain a quality assessment and assurance committee that identified quality deficiencies and failed to develop and implement appropriate plans of action to correct identified deficiencies. Six allegations of resident abuse were reported to Facility Administration from 02/17/13 to 04/04/13, involving Residents #1, #4, #19, #29, #30, and #31. Interview and record review revealed administrative staff failed to thoroughly investigate/report these allegations of abuse and failed to protect residents. The facility failed to recognize that their established abuse policy for reporting abuse was not effective, and therefore failed to implement any corrective actions to correct these problems. (Refer to F223, F225, F226, and F490.) The facility's failure to identify quality deficiencies and failure to develop and implement appropriate plans of action to correct identified deficiencies regarding protecting residents from abuse and reporting/investigating allegations of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Two Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.75 Administration (F490 and F520), with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13, and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The findings include: Review of the facility's policy and procedure entitled Quality Assurance/Continuous Quality Improvement, with no date, revealed systems should be in place so that problems were prevented from ever occurring. Further review of the policy revealed the primary purposes of the Quality Assurance/Continuous Quality Improvement plan were as follows: 1. To provide a means whereby negative outcomes related to resident care and safety could be identified and resolved through an interdisciplinary approach and effective systems of services and positive care measures rendered, reinforced, and expanded to improve care given. 2. To establish and provide a system whereby a specific process and the documentation relative to it was maintained to support evidence of an ongoing quality assurance/continuous improvement plan, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to nursing home residents. 3. To develop monitoring tools that provide an effective mechanism to assure that each resident received the necessary care and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 4. To assist facilities that provided care to residents to delineate lines of authority, responsibility, and accountability so that opened lines of communication and negative outcome resolutions may be achieved for optimum resident care on a continuous basis. 5. To develop plans of correction and evaluate corrective actions taken to obtain the desired results. 6. To provide a centralized, coordinated approach to quality assurance/continuous improvement to bring about a comprehensive program of quality assessment and assurance to meet the needs of the facility. The policy further stated all corrective activities would be monitored to determine appropriateness and/or the need for alternative measures. According to the policy/procedure, the Administrator of the facility was ultimately responsible for the quality assurance/continuous improvement program and was also responsible for ensuring the quality assurance/continuous improvement program of the facility was in compliance with federal, state, and local regulatory requirements. Based on interview and record review Immediate Jeopardy was identified on 03/01/13 and on 03/29/13 because of the facility's failure to identify/report/investigate allegations of abuse and for failure to protect residents from further potential abuse. The facility submitted two acceptable Allegations of Compliance (AOCs) to remove Immediate Jeopardy on 03/05/13 and on 04/05/13 that included reeducating all staff, including administrative staff, on abuse reporting, investigating, and protection. In addition, on 04/06/13 and 04/07/13, facility staff was retrained on abuse protocols that included investigation, reporting, and protection of residents. Further, the 03/05/13 AOC stated the facility had reviewed all incidents and investigations that occurred from June 2012 through the present time, with no concerns. However, during an interview with Resident #29 on 04/05/13, the resident stated he/she had reported an allegation of abuse to the facility's social worker approximately two to three months prior when the incident occurred (03/01/13). In addition, the 04/05/13 AOC stated an abuse investigation log was to be maintained by the Administrator to track/trend all allegations of abuse. However, there was no evidence these plans of action were effective in identifying allegations of abuse and ensuring all allegations were reported/investigated and residents were protected. On 03/29/13, 04/05/13, and 04/09/12, additional allegations of abuse related to Residents #19, #29, #30, and #31 were identified which had not been reported to the appropriate State Agencies, and had not been thoroughly investigated. Review of the investigation logs revealed no entry related to these allegations of abuse. In addition, an interview with Administrator #2 revealed the abuse log was not effective to identify facility failures to report and investigate allegations of abuse and to protect Residents #19, #29, #30, and #31. Per interview, Administrator #2 was not aware of these allegations of abuse. An interview on 04/09/13 at 11:09 AM with the Social Worker/Abuse Coordinator, who was a member of the monthly QA committee and as of 04/08/13 was no longer employed by the facility, revealed she did not have a way to track or a log to review any complaints or allegations related to abuse. She further stated there was "no way of knowing what allegations have been made" and she was not aware of who was supposed to review these allegations. Further interview revealed she gave any paperwork she had related to the allegations to the Administrator. An interview with Administrator #2 on 04/09/13 at 11:40 AM revealed that prior to 04/04/13 the facility did not have a system for tracking/trending abuse allegations. The Administrator further stated that the last QA meeting was held either "on 03/13/13 or 03/14/13." During the meeting, the Administrator stated they did not go into detail about past abuse allegations and he was told that all abuse allegations had been reported/investigated and residents had been protected. The Administrator stated he "didn't know why" the facility had not identified that other allegations of resident abuse had not been reported/investigated and residents had not been protected. The Administrator stated it took "a different set of eyes is all I can say" to identify the allegations. The Administrator further stated he did not feel staff was properly trained on how to identify abuse allegations. An interview on 04/04/13 at 3:15 PM, with the Chief Nurse Executive for the Corporation and a Corporate Consultant who was filling in at the facility as the DON, revealed audits conducted as part of the facility's AOCs had not been reviewed through the facility's QA program.

Based on interview, record review, and review of facility policy and procedures and investigations, it was determined the facility failed to maintain a quality assessment and assurance committee that identified quality deficiencies and failed to develop and implement appropriate plans of action to correct identified deficiencies. Six allegations of resident abuse were reported to Facility Administration from 02/17/13 to 04/04/13, involving Residents #1, #4, #19, #29, #30, and #31. Interview and record review revealed administrative staff failed to thoroughly investigate/report these allegations of abuse and failed to protect residents. The facility failed to recognize that their established abuse policy for reporting abuse was not effective, and therefore failed to implement any corrective actions to correct these problems. (Refer to F223, F225, F226, and F490.) The facility's failure to identify quality deficiencies and failure to develop and implement appropriate plans of action to correct identified deficiencies regarding protecting residents from abuse and reporting/investigating allegations of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Two Immediate Jeopardy situations were identified on 03/01/13 and 03/24/13 related to abuse. The Immediate Jeopardy was determined to exist on 02/17/13 and is ongoing at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226) and 42 CFR 483.75 Administration (F490 and F520), with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226). The facility was notified of the Immediate Jeopardy on 03/01/13 and 03/29/13, and was informed on 04/09/13 the Immediate Jeopardy was ongoing. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/17/13 with the facility alleging removal of the Immediate Jeopardy on 04/17/13. The State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 04/22-04/23/13, as alleged in the acceptable AOC, with remaining noncompliance at 42 CFR 483.13 Resident Behavior and Facility Practices (F223 - S/S "D" and F225 and F226 - S/S "E") and 42 CFR 483.75 Administration (F490 and F520 - S/S "E") while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy and procedure entitled Quality Assurance/Continuous Quality Improvement, with no date, revealed systems should be in place so that problems were prevented from ever occurring. Further review of the policy revealed the primary purposes of the Quality Assurance/Continuous Quality Improvement plan were as follows: 1. To provide a means whereby negative outcomes related to resident care and safety could be identified and resolved through an interdisciplinary approach and effective systems of services and positive care measures rendered, reinforced, and expanded to improve care given. 2. To establish and provide a system whereby a specific process and the documentation relative to it was maintained to support evidence of an ongoing quality assurance/continuous improvement plan, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to nursing home residents. 3. To develop monitoring tools that provide an effective mechanism to assure that each resident received the necessary care and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 4. To assist facilities that provided care to residents to delineate lines of authority, responsibility, and accountability so that opened lines of communication and negative outcome resolutions may be achieved for optimum resident care on a continuous basis. 5. To develop plans of correction and evaluate corrective actions taken to obtain the desired results. 6. To provide a centralized, coordinated approach to quality assurance/continuous improvement to bring about a comprehensive program of quality assessment and assurance to meet the needs of the facility. The policy further stated all corrective activities would be monitored to determine appropriateness and/or the need for alternative measures. According to the policy/procedure, the Administrator of the facility was ultimately responsible for the quality assurance/continuous improvement program and was also responsible for ensuring the quality assurance/continuous improvement program of the facility was in compliance with federal, state, and local regulatory requirements. Based on interview and record review Immediate Jeopardy was identified on 03/01/13 and on 03/29/13 because of the facility's failure to identify/report/investigate allegations of abuse and for failure to protect residents from further potential abuse. The facility submitted two acceptable Allegations of Compliance (AOCs) to remove Immediate Jeopardy on 03/05/13 and on 04/05/13 that included reeducating all staff, including administrative staff, on abuse reporting, investigating, and protection. In addition, on 04/06/13 and 04/07/13, facility staff was retrained on abuse protocols that included investigation, reporting, and protection of residents. Further, the 03/05/13 AOC stated the facility had reviewed all incidents and investigations that occurred from June 2012 through the present time, with no concerns. However, during an interview with Resident #29 on 04/05/13, the resident stated he/she had reported an allegation of abuse to the facility's social worker approximately two to three months prior when the incident occurred (03/01/13). In addition, the 04/05/13 AOC stated an abuse investigation log was to be maintained by the Administrator to track/trend all allegations of abuse. However, there was no evidence these plans of action were effective in identifying allegations of abuse and ensuring all allegations were reported/investigated and residents were protected. On 03/29/13, 04/05/13, and 04/09/12, additional allegations of abuse related to Residents #19, #29, #30, and #31 were identified which had not been reported to the appropriate State Agencies, and had not been thoroughly investigated. Review of the investigation logs revealed no entry related to these allegations of abuse. In addition, an interview with Administrator #2 revealed the abuse log was not effective to identify facility failures to report and investigate allegations of abuse and to protect Residents #19, #29, #30, and #31. Per interview, Administrator #2 was not aware of these allegations of abuse. An interview on 04/09/13 at 11:09 AM with the Social Worker/Abuse Coordinator, who was a member of the monthly QA committee and as of 04/08/13 was no longer employed by the facility, revealed she did not have a way to track or a log to review any complaints or allegations related to abuse. She further stated there was "no way of knowing what allegations have been made" and she was not aware of who was supposed to review these allegations. Further interview revealed she gave any paperwork she had related to the allegations to the Administrator. An interview with Administrator #2 on 04/09/13 at 11:40 AM revealed that prior to 04/04/13 the facility did not have a system for tracking/trending abuse allegations. The Administrator further stated that the last QA meeting was held either "on 03/13/13 or 03/14/13." During the meeting, the Administrator stated they did not go into detail about past abuse allegations and he was told that all abuse allegations had been reported/investigated and residents had been protected. The Administrator stated he "didn't know why" the facility had not identified that other allegations of resident abuse had not been reported/investigated and residents had not been protected. The Administrator stated it took "a different set of eyes is all I can say" to identify the allegations. The Administrator further stated he did not feel staff was properly trained on how to identify abuse allegations. An interview on 04/04/13 at 3:15 PM, with the Chief Nurse Executive for the Corporation and a Corporate Consultant who was filling in at the facility as the DON, revealed audits conducted as part of the facility's AOCs had not been reviewed through the facility's QA program. ---The facility provided an acceptable AOC on 04/17/13, which alleged removal of Immediate Jeopardy on 04/17/13 based on the following: On 04/11/13 and 04/12/13, the Chief Operating Officer performed a document search of the Administrator's office and computer for any files related to allegations of abuse, misappropriation, or neglect. There were six files identified, which had not been reported to appropriate State Agencies and had not been thoroughly investigated, in which the initial reports were submitted on 04/11/13 and 04/12/13 to the appropriate State Agencies. Administrator #1, Director of Nursing, Interim Social Services Director, Department Managers (MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Rehabilitation Manager) or Regional staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) conducted 20 interviews daily which were initiated on 04/13/13 with residents who have a BIMS score of 7 or above, to ensure residents feel protected without any evidence of abuse, neglect, or misappropriation. Findings of signs and symptoms of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. The Department Managers ( MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Rehabilitation Manager) or Regional staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) will visit 20 residents daily with a BIMS score of less than 7 and will speak to the Nurse and CNA (State Registered Nurse Aide) regarding any noted changes to the resident's behavior. In addition, a licensed nurse will complete a head to toe skin assessment for the 20 residents with BIMS score of less than 7, to ensure that no physical signs of abuse are present. The above interviews and skin audits will be placed in a binder called the AOC binder that will be located in the Administrator's office. Findings of signs and symptoms of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. The Administrator, Director of Nursing, Social Services Director, or Regional Staff will review all resident and staff questionnaires daily for grievances/concerns. Investigations of grievances/concerns will be initiated upon identification. All resident records were reviewed by the Clinical Regional Nurse Consultant on 04/12/13 for documentation regarding abuse, with no new incidents being identified. Ten resident records are being reviewed by Administrative Nurses (Director of Nursing, Staff Development Coordinator, MDS Coordinators, Unit Manager, Assistant Director of Nursing) or Regional Nurse Consultants ( Regional Nurse Consultants, Director of Clinical Programs, Chief Nurse Executive) daily to ensure that no other abuse allegations have been documented without reporting. This will continue until the removal of Immediate Jeopardy. The Chief Operating Officer and Chief Nursing Executive completed a review of all allegations of abuse by 04/10/13 to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. The Administrator will continue to report any allegations of abuse, neglect, or misappropriation as identified. The Chief Operating Officer or Regional Vice President of Operations will complete a daily review of abuse allegations, grievance reports, incident reports, and daily resident interviews to ensure appropriate protection, reporting, and investigations of abuse allegations. The Chief Nurse Executive or Regional Clinical Consultant will complete a daily onsite visit to review skin assessments to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. Daily reviews will continue until the removal of Immediate Jeopardy. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse investigations daily to ensure that the resident is protected, the perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log that will include documentation of the following: ensured protection of residents, perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and thorough investigation is completed. The Administrator and one of the following: Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will review the abuse investigation to ensure protection of the resident, that the perpetrator was removed from the resident care area, reports to the Inspector General were filed timely, and a thorough investigation has been completed. This will occur daily until removal of Immediate Jeopardy. ---Based on observation, interview, record review, and review of the facility's Allegation of Compliance (AOC), the State Survey Agency validated the AOC as follows: Interview with the Chief Operating Officer, on 04/23/13 at 2:12 PM, revealed he performed a search of the Administrator's office on 04/11/13 and 04/12/13 and identified six (6) files that had not been thoroughly investigated nor reported, that were submitted to the appropriate State Agencies on 04/11/13 and 04/12/13. Record review and interview on 04/23/13 at 11:32 AM with the Regional Nurse Consultant; at 11:53 AM with the Chief Nurse Executive; at 2:38 PM with Administrator #2; at 10:35 AM with the Director of Admissions; at 12:09 PM with the Quality of Life Director; at 12:21 PM with the Director of Nursing; at 12:38 PM with the Interim Social Services Director; at 12:45 PM with the Rehabilitation Service Manager; at 1:04 PM with the Dietary Manager; at 1:16 PM with the Housekeeping Manager; and at 1:23 PM with the Staff Development Coordinator revealed they had assisted with conducting twenty (20) interviews daily, seven (7) days a week, of residents with a BIMS of seven (7) or higher related to abuse/neglect. Further interviews and record review revealed the staff had also visited with twenty (20) residents a day, seven (7) days a week, who had a BIMS below seven (7), and had spoken to the Nurse and SRNA regarding any changes in behaviors or signs of abuse. Record review and interview on 04/23/13 at 1:23 PM with the Staff Development Coordinator; at 11:32 AM with the Regional Nurse Consultant; at 11:53 with the Chief Nurse Executive; and at 12:21 PM with the Director of Nursing revealed they had assisted with conducting twenty (20) skin assessments a day, seven (7) days a week, of the residents that were non-interviewable and had not identified any concerns related to physical abuse. Record review and interview on 04/23/13 at 11:32 AM with the Regional Nurse Consultant; at 11:53 AM with the Chief Nurse Executive; at 2:38 PM with Administrator #2; at 10:35 AM with the Director of Admissions; at 12:09 PM with the Quality of Life Director; at 12:38 PM with the Interim Social Services Director; at 12:45 PM with the Rehabilitation Service Manager; at 1:04 PM with the Dietary Manager; at 1:16 PM with the Housekeeping Manager; and at 1:23 PM with the Staff Development Coordinator revealed they had assisted with conducting interviews with twenty (20) staff members a day, seven (7) days a week, regarding their knowledge of the facility's policy on abuse/potential abuse. Interview on 04/23/13 at 10:35 AM with SRNA #8; at 10:53 AM with Housekeeper #4; at 11:03 AM with Registered Nurse #5; at 11:16 AM with Housekeeper #5; at 11:27 AM with Licensed Practical Nurse #4; at 11:37 AM with SRNA #5; at 11:45 AM with Dietary Aide #1; at 11:54 AM with Dietary Aide #2; at 12:05 PM with SRNA #7; at 12:12 PM with Registered Nurse #4; at 12:20 PM with SRNA #12; at 12:28 PM with SRNA #9; at 12:38 PM with SRNA #1; at 12:49 PM with Certified Medication Aide #1; at 12:56 PM with Certified Medication Aide #6; at 1:09 PM with SRNA #1; at 1:17 PM with Maintenance Worker #1; at 1:41 PM with Laundry Worker #1; and at 1:54 PM with Activity Assistant #1 revealed management staff had spoken with floor staff daily regarding their knowledge of the facility's policy on abuse and if they were aware of any potential abuse situations in the facility. Interview on 04/23/13 at 2:38 PM with Administrator #2; at 12:21 PM with the Director of Nursing; and at 12:38 PM with the Interim Social Services Director revealed they had met daily, seven days a week, and had reviewed all resident and staff questionnaires that had been conducted to identify any concerns. No concerns had been identified. Record review and interview on 04/23/13 at 1:46 PM with the Clinical Regional Nurse Consultant revealed she had conducted chart audits on 100% of the charts in the facility in an effort to identify potential abuse, which may have been documented but not reported. In addition, the Clinical Regional Nurse Consultant stated she had assisted with ten (10) chart audits a day, seven days a week, and had not identified any concerns related to abuse. Record review and interview on 04/23/13 at 12:21 PM with the Director of Nursing; at 1:23 PM with the Staff Development Coordinator; and at 11:32 AM with the Regional Nurse Consultant revealed they were conducting ten (10) chart audits a day, seven days a week, to review for signs of abuse that were reported and no concerns were identified. Interview with the Chief Operating Officer on 04/23/13 at 2:12 PM and the Chief Nurse Executive at 11:53 AM revealed, by 04/10/13, they had completed a review of all allegations of abuse received by the facility and no concerns were identified. Further interview with the Chief Operating Officer revealed he had assisted in completing daily reviews, seven (7) days a week, of abuse allegations, grievance reports, incident reports, and daily resident interviews with no concerns identified. Interview with the Chief Nurse Executive on 04/23/13 at 11:53 AM and the Regional Nurse Consultant at 11:32 AM revealed they were reviewing all daily skin assessments onsite. Record review and interview on 04/23/13 at 2:38 PM with Administrator #2; at 12:21 PM with the Director of Nursing; and at 12:38 PM with the Interim Social Services Director revealed they were meeting on numerous occasions daily to review any abuse investigations that were reported. The Administrator stated he utilized an abuse investigation log daily to keep track of all abuse allegations to ensure they were investigated, the residents were protected, and that the allegations had been reported timely to the appropriate State Agencies. Interview with the Chief Nurse Executive on 04/22/13 at 2:15 PM revealed she assists in reviewing the abuse investigation log on a daily, seven (7) days a week, basis.

Based on interview, record review, and review of the facility's investigation and policies it was determined the facility failed to have an effective system in place to ensure one of twenty-nine sampled residents (Resident #1) was free from abuse. On 02/17/13 at approximately 7:35 AM, staff observed Resident #1 sitting in a wheelchair located in the dining room next to the nurses' station, crying in pain, and requesting to go to bed. Licensed Practical Nurse (LPN) #1 refused to allow staff to take Resident #1 to bed and stated the resident would remain seated in the wheelchair until the resident quit "crying," "hollering," and/or "whining." LPN #1 placed a radio near Resident #1's head and turned up the volume. According to interviews, staff attempted to report the alleged abuse to the Social Worker/Abuse Coordinator, in accordance with facility policy; however, staff was unable to contact the Social Worker and left a voice mail message on the Social Worker's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, Director of Nursing, and Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. A review of the facility's policy revealed the Administrator and/or Director of Nursing (DON) and/or Social Worker was required to make immediate decisions related to the removal of the alleged abuser from direct care/contact. As a result of the facility's investigation, the facility determined the allegation of abuse was unsubstantiated on 02/22/13. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. The facility's failure to have an effective system in place to ensure residents were free from abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility including Resident #1. Immediate Jeopardy was identified on 03/01/13 and was determined to exist on 02/17/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 03/01/13. Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices. The findings include: A review of the facility's abuse policy, dated 01/2012, revealed the facility "upholds resident rights and strictly prohibits verbal, sexual, physical, and mental abuse of residents...." The policy stated that "any report or suspicion of an incident" of abuse was required to be "reported immediately to the charge nurse and/or Abuse Coordinator, as appropriate." The resident was to "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process." The Administrator and/or Director of Nursing and/or Social Worker would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse". A review of Resident #1's medical record revealed the resident was assessed by the facility to be moderately cognitively impaired, therefore, non-interviewable. Further review revealed the facility had assessed the resident to have a history of pain. A review of a facility pain assessment performed on Resident #1, dated 02/04/13, revealed the resident had "episodes of repetitive verbalizations unsure if episodes are pain or not as (he/she) has some actions were pain meds given." A review of Resident #1's physician's orders [REDACTED]. A review of the facility nurse's notes dated 02/14/13, revealed facility staff had contacted the resident's physician related to the resident's increase in pain and requested new pain medication. A review of Resident #1's Plan of Care dated 02/14/13 revealed the physician adjusted Resident #1's pain medications due to the resident's continued repetitive verbalizations and moaning even after the pain medication had been given. A review of the facility's investigation, dated 02/22/13, revealed on the morning of 02/17/13, after the morning meal, staff observed Resident #1 at the nurses' station crying and requesting to go to bed. The investigation revealed staff was interviewed and reported LPN #1 (the charge nurse) would not allow staff to put the resident to bed as the resident was "crying" and "yelling." One staff member reported LPN #1 made a comment that indicated she was going to "teach the resident a lesson." Further review revealed LPN #1 was "immediately" suspended pending the outcome of the investigation. In addition, according to the report, LPN #1 stated in interview she wanted Resident #1 to stay at the nurses' station in order for the nurse to monitor the resident's behavior. Documentation in the report revealed other residents on the unit were interviewed and one resident stated he/she had overheard LPN #1 say negative things about another resident. The investigation further stated abuse could not be substantiated. LPN #1 was no longer employed by the facility at the time of the investigation. Attempts to contact LPN #1 for interview were unsuccessful. A review of LPN #1's employee file revealed the LPN was terminated from the facility on 02/25/13 for falsification of documentation. Review of the facility's witness statement signed by State Registered Nurse Aide (SRNA) #2, and dated 02/17/13, revealed on 02/17/13 after breakfast LPN #1 told staff to leave Resident #1 at the nurses' station. The statement further revealed LPN #1 stated, "I'm going to teach (him/her) a lesson for hollering in the dining room. I'm leaving (him/her) up for a while." SRNA #2 reported music was playing at the nurses' station at the time. At approximately 10:00 AM, LPN #1 informed staff they could lay Resident #1 down in bed. An attempt was made on 03/01/13 at 9:55 AM, 03/02/12 at 10:05 AM, and 03/03/13 at 5:05 PM to interview SRNA #2 with no success. An interview with SRNA #3 on 03/01/13 at 12:29 PM, revealed on the morning of 02/17/13, between 9:00 AM and 9:30 AM, Resident #1 was "hollering" and the SRNA attempted to talk with the resident. According to interview, the resident told SRNA #3 that he/she was hurting and wanted to go to bed. While he was talking to the resident and the resident was "hollering," SRNA #3 stated LPN #1 turned up the volume "louder" on a radio that was playing music at the nurses' station. SRNA #3 stated he wheeled Resident #1 in the wheelchair around the corridors of the building for approximately 10 to 15 minutes and then brought the resident back to the nurses' station and told the staff the resident was hurting and had requested to go to bed. An interview with Kentucky Medication Aide (KMA) #1 on 03/01/13 at 12:01 PM revealed on the morning of 02/17/13 she had administered a physician ordered, scheduled, [MEDICATION NAME] (narcotic pain [MEDICATION NAME]) to Resident #1 at approximately 8:30 AM due to the resident's complaints of pain. A review of Resident #1's Medication Administration Record [REDACTED]. According to KMA #1, Resident #1 had told LPN #1 that he/she was in pain. KMA #1 stated she returned to the nurses' station approximately 30 to 45 minutes after she administered the pain medication to Resident #1 to begin a medication pass and the resident was still sitting in the chair at the nurses' station. KMA #1 stated she heard LPN #1 tell the resident in a loud voice, "You can't lay down till you stop crying." KMA #1 stated she thought the LPN's remark was inappropriate and was going to report the LPN after she had completed the medication pass; however, when she returned to the nurses' station after passing medications, Resident #1 was no longer sitting at the nurses' station and was lying in bed. KMA #1 stated Resident #1 could tell staff when he/she was hurting and in pain but could not tell staff where the pain was located. KMA #1 stated Resident #1 often experienced increased pain when sitting up in a chair and staff usually assisted the resident to bed after breakfast due to the resident's complaints of increased pain. The interview further revealed KMA #1 thought LPN #1's actions toward Resident #1 were abusive. A review of KMA 1's witness statement, signed and dated 02/17/13 by KMA #1, revealed on 02/17/13 she witnessed LPN #1 tell Resident #1 that the resident "would sit up until (he/she) stopped crying," and then the LPN turned up the volume of the radio at the nurses' station. Interview with Housekeeper #1 on 02/28/13 at 12:17 PM and again on 03/04/13 at 11:37 AM revealed Resident #1 would usually cry after breakfast in the mornings, would request to go to bed, and staff would assist the resident to bed. The housekeeper stated that following breakfast on the morning of 02/17/13 at approximately 7:35 AM, LPN #1 made a comment that Resident #1 was not going to bed because the resident was "whining" and "crying." According to Housekeeper #1, Resident #1 repeatedly said, "I want to go to bed, I'm hurting, take me to bed." Housekeeper #1 stated LPN #1 had a tendency to be loud and used a tone that was a combination of "hateful" and "rude." According to Housekeeper #1, on the morning of 02/17/13, LPN #1 was more than just loud and was verbally abusive to Resident #1. Housekeeper #1 further stated LPN #1 wheeled Resident #1 to the nurses' station, placed a radio near Resident #1's head, and turned up the volume of the radio. Review of Housekeeper's #1's written statement signed and dated 02/17/13 revealed after breakfast on the morning of 02/17/13 Resident #1 was "crying and wanting to go to bed." LPN #1 told Resident #1 that "as long as (he/she) whined and cried," the resident was "not going to bed." Further review of the witness statement revealed staff attempted to take the resident to bed and LPN #1 told staff "no." The witness statement went on to say LPN #1 obtained a radio, placed it at the nurses' station, and turned it up to "drown out" Resident #1 crying. Interview with Housekeeper #2 on 03/01/13 at 11:47 AM revealed on the morning of 02/17/13 LPN #1 would not allow facility staff to assist Resident #1 to bed. According to Housekeeper #2, Resident #1 did "cry" and holler" that he/she was in pain and wanted to go to bed. However, according to the housekeeper, LPN #1 stated to the resident that he/she had to sit in front of the desk until the resident quit "hollering." Housekeeper #2 further stated LPN #1 obtained a radio, placed it at the nurses' station near the resident's head, and turned the volume "up real loud." Further interview revealed she and other staff who had witnessed the incident discussed the incident and felt the incident needed to be reported. Housekeeper #2 stated she and another housekeeper attempted to contact the Social Worker/Abuse Coordinator to report the allegation, but the Social Worker/Abuse Coordinator did not answer the phone and she left a voice message regarding the incident. In addition, a review of the facility's witness statement signed by Housekeeper #2 and dated 02/17/13 revealed LPN #1 was talking to Resident #1 "in a way she shouldn't haven't." The witness statement further stated Resident #1 was crying in the dining room at breakfast, and LPN #1 refused to let staff put the resident to bed. According to Housekeeper #2's written statement, LPN #1 wheeled Resident #1 to the nurses' station, obtained a radio, and set it up at the nurses' station and turned it up "really loud" because the resident was crying. Interview with the Staff Development Coordinator/Nurse Manager on 02/28/13 at 5:35 PM, 03/04/13 at 11:07 AM, and again on 03/05/13 at 4:45 PM revealed she was at the facility on 02/17/13 and as she was coming out of her office between 11:30 AM and 11:40 AM, Housekeepers #1 and #2 met her in the hall to inform her they felt "uneasy" about an incident they had witnessed. According to the Staff Development Coordinator/Nurse Manager, the staff stated they were uncomfortable with the tone LPN #1 used with Resident #1. The Staff Development Coordinator/Nurse Manager stated she proceeded to talk with other staff related to the incident and had staff fill out witness statements. During this time, she stated she attempted to contact the Social Worker/Abuse Coordinator and had to leave a voice message for her and was not able to contact the DON for direction on the allegation. According to the Staff Development Coordinator/Nurse Manager, on 02/17/13 she contacted the facility's Nurse Consultant for direction, and was advised to obtain a written statement from LPN #1 and then to inform the LPN she was being sent home pending the facility investigation. Further interview revealed LPN #1 continued to remain in the facility at the nurses' station during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, DON, and Nurse Consultant. According to the Staff Development Coordinator/Nurse Manager, LPN #1 was removed from direct care at approximately 12:30 PM after she contacted the Nurse Consultant. Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM revealed on 02/17/13, at approximately 12:00 PM, she discovered she had received a voice mail message from the housekeepers at the facility and a second voice mail message from the Staff Development Coordinator/Nurse Manager. After she received the calls, the Social Worker/Abuse Coordinator stated she went to the facility on [DATE] and attempted to interview Resident #1; however, she was unable to get an adequate interview due to the resident's cognition level. The Social Worker/Abuse Coordinator stated her part of the investigation was to interview residents related to abuse. While interviewing residents on that day, the Social Worker/Abuse Coordinator stated one resident did report he/she had heard LPN #1 being rude to another resident; however, the resident was unsure if LPN #1 was talking to the resident or about the resident at the time. Interview with Administrator #1 on 02/28/13 at 5:20 PM revealed during the investigation he reviewed the witness statements and information that had been obtained, consulted with his regional staff, conducted three or four interviews for follow-up, and re-interviewed LPN #1 to ensure accuracy. According to Administrator #1, LPN #1 admitted Resident #1 was crying and yelling at the nurses' station and the LPN did ask staff to leave the resident up in the chair. According to Administrator #1, LPN #1 told him she wanted to observe the resident to see if the resident was in pain. Administrator #1 acknowledged during interviews he conducted, one SRNA reported LPN #1 stated that she was going to "teach a lesson" and make the resident "stay out there" at the nurses' station. Administrator #1 stated after the investigation, interview, and review of the witness statements he felt like he could not come to a "firm" conclusion to substantiate abuse. He further stated the facility unsubstantiated abuse because staff may have "misinterpreted" LPN #1's actions.

Based on interview, record review, and review of the facility's investigation and policies it was determined the facility failed to have an effective system in place to ensure one of twenty-nine sampled residents (Resident #1) was free from abuse. On 02/17/13 at approximately 7:35 AM, staff observed Resident #1 sitting in a wheelchair located in the dining room next to the nurses' station, crying in pain, and requesting to go to bed. Licensed Practical Nurse (LPN) #1 refused to allow staff to take Resident #1 to bed and stated the resident would remain seated in the wheelchair until the resident quit "crying," "hollering," and/or "whining." LPN #1 placed a radio near Resident #1's head and turned up the volume. According to interviews, staff attempted to report the alleged abuse to the Social Worker/Abuse Coordinator, in accordance with facility policy; however, staff was unable to contact the Social Worker and left a voice mail message on the Social Worker's telephone. Staff reported the allegation of abuse to the Staff Development Coordinator/Nurse Manager on 02/17/13, at approximately 11:40 AM, approximately four hours after staff observed the abuse. Interviews revealed LPN #1 continued to be in charge of resident care and remained on the floor with residents during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, Director of Nursing, and Nurse Consultant on what action to take. LPN #1 remained in direct resident care until 12:30 PM, approximately five hours after staff observed the abuse. A review of the facility's policy revealed the Administrator and/or Director of Nursing (DON) and/or Social Worker was required to make immediate decisions related to the removal of the alleged abuser from direct care/contact. As a result of the facility's investigation, the facility determined the allegation of abuse was unsubstantiated on 02/22/13. However, interview and record review revealed LPN #1 did not return to the facility and was terminated from the facility on 02/25/13 related to falsification of documentation. The facility's failure to have an effective system in place to ensure residents were free from abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility including Resident #1. Immediate Jeopardy was identified on 03/01/13 and was determined to exist on 02/17/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 03/01/13. Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/17/13 with the facility alleging removal of the Immediate Jeopardy on 04/17/13. The State Survey Agency (SSA) verified removal of the Immediate Jeopardy on 04/22-04/23/13, as alleged in the acceptable AOC, with remaining noncompliance at 42 CFR 483.13 Resident Behavior and Facility Practices F223 S/S "D", while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's abuse policy, dated 01/2012, revealed the facility "upholds resident rights and strictly prohibits verbal, sexual, physical, and mental abuse of residents...." The policy stated that "any report or suspicion of an incident" of abuse was required to be "reported immediately to the charge nurse and/or Abuse Coordinator, as appropriate." The resident was to "receive measures to ensure his or her immediate safety and well-being following the incident and during the investigation process." The Administrator and/or Director of Nursing and/or Social Worker would make "any immediate decisions related to the removal of individuals from direct care giving or direct contact related to the alleged or suspected abuse." A review of Resident #1's medical record revealed the resident was assessed by the facility to be moderately cognitively impaired, therefore, non-interviewable. Further review revealed the facility had assessed the resident to have a history of pain. A review of a facility pain assessment performed on Resident #1, dated 02/04/13, revealed the resident had "episodes of repetitive verbalizations unsure if episodes are pain or not as (he/she) has some actions were pain meds given." A review of Resident #1's physician's orders [REDACTED]. A review of the facility nurse's notes dated 02/14/13, revealed facility staff had contacted the resident's physician related to the resident's increase in pain and requested new pain medication. A review of Resident #1's Plan of Care dated 02/14/13 revealed the physician adjusted Resident #1's pain medications due to the resident's continued repetitive verbalizations and moaning even after the pain medication had been given. A review of the facility's investigation, dated 02/22/13, revealed on the morning of 02/17/13, after the morning meal, staff observed Resident #1 at the nurses' station crying and requesting to go to bed. The investigation revealed staff was interviewed and reported LPN #1 (the charge nurse) would not allow staff to put the resident to bed as the resident was "crying" and "yelling." One staff member reported LPN #1 made a comment that indicated she was going to "teach the resident a lesson." Further review revealed LPN #1 was "immediately" suspended pending the outcome of the investigation. In addition, according to the report, LPN #1 stated in interview she wanted Resident #1 to stay at the nurses' station in order for the nurse to monitor the resident's behavior. Documentation in the report revealed other residents on the unit were interviewed and one resident stated he/she had overheard LPN #1 say negative things about another resident. The investigation further stated abuse could not be substantiated. LPN #1 was no longer employed by the facility at the time of the investigation. Attempts to contact LPN #1 for interview were unsuccessful. A review of LPN #1's employee file revealed the LPN was terminated from the facility on 02/25/13 for falsification of documentation. Review of the facility's witness statement signed by State Registered Nurse Aide (SRNA) #2, and dated 02/17/13, revealed on 02/17/13 after breakfast LPN #1 told staff to leave Resident #1 at the nurses' station. The statement further revealed LPN #1 stated, "I'm going to teach (him/her) a lesson for hollering in the dining room. I'm leaving (him/her) up for a while." SRNA #2 reported music was playing at the nurses' station at the time. At approximately 10:00 AM, LPN #1 informed staff they could lay Resident #1 down in bed. An attempt was made on 03/01/13 at 9:55 AM, 03/02/12 at 10:05 AM, and 03/03/13 at 5:05 PM to interview SRNA #2 with no success. An interview with SRNA #3 on 03/01/13 at 12:29 PM, revealed on the morning of 02/17/13, between 9:00 AM and 9:30 AM, Resident #1 was "hollering" and the SRNA attempted to talk with the resident. According to interview, the resident told SRNA #3 that he/she was hurting and wanted to go to bed. While he was talking to the resident and the resident was "hollering," SRNA #3 stated LPN #1 turned up the volume "louder" on a radio that was playing music at the nurses' station. SRNA #3 stated he wheeled Resident #1 in the wheelchair around the corridors of the building for approximately 10 to 15 minutes and then brought the resident back to the nurses' station and told the staff the resident was hurting and had requested to go to bed. An interview with Kentucky Medication Aide (KMA) #1 on 03/01/13 at 12:01 PM revealed on the morning of 02/17/13 she had administered a physician ordered, scheduled, [MEDICATION NAME] (narcotic pain [MEDICATION NAME]) to Resident #1 at approximately 8:30 AM due to the resident's complaints of pain. A review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to KMA #1, Resident #1 had told LPN #1 that he/she was in pain. KMA #1 stated she returned to the nurses' station approximately 30 to 45 minutes after she administered the pain medication to Resident #1 to begin a medication pass and the resident was still sitting in the chair at the nurses' station. KMA #1 stated she heard LPN #1 tell the resident in a loud voice, "You can't lay down till you stop crying." KMA #1 stated she thought the LPN's remark was inappropriate and was going to report the LPN after she had completed the medication pass; however, when she returned to the nurses' station after passing medications, Resident #1 was no longer sitting at the nurses' station and was lying in bed. KMA #1 stated Resident #1 could tell staff when he/she was hurting and in pain but could not tell staff where the pain was located. KMA #1 stated Resident #1 often experienced increased pain when sitting up in a chair and staff usually assisted the resident to bed after breakfast due to the resident's complaints of increased pain. The interview further revealed KMA #1 thought LPN #1's actions toward Resident #1 were abusive. A review of KMA 1's witness statement, signed and dated 02/17/13 by KMA #1, revealed on 02/17/13 she witnessed LPN #1 tell Resident #1 that the resident "would sit up until (he/she) stopped crying," and then the LPN turned up the volume of the radio at the nurses' station. Interview with Housekeeper #1 on 02/28/13 at 12:17 PM and again on 03/04/13 at 11:37 AM revealed Resident #1 would usually cry after breakfast in the mornings, would request to go to bed, and staff would assist the resident to bed. The housekeeper stated that following breakfast on the morning of 02/17/13 at approximately 7:35 AM, LPN #1 made a comment that Resident #1 was not going to bed because the resident was "whining" and "crying." According to Housekeeper #1, Resident #1 repeatedly said, "I want to go to bed, I'm hurting, take me to bed." Housekeeper #1 stated LPN #1 had a tendency to be loud and used a tone that was a combination of "hateful" and "rude." According to Housekeeper #1, on the morning of 02/17/13, LPN #1 was more than just loud and was verbally abusive to Resident #1. Housekeeper #1 further stated LPN #1 wheeled Resident #1 to the nurses' station, placed a radio near Resident #1's head, and turned up the volume of the radio. Review of Housekeeper's #1's written statement signed and dated 02/17/13 revealed after breakfast on the morning of 02/17/13 Resident #1 was "crying and wanting to go to bed." LPN #1 told Resident #1 that "as long as (he/she) whined and cried," the resident was "not going to bed." Further review of the witness statement revealed staff attempted to take the resident to bed and LPN #1 told staff "no." The witness statement went on to say LPN #1 obtained a radio, placed it at the nurses' station, and turned it up to "drown out" Resident #1 crying. Interview with Housekeeper #2 on 03/01/13 at 11:47 AM revealed on the morning of 02/17/13 LPN #1 would not allow facility staff to assist Resident #1 to bed. According to Housekeeper #2, Resident #1 did "cry" and holler" that he/she was in pain and wanted to go to bed. However, according to the housekeeper, LPN #1 stated to the resident that he/she had to sit in front of the desk until the resident quit "hollering." Housekeeper #2 further stated LPN #1 obtained a radio, placed it at the nurses' station near the resident's head, and turned the volume "up real loud." Further interview revealed she and other staff who had witnessed the incident discussed the incident and felt the incident needed to be reported. Housekeeper #2 stated she and another housekeeper attempted to contact the Social Worker/Abuse Coordinator to report the allegation, but the Social Worker/Abuse Coordinator did not answer the phone and she left a voice message regarding the incident. In addition, a review of the facility's witness statement signed by Housekeeper #2 and dated 02/17/13 revealed LPN #1 was talking to Resident #1 "in a way she shouldn't haven't." The witness statement further stated Resident #1 was crying in the dining room at breakfast, and LPN #1 refused to let staff put the resident to bed. According to Housekeeper #2's written statement, LPN #1 wheeled Resident #1 to the nurses' station, obtained a radio, and set it up at the nurses' station and turned it up "really loud" because the resident was crying. Interview with the Staff Development Coordinator/Nurse Manager on 02/28/13 at 5:35 PM, 03/04/13 at 11:07 AM, and again on 03/05/13 at 4:45 PM revealed she was at the facility on 02/17/13 and as she was coming out of her office between 11:30 AM and 11:40 AM, Housekeepers #1 and #2 met her in the hall to inform her they felt "uneasy" about an incident they had witnessed. According to the Staff Development Coordinator/Nurse Manager, the staff stated they were uncomfortable with the tone LPN #1 used with Resident #1. The Staff Development Coordinator/Nurse Manager stated she proceeded to talk with other staff related to the incident and had staff fill out witness statements. During this time, she stated she attempted to contact the Social Worker/Abuse Coordinator and had to leave a voice message for her and was not able to contact the DON for direction on the allegation. According to the Staff Development Coordinator/Nurse Manager, on 02/17/13 she contacted the facility's Nurse Consultant for direction, and was advised to obtain a written statement from LPN #1 and then to inform the LPN she was being sent home pending the facility investigation. Further interview revealed LPN #1 continued to remain in the facility at the nurses' station during the time the Staff Development Coordinator/Nurse Manager initiated the investigation, talked with the other staff, and attempted to get direction from the Social Worker/Abuse Coordinator, DON, and Nurse Consultant. According to the Staff Development Coordinator/Nurse Manager, LPN #1 was removed from direct care at approximately 12:30 PM after she contacted the Nurse Consultant. Interview with the Social Worker/Abuse Coordinator on 02/28/13 at 4:53 PM revealed on 02/17/13, at approximately 12:00 PM, she discovered she had received a voice mail message from the housekeepers at the facility and a second voice mail message from the Staff Development Coordinator/Nurse Manager. After she received the calls, the Social Worker/Abuse Coordinator stated she went to the facility on [DATE] and attempted to interview Resident #1; however, she was unable to get an adequate interview due to the resident's cognition level. The Social Worker/Abuse Coordinator stated her part of the investigation was to interview residents related to abuse. While interviewing residents on that day, the Social Worker/Abuse Coordinator stated one resident did report he/she had heard LPN #1 being rude to another resident; however, the resident was unsure if LPN #1 was talking to the resident or about the resident at the time. Interview with Administrator #1 on 02/28/13 at 5:20 PM revealed during the investigation he reviewed the witness statements and information that had been obtained, consulted with his regional staff, conducted three or four interviews for follow-up, and re-interviewed LPN #1 to ensure accuracy. According to Administrator #1, LPN #1 admitted Resident #1 was crying and yelling at the nurses' station and the LPN did ask staff to leave the resident up in the chair. According to Administrator #1, LPN #1 told him she wanted to observe the resident to see if the resident was in pain. Administrator #1 acknowledged during interviews he conducted, one SRNA reported LPN #1 stated that she was going to "teach a lesson" and make the resident "stay out there" at the nurses' station. Administrator #1 stated after the investigation, interview, and review of the witness statements he felt like he could not come to a "firm" conclusion to substantiate abuse. He further stated the facility unsubstantiated abuse because staff may have "misinterpreted" LPN #1's actions. ---The facility provided an acceptable AOC on 04/17/13, which alleged removal of Immediate Jeopardy on 04/17/13 based on the following: All staff including Department Directors and Regional Staff received education regarding abuse, completed by an Independent Contractor by 04/06/13, with completion of a post-test. All staff were re-educated by the Department Directors and Regional Team on 04/12/13. Staff not scheduled, on leave or who work as needed will be re-educated upon returning to work. The Independent Contractor was secured on 04/07/13 to remain onsite at the facility daily until 04/13/13 to provide continued oversight and education related to abuse, to include investigation, reporting, and protection. The Independent Contractor will provide one on one education with Administrator #2, Director of Nursing, and the Interim Social Services Director regarding protection, reporting, and investigation of allegations of abuse by 04/12/13. The Independent Contractor initiated continued abuse education regarding identifying, reporting, and ensuring resident safety on 04/11/13. All staff scheduled to work will receive this re-education by 04/12/13. Staff not scheduled to work during that time frame, who work as needed, or who are on leave of absence will receive the education upon returning to work, by Administrator #2, Director of Nursing, Assistant Director of Nursing, Unit Manager, Social Services Director, Staff Development Coordinator, or Regional Staff. On 04/12/13 thirty-four (34) interviews were conducted by the Department Managers (Staffing Coordinator, Dietary Manager, Housekeeping Director) for residents with a Brief Interview for Mental Status (BIMS) score of seven (7) or above to determine their feelings of safety and identify any allegations of mistreatment or abuse. There were no concerns voiced. A body audit was complete for eighty-one (81) residents, there were an additional nine (9) residents who refused a body audit therefore the audit was not performed on those nine (9), by Administrative Nurses (MDS Coordinators, DON, Staff Development Coordinator), on 04/12/13 and regional nurses (Signature Care Consultants, Internal Audit Director -RN from the Corporate office, Director of Medical Review -RN from the corporate office) for residents with a BIMS score below 7 to ensure that no physical signs and symptoms of abuse were present. Results of body audits did not reflect any physical injuries. On 04/12/13 Department Managers (Dietary Manager, Staffing Coordinator) also met with licensed nurses and Certified Nurse Assistants (CNAs) (State Registered Nurse Aides) assigned to residents with a BIMS of 7 or less, 36 residents, to interview for any noted change of behavior or any signs of fear. All above interviews were placed in a binder called the AOC binder located In the Administrator's office. Administrator #2, Director of Nursing, Interim Social Services Director, Department Managers (MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Rehabilitation Manager) or Regional staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) conducted 20 interviews daily which were initiated on 04/13/13 with residents who have a BIMS score of 7 or above, to ensure residents feel protected without any evidence of abuse, neglect, or misappropriation. Findings of signs and symptoms of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. The Department Managers (MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Rehabilitation Manager) or Regional staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) will visit 20 residents daily with a BIMS score of less than 7 and will speak to the Nurse and CNA (State Registered Nurse Aide) regarding any noted changes to the resident's behavior. In addition, a licensed nurse will complete a head to toe skin assessment for the 20 residents with BIMS score of less than 7, to ensure that no physical signs of abuse are present. The above interviews and skin audits will be placed in a binder called the AOC binder that will be located in the Administrator's office. Findings of signs and symptoms of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. Previous investigations of allegations of abuse, neglect or misappropriation, grievance log, and incidents reports from 10/01/12 to the 04/10/13 were reviewed by Administrator #2, Director of Nursing, the Independent Contractor, and the Interim Social Services Director as a team for any documented evidence of abuse, neglect, or misappropriation. Results of the review identified sixteen (16) allegations in which initial reports have been submitted to the Office of Inspector General by the Administrator or Social Services Director. The Social Services Director or the Director of Nursing will weekly review grievances and incident reports starting 04/16/13 to determine if there are reportable allegations that have not been identified. Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. Staff interviews were conducted by the Independent Contractor, Vice President (VP) of Human Resources, RSM, Chief Nursing Executive, Director of Clinical Programs, VP of Recruiting, Nursing Supervisor, Dietary Manager, Housekeeping Director, and Business Office Manager for all staff that was present in the facility on 04/12/13 regarding the types of abuse, identification of the abuse coordinator, protection of the resident, and reporting of abuse. Staff members were asked if they had knowledge of any potential abuse that has not been reported. There were no findings reported. Staff not scheduled to work, on leave, or who worked as needed, will be interviewed by a member of the Department Director or Regional team upon return to work. Department Managers (MDS Coordinators, Dietary Manager, Housekeeping Director, Social Service Director, Administrator, Director of Nursing, Business Office Manager, Staffing Coordinator, Plant Operations Director, Unit Managers, Assistant Director of Nursing, Admissions Director, Activities Director, Medical Records Director, Staffing Coordinator, Rehabilitation Manager) or Regional Staff (Clinical Program Director, Regional Nurse Consultant, Signature Care Consultant, Internal Audit Director, Chief Nurse Executive, Clinical Reimbursement Consultant, Director of Medical Review) will conduct questionnaires for 20 staff members daily regarding their knowledge of any potential abuse. Findings of potential abuse will be reported immediately to the Charge Nurse. The Charge Nurse will remove the alleged perpetrator, if known, from the resident care area immediately. The Charge Nurse will notify the Administrator. The Administrator will immediately initiate an investigation, and report to the Office of Inspector General, any allegations of abuse or injuries of unknown origin. All resident records were reviewed by the Clinical Regional Nurse Consultant on 04/12/13 for documentation regarding abuse, with no new incidents being identified. Ten resident records are being reviewed by Administrative Nurses (Director of Nursing, Staff Development Coordinator, MDS Coordinators, Unit Manager, Assistant Director of Nursing) or Regional Nurse Consultants ( Regional Nurse Consultants, Director of Clinical Programs, Chief Nurse Executive) daily to ensure that no other abuse allegations have been documented without reporting. This will continue until the removal of Immediate Jeopardy. Home Office Staff (Corporate Attorney and Legal Nurse Consultant) have called a total of 92 families/guardians on 04/12/13 in regards to staff treatment and/or knowledge of potential abuse in which 46 messages were left multiple times. There have been no identified issues regarding abuse, neglect, or misappropriation for those families in which the regional or home office staff have spoken. Abuse reporting information including phone numbers has been posted in each resident room as of 04/12/13. Administrator #2 has been named the Abuse Coordinator in the facility as of 04/08/13. If facility staff cannot contact the Abuse Coordinator for any reason, the staff is to call the Director of Nursing or the Social Service Director. If the staff is unable for any reason to contact any of the above, the facility staff will contact Adult Protective Services, Ombudsman, or Elder Abuse Hot Line. The Chief Operating Officer and Chief Nursing Executive completed a review of all allegations of abuse, by 04/10/13, to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. The Administrator will continue to report any allegations of abuse, neglect, or misappropriation as identified. The Chief Operating Officer or Regional Vice President of Operations will complete a daily review of abuse allegations, grievance reports, incident reports, and daily resident interviews to ensure appropriate protection, reporting, and investigations of abuse allegations. The Chief Nurse Executive or Regional Clinical Consultant will complete a daily onsite visit to review skin assessments to ensure appropriate protection, reporting to the Office of Inspector General, and investigations of allegations of abuse. Daily reviews will continue until the removal of Immediate Jeopardy. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse investigations daily to ensure that the resident is protected, the perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log that will include documentation of the following: ensured protection of residents, perpetrator is removed from resident care area, reports to the Inspector General are filed timely, and thorough investigation is completed. The Administrator and one of the following: Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will review the abuse investigation to ensure protection of the resident, that the perpetrator was removed from the resident care area, reports to the Inspector General were filed timely, and a thorough investigation has been completed. This will occur daily until removal of Immediate Jeopardy. ---Based on observation, interview, record review, and review of the facility's Allegation of Compliance (AOC), the State Survey Agency validated the AOC as follows: Interview with on 04/23/13 at 11:32 AM with the Regional Nurse Consultant; at 11:53 AM with the Chief Nurse Executive; at 1:46 PM with the Clinical Regional Nurse Consultant; at 2:12 PM with the Chief Operating Officer; at 2:38 PM with Administrator #2; at 10:35 AM with the Director of Admissions; at 12:09 PM with the Quality of Life Director; at 12:21 PM with the Director of Nursing; at 12:38 PM with the Interim Social Services Director; at 12:45 PM with the Rehabilitation Service Manager; at 12:57 PM with the Central Supply and Staffing Manager; at 1:04 PM with the Dietary Manager; at 1:16 PM with the Housekeeping Manager; at 1:23 with the Staff Development Coordinator; and at 1:40 PM with the Director of Maintenance confirmed they had received training on abuse by the Independent Contractor on 04/06/13 and had completed a post test. The above Regional Staff and Department Directors verified they had also assisted with education of the remaining staff on 04/12/13. Review of post-test and interviews on 04/23/13 at 10:35 AM with SRNA #8; at 10:53 AM with Housekeeper #4; at 11:03 AM with Registered Nurse #5; at 11:16 AM with Housekeeper #5; at 11:27 AM with Licensed Practical Nurse #4; at 11:37 AM with SRNA #5; at 11:45 AM with Dietary Aide #1; at 11:54 AM with Dietary Aide #2; at 12:05 PM with SRNA #7; at 12:12 PM with Registered Nurse #4; at 12:20 PM with SRNA #12; at 12:28 PM with SRNA #9; at 12:38 PM with SRNA #1; at 12:49 PM with Certified Medication Aide #1; at 12:56 PM with Certified Medication Aide #6; at 1:09 PM with SRNA #1; at 1:17 PM with Maintenance Worker #1; at 1:41 PM with Laundry Worker #1; and at 1:54 PM with Activity Assistant #1 confirmed they were re-educated by Department Directors and/or Regional Staff. Record review and interview on 04/23/13 at 2:38 PM with Administrator #2; at 12:21 PM with the DON; and at 12:38 PM with the Interim Social Services Director revealed the Independent Contractor did provide them with one on one education related to protection, reporting, and investigation of allegations of abuse prior to 04/12/13. Record review and interview on 04/23/13 at 10:35 AM with SRNA #8; at 10:53 AM with Housekeeper #4; at 11:03 AM with Registered Nurse #5; at 11:16 AM with Housekeeper #5; at 11:27 AM with Licensed Practical Nurse #4, at 11:37 AM with SRNA #5, at 11:45 AM with Dietary Aide #1, at 11:54 AM with Dietary Aide #2; at 12:05 PM with SRNA #7; at 12:12 PM with Registered Nurse #4; at 12:20 PM with SRNA #12; at 12:28 PM with SRNA #9; at 12:38 PM with SRNA #1; at 12:49 PM with Certified Medication Aide #1; at 12:56 PM with Certified Medication Aide #6; at 1:09 PM with SRNA #1; at 1:17 PM with Maintenance Worker #1; at 1:41 PM with Laundry Worker #1; and at 1:54 PM with Activity Assistant #1 revealed they had been re-educated by the Independent Contractor by 04/12/13. Record review and interview on 04/23/13 at 12:57 PM with the Staffing Coordinator; at 1:04 PM with the Dietary Manager; and at 1:16 PM with the Housekeeping Director revealed they conducted interviews on 04/12/13 with residents who had a BIMS of 7 or above related to their feelings of safety and there were no concerns identified. Interview on 04/22/13 at 4:43 PM with Resident #29; at 4:50 PM with Resident C; at 4:55 PM with Resident #3; at 5:15 PM with Resident G; at 5:18 PM with Resident #31; at 5:25 PM with Resident #13; at 5:29 PM with Resident H; at 5:33 PM with Resident I; at 5:36 PM with Resident A; at 5:40 PM with Resident J; and at 5:48 PM with Resident K confirmed staff had asked them questions related to their feelings of safety. Record review and interview on 04/23/13 at 12:21 PM with the Director of Nursing, and 1:23 PM with the Staff Development Coordinator revealed they completed physical assessment on 04/12/13 on residents who had a BIMS score of below 7 to assess for signs of abuse and there were no concerns identified. Record review and interview on 04/23/13 at 12:57 PM with the Staffing Coordinator, and at 1:04 PM with the Dietary Manager revealed o

Based on interview, Fall/Change in Functional Status report, written statements, Care Plan policy, and record review, it was determined the facility failed to ensure services were provided to one (1) of three (3) sampled residents (Resident #38) in accordance with the resident's Comprehensive Care Plan (CCP). The facility assessed and care planned that staff was to place Resident #38 in a high visual area at times of confusion. However, on 09/04/11, Resident #38 had increased restlessness and confusion, staff did not place the resident in a high visual area, and the resident sustained [REDACTED]. The findings include: Review of the facility's Care Plan policy (dated December 2010) revealed resident care plans provided guidance to all staff caring for residents. A review of the medical record revealed the facility admitted Resident #38 on 04/27/07, with [DIAGNOSES REDACTED]. A review of Resident #38's psychosocial CCP, dated 07/21/11, revealed the resident was easily annoyed, had mood symptoms, was short-tempered, and experienced episodes of increased confusion. A review of interventions related to the facility's assessment of Resident #38 revealed the resident was to be placed in a high visual area when upset or annoyed. Staff was to monitor for the resident being short-tempered and annoyed and provide distractions such as activities, one-to-one visits, and wheelchair rides. Interview with State Registered Nurse Aide (SRNA) #1, on 09/08/11, at 6:36 PM, revealed the SRNA had provided care to Resident #38 on the evening of 09/04/11, stating the resident had been restless and "kept getting up" numerous times. SRNA #1 had been in Resident #38's room and provided assistance to the resident with toileting, redirecting the resident and assisting the resident back to the recliner six to seven times. SRNA #1 further stated Resident #38 was confused and continually talked about the need to "put the baby away" on the night of the fall. Further interview revealed Resident #38 had been restless the previous night, 09/03/11, and staff had placed the resident at the nurses' station for closer observation. However, SRNA #1 stated facility staff had not moved Resident #38 to the nurses' station, as per care plan, on the night of the resident's fall on 09/04/11. Review of a written statement by SRNA #5, dated 09/04/11, revealed she heard an alarm sounding from Resident #38's room and when she arrived to the room Resident #38 was on the floor in front of a chair. The SRNA's written statement also revealed Resident #38 had been "confused all evening worried about her babies and how she was going to get them home." Further review of the statement revealed staff had toileted Resident #38 prior to the fall, the resident had non-skid socks on both feet, and a chair sensor pad alarm was in place. The written statement further revealed the resident had been "up & down all day I had put her back in her chair several times this evening." Interview on 09/12/11, at 9:55 AM, with Registered Nurse (RN) #2, revealed on the night of 09/04/11, Resident #38 had been upset and "up and down" numerous times. According to the RN, she had been in the resident's room several times on the evening of 09/04/11, to either assist the resident to the bedside commode or to talk with the resident. The RN further revealed when the resident was restless and getting up and down on previous occasions, facility staff assisted the resident to the nurses' station in order to observe the resident. RN #2 stated she did not know why Resident #38 was not taken to the nurses' station, as per care plan, on the night of the fall. A review of the Fall/Change in Functional Status report, dated 09/04/11, revealed facility staff had assessed Resident #38 as restless on the evening of 09/04/11. Continued review revealed the resident sustained [REDACTED]. Interview with the Director of Nursing (DON) on 09/12/11, at 11:33 AM, revealed Resident #38 did have increased confusion at times especially if the resident's family had been to the facility to visit the resident. The DON further stated Resident #38 should have been assisted to the nurses' station when the resident exhibited signs of increased confusion.

Based on interview, record review, written statements, and the facility's Incident/Occurrence Investigation, it was determined the facility failed to ensure that one (1) of three (3) sampled residents (Resident #38) received adequate supervision to prevent injuries. The facility assessed Resident #38 as a falls risk due to having a history of unsafe transfer attempts and falls. The facility failed to follow the developed care plan to bring the resident to a high visual area for closer observation when confused. On the evening of 09/04/11, Resident #38 had been restless and confused; staff did not place the resident in a high visual area for closer observation. Resident #38 sustained a fall which resulted in a fractured hip. The findings include: A review of the falls policy (dated December 2010) revealed it was the intent of the facility to provide residents with assistance and supervision in an effort to avoid falls and minimize injury and complications that may result from a resident falling. A review of the medical record revealed the facility admitted Resident #38 on 04/27/07, with [DIAGNOSES REDACTED]. Review of the facility's fall risk assessment, dated 07/12/11, revealed the facility had assessed Resident #38 as a high risk for falls. Review of the Comprehensive Care Plan (CCP), dated 07/12/11, revealed Resident #38 was easily annoyed, had mood symptoms, was short-tempered, and experienced episodes of increased confusion. Interventions, dated 07/12/11, revealed staff was to place the resident in a high visual area when upset or annoyed, monitor the resident for being short-tempered and annoyed, and provide distractions such as activities, one-to-one visits, and wheelchair rides. A review of the nurse's notes written by RN #2, dated 09/04/11, and timed 10:15 PM, revealed between 9:00 PM and 9:30 PM, Resident #38's alarm was heard, staff went into the room and observed the resident walking to the bedside commode, at which time staff assisted the resident to sit on the commode. At 9:40 PM, Resident #38's alarm sounded again and the nurse aide from across the hall answered the alarm and found the resident sitting in the floor in front of the chair. Resident #38 complained of right hip and leg pain at the time the nurse aide entered the room. Interview on 09/08/11, at 6:36 PM, with SRNA #1 revealed Resident #38 attempted to get up unassisted on numerous occasions on the evening of 09/04/11. SRNA #1 stated Resident #38 "was having a bad night." SRNA #1 further stated she went into the resident's room six to seven times to assist the resident back to the chair because the resident "kept getting up," causing the chair alarm to sound. She stated Resident #38 was very confused, "talking about putting the baby away." SRNA #1 stated the resident continually got up to attempt to get facial tissues even though the tissues were within reach. SRNA #1 stated on the evening of 09/04/11, she left the floor to chart on the computer, leaving SRNA #5 on the floor to care for the residents. During the time she was gone, Resident #38 sustained the fall. Further interview revealed Resident #38 had been restless the previous night, 09/03/11, and staff had placed the resident at the nurses' station for closer observation. SRNA #5 stated that when Resident #38 had periods of increased confusion and restlessness facility staff would place her at the nurses' station, in a high visual area, for closer observation. However, SRNA #1 stated facility staff had not moved Resident #38 to the nurses' station, as per the care plan, the night of the resident's fall on 09/04/11. Review of a written statement from SRNA #5, dated 09/04/11, revealed SRNA #5 was answering a call light in another resident's room and heard Resident #38's chair alarm sounding. The statement revealed when SRNA #5 arrived in Resident #38's room, the resident had fallen and was on the floor in front of a chair. The written statement further revealed the resident had been confused all evening, "worried about her babies & how she was going to get them home." SRNA #5's statement further revealed Resident #38 had been "up & down all day I had put her back in her chair several times this evening." Interview with Registered Nurse (RN) #2 on 09/12/11, at 9:55 AM, revealed on the evening of 09/04/11, Resident #38 had been upset and "up and down" numerous times. RN #5 had been in the resident's room to assist the resident to the bedside commode, talk with the resident, or assist another resident from Resident #38's room. Interview further revealed when the resident was restless and getting up and down on previous occasions, facility staff assisted the resident to the nurses' station in order to observe the resident. RN #2 stated she did not know why Resident #38 was not taken to the nurses' station on the evening of 09/04/11. A review of the facility's Incident/Occurrence Investigation, dated 09/04/11, revealed Resident #38 had been restless, up and down, and staff had been in the resident's room several times prior to the resident's fall. A review of the Fall/Change in Functional Status report, dated 09/04/11, revealed facility staff had assessed Resident #38 as restless on the evening of 09/04/11. Continued review revealed the resident sustained [REDACTED]. A review of the hospital record for Resident #38 revealed the resident had surgical repair of a right hip fracture on 09/05/11. Interview with the Director of Nursing (DON) on 09/12/11, at 11:33 AM, revealed Resident #38 should have been taken to the nurses' station on the evening of 09/04/11, and further stated there was no staff to monitor the resident at the nurses' station since the nurse aide on the floor was in another resident's room at the time of the fall.

Based on interview, record review, written statements, and the facility's Incident/Occurrence Investigation, it was determined the facility failed to ensure that one (1) of three (3) sampled residents (Resident #38) received adequate supervision to prevent injuries. The facility assessed Resident #38 as a falls risk due to having a history of unsafe transfer attempts and falls. The facility failed to follow the developed care plan to bring the resident to a high visual area for closer observation when confused. On the evening of 09/04/11, Resident #38 had been restless and confused; staff did not place the resident in a high visual area for closer observation. Resident #38 sustained a fall which resulted in a fractured hip. The findings include: A review of the falls policy (dated December 2010) revealed it was the intent of the facility to provide residents with assistance and supervision in an effort to avoid falls and minimize injury and complications that may result from a resident falling. A review of the medical record revealed the facility admitted Resident #38 on 04/27/07, with [DIAGNOSES REDACTED]. Review of the facility's fall risk assessment, dated 07/12/11, revealed the facility had assessed Resident #38 as a high risk for falls. Review of the Comprehensive Care Plan (CCP), dated 07/12/11, revealed Resident #38 was easily annoyed, had mood symptoms, was short-tempered, and experienced episodes of increased confusion. Interventions, dated 07/12/11, revealed staff was to place the resident in a high visual area when upset or annoyed, monitor the resident for being short-tempered and annoyed, and provide distractions such as activities, one-to-one visits, and wheelchair rides. A review of the nurse's notes written by RN #2, dated 09/04/11, and timed 10:15 PM, revealed between 9:00 PM and 9:30 PM, Resident #38's alarm was heard, staff went into the room and observed the resident walking to the bedside commode, at which time staff assisted the resident to sit on the commode. At 9:40 PM, Resident #38's alarm sounded again and the nurse aide from across the hall answered the alarm and found the resident sitting in the floor in front of the chair. Resident #38 complained of right hip and leg pain at the time the nurse aide entered the room. Interview on 09/08/11, at 6:36 PM, with SRNA #1 revealed Resident #38 attempted to get up unassisted on numerous occasions on the evening of 09/04/11. SRNA #1 stated Resident #38 "was having a bad night." SRNA #1 further stated she went into the resident's room six to seven times to assist the resident back to the chair because the resident "kept getting up," causing the chair alarm to sound. She stated Resident #38 was very confused, "talking about putting the baby away." SRNA #1 stated the resident continually got up to attempt to get facial tissues even though the tissues were within reach. SRNA #1 stated on the evening of 09/04/11, she left the floor to chart on the computer, leaving SRNA #5 on the floor to care for the residents. During the time she was gone, Resident #38 sustained the fall. Further interview revealed Resident #38 had been restless the previous night, 09/03/11, and staff had placed the resident at the nurses' station for closer observation. SRNA #5 stated that when Resident #38 had periods of increased confusion and restlessness facility staff would place her at the nurses' station, in a high visual area, for closer observation. However, SRNA #1 stated facility staff had not moved Resident #38 to the nurses' station, as per the care plan, the night of the resident's fall on 09/04/11. Review of a written statement from SRNA #5, dated 09/04/11, revealed SRNA #5 was answering a call light in another resident's room and heard Resident #38's chair alarm sounding. The statement revealed when SRNA #5 arrived in Resident #38's room, the resident had fallen and was on the floor in front of a chair. The written statement further revealed the resident had been confused all evening, "worried about her babies & how she was going to get them home." SRNA #5's statement further revealed Resident #38 had been "up & down all day I had put her back in her chair several times this evening." Interview with Registered Nurse (RN) #2 on 09/12/11, at 9:55 AM, revealed on the evening of 09/04/11, Resident #38 had been upset and "up and down" numerous times. RN #5 had been in the resident's room to assist the resident to the bedside commode, talk with the resident, or assist another resident from Resident #38's room. Interview further revealed when the resident was restless and getting up and down on previous occasions, facility staff assisted the resident to the nurses' station in order to observe the resident. RN #2 stated she did not know why Resident #38 was not taken to the nurses' station on the evening of 09/04/11. A review of the facility's Incident/Occurrence Investigation, dated 09/04/11, revealed Resident #38 had been restless, up and down, and staff had been in the resident's room several times prior to the resident's fall. A review of the Fall/Change in Functional Status report, dated 09/04/11, revealed facility staff had assessed Resident #38 as restless on the evening of 09/04/11. Continued review revealed the resident sustained [REDACTED]. A review of the hospital record for Resident #38 revealed the resident had surgical repair of a right hip fracture on 09/05/11. Interview with the Director of Nursing (DON) on 09/12/11, at 11:33 AM, revealed Resident #38 should have been taken to the nurses' station on the evening of 09/04/11, and further stated there was no staff to monitor the resident at the nurses' station since the nurse aide on the floor was in another resident's room at the time of the fall.

Based on interview, record review, and facility policy review, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents regarding adequate supervision to prevent accidents for one of twenty-six sampled residents (Resident #1). The Facility Administration failed to have an effective system to ensure policies and procedures were implemented. Administration failed to ensure interventions for safe smoking were implemented, and failed to ensure all staff was trained and knowledgeable of emergency procedures. (Refer to F323 and F518.) On 07/15/11, Resident #1 entered the resident designated smoke room in his/her electric wheelchair while utilizing portable oxygen via nasal cannula. When Resident #1 was finishing his/her cigarette, Nursing Assistant (NA) #1, who was monitoring the smoking room, observed a flash and noted the resident's face/beard was on fire. NA #1 ran from the room to summon the nurse without first attempting to extinguish the fire and ensure residents in the smoke room were protected from further potential injuries. The resident sustained [REDACTED]. The facility's failure to have an effective system in place to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently caused and was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 07/20/11, and was determined to exist on 07/15/11. The facility was notified on 07/20/11. An acceptable Allegation of Compliance was received on 07/22/11, which alleged removal of Immediate Jeopardy on 07/19/11. The State Agency determined the Immediate Jeopardy was removed on 07/19/11, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.75 (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled "Contraband Discovery-Smoking" policy (dated December 2010) revealed all residents who smoked would require supervision by designated facility staff. The policy further revealed all smoking materials such as lighters, matches, and cigarettes, were required to be kept in the nurses' medication room and facility staff was responsible for lighting resident smoking materials. The policy also revealed smoking would not be permitted in any areas with oxygen related devices. A review of the facility's policy entitled "Fire Classes" (dated January 2005) revealed fire classes would be conducted for all personnel on a quarterly basis. The policy further revealed fire fighting procedures would be included in the class. The policy revealed fire classes would be conducted by the Safety Officer or other responsible person designated by the Administrator. A review of the facility's Incident/Occurrence Investigation dated 07/20/11, revealed Resident #1 had been smoking in the smoke room with his/her oxygen tank on the back of the wheelchair where the oxygen ignited, and caught Resident #1 on fire. RN #4 revealed Resident #1's face and hands were "charred black" and the resident's facial hair was singed. The Investigation further revealed the resident's physician was notified and the resident was transferred by ambulance to the local hospital. A review of the discharge summary from the trauma center dated 07/18/11, revealed Resident #1 had sustained first and second [MEDICAL CONDITION] the face (eyelids, nose, cheeks, and lips) and blisters to both hands. A review of the facility's Investigation Report completed on 07/20/11, revealed on 07/15/11, at 7:15 PM, Nursing Assistant (NA) #1 was assigned to monitor the resident's smoke break. According to the Investigation Report, Resident #1 entered the facility's designated smoking area in his/her electric wheelchair with an oxygen canister, which was turned on, attached to the back of the wheelchair, and a nasal cannula in his/her nose. The Investigation Report further revealed NA #1 had not observed the nasal cannula and gave Resident #1 a cigarette and proceeded to light the cigarette. The report revealed NA #1 saw smoke and observed Resident #1's facial hair smoking, and then an immediate flash of flame. NA #1 yelled for help and ran out of the room. When staff arrived to the smoke room Resident #1 had put out the fire on his/her face with his/her hands. The Investigation Report revealed upon returning to the smoke room staff observed Resident #1 attempting to put out the fire on the oxygen tubing by using his/her hands. An interview with Resident #1 on 07/19/11, at 1:45 PM, revealed he/she had never been told by facility staff to leave his/her oxygen outside the room. The resident also revealed he/she had taken the oxygen tank into the smoke room numerous times before. An interview conducted with NA #1 on 07/19/11, at 2:25 PM, revealed she had never received in-service training regarding the monitoring of residents in the smoke room until after the incident with Resident #1 on 07/15/11. The NA further revealed she had not been told residents could not bring oxygen tanks into the resident smoke room. An interview conducted with the Director of Nursing (DON) on 07/20/11, at 3:00 PM, revealed the Contraband Discovery-Smoking policy was reviewed with all new employees during orientation; however, the facility did not complete competency checks related to monitoring the residents' smoke breaks. The DON stated not bringing oxygen tanks into the smoke room "should be common knowledge." The DON further stated the facility had the employee to sign a check-off sheet to prove they attended the in-service; however the facility offered no pre-test or post-test to ensure the employee was knowledgeable regarding the information given in orientation. The DON stated she just assumed staff had a knowledge base of the information given in orientation. An interview conducted with the Administrator of the facility on 07/20/11, at 4:15 PM, revealed he had not been aware Resident #1 had a cigarette lighter in his/her possession at the time of the incident. The Administrator further revealed the residents were not permitted to enter the resident smoke room with oxygen, nor were they allowed to have cigarette lighters in their possession. The Administrator stated NA #1 should not have allowed the resident into the resident smoke room with the oxygen tank, and also should have taken the cigarette lighter, placed it at the nursing station, and reported the resident's behavior to the nurse. The Administrator revealed staff is required to attend new employee orientation, and then given an annual in-service on the Contraband Discovery-Smoking policy. The Administrator revealed since the incident on 07/15/11, the facility had added a new quality monitor to ensure the resident smoke break monitor was knowledgeable about and following the facility's policy regarding resident smoking. **An acceptable Allegation of Compliance (AOC) was received on 07/22/11, which alleged removal of immediate jeopardy as of 07/19/11. An extended survey was conducted on 07/22/11, which determined the immediate jeopardy was removed on 07/19/11. A review of the Allegation of Compliance revealed the following: - The Administrator, DON, and the Administrative team received an in-service provided by the Regional Nurse Consultant and the VP of Operations on 07/18/11, regarding the requirements of the quality assurance process. - The Quality Assurance Committee met on 07/18/11, to review the performance improvement plan and for further recommendations. - The VP of Operations or the Regional Nurse Consultant would be providing oversight daily. **The Allegation of Compliance was verified by the following: - A review of educational rosters dated 07/18/11, revealed the Administrator, DON, and the administrative team (Unit Managers, MDS Nurses, Social Services, Activity Director, Medical Records, Dietary Manager, Staff Development Coordinator, Housekeeping Supervisor, Maintenance Director, and Medical Director) were educated by the Regional Vice President and Regional Nurse Consultant regarding the QA process related to the smoke break monitoring system and to ensure that safety precautions were followed. An interview conducted with the Administrator on 07/22/11, at 2:30 PM, revealed the Administrator was reviewing the smoke break audit daily with the DON to ensure appropriate completion and follow-up as indicated. - A review of the minutes for a Quality Assurance meeting conducted on 07/18/11, revealed the Administrator, DON, and Medical Director, as well as the Plant Operations Director, Housekeeping Supervisor, and other Department Managers reviewed the Performance Improvement Plan which included findings of stated audits and the smoking, oxygen, fire safety, and contraband policy and procedures. The minutes also revealed the QA Committee would review the policies weekly for four weeks and then monthly for three months to ensure compliance. - An interview conducted with the Regional Nurse Consultant on 07/22/11, at 4:00 PM, revealed the Vice President of Operations or the Regional Nurse Consultant was providing oversight daily beginning on 07/18/11, and would continue for one week, then once weekly for four weeks, and then monthly for three months. Based on the above findings, it was determined the Immediate Jeopardy was removed on 07/19/11. Noncompliance continued with scope and severity lowered to "D" level based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of Policies/Procedures for the Fire/Smoking Safety program.

Based on interview, record review, and policy review, it was determined the facility failed to have an effective system to ensure all employees were trained in emergency procedures to include monitoring of resident smoke breaks. On 07/15/11, one of twenty-six sampled residents (Resident #1) entered the resident smoke room with portable oxygen attached to his/her electric wheelchair. The oxygen was on and the resident was receiving the oxygen via nasal cannula. NA #1, who was monitoring the smoke room, provided Resident #1 with a cigarette and light. The NA observed the resident relight his/her cigarette with a lighter he/she was carrying. When the resident was finishing his/her cigarette, the oxygen ignited, causing the resident's face and beard to catch on fire. The NA ran from the room to summon help and did not attempt to extinguish the fire or ensure residents were protected from further potential harm. (Refer to F323.) Based on the above findings, it was determined the facility's failure to have an effective system in place to ensure employees were adequately trained in emergency procedures related to fire, caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/20/11, and was determined to exist on 07/15/11. The facility was notified on 07/20/11. An acceptable Allegation of Compliance was received on 07/22/11, which alleged removal of Immediate Jeopardy on 07/19/11. The State Agency determined the Immediate Jeopardy was removed on 07/19/11, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.75 (F518) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy entitled "Fire Classes" (dated January 2005) revealed fire classes would be conducted for all personnel on a quarterly basis. The policy further revealed fire fighting procedures would be included in the class. The policy revealed fire classes would be conducted by the Safety Officer or other responsible person designated by the Administrator. A review of the facility policy entitled "Contraband Discovery-Smoking" (dated December 2010) revealed residents who smoke were required to be supervised by designated facility staff. The policy revealed all smoking materials were required to be kept in the nurses' medication room. The policy further stated the facility staff was required to light resident smoking material. The policy revealed smoking would not be permitted in areas with any oxygen related devices. The facility did not provide a policy related to new employee orientation. The facility also did not provide a policy related to monitoring resident smoke breaks. A review of the facility's Incident/Occurrence Investigation completed on 07/20/11, revealed Resident #1 had been smoking in the smoke room with his/her oxygen tank on the back of the wheelchair when the oxygen ignited, and caught Resident #1 on fire. RN #4 revealed Resident #1's face and hands were "charred black" and the resident's facial hair was singed. Per the report, Resident #1 sustained first and second [MEDICAL CONDITION] the face (eyelids, nose, cheeks, and lips) and blisters to both hands. A review of the facility's Investigation Report completed on 07/20/11, revealed Nursing Assistant (NA) #1 had been assigned to monitor the resident smoke room for a smoke break. The Investigation Report further revealed NA #1 had not seen the oxygen tubing, nor did she realize the oxygen was still on. NA #1 gave Resident #1 a cigarette and proceeded to light the cigarette. The Report revealed NA #1 saw smoke and the facial hair of Resident #1 on fire, and then an immediate flash of flame. The Report revealed NA #1 yelled for help, ran out of the room to the nurses' station to get help, did not attempt to extinguish the fire on the resident's face, and failed to ensure residents were protected from further harm. An interview conducted with NA #1 on 07/19/11, at 2:25 PM, revealed she monitored the resident's smoke breaks on most of the shifts she worked. The NA stated the only in-service she had received since employment, regarding monitoring resident smoke breaks and what to do in an emergency situation, was after the incident with Resident #1. The NA stated all she had been told regarding residents' smoke breaks was that the residents could only have two cigarettes per smoke break. Per interview, when Resident #1's oxygen ignited, NA #1 screamed for help and left the smoke room to get a nurse, leaving two residents in the smoke room alone (Residents #1 and #25). The NA stated she did not know what to do and just panicked. An interview conducted with the Staff Development Coordinator (SDC) on 07/20/11, at 3:50 PM, revealed she was responsible for the educational in-services for the staff. The SDC stated policies were reviewed; however, there was so much information to cover, the in-service was general. The SDC further stated she showed the employees where the fire blanket was kept in the resident smoke room, but did not demonstrate to the employees how to use the fire blanket or when to use it. The SDC further revealed the fire blanket was not mentioned in any of the facility's fire safety policies, but was kept for use in the resident smoke room. The SDC revealed she did not complete any competencies to assess the new employees' knowledge of the information she presented in new employee orientation. The SDC further stated the facility provided no special in-services to staff assigned to monitor the resident smoke room prior to the incident with Resident #1 on 07/15/11. An interview on 07/20/11, at 3:35 PM, with the facility's Maintenance Director (MD) revealed he was responsible for conducting in-services on fire safety. The MD stated the training he provided was not part of new employee orientation. Per interview, he told employees where the fire blanket was stored but did not instruct staff on how to use the fire blanket. The MD stated there could potentially be some employees who did not know how to use the fire blanket because the last in-service conducted on fire safety was on 03/17/11. The MD further stated the fire blanket should have been used for the incident with Resident #1 on 07/15/11. Per interview, the MD felt fire safety training was very important and someone could potentially die if the staff did not know fire safety. A review of the personnel file for NA #1 revealed the NA was hired on 04/01/11, and attended orientation on 04/01/11. The in-service record for NA #1 revealed on 04/01/11, NA #1 attended Fire/Disaster Safety and Risk Management Accident/Incident in-services provided by the SDC during the routine new employee orientation. **An acceptable Allegation (AOC) of Compliance was received on 07/22/11, which alleged removal of Immediate Jeopardy on 07/19/11. An extended survey was conducted on 07/22/11, which determined the Immediate Jeopardy was removed on 07/19/11. A review of the Allegation of Compliance revealed the following: - In-services began on 07/15/11, and all staff would be educated prior to working their next scheduled shift. In-services included monitoring residents' smoke break; smoking policy including oxygen not being allowed in the smoke room; safety interventions with a return demonstration of what to do in the presence of smoke and/or fire; what to do in an emergency situation; and where to find resident specific interventions to be implemented when smoking. - The Safety Awareness in-service to prevent accidents, including education on the facility's smoking policies and procedures, monitoring the smoke room, and oxygen and fire safety, has been revised by the Administrator, DON, Human Resources Director, and SDC, and added to the orientation agenda beginning 07/17/11. **The Allegation of Compliance was verified by the following: - A review of the education rosters revealed education was initiated on 07/15/11, and facility staff was in-serviced on the process to monitor scheduled smoke breaks/safety procedures with return demonstrations of emergency interventions prior to working their next shift. Interviews on 07/22/11, between 1:30 PM and 4:00 PM, with State Registered Nursing Assistants (SRNAs) #6, #12, and #13, Housekeeper #13, Licensed Practical Nurse #3, and RN #2 revealed staff was able to confirm fire/oxygen safety education had been provided and all staff was able to relate the appropriate emergency interventions that should be provided in the event of an emergency. Observations in the smoke room on 07/22/11, at 1:30 PM, revealed ME #1 and RN #1 were able to demonstrate the use of the fire blanket and location of the fire extinguisher. - A review of the orientation agenda regarding Safety/Awareness to prevent accidents/hazards revealed the agenda had been revised and added to the orientation of all new employees. This included education on RACE, smoking policies/procedures, monitoring the smoke room and safety procedures, and oxygen and fire safety. The new packet included pre and post tests for all newly hired employees with return demonstrations required for shutting off oxygen, placing the fire blanket on the flames, pulling the fire alarm, and possible evacuation. Based on the above findings, it was determined the Immediate Jeopardy was removed on 07/19/11. Noncompliance continued with scope and severity lowered to "D" level based on the facility's need to evaluate the effectiveness of Quality Assurance activities related to the implementation of Policies/Procedures for the Fire/Smoking Safety program.