Every finding on record at Maysville Nursing and Rehabilitation Facility

Based on observation, interview, record review, review of a Kentucky Revised Statute (KRS), and review of the facility's policies, the facility failed to ensure pain management was provided consistently with professional standards of practice for 1 of 49 sampled residents, Resident (R) 54.The facility failed to assess, monitor, and provide timely intervention for R54's chronic pain on 06/30/2026 when medication was not reordered timely enough so it could be delivered before exhausting the supply on hand. This failure resulted in R54 experiencing more than 24 hours of uncontrolled pain before a new prescription could be obtained, filled, and delivered.The findings include:Review of the facility's policy titled, Pain Management Policy, last reviewed 08/2025, revealed the facility ensures pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review revealed upon admission and re-admission, and as needed, pain would be assessed for each resident. Per the policy, the facility would provide pain management interventions to a resident experiencing pain that met professional standards of practice and followed the resident's comprehensive care plan.Review of the facility's policy titled, Medication Orders, dated 11/2019, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law were subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. Further review revealed before a controlled substance could be dispensed, the pharmacy must be in receipt of a prescription for controlled drugs. Therefore, per the policy, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication. Continued review revealed new prescriptions for controlled medications, meeting all state and federal requirements, must be received by the pharmacy either with a valid hard copy prescription or a valid electronic prescription. Review of Kentucky Revised Statute (KRS) 314.021(2), revealed nurses were responsible and accountable for making decisions based upon the individual's educational preparation and current clinical competence in nursing and required licensees to practice nursing with reasonable skill and safety. The KRS stated nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice, and be evidence-based.Review of R54's admission Record revealed the facility admitted him from an acute care facility on 12/15/2025 with diagnoses including cerebral infarction, sciatica, dorsalgia, and chronic pain.Review of R54's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating he was cognitively intact.Review of R54's Care Plan Report, initiated upon admission on [DATE] and revised on 03/16/2026, identified a focus for comfort, altered related to pain, osteoarthritis, hemiplegia, and hemiparesis. Further review revealed the goal of, Pain will be managed with goal range through the review date. Continued review revealed interventions included administer pain medications per orders, be alert for increased or unrelieved pain and notify the physician as indicated, monitor for non-verbal signs and symptoms of pain such as facial grimacing, withdrawal from social interactions, striking out, or clinching of muscles. Additional review revealed a focus, dated 12/16/2025, of alteration in musculoskeletal status related to hemiplegia and hemiparesis following cerebral infarction, morbid obesity, muscle weakness, unsteadiness on feet, osteoarthritis, and lumbago with sciatica. Further review revealed a goal of the resident would remain free from pain or at a level of discomfort acceptable to the resident through the review date. Interventions for that goal included give analgesics as ordered by the physician, monitor, and document for side effects and effectiveness.Review of R54's Orders revealed an order for oxycodone-acetaminophen 7.5 milligrams (mg)-325 mg, dated 02/27/2026, with instructions to give 1 tablet by mouth every 6 hours as needed. Further review revealed an order for oxycodone-acetaminophen 10 mg-325 mg, dated 05/27/2026, with instructions to give 1 tablet by mouth every 6 hours as needed for pain. Continued review revealed another order for oxycodone-acetaminophen 10 mg-325 mg, dated 06/30/2026, with instructions give 1 tablet by mouth every 6 hours as needed for pain.Review of R54's Medication Administration Record [MAR] for 06/2026, revealed staff administered four doses of oxycodone-acetaminophen 10 mg-325 mg per day for 10 days, three doses per day for 15 days, two doses per day for three days throughout the month. Further review revealed on 06/29/2026, R54 received two doses, last documented at 7:36 PM, followed by no doses at all on 06/30/2026. Review of a Controlled Drug Record for R54 for oxycodone/acetaminophen tablets 10-325 mg revealed a quantity of 24 was dispensed on 06/19/2026 and was signed as received on 06/20/2026, with the first dose signed out on 06/22/2026 at 10:15 PM, which indicated the refill was requested in advance sufficiently to prevent lapse in availability. Further review revealed the last dose from that quantity was signed out on 06/29/2026 at 7:45 PM.Review of the subsequent Controlled Drug Record for R54 for oxycodone/acetaminophen tablets 10-325 mg revealed a quantity of 30 was dispensed on 06/30/2026, signed as received on 07/01/2026, with the first dose signed out on 07/01/2026 at 3:45 PM. Review of R54's Progress Note, dated 06/30/2026 at 8:47 AM, revealed a call to Physician 2's office requesting a new prescription be sent to the pharmacy for the oxycodone/acetaminophen order.Observations on 07/07/2026 at 4:55 PM, 07/08/2026 at 7:40 AM, and 07/09/2026 at 10:30 AM revealed R54 was sitting in a wheelchair in his room. Observation on 07/08/2026 at 1:18 PM revealed R54 was sitting in a wheelchair out in facility. During an interview with R54 on 07/08/2026 at 10:47 AM, he stated he had undergone two back surgeries and had arthritis as well. He stated he got steroid shots in his shoulders and hips and had relied on pain medication for more than 30 years. He stated he could have oxycodone every six hours but sometimes had to wait 45 minutes longer for them. Also, he stated he had an outside physician, and staff was prone not to call for refills soon enough. He stated he had to go without the pain medication recently because the doctor's office was closed for the weekend, and he did not get the pain medication until Tuesday morning. During an additional interview with R54 on 07/09/2026 at 3:54 PM, he stated he went part of the evening then all the next day without pain medicine and usually took three or four pills per day, every six hours. He stated a couple of days before he was out of pain medicine, Licensed Practical Nurse (LPN) 8 had told him before she gave him a pill that he only had five left, so he backed off on requesting them. He stated his pain was terrible and an eight out of 10 where 10 was the worst. He stated he was usually up and about but spent all day in bed because he hurt so bad. He also stated he felt bad that nobody arranged to get his medicine for him. He stated he got his first pill after they arrived in the middle of the night, somewhere around 3:00 AM.During an interview with State Registered Nursing Assistant/Kentucky Medication Aide (SRNA/KMA) 3 on 07/09/2026 at 3:52 PM, she stated if a resident was out of pain medication, she would notify the nurse, then they would call pharmacy and check the emergency box. She stated, if the medication was not available, they would notify the nurse practitioner (NP). She stated they typically notified the pharmacy two to three days before running out of the medication.During an interview with LPN5 on 07/09/2026 at 10:51 AM, she stated R54 saw Physician 2, but his medications were still on automatic refill. For narcotics, she stated staff should look for the quantity left on the prescription or they could call pharmacy to see if the order was active or not. She stated, if the quantity was low, the nurse would be expected to call the doctor for a new prescription so it could get sent in right away and the medication would be on the next delivery that night. She stated Physician 2 was really easy to contact.During an interview with LPN2 on 07/09/2026 at 1:35 PM, she stated LPN6 called for refill prescriptions but had problems reaching the doctor's office. She stated LPN6 called the office, but the office never called back. She stated she was not aware of anyone trying to pull from the cubex (automated medication dispensing machine), and she was new and had only used the cubex once. She stated R54 was aggravated, as he preferred to have his pain medicine around the clock, to the point of waiting at the nurse's station for it. She stated he did not report to her of any excruciating pain, and she did not offer to send him to the Emergency Department. During an additional interview with LPN5 on 07/09/2026 at 3:35 PM, she stated the person responsible for giving medication could always see on the medication card the remaining quantity at the bottom. She stated medications could be ordered from the Medication Review on the individual chart by pushing the plus sign for each medication. She stated if the medications were ordered and not at the facility during medication administration, she would call the doctor to get a one-day order. She stated after speaking with the doctor, she would call the pharmacy to make sure the medication was not delivered or delivered and just not placed in the medication cart. She stated if pharmacy verified the medication had not been delivered, she would ask about the expected time of arrival. During an interview with LPN8 on 07/09/2026 at 3:58 PM, she stated nurses had to call Physician 2 or the on-call provider for a narcotic prescription. She stated when she saw R54 was low on pain medication, she called the office and left a message, but the office was closed the next day. She stated she tried to watch medications closely for Physician 2's patients because it was a little harder to get in touch with him than the nurse practitioner who covered the building for other residents. She stated, for pain medications, if the prescription was still active, staff could refill by ordering through the charting software. She stated, if there was not an active prescription, the medicine could not be withdrawn from the cubex. She stated that it was important to be sure to watch for what residents needed. During an interview with LPN4 on 07/09/2026 at 4:00 PM, she stated for pain medication, it was necessary to update the NP to get a prescription or update Physician 1 if after 5:00 PM. She stated it was also important to call pharmacy and check the emergency box, and she would not let the resident go without something for pain. She further stated when the resident got down to two or three days' worth of medication, staff re-ordered it. She stated, if it was a narcotic, she called pharmacy and ordered via the facility's software to ensure the resident did not run out. She stated it was important because it prevented the resident from having to experience pain due to lack of medicine. She stated if she could not contact any of the providers, she would contact the Director of Nursing (DON) for guidance.During an interview on 07/09/2026 at 4:25 PM with Physician 2, he stated he would have received a text or a phone message alerting him R54 needed a refill on his pain medication from the facility and then would have sent a prescription to the pharmacy. He stated the pharmacy would not authorize a one-time dose out of the emergency box or the cubex without an active prescription. He stated he could not say for sure when the facility alerted him to R54's need for a refill, but he was going to check his records and would call back with the information.During an additional interview with Physician 2 on 07/09/2026 at 4:31 PM, he stated he sent a refill in on 05/29/2026 and had changed the order to 10 mg from 5 mg. On 06/30/2026, he stated he received a request for a new prescription, sent it, then got a call back that it had not gone through, so he sent it again by e-scribe (electronic prescription) to the pharmacy. Physician 2 stated he used to be able to give a verbal order for an emergency box withdrawal in the interim, and now the current pharmacy would not process those unless there was an active prescription. He also stated the pharmacy did not send reminders on the need for refills, as they expected the nurses to send those when they were close to the last pill. He stated he thought the system should flag a medication nearing the need for a refill. He stated R54 had a long history with narcotics and had been seen by pain management before coming to the facility. Because of R54's history, he stated the 5 mg tablet was not enough to hold his pain. He stated prescription requests came late at night, during the night, or on the weekends, and there was no reason a nurse should not call him after hours because he was available 24/7.During an interview with Physician 1, who was the facility's Medical Director, on 07/09/2026 at 4:41 PM, he stated staff could reach out to him for help with a narcotic prescription, but he would have reached out to the resident's doctor. He stated if he could not reach the doctor in question, he would prescribe three days' worth until the issue could be resolved. He stated his expectation was the staff would anticipate the need for refills and manage that ahead of time. He stated he usually got a two-to-three-day notice for his own patients, and if it was over the weekend, he usually received a call on Thursday or Friday. He stated, if all else failed, he expected the staff to call the resident's doctor, and then if they could not, they could certainly call him. During an interview with the Director of Nursing (DON) on 07/09/2026 at 5:50 PM, she stated her awareness of what happened was the medication needed to be ordered. She stated LPN7 saw in the facility's software that it had, in fact, been ordered and assumed it would be delivered that evening. The DON stated, when it did not come from pharmacy, she called them to learn what was going on. The DON stated the pharmacy told the nurse they needed a prescription from the doctor, but it was late at night so LPN6 contacted him the next morning, and the medicine arrived that night with normal delivery. She stated her expectation was they contact the pharmacy and the doctor and review the medication card to determine if there were refills remaining. She stated her expectation was also the nurses reordered two to three days ahead so the medication was already replenished. She stated that it was important so residents did not experience pain. She stated it was still necessary to have an active prescription in order to pull from the Emergency Box. She stated they did not have the 10 mg oxycodone in the cubex, but it could be possible to get a one-time order for two 5 mg pills.During an interview with the Administrator on 07/09/2026 at 6:22 PM, she stated the nurse called the doctor and the pharmacy and thus made an honest effort to meet the resident's needs. She stated he had other pain management medications available. She stated when to reorder would depend on the resident and the medication. She stated as needed (PRN) medications were not on autofill, and that made reordering a little more challenging.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to limit as needed (PRN) orders for antipsychotic drugs to fourteen (14) days without the attending physician or prescribing practitioner evaluating the resident for the appropriateness of that medication for one (1) of twenty-four (24) sampled residents (Resident #15). The findings include: Review of the facility's policy titled, Medication Ordering and Prescribing Psychoactive Medication Use-General, not dated, revealed residents did not receive PRN (as needed) [CONDITION(S)] medications unless necessary to treat a diagnosed specific condition which must be documented in the record. The policy stated PRN orders for [CONDITION(S)] medications, which were antipsychotic medications, were limited to fourteen (14) days. Then, the PRN order for an antipsychotic could not be renewed until the physician or prescriber evaluated the resident to determine if the medication was appropriate. Per the policy, the evaluation should include direct evaluation and assessment of the resident's condition and progress to determine if the PRN antipsychotic medication was still needed. Review of Resident #15's medical record revealed the facility admitted the resident, with hospice care, on 12/16/2020, with diagnoses of Anxiety, Alzheimer's Dementia, Depression, and [CONDITION(S)]. Further review revealed hospice care was discontinued on 04/01/2021, with a Significant Change MDS Assessment completed, on 04/10/2021, which indicated, in section E for Behaviors, there were no behaviors exhibited from the resident for the month prior to 04/10/2021. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/08/2021, revealed the facility assessed the Resident with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), for severe cognitive impairment. Also, it revealed, in section E for Behaviors, no behaviors exhibited from the resident for the month prior to 07/08/2021. Review of the Quarterly MDS Assessment, dated 03/18/2021, section E for Behaviors, revealed no behaviors exhibited from the resident for the month prior to 03/18/2021. Review of Resident #15's Comprehensive Care Plan, dated 12/16/2020, revealed there was a focus of impaired thought process, related to severely impaired cognition, decision making with diagnosis of Dementia, Mood Disorder, and Depression. The goal was for the resident was to develop skills to cope with cognitive decline and maintain safety by the next review date. An intervention, dated and initiated on 12/16/2020, revealed to give [MEDICATION(S)] as ordered PRN for anxiety. Review of Resident #15's Order Summary Report, dated 10/2021, revealed an order for [MEDICATION(S)] (Lorazepam, an anti-anxiety agent) tablet 0.5 mg, one (1) tablet by mouth every twelve (12) hours as needed (PRN) for anxiety and comfort care. The order date and start date was 12/16/2020, with no indication of a fourteen (14) day stop date. Review of Resident #15's history and physical, dated 12/29/2020, revealed the resident was on [MEDICATION(S)] 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN, and it had been taken by the resident. Review of the resident's history and physical, dated 07/01/2021, revealed the resident was on [MEDICATION(S)] 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN, and it had been taken by the resident, starting 01/20/2021. Review of Resident #15's history and physical, dated 07/25/2021, from a psychiatric consultant, revealed, under Gradual Dose Reduction (GDR), that it was not recommended to discontinue medications, otherwise psychiatric symptoms would worsen. However, there was no reference to the resident receiving [MEDICATION(S)] 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN. Review of the Medication Administration Record (MAR) dated for the months of 12/2020, 05/2021, 07/2021, 08/2021, and 10/2021 revealed [MEDICATION(S)] 0.5 mg, one (1) tablet by mouth every twelve (12) hours, PRN for anxiety and comfort care was not given. Continued review, for 10/01/2021 through 10/06/2021, revealed [MEDICATION(S)] was not given. Additional review of the MAR revealed the medication [MEDICATION(S)] 0.5 mg, give one (1) tablet by mouth every twelve (12) hours PRN for anxiety and comfort care was given once on 01/10/2021, 01/16/2021, 02/08/2021, 02/09/2021, 02/11/2021, 02/12/2021, 02/15/2021, 02/16/2021, 02/17/2021, 03/06/2021, 03/07/2021, 03/11/2021, 03/12/2021, 03/16/2021, 03/17/2021, 03/21/2021, 04/08/2021, 06/14/2021, 06/24/2021, 09/21/2021 and 09/22/2021. It was given twice on 04/13/2021. The [MEDICATION(S)] tablets given were listed on the MAR as effective. Review of Communication with Practitioner Situation sheet, dated 10/07/2021, revealed Resident #15 was given [MEDICATION(S)] very few times in the last six (6) months. The physician discontinued [MEDICATION(S)] related to non-use. Review of the Pharmacy form Note to Attending Physician/Prescriber, dated 12/23/2020, revealed a recommendation by Pharmacist Consultant #2 to extend [MEDICATION(S)] 0.5 by mouth for PRN anxiety and comfort care for six (6) months and to re-assess the need at that time for Resident #15. The Physician/Prescriber Response was not given or signed. Review of the Pharmacy form Note to Attending Physician/Prescriber, dated 09/29/2021, revealed a recommendation, by Pharmacist Consultant #2, to extend [MEDICATION(S)] 0.5 by mouth for PRN anxiety and comfort care for six (6) months and to re-assess the need at that time for Resident #15. The physician declined the recommendation and did not wish to implement the change due to risk vs. benefit considered; however, no stop date or rationale was given to continue the current prescription. Interview with Resident #15's Physician was not successful. The physician was not available, on 10/07/2021 at 12:02 PM, and a voice message was left by the State Survey Agency (SSA) Surveyor, concerning Resident #15. A call, from the physician, was not returned as of 10/07/2021 at 6:15 PM, upon exit from the facility. Interview with Clinical Pharmacy Director #1, on 10/07/2021 at 11:35 AM, revealed the Pharmacist Consultant for the facility would make a recommendation(s) and would await a response from the physician. She stated pharmacists tried to clarify and follow-up with physicians concerning the pharmacy recommendations. Interview with Pharmacist Consultant #2, on 10/07/2021 at 12:15 PM, revealed the policy was for PRN [MEDICATION(S)] to have a fourteen day (14) stop date. He revealed he did not have a regimented time frame to review for PRN medications. He stated he had recommended, on 12/23/2020, an extended stop date of six (6) months because Resident # 15 was in hospice care. He stated he believed the resident was on hospice care until 03/29/2021. He stated he was informed the recommendation for Resident #15, made on 12/23/2020, had not been seen by the physician. He stated the recommendation for use of PRN antipsychotics was limited to fourteen (14) days with a rationale for a new order extending another fourteen (14) days or rationale for an extended period of time. He further revealed the resident had not used [MEDICATION(S)] PRN for 07/2021 and 08/2021. Also, he stated the resident had not used [MEDICATION(S)] PRN for 10/01/2021 through 10/06/2021, and he would recommend to discontinue the [MEDICATION(S)]. Interview with Licensed Practical Nurse (LPN) #1, 200 North Unit, on 10/07/2021 at 1:50 PM, revealed she was aware of Resident #15's [MEDICATION(S)] PRN medication. She stated the pharmacy made the recommendations and notified the physician if the resident was not taking PRN medications. She also stated the physician was not always timely in acting on pharmacy recommendations. Interview with Director of Nursing (DON), on 10/07/2021 at 2:45 PM, revealed the facility's policy was for a fourteen (14) day stop for PRN psychiatric medications and then to reassess the need. She stated the facility communicated with the pharmacy and checked daily for any recommendations. Then, she stated the recommendations were shared with the Nurse Managers through their Dash board system. She stated any recommendations from pharmacy were sent with three (3) copies. One (1) copy was given to the Nurse Manager, one (1) copy stayed in the binder in the Assistant Director of Nursing's (ADON) office, and the other was sent to the DON. She stated a copy was sent to the physician. Then, after the physician reviewed and sent back his response to the pharmacy recommendation, the completed copy was flagged and placed into the binder. The DON stated once the response to the pharmacy recommendation was completed, it was sent back to pharmacy. The DON revealed, through review of the resident's MAR, pharmacy made recommendations to the physician to discontinue a medication if it had not been taken. Interview with the Administrator, on 10/07/2021 at 2:54 PM, revealed the facility's policy was for anti-psychotics to be limited to fourteen days (14) days. She stated the physician placed the order and used medical judgment on why to continue the medication. She stated Psychiatric Services could document and recommend not to reduce the PRN psychiatric medication. The Administrator stated all PRN medications were reviewed in the morning clinical meeting.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement a baseline person-centered care plan for one (1) of twenty-four (24) sampled residents (Resident #61). Review of the resident's care plan for activities was incomplete after seven (7) weeks. The findings include: Review of the facility's policy titled, Base Line Care Plan, not dated, revealed the facility must develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care. Further review revealed the base line care plan must be developed within forty-eight (48) hours of a resident's admission, and it was to be a continuous changing document as changes occurred with the resident's plan of care. Additional review revealed there were thirty-two (32) care areas listed to be considered for care planning, including Activities. The policy further stated that each area listed should include specific interventions and should include the current date for the problem identified and initiated. The policy additionally stated that the admission care plan was to serve as a resident's plan of care until the comprehensive care plan was developed according to the Resident Assessment Instrument (RAI) process, no later than the resident's first quarterly assessment. Review of Resident #61's medical record revealed the resident was admitted from another facility, on 08/16/2021. The resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/27/2021, revealed the Brief Interview for Mental Status (BIMS) score for Resident #61 was three (3) of fifteen (15), indicating severe cognitive impairment. However, the resident was also assessed as being alert and oriented to person and place. Observation, on 10/05/2021 at 11:11 AM, revealed Resident #61 was in his/her private room, sitting on the couch, with puzzle books on the table untouched. Resident #61 pointed out a drawing of his/her house, detailed its location, and how he/she would like to go home. Resident #61 stated the bedspread was crooked but nobody cares that it was not set the way it should have been. The resident reported he/she was bored. Additional observation, on 10/05/2021 at 2:44 PM, revealed Resident #61 heading toward the door leading to the central/lobby area. He/she asked if the daughter was waiting outside the door. Additional observation, on 10/05/2021 at 4:40 PM, revealed Resident #61 again wandering in the unit hallway. The resident used a rollater for ambulation and stated he/she was looking for something to do. Review of Resident #61's Basic Care Plan, on the electronic medical record (EMR), revealed the element for staff dependence for activity, cognitive dependence, and social interaction had no interventions. Further review revealed that the only entries on the care plan were dated 08/16/2021. The review showed a care plan review date of 09/05/2021, but no reviews or updates were documented. Additional care plan review revealed it was not completed or updated on the EMR, with no review or updates recorded. The care plan was also redlined (alerted) with overdue indicators. Interview with the MDS Coordinator, on 10/07/2021 at 3:45 PM, revealed the Licensed Practical Nurse ( LPN) in the MDS office, printed off orders every day and then added those new interventions to the residents' individual care plans. She stated nurses had access to add goals and interventions but many did not because, with anything significant, they would have called the physician. Therefore, she stated, whatever orders came from the physician, generated the changes to the care plan during the daily updates. She also stated that a basic care plan was initiated as soon as the admission dataset was completed; and, the next day the MDS office staff was at work, trying to complete the comprehensive care plan. She further reported the care plan could be saved even while incomplete. She stated, when reviewing the care plan, if the button for Complete Review was not clicked, it would not show as completed. She stated she could not think of a situation that would lead to failure in the system to capture/complete a new care plan. She stated she believed there was a fourteen (14) day deadline for completion of the first comprehensive care plan. Interview with LPN #4 and Registered Nurse (RN) #1, on 10/07/2021 at 4:10 PM, revealed nurses scanned care plans for changes at the beginning of the shift, as well as getting verbal shift report. In addition, they stated the Acute Monitoring Log was always viewed at the beginning of the shift, then changes were added throughout the shift. LPN #4 also stated that updates to Activities interventions, for example, were communicated verbally, but the nurses would look to an individual care plan for specifics. Subsequent review of Resident #61's care plan revealed an activity care plan element had interventions added, on 10/07/2021, after being begun on 08/16/2021. Further, review of the various elements continued to show overdue status for care plan review. Interview with the Administrator, on 10/07/2021 at 5:22 PM, revealed her expectation that staff would look to the care plan to guide the care provided, and staff should all be looking at care plans every day. She further revealed staff used the projector at their team meetings and reviewed the care plans together. She also stated when staff members were discussing a resident, they were reviewing interventions that were in place and whether any goals or interventions should be added or removed. The Administrator additionally reported that every resident's care plan was reviewed regularly in this manner.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-four (24) sampled residents (Sampled Resident #26). Review of the comprehensive care plan (CCP) revealed Resident #26 required transfer by a mechanical device. However, nursing staff did a transfer, with Resident #26, without using a mechanical lift, which resulted in a fall. The findings include: Review of the facility's policy titled, Base Line Care Plan, not dated, revealed the facility must develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person centered care and met professional standards of quality of care for each resident. Review of the facility's Incident Report, dated 09/26/2021 at 5:25 PM, revealed the nurse walked into Resident #26's room to find the resident on the floor beside the bed. Nurse Aide #2 and State Registered Nurse Aide (SRNA) #4 were already in the room. Per the report, when the nurse asked what happened they stated we didn't know the resident was a Hoyer lift (brand of mechanical lift), and we tried to get him/her out of bed. The report stated the aides were re-educated on where to find information related to a resident's transfer status. In addition, the report stated Resident #26 denied pain/discomfort; no injuries were noted; and the physician and family were notified. Review of Resident #26's medical record revealed the facility admitted the resident, on 10/23/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) Assessment, dated 07/27/2021, for Brief Interview for Mental Status (BIMS) showed the resident scored twelve (12) of fifteen (15), for cognitively intact. Continued review revealed, under section J, one (1) fall with no injuries. Also, review of the Admission MDS Assessment, dated 10/30/2020, revealed, under section V, a concern care area identified for falls. Review of Resident #26's Aide Kardex, date of admission 10/23/2020, revealed, under Transferring, mechanical lift only, with green light pad. Further review revealed, under Mobility, non-ambulatory. Review of Resident #26's Comprehensive Care Plan (CCP), dated 10/23/2020, under Focus, Falls, revealed a potential risk for falls due to confusion and at high risk for falls. Under goals, the CCP listed for the resident to be free from injury through the review date of 08/23/2021. Further review revealed interventions were 1) added falling star program, date initiated 03/03/2020 and created 04/12/2021; 2) educated resident to allow staff to use mechanical lift for transfers, date initiated, created, and revised 08/23/2021; and 3) transfers with mechanical lift with Green lift pad, date initiated, created, and revised 06/09/2021. Further review of Resident #26's CCP, dated 10/26/2020, under Focus, Activities of Daily Living (ADL) related to Self Care Performance Deficit, revealed the intervention of transfer with mechanical lift only Green lift pad, date initiated 06/08/2021. Further review of Resident #26's CCP, dated 10/26/2020, under Focus, Limited Physical Mobility, revealed a goal of the resident would maintain his/her current level of mobility through the review date. The CCP stated, under interventions, the resident was non-ambulatory, with the date initiated and created of 10/26/2020, and the revision date of 08/11/2021. Interview with Nurse Aide #2, on 10/07/2021 at 1:54 PM, revealed she was assisting, with SRNA #4, in transferring Resident #26 from the bed to the chair when the resident was lowered to the floor. She stated the resident made the request to move to the chair. She stated Resident #26 had no injuries. In addition, Nurse Aide #2 stated the Kardex was available on the Kiosk on the floor, and she was not aware Resident #26 used a mechanical lift for transfers. Nurse Aide #2 further revealed she did not have access to the Kiosk the day of the fall. Interview with SRNA #4, on 10/07/2021 at 2:28 PM, revealed she tried to transfer Resident #26 because Nurse Aide #2 told her Resident #26 wanted to get in the chair. SRNA #4 stated she did not know if Resident #26 still used a lift. She stated she checked the Kardex, and it stated Resident #26 was transferred using a mechanical lift. She stated the resident refused to use the mechanical lift. SRNA #4 stated they used a gait belt and realized they could not transfer with only the gait belt. SRNA #4 stated, with the assist of Nurse Aide #2, they lowered Resident #26 to the floor. SRNA #4 further revealed she should have notified the nurse the resident refused to use the mechanical lift. SRNA #4 stated she should have followed the care plan and used the mechanical lift to transfer Resident #26. Interview with the Director of Nursing (DON), on 10/07/2021 at 2:28 PM, revealed an incident report was filled out by the nurse. She stated staff had access to the Kardex, located on the Kiosk, for information on resident care. She stated both Nurse Aide #2 and SRNA #4 reviewed the Kardex which stated the resident was transferred by using a mechanical lift. The DON stated Resident #26 was refusing transfer by a mechanical lift. She stated SRNA #4 should have notified the nurse and not transferred the resident. The DON stated the transfer information was on the Kardex and the aides did not follow the care plan. In addition, the DON stated training was provided to nursing staff during orientation concerning use of the Kardex. Interview with the Administrator, on 10/07/2021 at 3:06 PM, revealed SRNA #4 reviewed the Kardex for Resident #26 and had prior knowledge the resident was a mechanical lift. The Administrator stated Nurse Aide #2 and SRNA #4 should have told the nurse before the transfer, if resident refused the mechanical lift. In addition, the Administrator stated Nurse Aide #2 and SRNA #4 did not follow the care plan and immediately received education.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision and provide a mechanical device to prevent falls for one (1) of twenty-four (24) sampled residents (Resident #26). Resident #26 was assisted with transfer without use of a mechanical lift, which resulted in a fall. The findings include: Review of the facility's policy titled, Falls Program, undated, revealed this program identified residents at risk of falls, and if at risk, the resident would be placed in the Falling Stars program. Per the policy, after each fall, the environment would be assessed for causative factors. The policy stated, for the Falling Stars program, a symbol was placed beside the resident's name on the room number sign and on a list at the nurse's station. Review of the facility's protocol titled, Falls Follow-Up Protocol, undated, revealed an incident report would be completed at the time of the fall incident, with an attempt made to determine causative factors. In addition, a licensed nurse would assess the resident at the time of the incident. Per the policy, once the incident report was completed, it was given to the Director of Nursing (DON) and the Administrator. Review of the facility's Incident Report, dated 09/26/2021 at 5:25 PM, revealed the nurse walked into Resident #26's room to find the resident on the floor beside the bed. Nurse Aide #2 and State Registered Nurse Aide (SRNA) #4 were already in the room. Per the report, when the nurse asked what happened they stated we didn't know the resident was a Hoyer lift (brand of mechanical lift), and we tried to get him/her out of bed. In addition, the report stated Resident #26 denied pain/discomfort; no injuries were noted on the nursing assessment; and the physician and family were notified. Review of Resident #26's medical record revealed the facility admitted the resident, on 10/23/2020, with diagnoses including [CONDITION(S)], Anxiety, Diabetes Type 2, and Hypertension. The Quarterly Minimum Data Set (MDS) Assessment, dated 07/27/2021, for Brief Interview for Mental Status (BIMS) showed the resident scored twelve (12) of fifteen (15), for cognitively intact. Continued review revealed, under section J, one (1) fall with no injuries. Also, review of the Admission MDS Assessment, dated 10/30/2020, revealed, under section V, a concern care area identified for falls. Review of Resident #26's Medication Review Report, dated 10/2021, revealed the resident was a high risk for falls, active 10/23/2020, and was active, as of 08/23/2021, in the Falling star program (a program used to prevent falls). Review of Resident #26's Comprehensive Care Plan (CCP), revealed, under interventions, 1) the resident was non-ambulatory, with the date initiated and created of 10/26/2020, and the revision date of 08/11/2021; 2) the resident was educated to allow staff to use the mechanical lift for transfers, date initiated, created, and revised 08/23/2021; and 3) transfers to be done with the mechanical lift with Green lift pad, date initiated, created, and revised 06/09/2021. Review of Resident #26's Aide Kardex, date of admission 10/23/2020, revealed, under Transferring, mechanical lift only, with Green lift pad. Further review revealed, under Mobility, non-ambulatory. Interview with Resident #26, on 10/07/2021 at 1:45 PM, revealed he/she was the one that asked to be transferred, and it was his/her fault concerning the fall. The resident stated the aides had nothing to do with the fall because he/she had asked them not to use the mechanical lift. Interview with Nurse Aide #2, on 10/07/2021 at 1:54 PM, revealed she was assisting, with SRNA #4, in transferring Resident #26 from the bed to the chair using only a gait belt, when the resident was lowered to the floor. She stated the resident made the request to move to the chair and did not want to use the mechanical lift. She stated Resident #26 had no injuries. Nurse Aide #2 stated, before the resident was transferred, she should have notified the nurse that the resident refused to use the mechanical lift. Interview with SRNA #4, on 10/07/2021 at 2:28 PM, revealed she and Nurse Aide #2 tried to transfer Resident #26 from the bed to the chair. She stated she checked the Kardex, and it stated Resident #26 was transferred using a mechanical lift. She stated the resident refused to use the mechanical lift. SRNA #4 stated both she and Nurse Aide #2 used a gait belt for the transfer. She stated, at that time, they realized they could not transfer the resident with only the gait belt. SRNA #4 stated, with the assist of Nurse Aide #2, they lowered Resident #26 to the floor. Per the interview, SRNA #4 stated she should have notified the nurse that the resident refused to use the mechanical lift before Resident #26 was transferred. Interview with the Director of Nursing (DON), on 10/07/2021 at 2:28 PM, revealed an incident report was filled out by the nurse for the fall incident with Resident #26, on 09/26/2021. She stated both Nurse Aide #2 and SRNA #4 reviewed the Kardex which stated the resident was transferred only by using a mechanical lift. The DON stated, even though Resident #26 was refusing transfer by the mechanical lift, the aides should have notified the nurse and not transferred the resident using a gait belt. In addition, the DON stated training was provided to nursing staff during orientation concerning transferring a resident, using a mechanical lift. Interview with the Administrator, on 10/07/2021 at 3:06 PM, revealed SRNA #4 knew Resident #26 was a mechanical lift for transfers. The Administrator stated Nurse Aide #2 and SRNA #4 should have told the nurse before the transfer, if the resident refused the mechanical lift.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that one (1) of four (4) sampled residents, Resident #1, was protected from abuse. Review of the facility's investigation and interviews revealed Resident #1 was subjected to physical abuse by a staff member, on 11/06/2020, at approximately 8:30 AM. When in the shower, State Registered Nurse Aide (SRNA) #1 held Resident #1's arm down and sprayed the resident's hair while the resident yelled and attempted to stop her, after stating he/she did not want his/her hair washed. The findings include: Review of the facility's policy, Reporting Abuse to Facility Management, dated 11/02/2017, revealed the facility did not condone abuse by anyone, including staff members. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish. Review of the facility's investigation Five (5) Day Final Report revealed Resident #1 had requested SRNA #2 not to wash his/her hair during a shower; but, SRNA #1 entered the shower room, informed SRNA #2 that Resident #1 had to have his/her hair washed, and proceeded to take the shower wand from Resident #1. Per report, while SRNA #1 held Resident #1's arm, she sprayed Resident #1's hair while the resident yelled and tried to stop her. Per report, Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON) heard Resident #1 yelling and responded by entering, witnessing, and stopping the event. Continued review of the facility's investigation Five (5) Day Final Report revealed SRNA #1 was suspended immediately, and Resident #1 was assessed with [REDACTED]. In addition, the report stated resident interviews were conducted for residents with a BIMS score of eight (8) or higher, indicating the residents were interviewable, with no concerns identified. Per report, notifications were made to the Office of Inspector General (OIG), Adult Protective Services (APS), the Medical Director (MD), the ombudsman, families or responsible parties, and local law enforcement. Review of Resident #1's medical record revealed the resident was admitted to the facility, on 12/02/2019, with [DIAGNOSES REDACTED]. The facility assessed Resident #1, in an Annual Minimum Data Set (MDS) BIMS, with a score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of the Progress Notes for Resident #1, dated 11/06/2020, revealed the Social Services Director (SSD) followed-up with Resident #1, on 11/06/2020 at 3:39 PM, regarding the incident earlier that day, and Resident #1 had no recollection of the event and was in a pleasant mood, with no signs of, or complaints of, depression. Continued review revealed Resident #1 voiced he/she felt safe at the facility, and staff treated him/her well. Interview with Resident #1, on 11/25/2020 at 11:30 AM, revealed Resident #1 had no recollection of the events, on 11/06/2020, stating staff had always treated him/her well, and no one had mistreated him/her or forced him/her to do anything against the resident's will. Attempts to reach SRNA #1 during the course of the survey were unsuccessful. Interview with SRNA #2, on 11/25/2020 at 12:48 PM, revealed she worked with Resident #1, on the morning of 11/06/2020. She revealed Resident #1 originally did not want to get a shower, but agreed to do so for her, but stated he/she did not want his/her hair washed. She revealed she took Resident #1 to the shower, and Resident #1 was in the process of spraying him/herself with the shower wand, when SRNA #1 entered the shower room and asked if she had washed Resident #1's hair. She stated she informed SRNA #1 that Resident #1 did not want his/her hair washed, at which point SRNA #1 reached for the shower wand. SRNA #2 stated Resident #1 sprayed SRNA #1 to keep her away, and SRNA #1 said, Spray me all you want, before SRNA #1 grabbed the shower wand, held Resident #1's arm down, and sprayed Resident #1 in the face and hair with the shower wand. Per interview, SRNA #2 stated Resident #1 was screaming, at that point, as she tried to break up the situation and remove the shower wand from SRNA #1. SRNA #2 stated RN #1 and the ADON came in, at that time, and could not get SRNA #1 to de-escalate; but, they told SRNA #1 to get out of the shower room, and they helped to calm Resident #1. SRNA #2 stated she finished Resident #1's shower, and Resident #1 stated he/she did not know what was wrong with that girl (SRNA #1). Per interview, SRNA #2 stated she had worked with Resident #1, after the incident, and Resident #1 did not state anything about the incident or appear to be negatively impacted as a result of the incident. Interview with RN #1, on 11/25/2020 at 9:52 AM, revealed she shared an office with the ADON, across from the shower room, and heard Resident #1 yelling, on the morning of 11/06/2020, at approximately 8:15 AM. She revealed she and the ADON went into the shower room and saw SRNA #1 holding Resident #1's right arm down and spraying Resident #1's hair with the shower wand, while Resident #1 was saying, I don't want my hair washed! Per interview, RN #1 and the ADON stopped SRNA #1, got SRNA #1 out of the shower room, and assessed Resident #1, who had no injuries. RN #1 stated Resident #1 was upset over not wanting his/her hair washed, but when SRNA #2 took over the shower, the resident was calmed. Per interview, SRNA #1 was taken off the floor, brought to the Administrator's office, suspended, and later terminated. RN #1 stated SRNA #1's behavior was not normal for her, and she had often been requested by residents as a shower aide. Interview with the ADON, on 11/25/2020 at 1:53 PM, revealed her office was across from the shower room, and she and RN #1 heard noise, on the morning of 11/06/2020, and went to the shower room to investigate. She stated SRNA #1 was holding the shower wand, attempting to wash Resident #1's hair, while Resident #1 was very upset saying he/she did not want his/her hair washed. Per interview, the ADON stated she took the shower wand from SRNA #1, asked her to leave the shower, and stayed with Resident #1 until he/she was calmed. She stated she reported the incident to the Administrator and walked SRNA #1 out of the facility. In addition, she stated Resident #1 had not said anything else about the incident, and she had not noticed any changes in Resident #1's behavior or demeanor. The ADON stated she expected abuse not to be tolerated in the facility, and residents had the right to refuse care. Interview with the Social Services Director (SSD), on 11/25/2020 at 10:57 AM, revealed she was part of the investigation, and in addition to interviewing other interviewable residents who expressed no concerns, she interviewed Resident #1, who had no recall of the incident. She revealed there had been no changes in Resident #1's behaviors. Interview with the Interim Director of Nursing (RN #1), on 11/25/2020 at 3:20 PM, revealed she expected residents to be protected from harm, for abuse not to occur in the facility, and if anything did occur, it be investigated immediately. Interview with the Administrator, on 11/25/2020 at 2:21 PM, revealed RN #1 and the ADON came to her, on the morning of 11/06/2020, and reported the incident. She stated SRNA #1 was immediately suspended, and an investigation was initiated. Per interview, the Administrator stated she interviewed SRNA #1, who did not say why she sprayed Resident #1 and did not have a response when she was informed she was suspended. The Administrator stated SRNA #1 was terminated for violation of resident rights and abuse, as Resident #1 was clearly upset during the event.

Based on interview, record review, review of the facility investigation, and review of the facility policy, it was determined the facility failed to ensure the resident(s) were treated with respect and dignity and free from abuse for one (1) of eleven (11) sampled residents (Resident #5). On 03/16/2020, around 9:30 PM, State Registered Nurse Aide (SRNA) #3 and State Registered Nurse Aide (SRNA) #4 notified the north nurse that State tested Nurse Aide (STNA) #1, which is a nurse aide in training, spit in the face of Resident #5, after Resident #5 started spitting when being turned. STNA #1 was immediately suspended pending outcome of the investigation and was terminated on 03/17/2020. The findings include: Review of the facility's Resident Rights document (undated), provided all residents upon admission, revealed, The resident has a right to be treated with respect and dignity. Review of the facility policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. Record review revealed the facility initially admitted Resident #5 on 04/19/2019, and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimal Data Set (MDS) Assessment, dated 05/14/2019, revealed the facility assessed Resident #5's cognition as severely impaired, with a Brief Interview for Mental Status (BIMS) score of zero (0). Review of Resident #5's Comprehensive Care Plan, initiated 08/16/19, revealed Resident #5's thought processes impaired related to severely impaired cognition, moderately impaired decision making, related to [DIAGNOSES REDACTED]. Interventions to include engage the resident in simple, structured activities that avoid overly demanding tasks. In addition, the Comprehensive Care Plan, initiated on 05/04/2019, revealed a focus of social interaction impairment, related to resistive to care, [DIAGNOSES REDACTED]. Interventions to include two person assist to provide safe care due to history of noncompliance. Interview and/or observation of Resident #5 was unobtainable, as the resident no longer resided at the facility. Review of the facility final investigation dated 03/19/2020, revealed on 03/16/2020, it was reported State Training Nurse Aide (STNA) #1 spit in Resident #5's face. An investigation was initiated and the STNA #1 was immediately suspended pending investigation. The investigation concluded and STNA #1 was terminated. Attempts to interview the two SRNAs who witnessed the event were unsuccessful. Interview with SRNA #1, SRNA #2, and LPN #1 revealed they did not witness Resident #5's abuse, however, all received abuse training and re-education after the alleged abuse occurred from the Staff Development Coordinator. Interview with the Director of Nursing (DON) on 09/30/2020 at 3:27 PM, revealed she had only been employed at the facility for six (6) and was not able to speak to the incident. She revealed the DON who investigated the incident was no longer employed at the facility. STNA #1 was employed as a nurse aide in training. In addition, she stated the facility had a no tolerance abuse policy. It was her expectation that staff was knowledgeable of the types of abuse, when and how to report it, to keep residents safe, as this is their home. Interview with the Administrator on 09/30/2020 at 3:48 PM, employed one year at the facility, revealed she was notified on 03/16/2020 of the incident alleging STNA #1 spit in the face of Resident #5 after Resident #5 allegedly spit in STNA #1's face. The former Director of Nursing (DON) immediately suspended STNA #1, pending investigation and initiated the initial report. The former DON notified Regulatory agencies to include OIG, APS and Ombudsman, along with the MD and Family Representative. The charge nurse completed a head to toe skin assessment on Resident #5 and identified no concerns. The charge nurse initiated a head to toe assessment on all residents with BIMS<seven (7), identifying no issues. In addition, she conducted resident interviews with all residents with BIMS>seven (7) and identified no issues. Continued Administrator interview revealed she terminated STNA #1 on 03/17/2020. All staff were in-serviced on abuse and neglect, respect and dignity, along with education on dealing with uncooperative residents. Continued interview revealed she expects staff to treat all Residents with respect and dignity and report all allegations of abuse or alleged abuse immediately; likewise, it is not up to them to decide what abuse is, but if they see, hear or witness abuse, to report it immediately so the investigation can begin. Failure to recognize and/or report abuse allegations puts residents, staff and the facility at unnecessary safety and harm. The facility implemented the following actions to correct the deficient practice: 1. The former DON immediately suspended STNA #1 on 03/16/2020 around 09:30 PM, pending investigation. STNA #1 was terminated on 03/17/2020. 2. The former DON completed the initial investigation report on 03/16/2020, and faxed it to the Office of Inspector (OIG) and Ombudsman offices at 10:54 PM and 10:56 PM, respectively. The Administrator notified APS on 03/17/2020 at 08:12 AM. Additionally, the Physician 12:47 AM and Resident #5's Family Representative (husband) was notified on 03/17/2020 at 12:13 AM. 3. The Charge Nurse completed a head to toe skin assessment on Resident #5 on 03/16/2020, around 11:25 PM with no injuries noted. 4. The Charge Nurse and four additional staff members initiated a head to toe assessment on fifty-six (56) residents with BIMS scores less than seven (7), beginning 03/16/2020 through 03/17/2020; there were no issues identified. 5. The Social Services Director completed interviews with seventy-five (75) resident with BIMS scores of seven (7) or above, on 03/17/2020 between 9:00 AM and 5:00 PM with no other residents identifying issues with staff treatment. 6. The former DON conducted interviews with SRNA #3 and SRNA #4 who witnessed the incident and there were no other findings than what was reported. 7. The Staff Development Coordinator initiated a mandatory training for all staff titled Dealing with an Uncooperative Resident and on the Abuse and Neglect Policy on 03/16/2020 and completed the training on 03/18/2020. 8. All staff completed a post training Quiz between 03/16/2020 and 03/18/2020 to validate learning. 9. The Quality Assurance and Performance Improvement team met on 03/18/2020 to review the corrective action and monitoring to ensure continued compliance. The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of the Personnel file of STNA #1 revealed she was suspended on 03/16/2020 immediately and further review revealed a termination date of employment on 03/17/2020. 2. Review of Fax Transmission Verification Reports revealed notification of the OIG and Ombudsman was completed on 03/16/2020 at 10:54 PM and 10:56 PM respectively. Review of Resident #5's progress notes revealed the Physician and Family notifications were made on 03/17/2020. 3. Review of Resident #5's Medical Record revealed a head to toe Nursing Assessment was completed on 03/16/2020 at 11:25 PM by the Charge Nurse. 4. Review of the incident investigation file revealed head to toe assessments were performed by the Charge Nurse and staff nurses on residents with BIMS scores of seven (7) or less, beginning 03/16/2020 through 03/17/2020 with no issues identified. 5. Interview with the Social Services Director on 10/01/2020 at 2:11 PM, revealed she interviewed all interviewable residents with BIMS scores of greater than seven (7) on 03/16/2020 and 03/17/2020 and there were no other residents that felt they had been abused or not treated with dignity. Documentation of the interviews were reviewed in the incident investigation file. 6. Interview with the Administrator on 10/01/2020 at 2:30 PM revealed the previous DON conducted interviews with SRNA #3 and SRNA #4 (witnesses to the incident) and obtained witness statements. Witness statements from both SRNA #3 and SRNA #4 were reviewed in the incident investigative file. 7. Review of the investigative file and the In-service records revealed documentation of training on Abuse and Dealing with an Uncooperative Resident was conducted with all staff on 03/16/2020 and 03/18/2020. Continued review revealed all staff on the sign in sheet had corresponding quizzes titled Dealing with an Uncooperative Resident/Abuse Quiz. The training was conducted by the Staff Development Coordinator. Interviews on 10/01/2020 with SRNA #2 at 1:45 PM, SRNA #1 at 1:48 PM, LPN #2 at 4:37 PM, RN#1 at 4:44 PM and Social Services Director at 2:00 PM, all revealed they received education and training from the Staff Development Coordinator around mid-March on Abuse, Dealing with Uncooperative Residents, and Residents Rights. 8. Review of the investigative file revealed copies of quizzes titled Dealing with an Uncooperative Resident/Abuse Quiz that matched up to the names on the education sign in sheet. Interviews on 10/01/2020 with SRNA #2 at 1:45 PM, SRNA #1 at 1:48 PM, LPN #2 at 4:37 PM, RN#1 at 4:44 PM and Social Services Director at 2:00 PM, all revealed they were required to take a quiz on the training they received. Interview with the Administrator on 09/30/2020 at 3:48 PM and again on 10/01/2020 at 1:00 PM revealed all staff were educated on abuse and dealing with uncooperative residents by the staff development coordinator on 03/17/2020 and 03/18/2020. All staff completed a quiz at completion of the training and education. 9. Interview with the Administrator on 10/01/2020 at 1:00 PM revealed the QAPI team met on 03/18/2020 to review the final investigation and to review the corrective action that was implemented. She stated the QAPI determined the corrective action was affective and the facility was in compliance with the regulations.

Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to ensure all allegations of abuse were reported immediately, but not later than two (2) hours after the allegation is made, to the Administrator and to other officials in accordance with the State Law for one (1) of six (6) sampled residents (Resident #1). Per interview, staff were aware of Resident #1 having bruising of various stages of healing on 0[DATE]20; however, it was not reported to the facility's Administration and other officials until 01/13/2020. The findings include: Review of the facility's Policy, titled Reporting Abuse to Facility Management, dated 11/02/2017, revealed it was the policy of the facility that each resident has the right to be free from abuse and neglect. Further review revealed it was the responsibility of the facility's employees, facility consultants, attending physicians, family members, and visitors to promptly report any incident or suspected incident of neglect of abuse, including injuries of unknown source to the facility management. Continued review revealed injury of unknown origin was defined as an injury that the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury was suspicious because of either the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time or the incidence of injuries over time. Further review revealed all employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Administrator. Review of the facility's Policy, titled Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/03/17, revealed all alleged violations must be reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury. Review of Resident #1's medical record revealed the facility admitted the resident on 05/12/2017 and readmitted the resident on 04/12/2019 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/28/2019, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) score of eight (8) out of fifteen (15), indicating the resident had moderately impaired cognition. However, review of the Significant Change MDS Assessment, dated 12/23/2019 revealed the resident's BI[CONDITION] at that time was three (3) of fifteen (15) indicating severe cognitive impairment. Review of the facility's Investigation, dated 01/17/2020, revealed Licensed Practical Nurse (LPN) #1 was performing a routine skin assessment on 01/13/2020 for Resident #1 when she noted a discoloration, which appeared to be bruising on the resident's thighs and left upper back. Immediate action was taken with a head-to-toe skin assessment completed by LPN #1. No additional bruising was noted. It was noted Resident #1 had a diffused rash, primarily located on her abdomen, back and arms. The Advance Practice Registered Nurse (APRN) was asked to assess Resident #1 and she ordered labs and a dermatology consult. Appropriate notifications were made. Skin assessments were performed on non-interviewable residents with no concerns identified. All interviewable residents were interviewed with no concerns identified. Per the investigation, the facility concluded that the injuries were very likely the result of baseline fragile skin due to advanced age, exacerbated by steroid treatment for [REDACTED]. However, interviews revealed, during the investigation, staff were aware of skin injuries of unknown origin prior to the report to the Administration on 01/13/2020. Review of Facility's Incident Report revealed LPN #1's assessment of Resident #1 on 01/13/2020, revealed it was noted the resident had discoloration to bilateral upper extremities in various stages of healing (red to purple). Continued review revealed LPN #1 also assessed Resident #1 to have discoloration to the bilateral anterior thighs extending to the bilateral hips in various stages of healing (purple to back with slight yellowing). Discoloration to left flank and mid back (yellow in color). Further review revealed LPN #1 assessed Resident #1 to have self-inflicted scratches to the bilateral upper extremities, abdomen and chest related to pin point rash. Per review, there was no documented evidence the bruising in various stages of healing had been reported to Administration or reported to the appropriate authorities for an injury of unknown origin. Interview with LPN #1, on 02/05/2020 at 10:29 AM, revealed she has been with the facility for six (6) years and works the North Hallway on Mondays and Tuesdays where Resident #1 resides. LPN #1 provided care for Resident #1 on 01/13/2020 on day shift from 7:00 AM to 7:00 PM. LPN #1 stated she went in to do the resident's skin assessment and Resident #1 had discoloration all over the top of his/her thighs. She stated it was in the light purple stage, discolored but it was like a bruise. Continued interview revealed LPN #1 did not feel the areas were fresh and the injury had not recently occurred. She reported Resident #1 also had bruising to his/her left flank thighs and back. Further interview revealed at that point, LPN #1 stopped the skin assessment. Not being aware of the source of the bruises, LPN #1 asked LPN #3 to come in and look at the areas. LPN #1 stated she notified the previous Director of Nursing. She stated, the DON arrived and Resident #1 was in the wheelchair. The DON looked at the resident's legs, which were bruised and then retrieved the Regional Nurse who came and assessed the resident. Per interview, the DON thought it looked like purpura (a rash of purple spots due to small blood vessels leaking blood into the skin). The APRN was called to come and examine the resident. She arrived after lunch on 01/13/2020 and commented the areas did not look like purpura. It was at that time the DON notified the state. Interview with LPN #3, on 02/05/2020 at 9:48 AM, revealed she had worked January 13, 2020 on day shift 7:00 AM to 7:00 PM. LPN #3 stated during a routine skin assessment, LPN #1 noticed Resident #1 had bruising on the top of his/her thighs, back, and arms. LPN #3 came in to confirm the assessment of bruising to the thighs, back and arms. Per interview, LPN #3 stated she and LPN #1 were unsure of the origin of the bruising. Some areas were dark purple and some lighter in color as if they had been fading. LPN #3 stated they checked for possible blood clots or bruising from blood thinners. Continued interview revealed Resident #1 did not walk, but he/she did move around in the bed and at times hit the bed rails. LPN #3 revealed she had never witness anyone being rough or harsh with Resident #1 and the resident was care planned to have two staff to change the resident due to combativeness. Interview with State Registered Nursing Assistant (SRNA) #5, on 02/05/2020 at 1:39 PM, revealed she first noticed bruising on Resident #1's thighs on Friday 0[DATE]20. She stated Resident #1 was sitting in the wheelchair right beside his/her room and the lights were very bright. Continued interview revealed the areas on his/her legs looked like a Dalmatian spots; however, they did not look fresh. She reported the bruising looked as if they were old bruises. SRNA #5 stated she did not mention the bruises to the nurse and honestly thought the nurse was already aware because Resident #1 always had so many bruises. Further interview revealed the resident would grab at his/her thighs and arms. Interview with SRNA #4, on 02/05/2020 at 1:36 PM, revealed she had provided care for Resident #1 on Friday 0[DATE]20 and noticed bruising on her arms, which were self-inflicted. SRNA #4 stated Resident #1 would grab his/her own arms and squeeze as hard as possible. However, she was not aware of bruising on Resident #1's thighs or back. Interview with SRNA #3, on 02/05/2020 at 1:54 PM, revealed her normal work station was the North Hall where Resident #1 resides. SRNA #3 stated she was familiar with Resident #1 and stated Resident #1 had behaviors similar to other Dementia residents she had previously care for. She stated Resident #1 would be agitated and would kick the staff and often bite or hit his/her own self inflicting injury. He/She was confused and would have behaviors of smacking his/her legs and then look at the staff and say, how does that feel. Further interview revealed on Saturday 01/11/2020 the staff got Resident #1 up in the chair and he/she started hitting their legs and asking SRNA #3, how does that feel? SRNA stated, LPN #2 was there and stated he would report it on his computer, he did not say he was going to report the incident to anyone. Later that day, Resident #1 had visible bruising to his/her lower legs; however, she did not see any bruising on his/her back. Interview with [ENTITY] #2, on 02/05/2020 at 10:03 AM, revealed she gave Resident #1 her medications, but also assisted with her care. Resident #1 had confusion, which would vary from day to day. [ENTITY] #2 stated she was aware Resident #1 had bruising on Saturday 01/11/2020 on the 7:00 AM to 7:00 PM shift, prior to the bruising being reported on Monday 01/13/2020. She stated Resident #1 was in the hallway at the nurse's station, on 01/11/2020, when she saw bruises on the resident's legs. Per interview, [ENTITY] #2 reported the bruising to LPN #4 and LPN #5. Continued interview revealed it was the facility's policy for staff to report something new, such as bruising, up the change of command immediately when it was discovered. She stated as a Kentucky Medication Aide, I would report to the nurse on duty. The nurse would be the one to report to the Director of Nursing (DON) or the Administrator. Administration would report to the state and other agencies. Interview with LPN #4, on 02/05/2020 at 1:15 PM, revealed she worked on Saturday 01/11/2020 from 7:00 AM to 7:00 PM. Per interview, she stated none of the aides informed her about any bruising on Resident #1's back or thighs. Continued interview revealed she did not perform any treatments for Resident #1 over the weekend of 01/11/2020 and 01/12/2020 and was not aware of any bruising. Additionally, LPN #4 stated Resident #1 pinched himself/herself a lot. The resident hits his/her own arms and we did do treatments for skin tears on the arms. Interview was attempted, on 02/05/2020 at 1:24 PM, with LPN #5, however, the number provided by the facility was no longer in-service and LPN #5 no longer is working at the facility. Interview with LPN #2,on 02/05/2020 at 1:30 PM, revealed he could not remember if he provided care to Resident #1 between Thursday 0[DATE]20 to 01/13/2020 and had never been told he/she had bruising. He stated he was not informed by any of the SRNAs of concerns with Resident #1's skin and did not notice any issues when he care for Resident #1; however, he stated the resident has been combative. Further interview with LPN #2 revealed Resident #1 always has discoloration to their skin. Furthermore, he stated if there was any bruising out of the ordinary, the aides would have told him. Per interview, if there was an instance of new or unusual bruising it should be reported immediately to the DON. Interview with the DON, on 02/05/2020 at 3:19 PM, revealed she was familiar with the investigation from reading the report. She had only start as the acting DON on Monday 02/03/2020. Per interview, she stated according to the facility's policy, the staff should notify their supervisor or administration promptly when there is an injury of unknown origin or any allegation of neglect of abuse. Continued interview revealed when administration became aware of Resident #1's identified injury of unknown origin, it was reported promptly to the state and other agencies. Further interview revealed staff failed to immediately report Resident #1's injury of unknown origin to administration promptly and per the facility's policy and regulations. She stated it was her expectation for the staff to report promptly any actual or suspected incident of abuse, including injuries of an unknown source. Further interview revealed the staff were re-educated related to the facility's policies and expectations. Interview with the Administrator, on 02/05/2020 at 3:38 PM, she became aware of the bruising on Resident #1 when it was reported by LPN #1 on 01/13/2020. However, during the investigation, she became aware there had been bruising prior to the report by LPN #1 on 01/13/2020. Further interview revealed it would be her expectation the staff follow the facility's policy and report bruising or any injury of an unknown origin immediately upon discovery. Continued interview revealed the staff should report any issues of bruising to the nurse immediately, the nurse's responsibility is to do an incident report and to report to their direct supervisor, which would be the Unit Manager or DON. The DON would then notify the Administrator. Per interview, the facility would then make the appropriate notifications within the mandatory two (2) hour time.

Based on interview, record review, review of the facility's Policies, and review of the Kentucky Revised Statues (KRS), it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility and to State Agencies for two (2) of twenty (20) sampled Residents (Resident #1 and Resident #3). Nurse Aide (NA) #2 and NA #3 alleged they witnessed State Registered Nurse Aide (SRNA) #1 hit Resident #1 on the head on 05/20/19, at approximately 7:00 PM. Although NA #2 alleged she reported the abuse allegation immediately to Licensed Practical Nurse (LPN) #1; and reported the incident again to LPN #1 an hour later; LPN #1 denied being informed of the allegation of abuse. Therefore no action was taken, allowing SRNA #1 to work the rest of the shift on 05/20/19, and to work 05/21/19 and 05/22/19. Per the facility's Investigation, the Administrator was notified of the allegation of abuse two (2) days after the alleged witnessed abuse, on 05/22/19 at 5:00 PM; and State Agencies were notified two (2) days after the alleged witnessed abuse, on 05/22/19 at 7:00 PM. Additionally, NA #3 reported an allegation of abuse to the State Survey Agency (SSA) during the , on 05/29/19. NA #3 alleged while working with SRNA #1 on 05/21/19, she witnessed SRNA #1 enter a resident's room at approximately 10:00 PM, jerk the oxygen tubing off the resident's face, throw it on the bedside table, and tell the resident, I know you are not asleep. SRNA #1 also failed to provide incontinence care for this resident. NA #3 stated she had not reported this because she could not find a nurse; therefore no action was taken. SRNA #1 worked the rest of the shift on 05/21/19 and 05/22/19. The facility was unaware of the allegation regarding the unidentified resident until the SSA reported the allegation to the Administrator, on 05/30/19. The State Agencies were notified of the alleged abuse eight (8) days after NA #3 witnessed the alleged abuse. (Refer to F-600, F-607 and F-610) The facility's failure to ensure all allegations of abuse were reported immediately to the Administrator and to State Agencies within two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/30/19, and was determined to exist on 05/20/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/04/19, alleging removal of the Immediate Jeopardy on 06/01/19. The SSA determined the Immediate Jeopardy was removed on 06/01/19, as alleged prior to exit on 06/06/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Reporting Policy, undated revealed the facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. Any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported to the Administrator or Director of Nursing Services immediately. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment or offense. Failure to report may result in legal/criminal action being filed against the individual(s) withholding such information. Upon receiving reports of mistreatment, abuse, misappropriation of property, or neglect, the Administrator or Director of Nursing will immediately report the incident to the following agencies: Division of Licensing or Regulation, Adult Protective Services, Other Agencies, as appropriate (police, sheriff). In the event the Administrator or the Director of Nursing is not available, the charge nurse will report the incident immediately. Further review of the Policy, revealed employees accused of participating in the alleged abuse will be suspended without pay until the findings of the investigation have been reviewed by the Administrator. Review of the facility's Reporting Abuse to Facility Management Policy, dated 08/01/13, revealed the Administrator or Director of Nursing (DON) must be immediately notified of suspected abuse or incidents of abuse. All alleged violations must be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of KRS Chapter 209.020, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. 1. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, faxed to the Office of Inspector General (OIG, the SSA) on 05/22/19, at 7:00 PM, revealed an alleged incident of physical abuse occurred on 05/20/19. Per the Report, Nursing Assistant (NA) reported on 05/22/19, she witnessed another NA hit Resident #1 on the head. There were no injuries noted. Review of the facility Investigation Report, dated 05/24/19, signed by the Administrator, revealed an incident of physical abuse related to Resident #1 allegedly occurred on 05/20/19 at approximately 8:00 PM. NA #2 reported to LPN #1, while providing care to Resident #1, the resident was combative and SRNA #1 was kicked by the resident. SRNA #1 then hit the resident on top of the head and said, Don't act like that towards me. Further review of the Investigation, revealed NA #2 notified LPN #1 at approximately 8:00 PM and again at 9:00 PM of the allegation, and attempted to call the Nurse Aide Coordinator (NAC) on 05/21/19. However, LPN #1, denied NA #2 or any other employee approached her on 05/22/19 to report an incident of anyone hitting or abusing a resident in any manner. Per the Investigation, the Administrator was not notified of the allegation until 05/22/19 at 5:00 PM. Additional review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 05/22/19 after the allegation was reported to the Administrator and was terminated on 05/24/19. NA #2 and NA #3 were suspended for not reporting the allegation of abuse and terminated on 05/24/19. Per the Investigation, Resident #1 was interviewed on 05/22/19 at 7:00 PM and denied anyone being physically or verbally mean to him/her. Further review of the Investigation, revealed the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation; and Resident #1 had no injuries and denied the incident occurred. Per the Investigation, the resident's son and the Physician were notified of the allegation on 05/22/19 at 6:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 05/22/19 at 7:00 PM. Phone interview with NA #2, on 05/28/19 at 2:20 PM, and 05/29/19 at 3:52 PM, revealed on the evening of 05/20/19, she (NA #2) and NA #3 were partnered with SRNA #1 and they were assigned to Resident #1. Per interview, on that date at approximately 7:00 PM, Resident #1's chair alarm was sounding due to the resident leaning forward and she and NA #3 repositioned the resident in the chair while SRNA #1 reset the alarm. She stated Resident #1 became combative while being repositioned and as they were walking away, Resident #1 kicked SRNA #1 in the leg. Per interview, SRNA #1 then hit the resident on the top of the head and told the resident to never act like that again. NA #2 further stated she immediately reported what she had witnessed to LPN #1, who was in another resident's room with no other staff around. She stated LPN #1 stated she would take care of it. However, about an hour later, at approximately 8:00 PM, she realized SRNA #1 was still working on the floor so she again reported the allegation to LPN #1, who was at the nurse's station with no other staff in hearing distance. NA #2 stated LPN #1 again told her she would take care of it. The NA stated SRNA #1 worked the rest of the shift providing care to residents. Per interview, NA #2 did not attempt to notify any other nurses or management staff of the incident on 05/20/19. Additional interview with NA #2, on 05/28/19 at 2:20 PM, and 05/29/19 at 3:52 PM, revealed she attempted to call the Nurse Aide Coordinator (NAC) the following day to report the abuse; however, she was unable to reach her. NA #2 stated on 05/22/19 she received a text message from the NAC asking her to arrive early for her shift and she texted back at 3:11 PM, notifying the NAC of the abuse which she had witnessed on 05/20/19. Per interview, the NAC texted her back and asked her to call the NAC. NA #2 stated she then called the NAC and gave a statement regarding what she had witnessed related to SRNA #1 hitting Resident #1. Contined interview interview revealed when she arrived at the facility on 05/22/19 at 6:00 PM, she was interviewed again by the Administrator and she also gave a written Statement to the Administrator. Continued interview revealed she then went back to the floor to work and about thirty (30) minutes later, she was removed from the floor and suspended for five (5) days. She stated three (3) days later, on 05/24/19, she was terminated for not immediately reporting abuse. Phone interview with NA #3, on 05/29/19 at 3:14 PM, revealed she started working at the facility on 05/14/19. Per interview, she was orienting with SRNA #1 on the evening of 05/20/19, when Resident #1's chair alarm started sounding around 7:00 PM in the resident's room. She stated she (NA #3), NA #2 and SRNA #1 responded to the alarm, She and NA #2 assisted with positioning Resident #1 in the chair while SRNA #1 reset the chair alarm. NA #3 stated once Resident #1 was positioned correctly in the chair, they started to walk away when Resident #1 kicked SRNA #1 in the leg and SRNA #1 hit Resident #1 on the head. Further interview revealed she had been in orientation prior to this and had watched videos for three (3) days and during this time, received abuse training. She stated she was aware abuse was to be reported right away, but she did not report the abuse because NA #2 informed her she (NA #2) was going to report what happened. Phone interview with SRNA #1, on 05/28/19 at 3:30 PM, revealed she started working at the facility in (MONTH) (YEAR). Per interview, on 05/20/19, she was orienting NA #3 and around 8:00 PM, NA #2 asked her to assist with Resident #1 because the resident had become combative with NA #2 and NA #3. SRNA #1 stated Resident #1 grabbed SRNA #1's arms, so SRNA #1 grabbed the resident's wrists and simply moved them off her arms. She stated SRNA #4 approached her later that evening and informed her that NA #2 stated she witnessed SRNA #1 slap Resident #1, and NA #2 had reported it to the charge nurse. SRNA #1 denied she hit or abused Resident #1. Continued interview revealed she was suspended on 05/22/19, and terminated on 05/24/19. Review of the time clock data revealed SRNA #1 continued to work on 05/20/19 until clocking out at 10:07 PM; worked 05/21/19 from 1:56 PM until 10:27 PM, and worked 05/22/19 from 9:55 AM until 2:13 PM. Interview with the NAC, on 05/29/19 at 9:20 AM, revealed she did not get a phone call from NA #2 on 05/21/19; however, on 05/22/19 she did receive a text message around 3:10 PM from NA #2 stating SRNA #1 hit Resident #1 the last evening they worked together. Per interview as soon as she received the text she reported the allegation immediately to the Director of Nursing (DON), and the DON referred her to the Administrator. The NAC stated she then immediately notified the Administrator of the allegation and was instructed to phone NA #2 and SRNA #1 and obtain Statements. Observation on 05/29/19 at 9:20 AM, of the NAC cell phone text message, revealed a text message was received on 05/22/19 at 3:11 PM from NA #2, reporting the allegation of abuse. Continued interview with the NAC, on 05/29/19 at 9:20 AM, revealed while taking NA #2's statement, on 05/22/19, NA #2 reported on the evening of 05/20/19, Resident #1's alarm was sounding, and the resident was agitated and kicked SRNA #1. Per interview, NA #2 reported SRNA #1 then hit Resident #1 on the back of the head and told the resident not to act like that with her. Further interview revealed NA #2 stated she immediately reported the incident to a nurse, which she described as medium size with brown hair; however, NA #2 could not recall the nurse's name. The NAC stated NA #2 told her NA #3 also witnessed this incident. Additional interview with the NAC, on 05/29/19 at 9:20 AM, revealed she subsequently called SRNA #1 on 05/22/19 for a Statement. Per interview, SRNA #1 informed her she entered Resident #1's room to assist staff because Resident #1 was undressing and agitated on 05/20/19. The NAC further stated SRNA #1 reported Resident #1 grabbed SRNA #1's arms and SRNA #1 grabbed the resident's wrists. The NAC stated SRNA #1 denied striking the resident. Further interview with the NAC, on 05/29/19 at 9:20 AM, revealed she then called NA #3 on 05/22/19 at 5:00 PM, to obtain a statement and was told NA #3 could not recall any incident related to Resident #1. Per interview, the NAC and the Administrator called NA #3 a second time on 05/22/19 at 7:30 PM and NA #3 informed them, Resident #1 was hitting and kicking staff and SRNA #1 reached over and tapped the resident's head. The NAC further stated after the Statements were obtained from SRNA #1, NA #2 and NA #3, all three (3) staff were terminated. Continued interview revealed staff were trained to report abuse to the charge nurse, or call the Director of Nursing (DON) or Administrator; and staff received abuse training upon hire and throughout the year. Phone interview with LPN #1, on 05/29/19 at 3:39 PM, confirmed she was assigned to Resident #1 on the evening of 05/20/19. She stated NA #2 did not report any allegation of abuse to her on the evening of 05/20/19, nor was she aware Resident #1 was having behaviors that evening. Per interview, she was not aware of the allegation related to SRNA #1 hitting Resident #1 until she was interviewed via phone call from the Administrator making her aware, on 05/22/19. Additional interview revealed an allegation of abuse of any kind should be reported immediately. She stated if staff was to report abuse to her, she would report the allegation to the DON, and ensure the aleged perpetrator was removed from resident care immediately. Further interview revealed any allegation of abuse has to be reported to State Agencies within two (2) hours. Interview with NA #5, on 05/29/19 at 10:30 AM, revealed she had worked at the facility for a few months and worked the evening of 05/20/19. She stated on 05/20/19 she witnessed SRNA #4 tell SRNA #1, that NA #2 had reported SRNA #1 for hitting Resident #1. Continued interview revealed NA #5 was not a witness to any incident regarding Resident #1 being hit. However, she stated, if this incident of abuse was witnessed by NA #2 or other staff, and reported, SRNA #1 should had been suspended on 05/20/19, as soon as the incident was reported. Interview with SRNA #4, on 05/30/19 at 1:10 PM, revealed she worked the 2:00 PM to 10:00 PM shift on 05/20/19. She stated on 05/20/19 around 9:00 PM, NA #2 informed her SRNA #1 hit Resident #1 on the head. Per interview, she asked NA #2 if she had reported the abuse allegation and NA #2 stated she had reported it to LPN #1. Further interview revealed it was important to report abuse, in order to prevent further abuse, as no one deserved to be abused. She further stated she would consider it abuse to hit a resident on the head. Interview with the Director of Nursing (DON), on 05/30/19 at 6:50 PM, revealed on 05/22/19, at about 3:15 PM, the NAC showed her the text message she received from NA #2. Per interview, the DON then advised the NAC to show the text to the Administrator, as the Administrator took the lead on abuse investigations. Continued interview revealed it was determined during the facility's investigation, that NA #2, and NA #3 who witnessed the alleged abuse towards Resident #1 on 05/20/19 should have reported this immediately. Per interview, during the investigation, NA #2 stated she reported the allegation to LPN #1; however, LPN #1 denied being notified of the allegation on 05/20/19. The DON stated if the allegation had been reported immediately, the alleged perpetrator could have been removed from resident care on 05/20/19 and suspended to prevent further potential abuse to Resident #1 or other residents. She further stated SRNA #1 did continue to work the rest of the shift on 05/20/19 after the alleged abuse was witnessed and also worked on 05/21/19 and 05/22/19 before she was suspended on 05/22/19 and terminated on 05/24/19. Further interview revealed the facility did learn of the allegation on 05/22/19 about 3:15 PM, but failed to report the allegation to the State Agencies timely after learning of the allegation; as the facility was attempting to obtain witness Statements before it was reported. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed the NAC was informed of the allegation of abuse related to SRNA #1 hitting Resident #1 via text message from NA #2 on 05/22/19. She stated the NAC then informed her of the allegation on 05/22/19 at 5:00 PM. Per interview, the allegation of abuse should have been reported immediately on 05/20/19 to the nurse, management or the Administrator, in order for SRNA #1 to be removed from duty and suspended for the protection of the residents. She stated NA #2 did state she reported the abuse to LPN #1 on 05/20/19; however, LPN #1 denied the allegation was reported to her. Continued interview revealed as a result of staff failing to immediately report the allegation of abuse, SRNA #1 continued working on 05/20/19 and also worked on 05/21/19 and 05/22/19. The Administrator stated, the residents were not protected from further potential abuse during this timeframe related to staff's failure to report the allegation. Additional interview, revealed the regulations should be followed related to notification to State Agencies within two (2) hours of any allegation of abuse; however, due to the facility learning of the allegation two (2) days later, the facility was late reporting the allegation to the State Agencies. 2. During a phone interview on 05/29/19 at 3:14 PM, with NA #3, she stated she had worked with SRNA #1 on 05/21/19 from 6:00 PM to 10:00 PM on the South Hall as she was being trained by SRNA #1. NA #3 stated she and SRNA #1 were the only staff taking care of Group 5 that evening. NA #3 stated SRNA #1, Seemed aggressive with residents and acted like she did not want to do her job. NA #3 further stated, at the end of the shift on 05/21/19, SRNA #1 got upset when the nurse brought it to her attention that three (3) residents needed incontinence care. Continued interview revealed NA #3 and SRNA #1 entered a resident's room and SRNA #1 jerked the resident's oxygen cannula off the resident's face, threw it on the bedside table, and stated to the resident, I know you are not asleep. Continued interview revealed SRNA #1 did not perform incontinence care for the resident and left the resident soiled due to there were no briefs in the room. NA #3 further stated she learned in orientation she was to report abuse to a nurse; however, at the time this occurred, she could not find a nurse and therefore she did not report what she witnessed and went on home. The SSA notified the Administrator, on 05/30/19 at 11:00 AM, of the alleged abuse described by NA #3, related to the unnamed resident. The Administrator stated she was unaware of this allegation, but the facility would initiate an investigation. Review of the Long Term Care Facility-Self Reported Incident Form/Initial Report, presented to the State Survey Agency (SSA) Representative on 05/30/19 at 12:00 PM, revealed the SSA had reported that a NA witnessed SRNA #1 on 05/21/19, to not provide incontinence care to a resident and to jerk oxygen tubing off the resident and state to the resident, I know you're not asleep. Further review revealed the resident's name was unknown at this time. Phone interview with SRNA #1, alleged perpetrator, on 05/30/19 at 3:14 PM, revealed she denied jerking a resident's oxygen off or telling a resident, I know you are not asleep and also denied not performing incontinence care for a resident because there were no briefs in the room. Interview on 05/30/19 at 6:24 PM, with the Social Service Director, revealed she was informed by the Administrator of a new allegation of abuse related to SRNA #1 jerking oxygen tubing off an unnamed resident and being mean; and then refusing to provide care. She further stated this allegation of abuse should had been reported when the incident was witnessed to ensure the safety of the residents. Interview with the DON, on 05/30/19 at 6:50 PM, revealed she was informed earlier of a new allegation of abuse by the Administrator related to an unnamed resident and the investigation was ongoing. Per interview, she was informed the allegation was related to SRNA #1 jerking oxygen tubing off a resident and refusing to provide incontinence care. Further interview revealed it was her expectation any witnessed abuse or allegation of abuse be reported immediately to the nurse, immediate supervisor, management or the Administrator in order to protect the residents from further potential abuse. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed if NA #3 witnessed abuse by SRNA #1 on 05/21/19, NA #3 should have immediately reported the allegation. She stated once she was notified on 05/30/19 of the allegation of abuse, the investigation was initiated and was still ongoing. The Administrator stated she was at first unaware of who reported the allegation to OIG, and subsequently when the SDC interviewed NA #3 on the phone on 05/30/19, NA #3 told her she witnessed SRNA #1 jerk the resident's oxygen tubing off his/her face and state I know you're not asleep. Per interview, NA #3 also told the SDC, SRNA #1 failed to provide incontinence care to the resident. The Administrator stated NA #3 ultimately gave the SDC Resident #3's name as the victim. Further interview revealed the facility was unable to substantiate abuse occurred; however, it was her expectation staff immediately report any allegations of abuse to their immediate supervisor, management or the Administrator in order to protect the residents from further potential abuse. Per interview, if this allegation related to Resident #3 had been reported on 05/21/19, SRNA #1 would have been immediately removed from resident care to prevent further potential abuse; however, SRNA #1 did work the rest of the shift on 05/21/19 and also worked 05/22/19, until she was suspended related to another abuse allegation. During the SA Representative's interview with Resident #3 on 05/30/19 at 8:57 PM, the resident only answered answer yes or no to questions asked. Resident #3 was asked if he/she recalled a SRNA pulling oxygen from his/her face and the resident responded yes and attempted to remove his/her remove oxygen cannula. Resident #3 also stated, yes when questioned about being left wet during the same timeframe as when his/her oxygen was pulled off his/her face. When Resident #3 was questioned if he/she could recall the name of the aide who treated him/her in this manner, the resident responded, No to recalling the aide's name. Review of the facility's Abuse Investigation Report, dated 06/03/19, signed by the Administrator, revealed it was faxed to the Office of Inspector General on 06/03/19 at 11:46 AM. Per the Investigation, the SA Representative reported on 05/30/19 at 11:15 AM, during the survey investigation, an incident of neglect was reported to the SA Representative. It was alleged, on 05/21/19 at approximately 10:00 PM, SRNA #1 was witnessed failing to provide incontinence care to a resident, and also jerked the resident's oxygen off and stated, I know you are not asleep. NA #3 was witness to the incident and SRNA #1 was the accused. The Investigation revealed the facility identified Resident #3 as the unnamed resident related to the allegation. Per the Investigation, Resident #3 was interviewed on 05/30/19 and the resident denied the incident occurred, and also denied any similar incident had occurred. Continued review of the Investigation, revealed Resident #3 was interviewed again on 05/31/19, and denied the incident occurred. Additional review of the Investigation, revealed Resident #3's roommate who had a Brief Interview for Mental Status (BIMS) score of (15) out of fifteen (15) indicating the resident was cognitively intact, also denied witnessing the alleged incident. Further review of the Investigation, revealed staff who worked on the south side on 05/21/19 from 2:00 PM to 10:00 PM, were interviewed by the SDC and the NAC, on 05/30/19. Per the Investigation, SRNA #31, SRNA #32, NA #33, NA #34, SRNA #35, SRNA #36 and NA #37, denied witnessing the incident or a similar incident. Additional review of the Investigation, revealed a Statement was obtained on 05/30/19 (time unknown) by phone from NA #3, who stated she did witness an incident with SRNA #1 and a resident, and NA #3 stated the name of the resident. However, per the Statement, the interviewer informed NA #3 there was no resident with that name on the south side. Per the Statement, the interviewer could hear in the background on the phone, someone speak up and state Resident #3' name. When the interviewer asked who was in the background and named Resident #3 as the unnamed resident, the interviewer was told it was NA #2. (However, NA #2 did not work the evening of 05/21/19). Per the Statement, NA #3 then stated Resident #3 was the resident who SRNA #1 had mistreated on 05/21/19. The name of the interviewer was not documented on the Statement; however, the Administrator revealed on 05/30/19 at 7:40 PM, the Staff Development Coordinator (SDC) conducted this interview. Further review of the Investigation, revealed based on interviews and assessments, the facility was unable to substantiate abuse occurred. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/31/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/01/19. Review of the AoC revealed the facility implemented the following. 1. A head to toe assessment of Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was completed by LPN #6 on 05/22/19 and revealed no new areas of concern as compared to previous skin assessment on 05/14/19. Resident #1's head and scalp indicated no signs of injury as evidenced by no redness, bruising or indications of trauma. Interview with Resident #1 was attempted on 05/22/19, by LPN #6, revealed the resident didn't have time for the interview as he/she was looking for his/her candy. Resident #1 was re-approached one (1) hour later by Kentucky Medication Aide (KMA) #2 at which time he/she denied anyone had ever been physically or verbally mean to him/her. Resident #1 was interviewed again on 05/23/19, by the Social Services Director, and the resident denied anyone had been mean or had hit him/her. 2. The facility initiated an investigation on 05/30/19 upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) of an allegation involving an unknown resident who was referenced in the Immediate Jeopardy (IJ) notification document. The identity of the unknown resident was established during the facility's investigation based on staff interviews by the Staff Development Coordinator (SDC) and the Nurse Aide Coordinator (NAC) on 05/30/19, as Resident #3. Resident #3, who was assessed as having a BIMS of ten (10), was interviewed and he/she indicated the alleged incident had not occurred. A head-to-toe skin assessment was completed on Resident #3 by the DON, on 05/30/19. The skin assessment findings noted chronic, (previously identified) discolorations to bilateral hands. No other skin concerns were noted. Skin was assessed as dry and intact with no redness or breakdown in the peri area. SRNA #1 was suspended on 05/22/19, immediately upon the facility notification of the initial allegation, reported by NA #2, to have occurred on 05/20/19. SRNA #1 was terminated on 05/24/19, at the conclusion of the facility investigation. NA #2 and NA #3 were suspended on 05/22/19, and terminated on 05/24/19, due to failure to report the allegation per facility policy. SRNA #10 voluntarily terminated her position as of 03/17/19. NA #9 was suspended on 05/30/19, and remains suspended at this time as the facility continues to investigate the allegation stemming from the incident on 02/22/19. 3. An Ad Hoc Quality Assurance (QA) meeting with the Medical Director was held on 05/31/19 by the facility's Administrator and attended by the Director of Nursing and Regional Director of Operations. The following were reviewed during the Quality Assurance Meeting: [NAME] The survey findings as per the IJ notification. B. AoC and corresponding action plan. C. The on-going compliance monitoring audits. D. The results of interviewable resident interviews (BIMS of eight (8) and above). E. The results of the non-interviewable resident skin assessments (BIMS of seven (7) or lower). F. Staff re-education related to the facility policy and procedure titled Resident Protection Policy which addressed abuse, neglect, mistreatment and misappropriation. 4. Interviews were conducted by the Social Services Director, Admissions Coordinator, Activities Director, Housekeeping Supervisor, Dietary Manager and Human Resources Director on 05/31/19, with all residents assessed as interviewable based on the most recent BIMS scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. Skin assessments were performed by licensed staff on 05/31/19, for all residents assessed as non-interviewable based on current BIMS scores below eight (8). No skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. 5. The Regional Director of Operations (RDO), conducted in-service education with the facility Administrator on 05/30/19, regarding the facility's policy and procedure titled Resident Protection Policy, which addressed abuse, neglect, mistreatment and misappropriation. This policy also addressed requirements related to identifying, reporting, notifications, investigating and maintaining resident protection during the investigation process. The DON received in-service education on 05/30/19, by the Administrator, regarding the facility's Resident Protection Policy. In-service education was conducted by the facility's Administrator, on 05/30/19 with all staff on duty, which was twenty-one (21) out of one hundred eighty-five (185) employees at the time the IJ notification was presented including all licensed nurses, Kentucky Medication Aides (KMAs), SRNAs, and Department Managers including the Dietary Manager, MDS Nurse, Assessment Nurse, MDS Nurse, Activity Director, Assistant Administrator, Social Services Director, Admissions Director, Human Resources Director, DON, and Quality Assurance Nurse, regarding the Resident Protection Policy. 6. On 05/31/19, the DON, Nurse Aide Coordinator, Human Resources Director, Social Services Director, Bookk

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure its abuse policies were implemented for two (2) of twenty (20) sampled residents (Residents #1 and #3). Nurse Aide (NA) #2 and NA #3 alleged they witnessed State Registered Nurse Aide (SRNA) #1 hit Resident #1 on the head, on 05/20/19 at approximately 7:00 PM. Although NA #2 alleged she immediately notified Licensed Practical Nurse (LPN) #1 and notified LPN #1 again an hour later, LPN #1 denied being notified of the alleged abuse. There was no documented evidence the facility policy was implemented related to reporting abuse to the Administrator or to State Agencies and no documented evidence the facility's policy was implemented related to initiating an investigation. The allegation was not reported to the Administrator or to the State Agencies until 05/22/19, when the investigation was then initiated, two (2) days after the alleged abuse was witnessed. Also, there was no documented evidence the facility's policy was implemented related to protecting residents from abuse, as the alleged perpetrator, SRNA #1, continued to work on 05/20/19, and also worked 05/21/19 and 05/22/19, allowing the potential for further abuse. Additionally, interview with NA #3, revealed while she was working with SRNA #1 on 05/21/19, she witnessed SRNA #1 enter a resident's room at approximately 10:00 PM, jerk the oxygen tubing off the resident's face, throw it on the bedside table, and tell the resident, I know you are not asleep. NA #3 further revealed that SRNA #1 also failed to provide incontinence care for this resident. NA #3 stated what she witnessed was abuse; however, she did not report the abuse because she could not find a nurse. There was no documented evidence the facility implemented its policy related to reporting abuse to the Administrator or to State Agencies as the facility was uninformed of the allegation regarding the unidentified resident until the State Survey Agency (SA) informed the facility of the allegation on 05/30/19. In addition, there was no documented evidence the facility's policy was implemented related to protecting residents from abuse, as the perpetrator, SRNA #1, continued to work on 05/21/19 and 05/22/19, allowing the potential for further abuse. (Refer to F-600, and F-609 and F-610) The facility's failure to implement its policies and procedures regarding reporting, and investigating allegations of abuse, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/30/2019, and was determined to exist on 05/20/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/04/19, alleging removal of the Immediate Jeopardy on 06/01/19. The SSA determined the Immediate Jeopardy had been removed 06/01/19, as alleged, prior to exit on 06/06/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Reporting Policy, undated revealed any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported to the Administrator or Director of Nursing Services immediately. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment or offense. Upon receiving reports of mistreatment, abuse, misappropriation of property, or neglect, the Administrator or Director of Nursing will immediately report the incident to the following agencies: Division of Licensing or Regulation, Adult Protective Services, Other Agencies, as appropriate (police, sheriff). In the event the Administrator or the Director of Nursing is not available, the charge nurse will report the incident immediately. Further review of the Policy, revealed employees accused of participating in the alleged abuse will be suspended without pay until the findings of the investigation have been reviewed by the Administrator. Review of the facility's Reporting Abuse to Facility Management Policy, dated 08/01/13, revealed all alleged violations must be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the facility's Abuse Investigation Policy, dated 08/01/13, revealed all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will investigate the alleged incident. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Review of the facility's Protection Policy, undated, revealed residents should be protected from any harm during the course of an investigation. Examples of what can be done for protection of resident include: remove perpetrator (if known); assess and treat the injury; assess for any significant change in function and mood; Care Plan as necessary; notify physician and family; refer to social services; have nursing staff be acutely aware of resident needs; reduce external stimuli; and reduce number of caregivers, if possible. Further review of the Policy revealed employees accused of participating in the alleged abuse will be suspended without pay until the findings of the investigation have been reviewed by the Administrator. 1. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, which was faxed to the Office of Inspector General (OIG/ the SSA) on 05/22/19, at 7:00 PM, revealed an alleged incident of physical abuse occurred on 05/20/19. NA reported on 05/22/19, she witnessed another NA hit Resident #1 on the head. No injuries were noted. Review of the Investigation Report, dated 05/24/19, signed by the Administrator, revealed an incident of physical abuse involving Resident #1 allegedly occurred 05/20/19 at approximately 8:00 PM. NA #2 reported to LPN #1, while providing care to Resident #1, the resident was combative and SRNA #1 was kicked by the resident. SRNA #1 then hit Resident #1 on top of the head and said, Don't act like that towards me. Continued review of the Investigation, revealed NA #2 alleged she notified LPN #1 at approximately 8:00 PM and again at 9:00 PM of the allegation, and attempted to call the Nurse Aide Coordinator (NAC) on 05/21/19. However, per the Investigation, LPN #1, denied NA #2 or any other employee approached her on 05/22/19 to report an incident of anyone hitting or abusing a resident in any manner. According to the Investigation, this allegation of abuse was not reported to the Administrator until 05/22/19 at 5:00 PM, by the NAC. Continued review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 05/22/19 after the allegation was reported to the Administrator and was later terminated on 05/24/19. NA #2 and NA #3 were both suspended for not reporting the allegation of abuse and both were then terminated on 05/24/19. Resident #1 was interviewed on 05/22/19 at 7:00 PM and denied anyone being physically or verbally mean to him/her. According to the Investigation, the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation; and Resident #1 had no injuries and denied the incident occurred. Per the Investigation, the resident's son and the Physician were notified of the allegation on 05/22/19 at 6:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 05/22/19 at 7:00 PM. Interview with the Director of Nursing (DON), on 05/30/19 at 6:50 PM, revealed during the facility's investigation, it was identified NA #2 and NA #3, who witnessed the alleged abuse towards Resident #1 on 05/20/19, should have reported the alleged abuse immediately. Per interview, the investigation further identified NA #2 stated she reported the allegation to LPN #1; however, LPN #1 denied being notified of this allegation on 05/20/19, and the allegation was not reported to the Administrator and to State Agencies within two (2) hours, as per facility Policy. Further interview revealed the facility's Policy was not implemented related to initiating an investigation, as the investigation was not initiated until 05/22/19, two (2) days after the alleged violation was witnessed. Additional interview revealed the facility's Policy was not implemented related to protecting the residents and removing the alleged perpetrator, SRNA #1, from resident care in order to prevent further potential abuse to Resident #1 or other residents. The DON stated SRNA #1 continued to work the rest of the shift on 05/20/19 after the alleged abuse was witnessed and also worked on 05/21/19 and 05/22/19 before she was suspended on 05/22/19 and terminated on 05/24/19. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed she acknowledged the facility's written Policy was not implemented related to reporting abuse, investigating abuse, and protecting residents from further potential abuse related to the allegation of abuse for Resident #1. Per interview, the alleged abuse witnessed on 05/20/19 related to Resident #1 should have been reported to the Administrator and to State Agencies within two (2) hours, as per Policy. Additional interview revealed there should have been an investigation immediately initiated and SRNA #1, the alleged perpetrator, should have been immediately removed from direct resident care and suspended on 05/20/19, and not allowed to work the rest of the shift on 05/20/19, or on 05/21/19 and 05/22/19. 2. During the investigation a phone interview was conducted on 05/29/19 at 3:14 PM, with NA #3. NA #3 stated she worked on 05/21/19 from 6:00 PM to 10:00 PM on the South Hall with SRNA #1. Per interview, SRNA #1, Seemed aggressive with residents and acted like she did not want to do her job. NA #3 stated, at the end of the shift on 05/21/19, SRNA #1 got upset when the nurse brought it to her attention that three (3) residents needed incontinence care. Per interview, NA #3 and SRNA #1 entered a resident's room SRNA #1 jerked the resident's oxygen cannula off the resident's face, threw it on the bedside table, and stated to the resident, I know you are not asleep. Continued interview revealed SRNA #1 did not perform incontinence care for the resident and left the resident soiled because there were no briefs in the room. Further interview revealed she was new to the facility and could not remember all of the resident's names, and therefore could not give the resident's name. NA #3 stated what she witnessed was abuse, and she learned in orientation she was to report abuse to a nurse; however, at the time this occurred, she could not find a nurse and therefore she did not report what she witnessed and went on home. The SSA notified the Administrator of the allegation on 05/29/19. Interview with the DON, on 05/30/19 at 6:50 PM, revealed she was informed earlier today of a new allegation of abuse by the Administrator. Per interview, the allegation was related to SRNA #1 jerking oxygen tubing off an unnamed resident and refusing to provide incontinence care. Further interview revealed the facility failed to implement its policy related to reporting the allegation of abuse for the unnamed resident, as the alleged violation occurred on 05/21/19 and the staff member (NA #3) did not report the abuse. Per interview, the facility also failed to implement its policy related to protecting residents. The DON stated, as a result of NA #3 failing to report the abuse on 05/21/19, SRNA #1 was allowed to continue working the rest of the shift on 05/21/19, and to work 05/22/19, until she was suspended after her shift on 05/22/19 related to the allegation of abuse regarding Resident #1. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed she acknowledged the facility's written Policy was not implemented related to reporting abuse, and protecting residents from further potential abuse related to the allegation violation for Resident #3. Per interview, the alleged abuse witnessed on 05/21/19 related to Resident #3 should have been reported to the Administrator and to State Agencies within two (2) hours as per Policy. Additional interview revealed SRNA #1, the alleged perpetrator, should have been immediately removed from direct resident care and suspended on 05/21/19, and not allowed to work the rest of the shift on 05/21/19, or on 05/22/19. Per interview, SRNA #1 was suspended after her shift on 05/22/19 and terminated on 05/24/19, related to the allegation of abuse regarding Resident #1. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/31/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/01/19. Review of the AoC revealed the facility implemented the following. 1. A head to toe assessment of Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was completed by LPN #6 on 05/22/19 and revealed no new areas of concern as compared to previous skin assessment on 05/14/19. Resident #1's head and scalp indicated no signs of injury as evidenced by no redness, bruising or indications of trauma. Interview with Resident #1 was attempted on 05/22/19, by LPN #6, revealed the resident didn't have time for the interview as he/she was looking for his/her candy. Resident #1 was re-approached one (1) hour later by Kentucky Medication Aide (KMA) #2 at which time he/she denied anyone had ever been physically or verbally mean to him/her. Resident #1 was interviewed again on 05/23/19, by the Social Services Director, and the resident denied anyone had been mean or had hit him/her. 2. The facility initiated an investigation on 05/30/19 upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) of an allegation involving an unknown resident who was referenced in the Immediate Jeopardy (IJ) notification document. The identity of the unknown resident was established during the facility's investigation based on staff interviews by the Staff Development Coordinator (SDC) and the Nurse Aide Coordinator (NAC) on 05/30/19, as Resident #3. Resident #3, who was assessed as having a BIMS of ten (10), was interviewed and he/she indicated the alleged incident had not occurred. A head-to-toe skin assessment was completed on Resident #3 by the DON, on 05/30/19. The skin assessment findings noted chronic, (previously identified) discolorations to bilateral hands. No other skin concerns were noted. Skin was assessed as dry and intact with no redness or breakdown in the peri area. SRNA #1 was suspended on 05/22/19, immediately upon the facility notification of the initial allegation, reported by NA #2, to have occurred on 05/20/19. SRNA #1 was terminated on 05/24/19, at the conclusion of the facility investigation. NA #2 and NA #3 were suspended on 05/22/19, and terminated on 05/24/19, due to failure to report the allegation per facility policy. SRNA #10 voluntarily terminated her position as of 03/17/19. NA #9 was suspended on 05/30/19, and remains suspended at this time as the facility continues to investigate the allegation stemming from the incident on 02/22/19. 3. An Ad Hoc Quality Assurance (QA) meeting with the Medical Director was held on 05/31/19 by the facility's Administrator and attended by the Director of Nursing and Regional Director of Operations. The following were reviewed during the Quality Assurance Meeting: [NAME] The survey findings as per the IJ notification. B. AoC and corresponding action plan. C. The on-going compliance monitoring audits. D. The results of interviewable resident interviews (BIMS of eight (8) and above). E. The results of the non-interviewable resident skin assessments (BIMS of seven (7) or lower). F. Staff re-education related to the facility policy and procedure titled Resident Protection Policy which addressed abuse, neglect, mistreatment and misappropriation. 4. Interviews were conducted by the Social Services Director, Admissions Coordinator, Activities Director, Housekeeping Supervisor, Dietary Manager and Human Resources Director on 05/31/19, with all residents assessed as interviewable based on the most recent BIMS scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. Skin assessments were performed by licensed staff on 05/31/19, for all residents assessed as non-interviewable based on current BIMS scores below eight (8). No skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. 5. The Regional Director of Operations (RDO), conducted in-service education with the facility Administrator on 05/30/19, regarding the facility's policy and procedure titled Resident Protection Policy, which addressed abuse, neglect, mistreatment and misappropriation. This policy also addressed requirements related to identifying, reporting, notifications, investigating and maintaining resident protection during the investigation process. The DON received in-service education on 05/30/19, by the Administrator, regarding the facility's Resident Protection Policy. In-service education was conducted by the facility's Administrator, on 05/30/19 with all staff on duty, which was twenty-one (21) out of one hundred eighty-five (185) employees at the time the IJ notification was presented including all licensed nurses, Kentucky Medication Aides (KMAs), SRNAs, and Department Managers including the Dietary Manager, MDS Nurse, Assessment Nurse, MDS Nurse, Activity Director, Assistant Administrator, Social Services Director, Admissions Director, Human Resources Director, DON, and Quality Assurance Nurse, regarding the Resident Protection Policy. 6. On 05/31/19, the DON, Nurse Aide Coordinator, Human Resources Director, Social Services Director, Bookkeeper, Admissions Coordinator, Dietary Manager and the Director of Rehab conducted in-service education with staff from all other shifts and departments, which was one hundred thirty (130) out of one hundred eighty-five (185) employees including: nursing, housekeeping, laundry, dietary, maintenance, rehab, therapy, activities, business office/administrative staff and social services, who had not been in-serviced previously by the Administrator, on 05/30/19, on the Resident Protection Policy. All employees completed a post-test after receiving the in-service education. Any additional questions were addressed at that time. A final passing score of one hundred percent (100%) was required before being allowed to return to work. Any staff member who was unable to attend the in-service education was required to receive the education immediately upon return to work by their Supervisor, Administrator, DON, Nurse Aide Coordinator, Human Resources Director, Social Services Director, Bookkeeper, Admissions Coordinator, Dietary Manager or the Director of Rehab. There were fourteen (14) out of one hundred eighty-five (185) employees in-serviced via phone. There were nineteen (19) out of one hundred eighty-five (185) employees who had not been in-serviced and had not returned to work after 06/01/19. A sign was posted by the time clock and the Administrator cross-checked the work schedule with the in-service sign-in sheets to assure only educated staff worked. The facility did not utilize agency staff. 7. All new hire employees will receive in-service education during their new hire orientation regarding the facility's Resident Protection Policy. 8. The following audits will be conducted to validate ongoing compliance with the AoC plan and to ensure staff are providing care to residents in a manner that promotes dignity without mistreatment, neglect, abuse or misappropriation of resident property: [NAME] A minimum of four (4) residents with a BIMS' score of eight (8) or higher will be interviewed daily x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks, then every other week x eight (8) weeks, then monthly x one (1) month. These interviews will address if residents feel safe and comfortable; if residents are treated with dignity and respect; any concerns about the manner in which care was provided; and if staff was providing care to residents in a manner that promotes dignity without mistreatment, neglect, abuse or misappropriation of resident property. Areas of concern will be corrected upon discovery. These audits will be conducted by one of the following designees: DON, Unit Manager, Licensed Nurse, Admissions Coordinator, Housekeeping Supervisor, Dietary Manager, Nurse Aide Coordinator and Activities Director to ensure continued compliance with the facility's Resident Protection Policy. B. A minimum of four (4) residents with a BIMS' score of seven (7) or lower will have a comprehensive skin assessment conducted daily by licensed nursing staff x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks, then every other week x eight (8) weeks, then monthly x one (1) month by a licensed nurse daily to ensure continued compliance with the facility's Resident Protection Policy. C. Care of a minimum of four (4) residents with a BIMS' score of seven (7) or lower will be randomly observed daily x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks then every other week x eight (8) weeks, then monthly x one (1) month. Areas of concern will be addressed immediately upon discovery. These audits will be conducted by designated Administrative staff members, including: DON, Unit Manager, Licensed Nurse, Admissions Coordinator, Housekeeping Supervisors, Dietary Manager, Nurse Aide Coordinator and Activities Director daily to ensure continued compliance with the facility's Resident Protection Policy. 9. The Administrator will continue to report findings of the above ongoing audits to the Quality Assurance Committee attended by the Administrator, DON, Medical Director, Social Services Director, Housekeeping Supervisor, Dietary Manager, and the Activities Director which will meet weekly for four (4) weeks and then monthly thereafter for further recommendations. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's head-to-toe assessment, dated 05/22/16, revealed no areas that had not been identified on the 05/14/19 skin assessment. Review of Resident #1's Progress Note,s dated 05/23/19 10:50 AM, completed by the Social Services Director, revealed Resident #1 was cognitively assessed as having a BIMS of seven (7), indicating severe cognitive impairment. The Note further revealed the resident voiced no concerns and voiced he/she was being treated well by staff. Interview with LPN #6, on 06/05/19 at 1:34 PM, revealed on 05/22/19, she conducted a full head-to-toe skin assessment with particular focus on the head and neck area, as the assessment had been prompted as a result of an allegation of the resident being struck on top of his/her head. She stated she did not discover any evidence of injury to Resident #1. LPN #6 further stated she attempted to interview Resident #1 on 05/22/19, but Resident #1 was unwilling to answer questions at that time as the resident was looking for his/her candy. Interview with the Social Services Director (SSD), on 06/05/19 at 1:53 PM, revealed she interviewed Resident #1 on 05/23/19 and 05/24/19 and the resident denied anyone had ever hit or been mean to him/her. Interview with KMA #2, on 06/06/19 at 10:11 AM, revealed she questioned Resident #1 on 05/22/19 asking whether anyone at the facility had ever been verbally or physically mean to him/her, and the resident denied he/she had been treated mean. Interview with Resident #1, on 06/06/19 at 10:50 AM, revealed nobody had handled him/her roughly or mistreated him/her in any way. 2. Review of the facility's Resident Abuse Investigation Report, revealed an initial report was made to OIG on 05/30/19 regarding an incident that occurred on 05/21/19. Review of the Statement provided by NA #3, identified Resident #3 as the alleged abuse victim of SRNA #1. Review of Resident #3's head-to-toe skin assessments, revealed no new areas were documented on the 05/30/19 skin assessment that had not been previously identified on the 05/14/19 skin assessment. Interview with the DON, on 06/05/19 at 2:39 PM, revealed she conducted the skin assessment on Resident #3 on 05/30/19, and no new areas were discovered. She further stated, on that date, Resident #3 denied the reported allegation had occurred. Review of SRNA #1's employee file, revealed SRNA #1 was suspended on 05/22/19 due to the abuse allegation, and was terminated on 05/24/19, as they were unable to rule out abuse had occurred. Review of NA #2's employee file revealed NA #2 was suspended on 05/22/19 due to failure to report abuse per facility policy, and was terminated as a result on 05/24/19. Review of NA #3's employee file revealed NA #3 was suspended on 05/22/19 due to failure to report abuse per facility policy, and was terminated as a result on 05/24/19. Review of NA #10's employee file, revealed she voluntarily terminated her position on 04/03/19. Review of NA #9's employee file, revealed she was suspended on 05/30/19. Interview with the Administrator, on 06/06/19 at 1:39 PM revealed, although they were unable to substantiate abuse had occurred involving Resident #1, they could not completely rule out the possibility, and as a result terminated SRNA #1 from employment. She further stated NA #2 and NA #3 were terminated from employment due to failure to immediately report allegations per facility policy. 3. Review of the sign in sheet and itinerary titled, Ad Hoc Quality Assurance, dated 05/31/19, revealed the Medical Director, Administrator, DON, and Regional Director of Operations attended. The itinerary included review of: (1) Survey findings as per the IJ notification; (2) AoC and corresponding action plan; (3) On- going compliance monitoring audits; (4) Results of interviewable resident interviews (BIMS eight (8) and above); (5) Results of non-interviewable resident skin assessments (BIMS seven (7) or lower); and (6) Staff re-education to the facility Resident Protection Policy, which addressed abuse, neglect, mistreatment and misappropriation. Interview on 06/05/19 at 2:39 PM, with the DON, revealed she was present for the QA meeting on 05/31/19 in which the Medical Director was informed of the deficient practice. She stated during the meeting, there was discussion related to the actions they were implementing to correct the deficient practice. Interview with the Medical Director, on 06/05/19 at 3:06 PM, revealed he attended the conference on 05/31/19 and had a few phone conferences with management related to the deficient practice and the action plan as well. He stated it was his expectation staff treat residents appropriately, in a respectful way. He further stated, the Administrator and DON kept him apprised of any new findings related to the deficient practice as well as facility plans to prevent recurrence of the deficient practice. Interview with the Administrator, on 06/06/19 at 1:39 PM, revealed she facilitated the Ad Hoc QA meeting on 05/31/19. She stated the IJ citations were discussed, as well as the action plan and how to proceed with the AoC. The Administrator further stated she developed the staff inservices, and conducted the initial inservices the evening of 05/30/19. Per interview, she had been tracking the audits to ensure completion. 4. Review of the audits revealed BIMS scores were reviewed for all facility residents. Further review of audits revealed resident interviews were completed on 05/31/19 for all facility residents with a BIMS score of eight (8) or above. Questions asked of residents included: (1) Do you feel safe and comfortable here?; (2) Do you feel staff treat you and other residents with dignity and respect?; and (3) Do you have concerns about the manner in which care is provided to you or other residents? Review of resident responses to questions revealed no concerns were identified. Review of the audits revealed skin assessments were completed on 05/31/19 for all facility residents with a BIMS score of seven (7) or below. Review of skin assessments revealed no suspicious injuries which could be possibly indicative of abuse. Interview with the DON, on 06/05/19 at 2:39 PM, revealed she did most of the skin assessments on 05/31/19. She stated she compared the skin assessments she completed with the most recent previous skin assessment, looking for any discrepancies that could be indicative of abuse. She further stated she did not find any significant discrepancies. Interview with the Dietary Manager (DM), on 06/05/19 at 8:38 AM, revealed she conducted several resident interviews on 05/31/19, asking if residents felt safe, and if staff treated them with dignity and respect. Per interview, the residents she interviewed, did not express any concerns to her. Interview with the Human Resources Director (HRD), on 06/05/19 at 8:51 AM, revealed she interviewed residents on 05/31/19 regarding their care by staff, and asked if they felt safe. Per interview, no concerns were noted with the interviews. Interview with the Social Service Director (SSD), on 06/05/19 at 1:53 PM, revealed she conducted about five (5) resident interviews on 05/31/19, and these residents expressed no concerns about how they were treated at the facility. Interview with the Activities Director (AD), on 06/05/19 at 2:17 PM, revealed she interviewed residents on 05/31/19 as part of the initial audit, and the residents expressed no concerns to her related to how staff treated them. Interview with the Housekeeping Supervisor (HS), on 06/05/19 at 3:32 PM, revealed she interviewed four (4) to six (6) residents on 05/31/19, regarding their care by staff, and whether or not they felt safe, and the residents expressed no concerns to her. Interview with the Admissions Coordinator (AC), on 06/05/19 at 3:44 PM, revealed she spoke with six (6) or seven (7) residents on 05/31/19 regarding their care; regarding if they felt safe; and also asked them if anyone had ever been rough with them or rude to them. Per interview, the residents stated they had no concerns and liked the staff. 5. Review of the In-Service Training Report, dated 05/30/19 from 9:15 PM through 10:00 PM, revealed the Regional Director of Operations in-serviced the Administrator over the phone regarding the Resident Protection Policy, including Reporting Abuse to Facility Management. Interview on 06/06/19 at 1:39 PM, with the Administrator, revealed she received a telephone inservice by the Regional Director of Operations on the evening of 05/30/19, regarding the abuse policy, types of abus

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to initiate an investigation in response to an alleged violation of abuse, allowing for further potential abuse for one (1) of twenty (20) sampled residents (Residents #1). Nurse Aide (NA) #2 and NA #3 alleged they witnessed State Registered Nurse Aide (SRNA) #1 hit Resident #1 on the head on 05/20/19 and NA #2 alleged she reported the incident to LPN #1 immediately after the incident and again an hour later. However, LPN #1 denied this allegation being reported to her on 05/20/19, and there was no action taken. There was no documented evidence an investigation was initiated related to this allegation of abuse until 05/22/19, therefore SRNA #1 continued to work on 05/20/19, 05/21/19, and 05/22/19, allowing for the potential of further abuse. (Refer to F-600, F-607 and F-609) The facility's failure to ensure investigations were initiated for alleged violations of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/30/19, and was determined to exist on 05/20/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/04/19, alleging removal of the Immediate Jeopardy on 06/01/19. The State Survey Agency determined the Immediate Jeopardy was removedon 06/01/19, as alleged, prior to exit on 06/06/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Abuse Investigation Policy, dated 08/01/2013, revealed all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will investigate the alleged incident. The individual conducting the investigation will review the completed documentation forms and review the resident's medical record to determine events leading up to the incident. Further review of the Policy, revealed the individual conducting the investigation will interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (medically as appropriate); consult the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; interview all staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care or services. Continued review of the Policy, revealed the individual conducting the investigation will review all events leading up to alleged incident. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the investigation or until the results of the investigation have been reviewed by the Administrator. The results of the investigation will be recorded on approved documentation forms. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Review of the facility's Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, which was faxed to the Office of Inspector General (OIG/SSA) on 05/22/19, at 7:00 PM, revealed an alleged incident of physical abuse occurred on 05/20/19. Nursing Assistant (NA) reported on 05/22/19, she witnessed another NA hit Resident #1 on the head. No injuries were noted. Review of the facility's Long Term Care Facility-Self Reported Incident Form/Initial and Combined Report, which was faxed to the Office of Inspector General (OIG) on 05/22/19, at 7:00 PM. Review of the facility's Investigation Report, dated 05/24/19, signed by the Administrator, revealed an incident of physical abuse related to Resident #1 allegedly occurred 05/20/19 at approximately 8:00 PM. Per the Investigation, NA #2 reported to LPN #1, while providing care to Resident #1, the resident was combative and SRNA #1 was kicked by the resident. SRNA #1 then hit Resident #1 on top of the head and said, Don't act like that towards me. Continued review of the Investigation, revealed NA #2 notified LPN #1 at approximately 8:00 PM and again at 9:00 PM of the allegation, and attempted to call the Nurse Aide Coordinator (NAC) on 05/21/19. However, per the Investigation, LPN #1, denied NA #2 or any other employee approached her on 05/22/19 to report an incident of anyone hitting or abusing a resident in any manner. According to the Investigation, the Administrator was not notified of the allegation until 05/22/19 at 5:00 PM. Per the Investigation, the resident's son and the Physician were notified of the allegation on 05/22/19 at 6:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 05/22/19 at 7:00 PM. Continued review of the Investigation, revealed the alleged perpetrator, SRNA #1, was suspended on 05/22/19 after the allegation was reported to the Administrator and was later terminated on 05/24/19. NA #2 and NA #3 were both suspended for not reporting the allegation of abuse and both were then terminated on 05/24/19. Resident #1 was interviewed on 05/22/19 at 7:00 PM and denied anyone being physically or verbally mean to him/her. According to the Investigation, the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation; and Resident #1 had no injuries and denied the incident occurred. Review of NA #2's Witness Statement, dated 05/22/19 (no time recorded), revealed Resident #1's alarm was sounding; and NA #2, NA #3 and SRNA #1 entered Resident #1's room to check on the resident. NA #2 and NA #3 were repositioning the resident in the wheelchair while SRNA #1 reset the chair alarm and the resident was combative during this time. Continued review of the Statement, revealed when SRNA #1 was walking away, Resident #1 kicked SRNA #1 which resulted in SRNA #1 hitting Resident #1 on the top of the head, and SRNA #1 stated, Don't act like that towards me again. Phone interview was conducted with NA #2, on 05/28/19 at 2:20 PM, and 05/29/19 at 3:52 PM. NA #2 stated on the evening of 05/20/19, she (NA #2) and NA #3 were partnered with SRNA #1 and they were assigned to Resident #1. Per interview, on that date at approximately 7:00 PM, Resident #1's chair alarm was sounding due to him/her leaning forward and she and NA #3 repositioned the resident in the chair while SRNA #1 reset the alarm. She stated Resident #1 became combative while being repositioned in the chair and as they were walking away, Resident #1 kicked SRNA #1 in the leg. Per interview, SRNA #1 then hit Resident #1 on the top of the head and told the resident to never act like that again. Per interview, NA #2 immediately reported what she had witnessed to LPN #1, who was in another resident's room with no other staff around, and LPN #1 stated she would take care of it. However, NA #2 stated, about an hour later, at approximately 8:00 PM, she realized SRNA #1 was still working on the floor so she again reported the allegation to LPN #1, who was at the nurse's station with no other staff in hearing distance. Per interview, LPN #1 again told her she would take care of it. NA #2 stated SRNA #1 worked the rest of the shift providing care to residents, and NA #2 did not attempt to notify any other nurses or management staff of the incident on 05/20/19. Continued interview with NA #2, revealed she attempted to call the Nurse Aide Coordinator (NAC) the following day to report the abuse; however, she was unable to reach her. Per interview, on 05/22/19 NA #2 received a text message from the NAC asking her to arrive early for her shift and she texted back at 3:11 PM, notifying the NAC of the abuse which she had witnessed on 05/20/19. Per interview, the NAC texted NA #2 back and asked her to call the NAC. NA #2 stated she then called the NAC and gave a statement regarding what she had witnessed regarding SRNA #1 hitting Resident #1. Per interview, when she arrived at the facility on 05/22/19 at 6:00 PM, the Administrator interviewed her and she also gave a written Statement to the Administrator. Per interview, she then went back to the floor to work and about thirty (30) minutes later, she was removed from the floor and suspended for five (5) days. She further stated three (3) days later, on 05/24/19, she was terminated for not immediately reporting abuse. Review if the facility Summary of Interview with Witnesses, revealed NA #3 was interviewed on 05/22/19 at 5:00 PM, and stated she did not remember Resident #1 being combative or SRNA #1 hitting a resident. Further review revealed NA #3 was interviewed again on 05/22/19 at approximately 7:30 PM, and then stated she did recall that NA #3, NA #2 and SRNA #1 responded to Resident #1's alarm sounding. Further review revealed NA #3 stated when they responded and were providing care, the resident was hitting and kicking the aides. Additional review revealed after SRNA #1 reset the resident's alarm, SRNA #1 tapped the resident's head, and NA #3 did not recall if SRNA #1 stated anything. Phone interview with NA #3, on 05/29/19 at 3:14 PM, revealed she just started working at the facility on 05/14/19. She stated she was orienting with SRNA #1 on the evening of 05/20/19, when Resident #1's chair alarm started sounding around 7:00 PM. Per interview, she (NA #3), NA #2 and SRNA #1 responded to the sounding alarm, and she and NA #2 assisted with positioning Resident #1 in the chair while SRNA #1 reset the chair alarm. Per interview, once Resident #1 was re-positioned correctly in the chair, they started to walk away when Resident #1 kicked SRNA #1 in the leg and SRNA #1 hit Resident #1 on the head. Additional interview revealed she had been in orientation prior to this and had watched videos for three (3) days and during this time, received abuse training. She further stated she was aware abuse was to be reported right away, but she did not report the abuse because NA #2 informed her she (NA #2) was going to report what happened. Review of SRNA #1's Statement, dated 05/22/19 at 7:45 PM, revealed when she entered Resident #1's room after being asked to assist the resident, the resident was undressing causing his/her alarm to sound. According to the Statement, the resident was resisting care, being combative and hitting staff. Per the Statement, the resident grabbed SRNA #1's arm, digging his/her nails into her skin and SRNA #1 then removed the resident's hands from her arm. Phone interview with SRNA #1, on 05/28/19 at 3:30 PM, revealed had been employed at the facility since (MONTH) (YEAR). Per interview, on 05/20/19, she was orienting NA #3 and around 8:00 PM, NA #2 asked her to assist with Resident #1 because the resident had become combative during care with NA #2 and NA #3. SRNA #1 further stated Resident #1 grabbed SRNA #1's arms, so SRNA #1 grabbed the resident's wrists and simply moved them off her arms. Per interview, SRNA #4 approached her later that evening and informed her that NA #2 stated she witnessed SRNA #1 slap Resident #1, and NA #2 had reported it to the charge nurse. SRNA #1 then denied she hit or abused Resident #1. Additional interview revealed she was suspended on 05/22/19, and terminated on 05/24/19. Review of the time clock data, revealed SRNA #1 continued to work on 05/20/19 until clocking out at 10:07 PM; worked 05/21/19 from 1:56 PM until 10:27 PM, and also worked 05/22/19 from 9:55 AM until 2:13 PM. Interview with the NAC, on 05/29/19 at 9:20 AM, revealed she did not get a phone call from NA #2 on 05/21/19; however, on 05/22/19 she did receive a text message around 3:10 PM from NA #2 revealing SRNA #1 hit Resident #1 the last evening they worked together. Per interview as soon as she received the text she reported the allegation immediately to the Director of Nursing (DON), and the DON then referred her to the Administrator. The NAC stated she then immediately notified the Administrator of the allegation and was instructed by the Administrator to phone NA #2 and SRNA #1 and obtain their Statements. Review of the NAC cell phone text message, on 05/29/19 at 9:20 AM, revealed a text message was received on 05/22/19 at 3:11 PM from NA #2, reporting the allegation of abuse related to Resident #1. Continued interview with the NAC, on 05/29/19 at 9:20 AM, revealed while she was taking NA #2's statement, on 05/22/19, NA #2 reported on the evening of 05/20/19, Resident #1's alarm was sounding, and the resident was agitated and kicked SRNA #1. Per interview, NA #2 reported SRNA #1 then hit the resident on the back of the head and told the resident not to act like that with her. Per interview, NA #2 stated she immediately reported the incident to a nurse, which she described as medium size with brown hair; however, NA #2 could not recall the nurse's name. The NAC stated NA #2 told her NA #3 also witnessed the incident. Additional interview with the NAC, on 05/29/19 at 9:20 AM, revealed she also called SRNA #1 on 05/22/19 for a Statement. Per interview, SRNA #1 informed her she entered Resident #1's room to assist staff because Resident #1 was undressing and was agitated on 05/20/19. The NAC further stated SRNA #1 reported Resident #1 grabbed SRNA #1's arms and SRNA #1 then grabbed the resident's wrists. The NAC stated SRNA #1 denied striking the resident on 05/20/19. Further interview with the NAC, on 05/29/19 at 9:20 AM, revealed she then called NA #3 on 05/22/19 at 5:00 PM, to obtain a statement and NA #3 told her she could not recall any incident related to Resident #1. Per interview, the NAC and the Administrator called NA #3 a second time on 05/22/19 at 7:30 PM and NA #3 then stated, Resident #1 was hitting and kicking staff and SRNA #1 reached over and tapped the resident's head. Per interview, after the Statements were obtained from SRNA #1, NA #2 and NA #3, all three (3) staff members were terminated related to the allegation of abuse related to Resident #1. Review of LPN #1's Statement dated 05/22/19 at 6:30 PM, revealed she denied that NA #2 or any other NA reported any employee hitting a resident, including Resident #1, on 05/20/19. Phone interview with LPN #1, on 05/29/19 at 3:39 PM, verified she was assigned to Resident #1 on the evening of 05/20/19. LPN #1 stated NA #2 did not report any allegation of abuse to her on the evening of 05/20/19, nor was she aware Resident #1 was having behaviors that evening. Per interview, she was not aware of the allegation related to SRNA #1 hitting Resident #1 until she was interviewed via phone call by the Administrator on 05/22/19. Additional interview revealed any allegation of abuse should be reported immediately. She stated if staff was to report abuse to her, she would report the allegation to the DON, and also ensure the perpetrator was removed from resident care immediately. Further interview revealed any allegation of abuse had to be reported to State Agencies within two (2) hours. Interview with NA #5, on 05/29/19 at 10:30 AM, revealed on 05/20/19 she witnessed SRNA #4 tell SRNA #1, that NA #2 had reported SRNA #1 for hitting Resident #1. However, NA #5 stated she was not a witness to any incident regarding Resident #1 being hit. Further interview revealed if this incident of abuse was witnessed by NA #2 or other staff, and reported, SRNA #1 should had been suspended on 05/20/19. Interview with SRNA #4, on 05/30/19 at 1:10 PM, revealed she worked the evening shift on 05/20/19. She stated on 05/20/19 around 9:00 PM, NA #2 notified her SRNA #1 hit Resident #1 on the head. Per interview, she then asked NA #2 if she had reported the abuse allegation and NA #2 stated she had reported it to LPN #1. Additional interview revealed it was important to report abuse, in order to prevent further abuse, as no one deserved to be abused. Interview with the Director of Nursing (DON), on 05/30/19 at 6:50 PM, revealed on 05/22/19, at approximately 3:15 PM, the NAC showed her the text message she received from NA #2. The DON stated she then advised the NAC to show the text to the Administrator, as the Administrator took the lead on any abuse investigations. Per the DON, it was revealed during the facility investigation, NA #2, and NA #3 who witnessed the alleged abuse towards Resident #1 on 05/20/19, should have reported this immediately. Per interview, the investigation further revealed NA #2 stated she reported the allegation to LPN #1; however, LPN #1 denied being notified of the allegation on 05/20/19. The DON stated if the allegation had been reported immediately, the alleged perpetrator, SRNA #1 could have been removed from resident care on 05/20/19 and suspended in order to prevent further potential abuse to Resident #1 or other residents while the investigation was in progress. However, she stated, the investigation was not initiated until 05/22/19, two (2) days after the alleged violation was witnessed. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed NA #2 notified the NAC of the allegation of abuse related to SRNA #1 hitting Resident #1 via text message, on 05/22/19. Per interview, the facility investigation did reveal NA #2 stated she reported the abuse to LPN #1 on 05/20/19; however, LPN #1 denied the allegation was reported to her on that date. Per interview, the allegation of abuse should have been reported immediately on 05/20/19 to the nurse, management or the Administrator, in order for SRNA #1 to be removed from duty and suspended to protect residents from further potential abuse, and in order to initiate an investigation related to the allegation. Additional interview revealed as a result of staff failing to immediately report the allegation of abuse, SRNA #1 continued working on 05/20/19 and also worked on 05/21/19 and 05/22/19 and the investigation was not initiated until 05/22/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/31/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/01/19. Review of the AoC revealed the facility implemented the following. 1. A head to toe assessment of Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was completed by LPN #6 on 05/22/19 and revealed no new areas of concern as compared to previous skin assessment on 05/14/19. Resident #1's head and scalp indicated no signs of injury as evidenced by no redness, bruising or indications of trauma. Interview with Resident #1 was attempted on 05/22/19, by LPN #6, revealed the resident didn't have time for the interview as he/she was looking for his/her candy. Resident #1 was re-approached one (1) hour later by Kentucky Medication Aide (KMA) #2 at which time he/she denied anyone had ever been physically or verbally mean to him/her. Resident #1 was interviewed again on 05/23/19, by the Social Services Director, and the resident denied anyone had been mean or had hit him/her. 2. The facility initiated an investigation on 05/30/19 upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) of an allegation involving an unknown resident who was referenced in the Immediate Jeopardy (IJ) notification document. The identity of the unknown resident was established during the facility's investigation based on staff interviews by the Staff Development Coordinator (SDC) and the Nurse Aide Coordinator (NAC) on 05/30/19, as Resident #3. Resident #3, who was assessed as having a BIMS of ten (10), was interviewed and he/she indicated the alleged incident had not occurred. A head-to-toe skin assessment was completed on Resident #3 by the DON, on 05/30/19. The skin assessment findings noted chronic, (previously identified) discolorations to bilateral hands. No other skin concerns were noted. Skin was assessed as dry and intact with no redness or breakdown in the peri area. SRNA #1 was suspended on 05/22/19, immediately upon the facility notification of the initial allegation, reported by NA #2, to have occurred on 05/20/19. SRNA #1 was terminated on 05/24/19, at the conclusion of the facility investigation. NA #2 and NA #3 were suspended on 05/22/19, and terminated on 05/24/19, due to failure to report the allegation per facility policy. SRNA #10 voluntarily terminated her position as of 03/17/19. NA #9 was suspended on 05/30/19, and remains suspended at this time as the facility continues to investigate the allegation stemming from the incident on 02/22/19. 3. An Ad Hoc Quality Assurance (QA) meeting with the Medical Director was held on 05/31/19 by the facility's Administrator and attended by the Director of Nursing and Regional Director of Operations. The following were reviewed during the Quality Assurance Meeting: [NAME] The survey findings as per the IJ notification. B. AoC and corresponding action plan. C. The on-going compliance monitoring audits. D. The results of interviewable resident interviews (BIMS of eight (8) and above). E. The results of the non-interviewable resident skin assessments (BIMS of seven (7) or lower). F. Staff re-education related to the facility policy and procedure titled Resident Protection Policy which addressed abuse, neglect, mistreatment and misappropriation. 4. Interviews were conducted by the Social Services Director, Admissions Coordinator, Activities Director, Housekeeping Supervisor, Dietary Manager and Human Resources Director on 05/31/19, with all residents assessed as interviewable based on the most recent BIMS scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. Skin assessments were performed by licensed staff on 05/31/19, for all residents assessed as non-interviewable based on current BIMS scores below eight (8). No skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. 5. The Regional Director of Operations (RDO), conducted in-service education with the facility Administrator on 05/30/19, regarding the facility's policy and procedure titled Resident Protection Policy, which addressed abuse, neglect, mistreatment and misappropriation. This policy also addressed requirements related to identifying, reporting, notifications, investigating and maintaining resident protection during the investigation process. The DON received in-service education on 05/30/19, by the Administrator, regarding the facility's Resident Protection Policy. In-service education was conducted by the facility's Administrator, on 05/30/19 with all staff on duty, which was twenty-one (21) out of one hundred eighty-five (185) employees at the time the IJ notification was presented including all licensed nurses, Kentucky Medication Aides (KMAs), SRNAs, and Department Managers including the Dietary Manager, MDS Nurse, Assessment Nurse, MDS Nurse, Activity Director, Assistant Administrator, Social Services Director, Admissions Director, Human Resources Director, DON, and Quality Assurance Nurse, regarding the Resident Protection Policy. 6. On 05/31/19, the DON, Nurse Aide Coordinator, Human Resources Director, Social Services Director, Bookkeeper, Admissions Coordinator, Dietary Manager and the Director of Rehab conducted in-service education with staff from all other shifts and departments, which was one hundred thirty (130) out of one hundred eighty-five (185) employees including: nursing, housekeeping, laundry, dietary, maintenance, rehab, therapy, activities, business office/administrative staff and social services, who had not been in-serviced previously by the Administrator, on 05/30/19, on the Resident Protection Policy. All employees completed a post-test after receiving the in-service education. Any additional questions were addressed at that time. A final passing score of one hundred percent (100%) was required before being allowed to return to work. Any staff member who was unable to attend the in-service education was required to receive the education immediately upon return to work by their Supervisor, Administrator, DON, Nurse Aide Coordinator, Human Resources Director, Social Services Director, Bookkeeper, Admissions Coordinator, Dietary Manager or the Director of Rehab. There were fourteen (14) out of one hundred eighty-five (185) employees in-serviced via phone. There were nineteen (19) out of one hundred eighty-five (185) employees who had not been in-serviced and had not returned to work after 06/01/19. A sign was posted by the time clock and the Administrator cross-checked the work schedule with the in-service sign-in sheets to assure only educated staff worked. The facility did not utilize agency staff. 7. All new hire employees will receive in-service education during their new hire orientation regarding the facility's Resident Protection Policy. 8. The following audits will be conducted to validate ongoing compliance with the AoC plan and to ensure staff are providing care to residents in a manner that promotes dignity without mistreatment, neglect, abuse or misappropriation of resident property: [NAME] A minimum of four (4) residents with a BIMS' score of eight (8) or higher will be interviewed daily x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks, then every other week x eight (8) weeks, then monthly x one (1) month. These interviews will address if residents feel safe and comfortable; if residents are treated with dignity and respect; any concerns about the manner in which care was provided; and if staff was providing care to residents in a manner that promotes dignity without mistreatment, neglect, abuse or misappropriation of resident property. Areas of concern will be corrected upon discovery. These audits will be conducted by one of the following designees: DON, Unit Manager, Licensed Nurse, Admissions Coordinator, Housekeeping Supervisor, Dietary Manager, Nurse Aide Coordinator and Activities Director to ensure continued compliance with the facility's Resident Protection Policy. B. A minimum of four (4) residents with a BIMS' score of seven (7) or lower will have a comprehensive skin assessment conducted daily by licensed nursing staff x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks, then every other week x eight (8) weeks, then monthly x one (1) month by a licensed nurse daily to ensure continued compliance with the facility's Resident Protection Policy. C. Care of a minimum of four (4) residents with a BIMS' score of seven (7) or lower will be randomly observed daily x two (2) weeks over all shifts including weekends and holidays, then three (3) x weekly for two (2) weeks, then weekly x eight (8) weeks then every other week x eight (8) weeks, then monthly x one (1) month. Areas of concern will be addressed immediately upon discovery. These audits will be conducted by designated Administrative staff members, including: DON, Unit Manager, Licensed Nurse, Admissions Coordinator, Housekeeping Supervisors, Dietary Manager, Nurse Aide Coordinator and Activities Director daily to ensure continued compliance with the facility's Resident Protection Policy. 9. The Administrator will continue to report findings of the above ongoing audits to the Quality Assurance Committee attended by the Administrator, DON, Medical Director, Social Services Director, Housekeeping Supervisor, Dietary Manager, and the Activities Director which will meet weekly for four (4) weeks and then monthly thereafter for further recommendations. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's head-to-toe assessment, dated 05/22/16, revealed no areas that had not been identified on the 05/14/19 skin assessment. Review of Resident #1's Progress Note,s dated 05/23/19 10:50 AM, completed by the Social Services Director, revealed Resident #1 was cognitively assessed as having a BIMS of seven (7), indicating severe cognitive impairment. The Note further revealed the resident voiced no concerns and voiced he/she was being treated well by staff. Interview with LPN #6, on 06/05/19 at 1:34 PM, revealed on 05/22/19, she conducted a full head-to-toe skin assessment with particular focus on the head and neck area, as the assessment had been prompted as a result of an allegation of the resident being struck on top of his/her head. She stated she did not discover any evidence of injury to Resident #1. LPN #6 further stated she attempted to interview Resident #1 on 05/22/19, but Resident #1 was unwilling to answer questions at that time as the resident was looking for his/her candy. Interview with the Social Services Director (SSD), on 06/05/19 at 1:53 PM, revealed she interviewed Resident #1 on 05/23/19 and 05/24/19 and the resident denied anyone had ever hit or been mean to him/her. Interview with KMA #2, on 06/06/19 at 10:11 AM, revealed she questioned Resident #1 on 05/22/19 asking whether anyone at the facility had ever been verbally or physically mean to him/her, and the resident denied he/she had been treated mean. Interview with Resident #1, on 06/06/19 at 10:50 AM, revealed nobody had handled him/her roughly or mistreated him/her in any way. 2. Review of the facility's Resident Abuse Investigation Report, revealed an initial report was made to OIG on 05/30/19 regarding an incident that occurred on 05/21/19. Review of the Statement provided by NA #3, identified Resident #3 as the alleged abuse victim of SRNA #1. Review of Resident #3's head-to-toe skin assessments, revealed no new areas were documented on the 05/30/19 skin assessment that had not been previously identified on the 05/14/19 skin assessment. Interview with the DON, on 06/05/19 at 2:39 PM, revealed she conducted the skin assessment on Resident #3 on 05/30/19, and no new areas were discovered. She further stated, on that date, Resident #3 denied the reported allegation had occurred. Review of SRNA #1's employee file, revealed SRNA #1 was suspended on 05/22/19 due to the abuse allegation, and was terminated on 05/24/19, as they were unable to rule out abuse had occurred. Review of NA #2's employee file revealed NA #2 was suspended on 05/22/19 due to failure to report abuse per facility policy, and was terminated as a result on 05/24/19. Review of NA #3's employee file revealed NA #3 was suspended on 05/22/19 due to failure to report abuse per facility policy, and was terminated as a result on 05/24/19. Review of NA #10's employee file, revealed she voluntarily terminated her position on 04/03/19. Review of NA #9's employee file, revealed she was suspended on 05/30/19. Interview with the Administrator, on 06/06/19 at 1:39 PM revealed, although they were unable to substantiate abuse had occurred involving Resident #1, they could not completely rule out the possibility, and as a result terminated SRNA #1 from employment. She further stated NA #2 and NA #3 were terminated from employment due to failure to immediately report allegations per facility policy. 3. Review of the sign in sheet and itinerary titled, Ad Hoc Quality Assurance, dated 05/31/19, revealed the Medical Director, Administrator, DON, and Regional Director of Operations attended. Th

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure residents were free from abuse for two (2) of twenty (20) sampled residents (Residents #1 and #3). Staff interviews revealed on 05/20/19 at approximately 7:00 PM, Nurse Aide (NA) #2 and NA #3 witnessed State Registered Nurse Aide (SRNA) #1 hit Resident #1 on the head. Interview with NA #2, revealed she reported the allegation of abuse to Licensed Practical Nurse (LPN) #1 immediately after she witnessed the incident; and after realizing SRNA #1 was not removed from resident care, she reported the allegation to LPN #1 again at approximately 8:00 PM. However, interview with LPN #1, revealed she denied that the allegation of abuse had been reported to her on 05/20/19. SRNA #1 worked providing direct resident care the rest of the shift on 05/20/19; and worked 05/21/19 and 05/22/19. SRNA #1 was suspended on 05/22/19 after her shift related to the allegation of abuse. In addition, during the investigation related to Resident #1, interview was conducted with NA #3. She stated she was in orientation with SRNA #1 on 05/21/19, when she witnessed SRNA #1 enter a resident's room at approximately 10:00 PM, jerk the oxygen tubing off the resident's face, throw it on the bedside table, and tell the resident, I know you are not asleep. Interview with NA #3 further revealed she could not recall the name of the resident, but stated at the time this occurred, SRNA #1 also failed to provide incontinence care for this resident because there were no briefs in the resident's room. Although NA #3 stated what she witnessed was abuse, she further stated she did not report the abuse because she could not find a nurse. The facility was unaware of the allegation regarding the unidentified resident until the State Survey Agency (SSA) Representative informed the facility of the allegation on 05/30/19. SRNA #1 continued to work 05/21/19 and 05/22/19 until she was suspended on 05/22/19 after her shift, related to the allegation of abuse related to Resident #1. (Refer to F-607, F-609 and F-610) The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/30/19, and was determined to exist on 05/20/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/04/19, alleging removal of the Immediate Jeopardy on 06/01/19. The State Survey Agency determined the Immediate Jeopardy had been removed 06/01/19, as alleged, prior to exit on 06/06/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Reporting Abuse to Facility Management Policy, dated 08/01/13, revealed it is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Further review of the Policy, revealed the facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, and friends of other individuals. Per Policy, the Administrator or Director of Nursing (DON) must be immediately notified of suspected abuse or incidents of abuse. All alleged violations must be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Further review of the Policy, revealed employees accused of participating in the alleged abuse will be suspended without pay until the findings of the investigation have been reviewed by the Administrator. Additional review of the Policy, revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 02/18/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, dated 02/18/19, revealed a problem of moderately impaired cognition, and moderately impaired decision making. The goal stated optimal cognition would be maintained with no avoidable decline. The interventions included: introduce self, and explain intentions before providing care, Brief Interview for Mental Status (BIMS) quarterly and PRN (as needed) and Speech Therapy (ST) referral. Further review of the Comprehensive Care Plan, dated 02/18/19, revealed a problem of Behavioral Symptoms and resistive to care. The goal stated the resident would have a reduction of behavioral episodes related to crying and wanting to go home. The interventions included: redirect as needed by activity of choice; convey acceptance during periods of inappropriate behavior; ask for help if demonstrating abusive/resistive symptoms; keep environment as calm as possible; remove from public area when behaviors pose a risk for harm; and encourage diversional activities. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/02/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident under Section E, as having physical behavior towards others and as rejection of care and wandering occurring one (1) to three (3) days during the assessment period. Further, under Section E, Change in Behavior or other Symptoms, the facility assessed the resident as behavior or other symptoms worse as compared to prior Assessment. Observation on 05/28/19 at 2:10 PM, revealed Resident #1 was sitting in a wheelchair in the hallway with eyes closed. Resident #1 had a positioning cushion to the back of the wheelchair, and a tab chair alarm. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial and Combined Report, which was faxed to the Office of Inspector General (OIG) on 05/22/19, at 7:00 PM, revealed an alleged incident of physical abuse occurred on 05/20/19. Nursing Assistant (NA) reported on 05/22/19, she witnessed another NA hit Resident #1 on the head. No injuries were noted. Review of the facility's Investigation Report, dated 05/24/19, signed by the Administrator, revealed an incident of physical abuse related to Resident #1 allegedly occurred on 05/20/19 at approximately 8:00 PM and the incident was reported on 05/22/19 at 5:00 PM, to the Administrator. Per the investigation, NA #2 alleged she reported to LPN #1, while providing care to Resident #1, the resident was combative and SRNA #1 was kicked by the resident. SRNA #1 hit the resident on top of his/her head and said, Don't act like that towards me. Per the investigation, NA #2 notified LPN #1 at approximately 8:00 PM and again at 9:00 PM, and attempted to call the Nurse Aide Coordinator (NAC) on 05/21/19. However, LPN #1, denied that NA #2 or any other employee approached her on 05/22/19 to report an incident of anyone hitting or abusing a resident in any manner. Witnesses to the incident included NA #2, and NA #3. Further review of the Investigation, revealed Resident #1's son and the Physician were was notified of the alleged incident on 05/22/19 at 6:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 05/22/19 at 7:00 PM. Resident #1 was interviewed on 05/22/19 at 7:00 PM and denied anyone being physically or verbally mean to him/her. Furthe review revealed residents with a Brief Interview for Mental Status (BIMS) score lower than eight (8) received skin assessments and interviewable residents were interviewed related to abuse on 05/22/19 and 05/23/19, with no concerns noted. The alleged perpetrator, SRNA #1, was suspended on 05/22/19 after the allegation was reported to the Administrator and was terminated on 05/24/19 at the end of the investigation. Per the Investigation, NA #2 and NA #3 were suspended for not reporting the allegation of abuse and terminated on 05/24/19. Further review of the Investigation, revealed the facility was unable to determine if abuse occurred as all interviews conducted during the investigation revealed no facts to support the allegation; and Resident #1 had no injuries and denied the incident occurred. Per the Investigation, The two witnesses {NA #2 and NA #3} provided their account of events, but were only statements and not facts. Review of NA #2's Witness Statement, dated 05/22/19 (no time recorded), revealed Resident #1's alarm was going off; and NA #2, NA #3 and SRNA #1 entered Resident #1's room to check on the resident. Per the Statement, NA #2 and NA #3 were repositioning the resident in the wheelchair while SRNA #1 reset the chair alarm and the resident was combative during this time. Further review of the Statement, revealed when SRNA #1 was walking away, Resident #1 kicked SRNA #1 which resulted in SRNA #1 hitting Resident #1 on the top of the head, and SRNA #1 stated, Don't act like that towards me again. Phone interview with NA #2, on 05/28/19 at 2:20 PM, and 05/29/19 at 3:52 PM, revealed she had worked at the facility for about a month and was in the facility's nurse aide training program prior to the incident that occurred on 05/20/19. She stated on the evening of 05/20/19, she and NA #3 were partnered with SRNA #1 and they were assigned to Resident #1. Further interview revealed on that date at approximately 7:00 PM, Resident #1's chair alarm was sounding due to the resident leaning forward and she and NA #3 repositioned the resident in the chair while SRNA #1 reset the alarm. She stated Resident #1 became combative while being repositioned. Per interview, NA #2, NA #3 and SRNA #1 decided it would be best to walk away because they were trained if residents became combative to walk away and allow them time to calm down. NA #2 stated as they were walking away, Resident #1 kicked SRNA #1 in the leg and SRNA #1 hit the resident on the top of the head and told the resident to never act like that again. NA #2 stated she immediately reported what she had witnessed to LPN #1, who was in another resident's room with no other staff around. Per interview, LPN #1 stated she would take care of it. Continued interview with NA #2, revealed about an hour later, at approximately 8:00 PM, she realized nothing had been done because SRNA #1 was still working on the floor with residents. NA #2 stated she again reported the incident regarding the abusive behavior towards Resident #1 by SRNA #1, to LPN #1, who was at the nurse's station with no other staff in hearing distance. She stated LPN #1 again stated she would take care of it. NA #2 further stated SRNA #1 worked the rest of the shift providing care to residents. Per interview, NA #2 did not attempt to notify any other nurses or management staff of the incident on 05/20/19. Further interview with NA #2, revealed she attempted to call the Nurse Aide Coordinator (NAC) the following day to report the abuse; however, she was unable to reach her. She stated that on 05/22/19 she received a text message from the NAC asking her to arrive early for her shift and she texted back at 3:11 PM, informing the NAC of the abuse which she had witnessed on 05/20/19. NA #2 stated the NAC texted her back and asked her to call her. Per interview, NA #2 then called the NAC and gave a statement regarding what she had witnessed related to SRNA #1 hitting Resident #1. NA #2 stated when she arrived at the facility on 05/22/19 at 6:00 PM, she was pulled off the floor and interviewed again by the Administrator and also gave a written Statement to the Administrator. Further interview revealed she then went back to the floor to work and about thirty (30) minutes later, she was suspended for five (5) days. She stated three (3) days later, on 05/24/19, she was terminated for not immediately reporting abuse. Additional interview revealed during her orientation with SRNA #1, SRNA #1 would make remarks such as, She didn't want to mess with them, She did not like them or They got on her nerves, in reference to the residents. She further stated she had witnessed SRNA #1 being rude to residents before; however, she had never witnessed SRNA #1 being physically abusive with a resident until 05/20/19, when she witnessed SRNA #1 hit Resident #1. Review if the facility's Summary of Interview with Witnesses, revealed NA #3 was interviewed on 05/22/19 at 5:00 PM, and stated she did not recall Resident #1 being combative or SRNA #1 hitting a resident. Further review revealed NA #3 was then interviewed again on 05/22/19 at approximately 7:30 PM, and stated she did recall that NA #3, NA #2 and SRNA #1 responded to Resident #1's alarm sounding. NA #3 further revealed when they responded and were providing care, the resident was hitting and kicking the aides. Continued review revealed after SRNA #1 reset the resident's alarm, SRNA #1 tapped the resident's head. Phone interview with NA #3, on 05/29/19 at 3:14 PM, revealed she had worked at the facility since 05/14/19. She stated she was orienting with SRNA #1 on the evening of 05/20/19, when Resident #1's chair alarm started sounding around 7:00 PM in the resident's room. NA #3 stated she (NA #3), NA #2 and SRNA #1 responded to the alarm. She stated she and NA #2 assisted with positioning Resident #1 in the chair while SRNA #1 reset the chair alarm. Per interview, once the resident was positioned correctly in the chair, they started to walk away when Resident #1 kicked SRNA #1 in the leg and SRNA #1 hit Resident #1 on the head. Continued interview revealed NA #2 told NA #3 she was going to report this as abuse. NA #3 stated this happened during her first week working on the floor providing care to residents. Continued interview revealed she had been in orientation prior to this and had watched videos for three (3) days and had received abuse training. She stated she was aware abuse was to be reported right away. Per interview, she did not report the abuse because NA #2 informed her she (NA #2) was going to report what happened. Review of SRNA #1's Statement, dated 05/22/19 at 7:45 PM, revealed she entered Resident #1's room after being asked to assist the resident. Further review revealed the resident was undressing causing his/her alarm to sound. Per the Statement, the resident was resisting care, being combative and hitting staff. Continued review of the Statement, revealed the resident grabbed her arm, digging his/her nails into her skin and SRNA #1 then removed the resident's hands from her arm. Phone interview with SRNA #1, on 05/28/19 at 3:30 PM, revealed she had worked at the facility since (MONTH) (YEAR). She stated on 05/20/19, she was orienting NA #3 and around 8:00 PM, NA #2 asked her to assist with Resident #1 because the resident had become combative with NA #2 and NA #3. She stated Resident #1 grabbed SRNA #1's arms, so SRNA #1 grabbed the resident's wrists and simply moved them off her arms. SRNA #1 stated SRNA #4 approached her later that evening and hinted she needed to speak to her. Per interview, SRNA #4 informed SRNA #1, that NA #2 stated she witnessed SRNA #1 slap Resident #1, and NA #2 had reported it to the Charge Nurse. Per interview, SRNA #1 did not know the reason NA #2 would say this about her because this did not happen. SRNA #1 denied she hit or abused Resident #1. Further interview revealed she was suspended on 05/22/19, and terminated on 05/24/19. Review of the time clock data revealed SRNA #1 continued to work on 05/20/19 until clocking out at 10:07 PM. SRNA #1 also worked providing direct resident care on 05/21/19 from 1:56 PM until 10:27 PM, and worked on 05/22/19 from 9:55 AM until 2:13 PM. Interview with the Nurse Aide Coordinator (NAC), on 05/29/19 at 9:20 AM, revealed her main role was to make out the staff schedules. She stated she did not get a phone call from NA #2 on 05/21/19; however, on 05/22/19 she received a text message around 3:10 PM from NA #2 stating SRNA #1 hit Resident #1 the last evening they worked together. She further stated as soon as she received the text she reported the allegation immediately to the Director of Nursing (DON), and the DON referred her to the Administrator. Per interview, she then immediately notified the Administrator of the allegation, and the NAC was instructed by the Administrator to phone NA #2 and SRNA #1 and obtain Statements. Review of the NAC cell phone text message, on 05/29/19 at 9:20 AM, revealed a text message was received on 05/22/19 at 3:11 PM from NA #2, reporting the allegation regarding Resident #1. Further interview on 05/29/19 at 9:20 AM, with the NAC, revealed while taking NA #2's statement, on 05/22/19, NA #2 reported on the evening of 05/20/19, Resident #1's alarm was sounding, and the resident was agitated and kicked SRNA #1. Per interview, NA #2 further reported SRNA #1 then hit Resident #1 on the back of the head and told the resident not to act like that with her. Further interview revealed NA #2 stated she immediately reported the incident to a nurse, which she described as medium size with brown hair, but NA #2 could not recall the nurse's name. The NAC stated NA #2 told her NA #3 also witnessed the incident. Further interview with the NAC, revealed she then called SRNA #1 on 05/22/19 for a Statement. Per interview, SRNA #1 told her she entered Resident #1's room to assist staff because Resident #1 was undressing and agitated. The NAC stated SRNA #1 reported Resident #1 grabbed SRNA #1's arms and SRNA #1 grabbed the resident's wrists. However, per interview, SRNA #1 denied striking the resident. Additional interview with the NAC, on 05/29/19 at 9:20 AM, revealed she then called NA #3 on 05/22/19 at 5:00 PM, to obtain a statement and was told NA #3 could not recall an incident related to Resident #1. Per interview, the NAC and the Administrator called NA #3 a second time on 05/22/19 at 7:30 PM and NA #3 stated Resident #1 was hitting and kicking staff and SRNA #1 reached over and tapped the resident's head. The NAC stated after the Statements were obtained from SRNA #1, NA #2 and NA #3, all three (3) staff were terminated. Continued interview revealed staff were trained to report abuse to the Charge Nurse, or call the Director of Nursing (DON) or Administrator. Per interview, staff received abuse training upon hire and throughout the year. Review of LPN #1's Statement dated 05/22/19 at 6:30 PM, revealed she denied that NA #2 or any other NA approached her on 05/20/19 to report an incident of any employee hitting a resident, including Resident #1. Phone interview with LPN #1, on 05/29/19 at 3:39 PM, revealed she was assigned to Resident #1 on the evening of 05/20/19. She stated NA #2 did not report any allegation of abuse to her on the evening of 05/20/19, nor was she aware of Resident #1 having behaviors that evening. She further stated she was not aware of the allegation related to SRNA #1 hitting Resident #1 until she was interviewed per phone call from the Administrator making her aware, on 05/22/19. She stated that she had worked with SRNA #1, and she had a negative attitude; however, she had never witnessed SRNA #1 to be physically or verbally abusive to residents. Further interview revealed an allegation of abuse of any kind should be reported immediately. She stated if staff was to report abuse to her, she would report the allegation to the DON, and ensure the alleged perpetrator was removed from resident care immediately. Interview with NA #5, on 05/29/19 at 10:30 AM, revealed she had worked at the facility for a few months and had just graduated high school. She stated she worked the evening of 05/20/19 and she was best friends with SRNA #1. She stated on 05/20/19 she witnessed SRNA #4 tell SRNA #1, that NA #2 had reported SRNA #1 for hitting Resident #1. Further interview revealed NA #5 was not a witness to any incident regarding Resident #1 being hit. Further interview revealed if this incident of abuse was witnessed by NA #2 or other staff, and reported, SRNA #1 should have been suspended on 05/20/19, as soon as the incident was reported. Interview with SRNA #4, on 05/30/19 at 1:10 PM, revealed she worked the 2:00 PM to 10:00 PM shift on the evening of 05/20/19. She stated NA #2 came up to her on 05/20/19 around 9:00 PM, and informed her SRNA #1 hit Resident #1 on the head. Per interview, she asked NA #2 if she had reported the abuse allegation and NA #2 informed her she had reported it to LPN #1. Further interview revealed the next shift she worked she was asked by the NAC to write a written Statement because her named had been brought up during interviews regarding the abuse investigation related to Resident #1. SRNA #4 stated she did speak with SRNA #1 the evening of 05/20/19 after she was informed of the allegation, and SRNA #1 told her that she did not hit Resident #2. Per interview, SRNA #4 encouraged SRNA #1 to talk to someone in management related to the situation. Additional interview revealed it was important to report abuse, in order to prevent further abuse, as no one deserved to be abused. She further stated she would consider it abuse to hit a resident on the head. Interview with the Director of Nursing (DON), on 05/30/19 at 6:50 PM, revealed on 05/22/19, around 3:15 PM, the NAC came to her office and showed her the text message she received from NA #2. Per interview, the DON advised the NAC to show the text to the Administrator, as the Administrator took the lead on abuse investigations. Further interview revealed it was determined during the facility's investigation, staff who witnessed the incident regarding Resident #1 should have reported this immediately in order for the alleged perpetrator, SRNA #1, to be removed from resident care to prevent further potential abuse to Resident #1 or other residents. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed the NAC was notified of the allegation of abuse related to SRNA #1 hitting Resident #1 via text message from NA #2 on 05/22/19, and the NAC then informed her (Administrator) of the allegation on 05/22/19 at 5:00 PM. Further interview revealed the Administrator advised the NAC to obtain witness statements, and notify the nurses to do a skin assessment on Resident #1 and all residents with a Brief Interview for Mental Status (BIMS) lower than eight (8) and to interview interviewable residents related to any abuse at the facility. Per interview, SRNA #1, the alleged perpetrator, was suspended on 05/22/19 and terminated on 05/24/19. Further interview revealed staff should have ensured the allegation of abuse was reported to management or the Administrator on 05/20/19 at the time they witnessed the incident. The Administrator stated NA #2 did state she reported the allegation on 05/20/19 to LPN #1. However, LPN #1 denied being notified of the allegation. Continued interview revealed she and the State Agencies should have been notified of the allegation of abuse within two (2) hours of the witnessed abuse. She stated if the allegation of abuse had been reported promptly to the Administrator, SRNA #1 could have been suspended immediately after the witnessed incident for the protection of the residents. The Administrator stated the SRNA continued working on 05/20/19 and also worked on 05/21/19 and 05/22/19. 2. Review of Resident # 3's medical record revealed the facility admitted the Resident on 10/16/18 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, initiated 02/16/16, revealed Resident #3 had a communication problem related to minimal difficulty hearing, usually understood and usually understands others. The goal stated the resident used a form of communication to get needs met and to relate effectively with people. There were several interventions including: encourage resident to continue stating thoughts even if having difficulty; nursing to focus on a word or phrase that makes sense or respond to the feeling the resident was trying to express. Review of the Comprehensive Care Plan, initiated 02/18/16, revealed the resident had impaired breathing pattern related to [MEDICAL CONDITION] with goals stating the resident would have no complications related to shortness of breath; and would maintain a normal breathing pattern. There were several interventions including observe breathing patterns and report abnormalities to Physician; and oxygen at three (3) liters per nasal cannula. Review of the Comprehensive Care Plan, initiated 11/22/18, revealed the resident was frequently incontinent of bowel and bladder. The goal stated the resident would remain free of skin breakdown due to incontinence and brief use. There were several interventions including check and change every two (2) hours as needed; extensive assist of two (2) for toilet use; and adult briefs as needed. Review of Resident # 3's Annual Minimum Data Set (MDS) Assessment, dated 05/09/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of ten (10) out of fifteen (15), which indicated the resident was moderately cognitively impaired. Further review revealed the facility assessed the resident as having clear speech, usually understood, difficulty communicating some words or as able if prompted or given time. Continued review of the MDS Assessment, revealed the facility assessed the resident as receiving oxygen therapy; as requiring extensive assist of two (2) staff for bed mobility, transfers and toileting; as requiring extensive assist of one (1) staff for basic hygiene; and as incontinent of bowel and bladder. During the State Survey Agency's (SSA) investigation related to Resident #1's abuse allegation, a phone interview was conducted with NA #3, on 05/29/19 at 3:14 PM. NA #3 stated she had worked with SRNA #1 on 05/21/19 from 6:00 PM to 10:00 PM on the South Hall and was being trained by SRNA #1. Per interview, she and SRNA #1 were the only staff taking care of Group 5 that evening. She stated SRNA #1, Seemed aggressive with residents and acted like she did not want to do her job. NA #3 stated at the end of the shift on 05/21/19, SRNA #1 got upset when the nurse brought it to her attention that three (3) residents needed incontinence care. NA #3 stated that she and SRNA #1 entered an unidentified resident's room and SRNA #1 jerked the resident's oxygen cannula off the resident's face, threw it on the bedside table, and stated to the resident, I know you are not asleep. She further stated SRNA #1 did not perform incontinence care for the resident and left the resident soiled due to there were no briefs in the room. The NA stated that she was in orientation and could not remember all of the resident's names, and therefore could not give the name of this resident. NA #3 stated what she witnessed was abuse, and she learned in orientation she was to report abuse to a nurse; however, on this evening she could not find a nurse and therefore she did not report what she witnessed and went on home. The SSA notified the Administrator, on 05/30/19 at 11:00 AM, of the alleged abuse regarding the undetermined resident described by NA #3. The Administrator stated she was unaware of this allegation, but the facility would initiate an investigation. Review of the Long Term Care Facility-Self Reported Incident Form/Initial Report, presented to the SSA on 05/30/19 at 12:00 PM, revealed that the SSA Surveyor reported that a NA witnessed SRNA #1 on 05/21/19, to not provide incontinence care to a resident and to jerk oxygen tubing off the resident and state to the resident, I know you're not asleep. Resident unknown at this time. Further review revealed the alleged perpetrator was no longer employed at the facility; Abuse incident reported to the Administrator by OIG (SSA) on 05/30/19, and APS and Ombudsman notified. Phone interview with SRNA #1, alleged perpetrator, on 05/30/19 at 3:14 PM, revealed she denied jerking a resident's oxygen off or telling a resident, I know you are not asleep and denied not performing incontinence care for a resident because there were no briefs in the room. Interview on 05/30/19 at 6:24 PM, with the Social Service Director, revealed she was informed today by the Administrator of a new allegation of abuse related to SRNA #1 jerking oxygen tubing and being mean; and refusing to provide care to an unnamed resident. She stated this allegation should had been reported when the incident was witnessed to ensure the safety of the residents. Further interview revealed since the facility just learned of the allegation, they just started their investigation and her role in the investigation would be to interview the residents. Per interview, the Administrator provided her with the questions to ask the residents related to this allegation. Interview with the DON, on 05/30/19 at 6:50 PM, revealed she was informed earlier today of a new allegation of abuse by the Administrator. Per interview, she was told the allegation was related to SRNA #1 jerking oxygen tubing off an unnamed resident and refusing to provide incontinence care. The DON stated, the Administrator was taking the lead on this investigation and the investigation was ongoing. Further interview revealed this allegation of abuse should have been reported immediately to the nurse, immediate supervisor, management or the Administrator in order for the alleged perpetrator, SRNA #1, to be removed from resident care and to protect the residents from further potential abuse. Interview with the Administrator, on 05/30/19 at 7:40 PM, revealed if NA #3 witnessed abuse by SRNA #1 on 05/21/19, NA #3 should have reported it immediately. She stated once she was notified on 05/30/19 of the allegation of abuse, the investigation was initiated and was ongoing. She further stated she was at first unaware of who reported the allegation to OIG, and subsequently when the SDC interviewed NA #3 on the phone on 05/30/19, NA #3 told her she witnessed SRNA #1 jerk the resident's oxygen tubing off his/her face and state I know you're not asleep. Per interview, NA #3 also told the SDC, SRNA #1 failed to provide incontinence care to the resident. The Administrator stated NA #3 gave the SDC the resident's first name, but the SDC told NA #3 there was no resident on the hallway with that first name. Further interview revealed that someone in the background could be heard by the SDC giving another first name, which was Resident #3's name. She stated the person in the background was identified as NA #2, by NA #3. However, the Administrator stated NA #2 did not work the evening of 05/21/19. Further interview revealed the facility was unable to substantiate abuse occurred; however, it was her expectation that staff immediately report any allegations of abuse to their immediate supervisor, management or the Administrator. Per interview, if this allegation related to Resident #3 had been reported on 05/21/19, SRNA #1 would have been immediately removed from resident care to prevent further potential abuse; however, SRNA #1 worked the rest of the shift on 05/21/19 and 05/22/19, until she was sus

Based on interview, record review, review of facility policy, and review of KRS (Kentucky Revised Statutes) 525.120 Abuse of Corpse, it was determined the facility failed to treat each resident with respect and dignity for one (1) of twenty (20) sampled residents (Resident #2). Staff interviews, and review of the Statement written by State Registered Nursing Aide (SRNA) #8, revealed on [DATE] shortly after 8:00 PM, SRNA #8 and Nurse Aide (NA) #13 entered Resident #2's room and witnessed SRNA #1, Nurse Aide (NA) #9 and NA #10 providing post-mortem care to Resident #2. SRNA #8 and NA #13 witnessed SRNA #1, NA #9 and NA #10 giggling, squirting soap and making stick figures and smiley faces on the resident's body, playing with a knot on the resident's neck, playing with the Gastrostomy Tube ([DEVICE]) , and attempting to pull off the [MEDICAL CONDITION] bag. The findings include: Review of the facility's Resident Rights Policy, dated [DATE], revealed the facility would make every effort to assist each resident to assure residents were treated with respect and dignity. Review of KRS 525.120 Abuse of Corpse, revealed a person is guilty of abuse of a corpse when except as authorized by law, he intentionally treats a corpse in a way that would outrage ordinary family sensibilities. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Health Status Note, dated [DATE] at 8:08 PM, revealed the resident had no signs of life. The resident was pronounced deceased by the physician. Further review revealed that the resident's body could be released to the funeral home. During an investigation of an unrelated incident, the State Survey Agency (SSA) Representative conducted a phone interview with SRNA #8, on [DATE] at 4:16 PM. SRNA #8 stated, on [DATE] shortly after 8:00 PM, she entered Resident #2's room while SRNA #1, NA #10, and NA #9, were providing post-mortem care. She stated they were drawing stuff on the resident's body with soap, playing with the resident's [DEVICE] and trying to tear off the [MEDICAL CONDITION] bag. She further stated it was Disrespectful, and disgusting. Per interview, SRNA #8 asked SRNA #1 if she had ever done this type of care before (post mortem care) and SRNA #1 stated, Yes, and she wanted to teach NA #9 and NA #10. Continued interview revealed SRNA #8 then told SRNA #1, she needed to teach the NAs how to perform the care in the right way. Further interview revealed NA #13 was also in the room at the time and witnessed this incident. SRNA #8 stated she and NA #13 immediately reported this incident to Licensed Practical Nurse (LPN) #1 and provided written statements. Per interview, LPN #1 gave the statements to the Director of Nursing (DON) the following morning on [DATE]. Phone interview was attempted with NA #9, on [DATE] at 12:40 PM; however, a message could not be left, as the voice mail was not set up. NA #10 no longer worked at the facility, and the facility did not have a phone number to provide for this N[NAME] Phone interview with LPN #1, on [DATE] at 3:39 PM, revealed she was assigned to Resident #2 on [DATE], who was a Hospice resident, when the resident expired. LPN #1stated after the resident expired, the Hospice Aide asked staff to provide post mortem care. Further interview revealed SRNA #8 reported to her on [DATE], close to midnight, that SRNA #1, NA #9 and NA #10 were squirting soap all over Resident #2's body and being disrespectful while providing care after the resident passed. LPN #1 stated she did obtain two (2) statements, one (1) from SRNA #8 and one (1) from another NA, and she could not remember the NA's name. LPN #1 further stated she turned the statements into the DON, on [DATE]. Further interview revealed she (LPN #1) was not questioned by management or Administration about the incident. However, LPN #1 stated the Administrator did tell her on [DATE], she would talk to staff involved in the post mortem care for Resident #2 and find out what happened. Phone interview with LPN #2, on [DATE] at 11:35 AM, revealed when she reported to work on the morning of [DATE], LPN #1 made her aware of the incident related to Resident #2 and she read the statements written by SRNA #8 and NA #13. She stated, the statements revealed when Resident #2 passed away, SRNA #1, NA #9 (now a SRNA), and NA #10 were playing with Resident #2's body. She stated the statements revealed SRNA #1, NA #9/SRNA and NA #10 were playing with Resident #2's [DEVICE], squirting soap on his/her body and playing in it, flicking a knot which was on the resident's throat and opening and closing the resident's mouth. She stated the statements were from SRNA #8 and NA #13 who made them stop. Further interview revealed LPN #1 asked LPN #2 what she should do with the statements and LPN #2 told LPN #1 to report what happened because this was an issue. LPN #2 stated this incident really bothered her. Interview with SRNA #6, on [DATE] at 10:50 AM, revealed on the morning of [DATE] she read statements which had been left at the nurse's station, regarding staff's inappropriate behavior towards Resident #2, during post mortem care. She stated the statements were written by SRNA #8 and NA #13, who were witnesses to the way Resident #2 was being treated during post mortem care. Per interview, the statements revealed SRNA #1 and two (2) other girls were playing with the knot on the resident's neck and his/her [DEVICE]. She further stated when she read the statements, it disgusted her. Phone interview with SRNA #1, on [DATE] at 3:14 PM, revealed she had been asked by the Hospice Aide to perform post-mortem care for Resident #2 on the evening of [DATE]. She stated she was in orientation with NA #10 that evening. She stated that NA #9/SRNA, NA #10 and SRNA #1, got everything set up to provide the care, as she had never been trained on post-mortem care. She stated she remembered washing Resident #2's face, and then NA #10 grabbed the soap and started putting it on the resident's body. SRNA#1 stated NA #10 went to grab Resident #2's left arm to wash under the armpit when Resident #2's hand fell on his/her forehead. She stated that NA #10 stated, The resident looks stressed, and started laughing. SRNA #1 stated this frustrated her and she told NA #10 she needed to be respectful. Further interview revealed she was not asked to provide a written statement, but was counseled related to the incident. She stated the Staff Development Coordinator (SDC) brought SRNA#1, NA #10, and NA #9/SRNA together to discuss the incident and provide them with education about the proper way to provide post-mortem care. SRNA #1 stated she received a verbal warning and written information related to post-mortem care. Phone interview with Nurse Aide #13, on [DATE] at 4:15 PM, revealed, she had been working at the facility since (MONTH) 2019. She stated she worked the evening of [DATE] and during that evening while making rounds, she and SRNA #8 heard giggling. She further stated they walked room to room to find out where the giggling was coming from and when they arrived at Resident #2's room, they walked in and noted SRNA #1, NA #9, and NA #10 in the room. She stated the Hospice Nurse was at the nurse's station working on her computer and Resident #2's family was down the hall near the nurse's station. She stated she witnessed staff giggling and laughing while performing post-mortem care. The Nurse Aide stated they were drawing stick figures and smiley faces on the resident's body with the soap, and playing with the residents [DEVICE]. She further stated SRNA #1 finally told them to knock it off. Further interview revealed what she witnessed was very disrespectful, and if the resident had been alive it would have been considered abuse. NA #13 stated she and SRNA #8 reported what they witnessed to LPN #1, who asked them to write a statement, which they did and gave the statements to LPN #1. She further stated LPN #1 told SRNA #8 and NA #13 she was going to call the DON and let her handle the situation. NA #13 stated she never heard any more about it and was never questioned about her written statement. Interview with the DON, on [DATE] at 6:50 PM, revealed during post mortem care for Resident #2 on [DATE], staff performing care were exhibiting childlike inappropriate behavior and being disrespectful. Interview with the Administrator, on [DATE] at 7:40 PM, revealed LPN #1 had reported to her on [DATE] via telephone, that SRNA #8 had walked in Resident #2's room and witnessed staff not acting appropriately during post-mortem care. She stated the next morning on [DATE], she read the statement that was given to LPN #1 from SRNA #8, which revealed staff held soapy water up high and squirted it on the resident's body and staff moved a lipoma around that was on Resident #2's neck. The Administrator stated this was not respectful behavior toward the resident. Further interview, revealed it was determined the staff members needed re-education related to proper training related to post-mortem care, and providing respect and dignity with care, and education was provided for the staff involved who performed inappropriate care of the resident.

Based on observation, interview, record review and review of the facility's Policy and Guidelines, it was determined the facility failed to ensure it was free of medication error rates of five (5) percent or greater. Observation of medication administration pass, on 05/10/19, revealed twenty-two (22) medication opportunities, with two (2) errors, resulting in a medication error of nine percent (9%). This affected Resident #2 and Resident #3. The findings include: Review of the facility's Medication Administration Policy, undated revealed if it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident had difficulty swallowing or is tube-fed, using the following guidelines: 1) Long acting or [MEDICATION NAME] coated dosage forms should generally not be crushed; and an alternative should be sought; 2) The need for crushing medications is indicated on the resident's orders and the Medication Administration Record [REDACTED]. Review of the facility Medication Crushing Guidelines revealed the solid dosage forms of many medications should not be crushed or chewed for a variety of reasons. When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc) the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible. The rationale for not crushing some medications include: 1) [MEDICATION NAME] coated Tablets are designed to pass through the stomach whole and then dissolve in the intestinal tract to prevent the destruction of the medication by stomach acid to prevent the medication from irritating the stomach lining; and to achieve a prolonged action from the medication. 2) Timed Released Tablets are designed to release medication over a sustained period, usually eight (8) to twenty-four (24) hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these Timed Released Tablets should not be crushed. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 12/17/18, with [DIAGNOSES REDACTED]. Review of Resident #2's Physicians' Orders, dated (MONTH) 2019, revealed an order stating, may crush medications or open capsules as indicated per Pharmacy Protocol, with a start date of 12/17/18. Additional review revealed an order for [REDACTED]. Further review of the physician's orders [REDACTED]. Observation of medication administration, for Resident #2, on 05/10/19 at 8:20 AM, revealed Kentucky Medication Aide (KMA) #1 administered a [MEDICATION NAME], 325 mg tablet to Resident #2, crushed in applesauce. However, review of the Pharmacy label box warning for the [MEDICATION NAME], 325 mg tablets, revealed, take medication whole, do not crush or chew. This resulted in one (1) medication error. Interview, on 05/10/19, at 8:25 AM, with KMA #1, revealed she should have read the label on the pharmacy box more closely before administering medications to Resident #2. KMA #1 stated she should not have administered the medication to the resident crushed as per the Pharmacy label box warning. Continued interview revealed she would report the medication error to nurse on the unit, who would then alert the doctor, pharmacy, and family. Further interview revealed it was important to administer the correct medications in the correct form and as ordered by the physician in order to prevent negative side effects for the residents. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 02/22/16 with [DIAGNOSES REDACTED]. Review of Resident #3's Physician Orders, dated (MONTH) (YEAR), revealed [MEDICATION NAME] monoitrate Extended Release, thirty (30) mg, by mouth two (2) times a day for Hypertension. Observation during medication pass for Resident #2, on 05/10/19 at 8:45 AM, revealed KMA #2 administered an [MEDICATION NAME] Monoitrate Extended Release, thirty (30) mg tablet to Resident #3, crushed in applesauce. This resulted in one (1) medication error. However, review of the Pharmacy label box warning for the [MEDICATION NAME] Monoitrate Extended Release (30) mg tablets revealed, do not crush, may cause dizziness. This resulted in one (1) medication error. Interview, on 05/10/19 at 09:00 AM, with KMA #2, revealed she should not have administered an Extended Release medication for Resident #3 without a physician's orders [REDACTED]. Per interview, she knew an Extended Release medication could not be crushed because the effectiveness would be less therapeutic to the resident or the crushed medication could possibly cause adverse reactions. Interview, on 05/10/19 at 2:30 PM, with the Director of Nursing (DON), revealed she was made aware of the medication error made by KMA #1. Continued interview revealed medications with a Pharmacy label box warning to not crush, should not be crushed to prevent adverse reactions to the residents. Further interview, with the DON, revealed she was also made aware of KMA #2's medication error. Per interview, extended release medications should not be crushed. She stated proper medication administration was very important and she did not want any errors. Additional interview revealed medications should only be crushed if there was a (MONTH) Crush Medication physician's orders [REDACTED]. Continued interview with the DON, revealed there was no written facility Pharmacy Protocol related to which residents were not to be crushed; however, she expected Standards of Practice to be maintained during medication administration. Further interview revealed it was important that a resident received his/her medications in a safe way to ensure the most benefit was received. Further interview revealed it was her expectation staff would follow the physician's orders [REDACTED]. Interview, on 05/10/19 at 1:38 PM, with the Pharmacist Consultant, revealed (MONTH) Crush medications orders were required for medications to be administered in a crushed form. Continued interview revealed the Pharmacy did not provide the facility with an inclusive, Do Not Crush medication guideline; however, manufacturer's package inserts and pharmacy labels were available to nurses and KMAs as a reference to review to ensure medications were safe to crush. Additionally, [MEDICATION NAME] should not be crushed because the medication could upset the stomach; and in whole form they were [MEDICATION NAME] coated which was a protective mechanism. Per interview,[MEDICATION NAME] Release should not be crushed because Extended Release medications were typically designed to slowly release a medication over a long period of time; and when they were crushed that mechanism was destroyed and the medication was released in a shorter period of time. Per interview, this could potentially affect the whole profile of the medication and the desired therapeutic effect. Further, reviewing crush medication orders was part of her monthly review of each resident charts. She stated she relied on nursing staff to inform her of which residents were identified to require crushed medications in order for pharmacy to collaborate with the Physician related to appropriate alternatives forms of medications as necessary. Interview, on 05/10/19 at 2:00 PM, with the Advanced Practice Registered Nurse (APRN), revealed she typically wrote medication orders and if the nurses let her know if the resident was unable to take medications whole, she would collaborate with the pharmacy and determine appropriate alternates such as liquids and crushable medications or would give orders to crush medications as necessary. Continued interview revealed she expected nurses to inform her of medications that needed to be changed to to a crush safe medication. Additionally, she stated she was not aware of any Pharmacy Protocol guidelines to inform nurses of which medications were safe to crush. Continued interview with the APRN, revealed Resident #2's [MEDICATION NAME] tablet should not have been crushed as it could irritate the resident's stomach if administered crushed; and the nurse should have notified her for the need to change the [MEDICATION NAME] order to liquid medication. Continued interview revealed Resident #3's [MEDICATION NAME] Extended Release should not have been crushed because crushing this medicsation could cause dizziness; and if the reisdent could not take the medication whole, the nurse should have notified her for a necessary medication change for the medication to be given in a different form. Further interview revealed she expected the Pharmacist Consultant to collaborate with the Providers to ensure residents who could not take whole capsules or pills, were not prescribed medications that could not be crushed. Interview, on 05/10/19 at 2:45 PM with the Administrator, revealed only medications safe to crush should to be administered in crushed form and only with a physician's orders [REDACTED]. Further interview revealed she expected the facility policies and guidelines related to administration of medications to be followed.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure alternatives were attempted prior to use of a restraint; failed to ensure the restraint was used for the least amount of time; failed to have a systematic process for reduction of the restraint; and failed to implement interventions to prevent risks associated with the restraint for one (1) of two (2) sampled residents reviewed for restraints out of a total of twenty-eight (28) sampled residents (Resident #88). Review of the Pre-Restraining Assessment, dated 03/04/15, revealed Resident #88 was to be up in the recliner as needed for comfort, in reclined position secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe pain; and lift chair recliner to remain unplugged at all times secondary to fall. However, there was no documented evidence alternatives were attempted prior to the implementation of the restraint. In addition, although Physical Restraint Elimination Assessments, dated 06/11/18, 09/01/18, 11/01/18, and 01/23/19, revealed the resident was a good candidate for restraint elimination based on physical functioning and behavioral/social functioning assessment; and staff interviews revealed the resident had a history of [REDACTED]. Furthermore, the Monthly (MONTH) 2019 Physician's Orders, revealed orders stating the resident may be up in the recliner in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with chronic pain; however, the orders did not specify the recliner chair was to be unplugged, and did not specify the period of time for the use of the restraint. Also, the Comprehensive Care Plan (CCP) revised 01/10/19, did not indicate the period of time for the use of the restraint in order to ensure the restraint was used for the least amount of time. Additionally, the facility failed to implement interventions to prevent risks associated with the restraint, as per the CCP. The CCP revealed interventions for the resident to be toileted, checked and changed for incontinence care every hour. However, the resident had not been checked and changed or toileted for two (2) hours and fifty-three (53) minutes prior to sustaining a fall from the electric recliner chair which was in a reclined position and unplugged, on 02/11/19. The resident was transferred to the Hospital emergency room (ER) on 02/11/19, and was diagnosed with [REDACTED]. (Refer to F-656, F-657, and F-689) The findings include: Review of the facility Restraint Use Policy, dated 08/01/13, revealed restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints would be used to treat the residents medical symptoms and never for disciple or staff convenience, or for the prevention of falls. Per Policy, a physical restraint was defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body. The Policy stated, a resident in a chair that prevents the resident from rising was inappropriate utilization of equipment and was not permitted. Continued review revealed restraints are to be used under the written order of the physician and after obtaining consent from the resident/responsible party. The Policy further stated the order shall include the following: the specific reason for the restraint (as it relates to the resident's medical symptom); how the restraint will be used to benefit the resident's medical symptom; and the type of restraint and the period of time for the use of the restraint. Per Policy, restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraint, or total restraint elimination; and Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. Further review of the Policy, revealed documentation regarding the use of restraints would include full documentation of the episode leading to the use of physical restraint including not only the resident symptoms, but also the conditions, circumstances, and environment associated with the episode; and observation, Range of Motion (ROM) and repositioning flow sheets. Review of Resident #88's medical record revealed the facility admitted the resident on 09/01/10, with [DIAGNOSES REDACTED]. Review of Resident #88's Pre-Restraining Assessment, dated 03/04/15, which the facility was unable to submit during survey, and was provided post survey on 02/26/10 via email, revealed recommendations including: may be up in recliner as needed for comfort, in reclined position secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe pain; and lift chair recliner to remain unplugged at all times secondary to fall. Review of the Acknowledgement of Restraint Intervention forms, dated 03/25/15, 07/05/16, 06/30/17, and 08/03/18, signed by the resident representative, for the recliner, revealed acknowledgement for the use of restraint intervention in the treatment of [REDACTED]. Further review revealed there was the potential for several complications related to the use of the restraint such as: immobility, ulcers, contractures, decreased circulation, fractures related to trying to remove the restraint, incontinence, decreased range of motion, withdrawal/depression, decreased socialization, and possible death. Review of the Weekly Restraint Review, provided post survey on 02/26/19, via email, revealed a reduction attempt was made on 06/11/18, 09/01/18, 11/01/18, and 01/23/19 related to the resident's recliner restraint. However, the form did not specify how the reduction attempt was conducted; if there was a trial without the restraint and for what time period; if there was a less restrictive device used as a trial; or any specifics related to the reduction attempt. Review of the Physical Restraint Elimination Assessments, dated 06/11/18, 09/01/18, 11/01/18, and 01/23/19, revealed Resident #88 scored above twenty-one (21), indicating he/she was a good candidate for restraint reduction or elimination program, based on physical functioning and behavioral/social functioning assessment. However, the facility documented the resident was not a candidate for a restraint reduction or elimination program due to the recliner in reclined position helped for comfort secondary to [MEDICAL CONDITION] Disc disease with chronic severe pain and reduction of falls. Continued review revealed recommendations to continue use of the recliner; and recliner to remain unplugged at all times. Additionally, the Physical Restraint Elimination assessment dated [DATE], revealed the resident sometimes played with the recliner remote, not realizing what it did, was unable to get up on his/her own and was non-ambulatory. Review of Resident #88's CCP, revised 01/10/19, revealed the resident had the potential for trauma related to potential for falls; history of falls; high risk for falls; restraint use; and rejection of care. The first goal stated the resident would not have any injury to self, related to restraint use. The second goal stated the resident would not sustain serious injury related to rejection of care behaviors. The third goal stated staff would implement strategies to increase safety and decrease falls. The interventions included: check and release restraint per facility policy; check resident when reclined every thirty (30) minutes and release every two (2) hours for ten (10) minutes to help restore circulation; release restraint by putting footrest down; may be up in recliner, in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe Pain-restraint; recliner must be unplugged at all times; and dycem to recliner to prevent sliding. Per the CCP, there were several potential complications related to use of restraint; however, the CCP did not specify the complications. Also, there was no documented evidence the CCP included a time period for use of the recliner, or measures taken to systematically reduce or eliminate the need for restraint use. Additional review of the CCP, revised 01/10/19, revealed the resident was always incontinent of bowel and frequently incontinent of bladder and required assistance with toileting related to a history of acute [MEDICAL CONDITION], overactive bladder, vaginal bleeding and dryness. The goal stated the resident would have bowel and bladder incontinence managed through nursing intervention. The interventions included, but were not limited to: check and change every one (1) hour and as needed. Additional interventions included extensive assistance for two (2) staff with toileting; may wear adult briefs as needed; and per family request do not leave in the bathroom alone. Review of Resident #88's Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, and locomotion on and off the unit, toileting, and personal hygiene. Further review revealed the facility assessed the resident as not steady during transition from sitting to standing or on and off the toilet; only able to stabilize with staff assistance; and as ambulation did not occur. Per the MDS Assessment, the resident was continent of bowel and frequently incontinent of bladder. Continued review revealed the facility assessed the resident as having functional limitations in Range of Motion (ROM) for one (1) side upper extremities and as using a wheelchair for mobility. Per the MDS Assessment, the resident had no falls since the previous assessment; received a diuretic medication the past seven (7) days; received no therapy or restorative nursing; and had a physical restraint; chair that prevented rising daily. Review of Resident #88's State Registered Nursing Assistant (SRNA) Task: Restraint, dated 02/01/19 to 02/11/19, revealed it was signed every shift, to indicate the restraint was checked every thirty (30) minutes and released/repositioned every two (2) hours. However, there was no documented evidence of observation, range of motion and repositioning flow sheets, as per Policy. Review of Resident #88's Monthly (MONTH) 2019 Physician's Orders, revealed orders initiated 12/28/17, stating the resident may be up in the recliner in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with chronic pain. However, the Physician's Orders did not specify the period of time for the use of the restraint, nor did the orders specify the recliner chair was to be unplugged. Review of Resident #88's Progress Note, dated 02/11/19 at 8:00 PM, completed by Licensed Practical Nurse (LPN) #8, revealed the resident was sitting in his/her recliner chair with Oxygen on at two (2) liters per nasal cannula and then later was observed on the floor on his/her right side. Per the Note, the resident was assessed to have a laceration above the right eye and a bruise to the right shoulder, and the Physician and resident representative were called. Further review of the Note, revealed the resident was transferred to the hospital for evaluation and treatment related to a laceration above the right eyebrow. Review of Resident #88's Progress Note, dated 02/11/19 at 10:00 PM, completed by LPN #8, revealed the chair was unplugged and reclined at thirty (30) degrees, and the resident hit his/her head on the bedside table prior to the fall. Per the Note, the resident returned to the facility with fourteen (14) sutures to the right side of the head and bruising to the right shoulder. Additional review revealed a CAT Scan (computerized tomography scan uses computer processed combinations of many x-ray measurements taken from different angles to produce cross sectional images of specific areas of a scanned object) of the head, neck and right hip were negative. Review of the Hospital Discharge Summary, dated 02/11/19, revealed the Resident was discharged with a [DIAGNOSES REDACTED]. Further review revealed tests and procedures provided to the Resident included a CT on the brain without contrast, CT of the Cervical Spine without contrast, Xray of right hip and pelvis, laceration suturing, and continuous pulse oximetry monitoring. Interview with the Director of Nursing (DON on 02/21/19 at 11:00 AM, revealed the facility did not keep Kardexes (document utilized by the SRNAs as a guide to provide care), as they were not a part of the medical record. Therefore, they were unable to submit the Kardex which was in affect on 02/11/19, the day Resident #88 sustained the fall. Interview on 02/21/18 at 5:45 PM, with SRNA #11, revealed she was assigned to Resident #88 on 02/11/19, when the resident fell . She stated she had reviewed Resident #88's Nursing Assistant Kardex at the beginning of the shift on 02/11/19, prior to providing care, which stated the resident required two (2) staff for transfers and toileting every two (2) hours. She stated she knew the resident was to be assisted to the bathroom for toileting; however, she was unaware the resident was to be checked and changed for incontinence and toileted every hour, as per the CCP. She further stated the resident was to be checked every thirty (30) minutes and released from the reclined position of the recliner every (2) hours and she had put the recliner foot rest down during meal services/assistance at dinner around 6:00 PM, on the evening of 02/11/19. Additional interview with SRNA #11, revealed the evening of 02/11/19, she remembered Resident #88 was lying back in the recliner twenty (20) minutes prior to the fall and the resident had requested to be toileted. She stated she informed the resident she would assist him/her to the toilet after assisting another resident to bed. Per interview, when she returned to Resident #88's room to assist the resident to the toilet, after assisting two (2) other residents to bed, she found the resident on the floor in front of the recliner and the resident was lying on his/her right side. SRNA #11 revealed the resident had been last toileted at 5:07 PM, and therefore it had been two (2) hours and fifty-three (53) minutes since the resident was last toileted, prior to the resident sustaining the fall at 8:00 PM. Continued interview with SRNA #11, revealed the recliner was an electric model, and had to be plugged in to lower or recline the leg rest and prior to the fall the resident had been reclined in the chair with the chair unplugged. She stated when the chair was reclined with the leg rest up and unplugged, it prevented the resident from sitting up or putting the leg rest down and this was a restraint for the resident. Per interview, the resident was required to sit in his/her recliner with the leg rest elevated and the chair turned off when in his/her room alone due to being a fall risk. She further stated, Resident #88 must have leaned forward to pick something up that was out of reach and fell out of the chair on the evening of 02/11/19. She further stated she had observed the resident in the past to lean over the chair or lean down and try to pick things up while sitting reclined in his/her chair with the leg rest elevated, almost falling out of the chair. Further interview revealed she was not aware of any ROM/repositioning flowsheet, but she did frequently go into the resident's room and make sure he/she was sitting up in the chair and had everything he/she needed. Interview with Licensed Practical Nurse (LPN) #8, on 02/21/19 at 5:25 PM, via telephone, revealed he was assigned to Resident #88 on 02/11/19, when a SRNA alerted him to come quickly to Resident #88's room because the resident sustained [REDACTED].#8 stated he could not remember which SRNA notified him of this; however, he immediately entered Resident #88's room, assessed the resident, and then called 911. Continued interview revealed the family brought in the recliner chair, but he considered it a danger to the resident and the facility had been unsuccessful in getting the family to take the chair home. Per interview, the recliner chair was a restraint for the resident when it was reclined and unplugged and he had seen the resident attempt to climb out of the chair in the past. LPN #8 further stated he did not know when the resident was toileted last prior to the fall on 02/11/19. The nurse further stated he would not offer further information, and did not want to talk without legal representation. Observation of Resident #88, on 02/19/19 at 12:20 PM, revealed the resident was in his/her room sitting in a recliner, which was positioned between the right side of the bed and the wall. The bedside table was in front of the resident positioned over the recliner and the resident's legs and the resident's feet were under the bedside table, on the floor. The chair was unplugged and oxygen was in use per nasal cannula. There were staples to the right temporal side of his/her forehead, and fading yellow and green discoloration to the right side of his/her face around his/her check bone, eye, brow and forehead. Interview with the resident at the time of observation, revealed he/she fell recently and bumped his/her head on the concrete. Resident #88 was unable to elaborate further on fall event details. Review of Resident #88's Nursing Assistant Kardex, dated 02/21/19, revealed the resident may be up in recliner in reclined position as needed for comfort/restraint; check and release restraint per facility policy: check recliner when reclined every thirty (30) minutes and release every two (2) hours for ten (10) minutes to help restore circulation; release restraint by putting the footrest down; and recliner must be unplugged at all times. Continued review revealed the resident needed encouragement to use a reaching device; and call light should be in reach and staff should respond to the call light promptly. Further, the resident required extensive assistance of two (2) with transfers and toileting; use gait belt at all times; no ambulation; and required check and change (toileting) every hour and as needed. Further observation of Resident #88, on 02/21/19 at 10:50 AM, revealed the resident was in his/her room sitting in the recliner in the reclined position with oxygen in use per nasal cannula. The bedside table was positioned over the recliner in front of the resident and the chair was unplugged. The bedside table in conjunction with the recliner were preventing the resident from rising as the resident was leaning forward. On 02/21/19 at 11:00 AM, the State Surveyor alerted the Director of Nursing (DON) to the position of Resident #88's bedside table which was positioned over the resident's recliner in front of the resident. Interview with the DON, on 02/21/19 at 11:00 AM, revealed she had assessed the bedside table positioning in Resident #88's room and determined the placement was necessary. She further stated the bedside table was positioned under the recliners leg rest and in front of the resident because the resident could not reach his/her water otherwise. When questioned if the bedside table was a restraint for the resident, she stated it was not because the resident was unable to get up anyway with the chair reclined. The DON stated she had reviewed the facility Restraint policy, with the Administrator and Region Clinical Consultant, and determined the wording was wrong in the section that stated, a resident in a chair that prevents the resident from rising was inappropriate utilization of equipment and was not permitted. Per the DON, the policy should state if a resident was able to rise from a chair without staff assistance, it would not be permitted to place them in a chair that restricted their ability to rise without assistance. Interview with SRNA #10, on 02/21/19 at 5:04 PM, revealed she was assigned to Resident #88. She stated when the resident was in his/her room alone, the recliner leg rest was to be elevated and the recliner was to be unplugged. SRNA #10 further stated the resident spent most of his/her day in the recliner with the bedside table in front of the chair. Further interview revealed the resident was confused quiet often and would try to do things independently such as walk, try to get up from the bed or climb out of the chair. Per SRNA #10, the resident could not put the recliner footrest down independently. SRNA #10 stated the recliner kept the resident from falling; however, there were risks associated with the chair such as entrapment. Interview with LPN #2 on 02/21/19 at 5:26 PM , revealed she was assigned to Resident #88 who was confused at times and attempted to get up without assistance, and required assistance with mobility. Per interview, the interventions in place to prevent falls for Resident #88 included: elevating the footrest on the recliner and unplugging the recliner so the resident could not put it down; call light in reach; frequent checks every hour and putting the elevated footrest down every two (2) hours. She stated the resident was to be checked and changed, and toileted every hour as per the CCP. She further stated these interventions were documented as completed by the SRNAs in the kiosk TASK and she did walking rounds to ensure the SRNAs were providing care as per the CCP. LPN #10 stated the resident liked to sit in the recliner and the family wanted it unplugged so the resident did not attempt to use the remote and attempt to get up independently. LPN #10 further stated there was risk for injury due to the resident made attempts to get out of the chair without assistance while it was reclined, even prior to 02/11/19 when the resident fell . However, LPN #10 stated she was unaware of what least restrictive devices/interventions were used before reclining and unplugging the chair to reduce the resident's risk for falls. Interview with the Minimum Data Set (MDS) Nurse, on 02/21/19 at 6:17 PM revealed restraints were assessed quarterly to ensure the least restrictive device/restraint was in place for each individual resident. However, she stated trials of elimination of the recliner chairs were not attempted for Resident #88 related to confusion and risk of falls. Per interview, Resident #88's family insisted the recliner be used to reduce [MEDICAL CONDITION] in the resident's lower extremities and reduce falls. Per the MDS Nurse, the facility had multiple conversations with the family related to risk and benefits of using the recliner for [MEDICAL CONDITION] and fall reduction; however, the family continued to demand the use of the recliner. Interview with the DON, on 02/21/19 at 5:51 PM revealed, although Resident #88's restraint assessments stated the resident may be up in recliner as needed for comfort, in reclined position secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe pain; and lift chair recliner was to remain unplugged at all times secondary to falls; the restraint was used because the resident's family insisted. She further stated the recliner footrest remain elevated at all times to reduce the resident's lower extremity [MEDICAL CONDITION] and to prevent falls per family request. Per interview, staff determined the chair needed to be unplugged due to the resident's confusion; as he/she was not able to safety operate the electric recliners controls to elevate the footrest and recline the chair; however, the facility did not ensure Physician's Orders were obtained for the chair to be unplugged with the use of the restraint or ensure the orders specified the period of time for the use of the restraint. Continued interview with the DON, revealed the recliner did restrict Resident #88 from sitting up and putting his/her feet down, or rising without assistance when the foot rest was elevated and the chair was unplugged, and therefore this was a restraint for the resident. The DON stated, appropriate use of a restraint was important to prevent accidents; however, the facility did not follow policy related to ensuring there was full documentation of the episode leading to the use of physical restraint nor did the facility utilize observation, range of motion and repositioning flow sheets. She stated the facility only had the SRNAs document on the SRNAs task: Restraint, to indicate the restraint was checked and released. Further interview with the DON, revealed there should have been documented evidence of alternatives attempted prior to the use of the recliner chair restraint for Resident #88; and she was unaware if lesser restrictive devices were tried prior to the use of the restraint. Additional interview with the DON, revealed the facility completed quarterly Restraint Elimination Assessments with the MDS Assessment schedule to ensure restraints were appropriately used for each resident and restraint reduction trials were initiated. However, the DON stated Resident #88 was not a candidate for restraint reduction or elimination due to confusion and risk for falls; and therefore, there were no restraint reductions or elimination trials for this resident's recliner chair restraint. Continued interview with the DON, revealed Resident #88's CCP related to restraints did not specify the period of time for use of the restraint; however, this intervention should have been included to ensure the restraint was used for the least amount of time. Additional interview with the DON, revealed the SRNA assigned to Resident #88 should have ensured the resident was released from the recliner restraint for toileting every hour on 02/11/19 as per the CCP, in an attempt to prevent accidents such as the fall event that occurred on that date. Interview with Administrator, on 02/21/19 at 6:26 PM, revealed she expected the facility's policy and regulations related to restraints to be followed. Per interview, this was important to ensure residents remained free of unnecessary restraints and used the least restrictive devices. Continued interview revealed she did not want Resident #88's recliner; however, the family insisted the resident have it to reduce [MEDICAL CONDITION] in his/her legs. Per interview, the facility staff had discussed risk versus benefit of using the recliner for [MEDICAL CONDITION] multiple times in care conference meetings; and the family continued to demand the resident have the recliner. Continued interview revealed Resident #88's recliner remote used to recline and elevate the leg rest was disabled because the resident would adjust it independently and project him/herself out of the chair. The Administrator further stated Resident #88 should have been released from the restraint recliner chair to be toileted per the CCP, on 02/11/19, in an attempt to prevent injury and to ensure the resident received necessary care and his/her needs were met. Further interview revealed the facility policy and regulation should have been followed related to restraint use for Resident #88.

Based on observation, interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to develop and implement the Comprehensive Care Plan for each resident to meet the resident's medical, and nursing needs that are identified in the comprehensive assessment for one (1) of twenty-eight (28) sampled residents (Resident #88). Review of Resident #88's Physical Restraint Elimination Assessments, dated 06/11/18, 09/01/18, 11/01/18, and 01/23/19, revealed the facility documented the resident was not a candidate for a restraint reduction or elimination program due to the recliner in reclined position helped for comfort secondary to [MEDICAL CONDITION] Disc disease with chronic severe pain and reduction of falls. However, the Comprehensive Care Plan (CCP) initiated 09/04/12 and revised 01/10/19, was not developed with interventions to systematically reduce or eliminate the need for restraint and was not developed with interventions to indicate the period of time the restraint was to be used in order to ensure the restraint was used for the least amount of time. Also, the facility failed to implement interventions to prevent risks related to the use of the restraint, as per the CCP. Although the CCP revealed interventions for the resident to be toileted, checked and changed for incontinence care every hour, the resident had not been checked and changed or toileted for two (2) hours and fifty-three (53) minutes prior to sustaining a fall from the electric recliner chair which was in a reclined position and unplugged, on 02/11/19. Resident #88 was transferred to the Hospital emergency room (ER) on 02/11/19, and was diagnosed with [REDACTED]. (Refer to F-604, F-657, and F-689) The findings include: Review of the facility's Care Plan Policy, dated 08/01/13, revealed care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Specific resident problems would be addressed in the Care Plan, and information in the Care Plan was derived from resident assessments. All disciplines have access to the Care Plan. Interview with the Minimum Data Set (MDS) Nurse on 02/21/19 at 6:17 PM, revealed the Resident Assessment Instrument Version 3.0 Manual, was used as a guide for developing and implementing the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the facility Restraint Use Policy, dated 08/01/13, revealed restraints should only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints should be used to treat the resident's medical symptoms and never for disciple or staff convenience, or for the prevention of falls. Continued review revealed restraints are to be used under the written order of the physician and the order shall include the following: the specific reason for the restraint (as it relates to the resident's medical symptom); how the restraint will be used to benefit the resident's medical symptom; and the type of restraint and the period of time for the use of the restraint. Per Policy, restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraint, or total restraint elimination; and Care plans shall include the measures taken to systematically reduce or eliminate the need for restraint use. Review of the clinical record revealed the facility admitted Resident #88 on 09/01/10, with [DIAGNOSES REDACTED]. Review of Resident #88's Pre-Restraining Assessment, dated 03/04/15, which the facility provided post survey on 02/26/10 via email, revealed recommendations including: resident may be up in recliner as needed for comfort, in reclined position secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe pain; and lift chair recliner to remain unplugged at all times secondary to fall. Review of the Weekly Restraint Review, provided post survey on 02/26/19, via email, revealed a restraint reduction attempt was made on 06/11/18, 09/01/18, 11/01/18, and 01/23/19 related to the resident's recliner restraint. However, the Review did not specify how the reduction attempt was conducted; if there was a trial without the restraint and for what time period; if there was a less restrictive device used as a trial; or any specifics related to the reduction attempt. Review of the Physical Restraint Elimination Assessments, dated 06/11/18, 09/01/18, 11/01/18, and 01/23/19, revealed Resident #88 scored above twenty-one (21), indicating the resident was a good candidate for restraint reduction or elimination program, based on physical functioning and behavioral/social functioning assessment. However, the facility documented the resident was not a candidate for a restraint reduction or elimination program due to the recliner in reclined position helped for comfort secondary to [MEDICAL CONDITION] Disc disease with chronic severe pain and helped with reduction of falls. Further review revealed recommendations to continue use of the recliner; and recliner to remain unplugged at all times. Review of the CCP, revised 01/10/19, revealed Resident #88 had the potential for trauma related to potential for falls; history of falls; high risk for falls; restraint use; and the rejection of care. The CCP goals included: the resident would not have any injury to self, related to restraint use; the resident would not sustain serious injury related to rejection of care behaviors; and staff would implement strategies to increase safety and decrease falls. The CCP interventions included: check and release restraint per facility policy; check resident when reclined every thirty (30) minutes and release every two (2) hours for ten (10) minutes to help restore circulation; release restraint by putting footrest down; may be up in recliner, in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe Pain-restraint; recliner must be unplugged at all times; and dycem to recliner to prevent sliding. Per the CCP, there were several potential complications related to use of restraint; however, the CCP did not specify the complications. Also, there was no documented evidence the CCP included a time period for use of the recliner, or measures taken to systematically reduce or eliminate the need for restraint use. Additional review of Resident #88's CCP, revised 01/10/19, revealed the resident was always incontinent of bowel and frequently incontinent of bladder and required assistance with toileting related to a history of acute [MEDICAL CONDITION], overactive bladder, vaginal bleeding and dryness. The CCP goal stated the resident would have bowel and bladder incontinence managed through nursing intervention. The CCP interventions included, but were not limited to: check and change every one (1) hour and as needed. Additional interventions included extensive assistance for two (2) staff with toileting; may wear adult briefs as needed; and per family request do not leave in the bathroom alone. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed Resident #88 as requiring extensive assistance of two (2) staff for bed mobility, transfers, and locomotion on and off the unit, toileting, and personal hygiene. Additional review revealed the facility assessed the resident as not steady during transition from sitting to standing or on and off the toilet; only able to stabilize with staff assistance; and as ambulation did not occur. Further, the facility assessed the resident as continent of bowel and frequently incontinent of bladder. Per the MDS, the facility assessed the resident as having functional limitations in Range of Motion (ROM) for one (1) side upper extremities and as using a wheelchair for mobility. Also, per the MDS Assessment, the resident had no falls since the previous assessment; received a diuretic medication the past seven (7) days; received no therapy or restorative nursing; and had a physical restraint; chair that prevented rising daily. Review of the Monthly (MONTH) 2019 Physician's Orders, revealed orders initiated 12/28/17, stating the resident may be up in the recliner in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with chronic pain. However, the Physician's Orders did not indicate the period of time for the use of the restraint, nor did the orders specify the recliner chair was to be unplugged. Review of the Progress Note, dated 02/11/19 at 8:00 PM, completed by Licensed Practical Nurse (LPN) #8, revealed the resident was sitting in his/her recliner chair with Oxygen on at two (2) liters per nasal cannula and then later was observed on the floor on his/her right side. According to the Note, the resident was assessed to have a laceration above the right eye and a bruise to the right shoulder, and the Physician and resident representative were called. Per the Note, the resident was transferred to the hospital for evaluation and treatment related to a laceration above the right eyebrow. Review of Resident #88's subsequent Progress Note, dated 02/11/19 at 10:00 PM, completed by LPN #8, revealed the chair was unplugged and reclined at thirty (30) degrees, and the resident hit his/her head on the bedside table prior to the fall. According to the Note, the resident returned to the facility with fourteen (14) sutures to the right side of the head and bruising to the right shoulder. Review of the Hospital Discharge Summary, dated 02/11/19, revealed the Resident was discharged with a [DIAGNOSES REDACTED]. Further review revealed tests and procedures provided to the Resident included a CT Scan (computerized tomography scan uses computer processed combinations of many x-ray measurements taken from different angles to produce cross sectional images of specific areas of a scanned object) of the head, neck and right hip without contrast, CT of the Cervical Spine without contrast, Xray of right hip and pelvis, and all CT Scans and xrays were negative. Further review revealed the resident received laceration suturing, and continuous pulse oximetry monitoring. Interview with the Director of Nursing (DON on 02/21/19 at 11:00 AM, revealed the facility did not keep Kardexes (document utilized by the SRNAs as a guide to provide care), because they were not a part of the medical record. Per interview, the facility was unable to submit the Kardex which was in affect on 02/11/19, the day Resident #88 sustained the fall. Interview on 02/21/18 at 5:45 PM, with SRNA #11, revealed she was assigned to Resident #88 on 02/11/19, at the time the resident fell . Per interview, she had reviewed Resident #88's Nursing Assistant Kardex at the beginning of the shift on 02/11/19, prior to providing care, which stated the resident required two (2) staff for transfers and toileting every two (2) hours. Further interview revealed she knew the resident was to be assisted to the bathroom for toileting; however, she was unaware the resident was to be checked and changed for incontinence and toileted every hour, as per the CCP. Per interview, the resident was to be checked every thirty (30) minutes and released from the reclined position of the recliner every (2) hours and she had put the recliner foot rest down during meal services/assistance at dinner around 6:00 PM on the evening of 02/11/19. Additional interview with SRNA #11, revealed the evening of 02/11/19, she remembered Resident #88 was lying back in the recliner twenty (20) minutes prior to the fall and the resident had asked to be toileted. She further stated she informed the resident she would assist him/her to the toilet after assisting another resident to bed. SRNA #11 stated, when she returned to Resident #88's room to assist the resident to the toilet, after assisting two (2) other residents to bed, she found the resident on the floor in front of the recliner lying on his/her right side. Per interview, the resident had been last toileted at 5:07 PM, and therefore it had been two (2) hours and fifty-three (53) minutes since the resident was last toileted, prior to the resident sustaining the fall at 8:00 PM. Interview with Licensed Practical Nurse (LPN) #8, on 02/21/19 at 5:25 PM, via telephone, revealed he was assigned to Resident #88 on 02/11/19, and was alerted by a SRNA to come quickly to Resident #88's room because the resident sustained [REDACTED].#8 immediately entered Resident #88's room, assessed the resident, and then called 911. Further interview revealed the recliner chair was a restraint for the resident when it was reclined and unplugged and he had seen the resident attempt to climb out of the chair in the past. Per interview, he did not know when the resident was toileted last prior to the fall on 02/11/19. The nurse further stated he would not offer further information because he did not want to talk without legal representation. Interview with the Minimum Data Set (MDS) Nurse, on 02/21/19 at 6:17 PM revealed restraints were assessed quarterly to ensure the least restrictive device/restraint was in place for residents. However, trials of elimination of the recliner chairs were not attempted for Resident #88 related to confusion and risk of falls. She stated Resident #88's family insisted the recliner be used to reduce [MEDICAL CONDITION] in the resident's lower extremities and reduce falls. Further interview revealed she ensured the CCP was developed to include resident specific interventions related to restraints and toileting. Continued interview revealed it was important to develop a care plan with interventions to systematically reduce or eliminate the need for restraints and to indicate the period of time the restraint was to be used in order to ensure the restraint was used for the least amount of time; however, she had failed to ensure Resident #88's CCP was developed with these restraint interventions. Additionally, she stated all staff should provide care per the CCP to ensure the residents received necessary, good quality care to meet their needs and ensure the resident's safety. Interview with the DON, on 02/21/19 at 5:51 PM revealed it was her expectation the facility's policy and protocols, regulation and standards of practice be maintained related to development and implementation of the care plan. Additional interview revealed the facility completed quarterly Restraint Elimination Assessments with the MDS Assessment schedule to ensure restraints were appropriately used for each resident and restraint reduction trials were initiated. However, per interview, Resident #88 was not a candidate for restraint reduction or elimination due to confusion and risk for falls; and therefore, there were no restraint reductions or elimination trials for this resident's recliner chair restraint. She acknowledged the CCP did not include interventions for restraint reduction. Additional interview with the DON, revealed Resident #88's CCP related to restraints did not specify the period of time for use of the restraint; however, this intervention should have been included to ensure the restraint was used for the least amount of time. Continued interview with the DON, revealed the SRNA assigned to Resident #88 should have ensured the resident was released from the recliner restraint for toileting every hour on 02/11/19 as per the CCP, in an attempt to prevent accidents such as the fall event that occurred on that date. Interview with Administrator, on 02/21/19 at 6:26 PM revealed she expected the facility's policy and regulation to be followed related to implementing and developing the CCP. Per interview, Resident #88's CCP should have included interventions to use the least restrictive device for the least amount of time and to indicate the time period the recliner restraints would be used. Additionally, she stated she expected nursing staff to implement the CCP to ensure care needs were met. Per interview, it was important to toilet residents per their individualized care plan to ensure their needs were met and necessary care was provided. Continued interview revealed Resident #88's CCP should have been implemented related to toileting every hour as per the CCP, on 02/11/19, in an attempt to prevent injury.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure each resident's environment was free from accident hazards as is possible and each resident receives adequate supervision to prevent accidents for one (1) of five (5) sampled residents reviewed for falls out of a total of twenty-eight (28) sampled residents (Resident #88). Resident #88 was assessed by the facility per the Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/19, as requiring the assist of two (2) staff for toileting and as having a restraint-chair that prevents rising. Staff interviews revealed the resident had a history of [REDACTED]. The Comprehensive Care Plan revised 01/10/19, revealed interventions to check and change the resident for incontinence care/ toileting, every hour and as needed. However, on 02/11/19, when the resident was in the recliner chair restraint and requested to be toileted, State Registered Nursing Assistant (SRNA) #11 told the resident she would be back after assisting another resident to bed. Resident #88 sustained a fall on 02/11/19, while waiting to be toileted. Interview with SRNA #11, revealed the resident had been last toileted at 5:07 PM, revealing it had been two (2) hours and fifty-three (53) minutes since the resident was last toileted, prior to the resident sustaining the fall at 8:00 PM. After the fall on 02/11/19, Resident #88 was transferred to the Hospital emergency room (ER) where he/she was treated for [REDACTED]. Furthermore, the facility failed to complete a thorough investigation as there was no documented evidence the facility did a root cause analysis of the fall and there was no documented the facility made a reasonable effort to identify hazards and risks in the environment or implement a specific intervention to prevent further accidents. (Refer to F-604, F-656, and F-657 ) The findings include: Review of the facility's Fall Program Policy, undated, revealed the facility would identify residents at risk for falls. Further review, revealed after each fall, the environment would be assessed for causative factors. Review of the facility's Accidents/Incidents Policy, dated 08/01/13, revealed the facility would provide a safe and healthful environment. Additionally, the nurse should conduct an immediate investigation of all accidents including data such as the circumstance surrounding the accident; names of any witnesses and their account of the accident; and corrective action taken and other pertinent data as necessary or required. Continued review revealed an Accident/Incident Report would be completed and submitted to the Director of Nursing, the Administrator, and the Medical director. Review of Resident #88's medical record revealed the facility admitted the resident on 09/01/10, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP), initiated 09/04/12 and revised 01/10/19, revealed the resident had the potential for trauma related to potential for falls; history of falls; high risk for falls; restraint use; and rejection of care. The goals included: the resident would not have any injury to self related to restraint use; the the resident would not sustain serious injury related to rejection of care behaviors; and staff would implement strategies to increase safety and decrease falls. The interventions included: check recliner when reclined every thirty (30) minutes and release every two (2) hours for ten (10) minutes to help restore circulation; release restraint by putting footrest down; may be up in recliner, in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with Chronic Severe Pain-restraint; encourage resident to use reaching device; anticipate and meet the resident's needs; call light within reach and encourage use for assistance; and recliner must be unplugged at all times. Continued review of the CCP revealed there were several potential complications related to use of restraint; however, the CCP did not specify the potential complications. Additional review of the CCP, initiated 09/04/12 and revised 01/10/19, revealed the resident was always incontinent of bowel and frequently incontinent of bladder and required assistance with toileting related to a history of acute [MEDICAL CONDITION], overactive bladder, and vaginal bleeding and dryness. The goal stated bowel and bladder incontinence would be managed through nursing intervention. The interventions included: check and change every one (1) hour and as needed; extensive assist of two (2) staff for toileting; may wear adult briefs as needed; and per family request, do not leave in bathroom alone. Review of Resident #88's Fall Risk Assessment, dated 01/23/19, revealed the resident scored nine (9). According to the scale, if the total score was ten (10) or greater, the resident should be considered HIGH RISK for potential falls. Review of Resident #88's Physical Restraint Elimination Assessments, dated 06/11/18, 09/01/18, 11/01/18, and 01/23/19, revealed the resident scored above twenty-one (21), indicating he/she was a good candidate for restraint reduction or elimination program, based on physical functioning and behavioral/social functioning assessment. However, the facility documented Resident #88 was not a candidate for a restraint reduction or elimination program due to the recliner in reclined position helped for comfort secondary to [MEDICAL CONDITION] Disc disease with chronic severe pain and reduction of falls. Continued review revealed recommendations to continue use of the recliner; and recliner to remain unplugged at all times. Review of Resident #88's Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) revealing moderate cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, and locomotion on and off the unit, toileting, and personal hygiene. Additional review revealed the facility assessed the resident as not steady during transition from sitting to standing or on and off the toilet; only able to stabilize with staff assistance; and as ambulation did not occur. The facility further assessed the resident as continent of bowel and frequently incontinent of bladder. Further review revealed the facility assessed the resident as having functional limitations in Range of Motion (ROM) for one (1) side upper extremities and as using a wheelchair for mobility. The facility further assessed the resident as having no falls since the previous assessment; as receiving daily diuretic medication in the last seven (7) days; as receiving no therapy or restorative nursing; and as using a chair that prevented rising daily, which restricted freedom of movement and was a restraint. Review of Resident #88's State Registered Nursing Assistant (SRNA) Task: Restraint, dated 02/01/19 to 02/11/19, revealed it was signed every shift, to indicate the resident's restraint was checked every thirty (30) minutes and released/repositioned every two (2) hours. Review of the Monthly (MONTH) 2019 Physician's Orders, revealed orders initiated 12/28/17, stating the resident may be up in the recliner in reclined position as needed for position and comfort secondary to [MEDICAL CONDITION] Disc Disease with chronic pain; however, the Physician's Orders did not include orders to unplug the recliner chair. Review of the Progress Note, dated 02/11/19 at 8:00 PM, completed by Licensed Practical Nurse (LPN) #8, revealed Resident #88 was sitting in his/her recliner chair with Oxygen on at two (2) liters per nasal cannula and was later on the floor on his/her right side. Continued review revealed the resident was assessed to have a laceration above the right eye and a bruise to the right shoulder. Further, the resident had good range of motion in all extremities and the Physician and resident representative was called. Per the Note, the resident was transferred to the hospital for evaluation and treatment related to a laceration above the right eyebrow. Review of the Progress Note, dated 02/11/19 at 10:00 PM, completed by LPN #8, revealed the resident's chair was unplugged and reclined at thirty (30) degrees, and the resident hit his/her head on the bedside table prior to the fall. Continued review revealed the resident returned to the facility with fourteen (14) sutures to the right side of the head and bruising to the right shoulder. Further review of the Note, revealed a CAT Scan (computerized tomography scan uses computer processed combinations of many x-ray measurements taken from different angles to produce cross sectional images of specific areas of a scanned object) of the head, neck and right hip were negative. Review of the Hospital Discharge Summary, dated 02/11/19, revealed Resident #88 was discharged with a [DIAGNOSES REDACTED]. Per the Summary, tests and procedures provided to the resident included a CT on the brain without contrast, CT of the Cervical Spine without contrast, Xray of right hip and pelvis, laceration suturing, and continuous pulse oximetry monitoring. Interview with the Director of Nursing (DON on 02/21/19 at 11:00 AM, revealed the facility did not keep Kardexes (document utilized by the SRNAs as a guide to provide care), as they were not a part of the medical record. Therefore, they were unable to submit the Kardex which was in affect on 02/11/19, the day Resident #88 sustained the fall. Interview on 02/21/18 at 5:45 PM, with SRNA #11, revealed she was assigned to Resident #88 on 02/11/19, at the time the resident sustained [REDACTED].#88's Nursing Assistant Kardex before providing care, and per the Kardex, the resident required two (2) staff for transfers and toileting every two (2) hours. She stated she was aware the resident was to be assisted to the bathroom for toileting; however, she stated she was unaware the resident was to be toileted and/or checked and changed every hour as per the CCP. SRNA #11 stated she had put the recliner foot rest down during meal services at dinner around 6:00 PM on the evening of 02/11/19. Further interview with SRNA #11, revealed the evening of 02/11/19, she recalled Resident #88 was lying back in the recliner twenty (20) minutes prior to the fall when the resident requested to be toileted. Per interview, she informed the resident she would assist him/her to the toilet after assisting another resident to bed. She stated when she returned to Resident #88's room to assist the resident to the toilet, after assisting two (2) other residents to bed, she found the resident on the floor in front of the recliner lying on his/her right side. SRNA #11 stated the resident had been last toileted at 5:07 PM, revealing it had been two (2) hours and fifty-three (53) minutes since the resident was last toileted, prior to the resident sustaining the fall at 8:00 PM. Additional interview with SRNA #11, revealed the recliner was an electric model, and had to be plugged in to lower or recline the leg rest and prior to the fall the resident had been reclined in the chair with the chair unplugged. Per interview, when the chair was reclined with the leg rest up and unplugged, it prevented the resident from sitting up or putting the leg rest down and this was a restraint for the resident. SRNA #11 stated the resident was required to sit in his/her recliner with the leg rest elevated and the chair turned off when in his/her room alone due to being a fall risk. Per interview, Resident #88 must have leaned forward to pick something up that was out of reach and fell out of the chair on the evening of 02/11/19. SRNA #11 further stated she had observed the resident in the past to lean over the chair or lean down and try to pick things up while sitting reclined in his/her chair with the leg rest elevated, almost falling out of the chair. SRNA #11 stated she was not interviewed, nor did she write a statement related to the fall event. Interview with Licensed Practical Nurse (LPN) #8, on 02/21/19 at 5:25 PM, via telephone, revealed he was assigned to Resident #88 on 02/11/19, when on that date, a SRNA alerted him to come quickly to Resident #88's room because the resident sustained [REDACTED].#88's room, assessed the resident, and then called 911. Further interview revealed the resident's family brought in the recliner chair, which he considered to be a danger to the resident, but the facility had been unsuccessful in getting the family to take the chair home. LPN #8 confirmed the recliner chair was a restraint for the resident when it was reclined and unplugged and he had seen the resident attempt to climb out of the chair in the past. Per interview, he did not know when the resident was toileted last prior to the fall on 02/11/19. LPN #8 further stated he had completed the Incident Report after Resident #88's fall event. Additional interview revealed he would not offer further information, and did not want to talk without legal representation. Review of Resident #88's Resident Incident Report/Accident Follow up Assessment, dated 02/11/19, completed by LPN #8, revealed the fall occurred on Monday, 02/11/19 at 8:00 PM, and the resident did not recall what precipitated the fall. Per the Report, the fall occurred in the resident's room and prior to the fall, the resident was sitting in the recliner chair. Further review of the Report, revealed the resident was last toileted at 7:00 PM and the call bell was in reach prior to the fall. Additional review of the Report, revealed the causative factor was listed as: the resident fell on the floor and hit his/her head on the bedside table. Per the Report, staff caring for the resident at the time of the fall were LPN #8 and SRNA #11. According to the Report, recommendations/actions taken included: sending the resident to the hospital for further evaluation and treatment; new orders for treatment to sutures; and removal of sutures in fourteen (14) days. However, there was no documented evidence the Director of Nursing, the Administrator, or the Medical director signed or reviewed the Incident Report, as per Policy. In addition, there was no documented evidence of a thorough investigation related to Resident #88's fall. There was no documented evidence interviews or statements were obtained from staff involved or assigned to Resident #88 at the time of the fall on 02/11/19. The State Surveyor's interview with SRNA #11 on 02/21/18 at 5:45 PM, revealed the resident was last toileted at 5:07 PM on 02/11/19, prior to the fall, which differed from the Incident Report. In addition, there was no documented evidence of a Root Cause Analysis for the fall. There was also no documented evidence of the circumstances surrounding the accident and other pertinent data as necessary or required such as causative environmental factors, [MEDICATION NAME] (natural) or extrinsic (devices) causative factors for the fall. Furthermore, there was no documented evidence a targeted intervention was identified to reduce or prevent further fall events of the same nature. Further review of the CCP, revealed there was no documented evidence the CCP was revised, after the fall event on 02/11/19, to include an intervention to prevent further occurrence of an injury of the same nature. (Refer to F-657) Review of the CCP, provided to the State Surveyor post exit via email on 02/26/19, revealed hand written, at the top, of the CCP, was Resident #88's name and the date, 02/11/19. Continued review revealed the CCP stated Actual Fall. Per the CCP, therapy was to continue as ordered. (However, per Medical Record review the resident last received Therapy in (YEAR) and last received Restorative Nursing in (MONTH) of (YEAR)). Interventions on the CCP included: check range of motion; continue interventions on the at risk plan; monitor/document/report as needed for seventy-two (72) hours to physician for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture or agitation; neuro checks for seventy-two (72) hours; and continue current orders. Further, the CCP did not include a targeted intervention to prevent further occurrence of an injury of the same nature, after the fall event on 02/11/19. Observation on 02/19/19 at 12:20 PM, revealed Resident #88, was in his/her room sitting in a recliner, which was positioned between the right side of the bed and the wall. The bedside table was in front of the resident positioned over the recliner and the resident's legs and the his/her feet were under the bedside table, on the floor. The recliner chair was unplugged. Oxygen was in use per nasal cannula. Further observation revealed there were staples to the right temporal side of the resident's forehead, and fading yellow and green discoloration to the right side of his/her face around his/her check bone, eye, brow and forehead. Interview with the resident at the time of observation, revealed he/she fell and bumped his/her head on the concrete. Resident #88 was unable to elaborate further related to the fall. Observation of Resident #88, on 02/20/19 at 8:39 AM, revealed the resident was reclined in the recliner chair in his/her room and the recliner was unplugged. The resident had his/her eyes closed, and he/she was wearing pajamas, socks and shoes. Oxygen was in use per nasal cannula. Further, the bedside table was sitting parallel to the recliner on the left side. Review of the Nursing Assistant Kardex, dated 02/21/19, revealed Resident #88 may be up in recliner in reclined position as needed for comfort/restraint; check and release restraint per facility policy: check recliner when reclined every thirty (30) minutes and release every two (2) hours for ten (10) minutes to help restore circulation; release restraint by putting the footrest down; and recliner must be unplugged at all times. Additional review revealed the resident needed encouragement to use a reaching device; and call light should be in reach and staff should respond to the call light promptly. Continued review revealed the resident required extensive assistance of two (2) with transfers and toileting; use gait belt at all times; no ambulation; and required check and change (toileting) every hour and as needed. Observation of Resident #88, on 02/21/19 at at 9:58 AM and 10:50 AM, revealed the resident was in his/her room in the recliner with oxygen in use per nasal cannula. The resident was in the reclined position and the bedside table was in front of the resident positioned over the recliner and the resident's legs. The Resident was leaning forward and to the left and the chair was unplugged. Interview with the resident at the time of observation, revealed he/she was having a good morning; and just sitting here. On 02/21/19 at 11:00 AM, the State Surveyor alerted the Director of Nursing (DON) to the position of Resident #88's bedside table which was still positioned over the resident's recliner in front of the resident. Interview with the DON, on 02/21/19 at 11:00 AM, revealed she assessed the bedside table positioning in Resident #88's room and determined the placement was necessary. Per interview, the bedside table was positioned under the recliners leg rest and in front of the resident because the resident could not reach his/her water otherwise. The DON was questioned if the bedside table was a restraint for the resident, and she replied that it was not because the resident was unable to get up anyway with the chair reclined. Interview with SRNA #10, on 02/21/19 at 5:04 PM, revealed she had worked at the facility for three (3) years and was assigned to Resident #88. Per interview, she used the Kardex as a guide for providing care to each resident. She further stated if the resident was not eating, or if the resident was in the recliner chair in his/her room alone, the leg rest was to be elevated and the chair was to be unplugged. SRNA #10 stated the resident spent most of his/her day in the recliner in his/her room with the bedside table in front of the chair and over the resident's legs so he/she could reach the water pitcher. Continued interview revealed the resident was confused quite often and would try to walk, or try to get up from the bed or climb out of the recliner chair. However, she stated the resident was not independent and required two (2) staff for transfers. Further interview revealed the recliner kept the resident from falling because the resident could not put the elevated foot rest down independently; however, she further stated there were risks associated with the resident being reclined in the chair, such as entrapment. Interview with LPN #2, on 02/21/19 at 5:26 PM, revealed she was assigned to Resident #88 and had worked at the facility for four (4) and a half years. Per interview, she used the CCP and Physician's Orders as a guide for the necessary care each resident required. Additional interview revealed when a resident had a fall event, the nurse was to perform a head to toe assessment looking for obvious injuries, discoloration, abrasions, swelling, etc. Per interview, this assessment was to be documented on an Incident Report and in a Progress Note. She stated the information documented on the Incident Report and should include notification to the doctor and family; observations of the environment, time of fall, place (by bed, in front of chair); who found the resident; who reported the fall and their statement; and any devices or furniture that were a causative factor at the scene (bedside table, dresser, wheelchair). LPN #2 stated, at the time of the fall event, nursing staff should try to determine the root cause of the fall event by asking the resident and staff what happened and by assessing the environment for the causative factor. She stated staff who had contact with the resident prior to the fall should write out a statement of events. Additional interview revealed this information prompted the nurse to come up with another intervention to prevent recurrence. Continued interview with LPN #2, revealed the interventions in place to prevent falls for Resident #88 included: elevating the footrest on the recliner chair and unplugging the recliner so the resident could not put the foot rest down; ensuring the call light was in reach; frequent checks every hour and repositioning the resident by putting the recliner foot rest down every two (2) hours. Per interview, the resident was to be checked and changed, and toileted every hour according to the CCP. LPN #2 stated these interventions were documented as completed by the SRNAs in the kiosk and she did walking rounds to ensure the SRNAs were providing care as per the CCP. Per interview, Resident #88's family wanted the chair unplugged so the resident did not attempt to use the remote to get up independently and the recliner chair was a restraint for the resident. LPN #2 stated the resident had attempted in the past to get up from the recliner chair independently while the chair was reclined and unplugged, even before the fall on 02/11/19 and this put the resident at risk for injury. Interview with the Director of Nursing (DON), on 02/21/19 at 5:51 PM, revealed she had worked at the facility for five (5) years and was in the role as DON for the past year. Per interview, she expected the facility's policy and protocols, regulations and standards of practice to be maintained related to accidents/injuries and falls. She stated she also expected staff to provide necessary supervision and a safe environment to all residents. Additionally, she stated she expected the root cause of each fall event to be identified timely. Per the DON, the post fall paper work aided the nursing staff in determining what factors caused a fall and what interventions should be implemented to prevent further occurrences based on the causative factors. Continued interview revealed staff statements and the resident's account of the events leading up to the fall event also helped determine the root cause and appropriate intervention. However, further interview with the DON, revealed Resident #88's Incident/Accident Report related to the fall event on 02/11/19 did not identify causative factor(s) of the fall or a targeted intervention to prevent further falls of the same nature, and there was no documented evidence of interviews with staff assigned at the time of the fall or statements from staff involved. Continued interview with the DON, revealed the facility had a daily morning meetings, which included, but was not limited to the Administrator, MDS Nurse, and Assistant Director of Nursing. Per interview, Incidents/Accidents and falls were reviewed and discussed in the morning meeting from the Incident Reports in an attempt to find the cause of the fall event. She stated Resident #88's fall event which occurred on 02/11/19 would have been discussed in the morning meeting; however, she did not recall the details of the discussion. Continued interview with the DON, revealed Resident #88's recliner with elevated footrest was utilized due to the resident's family's request in order to help with lower extremity [MEDICAL CONDITION]. Additionally, she stated the rationale for unplugging the recliner was related to the resident's confusion; as the resident was unable to safety operate the electric recliners controls to elevate the footrest and recline the chair. The DON stated when the recliner's footrest was elevated and the chair was unplugged, this restricted the resident from sitting up and putting his/her feet down and this was a restraint for the resident. Additional interview with the DON, revealed the SRNA assigned to Resident #88 should have ensured the resident was released from the recliner restraint for toileting every hour on 02/11/19 as per the CCP, in an attempt to prevent accidents such as the fall event that occurred on that date. However, there was no documented evidence the facility had interviewed SRNA #11 after the fall event, to ensure interventions were implemented to prevent falls. Interview with Administrator, on 02/21/19 at 6:26 PM revealed she expected the facility's policy and regulation to be followed related to falls and accidents and injuries. Additionally, she expected a thorough assessment of each fall event with a good attempt to identify the root cause of the fall and determine an appropriate intervention to prevent further accidents/injuries or falls in order to maintain safety. However, per interview, this process was not followed for Resident #88's fall event on 02/11/19. Further interview revealed she did not want Resident #88's recliner as it was a restraint for the resident, but the resident's family insisted the resident use it to reduce [MEDICAL CONDITION] in his/her legs. Additional interview revealed Resident #88 should have been toileted every hour while in this restraint, prior to the fall event on 02/11/19, as per the CCP, in an attempt to prevent accidents such as falls.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals for six (6) of six (6) medication carts. Observation of the medication carts on Unit 1 and Unit 2 on 02/12/19, revealed loose unpackaged pills in the cart drawers; bottles of eye drops [MEDICATION NAME], Artificial Tears, and [MEDICATION NAME] eye drops which had been opened and were not marked with the open date or discard date, and were not labeled with resident identification; a tube of Fluconazole cream which had been opened and was not marked with the open date or discard date; a box of [MEDICATION NAME] which was not labeled with resident identification; and a box of Sucrets cough drops which was not labeled with resident identification. Findings include: Review of facility Policy titled, Medication Storage in the Facility, undated, revealed medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Additional review revealed medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified. Observation on 02/12/19, starting at 3:15 PM, of the medication carts in the facility revealed the following: Medication Cart #1, on Unit 1 (south), contained a box of [MEDICATION NAME] medication which was unlabeled with resident identification and a loose, unpackaged, unlabeled pink pill. Medication Cart #2, on Unit #1, contained a loose, white tablet which was unpackaged; and a loose, green tablet that was unpackaged in the medication drawer. Medication Cart #3, on Unit #1, contained a loose, white tablet which was unpackaged; and three (3) different bottles of eye drops [MEDICATION NAME], Artificial Tears, and [MEDICATION NAME] eye drops which had been opened, with no open date or discard date, and were not labeled with resident identification. Medication Cart #4, on Unit 2 (North), contained one (1) box of Sucrets cough drops, which was not labeled with resident identification. Medication Cart #5, on Unit 2 (North), contained one (1) box of [MEDICATION NAME] eye drops which was not labeled with resident identification. Medication Cart #6, on Unit 2 (North), contained a tube of Fluconazole cream which had been opened, and was not marked with the open date. There was also no discard date on the tube. Interview with Kentucky Medication Aide (KMA) #5, on 02/20/19 at 3:20 PM, revealed all medications should be labeled with the resident's name and when multidose medications were opened, they should be marked with the open date and the discard date. Continued interview revealed loose pills which were not packaged should be discarded because the medications were unlabeled and not safe to administer. She further stated unlabeled medications should never be administered to residents and should not be on the medication carts. She stated families would sometimes buy medications from the store shelf and bring those in for the residents and staff was to make sure a house stock label was placed on the container prior to placing the medication in the medication. Per interview, pharmacy checked the medication carts monthly and staff should be checking them daily. Interview with KMA #10 on 2/20/19 at 3:50 PM, revealed any medication without proper labeling should be discarded. Interview with Licensed Practical Nurse (LPN) #1, on 02/21/19 02:37 PM, revealed she worked both North and South units. Per interview, pharmacy came in once a month and checked the medication rooms and medication carts. Further interview revealed all medications should be labeled with the name of the medication, resident identification, and directions for administration of the medication. Additional interview revealed any multidose medication such as eye drops and medicated cream should be marked with the open date. Further interview revealed loose pills should not be in the medication drawers. Interview with the Director of Nursing (DON), on 02/21/19 at 02:56 PM, revealed she expected staff to monitor the medication carts and also expected medications to be stored according to facility policy. She stated all medications should be labeled, and if they were multidose medications, they should be marked with the open date in order for staff to know when to discard the medication. Further interview revealed the pharmacy checked the medication carts once a month the last score was ninety-six (96%). She stated she was mortified when she found out that all six (6) of the medication carts had issues with open dates and labeling. Continued interview revealed the facility did allow families to bring in medications for residents on an individualized basis, and she expected staff to check the resident's orders, compare, and make sure a house stock label was placed on the container prior to placing the medication in the medication cart. Additional interview revealed it was her expectation if found a loose pill in the cart, it would be identified by the person and pharmacy notified to order a replacement medication so the resident would not run out of the medication. Continued interview revealed it was deficient practice to have loose pills; opened eye drops without an open date and not labeled with resident identification; opened medicated cream without an open date; and [MEDICATION NAME] and Sucrets which were not unlabeled with resident identification. We should have followed our policy and we did not. Interview with the Administrator, on 02/21/19 3:44 PM, revealed pharmacy came in once a month and audited the medication carts and the medication refrigerators. She revealed it was her expectation staff follow facility policy and ensure all medications were stored properly.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the walk in freezer on 02/21/19 at 11:16 AM, revealed food products which were not labeled, dated or sealed. The findings include: Review of the facility Frozen Storage Policy, undated, revealed All frozen food will be properly wrapped, dated and labeled. Observation on 02/19/19 at 11:16 AM, in the kitchen walk in freezer, revealed one (1) dozen corn dogs on a stick in a plastic bag with no label and no date. The sticks were protruding out of the bag, and therefore the bag was not sealed. Further observation revealed two (2) packages of bologna, one (1) dated 12/25/18, and one (1) with no label or date. Continued observation revealed churros in a bag which were not labeled or dated, and four (4) pans of rolls with no labels and no dates. Interview with the Dietary Manager (DM), on 02/19/19 at 11:32 AM, revealed everything in the freezer should be labeled and dated. The Dietary Manager further stated once a week dietary staff would check the freezer to ensure all food items were labeled. Further interview with the DM, revealed the stock staff were responsible to check the freezer each Tuesday, to ensure all food items were labeled. Interview with the stock staff, during the interview with the DM, revealed she was responsible to check dates of the foods in the freezer. Interview on 02/21/19 at 07:18 PM, with the Administrator, revealed per facility policy, food items in the freezer were to be labeled, sealed, and dated when opened. Further interview revealed it was her expectation dietary staff follow the facility's policies and procedures. Continued interview revealed food items would not be safe to serve if they were not labeled, sealed, or dated after they were opened.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for three (3) of twenty-eight (28) sampled residents (Resident #51, #72, and #73). Observation on 02/19/19, revealed Resident #51 requested to be toileted, cleaned up, and dressed. State Registered Nurse Aide (SRNA) #1 responded by telling the resident that he/she would have to wait until after lunch to be toileted and to get washed up and dressed because staff was not permitted to provide care during meal service. Observation on 02/21/19, revealed two (2) Nursing Assistants (NA) walked in Resident # 72's room, unannounced and without knocking. As the NAs were exiting the resident's room, NA #1 shouted into the hallway, {He/she} ain't gonna eat! to other direct care staff who were delivering meal trays. Observation on 02/21/19, revealed staff failed to protect Resident #73's privacy/dignity by leaving the resident's bedroom door ajar, the bed curtain fully open and the window blinds up at maximum level during wound care. The findings include: Review of the facility Resident Rights Policy, dated 08/01/13, revealed employees shall treat residents with kindness, respect and dignity. Further review revealed, our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Review of Resident #51's medical record revealed the facility admitted the resident on 06/22/17, with [DIAGNOSES REDACTED]. Review of Resident # 51's Comprehensive Care Plan, initiated 02/27/17, revealed a problem of Activities of Daily (ADL) Living deficit related [MEDICAL CONDITION] right sided [MEDICAL CONDITION]. The goal stated the resident would receive adequate assistance with ADLs with staff encouragement to perform as much self-care as possible. The interventions included: extensive assist of two (2) staff with grooming, dressing, bathing, and transferring. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/27/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring two (2) staff to assist with toileting, bathing and transfers. Per the MDS Assessment, ambulation did not occur. Observation on 02/19/19 11:39 AM, revealed Resident #51 was sitting in the wheelchair in his/her gown, asking State Registered Nursing Assistant (SRNA) #1 to assist him/her as he/she needed to be toileted, and get dressed and cleaned up. SRNA #1 responded by telling the resident that he/she would have to wait until after lunch to be toileted and washed up and dressed because staff was not permitted to provide care when lunch trays were on the floor. Interview on 02/19/19 at 11:45 AM with Resident #51, revealed he/she had to wait every morning to get dressed and cleaned up. The resident stated staff would assist him/her up to the wheelchair around 7:30 AM every morning and then he/she had to wait until 11:30 AM or later to be assisted to the toilet, and then get cleaned up and dressed. Further interview revealed it was upsetting to him/her that he/she had to be in his/her gown until after lunch today, like on most days. Interview on 02/21/19 at 10:53 AM, with SRNA #1, revealed she had worked at the facility for about a month on the South Unit and she was assigned to resident on 2/19/19 on the day shift. Per interview, she recalled the conversation with Resident #51 on 02/19/19, regarding him/her needing care during lunch. She stated Resident #51 was care planned as requiring the assist of two (2) staff for care and she was trained staff were not to assist residents with a bed side bath or toileting during meal times. She further verified Resident #51 had asked to go to the bathroom and had asked to be cleaned up on 02/19/19, which for this resident would have involved washing the resident while he/she was on the toilet per his/her preference as that was not the resident's shower day. Further interview revealed most of the time Resident #51 was up and dressed before lunch. SRNA #1 further stated she felt like there was enough staff to provide resident care. Interview on 02/21/19 at 11:00 AM, with SRNA #2, revealed she had been employed at the facility since 2010. She further stated she was the trainer for SRNA #1 on 02/19/19. Per interview, Resident #51 did not like to get up very early in the mornings, but it would be inappropriate for a resident to still be in their gown at lunch time. She further stated staff did not provide full baths and showers during lunch time, because there were several residents on the floor that needed assistance with feeding. However, she stated staff should have at least assisted Resident #51 with toileting, getting washed off and dressed upon the resident's request on 02/19/19. Further interview revealed it was a dignity issue to not assist the resident at the time they were requesting assistance. Additional interview revealed there was enough staff to ensure necessary care was provided. Interview on 02/21/19 at 11:08 AM, with the Assistant Director of Nursing (ADON), revealed when a resident requested to get cleaned up, dressed, and toileted during lunchtime, staff should comply with that request. The ADON stated it was not appropriate for a resident to have to wait until the lunch meal was over in order to receive the care requested. Interview on 02/21/19 at 2:56 PM, with the Director of Nursing (DON), revealed she expected residents to receive care at the time of the request. She stated Resident #51 should have been promptly toileted upon request and then assisted with getting cleaned up and dressed per his/her request on 02/19/19. She further stated it was not ok for staff to neglect to assist the resident as requested, especially for a request for toileting and a request to get out of his/her bed clothes. Further interview revealed from 7:30 AM to 11:30 AM, was too long for Resident #51 to have to wait for care to be provided in the mornings. The DON stated she was not made aware that the resident was upset about his/her care needs not being met. Interview on 02/21/19 at 3:44 PM, with the Administrator, revealed it was not acceptable for a resident to have to wait to be toileted regardless of the meal times. She further stated when a resident was not toileted, this could lead to falls with them attempting to toilet themselves. The Administrator stated It is not okay with me, that Resident #51 did not receive care as requested. 2. Review of Resident #72's medical record revealed the facility readmitted the resident on 08/07/18 with [DIAGNOSES REDACTED]. Review of Resident #72's Quarterly Minimum Data Set (MDS) Assessment, dated 01/17/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Observation on 02/21/19 at 09:14 AM, revealed Nursing Assistant (NA) #1 entered Resident #72's room, without knocking and unannounced. Further observation revealed NA #1 exited the resident's room and yelled out, from the doorway, to other NAs and SRNAs, {He/she} ain't gonna eat!, loudly into the hallway where other direct care staff were observed delivering lunch trays to residents. Continued observation revealed NA #1 and NA #2 entered Resident #72's room, again without knocking and offered the resident's roommate a meal tray. Additional observation revealed NA #1 and NA #2 conversed with one another about personal topics as they assisted Resident #72 with meal tray set up and continued as they exited the resident's room. Additional observation revealed NA #1 and NA #2 continued with personal conversation as they entered the hallway where several other residents were present. Interview on 02/21/19 at 10:40 AM, with NA #1, revealed she had been employed with the facility for one (1) month and worked the South Side Unit where Resident #72 resided. Further interview revealed, although she was not yet state certified, she was aware she should always knock on a resident's door to request permission to enter the room prior to entering to maintain the resident's privacy and dignity because the facility was the resident's home. Continued interview revealed staff should only speak to the resident and not about personal business while delivering direct care. NA #1 stated, It's a dignity issue to talk about our personal issues while caring for our residents. Additional interview revealed staff should never yell out into the hallway about what a resident does or does not want because this is a privacy/confidentiality and dignity issue. Additional interview with NA #1, revealed she should not have yelled out into the hallway about the resident not eating lunch because this was a privacy/confidentiality issue and she should have maintained the resident's privacy. NA #1 stated, I wasn't thinking about it at the time because I was so focused on the task. Interview on 02/21/19 at 10:55 AM, with NA #2, revealed she had been employed with the facility for four (4) months and worked the South Side Unit on day shift from 06:00 AM-2:00 PM. Further interview revealed, although she was not yet state certified, she was aware she should always knock on a resident's door to request permission to enter, as this was a privacy/dignity issue. Further interview revealed she should speak to the resident and not speak to other staff about personal issues while delivering care. Interview on 02/21/19 at 11:55 AM, with SRNA #2, who was the facility's Nursing Assistant Mentor, revealed she was assigned to mentor four (4) Nursing Assistants on South Side Unit for the day, including NA #1 and NA #2. Further interview revealed she was also assigned to provide care to Resident #72. Continued interview revealed NA #1 and NA #2 should have knocked on Resident #72's door and requested permission to enter or announced their presence prior to entering the resident's room, advising this was a privacy/dignity concern. Additional interview revealed NA #1 and NA #2 should have discussed personal topics on their own time, and talked to the residents when delivering direct care. Per interview, NA #1 shouldn't have yelled down the hallway to other staff members about Resident #72 not eating, and should have discussed resident information in private with other staff members. Interview on 02/21/19 at 11:14 AM, with Licensed Practical Nurse (LPN #5)/Staff Development Coordinator/ Nursing Assistant Teacher/ revealed staff were aware they should always knock on residents' doors to request permission to enter. Further interview revealed she expected staff to speak only to the resident, and not about the resident while delivering direct care as this was a dignity issue. Continued interview revealed she would expect staff to maintain resident privacy and confidentiality by discussing a resident's likes/dislikes, needs, etc. in a private area; not by yelling the information into the hallway. Additional interview revealed staff had been educated on Resident Rights and she was disappointed that the Surveyor made observations of staff violating those rights. 3. Review of Resident #73's medical record revealed the facility admitted the resident on 01/21/10 with [DIAGNOSES REDACTED]. Review of Resident #73's Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/18, revealed the facility assessed the resident as having a BIMS score of zero (0) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #73's physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Observation of wound care on 02/21/19 at 9:48 AM, revealed LPN #4, LPN #3 and SRNA #2 entered Resident #73's room after knocking, washed their hands and applied gloves prior to assisting Resident #73 from the wheelchair to the bed to prepare for a dressing change. LPN #4 explained the dressing change procedure to the resident as the other staff positioned the resident for the dressing change. LPN #4 removed her soiled gloves after preparing supplies, washed hands and applied clean gloves. Continued observation revealed the resident's bedroom door remained ajar, the bed curtain remained fully open and the window blinds were up at maximum level. Additional observation revealed LPN #3 assisted Resident #73 to hold the resident's left lower extremity at an approximate forty-five (45) degree angle as LPN #4 cleansed the outer aspect of the left foot with wound cleanser. Observation of wound care revealed LPN #4 removed soiled gloves, washed hands and applied clean gloves, returning to the resident. LPN #4 applied Xeroform to the foot wound and covered the area with a non-adherent dressing and [MEDICATION NAME]. LPN #4 then removed her soiled gloves, washed her hands and donned clean gloves. Further observation revealed LPN #4 cleansed the area to Resident #73's right lower lateral leg with normal saline, applied [MEDICATION NAME] and covered and secured the area with kerlix. Additional observation revealed SRNA #2, LPN #3 and LPN #4 removed their soiled gloves, washed hands and donned clean gloves, prior to repositioning the resident and washed hands again prior to exiting resident's room. The resident's curtain blinds, bedroom door and privacy curtain remained open during the entire procedure. Interview on 02/21/19 at 11:55 AM, with SRNA #2, who was the facility's Nursing Assistant Mentor, revealed she should have ensured Resident #73's privacy curtain, window blinds and door were fully closed prior to assisting LPN #4 with wound care. Further interview with SRNA #2, revealed it was a privacy/dignity issue to keep resident's blinds, curtains or doors open while staff was providing care, and violated the resident's rights. Interview on 02/21/19 at 11:57 AM, with LPN #3, revealed she had been employed with the facility for over thirty-five (35) years and worked full-time on day shift on the South Side Unit. LPN #3 revealed she was assigned to provide care to Resident # 73 and was familiar with the resident's care needs. Further interview revealed she should have ensured Resident #73's door, privacy curtain and window blinds were closed to maintain the resident's privacy and dignity. Continued interview revealed she believed since the resident's room, sits up from the parking lot a bit, no one would be able to see inside the bedroom window, but stated it was a privacy concern if the window blinds were left open. Additional interview revealed she would ensure the resident's rights were protected in the future and close the door, blinds and privacy curtain prior to providing direct care. Interview on 02/21/19 at 11:59 AM, with LPN #4, revealed she had been employed with the facility for sixteen (16) years and worked full time on day shift on the South Side Unit. Further interview revealed she was assigned to provide care to Resident #73 and was familiar with the resident's care needs. Continued interview revealed she should have maintained the resident's privacy/dignity by closing the bedroom door and window blinds and pulling the resident's privacy curtain prior to performing wound care. Interview on 02/21/19 at 01:11 PM, with LPN #5/Staff Development Coordinator/ Nursing Assistant Teacher, revealed she expected staff to close the resident's doors, privacy curtains and blinds prior to performing any type of direct care for a resident as this was a privacy/dignity concern. Further interview revealed she expected staff to maintain resident privacy/dignity and provide the residents with a dignified existence at all times. Interview on 02/21/19 at 1:20 PM, with the DON, revealed she expected staff to maintain resident privacy, dignity and confidentiality to ensure residents' rights were never violated. Continued interview revealed she would expect staff to knock on the residents' door to announce their presence and/or request permission to enter prior to doing so to respect the resident's privacy and dignity. Additional interview revealed the DON expected staff to talk to the resident during personal care and not discuss staff's personal business. The DON revealed she expected staff to discuss resident concerns in private to protect resident confidentiality and stated it would never be acceptable to yell out resident information in the hallway. The DON revealed she would also expect staff to maintain resident privacy/dignity during direct care by closing the resident's door, privacy curtain and window blinds. Interview on 02/21/19 at 4:50 PM, with the Administrator, revealed she expected staff to maintain resident privacy, confidentiality and dignity at all times, without exception. Further interview revealed she expected staff to maintain resident dignity/privacy by knocking on all residents' doors and announcing their presence and requesting permission to enter. Continued interview revealed she expected staff to talk to the residents and not to talk to other staff about their personal issues while providing care. Additional interview revealed she expected staff to discuss resident information in a private location, never in the hallway and never by yelling out information for potential non-care providers to overhear which would be a confidentiality concern. The Administrator further stated, staff should maintain privacy by closing the residents' door and privacy curtain and shutting the window blinds prior to providing care.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the Comprehensive Care Plan was reviewed and revised to implement interventions to provide appropriate supervision of residents and protect residents from abuse for two (2) of eight (8) sampled residents (Residents #1 and #2). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate times that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of his/her pants and the other time in the groin area up the pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Interview and record review revealed the facility failed to revise Resident #2's and Resident #1's care plans to provide adequate supervision and protection to prevent further incidents. (Refer to F-223) The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was reviewed and revised to implement interventions to provide adequate supervision and protection to prevent further incidents was likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 08/29/14 and was determined to exist on 07/26/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14 prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.20, Resident Assessment, F-280 Care Plan Revision, with a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive" dated 08/01/13, revealed care plans were developed based on a thorough assessment which included the the Minimum Data Set (MDS) Assessment. Continued review revealed care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes. Policy review revealed however, assessments of residents were ongoing and care plans were revised regarding the resident and the resident's condition changed. The Policy revealed the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when the desired outcome was not met. Interview with staff revealed Resident #2 was seeking out Resident #1 and/or displaying inappropriate sexual behavior towards Resident #1 on 07/26/14, 07/28/14, 07/30/14, 08/04/14, and 08/09/14. 1. Record review revealed the facility admitted Resident #2 to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Review of Resident #2's Comprehensive Care Plan, revealed the resident was care planned for social interaction impaired related to inappropriate behavior which was undated. Review revealed on 07/26/14 this care plan was updated with redirecting Resident #2 from room [ROOM NUMBER] (where Resident #1 resided), and an intervention was implemented for every fifteen (15) minute checks. Continued review of the care plan revealed it was updated on: 07/30/14, with information regarding Resident #2 being sent to the hospital for a psych evaluation; 08/04/14, when the resident returned from the hospital, and the every fifteen (15) minute checks were once again implemented; 08/09/14 when Resident #2 was sent back out to the hospital for another psych evaluation; and 08/12/14 when the resident returned from hospital and an intervention implemented for a room change to another unit. However, review of the Comprehensive Care Plan revealed no documented evidence the care plan was revised to include interventions to provide increased supervision of Resident #2 to prevent further alleged sexual abuse incidents towards Resident #1. Review of the hospital record revealed Resident #2 was diagnosed with [REDACTED]. However, review of Resident #2's care plan revealed no documented evidence the care plan was revised to include the [DIAGNOSES REDACTED]. Review of the care plan revealed the facility again initiated every fifteen (15) minute checks of Resident #2. Review of the hospital record for Resident #2 revealed the resident was again admitted to the hospital Behavioral Health Unit on 08/09/14 and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED].#2's care plan revealed no documented evidence the care plan was revised to include the [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #1 to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of "00" out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of Resident #1's Comprehensive Care Plan, dated 12/24/13, revealed numerous care plans in place. However, further review of the Comprehensive Care Plan revealed no documented evidence it was updated or revised for this severely cognitively impaired resident's protection and safety from further alleged sexual abuse by Resident #2. Interview, on 09/11/14 at 8:40 AM, with the MDS Coordinator revealed MDS staff reviewed and revised care plans daily, Monday through Friday, from review of physician's orders [REDACTED]. The MDS Coordinator stated the floor nurses did not usually update or revise residents' care plans. She stated she did not remember Resident #2's alleged sexual abuse incidents being discussed in the morning meetings, and stated Resident #2's care plan did not address the alleged abusive behaviors. However, she indicated Resident #2's care plan should have been revised to address the alleged abusive behaviors. Interview with the DON, on 09/11/14 at 8:55 AM, revealed care plans were reviewed and revised by the MDS staff as necessary from the daily morning meeting information and review of the physician's orders [REDACTED].#2's sexually abusive behaviors were discussed in the morning meetings, and indicated if not the MDS staff would not have known to review and revise his/her care plan. Interview with the Administrator, on 08/29/14 at 6:45 PM, revealed changes in residents' conditions or behaviors were reported to all staff through every shift report. However, she stated MDS staff were responsible for updating and revising residents' care plans daily, Monday through Friday, based on review of the physician's orders [REDACTED]. The Administrator revealed she did not think "floor staff" updated residents' care plans. She further stated the care plans for both Resident #1 and Resident #2 should have been revised. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' Physicians and legal representative were immediately notified of an alleged sexual abuse incident for two (2) of eight (8) sampled residents (Residents #1 and #2). (Refer to F-223) Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate occasions that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of the resident's pants and the other time in the groin area up the resident's pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Furthermore, interviews revealed even though nursing staff observed and reported the above alleged abuse of Resident #1 by Resident #2, they were informed by the Administrator not to document the incidents, or conduct notifications to the Physician or Power of Attorneys (POAs) for Resident #1 and Resident #2. The facility's failure to ensure an effective system was in place to ensure the Physician and POA, or legal representative, were immediately notified of a potential incident of sexual abuse was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 08/29/14, and determined to exist on 07/26/14. The facility was notified of the Immediate Jeopardy on 08/29/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14 prior to exiting the facility on 09/11/14, with remaining non-compliance at F-157 Notifications of Changes, at a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure Physicians and legal representatives are notified in the event of an incident, accident or changes in the resident's condition. The findings include: Review of the facility's policy titled "Change in a Resident's Condition", dated 08/01/13, revealed the Nurse Supervisor/Charge Nurse was to notify the resident's Attending Physician or On-Call Physician when there was an incident involving the resident. Continued review of the facility policy revealed notifications of a change in condition were to be made within twenty-four (24) hours, except in the case of a medical emergency. Record review revealed Resident #1 was admitted by the facility on 12/12/13, with [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #2 on 04/12/12 with [DIAGNOSES REDACTED]. Interview with LPN #1 on 08/22/14 at 1:00 PM, revealed on 07/26/14 "sometime" after 2:00 PM, SRNA #1 reported Resident #2 had his/her hand in the waist band of Resident #1's pants. She stated staff was told on 07/26/14 by the Administrator not to document Resident #2's behaviors, but start every 15 minute checks. She stated neither the POAs for Residents #1 and #2, nor the Physician, were notified. Interview with the Director of Nursing (DON), on 08/29/14 at 8:00 PM, revealed she reported to the Administrator, on 07/28/14, it was reported to her Resident #2 was in the hallway pulling on Resident #1's shirt. However, interview with LPN #10, on 09/04/14 at 3:10 PM, Resident #2 was found in Resident #1's room with his/her hand up under the resident's shirt. Record review revealed no documented evidence the Physician or the POA for Resident #1 or Resident #2 was notified of the incident. Review of Resident #1's record revealed no documented evidence of this incident with Resident #2 and no documented evidence the Physician or family were notified. Interview with SRNA #7, on 09/04/14 at 2:25 PM, revealed on 08/04/14 when Resident #2 returned from a hospitalization , she entered Resident #1's room and observed Resident #2 with his/her hand pushed up under Resident #1's pant leg to the groin area. SRNA #7 further stated she removed Resident #2 from Resident #1's room and reported the incident to Licensed Practical Nurse (LPN) #10. Interview with SRNA #2, on 09/04/14 at 2:40 PM and on 09/10/14 at 9:25 AM, revealed on 08/04/14 she observed Resident #2's hand more than halfway down inside the front of Resident #1's pants, and she reported it to the nurse. However, review of Resident #1's clinical record revealed no documented evidence the resident's POA or Physician were notified of the alleged sexual abuse incidents by Resident #2 on 08/04/14 after his/her return to the facility from the hospital. Review of Resident #2's record revealed no documented evidence the POA or Physician were notified of these two incidents on 08/04/14. Interview with Resident #1's POA, on 08/22/14 at 12:15 PM, revealed when he was visiting one night, he was told by a nurse that his mother had been approached in the hallway by another resident but nothing happened. He stated the nurse said it was not a sexual thing. He further stated that nurse no longer worked at the facility. Continued interview revealed the POA had not been told anything else by anyone at the facility. Interview with the DON and the Administrator, on 08/29/14 at 3:45 PM, revealed on 07/30/14 Resident #2 continued to seek out Resident #1. Resident #2 was observed in the doorway of Resident #1's room reaching for him/her. Continued interview with the Administrator, on 08/29/14 at 3:45 PM, revealed Resident #2's POA was first notified of the behaviors by the Administrator on 07/30/14. She further stated there was no documented evidence of when the Physician was first notified of the incidents. Interview with Resident #2's POA, on 09/04/14 at 10:20 AM, revealed she could not remember the date she was notified of an incident regarding inappropriate behavior; she thought the Administrator had called on 07/26/14 but maybe it was 07/30/14. Interview with the Attending Physician for Resident #1 and Resident #2, on 08/22/14 at 4:00 PM, revealed he was made aware of Resident #2's sexual behaviors toward Resident #1 on 07/30/14, and he gave an order to send Resident #2 for a Psych evaluation. He stated he was not made aware of the behavior on 08/04/14 upon Resident #2's return to the facility, but was notified on 08/09/14 and ordered to send the resident back to the hospital for another psych evaluation. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete to ensure documentation of alleged sexual behaviors/abuse of residents for two (2) of eight (8) sampled residents (Residents #1 and #2). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate occasions that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of the resident's pants and the other time in the groin area up the resident's pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Furthermore, interviews revealed even though nursing staff observed and reported the above alleged abuse of Resident #1 by Resident #2, they were informed by the Administrator not to document the incidents. (Refer to F-223, F-490) The facility's failure to have an effective system in place to ensure clinical records were accurate and complete placed residents in a situation that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy was identified on 08/29/14 and was determined to exist on 07/26/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14 prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-514 Clinical Records, with a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Charting and Documentation" dated 08/01/13, revealed all services provided to the resident, or any changes in residents' medical or mental condition, should be documented in the resident's medical record. Further review revealed all incidents, accidents, or changes in the resident's condition must be recorded. Interview with staff revealed Resident #2 was seeking out Resident #1 and/or displaying inappropriate sexual behavior towards Resident #1 on 07/26/14, 07/28/14, 07/30/14, 08/04/14, and 08/09/14. Interview with LPN #1 on 08/22/14 at 1:00 PM, with LPN #6 on 08/25/14 at 7:30 AM, LPN #2 on 08/21/14 at 1:20 PM, and on 09/10/14 at 9:50 AM, LPN #10 on 08/21/14 at 3:20 PM, LPN #5 on 08/24/14 at 8:30 PM, revealed they were told not to document any inappropriate behavior by Resident #2. Interviews revealed when they called the Administrator, they were told by the Administrator whether to "document or not to document". Review of Resident #1's medical record revealed the facility admitted the resident on 12/12/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of '00" out of fifteen (15), which indicated severe cognitive impairment. Continued review of Resident #1's medical record revealed no documented evidence of the alleged sexual abuse incident on 07/26/14, 07/28/14, or the two incidents on 08/04/14. Review of Resident #2's medical record revealed the facility admitted the resident on 04/21/12, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2 to have a BIMS score of fifteen (15) out of fifteen (15) which indicated no cognitive impairment. Continued review of Resident #2's medical record revealed no documented evidence of: the alleged sexual abuse incident on 07/26/14; or of notification of the Physician or family/responsible party of the incident. In addition, there was no documentation of the incident on 07/28/14, or the two incidents on 08/04/14. Interview with with SRNA #8 on 09/04/14 at 2:22 PM and SRNA #7 on 09/04/14 at 2:25 PM, revealed Resident #2 continued to seek out Resident #1 and was observed going to Resident #1's room and had to be redirected away from there; however, review of the record revealed no documented evidence of this behavior in Resident #2's medical record. Further review of Resident #2's medical record revealed the resident was readmitted on [DATE] from the hospital, with checks every fifteen (15) minute checks. However, review of the "Monitoring" forms revealed no documented evidence the every fifteen (15) checks were performed 08/04/14 through 08/08/14. Interview, on 08/29/14 at 3:45 PM and 09/04/14 at 7:50 PM, with the Administrator revealed she was no sure why the every fifteen (15) minute checks were no documented; however, she indicated they should have been documented on the "Monitoring" forms as they were a part of the clinical record. Continued interview with the Administrator revealed she had not informed nurses not to document, and her expectation was for there to be documentation somewhere in the chart. The Administrator revealed it was up to nurses to use their nursing judgement on whether to document or not document residents' behaviors. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of facility's policies, it was determined the facility's Administration failed to have an effective system in place to ensure policies and procedures were implemented to ensure each resident was free from abuse and ensure care plan interventions related to supervision were implemented to prevent reoccurrence of potential abuse. The facility's failure affected two (2) of eight (8) sampled residents (Residents #1 and #2). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate times that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of his/her pants and the other time in the groin area up the pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Interview and record review revealed the facility failed to implement policy and procedures related to abuse, revision/implementation of care plans, notification of residents' physician and responsible party, and maintaining accurate clinical records. (Refer to F-157, F-223, F-225, F-226, F-280, F-282, and F-514) The facility Administration's failure to have an effective system in place to ensure the policies and procedures were implemented to ensure each resident was free from abuse and to ensure care plans were revised with interventions regarding supervision were implemented was likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 08/29/14 and was determined to exist on 07/26/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14 prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.75, Administration, F-490 effective Administration, with a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse Investigation", undated, revealed all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Per the Policy the investigation was to include interviewing the residents involved in incidents, staff members who were present at the time of the incident, the person reporting the incident, other residents, the residents' roommates, family members and visitors. The Policy revealed the investigation was to include review of documentation and the residents' medical record and review of events leading up to the incident. Review of the facility's policy titled, "Abuse Reporting", undated, revealed the person observing an incident should immediately report it to the Charge Nurse, who was to complete an Incident Report Form and immediately examine and interview the resident. The Charge Nurse was to document his/her findings of the examination and interview in the resident's medical record and report the findings to the Administrator. Continued review of the Policy revealed upon receiving reports of abuse the Administrator or DON would immediately report the incident to the State Survey Agency, Adult Protective Services and other agencies as appropriate. Review of the facility's policy titled, "Care Plans-Comprehensive" dated 08/01/13, revealed assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. The Policy revealed the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when the desired outcome was not met. Review of the facility's policy titled "Change in a Resident's Condition", dated 08/01/13, revealed the Nurse Supervisor/Charge Nurse was to notify the resident's Attending Physician or On-Call Physician when there was an incident involving the resident. Continued review of the facility policy revealed notifications of a change in condition were to be made within twenty-four (24) hours, except in the case of a medical emergency. Review of the facility's policy titled, "Charting and Documentation" dated 08/01/13, revealed all services provided to the resident, or any changes in residents' medical or mental condition, should be documented in the resident's medical record. Further review revealed all incidents, accidents, or changes in the resident's condition must be recorded. Interviews with facility staff revealed the Administrator was knowledgeable of Resident #2's inappropriate touching of Resident #1 since 07/26/14, when she was notified of the first incident by LPN #1/Charge Nurse. However, the Administrator failed to ensure immediate notification of Resident #1's and Resident #2's Physician and family/responsible party after the incident on 07/26/14. Staff interviews revealed Resident #2 continued to seek out Resident #1, and a total of four (4) allegations were reported to the Administrator regarding Resident #2 touching Resident #1 inappropriately. However, the Administrator failed to ensure Incident Reports regarding the incidents of alleged sexual abuse by Resident #2 were completed; failed to ensure the reporting of the alleged sexual abuse to the appropriate State Agencies; failed to ensure investigations were conducted after the incidents; failed to ensure Resident #1 was physically assessed for potential injury after each incident; and, failed to ensure Resident #1's and Resident #2's care plans were revised to ensure increased supervision of Resident #2 and protection for Resident #1. In addition, interviews with staff revealed the Administrator had told them not to document Resident #2's behavior in the resident's medical record. Interview with the DON, on 08/22/14 at 10:20 AM, on 08/29/14 at 7:40 PM, at 8:00 PM and 8:30 PM, on 09/10/14 at 10:00 AM and 09/11/14 at 8:55 AM, revealed the Administrator did not instruct her or anyone else to complete and Incident Report or start an investigation related to the incidents. Interview with the Administrator on 8/29/14 at 3:45 PM and at 6:45 PM and on 09/04/14 at 7:50 PM, revealed she was first informed of Resident #2 having "inappropriate sexual behaviors" on 07/26/14. The Administrator revealed she told LPN #1 to initiate every fifteen (15) minute checks of Resident #2. Per interview, she stated an investigation would be completed if the facility felt like there was abuse; however, she did not have staff complete an Incident Report or initiate an investigation on 07/26/14, because she did not see the incident with Resident #2 as abuse. The Administrator stated she did not have staff complete Incident Reports after any of the alleged incidents involving Resident #2, as she did not view them as reportable events. She stated she did not feel Resident #2 had acted willfully due to some reports of the resident having confusion. Continued interview with the Administrator revealed Resident #2's Physician was updated regarding the resident's "inappropriate sexual behavior"; however, there was no documented evidence of when the Physician was first notified. The Administrator stated Resident #2's POA was first notified on 07/30/14 regarding his/her behaviors, and she had not notified Resident #1's POA of any of the alleged incidents as she had not considered them abuse. The Administrator stated she was unsure if anyone had ever notified Resident #1's POA of the alleged incidents. The Administrator revealed Resident #2 was not care planned for Hypersexuality because the [DIAGNOSES REDACTED]. She stated she was not certain why the every fifteen (15) minute checks for Resident #2 were not performed and documented as completed for 08/04/14 through 08/08/14; however, stated the checks should have been completed as the facility felt that was how Resident #1 was kept safe. Per interview, it was nursing judgment whether or not to document resident behaviors, and her expectation was for documentation to be somewhere in residents' record. The Administrator stated she had not told nurses not to document in the residents' medical records. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to ensure policies and procedures were implemented related to abuse for one (1) of eight (8) sampled residents (Resident #1). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate times that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of his/her pants and the other time in the groin area up the pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Interview and record review revealed the facility failed to reported these allegations of abuse to the appropriate State Agencies, failed to investigate the allegations and failed to protect residents from further potential abuse. The facility failed to investigate the incidents involving Resident #2 as possible sexual abuse and report the alleged abuse to the State Agencies per the facility's policy and procedures. (Refer to F-223, F-225) The facility's failure to have an effective system in place to implement its abuse policies and procedures to prevent abuse was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 08/29/14 and was determined to exist on 07/26/14. The facility was notified of the Immediate Jeopardy on 08/29/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/2014, with the facility alleging removal of the Immediate Jeopardy on 09/03/14 . The Immediate Jeopardy was verified to be removed on 09/03/14, prior to exiting the facility on 09/11/14 with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-226 at a Scope and Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure policies and procedures are implemented to ensure residents are free from abuse. The findings include: Review of the facility's policies titled, "Abuse Reporting", undated, and "Abuse Investigations" undated, revealed the facility would not condone resident abuse by anyone including staff or other residents or visitors, and any incident of or suspicion of abuse was to be immediately reported to the Charge Nurse and the Administrator or Director of Nursing (DON). The Charge Nurse was to: examine and interview the resident and document the findings in the medical record; complete an Incident Report form; and, obtain a written, signed and dated statement from the person reporting the incident. The Administrator or DON was to immediately report the incident to the State Survey Agency, Adult Protective Services and other agencies as appropriate. The Administrator or his/her designee was to "immediately" and thoroughly investigate all reports of resident abuse, and the investigation was to include review of the residents' medical records and completed documentation forms. The Administrator or his/her designee was also to interview: the person(s) reporting the incident; any witness to the incident; the resident if medically appropriate; staff members on all shifts who had contact with the resident when the alleged incident occurred; the resident's roommate, family members, and visitors, and consult the Physician. The DON was to have Social Services (SS) monitor the resident. Results of the investigation were to be reported to the State Agencies within five (5) working days. Interview revealed allegations of sexual abuse and/or inappropriate behavior by Resident #2 towards Resident #1, which were reported to occur on 07/26/14, 07/28/14, 07/30/14, 08/04/14, and 08/09/14, were not documented in the medical record, incidents reports were not completed, Resident #1 was not assessed for potential injury, State Agencies were not notified, and investigations were not conducted per the faciltiy's policy. The State Survey Agency requested Incident Reports and investigations regarding Resident #2's alleged sexual abuse of Resident #1 for 07/26/14 and 08/04/14; however, the facility denied the request and did not provide the requested documentation. Therefore, no documented evidence of an investigations by the facility as per facility policy was provided to the State Survey Agency for review. Interview with LPN #1 on 08/22/14 at 1:00 PM, with LPN #6 on 08/25/14 at 7:30 AM, LPN #2 on 08/21/14 at 1:20 PM, and on 09/10/14 at 9:50 AM, LPN #10 on 08/21/14 at 3:20 PM, LPN #5 on 08/24/14 at 8:30 PM, revealed they were told not to document any inappropriate behavior by Resident #2. Further interview revealed Resident #1 was not assessed after each incident for potention injury and no incident reports were comploeted. However, per the facility's policy stated the Charge Nurse was to examine and interview the resident and document the findings in the medical record; complete an Incident Report form; and, obtain a written, signed and dated statement from the person reporting the incident. In addition, interviews with staff revealed the were to call the Administrator after each incident and the Administrator determined what should and should not be documented. Interview with the DON on 09/10/14 at 10:00 AM revealed the Administrator led interviews and gave directions on who was to be interviewed when incidents occurred. Interview with the Administrator on 09/04/14 at 7:50 PM revealed she had not considered any of the incidents involving Resident #2 touching Resident #1 inappropriately as abuse as Resident #2 was sometimes confused. She stated she had never notified Resident #1's POA of any of the incidents as she hadn't considered it abuse, and first notified Resident #2's POA on 07/30/14 when the resident was sent out to the hospital. Interview, on 08/22/14 at 10:00 AM, with the Social Service Director (SSD) revealed she had been told Resident #2 was going into Resident #1's room, and indicated Resident #2 was having "inappropriate behaviors" which were "not his norm" and he/she was "confused". The SSD stated she had not received complaints from any residents, therefore she had not investigated or interviewed other residents, as per facility policy. She stated she did not "just...go around asking questions", and was uncertain if any residents were questioned or examined after the incidents involving Resident #2. The SSD stated "usually" if an incident occurred the Administrator would ask her to conduct interviews with staff and residents; however the Administrator had not asked her to investigate any incidents involving Resident #2 and Resident #1. Continued interview on 09/04/14 at 7:50 PM with the Administrator revealed she did not have staff complete Incident Reports because she did not see the incidents with Resident #1 and Resident #2 as reportable to State Agencies. The Administrator revealed the facility's policy was to report incidents of abuse immediately; however, she had not considered the incidents involving Resident #2 as abuse because he/she was occasionally confused. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure all allegations of resident to resident sexual abuse were thoroughly investigated, ensure allegations were immediately reported to the appropriate State Agencies, and to ensure residents were protected from further abuse for one (1) of eight (8) sampled residents (Resident #1). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate times that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of his/her pants and the other time in the groin area up the pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Interview and record review revealed the facility failed to reported these allegations of abuse to the appropriate State Agencies, failed to investigate the allegations and failed to protect residents from further potential abuse. The facility failed to investigate the incidents involving Resident #2 as possible sexual abuse and report the alleged abuse to the State Agencies. Therefore, the facility failed to ensure a physical examination of Resident #1 and other non-interviewable residents was performed to assess for possible injury, and failed to interview other interviewable residents regarding Resident #2's behaviors. (Refer to F-223) The facility's failure to have an effective system in place to ensure allegations of resident to resident sexual abuse were investigated thoroughly, to ensure residents were protected from abuse and to immediately report the incidents to the appropriate State Agencies, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 08/29/14 and was determined to exist on 07/26/14. The facility was notified of the Immediate Jeopardy on 08/29/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/2014, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14, prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-225 at a Scope & Severity (S/S) of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure all allegations of abuse were thoroughly investigated, and the allegations of abuse were immediately reported to the appropriate State Agencies. The findings include: Review of the facility's policy titled, "Abuse Reporting", undated, revealed the facility revealed the person observing an incident of resident abuse or suspecting resident abuse was to immediately report such incidents to the Charge Nurse and the Administrator or Director of Nursing (DON). Per the Policy, upon receiving a report of suspected abuse, the Charge Nurse "must" complete an Incident Report Form and obtain a "written, signed and dated statement from the person reporting the incident". The Policy stated "upon receiving reports of" abuse the Administrator or DON would "immediately" report the incident to the State Survey Agency, Adult Protective Services (APS) and other agencies as appropriate. Continued review of the Policy revealed an "immediate investigation" would be made and results provided to the Administrator within five (5) working days of the occurrence of the incident, and reported to the State Agencies within the five working days. Review of the facility's policy titled, "Abuse Investigations", undated, revealed all reports of resident abuse, neglect and injuries of unknown source should be promptly and thoroughly investigated by facility management. The Policy stated the Administrator, or his/her designee would investigate alleged incidents and review completed documentation forms and review residents' medical records to determine events leading up to the incident. The Policy revealed the Administrator or his/her designee as part of the investigation would interview: the person(s) reporting the incident; any witness to the incident; the resident (as medically appropriate); staff on all shifts who had contact with the resident during the period of the alleged incident; the resident's roommate, family members, and visitors. Also, as part of the investigation the resident's Physician was to be consulted as needed to determine the resident's current level of cognitive function and medical condition, and all events leading up to the alleged incident were to be reviewed. Interview with staff revealed Resident #2 was seeking out Resident #1 and/or displaying inappropriate sexual behavior towards Resident #1 on 07/26/14, 07/28/14, 07/30/14, 08/04/14, and 08/09/14. Interview with LPN #1 on 08/22/14 at 1:00 PM, revealed she reported Resident #2's behavior towards Resident #1 on 07/26/14 to the Administrator and the Administrator told LPN #1 not to document the incident. LPN #1 stated when nurses made calls to the Administrator, they were told to document or not to document incidents by the Administrator. LPN #1 further revealed she had not physically assessed Resident #1 for any possible injuries and did not complete an Incident Report as per facility policy. Interview, on 08/21/14 at 1:20 PM and on 09/10/14 at 9:50 AM, with LPN #2 revealed she reported the incident on 07/28/14 to the DON as soon as she was informed. However, she did not document what happened because she was told in morning shift change report not to document behaviors between Resident #2 and Resident #1. LPN #2 revealed after reporting the incident to the DON, she had not performed a physical examination on Resident #1 for possible injury and had not completed an Incident Report after the incident, as per facility policy. According to LPN #2, facility nurses waited for instructions from the Administrator or the DON on what to do. Review of the "Patient Information" form, dated 07/30/14, revealed Resident #2 was transferred to the hospital due to "inappropriate behaviors with females (touching inappropriately), difficult to redirect", and continued "to repeat behaviors." Interview with SRNA #7 on 09/04/14 at 2:25 PM, revealed she observed Resident #2 in Resident #1's room on what she believed to be 08/04/14, the day Resident #2 was readmitted to the facility from the hospital. SRNA #7 reported Resident #1's pant leg was pushed up to his/her thigh, and Resident #2 had his/her hand up inside the pant leg to the groin area. She stated she was uncertain who she had reported it to, but thought it was LPN #10. Interview, on 08/21/14 at 3:20 PM and 09/04/14 at 3:10 PM, with LPN #10 revealed she indicated she had not had anything reported to her about Resident #2 having his/her hand up in Resident #1's pant's leg. She stated she recalled another nurse, LPN #2 reported to her Resident #2 had his/her hand up in Resident #1's shirt one (1) time; however, could not recall the exact date. Interview with SRNA #2, on 08/21/14 at 1:20 PM, revealed she had observed Resident #2 in Resident #1's room on 08/04/14, the day Resident #2 had returned from the hospital. The SRNA reported Resident #2 had more than half of his/her hand down the front of Resident #1's pants and stated, Resident #2's "fingers were touching" Resident #1's "pubic area". Continued interview revealed SRNA #2 reported the incident to LPN #2. However, there was no documented evidence the facility reported or investigated the allegation of sexual abuse. Review of Resident #2's record revealed a Nurse's Note dated 08/09/14 which stated Resident #2 "entered another female resident's room". Interview with the Administrator on 08/29/14 at 3:45 PM, revealed on 08/09/14 it was Resident #2 was "trying" to go to Resident #1's room. Requests were made by the State Survey Agency for any Incident Reports and investigations regarding Resident #2's alleged sexual abuse on 07/26/14 and 08/04/14; however, the facility denied the requests. Interview with the DON on 09/10/14 at 10:00 AM, revealed it was facility policy to interview other residents and to interview, examine and not to bathe the alleged victim when there was an allegation of abuse. The DON stated she had texted the Administrator about the incident on 07/28/14. However, the DON stated the Administrator had not instructed anyone that she was aware of to start an investigation. According to the DON, no physical assessments were performed on Resident #1 or other non-interviewable residents, and no interviews with interviewable residents were conducted. The DON stated the Administrator had not informed her to complete an Incident Report, so she had not completed one (1). Continued interview with the DON on 09/11/14 at 8:55 AM, revealed the facility always did Incident Reports on resident falls or skin tears; however for residents' behaviors it boiled down to whether there was an injury or not. She reported staff were supposed to complete an Incident Report on any behavior which caused physical or emotional injury. The DON stated typically, if there was not an injury and the incident did not affect the resident emotionally an Incident Report was not done. Per interview, she stated staff was instructed to call the Administrator if a behavior occurred, and the Administrator decided if it was reportable or not. The DON revealed if an incident occurred the resident was assessed and typically Social Services followed up with all incidents. Per interview, she stated she did not train the facility's nurses that all incidents were to be put on Incident Reports, such as skin tears which were not put on Incident Reports. Interview with the Social Service Director (SSD), on 08/22/14 at 10:00 AM, revealed she was told that Resident #2 was going into Resident #1's room, but was aware of Resident #2's behaviors. Continued interview revealed the Administrator did not ask her to investigate any incidents involving Resident #1 and Resident #2. Further interview with the Administrator, on 09/04/14 at 7:50 PM, revealed she did not have staff complete Incident Reports because she did not see the incidents with Resident #1 and Resident #2 as reportable. She stated it was up to the nurses and their nursing judgement whether or not to document residents' behaviors. The Administrator revealed the facility's policy was to report incidents of abuse immediately, but she did not consider the incidents involving Resident #2 as abuse because occasionally the resident was confused; therefore, no investigations were completed. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans were implemented to ensure supervision and residents were protected from abuse for one (1) of eight (8) sampled residents (Resident #2). Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and the resident's care plan was revised to perform every fifteen (15) minute checks of the resident. However, review of the "Monitoring" forms revealed no documented evidence the every fifteen (15) minutes checks were completed 08/04/14 through 08/08/14. On 08/04/14 Resident #2 was observed on two (2) separate occasions that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of the resident's pants and the other time in the groin area up the resident's pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. (Refer to F-223) The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was implemented for supervision and protection of other residents to prevent further abuse was likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 08/29/14 and was determined to exist on 07/26/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14, with the facility alleging removal of the Immediate Jeopardy on 09/03/14. The Immediate Jeopardy was verified to be removed on 09/03/14 prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.20, Resident Assessment, F-280 Care Plan Revision, with a Scope and Severity of "D" while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive" dated 08/01/13, revealed the an individualized comprehensive care plan which included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. The Policy revealed care plans were developed based on a thorough assessment which included the the Minimum Data Set (MDS) Assessment. Interview with staff revealed Resident #2 was seeking out Resident #1 and/or displaying inappropriate sexual behavior towards Resident #1 on 07/26/14, 07/28/14, 07/30/14, 08/04/14, and 08/09/14. Review of Resident #2's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a score of fifteen (15) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Review of the Comprehensive Care Plan, revealed Resident #2 had an undated care plan for social interaction impaired related to inappropriate behavior with an intervention for every fifteen (15) minute checks dated 07/26/14. Even though Resident #2 was on the every fifteen (15) minute checks staff interviews revealed reports of Resident #2's behaviors continuing. Interview with LPN #2, on 08/21/14 at 1:20 PM and 09/10/14 at 9:50 AM, which revealed she was informed of an incident where Resident #2 had his/her hand under Resident #1's shirt by a SRNA on 07/28/14; interview with SRNA #7, on 09/04/14 at 2:25 PM which revealed Resident #2 had been redirected from Resident #1's room three (3) to four (4) times daily by her prior to him/her being sent to the hospital on [DATE]; interview with LPN #6, on 08/29/14 at 2:45 PM, which revealed during a morning meeting on 07/30/14 another nurse came and got the Director of Nursing (DON), and and the DON came back to inform the Administrator Resident #2 had been attempting to get at Resident #1 again. LPN #6 stated Resident #2 was sent to the hospital for a psych evaluation that day, 07/30/14. Hospital record review revealed Resident #2 was admitted to the hospital's behavior unit, diagnosed with [REDACTED]. Review of Resident #2's care plan revealed on 08/04/14, every fifteen (15) minute checks to be completed. However, review of the "Monitoring" forms revealed no documented evidence the every fifteen (15) minute checks were completed from 08/04/14 through 08/08/14. Interview, on 09/04/14 at 2:25 PM, with SRNA #7 revealed she observed Resident #2 on 08/04/14 in Resident #1's room with Resident #1's pant's leg pushed up to the thigh area, and Resident #2 with his/her hand up inside the pant's leg to the groin area. Additionally, interview on 08/21/14 at 1:20 PM, with SRNA #2, revealed she observed Resident #2, on 08/04/14 in Resident #1's room with more than half of Resident #2's hand down the front of Resident #1's pants where he/she was "no doubt" touching" Resident #1's "pubic area" with his/her fingers. Interview with LPN #11 on 08/29/14 at 3:25 PM, revealed she didn't know if every fifteen (15) minutes checks were added to Resident #2's care plan or not. Interview with LPN #9 on 08/29/14 at 8:00 PM, revealed she had cared for Resident #2 "for over a year"; however, was unsure what his/her care plan interventions were. Interview with Registered Nurse (RN) #1 on 08/29/14 at approximately 7:40 PM, revealed she was unsure what Resident #2's care plan said; however, knew from shift report she was to monitor the resident's whereabouts. Interview, on 09/11/14 at 8:40 AM, with the MDS Coordinator revealed MDS staff reviewed and revised care plans daily, Monday through Friday, from review of physician's orders [REDACTED]. She indicated she did not recall hearing anything about the every fifteen (15) minute checks. However, the MDS Coordinator stated Resident #2's care plan noted every fifteen (15) minute checks. Interview with the Administrator, on 08/29/14 at 6:45 PM, revealed changes in residents' conditions or behaviors were reported to all staff through every shift report. Additional interview, on 09/04/14 at 7:50 PM, with the Administrator revealed she was not certain why from 08/04/14 through 08/08/14, the every fifteen (15) minute checks for Resident #2 were not completed and documented as done per the care plan. She stated, however, the every fifteen (15) minute checks should have been completed as per the care plan. Per interview, the facility felt through the every fifteen (15) minute checks was how Resident #1 was kept safe. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by the Interdisciplinary Team on 07/25/14 and 08/07/14. A Quality Assurance process was implemented by the Administrator on 08/29/14 to monitor on a continuing basis this Allegation of Compliance through a daily monitoring meeting during which the Administrator, DON, Assistant DON, charge nurses and therapy team review Physician orders, nursing supervisor reports, 24-hour nursing communication sheets, care plan revisions, conduct daily physical rounds in the facility, review incident reporting and ensure appropriate Physician and legal representative notifications. The daily monitoring will continue for the next three (3) months and weekly thereafter. The facility will also utilize the Interact II Stop and Watch Program to gather input from all staff regarding any changes noted or observed with any resident's behavior or otherwise. In the absence of the Administrator, the DON will assume the responsibility. On weekends, the Charge Nurse will compete this process. The DON will conduct a quality assurance audit for accuracy of clinical records on 10% of records on a monthly basis to ensure compliance. 10. For continued monitoring of the Allegation of Compliance, a member of the governing body, either the Executive Vice President or the Vice President of Clinical Services, will be in attendance at monthly quality assurance meetings for the next three (3) months. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Copies of skin assessments, performed by licensed staff, for Resident #1 on 07/28/14 and 08/05/14 were reviewed. No concerns were revealed during this review. A review of the complete assessment by the Physician on 07/31/14 revealed no concerns. 2. A review of every 15 minute checks of Resident #2 by nursing staff, for the period of 07/26/14 through 07/30/14, revealed no concerns. Observation of Resident #2 on 09/04/14 at 10:05 AM, revealed the resident to be sitting in the dining room with a staff member playing cards. Interview with SRNA #6 on 09/04/14 at 10:09 AM, revealed she was assigned to do 1:1 with Resident #2. Interview with the Administrator on 09/11/14 at 1:55 PM, confirmed Resident #2 was started on 1:1 monitoring on 08/29/14 and the monitoring was ongoing. 3. The facility provided the in-service sign in sheets for training of the Administrator and the DON on 08/29/14, by the Vice President of Clinical Services, related to the following: accuracy of clinical records related to documentation and notification of the Physician and the POA; the definitions of abuse; identification, reporting and investigation of abuse; implementation of the facility's Protection Policy; and care plan revisions. Interview with the Administrator on 09/11/14 at 1:47 PM, and the DON on 09/11/14 at 1:35 PM, revealed both had attended the in-service training and were able to verbalize their understanding of the education. 4. The facility provided a copy of the in-service sign-in sheets for 08/29/14 and 08/30/14. Review of the records revealed training was provided for all staff regarding the following: accuracy of the clinical record; documentation and notification of the Physician and the POA; definitions of abuse; identification, reporting and investigating abuse; and revision of care plans. Interview with SRNA #10 on 09/11/14 at 2:25 PM, revealed she had attended the in-service related to abuse. Interview with SRNA/Restorative #9, on 09/11/14 at 1:23 PM, revealed she had attended the in-service related to abuse and how to respond. Interview with the Housekeeping Supervisor on 09/11/14 at 1:30 PM, revealed she had attended the in-services related to abuse, documentation, and notification. Interview with Maintenance staff on 09/11/14 at 1:12 PM, revealed he had attended the abuse in-services. Interview with the Activity Assistant, on 09/11/14 at 1:26 PM, revealed she had received training on abuse and attended the in-service on 08/30/14. Interview with RN #2, on 09/11/14 at 1:25 PM, revealed she attended the in-service on 08/29/14 related to abuse, documentation, notification, reporting, identifying, investigating, and revision of care plans. 5. The facility provided a copy of audits completed, beginning 08/30/14 and ending 09/02/14, for all resident records regarding accurate notification of the Physician and the legal representative, and a review of resident assessments and care plans to ensure completeness and accuracy. Review of the audit completed on 08/30/14, related to residents who triggered on the MDS assessment for behaviors that affect others, revealed the care plans reflected current interventions. Interview with RN #2/MDS Nurse, on 09/11/14 at 1:05 PM, revealed all resident records were reviewed for documentation, Physician and POA notification, current behavior interventions, and complete and accurate assessments and care plans. 6. The facility provided interview audits completed on 08/30/14 for female residents, and on 09/02/14 for male residents, regarding whether they had been touched inappropriately by a male resident or anyone since residing at the facility. No concerns were voiced by any residents. 7. Interview with the POA for Resident #2, on 09/04/14 at 9:20 AM, revealed she had spoken with the vice President of Clinical Services and the Administrator. She confirmed she was not sure when she was first notified, but she was now aware of all allegations of inappropriate behavior on the part of Resident #2, and was aware of actions taken by the facility. Interview with the POA for Resident #1, on 09/10/14 at 4:30 PM, revealed he had spoken with the Vice President of Clinical Services and told her we was aware of the inappropriate behavior toward his mother, as he had been told by facility staff. 8. Interview with the Attending Physician for Resident #1 and Resident #2, on 09/10/14 at 5:35 PM, revealed he had spoken with the Vice President of Clinical Services and was aware of Resident #2's change in behavior. 9. Review of the Quality of Care meeting minutes revealed residents with identified skin areas were reviewed on 07/25/14 and 08/07/14. Interview with the Administrator, on 09/11/14 at 5:10 PM, revealed the team met daily to monitor care plan revisions, incident reporting, and appropriate notification of the Physician and POA. The medical record audit is scheduled to be initiated 09/17/14 and completed by the end of each month. Review of the audit tool utilized to monitor 10% of resident records for accuracy on a monthly basis revealed no concerns. 10. Interview with the Vice President of Clinical Services on 09/11/14 at 5:00 PM, revealed she or the Executive Vice President of Clinical Services would attend the monthly QA meeting for three (3) months. Monthly QA meetings are scheduled 09/17/14, 10/15/14, and 11/19/14.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to protect one (1) of eight (8) sampled residents from abuse (Resident #1). The facility failed to implement policy and procedures to initiate an investigation of alleged abuse and implement interventions to prevent recurrence. Interviews with nurses and State Registered Nursing Assistants (SRNAs) revealed Resident #2 was observed touching Resident #1 inappropriately on several different occasions. On 07/26/14, a visitor pointed at Resident #1 and Resident #2 and told a SRNA "you need to do something about this", as Resident #2 was observed with his/her hand inside the waist band of Resident #1's pants. On 7/28/14, Resident #2 had his/her hand under Resident's #1's shirt. On 07/30/14 sought out Resident #1, displayed inappropriate behaviors (touching inappropriately), was difficult to redirect, and was sent out to the hospital for a psychiatric (psych) evaluation. On 08/04/14, Resident #2 was readmitted and was observed on two (2) separate occasions that day to have more than half of his/her hand in Resident #1's pants, once near Resident #1's pubic area down the front of the resident's pants and the other time in the groin area up the resident's pant's leg. In addition, staff interviews revealed Resident #2 tried unsuccessfully on other occasions to seek out Resident #1; however, staff intervened before he/she was able to touch Resident #1. On 08/09/14 at 10:40 AM Resident #2 was found in Resident #1's room again, redirected out of the room; however, continued to return. Resident #2 was sent back out to the hospital on [DATE] for another psych evaluation. Furthermore, interviews revealed even though nursing staff observed and reported the above alleged abuse of Resident #1 by Resident #2, they were informed by the Administrator not to document the incidents, or conduct notifications to the Physician or Power of Attorneys (POAs) for Resident #1 and Resident #2. The facility's failure to have an effective system in place to ensure residents remained free from abuse was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 08/29/14 and was determined to exist on 07/26/14. The facility was notified of the Immediate Jeopardy on 08/29/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/2014, with the facility alleging removal of the Immediate Jeopardy on 09/03/14 . The Immediate Jeopardy was verified to be removed on 09/03/14, prior to exiting the facility on 09/11/14, with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-223 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse Reporting", undated, revealed the facility would not condone resident abuse by anyone, including other residents. Policy review revealed the definitions of abuse were provided to assist staff members in recognizing incidents of abuse, and sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. Continued review of the facility's policy revealed, upon receiving a report of suspected abuse, the Charge Nurse was to examine and interview the resident, and record the findings of the examination in the resident's medical record. The Policy revealed upon receiving information concerning abuse, the Director of Nursing (DON) was to request a representative of the Social Services Department (SSD) monitor the resident's feelings concerning the incident and the resident's reaction to his/her involvement in the investigation. According to the Policy, any concerns and conversations were to be documented. Record review for Resident #1 revealed the facility admitted him/her on 12/12/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/07/14, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of "00", which indicated the resident was severely cognitively impaired. Record review for Resident #2 revealed the facility admitted the resident on 04/21/12, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/26/14, revealed the facility assessed Resident #2 to have a BIMS score of fifteen (15) out of fifteen (15) indicated the resident was cognitively intact. Review of Resident #2's Comprehensive Care Plan revealed an undated problem for "social interaction impaired related to inappropriate behavior. Interview with LPN #1 on 08/22/14 at 1:00 PM, revealed on 07/26/14 "sometime" after 2:00 PM, SRNA #1 reported to her a visitor had tapped the SRNA on the arm and said, "you need to do something about this", indicating Resident #1 and Resident #2. LPN #1 stated SRNA #1 reported to her, she observed Resident #1 and Resident #2 in the hallway where Resident #2 had his/her hand in the waist band of Resident #1's pants. Continued interview revealed LPN #1 reported SRNA #1's observations to the Administrator by telephone, and the Administrator told LPN #1 not to document the incident. LPN #1 stated when nurses made calls to the Administrator, they were told to document or not to document incidents by the Administrator. She stated the Administrator told her not to document Resident #2's behavior in the Nurse's Notes. LPN #1 declined to say if she had been told not to document something before, stating, "I would rather not answer that". LPN #1 revealed she had not physically assessed Resident #1 for any possible injuries after SRNA #1's reported allegation. Interview with SRNA #1 on 08/25/14 at 4:35 PM, revealed she observed Resident #2 being sexually inappropriate to Resident #1. She stated she observed Resident #2 having his/her hand inside the waist line of Resident #1's pants. Continued interview revealed a visitor touched her on the arm and said, "you might want to do something about this". SRNA #1 stated she did not remember the date of the incident, but thought it occurred between 4:30 PM and 5:00 PM. SRNA #1 indicated she had reported her observations to LPN #1. A telephone interview with LPN #6 on 08/25/14 at 7:30 AM, revealed LPN #6 overheard the conversation between the visitor and SRNA #1 on 07/26/14, concerning the need for an intervention between Resident #1 and Resident #2. LPN #6 stated LPN #1/Charge Nurse telephoned the Administrator to report the incident and when LPN #1 got off the telephone with the Administrator she said the Administrator said not to document the incident in the Nurse's Notes. Continued interview with LPN #6 revealed, nurses were "supposed to call the Administrator" and she told the nurses "whether to document or not". LPN #6 stated she "honestly" did not know if there would be "reprisal" if she had documented the incident. According to LPN #6, she had heard from the Administrator not to document on other incidents; however, "would rather not discuss" that. Continued review of Resident #2's Comprehensive Care Plan revealed the undated problem for "social interaction impaired related to inappropriate behavior" was updated on 07/26/14 regarding the resident being "redirected from room [ROOM NUMBER]" (Resident #1's room) with an intervention for every fifteen (15) minute checks. Review of the "Monitoring" forms revealed Resident #2 was on every fifteen (15) minute checks from 07/26/14 at 10:00 PM to 07/29/14 at 9:45 PM. Even though Resident #2 was on every fifteen (15) minute checks, interview with LPN #2 on 08/21/14 at 1:20 PM, and on 09/10/14 at 9:50 AM, revealed on Monday, 07/28/14, SRNA #2 reported to her Resident #2 had his/her hand under Resident #1's shirt. She stated she did not consider this appropriate behavior, and indicated she reported the incident to the DON as soon as she was made aware of it. LPN #2 explained when an incident occurred, the nurse reported it to the Administrator or the DON and waited for instructions on what to do. Continued interview revealed LPN #2 did not document the incident because she was told in the morning shift change report not to document behaviors between Resident #2 and Resident #1. LPN #2 stated she did not feel comfortable with being told not to document Resident #2's behaviors toward Resident #1; however, she verbally passed it on to the next oncoming nurse, but did remember who that nurse was. Further interview revealed LPN #2 did not perform a physical exam on Resident #1 for possible injury and did not complete an Incident Report as per facility policy. There was no documented evidence LPN #2 took any action to ensure Resident #1 was protected from further potential abuse by Resident #2. Interview with LPN #10 on 08/21/14 at 3:20 PM, revealed on 07/28/14 it was reported to her in shift change report by LPN #5 that Resident #2 was on every fifteen (15) minute checks because he/she had sexual behaviors towards Resident #1. She stated she was also told by LPN #5 in report not to document any inappropriate behavior by Resident #2. Continued interview revealed she did not feel comfortable with those instructions, but had passed the information along to the next nurse during shift report. Subsequent interview with LPN #10, on 09/04/14 at 3:10 PM, revealed the LPN #2/Charge Nurse told her Resident #2 was found in Resident #1's room with his/her hand up under the resident's shirt. LPN #10 stated LPN #2 told her she had called the DON because the Administrator was out of the facility. Interview with LPN #5 on 08/24/14 at 8:30 PM, revealed she was told "in report" not to document resident behaviors in the Nurse's Notes, but was not sure who told her this. LPN #5 stated nurse were "supposed to call the Administrator or the DON for incidents and then receive instructions on what to do". LPN #5 reported nurses had "a list of incidents" which required "calling the Administrator" about. The Surveyor requested a copy of the list; however, a copy was never provided. Interview with LPN #6 on 08/29/14 at 2:45 PM, revealed during a meeting on 07/30/14, at approximately 9:30 AM, LPN #11 came into the meeting and asked to speak to the DON outside of the room. Continued interview revealed after a few minutes the DON came back into the meeting and told the Administrator Resident #2 was "trying to go towards" Resident #1 again. According to LPN #6, the Administrator told her to call Resident #2's Physician and get an order to send the resident "out" to the hospital. LPN #6 indicated she notified the Physician as per the Administrator's instructions on 07/30/14. Review of Resident #2's Comprehensive Care Plan revealed the undated problem for "social interaction impaired related to inappropriate behavior" was updated on 07/30/14 stating the resident was sent to the hospital psych unit. Interview with SRNA #7 on 09/04/14 at 2:25 PM, revealed she had to redirect Resident #2 away from Resident #1's room three (3) to four (4) times daily before Resident #2 went out to the hospital on [DATE]. Interview with SRNA #8 on 09/04/14 at 2:22 PM, revealed she had redirected Resident #2 from Resident #1's room one or twice, maybe more often, before Resident #2 went to the hospital on [DATE]. Continued review of Resident #2's medical record revealed a "Patient Information" form, dated 07/30/14, which noted Resident #2 was transferred to the hospital on [DATE]. Review of the Form revealed Resident #2's mental status was documented to be alert and oriented times three (3), which indicated the resident was alert and oriented to person, place and time. The Form noted Resident #2 had a BIMS score of ten (10) out of fifteen (15), which indicated the resident was now assessed as moderately cognitively impaired. Continued review of the Form revealed Resident #2 had displayed "inappropriate behaviors with females (touching inappropriately), difficult to redirect", and continued "to repeat behaviors." Review of the "Transfer and Discharge" form dated 07/30/14 revealed the reason checked for transfer was "the safety of individuals in our facility is endangered". Continued review of the "Transfer and Discharge" form revealed the reason "...as set forth in the clinical record" was documented to be "inappropriate behaviors with females". Review of Resident #2's hospital record revealed the resident was admitted to the hospital Behavioral Health Unit from the emergency room (ER) on 07/30/14 at 3:37 PM for sexually inappropriate behaviors with females, and on admission was alert to person, place and time. Continued review of the hospital records revealed Resident #2's history was taken by phone by the hospital's Licensed Clinical Social Worker (LCSW) from an unidentified facility Registered Nurse (RN). The LCSW documented Resident #1 recently had began to "experience sexualized behaviors" towards another resident who had Severe [MEDICAL CONDITION]. Per the hospital documentation the facility RN told the hospital LCSW "for the past two (2) days" Resident #2 had been "wheeling" up to a "particular" resident and was touching his/her genital area without the resident's consent. Further review of the hospital record revealed Resident #2 was admitted to the hospital's Behavioral Health Unit because of the "seriousness" of the resident's "sexually aggressive behaviors". In addition, review of the hospital record revealed a Physician's Progress Note, dated 08/03/14 at 7:37 AM, which noted Resident #2 had a [DIAGNOSES REDACTED].#2 back to the facility on [DATE]. Further record review revealed the facility readmitted Resident #2 on 08/04/14 to the same room, on the same hall as Resident #1. Review of the Admission Nursing Assessment revealed the resident was assessed to be oriented to person, place and time. Review of Resident #2's Comprehensive Care Plan revealed it had been revised to include an intervention for fifteen (15) minute checks to start on 08/04/14. However, review of the "Monitoring" forms revealed no documented evidence every fifteen (15) minute checks were completed from 08/04/14 through 08/08/14. Staff interviews revealed on 08/04/14 after Resident #2's return from the hospital two (2) separate incidents occurred in which Resident #2 was observed, once by SRNA #7 and at another time by SRNA #2, with his/her hand up inside Resident #1's pant's leg. Continued interview with SRNA #7 on 09/04/14 at 2:25 PM, revealed she observed Resident #2 in Resident #1's room on what she believed to be 08/04/14, the day Resident #2 was readmitted to the facility from the hospital. SRNA #7 reported Resident #1's pant's leg was pulled up and Resident #2 had his/her hand up the pant's leg to the groin area. She stated she was uncertain who she had reported it to, but thought it was LPN #10. Interview, on 08/21/14 at 3:20 PM and 09/04/14 at 3:10 PM, with LPN #10 revealed she indicated she had not had anything reported to her about Resident #2 having his/her hand in Resident #1's pants. She stated she recalled another nurse, LPN #2 reported to her Resident #2 had his/her hand up in Resident #1's shirt one (1) time; however, could not recall the exact date. Interview with SRNA #2, on 08/21/14 at 1:20 PM, revealed she had observed Resident #2 in Resident #1's room on Monday, 08/04/14, the day Resident #2 had returned from the hospital. The SRNA reported Resident #2 had more than half of his/her hand in the front of Resident #1's pants and stated, "no doubt" Resident #2's "fingers were touching" Resident #1's "pubic area". Continued interview revealed SRNA #2 reported the incident to LPN #2. Interview, on 08/21/14 at 1:20 PM, on 09/09/14 at 3:50 PM and on 09/10/14 at 9:55 AM, with LPN #2 revealed she could only recall SRNA #2 informing her on 07/28/14 of Resident #2 having his/her hand up in Resident #1's shirt. She indicated she did not recall SRNA #2 informing her of any other incidents regarding Resident #2's behaviors. Interview with SRNA #5, on 08/21/14 at 1:00 PM and on 09/04/14 at 2:45 PM, revealed approximately two (2) weeks prior to 08/21/14, uncertain of exact date, she had witnessed Resident #2 go into Resident #1's room and try to reach for the resident's genital area. She explained however, the overbed table was in the way and Resident #2 could not reach Resident #1's genital area. Continued interview revealed she and LPN #11 then intervened and removed Resident #2 from Resident #1's room. Review of Resident #2's record revealed a Nurse's Note dated 08/09/14 timed 10:40 AM which stated Resident #2 "entered another female resident's room", was removed and sent to activities. Interview with the Administrator on 08/29/14 at 3:45 PM, revealed on 08/09/14 it was reported to her Resident #2 was "trying" to go to Resident #1's room, was "easily redirected", but "when staff left" he/she would "go right back" to Resident #1's room. She stated she told staff to "go ahead and notify" the Physician and have Resident #2 sent back out to the hospital for another psych evaluation because of his/her "continued approaches" to Resident #1. Review of Resident #2's "Monitoring" forms revealed on 08/09/14 every fifteen (15) minute checks were documented beginning at 10:45 AM which were documented until 1:45 PM, and at 2:00 PM it was documented the resident was out of the facility. Review of the Transfer and Discharge Form, dated 08/09/14, revealed Resident #2 was transferred back to the hospital with the reason checked for transfer as "the safety of individuals in our facility is endangered". Continued review of the "Transfer and Discharge" form revealed the reason Resident #2 was transferred to the hospital was for "inappropriate behaviors toward female residents". Review of the "Patient Information" form, dated 08/09/14, revealed Resident #2's mental status was documented to be alert, and had "again went to female room-intending inappropriate behavior". Review of the hospital record for Resident #2 revealed the resident was again admitted to the hospital Behavioral Health Unit on 08/09/14 at 3:07 PM. Review of the Physician's Note, dated 08/09/14 at 3:20 PM, revealed Resident #2 had stated he/she had been a "bad boy" and was touching the ladies. Continued review of the Note revealed Resident #2 had also stated he/she had been trying to touch the ladies for a long time and finally "got my hands on one today". Continued review of the hospital record revealed Resident #2 was assessed by hospital staff to be alert to person and place, and to the current President. Record review revealed the facility readmitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment, dated 08/12/14, revealed Resident #2 was oriented to person, place and time on readmission to the facility. Interview with Resident #2 on 08/20/14 at 7:08 PM, revealed the resident was aware he/she had touched Resident #1 inappropriately, and stated, "I touched someone I was not supposed to". Continued interview revealed Resident #2 reported he/she "liked" Resident #1, and did not know how many times he/she had touched Resident #1. Resident #2 stated he/she touched Resident #1 "here", and pointed and rubbed his/her hand over the genital area. Resident #2 further reported touching Resident #1 inside his/her clothes. Interview with with Resident #1's POA on 08/22/14 at 12:15 PM, revealed he was visiting one night and was told by a nurse, who no longer worked at the facility, Resident #1 had been approached in the hallway by another resident, but nothing happened and the nurse said it was not a "sexual thing". He stated he had not been told of any other incidents, and reported he was unaware there were other incidents. Interview with Resident #2's POA, on 09/04/14 at 10:20 AM, revealed she could not remember the date she was notified of an incident regarding inappropriate behavior by the resident towards another resident. Interview with Resident #1's and Resident #2's attending Physician, on 08/20/14 at 4:00 PM, revealed he became aware of Resident #2's sexual behaviors toward Resident #1 on 07/30/14, and gave an order to send Resident #2 to the hospital for a psych evaluation. The Physician indicated he was only aware of Resident #2's behaviors on 07/30/14 and on 08/09/14. Interview with the Social Service Director (SSD), on 08/22/14 at 10:00 AM, revealed she indicated she was told that Resident #2 was going into Resident #1's room on 07/30/14, but was not told anything else about Resident #2's behaviors. The SSD stated no other residents had made any complaints about Resident #2; therefore, she did not investigate or interview other residents and no one asked her to investigate or question the residents. She further stated she was uncertain if any other residents were questioned or examined. Continued interview revealed if there was an incident, the Administrator would ask her to conduct interviews with the staff and residents. However, the Administrator did not ask her to investigate any incidents involving Resident #1 and Resident #2. Interview with the DON, on 08/22/14 at 10:20 AM and on 08/29/14 at 7:40 PM, at 8:00 PM and 8:30 PM, revealed she was first notified of Resident #2's behaviors towards Resident #1 on 07/28/14 "around noon". She stated she "immediately" texted the Administrator who sent the Social Worker to perform a BIMS on Resident #2. The DON revealed it was reported to her Resident #2 had been sitting in Resident #1's "doorway in the hall pulling on" Resident #1's shirt. She stated she couldn't say if family or the Physician was notified because "nothing happened", and the Administrator did not instruct anyone that she was aware of to start and investigation. According to the DON, the every fifteen (15) minute checks were continued, an assessment was performed on Resident #2 to determine the reason for the change in the resident's behavior. She stated it was her "understanding" there was "no distress" noted to Resident #1 per the nurses; therefore she did not conduct an assessment of Resident #1 for potential injury. The DON stated she had not "talked" to Resident #2 "about the incident". Per interview, she stated no physical examinations were performed on other non-interviewable residents after the incidents which occurred prior to Resident #2 being sent out to the hospital on [DATE]. She stated she was told in the "morning meeting" on 07/30/14 Resident #2 was "seeking out" Resident #1. Continued interview with the DON revealed on 07/30/14, Resident #2 was observed "heading towards" Resident #1's room, was stopped by staff and redirected to an activity and the Administrator "moved forward" with sending Resident #2 out to the hospital. Interview with the Administrator on 8/29/14 at 3:45 PM and at 6:45 PM, revealed on 07/26/14 "in the evening" it was the first time she was informed of Resident #2 having "inappropriate sexual behaviors". The Administrator reported the "first thing" staff told her on 07/26/14 was Resident #2 had his/her hands "down" Resident #2's pants; however, after she asked questions it was "said" Resident #2 had his/her "fingers in the waistband" of Resident #1's pants. She stated she thought it was LPN #6 who called and reported this to her; however, stated she had no documentation of the phone call. The Administrator revealed she told LPN #6 to keep Resident #2 on one on one (1:1) observations until she called her back. The Administrator stated she called and spoke to the Corporate Nurse, and then called the facility and spoke to LPN #1 and told her to initiate every fifteen (15) minute checks. She stated she asked if there were any other changes to Resident #2, and LPN #1 told her "no, not really". Per interview, the Administrator stated she asked LPN #1 what Resident #2's last assessed BIMS were, and LPN #1 told her fifteen (15). She stated the two (2) residents should have been separated and protected. The Administrator stated she had not felt Resident #2's behaviors were "willful at any time" because when he/she was "questioned", he/she didn't "answer appropriately to the questions being asked" which "showed cognitive impairment". She stated the every fifteen (15) minute checks were how the facility "felt" they had "kept the residents safe". According to the Administrator, the DON reported to her on 07/28/14 a nurse had told her Resident #2 had "hold of" Resident #1's shirt, "pulling on the bottom of the shirt". The Administrator explained she asked the DON if a physical assessment was completed on Resident #2 to try to determine the "root cause" for the "changes" in his/her behaviors. The Administrator indicated a physical assessment of Resident #2 was completed, and LPN #2 reported the assessment did not reveal "any reason for the changes". She stated she had the Social Worker reassess Resident #2's BIMS on 07/28/14, and the Social Worker reported the resident's BIMS as "seven (7)" after the reassessment. Per interview, it was reported to the DON on 07/30/14 Resident #2 was "continuing to seek" out Resident #1. Resident #2 had gone to Resident #1's doorway and was reaching toward him/her. She stated the DON notified her of this information, and she had "them" call the Physician for "a psych eval". The Administrator revealed Resident #2's Physician had been "updated" of Resident #2's "inappropriate sexual behavior" on 07/29/14; however, there was no documentation of when the Physician was first notified. Continued interview with the Administrator on 08/29/14 at 3:45 PM revealed Resident #2 returned to the facility on [DATE], with no "report" of behaviors or issues, and "appeared" to be the same "as we all knew" him/her, friendly and cooperative. The Administrator stated; however, on 08/09/14 after she was notified of Resident #2 still trying to go into Resident #1's room, being redirected out of the room and going right back, Resident #2 was sent to the hospital again for another psych eval. She stated Resident #2 was readmitted to the facility, 08/12/14, to another unit after the last hospitalization for psych evaluation and there had been no further "episodes of behaviors" towards other residents. The Administrator stated she had not told the nurses not to document or not to report Resident #2's behaviors towards Resident #1. Additional interview with the Administrator, on 09/04/14 at 7:50 PM, revealed she was uncertain why the every fifteen (15) minute checks for Resident #2 were not performed and documented as being done for 08/04/14 through 08/08/14; however, stated the fifteen (15) minute checks should have been completed. She stated the every fifteen (15) minutes checks of Resident #2 were how the facility felt they kept Resident #1 safe. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/09/14 that alleged removal of the IJ effective 09/03/14. Review of the AOC revealed the facility implemented the following: 1. Resident #1 was assessed by means of a head to toe skin assessment on 07/28/14 by an LPN, and again on 08/05/14. Both skin assessments indicated Resident #1's skin was intact with no redness. A complete assessment of Resident #1 was conducted by the Physician on 07/31/14 and documented as follows: "advanced dementia, otherwise, no significant issues to deal with. Chart is reviewed. (Resident) is seen. Her exam is unchanged. Plans: for ongoing care by current written orders". 2. After the incident on 07/26/14, Resident #2 was removed from the area and 1:1 supervision (for one hour) by activities staff was provided, followed by every 15 minute checks by nursing staff. On 08/29/14 at 9:00 PM, 1:1 monitoring was initiated, as directed by the Administrator, for Resident #2. This will be ongoing. 3. On 08/29/14 at 9:15 PM, an in-service was conducted by the Vice President of Clinical Services for the Administrator and Director of Nursing (DON) on the following: definitions of abuse; reporting obligations related to abuse allegations; identification of abuse; investigation of abuse allegations; implementation of the facility's Resident Protection Policy; and accuracy of the clinical record. The Administrator and the DON were able to verbalize understanding of the education. 4. On 08/29/14 at 10:30 PM, 08/30/14 at 10:30 AM and 08/30/14 at 1:00 PM, the Social Service Director, Dietary Manager, Activity Director and all licensed staff were in-serviced by the Administrator and the DON on accuracy of clinical records, as related to documentation and notification of the Physician and the Power of Attorney or legal representative. On 08/29/14 at 10:00 PM, 08/30/14 at 10:00 AM, and 08/30/14 at 2:00 PM, all staff were in-serviced by the Administrator and the DON related to accuracy of the clinical record. On 08/29/14 at 10:00 PM and 10:30 PM, 08/30/14 at 10:00 AM and 10:30 AM and 08/30/14 at 1:00 PM and 2:00 PM, the Administrator and the DON educated all staff on the following: the definitions of abuse; reporting obligations of abuse allegations; identification of abuse; investigation of abuse allegations and implementation of the facility's Resident Protection Policy; accuracy of the clinical record; and revision of care plans. A question and answer period was held at the conclusion of all in-services to establish competency. Twelve (12) employees out of the facility for medical leave, maternity leave or vacation were educated by the DON via telephone. No staff will be permitted to work until they have been educated. 5. All resident records were reviewed by the DON, Minimum Data Set (MDS) staff, Admission Nurse, and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure accurate notification of the Physician and legal representatives. All residents who triggered on the MDS assessment for behaviors that affect others were reviewed on 08/30/14 by MDS staff and administrative nurses to ensure the care plan reflected current interventions. All resident assessments and care plans were reviewed by the DON, MDS staff, Admission Nurse and administrative nurses, starting on 08/30/14 and ending on 09/02/14, to ensure completeness and accuracy. 6. All female residents were questioned by the Social Service Director and the Activity Director on 08/30/14, beginning at approximately 9:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All residents answered "No". All male resident were interviewed by the DON and the administrative nurses on 09/02/14, beginning at approximately 10:30 AM, regarding whether they had been touched inappropriately by a male resident or anyone since they had resided at the facility. All responded "No". 7. As confirmed by Resident #2's Power of Attorney, the Charge Nurse of the facility made her aware of the initial occurrence and subsequently updated her related to Resident #2's continued persistence in propelling toward Resident #1's room. On 08/05/14 the facility Administrator met with Resident #2's POA at length to discuss future plans, room changes, etc. On 08/30/14 at 10:45 AM, the Vice President of Clinical Services met with Resident #2's POA to validate she was notified of all allegations of inappropriate behavior and actions taken by the facility. Resident #1's son was contacted by the Vice President of Clinical Services at 4:00 PM on 08/30/14 to ensure he was aware of the above concerns. He stated he was aware and had been notified by facility staff. No other concerns were expressed. 8. On 08/30/14 at 3:05 PM, the Attending Physician for Resident #1 and Resident #2 was contacted by the Vice President of Clinical Services. The Physician stated he was well aware of (Resident #2's) change in behavior. He stated he informed the surveyor he had been notified and updated concerning both residents (#1 and #2). 9. Based on the weekly skin assessments, all residents with identified skin areas were reviewed in the weekly Quality of Care meetings by

Based on interview, record review, and review of the emergency room (ER) report and hospital record, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure ongoing assessment, failed to ensure the Physician was informed of all changes, and failed to implement timely treatment to Resident #1's right lower leg. On 08/28/11, Resident #1 was hospitalized , treated with Intravenous (IV) antibiotics, and required surgical intervention for an infection in the right lower leg. The findings include: Review of the ER report, dated 08/28/11, revealed Resident #1 presented in the ER with significant soft tissue swelling, with a fluctuant area on his right lower leg where the blisters had resolved, but he/she had [DIAGNOSES REDACTED] (redness of the skin which can occur with infection and/or inflammation), [MEDICAL CONDITION] and possible abscess. The resident was started on intravenous (IV) antibiotics and a needle was used to aspirate large amounts of gross purulent fluid. Further review of the ER report revealed, after the purulent fluid was drained from both abscesses, the area was irrigated thoroughly until the fluid ran clear, and the fluctuant areas were completely resolved using suction. On 08/29/11, the resident was taken to the operating room and an incision was made to the lower right leg, and large amounts of purulent fluid was drained from both abscesses. The whole pretibial area was swollen and appeared to be one continuous fluctuant area with some [MEDICAL CONDITION]. There was dried skin that was consistent with prior blisters that had already popped and mild cracks in the skin where it had been dry and irritated. Review of Resident #1's clinical record revealed the facility admitted Resident #1 on 05/25/11, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 06/10/11, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was oriented with no cognitive impairment. Review of the Comprehensive Care Plan, developed on 06/14/11 revealed the facility had developed a Care Plan for impaired skin integrity, with interventions that included report any red or open areas and weekly skin checks. Record review of the Orthopedic Physician's report, dated 08/22/11, revealed when the cast to the resident's lower right leg was removed, the leg looked good with minimal redness over the tibia. The skin was dry and peeling; however, there was no tenderness and no signs of infection. Interview with the Orthopedic Physician, on 09/22/11 at 3:20 PM, revealed when the cast was removed on 08/22/11, the skin was slightly red, with dry peeling areas of skin; however, there were no open areas, no blisters, no swelling, and no signs of infection. Interview with Resident #1's spouse, on 09/27/11 at 6:00 PM, revealed he/she was with Resident #1 when the cast was removed. The spouse stated the right lower leg was slightly red and had dry skin patches. He/she further stated the skin did not have any open areas or blisters until later in the evening. Per interview, Resident #1's bed was broken and the resident was placed in a chair until the bed was repaired, and it was at that point, with the leg hanging down, the blisters developed. He/she informed Licensed Practical Nurse (LPN) #5 about the blisters; however, LPN #5 told the resident's spouse this was normal and the doctor had ordered mineral oil for the blisters. Review of the Weekly Nurses Notes, dated 08/22/11, revealed LPN #5 documented under Skin Condition, "the cast was removed from the right lower leg, red patchy areas, skin cracked". Further review of the Weekly Nurses Notes, on 08/22/11 at 6:50 PM, revealed LPN #5 documented the resident had fluid filled intact blister to shin and intact fluid filled blister to ankle inner aspect. Interview with LPN #5, on 09/23/11 at 10:00 AM, revealed the evening of 08/22/11, Resident #1 had developed clear fluid filled blisters on his/her lower right leg. She further stated the leg appeared slightly discolored, with dry peeling skin. Review of the physician's orders [REDACTED]. However, interview with the Orthopedic Physician, on 09/22/11 at 3:20 PM, revealed he had never given an order to apply mineral oil to the resident's leg. He stated, "I would never give an order for [REDACTED]. He further stated the facility had not contacted his office about Resident #1's right lower leg developing blisters and the last time his office had been contacted by the facility was 08/15/11. Interview with Resident #1's Physician, on 09/22/11 at 2:20 PM, revealed he received a fax on 08/23/11 stating the resident had developed clear fluid filled blisters and they had been using mineral oil for the dry skin. He further stated he had not given the order to use mineral oil on the resident's leg. Interview with LPN #5, on 09/28/11 at 8:50 AM, revealed it had been a nurses order to apply the mineral oil to the areas of dry skin. She further stated she did not know why she wrote the Orthopedic Physician's name of the order. Interview with Resident #1's spouse, on 09/27/11 at 6:00 PM, revealed he/she reported to the nurses on Thursday, 08/25/11, the pain in the resident's leg had become worse and when he/she questioned the appearance of the leg, LPN #2 stated there was nothing wrong, and the appearance was the same as the day the cast had been removed. Further interview revealed, by Friday, 08/26/11, Resident #1 had become increasingly more confused. Per interview, the spouse reported to LPN #4 the resident had been seeing things that were not there, and again voiced concerns about the appearance of the resident's leg and the resident's increased pain in the right lower leg. The spouse was told the leg appeared normal and the resident had just received pain medication. Review of the Weekly Nurses Notes for the week of 08/21/11 to 08/26/11, revealed the only documentation related to the blisters on the resident's leg was made by LPN #5 on 08/22/11. Further interview with Resident #1's spouse, on 09/27/11 at 6:00 PM, revealed on Saturday, 08/27/11, the spouse again was told, by LPN #5 the leg appeared to be healing and the reddened areas were normal. The spouse stated he/she became very upset and insisted the Physician be notified. He/she further stated the leg had become a "very angry shade of red", very swollen, and the pain had become even more severe in the leg. Further interview revealed, he/she came to the facility, on the evening of 08/27/11, after Resident #1 called and reported he/she was seeing people in his/her room and the pain had become a lot worse. The spouse spent the night with the resident and was awake all night because Resident #1 was hurting and the nurse was unable to reposition his/her leg in a manner to relieve the pain. Record review of the Weekly Nurses Notes, dated 08/27/11 at 1:15 AM, revealed the resident was complaining of leg pain and requesting pain medication. The resident was unable to receive pain medication because he/she had received pain medication for leg pain at 12:00 AM. Further review of the Weekly Nurses Notes revealed the nurse tried to reposition the leg to help with the pain but was unable to change the position enough to make a difference. Review of the Weekly Nurses Notes, dated 08/27/11 at 9:00 AM, revealed new treatment to the right lower leg. Further review revealed at 2:30 PM, the Attending Physician was notified of right lower leg and treatment was changed secondary to fluid filled blister type areas and that the resident was seeing little people. Review of the Physician Order's, dated 08/27/11 at 9:00 AM, revealed an order to discontinue the mineral oil to leg and apply [MEDICATION NAME] and cover with ABD pad and dry dressing to right lower leg shin area and inner ankle, change daily and as needed for fourteen (14) days for burst blisters. Further review of the Care Plan revealed an intervention added on 08/27/11, for [MEDICATION NAME] and cover with ABD pad and dry dressing to right lower leg every day and as needed for fourteen (14) days for blisters. However, interview with LPN #5, on 09/22/11 at 10:00 AM, revealed the order for [MEDICATION NAME] and cover with ABD pad and dry dressing was a nursing order, not a physician's orders [REDACTED]. Interview with Resident #1's Physician, on 09/22/11 at 2:20 PM, revealed when LPN #5 called him on 08/27/11 at 2:00 PM, she notified him of the increased pain from the bladder spasms but did not inform him of increased pain in the leg, the change in the resident's mental status, or the change in the appearance of the right lower leg. Interview further revealed he had never given an order for [REDACTED]. Record review of the Weekly Nurses Notes, dated 08/28/11 at 1:00 AM, revealed Resident #1's temperature was 99.6 and pain medication was given; and, at 8:00 AM, Resident #1's temperature was still 99.6. Further review revealed LPN #5 documented the leg was red, with fluid filled blisters and warm to the touch. Continued interview with Resident #1's spouse, on 09/27/11 at 6:00 PM, revealed on 08/28/11, when the first shift nurse came into the room to assess the resident, he/she told the nurse the Physician needed to be called immediately and the resident's leg needed to be addressed because it was infected. Interview with LPN #7, on 09/25/11 at 5:30 PM, revealed she had taken care of Resident #1 on 08/27/11 and 08/28/11. She stated Resident #1 had not complained of pain to her nor had the wife reported any complaint of pain in the right leg. She further stated the right lower leg had a blister which had burst with clear drainage. She further stated the leg appeared slightly red with dry slough skin; however, she did not notify the Physician. Interview with LPN #5, on 09/23/22 at 10:00 AM, revealed she had taken care of Resident #1 on 08/27/11 and 08/28/11. She stated, on 08/27/11 she noticed the leg had started to look different. Further interview revealed the blisters were flat and not fluid filled. She stated the skin was dry and sloughing off, the color was off, and the areas where the blisters had been were raw looking and had dry skin around the edges. She further stated the leg was not warm to the touch nor was it red or swollen. She stated, on 08/28/11, when she arrived at work, LPN #7 reported to her in report, Resident #1 had complained of pain in the right leg and the wife had spent the night. She stated she went to Resident #1's room first and she assessed the leg at that time and found a raised area which was not there the day before. She further stated she had only assessed one raised area, it was fluid filled with serious sanguineous (blood tinged) fluid, it had become slightly reddened, but it was not warm to the touch. Interview with Resident #1's Physician, on 09/22/11 at 2:20 PM, revealed he should have been notified sooner about the change in the leg. He stated, "An abscess can develop over night but I cannot prudently say two abscesses, that size, could develop over night. It appeared the blisters had burst and the blister cover had obviously dried up, almost completely resolved, but the subcutaneous layer underneath the area had become infected at some point and the abscess developed". He stated the right lower leg appeared an angry deep red, with fluctuant, very swollen, pretibial (from the ankle to just below the knee), and there was significant soft tissue swelling. He stated the whole area underneath was one large abscess. He further stated there was an open area which appeared to be an old blister which had burst at some point, with granulation tissue. Interview further revealed there was a second abscess on the inner aspect of the ankle. This area was described as being the size of a baseball with fluctuant, dark red in color, warm to the touch, with sloughing skin. He further stated, LPN #5's skin assessment completed on 08/28/11, before Resident #1 was sent to the emergency room (ER), did not accurately describe the appearance of the resident's lower right leg. Record review revealed on 08/28/11, Resident #1 was hospitalized , treated with Intravenous (IV) antibiotics, and required surgical intervention for an infection in the right lower leg.