Every finding on record at Marion Regional Nursing Home

Based on observations, interviews, record review, and review of a facility policy titled, Nebulizer Masks, Tubing and Bag Protocol, the facility failed to ensure Resident Identifier (RI) #13's oxygen tubing was labeled/dated; and further failed to ensure RI #34, RI #37, and RI #263's nebulizer masks were covered when not in use. This deficient practice affected four of five residents sampled for respiratory care. Findings Include: A review of a facility policy titled, Nebulizer Masks, Tubing and Bag Protocol, with a last modified date of 02/12/2025, documented: . Rationale: To provide infection control and protection for residents using nebulizer treatments. Policy: It is the policy . that nebulizer masks and tubing should be dried and stored when not in use. Procedure: . 2. The residents name . and the date should be written on the bag, tubing and mask . RI #13 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #13's physicians orders dated 11/20/2024 documented: . Continuous; Oxygen Delivery Method: Nasal Cannula . On 02/18/2025 at 04:10 PM, the surveyor observed RI #13's oxygen concentrator with tubing by bedside. There was no date noted on the tubing. On 02/18/2025 at 4:25 PM an interview was conducted with Licensed Practical Nurse (LPN) #11. LPN #11 said there should be a date on the tubing. RI #34 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #34's physicians orders dated 01/15/2025 documented: . ipratropium-albuterol (DUO-NEB) . 3 mL (milliliters) NEBULIZATION Every 4 hours PRN (as needed) . On 02/18/2025 at 4:03 PM, RI #34's nebulizer mask was observed laying face side down on bedside table. The mask was not in a bag and no date was observed on the mask or the tubing. On 02/19/2025 at 3:44 PM, RI #34's nebulizer mask was observed laying face side down on the dresser and was not in a bag or dated. RI #37 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #37's physician's orders dated 01/23/2025 documented: . ipratropium-albuterol (DUO-NEB) . 3 mL NEBULIZATION Every 2 hours PRN . On 02/19/2025 at 3:48 PM, RI #37's nebulizer mask was observed laying face side down on the dresser and not in a bag. RI #263 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure. RI #263's physician orders dated 02/14/2025, documented: . ipratropium-albuterol (DUO-NEB) . 3 mL (milliliters) NEBULIZATION Every 6 hours . On 02/18/2025 at 3:55 PM, RI #263's nebulizer face mask was observed laying face down on the bedside table and not in a bag. On 02/19/2025 at 3:48 PM, RI #263's nebulizer mask was observed laying on the nebulizer machine and not in a bag. Neither the nebulizer mask nor the tubing were dated. On 02/19/2025 at 4:51 PM, LPN #12 accompanied the surveyor to RI #34, RI #37, and RI #263's room and observed that the residents' nebulizer masks were not covered or in a bag. On 02/19/2025 at 5:15 PM, an interview was conducted with LPN #12 who said nebulizer mask should be labeled with the resident's name and date and stored in a bag. LPN #12 the night shift nurse was responsible for changing the nebulizer mask and bag monthly. LPN #12 said germs could get on the mask when not covered. LPN #12 said uncovered nebulizer mask was an infection control issue. On 02/20/2025 at 9:33 AM, an interview was conducted with the Infection Preventionist (IP) who was a Registered Nurse (RN). The IP said resident's oxygen tubing was changed every 30 days or as needed, because bacteria could build up on the tubing. The IP said the oxygen tubing should be dated. The IP said when not in use, nebulizer mask should be stored in a Ziploc bag with the resident's name on it. She further stated that if there was no name on it, someone else could use it and that would be cross-contamination. During an interview on 02/20/2025 at 12:34 PM with the Director of Nursing (DON), who stated nebulized mask should be stored in a bag labeled with the date. The DON said uncovered nebulizer mask could get contaminated. The DON said oxygen tubing should be dated and the concern with it not being dated would be staff would not know when it was last changed.

Based on observations, interviews, resident record review, and review of a facility policy titled Resident's Rights: Privacy and Confidentiality the facility failed to honor resident privacy rights when Certified Nursing Assistant (CNA) #10 failed to knock on doors and gain permission to enter, before entering resident rooms on 02/18/2025 during the evening dining observation. This affected Resident Identifier (RI) #28 and RI #32, two of 19 sampled residents. Findings include: Review of a facility policy titled Resident's Rights: Privacy and Confidentiality with a review date of 03/2020, revealed the following: . Policy: It is the policy of [NAME] Regional Nursing Home that residents' confidentiality and privacy should be protected. Procedure: 1. Residents . have the right to- . b) Privacy while in their rooms. Staff should respectfully knock on doors or verbally announce the request to enter the room prior to entry. RI #32 was admitted to the facility on [DATE]. RI #28 was admitted to the facility on [DATE]. On 02/18/2025 at 5:11 PM, CNA #10 was observed removing a meal tray from the meal cart, and without knocking on the door or gaining permission to enter the room, CNA #10 entered RI #28's and RI #32's room and set up RI #28's meal tray. CNA #10 exited the room, removed RI #32's meal tray from the meal cart and reentered the room again, without knocking on the door or gaining permission to enter. After setting up RI #32's meal tray, CNA #10 exited the residents' room. On 02/18/2025 at 5:13 PM, CNA #10 reentered RI #28's and RI #32's room, without knocking on the door, or gaining permission to enter the residents' room. On 02/18/2025 at 5:14 PM, the surveyor conducted an interview with CNA #10. When asked what she should do before entering a resident's room, CNA #10 said knock on the door before entering the room. When asked why this was not done before she entered RI #28's and RI #32's room when passing out the residents' meal trays, CNA #10 said, she did not realize she had not knocked on the residents' door. On 02/20/2025 at 11:52 AM, the surveyor conducted an interview with the Clinical Nurse Educator (CNE). The CNE said, staff were taught they were supposed to knock on the resident's door and introduce themselves before entering the resident's room. When asked what type of concern this would be when not done, the CNE said, this would be an invasion of the resident's privacy, it may startle the resident, and it could be a dignity concern.

Based on resident record review, interviews, review of a facility policy titled Protecting Residents from Abuse, Neglect and Exploitation, review of the facility investigative file, and review of a Facility Reported Incident (FRI) to the State Agency, the facility failed to protect Resident Identifier (RI) #25's right to be free from abuse on 09/14/2024 when RI #313, a resident with unmanaged behaviors, hit RI #25 in the face. RI #25 described the incident as abusive. This deficient practice was cited as a result of the investigation of the complaint/report number AL00048923 and affected RI #25, one of two residents sampled for abuse. Cross Reference F740 Findings include: A facility policy titled, Protecting Residents from Abuse, Neglect, and Exploitation documented: . Policy: It is the policy of [NAME] Regional Nursing Home to protect residents from abuse. This includes but is not limited to verbal, physical, mental/emotional, . Procedure: . When protecting residents from abuse, utilizes the following prevention/intervention strategies: . D) Ongoing assessment, care planning and monitoring of residents with needs or behaviors that may lead to inadequate care, including abuse/neglect. E) Assessing residents with signs and symptoms of behavioral issues with the development of targeted care plans that can assist in resolving behavioral issues. On 09/14/2024 at 8:11 PM the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse occurred at 6:29 PM that evening after RI #313 took a book from RI #25's side of the room, RI #25 took the book away from RI #313, and then RI #313 slapped RI #25 on the left side of the face. RI #313 was admitted to the facility on [DATE] and had diagnoses to include: Alzheimer's Disease and Mood Disorder. RI #313's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 documented a Brief Interview of Mental Status (BIMS) score of four of 15 which indicated severe cognitive impairment. The MDS also documented RI #313 was able to walk independently without assistance of a wheelchair or walker. RI #25 was admitted to the facility on [DATE]. On 02/20/2025 at 9:36 AM a telephone interview was conducted with LPN #13 who said around 6:30 PM on 09/14/2024 while charting at the desk, she heard RI #25 say, help, help. LPN #13 said, she responded and found RI #313 had hit RI #25 on the face and RI #25 had redness on his/her cheek. LPN #13 said, RI #313 was confused, had Dementia, and would pick up items. LPN #13 said, RI #25 had been physically abused. RI #313's Nursing Note dated 09/13/2024 at 3:15 PM, was signed by LPN #13 who documented: . Resident has been exhibiting some hostile behavior, resisting care, taking others belongings and becoming very agitated when request are made. Hospice physician ordered Depakote . TID which should begin this evening. On 02/20/2025 at 1:00 PM a follow up interview was conducted with LPN #13 regarding the incident on 09/13/2024 and RI #313's rummaging behavior. LPN #13 said, RI #25 had a lot of items around and RI #313 would go and pick up the personal items. LPN #13 said on 09/13/2024, RI #313 required staff redirection. When asked what level of supervision RI #313 required, LPN #13 said, RI #313 was monitored visually and redirected as needed and did not require one-on-one. On 02/20/2025 at 12:20 PM, an interview was conducted with the Director of Nursing (DON) who said, RI #313 was confused and had advanced Dementia. The DON was asked about RI #313's documented behaviors on 09/13/2024 of agitation and taking others personal belongings. The DON said, RI #313 would plunder through RI #25's personal items and required redirection. The DON said, the staff were visually monitoring RI #313 for behaviors but there was no documentation of monitoring. The DON said, the incident on 09/14/2024 when RI #313 hit RI #25 was considered abuse. The facility did not provide any evidence of RI #313 being monitored for behaviors. On 02/20/2025 at 10:06 AM an interview was conducted with the Administrator (ADM) who said, she was notified by the Social Worker and the DON of the incident around 7:00 pm on 09/14/2024. The ADM said, RI #313 and RI #25 shared a room, RI #313 was confused, walked to RI #25's side of the room pilfering, picked up a book of RI #25's, and when RI #25 tried to get the book back, RI #313 hit RI #25 in the left side of the cheek. The ADM said, redness was noted to RI #25's cheek, the roommates were separated, notifications were made, and an investigation was initiated. When asked what the investigation revealed, the ADM said, based on RI #25's testament and the redness on RI #25's cheek, the incident was substantiated. The ADM said, the incident was reported as resident on resident physical abuse.

Based on interviews, record review, and the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to ensure: 1) Resident Identified (RI) #23's annual Minimum Data Set (MDS) assessment dated [DATE] section A1500 was coded accurately to reflect RI #23's Preadmission Screening and Resident Review (PASRR) Level II. 2) RI #25's annual MDS assessment dated [DATE] section A1500 was coded accurately to reflect RI #25's PASRR Level II. This deficient practice affected two of 19 sampled residents whose MDS was reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, revealed the following: . A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition 1) RI #23 was admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder, Anxiety Disorder, and Dementia with Behavioral Problem. RI #23's medical record contained a PASRR Level II Service Determination dated 10/12/2023. RI #23's annual MDS dated [DATE] documented: . A1500 Preadmission Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR . was marked 0 indicating No. On 02/20/2025 at 11:02 AM an interview was conducted with the MDS Coordinator. When asked if RI #23 was marked on the MDS as a Level II, she said no. In referencing RI #23's Level II document, the MDS Coordinator noted where RI #23's document revealed he/she was a Level II. When asked what the importance of the MDS being marked correctly, she said to ensure accuracy of the MDS data. 2) RI #25 was admitted to the facility on [DATE] with a diagnosis of Mood Disorder. RI #25's medical record contained a PASRR Level II Service Determination dated 03/04/2024. RI #25's annual MDS dated [DATE] documented: . A1500 Preadmission Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR . was marked 0 indicating No. On 02/20/2025 at 11:13 AM a follow up interview was conducted with the MDS Coordinator. When asked if RI #25 was marked on the MDS as a Level II, she said no. In referencing RI #25's Level II document, the MDS Coordinator noted that RI #25's document revealed he/she was a Level II. When asked why RI #25's MDS was not marked as being a Level II, she said this was miss coded and it would be corrected right away. When asked what the importance of the MDS being marked correctly, she said to ensure accuracy of the MDS data.

Based on interviews, resident record review, and review of the facility's investigative file, the facility failed to develop and implement immediate interventions to prevent other residents from being affected by Resident Identifier (RI) #313's behaviors. The facility failed to develop targeted care plans to assist in resolving RI #313's behaviors, failed to monitor RI #313 for behaviors that led to abuse, and failed to assess RI #313's required level of supervision to protect other residents. On 09/13/2024, RI #313's Nurses' Notes documented that RI #313 was exhibiting hostile behavior, resisting care, taking others' belongings, and becoming very agitated when requests were made. On 09/14/2024, RI #313 continued to have behaviors including taking RI #25's, his/her roommate's, belongings which resulted in RI #313 hitting RI #25 in the face. This deficiency was cited as a result of the investigation of complaint/report number AL00048923 and affected RI #25 one of six residents sampled for behavior concerns. Cross Reference F600 Findings include: RI #25 was admitted to the facility on [DATE]. RI #313 was admitted to the facility on [DATE] and had diagnoses to include: Alzheimer's Disease and Mood Disorder. RI #313's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 documented a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated severe cognitive impairment. RI #313 had a care plan dated 08/09/2024 that documented . Problem onset: I have a diagnosis of dementia, I am becoming increasingly more confused, and anxious. I have difficulty comprehending conversations . Approaches . Monitor resident for . behaviors, including wandering and aggressiveness. RI #313's Nursing Note dated 09/13/2024 at 1:48 PM documented: . New order per hospice start Depakote . TID (three times a day). RI #313's Nursing Note dated 09/13/2024 at 3:15 PM, signed by LPN #13 documented: . Resident has been exhibiting some hostile behavior, resisting care, taking others belongings and becoming very agitated when request are made. Hospice physician ordered Depakote . TID which should begin this evening. RI #313's Nursing Note dated 09/14/2024 at 7:00 PM, signed by LPN #13 documented: . At approximately 1820 (6:20 PM) resident's roommate began yelling help me, help me. When staff entered room resident was standing in her room holding a book that apparently belonged to (his/her) roommate. The roommate took the book away from the resident at which point resident slapped roommate in the face (left cheek). Slight erythema observed but roommate denies any pain at this time. Resident's were immediately separated. Resident is at nurses' station at this time, . DON . notified and orders received for Ativan (by mouth or intramuscular every six hours as needed) . for agitation. On 02/20/2025 at 9:36 AM a telephone interview was conducted with LPN #13, and she was asked about the incident on 09/14/2024 between RI #313 and RI #25. LPN #13 said, she was at the desk charting and she heard RI #25 say help, help. RI #313 had picked up a book belonging to RI #25, and when RI #25 tried to get the book back and RI #313 slapped RI #25 in the face. LPN #13 said, RI #313 had Advanced Dementia and was confused. LPN #13 said, at that time RI #313 was at the stage of Dementia where he/she picked things up. On 02/20/2025 at 1:00 PM in a follow up interview, LPN #13 was asked about RI #313 having hostile behavior as noted on 09/13/2025. LPN #13 stated, RI #25, RI #313's roommate had a lot of things around the room and RI #313 would go pick up the items and RI #313 required redirection. LPN #13 said, interventions that were used were staff would redirect RI #313 and one day there were medication changes. LPN #13 was asked what level of supervision RI #313 required. LPN #13 said, she did not think RI #313 required one on one supervision and RI #313 was just monitored visually and redirected as needed. On 02/20/2025 at 12:20 PM the Director of Nursing (DON) was asked about RI #313's Nursing Note dated 09/13/2024. The DON said, the note documented concerns of resisting care, taking others' belongings, and agitation. The DON said, RI #313 had Dementia that was pretty severe, RI #313 would be in the hallway and try to pick up something in the hallway and plundered through RI #25's side of the room. The DON said, RI #313 fiddled with stuff mostly in their room but also in the hallway. The DON gave an example of RI #313 picking up a bracelet and saying it was his/hers and then RI #313 would become resistive when redirection was attempted. The DON said, RI #313 would say it was his/hers and others could not have it. When asked how RI #313 was monitored, the DON said, they were watching RI #313. The DON said, they did not have monitoring sheets or documentation of the monitoring. When asked about what level of supervision RI #313 required after the incident of increased behaviors on 09/13/2024 the DON said, she did not think they did one-on-one, but they watched RI #313. The DON did not believe the incident could have been prevented because RI #313 was so Demented. On 02/20/2025 at 2:29 PM an interview was conducted with RI #25 who said, RI #313 would get into his/her personal items a bunch of times. When asked if this behavior was reported to staff, RI #25 said yes, he/she had notified staff of the behavior several times. When asked what staff did in response to the behavior, RI #25 said, staff would retrieve the item, tell RI #313 the item did not belong to him/her, and give the personal item back to RI #25.

Based on interviews, review of Resident Identifier (RI) #34's medical record, and a facility policy titled Psychotropic Medication Utilization the facility failed to ensure RI #34 was not ordered and administered a PRN (as needed) antipsychotic medication, Haldol, for greater than 14 days, without documented rationale in the resident's medical record for the continued use of the PRN antipsychotic medication. This deficient practice affected RI #34, one of six residents sampled for unnecessary medications. Findings include: A review of a policy titled Psychotropic Medication Utilization documented: Rationale: To provide guidelines for the utilization of psychotropic medications. 10. Psychotropic medications used on a PRN (as needed) basis should have a specific condition and indication for the PRN use documented in the resident's medical record and is subject to limitations as noted: . a. PRN orders for psychotropic medications, excluding antipsychotics should be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. b. PRN orders for antipsychotic medications only, should be limited to 14 days. If the attending Physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they should evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate . RI #34 was admitted to the facility 01/15/2025 with diagnoses to include anxiety and agitation. A review of RI #34's medication orders revealed an order dated 01/24/2025 for two (2) milligrams of haloperidol (Haldol), an antipsychotic medication, every 4 hours by mouth as needed for agitation. The order did not include a duration or end date. RI #34's Medication Administration Report from 01/26/2025 through 02/14/2025 documented that Haldol 2 milligrams was administered 20 times during that time period. On 02/20/2025 at 12:52 PM an interview was conducted with the Director of Nursing (DON). The DON said that the order for PRN Haldol for RI #34 started on 01/24/2025 and ended on 02/18/2025 (24 days). The DON said it was the Registered Nurses' responsibility to track the start and end dates of psychotropic medications. According to the DON, facility policy permitted a PRN psychotropic medication to remain on the physician's order for fourteen days. The DON said that RI #34 had not been reevaluated for the continued appropriateness of the medication. The DON said that the PRN psychotropic order for RI #34 should have been discontinued by day fourteen.

Based on observations, interviews, record review, and review of the facility's Procedure for Passing Meal Trays, the facility failed to ensure Certified Nursing Assistant (CNA) #10 distributed residents' meal trays in a manner to prevent the spread of infection between himself and residents. CNA #10 failed to perform hand hygiene before handling and delivering dinner meal trays for Resident Identifier (RI) #28 and RI #32 from the meal cart on 02/18/2025 during the evening dining observation. This deficient practice affected RI #28 and RI #32, two of 19 sampled residents. Findings Include: Review of an undated procedure form titled, Procedure for Passing Meal Trays, revealed the following: . 5. Staff should perform hand hygiene between each resident . RI #32 was admitted to the facility on [DATE]. RI #28 was admitted to the facility on [DATE]. On 02/18/2025 at 5:11 PM the surveyor observed CNA #10 removed RI #32's dinner meal tray from the meal cart without performing hand hygiene. CNA #10 entered RI #32's room, set up the meal tray for RI #32, exited the room, removed RI #28's meal tray from the dinner meal cart without performing hand hygiene, and re-entered the room with RI #28's meal tray. On 02/18/2025 at 5:14 PM, the surveyor conducted an interview with CNA #10 who said, she should sanitize her hands before she entered a resident's room. CNA #10 said staff not sanitizing their hands before they took a resident's food tray into the room could cause food borne illness. CNA #10 said she should have sanitized her hands before touching the residents' meal trays. On 02/20/2025 at 9:33 AM, the surveyor conducted an interview the Registered Nurse (RN)/Infection Preventionist (IP). The IP said, before removing a resident's meal tray from the meal cart staff should perform hand hygiene. The IP said, there was a potential for cross-contamination if hand hygiene was not performed. The IP said, staff should perform hand hygiene after providing any service for the resident. On 02/20/2025 at 11:52 AM, the surveyor conducted an interview with the Clinical Nurse Educator (CNE). The CNE said, in orientation staff were taught to perform hand hygiene before removing a residents meal tray from the food cart. The CNE said, when hand hygiene was not performed there was a potential for cross-contamination.

Based on interviews, medical record reviews and review of a facility policy titled, Care Plan Policy, the facility failed to ensure baseline care plans were developed within 48 hours of admission for the following Resident Identifier (RI) #'s and investigated care areas: 1. RI #36, tube feeding, risk for falls, nutrition, range of motion, 2. RI #30, Dementia, [MEDICAL CONDITION] medications, 3. RI #12, oxygen use, 4. RI #18, risk for falls, Dementia, [MEDICAL CONDITION] medication, 5. RI #21, Dementia, [MEDICAL CONDITION] medications, and 6. RI #34, tube feeding and insulin use. This deficient practice affected RI #36, 30, 12, 18, 21 and 34, six of 16 residents whose care plans were reviewed. Findings Included: A review of a facility policy titled, Care Plan Policy, with a Revised Date: 9/19, revealed: . Procedure: . A baseline care plan should be developed within 48 hours of a resident's admission . Must provide the resident and their representative with a summary of the baseline care plan. All assessment and care plan documentation should be completed as required by both State and Federal regulations. 1.) RI #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #36's medical record revealed admission medication orders dated 07-25-2019, for RI #36's medications to be given per PEG (Percutaneous Endoscopic Gastrostomy) Tube. Further review of RI #36's medical record revealed no baseline care plans were developed within 48 hours of admission for RI #36's peg tube, nutrition, risk for falls or range of motion. Care plans for each of these care areas were developed on 08/13/19, 19 days after RI #36's admission to the facility. 2.) RI #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #30's medical record revealed MEDICATION ORDERS FOR [REDACTED] Further review of RI #30's medical record revealed no baseline care plans were developed within 48 hours of admission for RI #30's [DIAGNOSES REDACTED]. Care plans for these care areas were developed on 05/06/2019, 13 days after RI #30's admission to the facility. 3.) RI #12 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #12's medical record revealed an order for [REDACTED]. Further review of RI #12's medical record revealed no baseline care plan was developed within 48 hours of admission for RI #12's oxygen therapy. 4.) RI #18 was admitted to the facility on [DATE]. RI #18's [DIAGNOSES REDACTED]. A review of RI #18's medical record revealed MEDICATION ORDERS FOR [REDACTED] Further review of RI #18's medical record revealed no baseline care plans were developed within 48 hours of admission for RI #18's [DIAGNOSES REDACTED]. Care plans for these care areas were developed on 07/10/2019, 19 days after RI #18's admission to the facility. 5.) RI #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #21's medical record revealed MEDICATION ORDERS FOR [REDACTED] Further review of RI #21's medical record revealed no baseline care plans were developed within 48 hours of admission for RI #21's [DIAGNOSES REDACTED]. 6.) RI #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #34's medical record revealed admission medication orders, dated 07-25-2019, for RI #34's medications to be given per PEG Tube. Further review of RI #34's medical record revealed no baseline care plans were developed within 48 hours of admission for RI #34's peg tube or [DIAGNOSES REDACTED]. Care plans for each of these care areas were developed on 07/18/19, seven days after RI #34's admission to the facility. On 09/19/19 at 4:16 p.m., an interview was conducted with Employee Identifier (EI) #4, Registered Nurse (RN) Supervisor. EI #4 was asked who was responsible for developing baseline care plans. EI #4 stated whomever did the admission, usually RN Supervisors, developed the (IP[NAME]) initial plan of care. EI #4 was asked what was the purpose of the IP[NAME]. EI #4 said it let the nurses and Certified Nursing Assistants (CNAs) know how to care for the resident and if they needed a bedtime snack, oral care, turned and vital signs, the basics. EI #4 was asked what was the purpose of the baseline care plan. EI #4 replied to know how to care for the residents, their plan of care. EI #4 was asked did she do fall risk assessments on admission. EI #4 stated she did not, but she thought Minimum Data Set (MDS) did. EI #4 was asked did she use any assessment to score the resident for risk for falls so the staff would know how to observe them. EI #4 stated she did not and that everybody could be at risk for falls. EI #4 was asked did she do an assessment for pressure ulcer risk. EI #4 said they did a Braden scale in the computer. EI #4 was asked what she did with that information from the Braden scale. EI #4 replied it was available for the nurses to see and the doctors as well. EI #4 was asked if she did a care plan for a resident's risk for developing pressure ulcers. EI #4 answered not upon admission, no. On 09/19/19 at 4:51 p.m., an interview was conducted with EI #3, RN/MDS Coordinator. EI #3 was asked what role did she have in developing baseline care plans. EI #3 said when she began doing MDS in March, the process was already in place for RN Supervisors to do them. EI #3 was asked what should baseline care plans address. EI #3 stated, the most basic needs: fall risk, elopement, wounds on admission, risk for pressure ulcers; anything that puts the resident at risk; medications that need monitoring, diabetes and other things like [MEDICAL TREATMENT]. EI #3 was asked, after reviewing the IP[NAME] being filled out by the RNs on admission, should it be considered a baseline care plan. EI #3 answered, no, it should not because it did not address fall risk, elopement risk or pressure ulcer development. EI #3 further stated they were attaching a medication list with [DIAGNOSES REDACTED].

Based on observations, interview, medical record review and review of a facility policy titled, Oxygen Concentrator Humidifier Bottles, Tubing and Filter Care, the facility failed to ensure Resident Identifier (RI) #12 had water in his/her humidifier bottle during three of three days of the survey. This deficient practice affected RI #12, one of three residents sampled for oxygen (O2) use. Findings Included: A review of a facility policy titled, Oxygen Concentrator Humidifier Bottles, Tubing, and Filter Care, with a last reviewed date of 9/19, revealed: . Procedure: 1. O2 concentrator humidifier bottles will be checked each 12 hr (hour) shift by the LPN (Licensed Practical Nurse) for adequate water levels. Task will be verified by a Long Term Task Order. RI #12 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #12's medical record document titled, Order List By Department, revealed: . Respiratory Care . Oxygen Therapy . Date 12-27-2018 Status Active . Nasal Cannula, O2 (LPM (Liters per minute)): 2 Maintain SaO2 (oxygen saturation) (%): >90 O2 Indication: Shortness of Breath . On 09/17/19 at 9:47 a.m., the surveyor observed RI #12's oxygen infusing at 2 LPM, with no water in the humidifier bottle at that time. On 09/18/19 at 8:37 a.m., the surveyor observed RI #12's humidifier bottle still empty at that time. Resident's breakfast tray on overbed table. Stated he/she was going to put oxygen on when he/she finished breakfast. On 09/19/19 at 9:00 a.m., the surveyor observed RI #12's O2 infusing with humidifier bottle still empty at that time. On 09/19/19 at 9:05 a.m., the surveyor asked Employee Identifier (EI) #8, Registered Nurse (RN)/Director of Nursing to accompany the surveyor to RI #12's room. The surveyor asked EI #8 to look at RI #12's oxygen and tell the surveyor what she saw. EI #8 began uncoiling RI #12's oxygen tubing. She explained to RI #12 that she was going to turn the concentrator off to uncoil the tubing. EI #8 was asked what was in RI #12's humidifier bottle. EI #8 stated it was empty and should have water in it. EI #8 then unhooked the bottle from the concentrator. The surveyor asked what was the white substance at the bottom of the bottle. EI #8 stated she did not know, but she was replacing it any way. She left the room and brought back a new humidifier bottle filled with water. EI #8 was asked should RI #12 have had water in her humidifier bottle. EI #8 said yes. The surveyor informed EI #8 that RI #12 had not had any water observed in his/her humidifier bottle all three days of the survey. On 09/19/19 at 10:12 a.m., a second interview was conducted with EI #8, RN/DON. EI #8 was asked where did nurses document the administration of O2, including the humidifier bottles. EI #8 said it was in the computer for Q (every)12 hr (hour) charting. The DON then instructed the surveyor where to go in computer. There was no documentation found by surveyor or DON. The DON left the room and then returned and stated RI #12 did not have the Q 12 hr documentation on his/her Medication Administration Record [REDACTED]. EI #8 was asked what was the concern with not checking the humidifier bottle. EI #8 answered, RI #12's bottle not having water in it.

Based on interview, record review, and a facility document titled Annual Training Protocol, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), received the mandatory 12 hours of Continuing Education Units (CEUs) for annual training, to include dementia and abuse training, from 7/25/2018 to 7/25/2019. This affected one of five CNA's whose mandatory 12 hours of CEUs for annual training to include dementia and abuse training that were reviewed. Finding include: A review of a facility document, titled Annual Training Protocol with no date, revealed . 3. Annual Education Topics: * Abuse * Dementia . 4. Training for Nurse Aides will be 12 hours per rolling year from hire date. A review of EI #1's mandatory annual 12 CEU training, which was to include Dementia and Abuse Training, revealed that EI #1 was hired to the facility on [DATE]. From 7/25/2018 to 7/25/2019 she had received only 7.5 CEU hours, which did not include Dementia and Abuse training. EI #1 did not meet the required mandatory annual 12 CEUs, to include with Dementia and Abuse training. On 9/19/19 at 2:32 p.m., an interview was conducted with EI #2, Staff Development Coordinator/Licensed Practical Nurse (LPN). EI #2 was asked who was responsible for ensuring mandatory training of Continuing Education Units (CEUs) for the CNAs at the facility. EI #2 stated she was. EI #2 was asked how many mandatory CEUs/training hours were required for the CNAs per year by their hire date. EI #2 stated the CNAs should have 12 hours, including Dementia and Abuse training. EI #2 was asked how many mandatory CEU hours did EI #1 have of the required annual 12 hours of CEUs. EI #2 stated EI #1 had 7.5 hours. EI #2 was asked why did EI #1 not have the mandatory 12 hours of CEUs. EI #2 stated she did not notice that EI #1 did not have what she needed from 7/25/2018 to 7/25/2019. EI #2 was asked why should EI #1 have the required 12 hours of CEUs. EI #2 stated that the CEUs help the CNA to keep up with the changes in how to take care of the residents. EI #2 was asked how many CEU hours of Dementia and Abuse training did EI #1 have for the required CEUs by their hire date. EI #2 stated EI #1 did not have any CEUs for Dementia or Abuse. EI #2 was asked why did EI #1 not have the required annual CEU hours of Dementia and Abuse training. EI #2 stated she did not notice that EI #1 did not have the Dementia or Abuse training. EI #2 was asked why should EI # 1 have the required mandatory annual CEU hours, to include Dementia and Abuse training. EI #2 stated EI #1 needed these CEUs for Dementia and Abuse to adequately take care of her residents.

Based on observation, interview, and review of a facility policy titled FOOD AND SUPPLY STORAGE and REFRIGERATED STORAGE LIFE OF FOODS, the facility failed to ensure chicken salad in a black plastic container and 4 pieces of toffee cake in a disposable plate, with no date documented for date opened and no use by date, were dated. This had a potential to affect sixty-three out of sixty-five residents receiving meals from dietary. Findings Include: A review of the facility policy titled FOOD AND SUPPLY STORAGE, with a revised date of 1/18, documented: .PR[NAME]EDURES: .The words .use-by . should precede the date .Foods past the use by .date should be discarded .label and date unused portions . A review of the facility policy titled REFRIGERATED STORAGE LIFE OF FOODS, with a date of January, (YEAR), documented: .Label when product is opened. The time listed is added to today's date . Food Item . Commercially Prepared Salads .OPENED .+3 days . On 08/06/18 at 4:30 p.m., during the kitchen tour with Employee Identifier (EI) #1, an Interim Dietary Manager, the surveyor observed the following item in the refrigerator cooler 3: Chicken Salad, in a black plastic container, with no date documented for date opened and no use by date. On 08/06/18 at 4:35 p.m., during the kitchen tour with EI #1, the surveyor observed the following items in the refrigerator cooler 2: 4 pieces of toffee cake, in a disposable plate, with no date documented for date opened and no use by date. On 08/07/18 at 3:45 p.m., an interview was conducted with EI #1, an Interim Dietary Manager. EI #1 was asked did the chicken salad, in a black plastic container in refrigerator 3, and the 4 pieces of toffee cake, in a disposable plate in refrigerator 2, have a label with a use by date. EI #1 stated, no. EI #1 was asked should the chicken salad, in a black plastic container in refrigerator cooler 3, and the 4 pieces of toffee cake, in a disposable plate in refrigerator 2, have a label with a use by date. EI #1 stated, yes. EI #1 was asked why did the chicken salad, in a black plastic container in refrigerator cooler 3, and the 4 pieces of toffee cake, in a disposable plate in refrigerator 2, not have a label with a use by date. EI #1 replied the staff just missed labeling and dating the chicken salad and toffee cakes. EI #1 was asked did the facility have a policy on labeling and dating refrigerator items in the refrigerator. EI #1 stated yes. EI #1 was asked what was the facility policy on labeling and dating refrigerator items. EI #1 stated you should put an orange label with the food name, current date, use by date, and staff initials. EI #1 was asked if the facility policy was followed. EI #1 stated no. EI #1 was asked what the potential harm of not labeling food items with a use by date in a refrigerator. EI #1 stated the food not being labeled and not having a use by date could make a resident sick. On 08/07/18 at 3:50 p.m., an interview was conducted with EI #2, a Registered Dietitian. EI #2 was asked should food items, placed in the refrigerator, have a label with a use by date on the food items. EI #2 stated, yes. EI #2 was asked did the facility have a policy on labeling and dating refrigerator items in the refrigerator. EI #2 stated yes. EI #2 was asked what was the facility policy on labeling and dating refrigerator items. EI #2 stated after you open the refrigerated food item, you should label and date with a use by date. EI #2 was asked what was the potential harm of not labeling food items with a use by date in a refrigerator. EI #2 stated that a resident could obtain a food borne illness.

Based on observation, interview and a facility policy titled, Resident Rights :Privacy and Confidentiality, the facility failed to ensure RI (Resident Indentifer) #213 MAR ( Medication Administration Record) computer screen was not left up/unlocked and open for public view. This deficient practice affected RI #213 one of 16 sampled residents. Findings Include: A review of a facility policy titled, Resident Rights :Privacy and Confidentially, with a revised date of 10/17 revealed: Rationale: To provide guidelines to help preserve and protect residents confidentiality and privacy Procedure: .(B) Confidentiality for his/her personal and clinical records. Ensure that Med cart lab top screens are not easily viewed by anyone other than Nurse administering medications and that screen is neutral or top is closed when exiting workstation. Ensure that .computers are logged off before exiting workstation. RI #213 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #213's medications included [MEDICATION NAME] for depression, [MEDICATION NAME] for depression and [MEDICATION NAME] for depression. On 8/7/18 at 2:46 p.m., the surveyor observed RI #213's MAR indicated [REDACTED]. EI #3 was asked if RI #213's screen should have been left unlocked and open for public view. EI #3 said no RI #213's MAR indicated [REDACTED] On 8/7/18 at 5:15 p.m. an interview was conducted with EI #3, Licensed Practical Nurse. EI #3 was asked what was the facilities policy regarding the MAR indicated [REDACTED]. EI #3 was asked if RI #213's MAR indicated [REDACTED]. EI #3 said, Yes. EI #3 was aked what was the potential harm with RI #213's MAR indicated [REDACTED]. EI #3 said, Privacy Issues

Based on observation, interview and a review of a facility policy titled Medication Administration, the facility failed to ensure a Licensed Practical Nurse (LPN), did not touch inside the medication cup, water cup, and pill crush bag with her bare finger when administering medication to Resident Identifier (RI) #61. This affected one of two residents observed during medication administration who received medication by Percutaneous Endoscopic Gastrostomy (PEG) Tube. Finding Include: RI #61 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility policy titled Medication Administration last revised date (MONTH) (YEAR), revealed, . Procedure: . Medication Administration: . 5. Medications should be given maintaining aseptic technique. Inside the medicine souffle cup, plastic med cup, or crush pouch should not be touched. On 8/7/18 at 3:10 p.m., an observation was made of Employee Identifier (EI) #3 LPN setting up medications for RI #61. EI #3 was observed to put her bare finger into the medication cup, water cup, and pill crush bag when setting up medication for RI #61, a resident who received medication per PEG Tube. An interview was conducted on 8/7/18 at 3:35 p.m. with EI #3. EI #3 was informed that she was observed putting her bare finger into RI #61 medication cup, water cup, and pill crush bag. She was asked what was that considered. EI #3 said contamination. EI #3 was asked what potential affect could that have on the resident. EI #3 replied, contamination is passing germs to the resident. EI #3 was asked when germs are passed to the resident what can happen. EI #3 said sickness flu, or viruses. EI #3 was asked what should she do when giving medication. EI #3 said, wash your hands and wear gloves. EI #3 was asked was she wearing gloves when setting up RI #61 medication. EI #3 said not when she was setting up the medication. An interview was conducted on 7/8/18 at 4:30 p.m. with EI #4, an Certified Licensed Practical Nurse (CLPN)/Infection Control Nurse. EI #4 was informed that during medication administration a nurse was observed putting her ungloved/bare finger into a medication cup, water cup, and pill crush bag. She was asked what was that considered. EI #4 said contamination. EI #4 was asked what affect could contamination have on the resident. EI #4 said, any germ she (the nurse) had on her finger could be transferred to the medication, and when the resident swallowed the medication it exposed them to the bacteria. EI #4 was asked when the resident is exposed to the bacteria what affect could it have on the resident. EI #4 said it could make them sick, resulting into infection.

Based on observation, interview and a review of facility policies, MEAL TEMPERATURE RECORD, Taste and Temperature by Menu Cycles Report, MEAL/TRAY ASSEMBLY PROCEDURES, STORAGE OF POTS, DISHES, FLATWARE, UTENSILS, FOOD AND SUPPLY STORAGE, Food and Supply Storage Procedures (Cont.), Proper Refrigerator Storage and HAND HYGIENE, The facility failed to ensure: 1) the correct temperatures were written down for the chicken and dumplings, carrots, pureed chicken and dumplings, pureed carrots and temperatures were taken and written down for hamburger patties, chicken fingers, french fries and milk on 6/28/2017 during the lunch meal, 2) a dietary staff did not stack plate warmers on top of each other with water in the warmers, 3) roast beef base in the cooler was labeled with a use by date, 4) apple bars were not on the bottom shelf of the meat rack in the cooler, 5) spinach was not out of date in the cooler, 6) a cup was not in the corn meal bag, 7) hamburger patties were sealed properly in the freezer and 8) a dietary staff did not turn the sink faucet off with bare hands. This had the potential to affect 71 of 73 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, MEAL TEMPERATURE RECORD with a revised date of 01/17 revealed: POLICY All food items are evaluated for temperature .prior to meal service . PROCEDURES: . an accurate temperature of all menu items is to be taken and recorded . A review of a facility policy titled MEAL /TRAY ASSEMBLY PROCEDURES with a revised date of 1/16 revealed: .Supervisor/Designee . Checks meals for accuracy. Completes temperatures as noted on log. On 6/28/2017 at 10:42 a.m., the surveyor observed (Employee Identifier) EI #8, Cook, taking the temperatures of the chicken and dumplings, carrots, bread, pureed chicken and dumplings, and pureed carrots. She did not write the temperatures down as soon as she took them. She did not take the temperatures of the tomato soup, milk , hamburger patties, french fries, and chicken tenders. After taking temperatures of the regular food items and pureed food items on the menu, she went back to record the temperatures of each food items on the menu sheet. The temperatures that she wrote down was not the correct temperatures for the regular and pureed food items. On 6/29/2017 at 9:38 a.m., the surveyor conducted an interview with EI #8, the cook. EI #8 was asked what was the temperature of the chicken and dumplings. EI #8 replied, 155 degrees F (Fahrenheit). EI #8 was asked what was the temperature of the carrots. EI #8 replied, 160 degrees. EI #8 was asked what was the the temperature of the pureed chicken and dumplings. EI #8 replied, 141 degrees. EI #8 was asked what was the temperature of the pureed carrots. EI #8 replied, she did not write it down. EI #8 was asked where were the recorded temperatures for the hamburger patties, tomato soup, chicken fingers, french fries and milk. EI #8 replied, she did not know she had to record all extra stuff on the menu. EI #8 was asked who was responsible for taking food temperatures on the tray line. EI #8 replied, the cook. EI #8 was asked did she write down food temperatures as she took them on the trayline. EI #8 replied, no she did not. EI #8 was asked why was her food temperatures on the trayline different from the surveyor. EI #8 replied, because she did not write them down as soon as she did them. EI #8 was asked what was the facility policy on writing down food temperatures on the tray line. EI #8 replied, she did not know. EI #8 was asked what was the potential harm in not taking food temperatures on the tray line. EI #8 replied, someone could get sick and if she did not write them down she could forget. On 6/29/2017 at 11:03 a.m., the surveyor conducted an interview with EI #9, Director of Food and Nutrition. EI #9 was asked what was the facility policy on recording food temperatures on the trayline. EI #9 replied, they were suppose to write down everything on the trayline. EI #9 was asked who was responsible for taking food temperatures on the tray line. EI #9 replied, the cook. EI #9 was asked when were cooks suppose to write the food temperatures down. EI #9 replied, as soon as they take them. EI #9 was asked what was the potential harm in not taking food temperatures. EI #9 replied, the food could be in the danger zone to long or it could be dangerous food. EI #9 was asked what was the potential harm in not writing food temperatures down immediately. EI #9 replied, they can not rely on memory and the temperatures would be inaccurate. 2) A review of a facility policy titled, STORAGE OF POTS, DISHES, FLATWARE, UTENSILS with a revised date of 1/16 revealed: POLICIES: Pots, dishes, and flatware are stored in such a way to prevent contamination by splash, dust, pests, or other means. PROCEDURES: .Air dry all . including pots, dishes, .before storage .Do not stack or store when wet. On 6/28/2017 at 5:50 p.m., the surveyor observed EI #10, Dietary staff, on the clean side of the dish room putting up dishes. The worker stacked 10 hot plates on top of each other. In five of the hot plates there was water in them. On 6/29/2017 at 9:44 a.m., the surveyor conducted an interview with EI #10. EI #10 was asked what items were stacked on top of each other on 6/28/2017. EI #10 replied, metal hot plates. EI #10 was asked why were they stacked on top of each other. EI #10 replied, to take to the warmer. EI #10 was asked what was in the hot plates. EI #10 replied, spots of water. EI #10 was asked what was the facility policy regarding stacking wet dishware on top of each other. EI #10 replied, they should air dry before stacking. EI #10 was asked why should dishware not be stacked while wet. EI #10 replied, bacteria can grow if stack wet. On 6/29/2017 at 10:07 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked what was the facility policy regarding stacking wet dishware on top of each other. EI #9 replied, dishes were suppose to air dry prior to putting away. EI #9 was asked why should dishware not be stacked while wet. EI #9 replied, wet nesting, which could cause bacteria to grow. 3) A review of a facility policy titled, FOOD AND SUPPLY STORAGE with a revised date of 1/17 revealed: POLICIES: All food .used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .PROCEDURES: .Cover, label and date unused portion and open packages. On 6/27/2017 at 2:45 p.m., the surveyor along with EI #9, Director of Food Services toured cooler number one. There was a container of Roast Beef Base opened with no use by date. On 6/29/2017 at 11:14 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked what was the use by date of the roast beef base. EI #9 replied, she did not know. EI #9 was asked who was responsible for labeling food items. EI #9 replied, everyone. EI #9 was asked when should food items be labeled. EI #9 replied, when received, when opened, when packaged was opened and not completely used and when food items are taken out of the original container. EI #9 was asked what was the potential harm when there was no open or use by date on food products. EI #9 replied, a foul product could be used, poor product, out of date and unsafe. 4) A review of a policy titled, Proper Refrigerator Storage with no revised date revealed: .Top-to-bottom storage of different foods in the same refrigerator . Whole Fish .Whole Meat .Pork .Ground Meat . Poultry . A review of a policy titled, Food and Supply Storage Procedures (Cont.), (continued) .REFRIGERATED STORAGE . Separate refrigerated goods by category (meat, fish, poultry, dairy, produce). On 6/27/2017 at 2:45 p.m., the surveyor along with EI #9 toured number two cooler. The surveyor observed cakes and pies on the first shelf. Ground beef, ham and pulled pork was on the second shelf. Bacon and ground turkey was on the third shelf and a sheet pan of apple bars was on the fourth shelf. On 6/29/2017 at 11:25 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked what food items was on the bottom shelf in the cooler. EI #9 replied, apple bars. EI #9 was asked what was on the second shelf. EI #9 replied, ground beef. EI #9 was asked what was on the third shelf. EI #9 replied, bacon. EI #9 was asked what was on the fourth shelf. EI #9 replied, apple bars. EI #9 was asked why was the apple bars on the bottom shelf. EI #9 replied, someone made a bad decision. EI #9 was asked who was responsible for putting food items into the cooler. EI #9 replied, everybody. EI #9 was asked what was the facility policy on how food should be placed on a meat rack in the cooler. EI #9 replied, ready to eat food on the top shelf, fish, whole meats, pork and beef, ground meats and poultry on the last shelf. EI #9 was asked what was the potential harm when apple bars were on the bottom shelf and meats were above the apple bars. EI #9 replied, anything above could contaminate if dripping. 5) A review of a policy titled, FOOD AND SUPPLY STORAGE with a revised date of 1/17 revealed: .PROCEDURES .do not .place on patient trays/resident plates past the date on the product. Foods past the use by .date should be discarded . On 6/27/2017 at 2:45 p.m., the surveyor observed a pan of spinach in the number two cooler. There was a cooked date of 6/20/2017 and a use by date of 6/23/2017. On 6/29/2017 at 11:30 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked what was the prepared date of the spinach in the cooler. EI #9 replied, she did not know. EI #9 was asked was the spinach out of date for use. EI #9 replied, she believe it was. EI #9 was asked why was the spinach in the cooler. EI #9 replied, it had not been removed. EI #9 was asked what was the facility policy on out of date food in the cooler. EI #9 replied, they did not keep out of date food in the cooler. EI #9 said out of date food should be discarded. EI #9 was asked who was responsible for removing out of date food in the cooler. EI #9 replied, everybody. EI #9 was asked when should expired foods be removed from the cooler. EI #9 replied, when it expires. EI #9 was asked what was the potential harm when food items were expired in the cooler and served to the residents. EI #9 replied, they could grow foul things, could have a bacteria, could make people ill and it was a poor quality of food. 6) A review of a facility policy titled FOOD AND SUPPLY STORAGE with a revised date of 1/17 revealed: .Dry Storage .Scoops may be stored in bins with a scoop holder. The food level must be no closer than one-inch below the handle of the scoop. On 6/27/2017 at 3:25 p.m., the surveyor observed a bag of corn meal with a small plastic cup inside the bag. On 6/29/2017 at 11:35 a.m., an interview was conducted with EI #9. EI #9 was asked what item was in the yellow corn meal mix. EI #9 replied, a dish. EI #9 was asked why was it in the corn meal. EI #9 replied, she did not know. EI #9 was asked what was the facility policy regarding items such as a dish being left in the corn meal. EI #9 replied, a dish should have not been in the corn meal. EI #9 was asked who was responsible for making sure no item were left in the corn meal. EI #9 replied, the person using it. EI #9 was asked what was the potential harm when items such as a dish was left in the corn meal and the corn meal was used to prepare corn bread for the residents. EI #9 replied, could be a physical contaminant and could cause cross contamination. 7) A review of a facility policy titled Food and Supply Storage Procedures with a revised date of 1/17 revealed: .Frozen Storage .Wrap food tightly to prevent cross contamination. On 6/27/2017 at 3:05 p.m., the surveyor observed a bag of hamburger patties opened in freezer number two. There was no open date or use by date on the bag. The bag was not sealed and the hamburger patties were out of the original container. On 6/29/2017 at 11:40 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked what was in the freezer and not sealed properly. EI #9 replied, burgers. EI #9 was asked was the package opened. EI #9 replied, yes. EI #9 was asked how was the hamburger patties sealed in the freezer. EI #9 replied, some packages were opened and not completely sealed. EI #9 was asked how should packages be sealed. EI #9 replied, sealed where no air can get in and label and date it. EI #9 was asked who was responsible for putting food items in the freezer. EI #9 replied, everybody. EI #9 was asked what was the potential harm when food items were opened in the freezer and the food was used to prepare for residents to consume. EI #9 replied, could be cross contamination and beyond the date for use. 8) A review of a facility policy titled, HAND HYGIENE with a revised date of 1/17 revealed: .PROCEDURES: Use a paper towel to turn off the faucet to avoid contact with faucet germs. On 6/28/2017 at 5:50 p.m., the surveyor observed dietary staff washing carts on the clean side of the dish room. She pulled a rag from the red bucket and washed carts on the outside, inside and on top of the cart. She pulled her gloves off and went to wash her hands and turned the faucet off with her bare hands. On 6/29/2017 at 11:45 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked how should staff wash their hands. EI #9 replied, wet hands, use the hottest water you can bare. EI #9 replied, leather up all of their hands around the fingers and up to the elbows and then dry their hands with a paper towel and turn the water off with the paper towel. EI #9 was asked what was the potential harm when staff hands were not washed properly in the kitchen and staff was handling clean dishes. EI #9 replied, staff would contaminate the dishes.

Based on observation and interview the facility failed to ensure EI #6 (Employee Identifier) wore an apron while loading soiled laundry into a washer on the dirty side of the laundry room. This had the potential to affect 63 residents whose clothing were laundered by the facility. Findings Include: On 6/28/2017 at 8:57 a.m., the surveyor observed EI #6, Tech one, load a washer on the dirty side of the laundry room with no apron on. She went around to the side of the machine and her clothes touched a chemical container. After she loaded the washer, she went to the dryer to take clothes out. Her clothes touched clean shirts, a gown and a pair of pants. On 6/28/2017 at 12:45 p.m., the surveyor conducted an interview with EI #6, Tech one. EI #6 was asked what PPE (Personal Protective Equipment) did she have on while loading the washer. EI #6 replied, she did not have on an apron. EI #6 was asked what PPE should she have on when loading the washer on the dirty side. EI #6 replied, apron and gloves. EI #6 was asked what was the facility policy regarding the use of PPE on the dirty side of the laundry room. EI #6 replied, they should wear apron and gloves on the dirty side. EI #6 was asked when should she wear PPE. EI #6 replied, when they pick up the residents dirty clothes they should have on an apron and gloves. EI #6 was asked what PPE did she have on when taking clothes out of the dryer. EI #6 replied, no apron or gloves. EI #6 was asked what was the potential harm when residents clean clothes touched her clothes after leaving the dirty side without EI # 6 wearing an apron. EI #6 replied, contamination. EI #6 was asked did clothes from the dryer touch her clothes. EI #6 replied yeah they did. On 6/28/2017 at 12:50 p.m., the surveyor conducted an interview with EI #7, Environmental Services Supervisor. EI #7 was asked what PPE should they have on when loading on the dirty side of the laundry room. EI #7 replied, aprons and gloves. EI #7 was asked did the worker this morning have on PPE on the dirty side of the laundry room. EI #7 replied, no. EI #7 was asked why not. EI #7 replied, they ran out and have not reordered. EI #7 was asked what was the potential harm when residents clothes touched staff clothes and no apron was used on the dirty side. EI #7 replied, contamination.

Based on observations, record review, interview and review of a facility policy titled Feeding Residents, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #2 did not stand while feeding Resident Identifier (RI) #3 the lunch and dinner meals on 06/28/17. This affected RI #3, one of five residents observed being assisted with meals. Findings Include: A facility policy titled Feeding Residents, with a reviewed date of December 2015, documented: Rationale: To provide guidelines for assisting residents with meals. Policy: It is the policy of . that each resident requiring assistance with meals should be treated with respect and dignity. Procedure: . 4. Staff should be seated during meals at the resident's eye level . RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An Annual Minimum Data Set assessment with an Assessment Reference date of 06/21/17, assessed RI #3 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. RI #3 was also assessed as being totally dependent on staff for eating. On 06/28/17 at 11:43 a.m., the surveyor observed EI #2, a CNA, feeding RI #3 the lunch meal. EI #2 was standing while feeding RI #3. On 06/28/17 at 11:54 a.m., EI #3 remained standing while feeding RI #3. On 06/28/17 at 5:04 p.m., the surveyor observed EI #2 feeding RI #3 the dinner meal. EI #2 was standing while feeding RI #3. On 06/28/17 at 6:11 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2, when he was observed feeding RI #3 the lunch and dinner meals on 06/28/17, what position was he in. EI #2 said he was standing. The surveyor asked EI #2 what position should he have been in when feeding RI #3. EI #2 said he knew he should have been sitting. The surveyor asked EI #2 what type issue was it when you stand and feed a resident. EI #2 replied, It's like a dignity issue. On 06/29/17 at 2:00 p.m., the surveyor conducted an interview with EI #1, the Assistant Director of Nursing. The surveyor asked EI #1 how should staff be positioned when feeding a resident. EI #1 replied, They should be sitting. The surveyor asked EI #1 what was it considered when a staff stands while feeding a resident. EI #3 said, A dignity issue.

Based on record review and interviews, the facility failed to ensure: 1) Resident Identifier (RI) #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], and Annual MDS assessment dated [DATE], reflected RI #3's height; 2) RI #10's Quarterly MDS assessment dated [DATE], reflected RI #10 was receiving [MEDICAL TREATMENT]; and 3) RI #11's Annual MDS assessment dated [DATE], reflected RI #11 was receiving [MEDICAL TREATMENT] during these assessment periods. This affected three of 13 sampled residents whose MDS assessments were reviewed. Findings Include: 1) RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an Assessment Reference Date (ARD) of 03/22/17, assessed RI #3 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. Under Section K - Swallowing/Nutritional Status, RI #3 was coded O under height. RI #3's Annual MDS assessment with an ARD of 06/21/17, under Section K - Swallowing/Nutritional Status, also coded RI #3 as O under height. On 06/29/17 at 1:21 p.m., the surveyor conducted an interview with the MDS Coordinator, Employee Identifier (EI) #5. The surveyor asked EI #5 should RI #3's height be coded on the MDS. EI #5 replied, Yes it should. The surveyor asked EI #5 was RI #3's height coded on the 03/22/17 Quarterly and 06/21/17 Annual MDS's. EI #5 said no. The surveyor asked EI #5 were the MDS assessments accurate. EI #3 replied, No Ma'am not if they don't have all the information. 2) RI #10 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #10's Physician order [REDACTED]. . TAKE TO [MEDICAL TREATMENT] ON MON (Monday), WED (Wednesday) & (and) FRIDAY . A Quarterly MDS assessment with an ARD of 03/15/17, assessed RI #10 as scoring a two on the Brief Interview for Mental Status (BIMS) indicating severely impaired cognition, Under Section O - Special Treatments, Procedures, and Programs, RI #10 was not coded as having received [MEDICAL TREATMENT] services during this assessment period. On 06/29/17 at 11:35 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 was RI #10 receiving [MEDICAL TREATMENT]. EI #5 replied, Yes. The surveyor asked EI #5 was the [MEDICAL TREATMENT] coded on RI #10's 03/15/17 Quarterly MDS. EI #5 said no. The surveyor asked EI #5 should the [MEDICAL TREATMENT] have been coded on the MDS assessment. EI #5 replied, Yes. The surveyor asked EI #5 was this assessment an accurate assessment. EI #5 replied, No. EI #5 said not having an MDS assessment coded accurately may result in the resident not being taken care of correctly. 3) RI #11 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #11's Physician order [REDACTED]. . [MEDICAL TREATMENT] Monday, Wednesday and Friday . An Annual MDS assessment with an ARD of 04/12/17, assessed RI #11 as scoring a 15 on the BIMS indicating no impaired cognition. Under Section O - Special Treatments, Procedures, and Programs, RI #11 was not coded as having received [MEDICAL TREATMENT] services during this assessment period. On 06/29/17 at 11:30 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 was RI #11 receiving [MEDICAL TREATMENT]. EI #5 replied, Yes. The surveyor asked EI #5 was the [MEDICAL TREATMENT] coded on RI #11's 04/12/17 Annual MDS. EI #5 said no. The surveyor asked EI #5 should the [MEDICAL TREATMENT] have been coded on RI #11's Annual MDS assessment. EI #5 replied, Yes. The surveyor asked EI #5 was this assessment an accurate assessment. EI #5 replied, No. The surveyor asked EI #5 what was the harm when a MDS assessment was not accurately coded. EI #5 said the MDS may not accurately reflect the care of the resident.

Based on observations and interviews, the facility failed to ensure the total number of hours actually worked by the RNs (Registered Nurses), LPNs (Licensed Practical Nurses) and CNAs (Certified Nursing Assistants), were posted on the Daily Staffing Sheet at the beginning of the 7a -7p shifts on 06/28/17 and 06/29/17. This had the potential to affect all 73 residents in the facility. Findings Include: On 06/28/17 at 8:23 a.m., the surveyor observed the Daily Staffing Sheet posted for the 7a -7p shift. There were no number of hours actually worked for the RNs, LPNs and CNAs posted on the sheet. On 06/29/17 at 11:36 a.m., the surveyor observed the Daily Staffing Sheet posted for the 7a -7p shift. There were no number of hours actually worked for the RNs, LPNs and CNAs posted on the sheet. On 06/29/17 at 1:31 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the LPN responsible for posting the 7a -7p Daily Staff Sheets on 06/28/17 and 06/29/17. The surveyor asked EI #3 when did she put the number of hours actually worked for the RNs, LPNs and CNAs on the Daily Staff Sheets. EI #3 replied, About 6 p.m. in the evening. The surveyor asked EI #3 had she ever been told that the number of hours actually worked should be posted at the beginning of the shift. EI #3 said no. On 06/29/17 at 2:00 p.m., the surveyor conducted an interview with EI #1, the Assistant Director of Nursing. The surveyor asked EI #1 what information should be on the Daily Staffing Sheets. EI #3 said the number of hours the RNs, LPNs and CNAs worked. The surveyor asked EI #1, when should the hours worked be posted. EI #1 replied, In the morning.

Based on observation, interview and record review the facility failed to ensure Employee Identifier (EI) #1 Certified Nursing Assistant (CNA) opened and cleaned Resident Identifier (RI) #1's during the provision. RI #1 has a history of Urinary Tract Infection [MEDICAL CONDITION]. This affected one of one resident's for whom an observation of Perineal Care was done. Findings Include: A facility policy titled: Incontinent Care. Policy: It is the policy of Marion Regional Nursing Facility that incontinent care should be properly provided. Procedure: When providing incontinent care, the guidelines below should be followed. : . Female: .Wash the pubic area first, .Open labia, wash downward in the middle over the urethra and vaginal openings RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2016 documented RI #1 as having a score of 15 for Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact for decision making. RI #1 was totally dependant on staff for Personal hygiene/Bathing with assistance of one person, and always incontinent of bowel and bladder. A review of RI #1's Physician order [REDACTED]. Urinalysis (UA) R/T (related to) nausea 4. Resume Bactrim DS 800/160 mg(milligrams) one by mouth every day at 08:00. A second order dated 11/25/16 documented UA with Culture and Sensitivity R/T confusion. RI #1 was sent to the Emergency Department for evaluation and treatment and remained in the hospital until his/her return to the facility on [DATE]. RI #1's Physician order [REDACTED]. [MEDICATION NAME] + [MEDICATION NAME] DS 800 mg-160 mg Give 1 tablet Oral. Indication: Preventative. On 12/13/16 at 10:00 a.m. EI #1 CNA was observed performing perineal care for RI #1. EI #1 failed to open RI #1's labia and clean down the middle of the area. During an interview on 12/13/16 at 4:26 p.m. EI #1 was asked to review the facility policy and tell the surveyor what should be done in regard to a female resident's labia while providing perineal care. EI #1 replied, open it and wash down the middle. She was asked why she did not open the labia and clean the area. EI #1 replied that she spread it apart the best she could. EI #1 was asked what the potential for harm was if the labia was not opened and cleaned. She replied UTI's and Infections. On 12/13/16 at 5:30 p.m. EI #2 Infection Control Licensed Practical Nurse, was asked if she was present during the surveyor's observation of Perineal Care for RI #1. She stated, Yes. She was asked what the policy documented regarding a female resident's labia being cleaned. EI #2 replied, to be opened and cleaned straight down. EI #2 was asked if that was the way EI #1 provided RI #1's perineal care. She replied not from where she could see; she did not open it wide enough so it could be cleaned. EI #2 was asked what the potential for harm was if the labia was not opened and cleaned during perineal care. She stated, Bacteria stays in there and they can get a UTI. EI #2 was asked if RI #1 had a history of [REDACTED]. She replied that she had done a urinalysis for RI #1 and that she believed he/she was on preventative medication. EI #2 was asked what infections she was currently monitoring. She replied, one for [MEDICAL CONDITION] and one UTI at the moment.

Based on observation, interview and record review the facility failed to ensure Employee Identifier (EI) #1 Certified Nursing Assistant (CNA)removed her dirty gloves and washed her hands after completing perineal care for Resident Identifier (RI) #1. EI #1 touched RI #1's clean linens and brief, and positioned him/her in bed with the dirty gloves. This affected one of one observation for Perineal care. Findings Include: A facility policy titled: Incontinent Care. Policy: It is the policy of Marion Regional Nursing Facility that incontinent care should be properly provided. Procedure: When providing incontinent care, the guidelines below should be followed. : . Female: .Wash the pubic area first, . Remove gloves, wash/foam hands, apply clean gloves. Wash buttocks using clean area of washcloth moving from anal area up buttocks Remove gloves and wash hands before touching clean linen. RI #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's Significant Change 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2016 documented RI #1 as having a score of 15 for Brief Interview for Mental Status (BIMS) which indicated he/she was cognitively intact for decision making. RI #1 was totally dependant on staff for Personal hygiene/Bathing with assistance of one person and always incontinent of bowel and bladder. A review of RI #1's Physician order [REDACTED]. Urinalysis (UA) R/T (related to) nausea 4. Resume Bactrim DS 800/160 mg(milligrams) one by mouth every day at 08:00. A second order dated 11/25/16, documented UA with Culture and Sensitivity R/T confusion. RI #1 was sent to the Emergency Department for evaluation and treatment on 11/25/16 and remained in the hospital until his/her return to the facility on [DATE]. RI #1's Physician order [REDACTED]. [MEDICATION NAME] + [MEDICATION NAME] DS 800 mg-160 mg Give 1 tablet Oral. Indication: Preventative. On 12/13/16 at 10:00 a.m. EI #1 was observed performing perineal care for RI #1. EI #1 failed to remove her dirty gloves after completing perineal care and wash her hands before she touched RI #1's clean linen and brief, and positioned him/her in bed. During an interview on 12/13/16 at 4:26 p.m. EI #1 was asked to review the facility policy and tell the surveyor what should be done after she had completed perineal care. EI #1 replied, change gloves and wash hands. EI #1 was asked why she failed to remove her gloves, wash her hands and apply new gloves before she touched RI #1's clean linens and brief, and positioned him/her in bed. EI #1 stated, I don't know. She was asked what the potential for harm was if she did not do this. EI #1 stated, Contamination of clean items. EI #1 was asked when her last inservice was for proper perineal care. She replied, a few months back. On 12/13/16 at 5:30 p.m. EI #2 Infection Control Licensed Practical Nurse, was asked if she was present during the surveyor's observation of Perineal Care for RI #1. She stated, Yes. EI #2 was asked what should be done after the perineal care is completed regarding placing the resident's clean brief and pads, and positioning the resident. She replied, change gloves, foam or wash hands when completely done. EI #2 was asked if EI #1 removed her gloves and washed her hands before touching RI #1's clean brief and pads, and positioning him/her in bed. She stated, No. She was asked what the potential for harm was if this was not done. EI #2 replied, it has the potential to transfer bacteria from the perineal area to the clean linens and brief. EI #2 was asked if RI #1 had a history of [REDACTED]. She replied that she believed the resident was on preventative medication.

Based on interviews, record review, and review of the facility's abuse policies and procedures, the facility failed to prevent verbal and mental abuse from occurring after becoming aware of an allegation expressed by Resident Identifier (RI) #2. RI #2, an alert and oriented resident with a recent right ankle fracture and who likes to watch television (TV) was repeatedly subjected to verbal and mental abuse inflicted by Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) on 04/04/13, even though several staff members (two Registered Nurse (RN) Supervisors, Activity Director and Activity Assistant) were aware of the allegation of abuse. On 04/04/13 around 1:30 PM to 2:30 PM, the Environmental Service Director, EI #10, stated she was summoned to RI #2's room. RI #2 asked EI #10 to turn her television on. EI #10 stated she found RI #2's TV remote on RI #2's roommate's TV stand, an area that was out of RI #2's reach. After EI #10 turned, RI #2's TV on, the resident informed EI #10 that EI #1 (CNA) had willfully taken and hid her remote because she had "pooped " (had a bowel movement) on herself. After leaving the resident's room, EI #10 informed EI #8, the Activity Director, about the incident because she felt RI #2 was being punished. EI #14, a CNA assigned to care for RI #2 during the 3:00 PM to 11:00 PM shift, stated around 2:30 PM to 3:00 PM, RI #2 pressed her call light. When EI #14 entered the resident's room, RI #2 asked the CNA to give her the remote. The remote control was not within the resident's reach again. At 2:30 PM, after being made aware of the incident, the RN Supervisor, EI #6, entered RI #2's room; the resident's TV was on. According to EI #6, RI #2 told her EI #1 had turned her TV off without her permission and placed the remote on her roommate's TV stand. EI #6 stated RI #2 felt as though she was being punished for having a toileting accident on herself. EI #6 stated she apologized to the resident and instructed RI #2 to press her call light if it happens again. At 2:55 PM, RI #2 pressed her call light and requested the RN Supervisor, EI #6. EI #6 entered RI #2's room at 3:00 PM and observed RI #2 lying in bed, the TV was off and the remote was behind the TV, out of the resident's reach. RI #2 informed EI #6 that EI #1 (CNA) had come to her room, turned the TV off, placed the TV remote out of her reach and walked out the room. The RN Supervisor, EI #6, turned RI #2's TV on and placed the remote within the resident's reach. After leaving RI #2's room, EI #6 called the CNA into her office and questioned her about RI #2's remote. According to EI #6, EI #1 told her the resident was mad at her because she (CNA) had fussed at the resident for having a bowel movement everywhere. EI #1 stated she may have turned the TV off, but she could not remember. Before the supper trays were delivered on 04/04/2013, EI #1 offered to assist EI #14 in caring for RI #2. EI #14 witnessed EI #1 intentionally turn the resident's TV off and place the remote control on the nightstand next to the window. According to EI #14, EI #1 told the resident in a loud voice, "Since you did not call for the bedpan, there's no sense in you laying in here watching TV." EI #14 stated after EI #1 left RI #2's room, she turned the resident's TV on and gave the resident her remote. A review of EI #1's Time Card revealed this CNA continued to work her shift on 04/04/13 after the staff was aware of the incident concerning RI #2. According to the time sheet, EI #1 also worked on 04/06/13, 04/07/13, 04/08/13 and 04/10/13 caring for other residents. EI #1 was not removed from direct patient care until 04/10/13 at 8:25 PM. EI #1 described the resident (RI #2) as embarrassing and explained how RI #2 soils herself and will not tell anyone what she has done. EI #1 stated RI #2 will not use the call light when she has a bowel movement and will call the staff afterwards. With staff knowledge that EI #1 willfully and intentionally turned the resident's TV off and took the remote, the staff failed to respond and continued to allow EI #1 the opportunity to continue take and hide the resident's remote and turn the TV off without her permission. This deficient practice placed RI #2, one of three sampled residents reviewed for abuse in immediate jeopardy as it was likely to cause serious injury, harm and/or death. This deficient practice had the potential to affect the remaining 61 residents of the facility. On 04/11/13 at 5:54 PM, the Administrator, Interim Director of Nursing, Minimum Data Set (MDS) Coordinator, Social Service Director/Abuse Coordinator, Activity Director, Rehab Director, Human Resources Director, Staff Development Nurse, Medical Records Staff, and two Registered Nurse (RN) Supervisors were notified immediate jeopardy had been identified in the area of Abuse, F 223. The immediate jeopardy began on 04/04/13. After the facility implemented immediate corrective action, the immediate jeopardy was abated on-site on 04/12/13 and the scope/severity lowered to a "D" level. Findings include: The facility's policy titled "Preventing Resident Abuse (C 150), with a revised date of 05/23/05, documented " ... Marion Regional Nursing Home will not condone any form of resident abuse ... ." Centers for Medicare and Medicaid Services (CMS), Appendix PP of the "State Operations Manual" with a revised date of 01/07/11, defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of age, ability or comprehend, or disability. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. On 04/09/13, the State Agency received an anonymous complaint. According to the complainant, on 04/04/13 around 9:00 AM, RI #2 had a bowel movement and called for assistance. Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) responded and reportedly took RI #2's remote control and intentionally placed it out of her reach near RI #2's roommate because RI #2 had soiled herself instead of calling for assistance. EI #1 reportedly took RI #2's remote two additional times that morning placing it out of the resident's reach each time. EI #8, the Activity Director returned the remote to RI #2 twice and EI #10, Environmental Service Director, returned the remote once. Both EI #8 and EI #10 reported the incidents to EI #6 and EI #7, both Registered Nurse (RN) Supervisors. EI #6 and EI #7 reported the incidents to EI #4, the Administrator and EI #5, the Director of Nursing. EI #4 and EI #5 reportedly decided not to report the incidents to the State Agency. The CNA, EI #1, reportedly denied taking the remote. The complainant reported EI #1 is a bully toward the residents. Resident Identifier (RI) #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's x-ray report indicated on 01/06/13 had experienced a fall and was unable to bear weight. The an x-ray report of her right ankle revealed a mildly displaced [MEDICAL CONDITION] tibia and a questionable subtle fracture at the lateral malleolus. The Significant Change in Status Minimum Data Set, with an assessment reference date of 02/10/13, identified RI #2 as being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 13. RI #2 was assessed as requiring extensive assistance with bed mobility, being totally dependent on staff for transfers and her ability to walk in room did not occur during this assessment period. RI #2's activities care plan, with a problem onset date of 02/20/13, had a documented goal of " ... Resident to engage in individual leisure activities of choice in room ..." and a documented approach of " ... Encourage resident to continue leisure activities including ... watching television ... ." During the initial tour of the facility on 04/10/13 at 8:50 AM, RI #2 was asked to tell the State Surveyor the recent problems she had with her remote control. RI #2 stated EI #1 treats her badly by talking and saying ugly hateful words to her. When asked how that makes her feel, RI #2 stated that it doesn't make her feel too good. In a follow-up on interview with RI #2 on 04/10/13 at 2:00 PM, she was asked if anyone had ever taken her TV remote control away from her. RI #2 said "yes, (EI #1)." When asked why EI #1 took her remote, RI #2 stated she guessed EI #1 didn't want her watching TV that day. RI #2 further stated "I don't know why she's always so mean to me." During a telephone interview on 04/10/13 at 2:15 PM, EI #10, Environmental Service Director (EVS) was asked about the incident in which RI #2 reported to her that someone removed her remote control. EI #10 stated it happened two different times in the same week. EI #10 stated the first time occurred on Monday, 04/01/13, when RI #2 asked her to turn her TV on because the resident did not have her remote. EI #10 stated she asked RI #2 why she didn't have her remote and RI #2 told her EI #1 (CNA) had hid it from her. EI #10 stated she found the remote on the other side of the room on RI #2's roommate's TV stand. EI #10 stated she did not tell anyone about this because she thought the CNA might have just placed the remote out of the way. EI #10 stated the second time occurred on 04/04/13 around 1:30 PM to 2:30 PM, when RI #2 called EI #10 into her room as she (EI #10) was passing by her door. According to EI #10, RI #2 asked her to turn her TV on. EI #10 asked RI #2 where was her remote. RI #2 informed her that EI #1 (CNA) hid her remote. EI #10 asked RI #2 why did EI #1 hide her remote. RI #2 stated EI #1(CNA) hid her remote because she had "pooped" (had a bowel movement) on herself. EI #10 stated she found RI #2's remote in the same place she had located it the first time, on RI #2's roommate's TV stand. When asked if RI #2 could have put the remote on the table herself, EI #10 said, "No." EI #10 was asked what she considered this incident. EI #10 stated she considered the incident abuse and explained that it was like grounding RI #2, something you would do if you were going to punish someone. When asked if she told anyone about the second incident, EI #10 stated she told EI #8, the Activity Director, who told EI #10 to tell the RN Supervisor, EI #6. EI #10 was asked if she told the RN Supervisor, EI #6. EI #10 stated she attempted to tell EI #6 twice, but the RN Supervisor was on the telephone. EI #10 stated she informed the Activity Director (EI #8) that EI #6 was on the telephone. EI #8 found EI #6, told her what happened and EI #6, requested a statement about the incident. EI #10 stated she wrote her statement and gave it to EI #8 (Activity Director) on 04/04/13. A handwritten unsigned statement addressed to EI #6, the RN Supervisor, and dated 04/04/13 documented "There has been twice this week that (RI #2) has asked me to turn her TV on and put it on the channel she wanted to watch. I asked her about her remote and she said (EI #1) had taken it away from her and hid it, both times she had put it on (RI #2's roommate) table with her TV. Today when I asked her why she took it she said it was because she had pooped on herself and (EI #1) had to clean her up." During a follow-up interview on 04/11/13 at 1:45 PM, EI #10 acknowledged she wrote the above handwritten unsigned statement. During an interview on 04/10/13 at 1:30 PM, EI #8, the Activity Director, was asked if there were any times she had to give RI #2 her remote control back. EI #8 did not have to give RI #2 her remote, but stated EI #10 had given the remote back to RI #2. She further stated EI #1 (CNA) apparently took it again and EI #6 came in and gave it back to the resident. When asked if RI #2 was able to place the remote control out of her own reach, EI #8 said no. According to EI #8, EI #11, the Activity Assistant overheard EI #1 (CNA) asking RI #2 who gave her the remote control back. EI #8 reported to the RN Supervisor (EI #6) what EI #10 had told her about the incident. EI #8 also told EI #10 to write a statement. According to EI #8, EI #10 gave her the statement and she then gave it to EI #6. The same day she informed her of the incident EI #8 was asked what she considered this incident as. EI #8 stated "punishing the resident for pooping on herself." During an interview on 04/11/13 at 10:05 AM, EI #11, the Activity Assistant was asked if she overheard EI #1 ask RI #2 who gave her the remote back on 04/04/13. EI #11 responded, "Yes." EI #11 heard this around 1:45 PM. EI #11 was asked what she overheard. EI #11 stated "I heard her (EI #1) say who gave your remote back to you." When asked if she told anyone what she overheard, EI #11 stated she told the Activity Director, EI #8. EI #11 was asked why she told EI #8. EI #11 stated she told EI #8 because EI #10 (EVS) had informed her that EI #1 had taken the resident's remote earlier in the day. When asked what she considered this incident as, EI #11 replied, "To me it's abuse because the remote control is hers and it's taking her belongings." In an interview on 04/11/13 at 8:45 AM, EI #14, a Certified Nursing Assistant (CNA) who was assigned to care for RI #2 on 04/04/13, was asked if she provided care to RI #2 on 04/04/13. EI #14 said yes, she was assigned to care for RI #2 from 3:00 PM to 11:00 PM. EI #14 was asked about the incident when the CNA (EI #1) removed RI #2's remote control. EI #14 stated when she did her walk--around 2:30 PM to 3:00 PM, RI #2 pressed her call light. EI #14 stated she went to RI #2's room to answer the call light and the resident asked for her remote, EI #14 gave the resident her remote and left the room. EI #14 stated then before the supper trays came out she went back to check on the residents she was assigned to. According to EI #14, EI #1 was coming out of an activity and offered to help with RI #2. EI #14 stated when she and EI #2 went into RI #2's room to change her, EI #1 took the resident's remote and turned the TV off. When asked why EI #1 took the remote, EI #14 stated because RI #2 did not call for the bedpan. EI #14 witnessed EI #1 take the remote and place it on the night stand against the window out of her reach. EI #14 was asked if RI #2 could have gotten the remote if she wanted it and EI #14 said no. EI #14 was asked what exactly EI #1 said to RI #2 about the remote. EI #14 said EI #1 told RI #2 "Since you did not call for the bedpan, there's no sense in you laying in here watching TV." EI #14 stated when they were finished providing care, EI #1 walked out of the room and she (EI #14) gave the resident her remote. According to EI #14, RI #2 told her she had not watched TV all day because EI #1 had taken her remote from her. When asked if she thought what the CNA (EI #1) did was abuse, EI #14 replied, "Oh yes." When asked what is her responsibility when she sees something that may be abuse, EI #14 stated if EI #6 (RN Supervisor) had not come to her shortly after it happened, she would have reported it to her. In a follow-up interview with EI #14 on 04/11/13 at 1:50 PM, she was asked what tone of voice EI #1 used when she spoke with the resident about her remote. EI #14 answered, "She (EI #1) has a loud voice; it comes off rudely, not any tone that should be used when speaking to a resident." In an interview on 04/10/13 at 6:23 PM, EI #6, the RN Supervisor, was asked what prompted her to do an investigation of this incident with RI #2. EI #6 replied because RI #2 was upset. EI #6 stated she started an investigation Thursday afternoon (04/04/13) after RI #2 complained about the aide turning her TV off. According to EI #6, RI #2 thought the CNA removing the remote was punishment for "pooping" on herself. When asked had anyone reported to her something they thought was abuse, EI #6 said RI #2 thought she was being punished. EI #6 was asked what she did after she learned of the incident. EI #6 stated that she went to RI #2's room at 2:30 PM; the resident's TV was on. RI #2 told EI #6 that EI #1 had turned her TV off and put her remote on her roommate's table because she had "pooped" on herself. EI #6 stated she apologized to RI #2 and told her to put on her call light if it happened again. EI #6 stated she reported this to the Administrator, EI 4, who told her to treat it as a grievance and let the Director of Nursing (EI #5) know what she was doing. EI #6 stated the facility should have treated this as abuse from the beginning. EI #6's typed statement dated 04/04/13 documented, "It was brought to my attention by (EI #8, the Activity Director) that resident in room (RI #2's room) was upset about a CNA turning tv off and hiding remote control ... stated that the CNA was (EI #1). I went to (RI #2's) room around 14:30 (2:30 PM) to interview resident in regards to tv being turned off. (RI #2) was lying in bed with tv on ... ." EI #6 asked RI #2 how was her day, RI #2 responded "not good." When asked why her day was not good, RI #2 replied "she kept cutting my tv off and hiding my remote." EI #6 asked "Who was cutting your tv off?" RI #2 answered "(EI #1) and hiding my remote so I couldn't turn it back on." When asked why EI #1 would do that, RI #2 stated she didn't know, probably because she had pooped on herself but she couldn't help it. EI #6 told RI #2 she was sorry that this happened that is was not acceptable and if it happens again to immediately use her call light and call for EI #6. EI #6 stated she then left RI #2's room. Then about 2:55 PM, RI #2 turned her call light on and requested to speak with EI #6. EI #6 stated she returned to RI #2's room at 3:00 PM; the resident was laying in bed, the tv was off and the remote control was behind the tv out of the resident's reach. RI #2 stated EI #1 did not say why, but she turned the tv off and walked out. EI #6 stated she turned the tv back on and made sure the remote control was in reach of the resident. EI #6 then stated she called EI #1 into her office. EI #1 told EI #6 that RI #2 was mad at her because she had fussed at her for pooping everywhere. When asked if she had touched RI #2's remote, EI #1 said she may have turned the tv off, but she didn't remember. In an interview on 04/10/13 at 5:30 PM, EI #1 (CNA) was asked had she ever provided care to RI #2. EI #1 said yes. When asked about RI #2, EI #1 stated "She (RI #2) wants you to do everything for her now she won't even use her call light when she has a BM (bowel movement). She will call you after she does it. She can not walk now." "She goes to activities (and) messes on herself (and) won't tell anyone she did it. You can smell it. She is embarrassing to CNAs because it make us like we are not doing our job. When you know she (RI #2) can do better." When asked if she ever gets frustrated with RI #2 because she thinks RI #2 could do better, EI #1 said yes. EI #1 stated if she removed RI #2's remote, it was an accident and she forgot to give the remote back. When asked if she forgot more than once and removed the remote out of the resident's reach, EI #1 stated she could have. According to EI #1's "Time Card Screen" printed on 04/11/13, EI #1 clocked in the facility on 04/04/13 at 6:18 AM and clocked out at 10:58 PM; on 04/06/13 EI #1 clocked in at 2:27 PM and clocked out at 10:55 PM; on 04/07/13 EI #1 clocked in at 2:28 PM and clocked out at 10:54 PM; on 04/08/13 EI #1 clocked in at 2:26 PM and clocked out at 10:57 PM; and on 04/10/13 EI #1 clocked in at 2:23 PM and clocked out at 8:23 PM. On 04/10/13 at 8:25 PM, the Surveyor observed the RN Supervisor, EI #7 send EI #1 (CNA) home. In an interview with EI #7, a RN Supervisor, on 04/10/13 at 8:30 PM, she was asked who instructed her to send the CNA (EI #1) home. EI #7 replied that as a supervisor she made the decision to send EI #1 home until the investigation was over. When asked what prompted her decision, EI #7 stated, "Because that is what we are suppose to do when there is an allegation, send them home until it is investigated." EI #7 was asked if she was aware of the incident on 04/04/13 and she said yes. When asked why she didn't send EI #1 home on that date, EI #7 stated she notified the Director of Nursing (EI #5) on the afternoon of 04/04/13 and they talked to EI #1 (CNA) and told her not to do it anymore. EI #7 was asked about the facility's policy on abuse allegations. EI #7 explained to notify the Abuse Coordinator (EI #) or the Administrator (EI #4), do and investigation, take statements from the people involved and send them home until the investigation is completed. When asked was there any reason EI #1 was not sent home on 04/04/13, EI #7 replied, "I'm not sure." In a third interview with RI #2, in the presence of the Activity Director (EI #8) on 04/10/13 at 7:18 PM, she was asked to repeat to the State Surveyor what she had told the staff about her remote. RI #2 stated EI #1 took her remote away from her about three of four times that day. RI #2 could not remember the exact day, but stated it was one day last week. When asked how that made her feel, RI #2 replied not too good. RI #2 was asked why did EI #1 take her remote and she stated she thought it was because she had an accident in her incontinent brief that day. According to RI #2, she told the Activity Assistant she had hoped she would get to watch the music awards but she was afraid EI #1 would come and get her remote. When asked if she thought it was an accident that EI #1 took her remote, RI #2 said, "No." RI #2 was asked if she asked EI #1 for her remote and she said yes, but EI #1 told her she didn't need the remote, then EI #1 turned her TV off. RI #2 stated she got a nurse (EI #6) to turn her TV back on. According to RI #2, EI #1 was picking on her. This deficiency was cited as a result of the investigation of complaint/report number AL 787. ************************* On April 12, 2013 at 10:45 PM, the facility submitted an Allegation of Compliance (AOC) which documented: "F223: (EI #1) willfully turned TV off and took remote and hid it from (RI #2) as punishment for soiling herself on or about 4/4/13. Marion Regional ... Nursing Home understands that the above referenced allegation has been substantiated. As such, please be advised that the following actions have taken place in response: 1. (EI #1) was removed from providing care to (RI #2) immediately after the above referenced allegation came to our attention. 2. (EI #2), as of approximately 8:30 p.m. on April 10, 2013, was placed on administrative leave pending the outcome of immediate jeopardy investigation by the State of Alabama. 3. (Corporation Name) Employment Services is currently reviewing (EI #1's) employment status with (Corporation Name). 4. (Corporation Name) anticipates that (EI #1's) employment with (Corporation Name) will be discontinued in the very near future, either by termination, separation or as a consequence of the abuse allegation's substantiation. Additionally, as of April 12, 2013 (Corporation Name) appoints (EI #15) (Corporation Name) Risk Manager, to serve for a period of one (1) month as its Abuse Coordinator. (EI #15) will take the following actions: 1. (EI #15) will ensure that all residents and/or family members are interviewed to help determine if same/similar acts of abuse have taken place. This task will be accomplished by April 15, 2013. 2. As another avenue to help ensure all residents are interviewed, (EI #15) will ensure that residents attending the next Residents' Council meeting on April 15, 2013 regarding possible abuse and injury allegations. 3. Review the 24 Hour Grievance Log to determine if other instances of possible abuse are identified, investigated, and reported in accordance with applicable federal and state laws, rules, and regulations. (EI #15) will accomplish this task during the one (1) month period. Thereafter and as noted below, (EI #2) will continue in the Abuse Coordinator role and will report to (EI #15) and (EI #16) that such allegations have been properly handled to help ensure ongoing compliance. Once (EI #15) completes her one (1) month as Abuse Coordinator, those duties will revert back to (EI #2). Prior to (EI #2) re-assuming that role, (EI #15) will provide retraining to (EI #2) regarding the (Corporation Name) abuse policy and procedure. Thereafter, (EI #2) will continue to report allegations and investigations to (EI #15) and to (EI #16), (Corporation Name) VP (Vice President) for (name of local hospital). (EI #2) will be monitored by (EI #15) and (EI #16) for a period of three (3) months. Monitoring will be accomplished by monthly reviewing the 24 Hour Grievance Log and verifying that (EI #2) has sufficient documentation evidencing proper identification, investigation, and reporting of allegations." ************************* After reviewing the facility's AOC, in-service records, and interviews with staff, the immediate jeopardy was relieved on-site on 04/12/13 at 11:59 PM with the scope lowered to a "D" level to allow the facility time to monitor and/or revise its corrective actions to achieve compliance. At the direction of CMS (Centers for Medicare and Medicaid Services), the survey exit date has been changed to 4/15/13 and the immediate jeopardy was abated on this date.

Based on interviews and record reviews, the facility failed to report an allegation of abuse to the State Agency within 24 hours. Resident Identifier (RI) #2, an alert and oriented resident, was repeatedly subjected to verbal and mental abuse inflicted by Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) on 04/04/13, even though several staff members (two Registered Nurse (RN) Supervisors, Activity Director and Activity Assistant) were aware of the allegation of abuse. With staff knowledge that EI #1 willfully and intentionally turned the resident's TV off and took her remote, the staff failed to respond and continued to allow EI #1 the opportunity to take and hide the resident's remote and turn the TV off without her permission. The facility's management treated this incident as a grievance and not an allegation of abuse. This incident was not reported to the State Agency within 24 hours of the staff becoming aware on 4/04/2013. On 04/10/13, the State Agency received a report from the facility describing this incident as misappropriation of resident property and not an allegation of abuse. This deficient practice placed RI #2, one of three sampled residents reviewed for abuse in immediate jeopardy as it was likely to cause serious injury, harm and/or death. This deficient practice had the potential to affect the remaining 61 residents of the facility. On 04/11/13 at 5:54 PM, the Administrator, Interim Director of Nursing, Minimum Data Set (MDS) Coordinator, Social Service Director/Abuse Coordinator, Activity Director, Rehab Director, Human Resources Director, Staff Development Nurse, Medical Records Staff, and two Registered Nurse (RN) Supervisors were notified immediate jeopardy in the area of Resident Behavior and Facility Practices, F 225 had been identified. The immediate jeopardy began on 04/04/13. After the facility implemented immediate corrective action, the immediate jeopardy was abated on-site on 04/12/13 and the scope/severity lowered to a "D" level. Findings include: The facility's policy titled "Reporting Abuse (C154) with a revised date of August 2011, documented " ... Procedure: 1. MRNH (Marion Regional Nursing Home) will not condone resident abuse by anyone, including staff member, ... A member of the Abuse Investigation Team will complete the State of Alabama's Report of Abuse, Neglect, Misappropriation of Resident Property and Injury of Unknown Origin online within 24 hrs (hours) to the attention of "Complaint Unit" ... ." On 04/04/13 around 1:30 PM to 2:30 PM, the Environmental Service Director, EI #10, was summoned to RI #2's room. RI #2 informed her EI #1, CNA had willfully taken and hid her remote because she had "pooped " (had a bowel movement) on herself. Around 1:45 PM, the Activity Assistant, EI #11, overheard EI #1 ask the resident who gave her the remote back. EI #14, the CNA assigned to care for RI #2 during the 3:00 PM to 11:00 PM shift, stated around 2:30 PM to 3:00 PM, RI #2 pressed her call light. When EI #14 entered the resident's room, RI #2 asked the CNA to give her the remote. The remote control was not within the resident's reach again. At 2:30 PM, after being made aware of the incident, the RN Supervisor, EI #6, entered RI #2's room. According to EI #6, RI #2 told her EI #1 had turned her TV off without her permission and placed the remote on her roommate's TV stand. EI #6 stated RI #2 felt as though she was being punished for having a toileting accident on herself. EI #6 stated she apologized to the resident and instructed RI #2 to press her call light if it happens again. At 2:55 PM, RI #2 pressed her call light and requested the RN Supervisor, EI #6. EI #6 entered RI #2's room at 3:00 PM and observed RI #2 lying in bed, the TV was off and the remote was behind the TV, out of the resident's reach. RI #2 informed EI #6 that EI #1 (CNA) had come to her room, turned the TV off, placed the TV remote out of her reach and walked out the room. The RN Supervisor, EI #6, turned RI #2's TV on and placed the remote within the resident's reach. After leaving RI #2's room, EI #6 called the CNA into her office and questioned her about RI #2's remote. According to EI #6, EI #1 told her the resident was mad at her because she (CNA) had fussed at the resident for having a bowel movement everywhere. EI #1 stated she may have turned the TV off, but she could not remember. Then just before the supper trays were delivered, EI #1 offered to assist EI #14 in caring for RI #2. EI #14 witnessed EI #1 intentionally turn the resident's TV off and place the remote control on the nightstand next to the window. According to EI #14, EI #1 told the resident in a loud voice, "Since you did not call for the bedpan, there's no sense in you laying in here watching TV." In an interview on 04/11/13 at 8:15 AM, EI #4 (Administrator) was asked if he was familiar with the process when there is an allegation of abuse. EI #4 replied no, but he has a team (Director of Nursing, RN Supervisor and Social Worker) that is. When asked whose responsibility was it to report an allegation of abuse to the State Agency, EI #4 said the Administrator was ultimately responsible, but he expected to get the facts from the investigation so he could make an accurate report. The Administrator (EI #4) was asked what his responsibility was for reporting an allegation of abuse to the State Agency. EI #4 stated there is a certain time to report it, 24 hours. When asked if any of the above mentioned procedures were followed, EI #4 stated he was unsure if the incident was reported to the State Agency. EI #4 stated he guessed he should have followed up and not assumed it would be handled. According to the "Alabama Department of Public Health Online Incident Reporting System", EI #2 submitted an allegation of misappropriation of resident property on 04/10/13 at 8:01 PM. This report indicated the incident occurred on 04/04/13 at 4:00 PM, when RI #2 told staff that EI #1 would not let her have her TV remote when she (EI #1) works. She (RI #2) stated, "She (EI #1) told me I don't need a remote." This deficiency was cited as a result of the investigation of complaint/report number AL 787. ************************* On April 12, 2013 at 10:45 PM, the facility submitted an Allegation of Compliance (AOC) which documented: "F225 Failed to report allegations of abuse once facility became aware of them The allegation of abuse regarding (RI #2) and (EI #1) was reported to the state as of Wednesday, April 10, 2013. Accordingly, an investigation has begun and will be complete within the appropriate time frame as required by applicable state laws, rules, and regulations. It appears the break down in (Corporation Name's) abuse identification, investigation, and reporting policies and procedures came about in the staff's failure to appreciate that (EI #1's) actions described above, and as substantiated by the State of Alabama, constituted resident abuse. As such, (Corporation Name) has taken the following actions in response: 1. (Corporation Name) will retrain all employees whose job duties entail interaction with and care for residents. This includes, but is not limited to, nursing, dietary, housekeeping, and maintenance. All current (Corporation Name) staff receiving refresher training will take a post test to measure their knowledge and understanding. Furthermore, all current (Corporation Name) staff will re-take said post test once a week for six (6) weeks, and thereafter once a month for three (3) months. As of April 12, 2013, (EI #15), HR (Human Resource) Director has retrained most employees regarding types of abuse, the definitions of each, how to report suspected abuse, to report any such suspected abuse to the Abuse Coordinator. If/when (Corporation Name) staff is unable to timely contact the Abuse Coordinator, (Corporation Name) staff will report any such suspected abuse to (EI #17), (Corporation Name) Chief Compliance Officer. Additionally, employees will receive information regarding how to contact their local ombudsman and how to contact the Alabama Elder Care Hotline, namely by providing to all employees a "cheat sheet" containing said information. This task will be accomplished by (EI #15) by the end of the day on April 15, 2013. Attached is a list of (Corporation Name) staff who have already received such training as of April 12, 2013, and a copy of the materials provided during such training. Also attached is a list of (Corporation Name) staff yet to receive said training. (Corporation Name) staff who provide direct resident care and who have not yet received training will not be permitted to resume resident care activities until such time as the training has been received. 2. To help ensure timely reporting of allegations, the applicable ombudsmen's contact information is prominently displayed in at least four (4) locations within (Corporation Name). Additionally, a poster listing resident's rights are also prominently displayed within in at least two (2) locations within (Corporation Name). Upon admission to (Corporation Name), resident's receive a brochure that describes the ombudsman program and provides contact information should the resident seek to contact the ombudsman. A copy of the said brochure has been provided to the surveyors. Lastly, the Alabama Elder Care Hotline phone number is prominently displayed in at least two (2) locations within (Corporation Name). 3. To help ensured ongoing training and compliance, (Corporation Name) staff will receive training as follows" a. The (Corporation Name) abuse policy and procedure is and will continue to be discussed and presented to all new employees during their orientation process. b. All employees will receive refresher training at least annually. Such training will be a component of their annual employment review. When accomplishing this task, (Corporation Name) staff will receive abuse policy and procedure training and will take a post test to help ensure their knowledge and understanding. c. To monitor and measure (Corporation Name) staff's knowledge and understanding, (EI #15) will ensure that, for the next six (6) months, a sampling of at least three (3) (Corporation Name) staff will be chosen monthly and interviewed to help ensure their ongoing understanding and knowledge of the (Corporation Name) abuse policy and procedure. 4. As noted above and as of April 12, 2013, (Corporation Name) appoints (EI #15), (Corporation Name) Risk Manager, to serve for a period of one (1) month as its Abuse Coordinator. In this role, (EI #15) will thoroughly investigate all such reports of suspected abuse and will document information including, but not limited to the following: a. Interview resident and resident's family b. Interview relevant (Corporation Name) staff c. Interview other resident's as appropriate to determine extent of possible abuse. d. Interview any and all other witnesses e. Obtain written statements from all witnesses f. Document medical evaluation of resident(s) effected g. Document all care provided by staff and physicians to the resident h. Will report investigational findings to (EI #16) and the appropriate state agency as required by applicable federal or state laws, rules, or regulations." ************************* After reviewing the facility's AOC, in-service records, and interviews with staff, the immediate jeopardy was relieved on-site on 04/12/13 at 11:59 PM with the scope lowered to a "D" level to allow the facility time to monitor and/or revise its corrective actions to achieve compliance. At the direction of CMS (Centers for Medicare and Medicaid Services), the survey exit date has been changed to 4/15/13 and the immediate jeopardy was abated on this date.

Based on observation, interviews and record reviews, the facility failed to 1) prevent verbal and mental abuse; 2) identify a reported incident as an allegation of abuse; 3) investigate an allegation of abuse; 4) protect Resident Identifier (RI) #2 and other residents from further abuse; and 5) report an allegation of abuse to the State Agency within 24 hours. Resident Identifier (RI) #2, an alert and oriented resident, was repeatedly subjected to verbal and mental abuse inflicted by Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) on 04/04/13, even though several staff members (two Registered Nurse (RN) Supervisors, Activity Director and Activity Assistant) were aware of the allegation of abuse. With staff knowledge that EI #1 willfully and intentionally turned the resident's TV off and took her remote, the staff failed to respond and continued to allow EI #1 the opportunity to take and hide the resident's remote and turn the TV off without her permission. The facility's management treated this incident as a grievance and not an allegation of abuse. After the incident was reported, the Certified Nursing Assistant (EI #1) was allowed to continue to work; she was not removed from the facility thus, allowing her to continue to abuse RI #2. This incident was not reported to the State Agency within 24 hours of the staff becoming aware on 4/04/2013. On 04/10/13, the State Agency received a report from the facility describing this incident as misappropriation of resident property and not an allegation of abuse. This deficient practice placed RI #2, one of three sampled residents reviewed for abuse in immediate jeopardy as it was likely to cause serious injury, harm and/or death. This deficient practice had the potential to affect the remaining 61 residents of the facility as they continued to allow EI #1 to work until she was removed on 04/10/13 at 8:25 PM. On 04/11/13 at 5:54 PM, the Administrator, Interim Director of Nursing, Minimum Data Set (MDS) Coordinator, Social Service Director/Abuse Coordinator, Activity Director, Rehab Director, Human Resources Director, Staff Development Nurse, Medical Records Staff, and two Registered Nurse (RN) Supervisors were notified that immediate jeopardy in the area of Resident Behavior and Facility Practices, F 226 had been identified. The immediate jeopardy began on 04/04/13. After the facility implemented immediate corrective action, the immediate jeopardy was relieved on-site on 04/12/13 and the scope/severity lowered to a "D" level. Findings include: The facility's policy titled "In-Service Training on Abuse (C151)" with a revised date of August 2012, documented " ... Policy: It is the policy of Marion Regional Nursing Home that employees should be properly trained to spot, report and protect against abuse. Procedure: When educating staff, the guidelines below should be followed: ...c. Who is responsible for reporting abuse; d. The time frame for reporting abuse ...4. Inquiries concerning the facility's abuse prevention training program should be directed to the Social Worker, the DON (Director of Nursing), or the Administrator ... ." The facility's undated policy titled "Abuse Investigation (C155)" documented " ... Policy: All reports of suspected resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. Procedure: 1. Should an incident or suspected incident of resident abuse, neglect, or injury or an unknown source be reported, the administrator, or his designee, will appoint a member of management to investigate the alleged incident. 2. The administrator will provide to the person in charge of the investigation a copy of the "Resident Abuse Report Form" and any supporting documents relative to the alleged incident. 3. The individual conducting the investigation will, as a minimum: a. Review and ensure the completion of a Resident Abuse Form; ... d. Interview any witnesses to the incident; ... f. Advise the resident's attending physician of the matter and solicit his/her input regarding the resident's current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; ... ." The facility's policy titled "Reporting Abuse (C154) with a revised date of August 2011, documented " ... Procedure: 1. MRNH (Marion Regional Nursing Home) will not condone resident abuse by anyone, including staff member, ... A member of the Abuse Investigation Team will complete the State of Alabama's Report of Abuse, Neglect, Misappropriation of Resident Property and Injury of Unknown Origin online within 24 hrs (hours) to the attention of "Complaint Unit" ... ." The facility's policy titled "Protecting Residents from Abuse (3H.BNF.9500.0200.0710.) with a revised date of July 2010 documented " ... Policy: It is the policy of Marion Regional Nursing Home that residents should be protected from abuse. Procedure: When protecting residents from abuse, the guidelines below should be followed: 1. Preventing resident abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment ... ." A typed letter titled "Marion Regional Rehab & LTC (Long Term Care) Staff Meeting August 27, 2012" documented " ... We have revised our Abuse policy to include all seven types of abuse which include - ... Mental/Emotional Verbal ... I am the facility Abuse Investigator. You can report suspected abuse to any supervisor or member of management. Once reported, I will investigate and gather facts. We have 24 hrs (hours) to notify staff of an accusation of abuse. The staff member involved will be off work until the investigation is concluded ... ." According to the sign in sheet, EI #2, the Social Worker/Abuse Coordinator, conducted this meeting on 08/27/12 at 2:00 PM. On 04/04/13 around 1:30 PM to 2:30 PM, the Environmental Service Director, EI #10, was summoned to RI #2's room. RI #2 informed her EI #1, CNA had willfully taken and hid her remote because she had "pooped " (had a bowel movement) on herself. Around 1:45 PM, the Activity Assistant, EI #11, overheard EI #1 ask the resident who gave her the remote back. EI #14, the CNA assigned to care for RI #2 during the 3:00 PM to 11:00 PM shift, stated around 2:30 PM to 3:00 PM, RI #2 pressed her call light. When EI #14 entered the resident's room, RI #2 asked the CNA to give her the remote. The remote control was not within the resident's reach again. At 2:30 PM, after being made aware of the incident, the RN Supervisor, EI #6, entered RI #2's room. According to EI #6, RI #2 told her EI #1 had turned her TV off without her permission and placed the remote on her roommate's TV stand. EI #6 stated RI #2 felt as though she was being punished for having a toileting accident on herself. EI #6 stated she apologized to the resident and instructed RI #2 to press her call light if it happens again. At 2:55 PM, RI #2 pressed her call light and requested the RN Supervisor, EI #6. EI #6 entered RI #2's room at 3:00 PM and observed RI #2 lying in bed, the TV was off and the remote was behind the TV, out of the resident's reach. RI #2 informed EI #6 that EI #1 (CNA) had come to her room, turned the TV off, placed the TV remote out of her reach and walked out the room. The RN Supervisor, EI #6, turned RI #2's TV on and placed the remote within the resident's reach. After leaving RI #2's room, EI #6 called the CNA into her office and questioned her about RI #2's remote. According to EI #6, EI #1 told her the resident was mad at her because she (CNA) had fussed at the resident for having a bowel movement everywhere. EI #1 stated she may have turned the TV off, but she could not remember. Then just before the supper trays were delivered, EI #1 offered to assist EI #14 in caring for RI #2. EI #14 witnessed EI #1 intentionally turn the resident's TV off and place the remote control on the nightstand next to the window. According to EI #14, EI #1 told the resident in a loud voice, "Since you did not call for the bedpan, there's no sense in you laying in here watching TV." During an interview on 04/10/13 at 4:00 PM, EI #3, the Staff Development Nurse, stated on last week the Activity Director (EI #8) asked her if she had to report what a resident told her. The Activity Director informed EI #3 that RI #2 stated EI #1, a Certified Nursing Assistant (CNA) had removed her TV remote to the other side of the room where the resident could not reach it. EI #3 stated she told the Activity Director yes. When asked what made her think this incident needed to be reported, EI #3 stated because the resident (RI #2) told someone that EI #1 had removed her remote because she had a bowel movement in the bed and didn't use her call light. EI #3 stated, "You cannot retaliate against a resident, so I saw that as abuse." EI #3 was asked what steps she taught the staff to follow when they suspected abuse. According to EI #3, the staff are taught to report abuse immediately to the Abuse Coordinator, EI #2. Once an accusation has been made, it should be reported within 24 hours to the State Agency. EI #3 stated for the protection of the resident, the employee is off work until the investigation is completed. Once the investigation is completed, it is sent to the State Agency. If the accusation is unfounded, the employee can return to work. If the accusation is found to be true, the employee is terminated and reported to the Nurse Aide Registry. In a follow-up interview on 04/11/13 at 5:15 PM, EI #3, the Staff Development Nurse stated the last in-service on abuse was 12/06/12 and EI #1, (CNA) attended. On 04/10/13 at 8:25 PM, the Surveyor observed the RN Supervisor, EI #7 send EI #1 (CNA) home. In an interview with EI #7, a RN Supervisor, on 04/10/13 at 8:30 PM, she was asked who instructed her to send the CNA (EI #1) home. EI #7 replied that as a supervisor she made the decision to send EI #1 home until the investigation was over. When asked what prompted her decision, EI #7 stated, "Because that is what we are suppose to do when there is an allegation, send them home until it is investigated." EI #7 was asked if she was aware of the incident on 04/04/13 and she said yes. When asked why she didn't send EI #1 home on that date, EI #7 stated she notified the Director of Nursing (EI #5) on the afternoon of 04/04/13 and they talked to EI #1 (CNA) and told her not to do it anymore. EI #7 was asked about the facility's policy on abuse allegations. EI #7 explained to notify the Abuse Coordinator (EI #) or the Administrator (EI #4), do and investigation, take statements from the people involved and send them home until the investigation is completed. When asked was there any reason EI #1 was not sent home on 04/04/13, EI #7 replied, "I'm not sure." EI#7 was asked what she did about the information that was reported to her. EI #7 explained she asked EI #1 if she put the resident's remote behind the TV. At first EI #1 said no, then changed her mind and said she could not remember. EI #7 stated she told EI #1 not do it anymore, to not go back in RI #2's room. When asked what type of allegation she considered this incident, EI #7 answered misappropriation of personal property. During a follow-up interview on 04/11/13 at 2:15 PM, the RN Supervisor (EI #7) was asked to define abuse. EI #7 defined abuse as, "When you mistreat someone in any form verbal, physical, emotional, sexual." When asked if she still considered this incident between the CNA (EI #1) and the resident (RI #2) as misappropriation of personal property, EI #7 replied, "No, I would say emotional abuse." In a third interview with EI #7 on 04/12/13 at 7:00 PM, she was asked why she did not think the incident with RI #2 and EI #1 was an allegation of abuse. EI #7 explained it was when she interviewed EI #1, the CNA said she did not do it and it was reported to the Administrator, who said to handle it as a grievance. In an interview on 04/10/13 at 6:23 PM, EI #6, the RN Supervisor, who had been employed in the facility since August 2012, stated she supervised Licensed Practical Nurses (LPNs) and CNAs. When asked what training had she received on abuse, EI #6 stated in new employee orientation the types of abuse was discussed and to report it immediately to your supervisor, the Director of Nursing (DON), then the Administrator. EI #6 was asked what prompted her to do an investigation of this incident with RI #2's remote. EI #6 replied because RI #2 was upset. EI #6 stated the Administrator told her to treat the incident as a grievance. When asked what has been done since she reported the incident to the Administrator, EI #6 stated she made sure EI #1 was not assigned to RI #2. EI #6 was asked if she was finished with her investigation. EI #6 had not completed her investigation and stated she was still waiting on EI #1's statement. EI #6 was asked what her responsibility was when the person she reported abuse to did nothing about it. EI #6 answered that she would report it herself to the State or go up the chain of command. EI #6 stated the facility should have treated this as abuse from the beginning. When asked if she felt this was abuse, EI #6 replied yes and explained she felt it was mental or psychological abuse. (On 04/10/13 at 5:20 PM, the surveyor observed EI #1 in RI #2's room feeding her roommate.) EI #6 was asked why EI #1 was observed assisting RI #2's roommate with her supper meal. EI #6 stated there was no reason EI #1 should have been in RI #2's room and explained that she encouraged EI #1 not to go in RI #2's room, but she didn't tell her not to go in the room. EI #6 acknowledged that she was unaware EI #1 was in RI #2's room. When asked who would have told EI #1 to feed RI #2's roommate, EI #6 said no one, and added that EI #1 just goes and does things on her own. EI #6 stated it was on 04/04/13 that she told EI #1 she would not be allowed in RI #2's room. When asked how the facility was ensuring the resident's safety, EI #6 replied we have not done a good job of it with this incident. In a follow-up interview on 04/10/13 at 8:15 PM, EI #6 was asked what happens now with the investigation. EI #6 replied that she asked EI #1 to leave pending further investigation. EI #6 explained she should have asked EI #1 to leave on Thursday, 04/04/13. According to EI #1's "Time Card Screen" printed on 04/11/13, EI #1 clocked in the facility on 04/04/13 at 6:18 AM and clocked out at 10:58 PM; on 04/06/13 EI #1 clocked in at 2:27 PM and clocked out at 10:55 PM; on 04/07/13 EI #1 clocked in at 2:28 PM and clocked out at 10:54 PM; on 04/08/13 EI #1 clocked in at 2:26 PM and clocked out at 10:57 PM; and on 04/10/13 EI #1 clocked in at 2:23 PM and clocked out at 8:23 PM. From 04/04/13 to 04/10/13, EI #1 was assigned to 17 residents' rooms caring for 25 residents after the staff was made aware EI #1 (CNA) had punished a resident on 04/04/13 for having a bowel movement in her bed. In an interview on 04/11/13 at 2:30 PM, EI #2, the Social Worker/Abuse Coordinator, was asked how long had she been the Abuse Coordinator. EI #2 stated since she was hired. EI #2 had been employed with the facility for three years. When asked the difference between an abuse allegation and a grievance, EI #2 stated if something is done willfully, that is abuse and a grievance is something that someone did that was not intentional. EI #2 stated the only way you could determine it was willful would be to do an investigation. EI #2 was asked what she considered the incident where the CNA (EI #1) took the resident's remote control and hid it because the resident did not call for assistance when she had a bowel movement. EI #2 replied, "I consider that abuse." When asked when she became aware of the incident, EI #2 stated late yesterday (04/10/13). EI #2 was asked if she told EI #6, an RN Supervisor to handle this incident as a grievance and she said yes. EI #2 was asked why she told EI #6 to handle this as a grievance, if she thought it was abuse. EI #2 stated she did not think it was abuse when EI #6 initially told her about the incident on Friday, 04/05/13. EI #2 stated it wasn't until yesterday (04/10/13) that she found out the CNA was hiding the remote from the resident. According to EI #2 she asked EI #6 why the CNA (EI #1) was hiding the remote. The RN Supervisor (EI #6) told EI #2 it was because the CNA (EI #1) was punishing the resident for using the bathroom on herself. According to the "Alabama Department of Public Health Online Incident Reporting System", EI #2 submitted an allegation of misappropriation of resident property on 04/10/13 at 8:01 PM. This report indicated the incident occurred on 04/04/13 at 4:00 PM, when RI #2 told staff that EI #1 would not let her have her TV remote when she (EI #1) works. She (RI #2) stated, "She (EI #1) told me I don't need a remote." In an interview on 04/11/13 at 10:00 AM, EI #5 stated she has been the Interim Director of Nursing since February 2013. EI #5 was asked when she became aware of the issue between RI #2 and EI #1. EI #5 stated it was on Friday 04/05/13 after the 9:00 AM meeting, when EI #6, RN Supervisor, requested to see her, the Administrator (EI #4), the Social Worker/Abuse Coordinator (EI #2) and another RN Supervisor (EI #7). According to EI #5, EI #6 told the group that RI #2 reported that EI #1 took her remote and placed it out of the resident's reach. EI #5 stated EI #6 asked if she should she treat this as abuse or a grievance. EI #5 stated she told the group she didn't know and the Administrator (EI #4) stated lets treat this as a grievance. EI #5 stated she asked if that is what they normally do and EI #2 (Abuse Coordinator) and EI #4 (Administrator) both said yes. EI #5 stated she trusted the knowledge of EI #2 and EI #4 because the two of them had experience in the matter. According to EI #5 in her role of Interim DON she was only to assist with personnel issues and help improve employee morale. In an interview on 04/11/13 at 8:15 AM, EI #4 (Administrator) was asked if he was familiar with the process when there is an allegation of abuse. EI #4 replied no, but he has a team (Director of Nursing, RN Supervisor and Social Worker) that is. When asked whose responsibility was it to report an allegation of abuse to the State Agency, EI #4 said the Administrator was ultimately responsible, but he expected to get the facts from the investigation so he could make an accurate report. The Administrator was asked how he identified what is or might be considered abuse. He gave several examples including mistreatment by staff and retaliation. EI #4 was asked what he was told about the incident between EI #1 and RI #2 that occurred on 04/04/13. EI #4 stated he was told EI #1 (CNA) placed the remote control out of RI #2's reach; that EI #5 (DON) and EI #6 (RN Supervisor) confronted EI #1 Thursday (04/04/13) afternoon. When confronted, EI #1 said she didn't do it, then she said maybe she did. When asked what were his instructions to EI #5 and EI #6, the Administrator stated he told them to investigate the incident, then he left for an out of state meeting. EI #4 was asked if he told EI #5 and EI #6 to treat the incident as a grievance. EI #5 said he talked about whether to treat the incident as a grievance with the team during the meeting and EI #2 (Social Worker/Abuse Coordinator) said she would treat it as a grievance. EI #4 stated he assumed the staff would handle the incident and further explained that he was learning the process so he relied on his team. When asked what it sounded like if the CNA (EI #1) was indeed taking the resident's remote, EI #4 replied that sounds like abuse. EI #4 was asked what his responsibility was towards a resident when an allegation of abuse has been made. EI #4 replied to protect them. When asked how does he ensure a resident is protected, EI #4 stated by asking the staff not to work, then starting an investigation. EI #4 explained the appropriate action would be taken pending the outcome of the investigation. The Administrator (EI #4) was asked what his responsibility was for reporting an allegation of abuse to the State Agency. EI #4 stated there is a certain time to report it, 24 hours. When asked if any of the above mentioned procedures were followed, EI #4 stated he was unsure if the incident was reported to the State Agency, if the resident was protected or if the CNA was suspended because he left town. EI #4 stated he guessed he should have followed up and not assumed it would be handled. During a follow-up interview on 04/12/13 at 5:35 PM, EI #4, the Administrator was asked why he did not think the incident involving the remote was abuse when the RN Supervisor (EI #6) reported the incident to him on 04/04/13. EI #4 explained that he didn't know and he asked EI #6 what she thought. According to EI #4, EI #6 told him she didn't know and that she was going to talk with the Director of Nursing, EI #5. EI #4 stated on Friday 04/05/13, it became a group consensus to treat the incident as a grievance. This deficiency was cited as a result of the investigation of complaint/report number AL 787. ************************* On April 12, 2013 at 10:45 PM, the facility submitted an Allegation of Compliance (AOC) which documented: "F226 Failed to implement 4/7 components of facility abuse policy and procedure (EI #15) will review and revise its policies and procedures to ensure they are current and consistent with applicable federal and state laws, rules, and regulations. A copy of any and all such revised policies will be provided to the State of Alabama for review and approval by Wednesday, April 17, 2013. (Corporation Name) staff, as noted above will receive appropriate training regarding (Corporation Name) abuse policy and procedure. " ************************* After reviewing the facility's AOC, in-service records, and interviews with staff, the immediate jeopardy was relieved on-site on 04/12/13 at 11:59 PM with the scope lowered to a "D" level to allow the facility time to monitor and/or revise its corrective actions to achieve compliance. At the direction of CMS (Centers for Medicare and Medicaid Services), the survey exit date has been changed to 4/15/13 and the immediate jeopardy was abated on this date.

Based on interviews and record reviews, the facility's Administrator, Director of Nursing and Abuse Coordinator failed to provide management and oversight to ensure the facility's abuse policies and procedures were implemented. With staff knowledge that Employee Identifier (EI) #1, a Certified Nursing Assistant willfully and intentionally turned Resident Identifier (RI) #2's TV off and took her remote on 04/04/13. The staff failed to respond and continued to allow EI #1 the opportunity to take and hide the resident's remote and turn the TV off without her permission. The facility's management staff failed to identify this incident as an allegation of verbal and mental abuse, in that they treated this incident as a grievance; prevent verbal and mental abuse because they allowed the alleged perpetrator to continue to provide care to this resident; timely investigate an allegation of abuse; protect Resident Identifier (RI) #2 and other residents from further abuse, when they failed to remove this CNA from direct patient care; and report an allegation of abuse to the State Agency within 24 hours. This deficient practice placed RI #2, one of three sampled residents reviewed for abuse and had the potential to affect the remaining 61 residents residing in the facility, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. On 04/11/13 at 5:54 PM, the Administrator, Interim Director of Nursing, Minimum Data Set (MDS) Coordinator, Social Service Director/Abuse Coordinator, Activity Director, Rehab Director, Human Resources Director, Staff Development Nurse, Medical Records Staff, and two Registered Nurse (RN) Supervisors were notified immediate jeopardy in the area of Administration, F 490 had been identified. The immediate jeopardy began on 04/04/13. After the facility implemented immediate corrective action, the immediate jeopardy was abated on-site on 04/12/13 and the scope/severity lowered to a "D" level. Findings include: Refer to F 223 and F 226. The Social Services Director "Job Description" with a review date of June 2010 documented " ... Regulatory Knowledge: Complies with regulatory and accrediting agency requirements ... ." The Director of Nurses "Job Description" with a review date of June 2010 documented " ... Regulation Compliance: Ensures the facility is in compliance with various legal, statutory and regulatory requirements ... ." The Administrator's "Job Description" with a review date of 06/15/10 documented " ... Leadership: Responsible for ensuring the maintenance of high quality, effective and efficient operations of the facility. This includes direction and use of various management programs, communications, techniques, policies and procedures guidelines, etc. Regulation Compliance: Ensures that the facility is in compliance with various legal, statutory and regulatory requirements ... ." In an interview on 04/11/13 at 2:30 PM, EI #2, the Social Worker/Abuse Coordinator, was asked how long had she been the Abuse Coordinator. EI #2 stated since she was hired. EI #2 had been employed with the facility for three years. EI #2 was asked what she considered the incident where the CNA (EI #1) took the resident's remote control and hid it because the resident did not call for assistance when she had a bowel movement. EI #2 replied, "I consider that abuse." When asked when she became aware of the incident, EI #2 stated late yesterday (04/10/13). EI #2 was asked if she told EI #6, an RN Supervisor to handle this incident as a grievance and she said yes. EI #2 was asked why she told EI #6 to handle this as a grievance, if she thought it was abuse. EI #2 stated she did not think it was abuse when EI #6 initially told her about the incident on Friday, 04/05/13. EI #2 stated it wasn't until yesterday (04/10/13) that she found out the CNA was hiding the remote from the resident. According to EI #2 she asked EI #6 why the CNA (EI #1) was hiding the remote. The RN Supervisor (EI #6) told EI #2 it was because the CNA (EI #1) was punishing the resident for using the bathroom on herself. In an interview on 04/11/13 at 10:00 AM, EI #5 stated she has been the Interim Director of Nursing since February 2013. EI #5 was asked when she became aware of the issue between RI #2 and EI #1. EI #5 stated it was on Friday 04/05/13 after the 9:00 AM meeting, when EI #6, RN Supervisor, requested to see her, the Administrator (EI #4), the Social Worker/Abuse Coordinator (EI #2) and another RN Supervisor (EI #7). According to EI #5, EI #6 told the group that RI #2 reported that EI #1 took her remote and placed it out of the resident's reach. EI #5 stated EI #6 asked if she should she treat this as abuse or a grievance. EI #5 stated she told the group she didn't know and the Administrator (EI #4) stated lets treat this as a grievance. EI #5 stated she asked if that is what they normally do and EI #2 (Abuse Coordinator) and EI #4 (Administrator) both said yes. EI #5 stated she trusted the knowledge of EI #2 and EI #4 because the two of them had experience in the matter. According to EI #5 in her role of Interim DON she was only to assist with personnel issues and help improve employee morale. In an interview on 04/11/13 at 8:15 AM, EI #4, the Administrator, was asked if he was familiar with the process when there is an allegation of abuse. EI #4 replied no, but he has a team (Director of Nursing, RN Supervisor and Social Worker) that is. When asked whose responsibility was it to report an allegation of abuse to the State Agency, EI #4 said the Administrator was ultimately responsible, but he expected to get the facts from the investigation so he could make an accurate report. The Administrator was asked how he identified what is or might be considered abuse. He gave several examples including mistreatment by staff and retaliation. EI #4 was asked what he was told about the incident between EI #1 and RI #2 that occurred on 04/04/13. EI #4 stated he was told EI #1 (CNA) placed the remote control out of RI #2's reach; that EI #5 (DON) and EI #6 (RN Supervisor) confronted EI #1 Thursday (04/04/13) afternoon. When confronted, EI #1 said she didn't do it, then she said maybe she did. When asked what were his instructions to EI #5 and EI #6, the Administrator stated he told them to investigate the incident, then he left for an out of state meeting. EI #4 was asked if he told EI #5 and EI #6 to treat the incident as a grievance. EI #5 said he talked about whether to treat the incident as a grievance with the team during the meeting and EI #2 (Social Worker/Abuse Coordinator) said she would treat it as a grievance. EI #4 stated he assumed the staff would handle the incident and further explained that he was learning the process so he relied on his team. When asked what it sounded like if the CNA (EI #1) was indeed taking the resident's remote, EI #4 replied that sounds like abuse. EI #4 was asked what his responsibility was towards a resident when an allegation of abuse has been made. EI #4 replied to protect them. When asked how does he ensure a resident is protected, EI #4 stated by asking the staff not to work, then starting an investigation. EI #4 explained the appropriate action would be taken pending the outcome of the investigation. The Administrator (EI #4) was asked what his responsibility was for reporting an allegation of abuse to the State Agency. EI #4 stated there is a certain time to report it, 24 hours. When asked if any of the above mentioned procedures were followed, EI #4 stated he was unsure if the incident was reported to the State Agency, if the resident was protected or if the CNA was suspended because he left town. EI #4 stated he guessed he should have followed up and not assumed it would be handled. During a follow-up interview on 04/12/13 at 5:35 PM, EI #4, the Administrator was asked why he did not think the incident involving the remote was abuse when the RN Supervisor (EI #6) reported the incident to him on 04/04/13. EI #4 explained that he didn't know and he asked EI #6 what she thought. According to EI #4, EI #6 told him she didn't know and that she was going to talk with the Director of Nursing, EI #5. EI #4 stated on Friday 04/05/13, it became a group consensus to treat the incident as a grievance. This deficiency was cited as a result of the investigation of complaint/report number AL 787. ************************* On April 12, 2013 at 10:45 PM, the facility submitted an Allegation of Compliance (AOC) which documented: "F490 Administration staff failed to provide oversight and management to ensure abuse policy and procedure is implemented when become aware of abuse allegations. As noted above, (EI #15) will review daily the 24 Hour Grievance Log to help ensure: 1.) All allegations of abuse and injury are properly recorded. 2.) Allegations of abuse and injury recorded are thoroughly investigated. 3.) Will meet and discuss with staff to ensure that all such allegations are timely and thoroughly investigated. 4.) Will ensure that all such allegations are properly reported to the applicable state agency(s). 5.) Will report and discuss all such allegations with (EI #16) to help ensure proper management and oversight. (Names of facility Administration Staff) will submit to abuse retraining. All but (EI #5) have already completed same. Additionally, the facts surrounding this allegation and the breakdown in process leading to not treating such as abuse and therefore failing to report same have been discussed. All have voiced their understanding of the policy and process and agree to abide by same going forward. ************************* After reviewing the facility's AOC, in-service records, and interviews with staff, the immediate jeopardy was relieved on-site on 04/12/13 at 11:59 PM with the scope lowered to a "D" level to allow the facility time to monitor and/or revise its corrective actions to achieve compliance. At the direction of CMS (Centers for Medicare and Medicaid Services), the survey exit date has been changed to 4/15/13 and the immediate jeopardy was abated on this date.

Based on observation, record review and interview, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), failed to provide care according to a resident's plan of care, when she (EI #1) used a one person physical assist, instead of a two person physical assist, to transfer Resident Identifier (RI) #1, on 09/20/10. In March 2010, Resident Identifier (RI) #1 was assessed as not being able to attempt the test for balance while standing without physical help. The facility assessed RI #1and determined she was at high risk for falls, totally dependent upon two (2) staff members for transfers and requiring the use of a mechanical lift to transfer safely. RI #1's current care plans and Activities of Daily Living (ADL) sheet instruct nursing staff to transfer times (X) 2 assist with a hoyer lift / sling. On 09/20/10 around 2:15 PM, EI #1 (CNA) got RI #1 up using a stand up lift to take the resident to the bathroom. EI #1 reported that she was suppose to get assistance when using the lift to transfer residents; however, she (EI #1) said that she would perform the transfer by herself if she (EI #1) felt comfortable. EI #1 said that she was about to pull up RI #1's dress to pull down her adult brief when the stand up lift started going down too fast. EI #1 said it was like emergency release. EI #1 reported that she tried to stop the lift by using the remote; but, it would not work. The lift continued to go down too fast before EI #1 could get RI #1 out or get behind the resident. According to EI #1, RI #1 fell in the bathroom, with the lift belt tight underneath her armpits; RI #1 cried out in pain. EI #1 asked RI #1's roommate to activate the call light, ran to the door and called out for help. EI #3, a Registered Nurse (RN), and EI #10, a Licensed Practical Nurse (LPN), responded to EI #1's call for help. Upon entering RI #1's room, EI #3 (RN) and EI #10 (LPN) reported that RI #1 was in a sitting or crouching position on the bathroom floor with her left leg underneath her and the lift belt tightly around her armpits. EI #3 described RI #1 as being blue around the mouth. EI #3 and EI #10 assisted EI #1 with getting RI #1 out of the bathroom, and onto the floor in the resident's room. A Hoyer lift had to be used to transport RI #1 back to bed. Because RI #1 was complaining of left arm and leg pain, X-rays were ordered and the resident was sent out to the emergency room (ER) in Hamilton, Alabama for further evaluation and treatment of [REDACTED].#1 also had a fractured left humerus, in addition to, the fractured left femur. Amputation was considered as a possible intervention for treatment of [REDACTED].#1) underwent surgery to repair her broken left humerus and femur on 9/21/10. This deficient practice affected RI #1, one of four sampled residents care planned for falls. On November 2, 2010 at 1:24 PM, the facility's Administrator (EI #7) was notified that after a review by the Atlanta Regional Office for the Centers of Medicare / Medicaid Services (CMS), F 281 at "J" level would be cited, and a revised CMS 2567 report would be sent today (11/02/10) to the facility. The IJ began on September 20, 2010, and continued until October 16, 2010, when the facility implemented corrective actions to remove the immediacy and prevent any future reoccurrence. The Administrator (EI #7) was advised that although the immediacy was removed on 10/16/10, the facility is required to submit a plan of correction (POC) for F 281. Findings Include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE], assessed RI #1 as having moderately impaired daily decision making skills, with short term memory problems. RI #1 is coded as being totally dependent on two staff members for physical assistance with transfer and toilet use; the resident's mode of transfer is identified as a mechanical lift. The resident is assessed as not being able to attempt the test for balance while standing without physical help. The Resident Assessment Protocol Summary (RAPS) identified falls as a problem area for RI #1, under section V of this MDS. In comparison, a Quarterly MDS dated [DATE], assessed that RI #1's memory and decision making skills remained the same. RI #1 is coded as requiring extensive to total assist of staff for transfers and bed mobility. RI #1 had no history of falls during this assessment period. A "Fall Risk Assessment" dated 09/16/10, identifies RI #1 as "chair bound, unable to stand, takes 3-4 medications currently and/or within the last 7 days (underlined- [MEDICATION NAME], Cathartics, Diuretics, Hypoglycemic and Sedatives), and has predisposing diseases of Diabetes and Fractures." According to this assessment, a "Total Score of 10 or above represents HIGH RISK." RI #1's score was 10, indicating she was at high risk for falls. RI # 1's care plans for Potential for Falls, Impaired Physical Mobility and ADL (activities of daily living) Deficit revealed that these three care plans were last reviewed on 09/15/10. All three care plans document the approach, "Transfer per 2 assist" with Hoyer sling lift/leg. The September 2010 Activities of Daily Living (ADL) Sheets, which are used by CNAs to document care, listed the following resident care need for RI #1: "UP TO W/C (wheelchair) DAILY- TRANSFER X (times) 2 ASSIST WITH HOYER LIFT- REPO (reposition) EVERY HOUR OR LEG SLING OR CHORUS IF ABLE - LEAVE SLING IN CHAIR FOR RETURN TO BED." A "Fall/Unusual Occurrence" report signed by the Administrator (EI #7) on 09/27/10, identified RI #1 as the resident involved in a fall from a stand up lift on 09/20/10. This fall report documented the following description: "It was reported on 9/20/10 at approximately 2:15 pm that CNA (EI #1's name) had gotten resident (RI #1's name) up in the stand up lift to take her to the bathroom. (EI #1) states that 'as I was about to pull up her dress to pull down her pull up the stand up lift started going down to fast for me to pull her out and get behind her.' Ms. (RI #1's name) fell to the floor. As a result of the fall Ms. (RI #1's name) sustained a displaced and probably impacted fracture at the neck of the left humerus. She (RI #1) also sustained a displaced oblique [MEDICAL CONDITION] femoral shaft. Radiological findings also indicated [MEDICAL CONDITION] and [MEDICAL CONDITION] joint disease. ...As a result of the radiological findings Ms. (RI #1's name) was transferred to North Mississippi Medical Center in Tupelo. Ms. (RI #1's name) sponsor and physician was notified. The lift in question was immediately taken out of service. (EI #13's name), Biomedical Medical Tech. was notified. He (EI #13) came on 09/21/10 and inspected the lift. ...The lift has not malfunctioned again. Ms. (EI #1's name) reports in her statement that when the left (lift) was going down she attempted to use the remote hand control and it would not work. After continuing to try the control it did eventually work. (EI #13's name) will replace some parts to include the remote hand control that he fills (feels) may have caused a malfunction. ...There are no indications that (EI #1's name) was not using the lift correctly. However, as a safety measure (EI #1's name) will be re-inserviced on use of the lift and will be checked for competence Conclusion: It is my opinion that the cause of the fall was due to a malfunction of the lift. ..." A "Work Order Report" dated 10/12/10, listed the task code, "Erratic Performance" for the patient lift, and included the comments of: "Troubleshot and found that handset had loose item inside and when held at a certain angle. Stand up would go into down mode on it's own without pressing 'down button' on handset. Replaced handset and controller unit. Checked operation of stand up. PASSED. Returned to service." The facility's fall investigation report contained a signed statement from EI #1, the CNA assigned to RI #1 on 09/20/10. EI #1's "Employee Statement" dated 09/20/10, documents: "I was taking (Name of resident) to the bathroom, as I was about to pull up her dress to pull down her pullup the stand-up lift started going down fast, to (too) fast for me to pull her out and get behind her. I got help from CNAs and nurses we pulled her out into the middle of her room, layed her down on the floor got a net & (and) a net lift to put her in her bed. As I was trying to stop the lift I was trying to use the remote and it would not work. The lift went completly (completely) down and about a min (minute) after it went down the remote started working and we were able to get her to the floor and back in bed." On 10/14/10 at 10:10 AM, EI #1 (RI #1's CNA) was interviewed regarding RI #1's fall on 09/20/10. She recalled that RI #1 was not completely over the toilet. The lift had started to go down while she was trying to pull up RI #1's dress. She added that it was like emergency release; RI #1 was going down. According to EI #1, RI #1 cried out that she was hurting. EI #1 said that she got RI #1's roommate to put on the call light for help, went to the door and called out for help. EI #1 demonstrated how RI #1's body was positioned by raising her arms up above her head, and said the resident was hanging. She said it took 3 minutes for RI #1 to get her breath good. EI #1 acknowledged that she was supposed to use two for transfer; but, she would do it as a one person transfer, if she felt comfortable. On 10/13/10 at 6:35 PM, RI #1 was observed in bed with a sling on her left arm. She was asked what happened. RI #1 stated, "dropped me from the lift." She was asked if anything else hurt. She replied, "Just my shoulder and leg." Contained within the facility's fall investigation report was a signed statement from EI #3, a Registered Nurse (RN) on-duty on 09/20/10. EI #3's "Employee Statement" dated 09/20/10, documents: "I was at the east desk when (EI #9 maintenance man) said they need a nurse in (RI #1's room location). Upon entering room (EI #1) had (RI #1) in bathroom on the stand up lift and RI #1 was in a sitting position with belt from lift still around her. (EI #1) stated, "when I went to pull down her pull up the lift when (went) down really fast and I could not get behind her." EI #10 (licensed practical nurse) entered room and we got RI #1 out of bathroom to middle of floor and eased her down and placed a pillow under her head. She (RI #1) was blue around the mouth. Then she was assisted to bed with hoyer lift... . Then she (RI #1) was c/o (complaining of) left leg pain so we ordered xray." On 10/14/10 at 9:42 AM, EI #3 (a RN) was interview regarding RI #1's fall on 09/20/10. EI #3 recalled going to the east desk and the maintenance man (EI #9) telling her that help was needed in RI #1's bathroom. EI #3 said that RI #1 was in the lift and the resident went down. She demonstrated how RI #1's left leg was positioned back behind and underneath the resident. EI #3 said that RI #1's arms were on something and showed the surveyor how the resident's elbows were bent at shoulder level. EI #3 was asked if the lift belt was pressing the resident's shoulder upward. She affirmed that it was, and described it as being tight underneath the resident's arms. She revealed that the lift wouldn't move. EI #3 recalled that EI #1 was in RI #1's bathroom with the resident. EI #3 said that RI #1 had her leg back, the lift was down and it wouldn't go up or down. EI #3 was asked if there was anyone else in the room. EI #3 answered that only EI #1 and RI #1 were present. EI #3 was asked the number of staff needing to be present when a mechanical lift is used. She replied, two. EI #10, a Licensed Practical Nurse (LPN) who was on-duty at the time of the incident, emailed the facility an undated employee statement which documents: "On September 20, 2010, at approximately 1415 (2:15 PM), I was at the computer on the middle desk when I heard RN supervisor (EI #3) say loudly, 'She needs some help in there'. I observed (EI #3) standing outside of (RI #1's room). I proceeded to (RI #1's room location) and observed (EI #1), C.N.A. with resident (RI #1). (RI #1) was in the stand up lift, and (EI #1) stated that the lift would not work. (RI #1) was in a crouching position, with the lift belt underneath her armpits quite tightly. ...At that point, after ascertaining that (RI #1) was able to respond to verbal stimuli, several persons were required to put her (RI #1) in the Hoyer lift and transfer her (RI #1) to the bed. ...(RI #1) did complain of left arm pain, and leg pain, and subsequently she was taken to radiology for X-rays." On 10/14/10 at 8:30 AM, EI #10 (an LPN) was interviewed regarding RI #1's fall on 09/20/10. During the interview, EI #10 corroborated her emailed statement by providing a similar description of the incident. She revealed that the lift went down and the CNA couldn't get RI #1 back up onto the toilet during the transfer. She described RI #1 as being a large lady with a lot of weight. EI #10 said RI #1 slid down into the sling; she (EI #10) demonstrated this by showing the surveyor that the sling was underneath the resident's arms. EI #10 said that she thought RI #1's leg got twisted as she was going down. She recalled that the CNA (EI #1) stated, "this lift isn't working." EI #10 was asked the number of CNAs needed to use the lift for transfer. EI #10 answered that it is her understanding that two CNAs are required to use all lifts. When asked if she assessed RI #1, EI #10 replied that she wasn't the resident's nurse; she explained that she helped get RI #1 on the floor, got the hoyer lift and got the resident to bed. EI #10 was asked about injuries to the resident; she responded that RI #1 complained of arm pain and was sent for X-rays. According to X-ray reports, RI #1 had X-rays on 09/20/10, of her left knee, left shoulder and left elbow. The left elbow X-ray revealed no fracture. The left knee X-ray showed a displaced [MEDICAL CONDITION] femoral shaft (broke hip / leg). The left shoulder X-ray showed that RI #1 had a: "...Displaced and probably impacted fracture at the surgical neck of the left humerus. There were separate fracture fragments at the greater and lesser tuberosities." RI #1's progress notes titled "General Documentation" dated 09/20/10 documents, "...15:40 (3:40 PM) GENERAL:,--DAUGHTER (name of daughter) SPONSOR NOTIFIED (electronically signed by EI # 3). GENERAL:, TRANSFERRED TO ER (emergency room ) PER (by) STRETCHER." A Mississippi hospital's "History & Physical" report, with a dictation date of 09/20/10, revealed that RI #1 was admitted to the hospital on [DATE]. This history and physical report documents the following: "HISTORY OF PRESENT ILLESS: ...By report she was dropped off of a lift in transport at her nursing home sustaining a left femur fracture. While at the emergency room in Hamilton, Alabama, was also complaining of left arm pain and a left proximal humerus fracture was also identified. ...PLAN: admission, splinting to left lower extremity, heel protectors, internal medicine consult, left arm sling, [MEDICATION NAME], may need surgical treatment for [REDACTED]. It may be appropriate to let her heal with a nonunion or even consider an amputation but of course it is premature to make that decision tonight. I talked with her about having (name of doctor) treat her tomorrow for shoulder fracture. I will attempt to convey this information to him this evening. ..." An "Operative Report for RI #1, with a dictation date of 09/21/10, documents: "...OPERATION: 1) Open reduction internal fixation, distal femur, ...2) Open reduction internal fixation, proximal humerus. ..." The facility's fall investigation file contained a document signed by EI #7 (Administrator) and dated 09/24/10 at 2:45 PM, which documents: (RI #1) returned to our facility today. (RI #1's daughter) came to me to find out what had happened. EI #21 (Social Worker) and I talked with (RI #1's daughter). I explained to (RI #1's daughter) what I had found in my investigation and that it is my opinion that the lift malfunctioned. (RI #1's daughter) stated that that (word repeated) was what her mother told her. She asked what we had done to prevent this from happening again. I explained that items identified that might have caused the accident were being replaced. She asked if we would continue to use a lift on her. I explained that since her mother was totally non- ambulatory that we were limited on what we could use but assured her that we would do everything possible to prevent this from happening again; that accidents were accidents and that I could not assure her that this would not happen again. She stated that she was concerned because the doctors told her that her bones were very brittle and that she could not sustain another drop. I again assured her that we would do everything possible to prevent this from happening again. ..." On 10/14/10 at 8:47 AM, the sponsor of RI #1 was interviewed. RI #1's sponsor communicated to the surveyor that her biggest concern was that the facility was using a lift that malfunctioned and only one staff was transferring her mother (RI #1). On 10/15/10 at 9:40 AM, EI #7, the Administrator, was interviewed regarding his investigative findings. He was asked what he determined to be the cause of the fall. He answered that the lift mal-functioned. He was asked if he determined any other possible cause that could have contributed to RI #1's injuries. He replied if the lift had been working properly, no injury would have occurred. He was asked about the CNA doing a one person transfer and could this have caused an injury; he affirmed that it could. EI #7 was asked if it was ok for EI #1 to transfer with one while using the mechanical lift. He said that based on what he had found out after the incident, staff were supposed to be using 2 for transfer. On 10/14/10 at 9:50 AM, EI #8, the staff development nurse, was interviewed. She was asked when EI #1 had been trained on the mechanical lifts. She revealed EI #1 was hired on 05/27/09 and was trained on 06/01/09. After the fall on 09/20/10, EI #1 was retrained on the lift on 09/24/10 and 09/25/10. She further explained that she teaches staff how the lifts work and how to lift. EI #8 explained that 2 people are required to safely transfer with a lift. A facility training document titled, "HOYER/SLING LIFT CHECK OFF" documents, ...11. ONE IS TO MOVE LIFT WITH THE OTHER CNA GUIDING AND MONITORING RESIDENT FOR SAFE TRANSFER. ..." On 10/15/10 at 2:40 PM, EI #2, the Director of Nursing (DON) was interviewed regarding the fall RI #1 sustained on 09/20/10. EI #2 was asked if it is OK for CNAs to do a one person transfer with the mechanical lift. She replied that she didn't think so. EI #2 was asked the importance of two CNAs/staff when transferring with a mechanical lift. She replied that she thought the main things were for someone to control the lift and the other person guided the resident. This deficiency was cited as the result of an investigation into Complaint # AL 309. ****************************************** On 10/16/10, the Administrator (EI #7) provided the survey team an acceptable Allegation of Credible Compliance (AOC). AOC This plan of correction constitutes a written credible allegation of substantial compliance with federal and Medicaid requirements, and state requirements when necessary. F 281 RI 1 Failed to have operational procedure in place for maintenance of mechanical lift and documentation of maintenance lift program. How The mechanical lift that was used to transfer resident identifier RI 1 malfunctioned allowing RI 1 to fall to the floor. She was assessed by the RN in charge. There was not enough room in the bathroom so RI 1 was eased out into the room by using the sling that RI 1 was in. Nursing staff placed a pillow under RI 1's head and an assessment and vital signs were done. Assistance was called for and another hoyer lift was used to place RI 1 on the bed. MD was notified that RI 1had fallen and new orders were taken to order X-rays. RI 1 was transferred to radiology via stretcher and X-rays obtained. RI 1 experienced no additional pain or discomfort as reported by radiology. RI 1 was transferred back to room via stretcher and placed back to bed via hoyer lift. Radiology reports were received. MD and family were notified of findings. New orders were given to transfer RI 1 to emergency room for further evaluation and report was called to the ER nurse. RI 1 was transferred to ER via stretcher. ER MD consulted an Orthopedic surgeon at NMMC (North Mississippi Medical Center) -Tupelo regarding radiology findings. The decision was then made to transfer RI 1 to NMMC-Tupelo via ambulance. Surgery was performed and procedure was tolerated well. RI 1 was readmitted to our facility on 9/24/10. C.N.A that transferred RI 1 indicated that the lift had malfunctioned and allowed RI 1 to fall to the floor. The lift in question was immediately taken out of operation for evaluation by Biomedical tech. Biomedical tech came on 9/21/10 and inspected the lift. The lift was tested several times using staff and there was no malfunction identifed at this time. Biomedical tech stated that he would go ahead and order some parts that may have caused the incident. The lift in question continued to be out of commission until the Biomedical tech returned on 10/12/10. Upon further evaluation on 10/12/10, Biomedical tech troubleshot and found that the handset had loose item inside and when held at a certain angle the stand up would go into down mode on it's own without pressing "down button" on handset. These findings were witnessed by facility staff also. The Biomedical tech replaced handset and controller unit. Checked operation of stand up and lift passed check. The lift was returned to service on 10/12/10. Based upon our investigation of this incident, we also noted that all of our staff who uses mechanical lifts was not following facility policy and procedure of two (2) person assist on all mechanical lifts. Inservices on proper use of mechanical lifts were started on 09/24/10 and will end no later than 10/15/10. These inservices were conducted by Staff Development. How Each mechanical lift is identified by an identification number on the lift. An inspection checklist based on manufacture's recommendation has been developed. All mechanical lifts were inspected 10/16/10 based on manufactures recommendation and found to be functioning properly. All staff using mechanical lift, will be inserviced on proper use of lift and for signs to look for that may indicate that the lift may need to be checked by Facility Operation department and/or Biomedical tech. Our Staff Development department began inservices on 9/24/10 and will be completed no later than 10/15/10. What Staff inservices began on 9/24/10 and will be completed no later than 10/15/10 for all staff who use mechanical lift and checks for ensuring proper functioning and importance of a two (2) person assist in using mechanical lifts. Any identified concerns will be reported to Facility Operations department and the lift will be taken out of service until cleared by the Facility Operations department. Any identified areas of concern by Facility Operations department will also be reported to the Biomedical tech. The Biomedical tech will also check the lifts on monthly rounds. The logs of Facility Operations and Biomedical checks will be kept in the Facility Operations department. How The Facility Operations department will be responsible for keeping on file documentation of the inspection checklist. Findings of the inspections will be reported monthly through the weekly falls/skincare meetings. The Facility Operations manager will be responsibility for ensuring that his department performs the inspections and the findings of the inspections will be kept on file in the Facility Operations department. ****************************************************** The Allegation of Compliance was received and reviewed on 10/16/10; the surveyors conducted activities to ensure the Allegation of Compliance was being implemented to determine if the AOC was effective in removing the immediacy of F 281. On 10/16/10, the surveyors received attendance records for In-service conducted to educate the staff on the falling star program and need for two person assistance with transfers. On 10/16/10, random interviews with staff indicated they could identify the number of staff needed to transfer with mechanical lifts, the falling star program and care plan revision. Per instructions from the Atlanta Regional Office for the Centers of Medicare and Medicaid Services (CMS), on 11/02/10 at 3:20 PM, the Administrator was notified that the scope and severity of "J" for F281, was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to sustain substantial compliance.

Based on observation, record review and interview, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), failed to obtain the assistance of another staff member to assist with transferring Resident Identifier (RI) #1 with a stand up mechanical lift, in accordance with facility practice and the resident's plan of care. The facility assessed RI #1 as being at high risk for falls, totally dependent upon two (2) staff members for transfers and requiring the use of a mechanical lift to transfer safely. In March 2010, RI #1 was assessed as not being able to attempt the test for balance while standing without physical help. Contrary to the manufacturer's recommendations for the stand up lift model RPS350-1, EI #1 utilized the stand up lift as a transport device to take RI #1 to the bathroom. On 09/20/10 around 2:15 PM, EI #1 (CNA) got RI #1 up using a stand up lift to take the resident to the bathroom. EI #1 reported that she was suppose to get assistance when using the lift to transfer residents; however, she (EI #1) said that she would perform the transfer by herself if she (EI #1) felt comfortable. EI #1 said that she was about to pull up RI #1's dress to pull down her adult brief when the stand up lift started going down too fast. EI #1 said it was like emergency release. EI #1 reported that she tried to stop the lift by using the remote; but, it would not work. The lift continued to go down too fast before EI #1 could get RI #1 out or get behind the resident. According to EI #1, RI #1 fell in the bathroom, with the lift belt tight underneath her armpits; RI #1 cried out in pain. EI #1 asked RI #1's roommate to activate the call light, ran to the door and called out for help. EI #3, a Registered Nurse (RN), and EI #10, a Licensed Practical Nurse (LPN), responded to EI #1's call for help. Upon entering RI #1's room, EI #3 (RN) and EI #10 (LPN) reported that RI #1 was in a sitting or crouching position on the bathroom floor with her left leg underneath her and the lift belt tightly around her armpits. EI #3 described RI #1 as being blue around the mouth. EI #3 and EI #10 assisted EI #1 with getting RI #1 out of the bathroom, and onto the floor in the resident's room. A Hoyer lift had to be used to transport RI #1 back to bed. Because RI #1 was complaining of left arm and leg pain, X-rays were ordered and the resident was sent out to the emergency room (ER) in Hamilton, Alabama for further evaluation and treatment of [REDACTED].#1 also had a fractured left humerus, in addition to, the fractured left femur. Amputation was considered as a possible intervention for treatment of [REDACTED].#1) underwent surgery to repair her broken left humerus and femur on 9/21/10. This deficient practice affected RI #1, one of four sampled residents for falls. On October 15, 2010 at 6:30 PM, the facility's Administrator (EI #7) and Director of Nursing (EI #2) were notified by the survey team of deficient practice in the area of accidents and supervision (F323), which constituted substandard quality of care at an immediate jeopardy (IJ) level of "J". The survey team conducted a partial extended survey. The IJ began on September 20, 2010, and continued until October 16, 2010, when the facility implemented corrective actions to remove the immediacy and prevent any future reoccurrence. Findings Include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE], assessed RI #1 as having moderately impaired daily decision making skills, with short term memory problems. RI #1 is coded as being totally dependent on two staff members for physical assistance with transfer and toilet use; the resident's mode of transfer is identified as a mechanical lift. The resident is assessed as not being able to attempt the test for balance while standing without physical help. The Resident Assessment Protocol Summary (RAPS) identified falls as a problem area for RI #1, under section V of this MDS. In comparison, a Quarterly MDS dated [DATE], assessed that RI #1's memory and decision making skills remained the same. RI #1 is coded as requiring extensive to total assist of staff for transfers and bed mobility. RI #1 had no history of falls during this assessment period. A "Fall Risk Assessment" dated 09/16/10, identifies RI #1 as "chair bound, unable to stand, takes 3-4 medications currently and/or within the last 7 days (underlined- Antihistamines, Cathartics, Diuretics, Hypoglycemic and Sedatives), and has predisposing diseases of Diabetes and Fractures." According to this assessment, a "Total Score of 10 or above represents HIGH RISK." RI #1's score was 10, indicating she was at high risk for falls. RI # 1's care plans for Potential for Falls, Impaired Physical Mobility and ADL (activities of daily living) Deficit revealed that these three care plans were last reviewed on 09/15/10. All three care plans document the approach, "Transfer per 2 assist" with Hoyer sling lift/leg. The September 2010 Activities of Daily Living (ADL) Sheets, which are used by CNAs to document care, listed the following resident care need for RI #1: "UP TO W/C (wheelchair) DAILY- TRANSFER X (times) 2 ASSIST WITH HOYER LIFT- REPO (reposition) EVERY HOUR OR LEG SLING OR CHORUS IF ABLE - LEAVE SLING IN CHAIR FOR RETURN TO BED." A "Fall/Unusual Occurrence" report signed by the Administrator (EI #7) on 09/27/10, identified RI #1 as the resident involved in a fall from a stand up lift on 09/20/10. This fall report documented the following description: "It was reported on 9/20/10 at approximately 2:15 pm that CNA (EI #1's name) had gotten resident (RI #1's name) up in the stand up lift to take her to the bathroom. (EI #1) states that 'as I was about to pull up her dress to pull down her pull up the stand up lift started going down to fast for me to pull her out and get behind her.' Ms. (RI #1's name) fell to the floor. As a result of the fall Ms. (RI #1's name) sustained a displaced and probably impacted fracture at the neck of the left humerus. She (RI #1) also sustained a displaced oblique fracture of the distal femoral shaft. Radiological findings also indicated Osteoporosis and degenerative joint disease. ...As a result of the radiological findings Ms. (RI #1's name) was transferred to North Mississippi Medical Center in Tupelo. Ms. (RI #1's name) sponsor and physician was notified. The lift in question was immediately taken out of service. (EI #13's name), Biomedical Medical Tech. was notified. He (EI #13) came on 09/21/10 and inspected the lift. ...The lift has not malfunctioned again. Ms. (EI #1's name) reports in her statement that when the left (lift) was going down she attempted to use the remote hand control and it would not work. After continuing to try the control it did eventually work. (EI #13's name) will replace some parts to include the remote hand control that he fills (feels) may have caused a malfunction. ...There are no indications that (EI #1's name) was not using the lift correctly. However, as a safety measure (EI #1's name) will be re-inserviced on use of the lift and will be checked for competence Conclusion: It is my opinion that the cause of the fall was due to a malfunction of the lift. ..." A "Work Order Report" dated 10/12/10, listed the task code, "Erratic Performance" for the patient lift, and included the comments of: "Troubleshot and found that handset had loose item inside and when held at a certain angle. Stand up would go into down mode on it's own without pressing 'down button' on handset. Replaced handset and controller unit. Checked operation of stand up. PASSED. Returned to service." The facility's fall investigation report contained a signed statement from EI #1, the CNA assigned to RI #1 on 09/20/10. EI #1's "Employee Statement" dated 09/20/10, documents: "I was taking (Name of resident) to the bathroom, as I was about to pull up her dress to pull down her pullup the stand-up lift started going down fast, to (too) fast for me to pull her out and get behind her. I got help from CNAs and nurses we pulled her out into the middle of her room, layed her down on the floor got a net & (and) a net lift to put her in her bed. As I was trying to stop the lift I was trying to use the remote and it would not work. The lift went completly (completely) down and about a min (minute) after it went down the remote started working and we were able to get her to the floor and back in bed." On 10/14/10 at 10:10 AM, EI #1 (RI #1's CNA) was interviewed regarding RI #1's fall on 09/20/10. She recalled that RI #1 was not completely over the toilet. The lift had started to go down while she was trying to pull up RI #1's dress. She added that it was like emergency release; RI #1 was going down. According to EI #1, RI #1 cried out that she was hurting. EI #1 said that she got RI #1's roommate to put on the call light for help, went to the door and called out for help. EI #1 demonstrated how RI #1's body was positioned by raising her arms up above her head, and said the resident was hanging. She said it took 3 minutes for RI #1 to get her breath good. EI #1 acknowledged that she was supposed to use two for transfer; but, she would do it as a one person transfer, if she felt comfortable. On 10/13/10 at 6:35 PM, RI #1 was observed in bed with a sling on her left arm. She was asked what happened. RI #1 stated, "dropped me from the lift." She was asked if anything else hurt. She replied, "Just my shoulder and leg." Contained within the facility's fall investigation report was a signed statement from EI #3, a Registered Nurse (RN) on-duty on 09/20/10. EI #3's "Employee Statement" dated 09/20/10, documents: "I was at the east desk when (EI #9 maintenance man) said they need a nurse in (RI #1's room location). Upon entering room (EI #1) had (RI #1) in bathroom on the stand up lift and RI #1 was in a sitting position with belt from lift still around her. (EI #1) stated, "when I went to pull down her pull up the lift when (went) down really fast and I could not get behind her." EI #10 (licensed practical nurse) entered room and we got RI #1 out of bathroom to middle of floor and eased her down and placed a pillow under her head. She (RI #1) was blue around the mouth. Then she was assisted to bed with hoyer lift... . Then she (RI #1) was c/o (complaining of) left leg pain so we ordered xray." On 10/14/10 at 9:42 AM, EI #3 (a RN) was interview regarding RI #1's fall on 09/20/10. EI #3 recalled going to the east desk and the maintenance man (EI #9) telling her that help was needed in RI #1's bathroom. EI #3 said that RI #1 was in the lift and the resident went down. She demonstrated how RI #1's left leg was positioned back behind and underneath the resident. EI #3 said that RI #1's arms were on something and showed the surveyor how the resident's elbows were bent at shoulder level. EI #3 was asked if the lift belt was pressing the resident's shoulder upward. She affirmed that it was, and described it as being tight underneath the resident's arms. She revealed that the lift wouldn't move. EI #3 recalled that EI #1 was in RI #1's bathroom with the resident. EI #3 said that RI #1 had her leg back, the lift was down and it wouldn't go up or down. EI #3 was asked if there was anyone else in the room. EI #3 answered that only EI #1 and RI #1 were present. EI #3 was asked the number of staff needing to be present when a mechanical lift is used. She replied, two. EI #10, a Licensed Practical Nurse (LPN) who was on-duty at the time of the incident, emailed the facility an undated employee statement which documents: "On September 20, 2010, at approximately 1415 (2:15 PM), I was at the computer on the middle desk when I heard RN supervisor (EI #3) say loudly, 'She needs some help in there'. I observed (EI #3) standing outside of (RI #1's room). I proceeded to (RI #1's room location) and observed (EI #1), C.N.A. with resident (RI #1). (RI #1) was in the stand up lift, and (EI #1) stated that the lift would not work. (RI #1) was in a crouching position, with the lift belt underneath her armpits quite tightly. ...At that point, after ascertaining that (RI #1) was able to respond to verbal stimuli, several persons were required to put her (RI #1) in the Hoyer lift and transfer her (RI #1) to the bed. ...(RI #1) did complain of left arm pain, and leg pain, and subsequently she was taken to radiology for X-rays." On 10/14/10 at 8:30 AM, EI #10 (an LPN) was interviewed regarding RI #1's fall on 09/20/10. During the interview, EI #10 corroborated her emailed statement by providing a similar description of the incident. She revealed that the lift went down and the CNA couldn't get RI #1 back up onto the toilet during the transfer. She described RI #1 as being a large lady with a lot of weight. EI #10 said RI #1 slid down into the sling; she (EI #10) demonstrated this by showing the surveyor that the sling was underneath the resident's arms. EI #10 said that she thought RI #1's leg got twisted as she was going down. She recalled that the CNA (EI #1) stated, "this lift isn't working." EI #10 was asked the number of CNAs needed to use the lift for transfer. EI #10 answered that it is her understanding that two CNAs are required to use all lifts. When asked if she assessed RI #1, EI #10 replied that she wasn't the resident's nurse; she explained that she helped get RI #1 on the floor, got the hoyer lift and got the resident to bed. EI #10 was asked about injuries to the resident; she responded that RI #1 complained of arm pain and was sent for X-rays. According to X-ray reports, RI #1 had X-rays on 09/20/10, of her left knee, left shoulder and left elbow. The left elbow X-ray revealed no fracture. The left knee X-ray showed a displaced fracture of the distal femoral shaft (broke hip / leg). The left shoulder X-ray showed that RI #1 had a: "...Displaced and probably impacted fracture at the surgical neck of the left humerus. There were separate fracture fragments at the greater and lesser tuberosities." RI #1's progress notes titled "General Documentation" dated 09/20/10 documents, "...15:40 (3:40 PM) GENERAL:,--DAUGHTER (name of daughter) SPONSOR NOTIFIED (electronically signed by EI # 3). GENERAL:, TRANSFERRED TO ER (emergency room ) PER (by) STRETCHER." A Mississippi hospital's "History & Physical" report, with a dictation date of 09/20/10, revealed that RI #1 was admitted to the hospital on [DATE]. This history and physical report documents the following: "HISTORY OF PRESENT ILLESS: ...By report she was dropped off of a lift in transport at her nursing home sustaining a left femur fracture. While at the emergency room in Hamilton, Alabama, was also complaining of left arm pain and a left proximal humerus fracture was also identified. ...PLAN: admission, splinting to left lower extremity, heel protectors, internal medicine consult, left arm sling, analgesia, may need surgical treatment for [REDACTED]. It may be appropriate to let her heal with a nonunion or even consider an amputation but of course it is premature to make that decision tonight. I talked with her about having (name of doctor) treat her tomorrow for shoulder fracture. I will attempt to convey this information to him this evening. ..." An "Operative Report for RI #1, with a dictation date of 09/21/10, documents: "...OPERATION: 1) Open reduction internal fixation, distal femur, ...2) Open reduction internal fixation, proximal humerus. ..." The facility's fall investigation file contained a document signed by EI #7 (Administrator) and dated 09/24/10 at 2:45 PM, which documents: (RI #1) returned to our facility today. (RI #1's daughter) came to me to find out what had happened. EI #21 (Social Worker) and I talked with (RI #1's daughter). I explained to (RI #1's daughter) what I had found in my investigation and that it is my opinion that the lift malfunctioned. (RI #1's daughter) stated that that (word repeated) was what her mother told her. She asked what we had done to prevent this from happening again. I explained that items identified that might have caused the accident were being replaced. She asked if we would continue to use a lift on her. I explained that since her mother was totally non- ambulatory that we were limited on what we could use but assured her that we would do everything possible to prevent this from happening again; that accidents were accidents and that I could not assure her that this would not happen again. She stated that she was concerned because the doctors told her that her bones were very brittle and that she could not sustain another drop. I again assured her that we would do everything possible to prevent this from happening again. ..." On 10/14/10 at 8:47 AM, the sponsor of RI #1 was interviewed. RI #1's sponsor communicated to the surveyor that her biggest concern was that the facility was using a lift that malfunctioned and only one staff was transferring her mother (RI #1). On 10/15/10 at 9:40 AM, EI #7, the Administrator, was interviewed regarding his investigative findings. He was asked what he determined to be the cause of the fall. He answered that the lift malfunctioned. He was asked if he determined any other possible cause that could have contributed to RI #1's injuries. He replied if the lift had been working properly, no injury would have occurred. He was asked about the CNA doing a one person transfer and could this have caused an injury; he affirmed that it could. EI #7 was asked if it was ok for EI #1 to transfer with one while using the mechanical lift. He said that based on what he had found out after the incident, staff were supposed to be using 2 for transfer. On 10/14/10 at 9:50 AM, EI #8, the staff development nurse, was interviewed. She was asked when EI #1 had been trained on the mechanical lifts. She revealed EI #1 was hired on 05/27/09 and was trained on 06/01/09. After the fall on 09/20/10, EI #1 was retrained on the lift on 09/24/10 and 09/25/10. She further explained that she teaches staff how the lifts work and how to lift. EI #8 explained that 2 people are required to safely transfer with a lift. A facility training document titled, "HOYER/SLING LIFT CHECK OFF" documents, ...11. ONE IS TO MOVE LIFT WITH THE OTHER CNA GUIDING AND MONITORING RESIDENT FOR SAFE TRANSFER. ..." On 10/15/10 at 2:40 PM, EI #2, the Director of Nursing (DON) was interviewed regarding the fall RI #1 sustained on 09/20/10. EI #2 was asked if it is OK for CNAs to do a one person transfer with the mechanical lift. She replied that she didn't think so. EI #2 was asked the importance of two CNAs/staff when transferring with a mechanical lift. She replied that she thought the main things were for someone to control the lift and the other person guided the resident. The "OWNER'S OPERATING AND MAINTENANCE MANUAL" for the stand up lift model RPS350-1 (lift used on RI #1 on 09/20/10) documents: "...NOTE: The stand up lift may be operated by one (1) healthcare professional for ALL lifting preparation, transferring from and transferring to procedures with a cooperative, weight-bearing individual able to support the majority of his/her own weight. However, since medical conditions vary, Invacare recommends that the healthcare professional evaluate the need for assistance and determine whether more than one (1) assistant is appropriate in each case to safely perform the transfer. ...WARNING STANDING SLINGS - DO NOT use the standing sling in combination with the stand up lift as a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Moving a person using the standing sling in combination with the stand up lift over ANY distance is NOT recommended. ..." This deficiency was cited as the result of an investigation into Complaint # AL 309. ****************************************** On 10/16/10, the Administrator (EI #7) provided the survey team an acceptable Allegation of Credible Compliance (AOC). AOC This plan of correction constitutes a written credible allegation of substantial compliance with federal and Medicaid requirements, and state requirements when necessary. F 323 RI 1 Failed to have operational procedure in place for maintenance of mechanical lift and documentation of maintenance lift program. How The mechanical lift that was used to transfer resident identifier RI 1 malfunctioned allowing RI 1 to fall to the floor. She was assessed by the RN in charge. There was not enough room in the bathroom so RI 1 was eased out into the room by using the sling that RI 1 was in. Nursing staff placed a pillow under RI 1's head and an assessment and vital signs were done. Assistance was called for and another hoyer lift was used to place RI 1 on the bed. MD was notified that RI 1had fallen and new orders were taken to order X-rays. RI 1 was transferred to radiology via stretcher and X-rays obtained. RI 1 experienced no additional pain or discomfort as reported by radiology. RI 1 was transferred back to room via stretcher and placed back to bed via hoyer lift. Radiology reports were received. MD and family were notified of findings. New orders were given to transfer RI 1 to emergency room for further evaluation and report was called to the ER nurse. RI 1 was transferred to ER via stretcher. ER MD consulted an Orthopedic surgeon at NMMC (North Mississippi Medical Center) -Tupelo regarding radiology findings. The decision was then made to transfer RI 1 to NMMC-Tupelo via ambulance. Surgery was performed and procedure was tolerated well. RI 1 was readmitted to our facility on 9/24/10. C.N.A that transferred RI 1 indicated that the lift had malfunctioned and allowed RI 1 to fall to the floor. The lift in question was immediately taken out of operation for evaluation by Biomedical tech. Biomedical tech came on 9/21/10 and inspected the lift. The lift was tested several times using staff and there was no malfunction identifed at this time. Biomedical tech stated that he would go ahead and order some parts that may have caused the incident. The lift in question continued to be out of commission until the Biomedical tech returned on 10/12/10. Upon further evaluation on 10/12/10, Biomedical tech troubleshot and found that the handset had loose item inside and when held at a certain angle the stand up would go into down mode on it's own without pressing "down button" on handset. These findings were witnessed by facility staff also. The Biomedical tech replaced handset and controller unit. Checked operation of stand up and lift passed check. The lift was returned to service on 10/12/10. Based upon our investigation of this incident, we also noted that all of our staff who uses mechanical lifts was not following facility policy and procedure of two (2) person assist on all mechanical lifts. Inservices on proper use of mechanical lifts were started on 09/24/10 and will end no later than 10/15/10. These inservices were conducted by Staff Development. How Each mechanical lift is identified by an identification number on the lift. An inspection checklist based on manufacture's recommendation has been developed. All mechanical lifts were inspected 10/16/10 based on manufactures recommendation and found to be functioning properly. All staff using mechanical lift, will be inserviced on proper use of lift and for signs to look for that may indicate that the lift may need to be checked by Facility Operation department and/or Biomedical tech. Our Staff Development department began inservices on 9/24/10 and will be completed no later than 10/15/10. What Staff inservices began on 9/24/10 and will be completed no later than 10/15/10 for all staff who use mechanical lift and checks for ensuring proper functioning and importance of a two (2) person assist in using mechanical lifts. Any identified concerns will be reported to Facility Operations department and the lift will be taken out of service until cleared by the Facility Operations department. Any identified areas of concern by Facility Operations department will also be reported to the Biomedical tech. The Biomedical tech will also check the lifts on monthly rounds. The logs of Facility Operations and Biomedical checks will be kept in the Facility Operations department. How The Facility Operations department will be responsible for keeping on file documentation of the inspection checklist. Findings of the inspections will be reported monthly through the weekly falls/skincare meetings. The Facility Operations manager will be responsibility for ensuring that his department performs the inspections and the findings of the inspections will be kept on file in the Facility Operations department. ****************************************************** The Allegation of Compliance was received and reviewed on 10/16/10; the surveyors conducted activities to ensure the Allegation of Compliance was being implemented to determine if the AOC was effective in removing the immediacy of F 323. On 10/16/10, the surveyors received attendance records for In-service conducted to educate the staff on the falling star program and need for two person assistance with transfers. On 10/16/10, random interviews with staff indicated they could identify the number of staff needed to transfer with mechanical lifts, the falling star program and care plan revision. On 10/16/10 at 1:33 PM, the facility's Administrator, and the Director of Nursing were notified that the Immediate Jeopardy in F 323 was relieved onsite at 1:33 PM; the scope and severity level was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to prevent any further reoccurrence.