Every finding on record at Merry Wood Lodge

Based on interviews, resident record review, review of the facility investigative files, review of Facility Reported Incidents (FRI), and review of a facility policy titled Abuse Prohibition, the facility failed to protect the rights of Resident Identifier (RI) #22 and RI #21, to be free from verbal and physical abuse perpetrated by RI #101. Specifically, the facility failed to provide adequate supervision and interventions per facility policy to prevent occurrences of abuse perpetrated by RI #101. RI #101 was admitted to the facility in July of 2024 with Dementia and Behaviors and was care planned for exhibiting physical behaviors. On 10/04/2024 RI #101 hit RI #22 in the chest while in the dining area for the lunch meal. Witnesses stated, RI #22 put his/her hands up in self-defense while being hit and someone in that situation would feel very upset and scared. Further, on the next day 10/05/2024, just after every 15-minute monitors for the incident the day before had ended, the facility failed to provide adequate supervision and interventions to prevent RI #101 from verbally and physically abusing RI #21. RI #101 called RI #21 a son of a bitch and hit RI #21 in the face while sitting in the day area watching television. Witnesses stated, a person being hit in the face in their own home would feel scared or unsafe and it would hurt to be hit in the face. This affected RI #21 and RI #22, two of five residents sampled for abuse. This deficiency was cited as a result of the investigation of FRI/complaint/report numbers AL00049207 and AL00049197. Findings include: A facility policy titled Abuse Prohibition with a revised date of 10/24/2022, documented the following: POLICY Centers prohibit abuse, mistreatment, neglect, . for all patients. The Center will implement an abuse prevention program through the following: . Prevention of Occurrences; . Federal Definitions: Abuse is defined as the willful infliction of injury, . intimidation, . or mental anguish. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, . physical abuse, and mental abuse . Verbal Abuse is any use of oral, written, or gestured language that is willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Physical Abuse includes, hitting, slapping, pinching, kicking, . PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, . for all patients. 5. Actions to prevent abuse, . will include: . 5.2 identifying, correcting, and intervening in situations in which abuse, . is more likely to occur; . 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 6.3.1 The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. 6.3.2 The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. 9. The Administrator or designee will: 9.1 Take all necessary corrective action depending on the results of the investigation; 9.3 Take steps to revise patients' care plan where indicated if there is a change in the patient's medical, nursing, physical, mental or psychosocial needs or preferences as a result of an incident of abuse; . 9.5 Take appropriate corrective actions. On 10/04/2024 the State Agency received a Facility Reported Incident (FRI) alleging RI #101 placed his/her open hand on RI #22's chest in the Memory Care unit. The report indicated the facility notified local law enforcement and RI #101 was placed on every 15-minute checks for 24 hours to monitor for additional aggressive behaviors. RI #101 was admitted to the facility on [DATE] with diagnoses to include Dementia with Behavioral Disturbance, Mild Neurocognitive Disorder due to known Physiological Condition with Behavioral Disturbance, and Mood Disorder. A review of RI #101's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/04/2024 revealed a Brief Interview for Mental Status (BIMS) score of a 6 of 15 which indicated severely impaired cognition. RI #22 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Alzheimer's Dementia with Behavioral Disturbance and Expressive Language Disorder. A review of RI #22's quarterly MDS assessment with an ARD of 09/30/2024 revealed a BIMS score of 9 of 15 which indicated moderately impaired cognition. Review of the facility investigative file for the incident dated 10/04/2024 revealed a Resident to Resident Investigation Summary involving RI #101 and RI #22 that documented: . Investigation Conclusion: Based on current evidence abuse was not substantiated . The investigation does demonstrate that the event did occur, . (RI #101) did strike (his/her) open hand on . (RI #22's) upper chest. While (RI #101) and (RI #22) are severely cognitively impaired the actions were deliberate. Also included in the facility investigative file was a letter addressing To Whom it May Concern: that documented the actions were deliberate as follows: . Allegation Summary: On October 4, 2024, it was reported that (RI #101) had reached out with an open hand and struck (RI #22's) upper chest. According to staff in the area at the time, (RI #101) started to get loud and when staff noted what was occurring, they saw (RI #101) with (his/her) open hand on (RI #22's) upper chest area. One aide present stated that (RI #101) struck (RI #22). (RI #22) also had (his/her) hands up in what staff felt was blocking position. Center Conclusion: The investigation does demonstrate that the event did occur, (RI #101) did strike (his/her) open hand on (RI #22's) upper chest. the actions were deliberate. A WITNESS INTERVIEW RECORD dated 10/04/2024 and signed by Certified Nursing Assistant (CNA) #3 documented: . What did you see? (RI #101) was up and down with . (agitation) before staff could redirect (he/she) swung an open hand at (RI #22's) chest area (RI #22) then put hands up to protect (himself/herself) . A Witness Statement dated 10/04/2024 for Licensed Practical Nurse (LPN) #4 documented: . What did you see? Once I heard (RI #101) hollering I (turned) around to see (RI #101) in front of (RI #22) who was putting (his/her) hands up in defense blocking (his/her) face. A telephone interview was conducted on 10/16/2024 at 4:06 PM with CNA #3 who witnessed the incident on 10/04/2024 during lunch time on the Memory Care Unit. CNA #3 said, RI #101 was fussing and cursing and rolled his/her wheelchair over to the table where RI #22 was eating lunch and struck RI #22. CNA #3 said, RI #22 then put his/her hands up to his/her face in a defensive and protective manner. CNA #3 said, RI #101 curses and hits out at staff on a daily basis. When asked what type of abuse this incident would be considered, CNA #3 said, it was physical abuse. CNA #3 said, someone in that situation would be very upset. On 10/16/2024 at 3:15 PM LPN #4 was asked about the incident between RI #101 and RI #22 on 10/04/2024. LPN #4 said, she was at the nursing station and heard RI #101 cursing and yelling loudly, so she turned around and saw RI #101 in front of RI #22 who had both hands up blocking his/her face. LPN #4 said, she saw the end of the hit as RI #101's hands were coming off of RI #22. LPN #4 said, this happened in the dining room during lunch. LPN #4 said, prior to the incident RI #101 had been cursing. LPN #4 said, she ran over and separated the residents, both were assessed for injury, and no physical injury was noted. LPN #4 said, every 15-minute checks were initiated to monitor RI #101. LPN #4 said, what she witnessed was physical abuse and someone in that situation, being hit while eating their meal, would feel upset and scared. On the next day, 10/05/2024 at 6:09 PM the State Agency received a Facility Reported Incident (FRI) alleging RI #101 was witnessed striking RI #21 on the Memory Care unit. RI #21 was admitted to the facility on [DATE] with diagnoses of Dementia without Behavior Disturbance. RI #21's quarterly MDS assessment with an ARD date of 07/29/2024 revealed a BIMS score of 5 of 15 which indicated severely impaired cognition. Review of the facility investigative file for the incident dated 10/05/2024 revealed a Resident to Resident Investigation Summary that documented RI #101 had verbally and physically aggressive history and included that the actions were deliberate as follows: . The investigation does demonstrate that the event did occur (RI #101) did strike (his/her) open hand on (RI #21's) face. While (RI #101) and (RI #21) are severely cognitively impaired the actions were deliberate. this investigation cannot substantiate abuse at this time. A review of a facility handwritten witness statement from CNA #5 dated 10/05/2024 at 3:20 PM documented: . (RI #101) kept . standing up snatching on (RI #21's) wheelchair. (RI #21) told (RI #101) to stop (RI #101) cussed . (at) (RI #21) and hit (RI #21) in the face. A more detailed handwritten statement signed by CNA #5, dated 10/11/2024 documented: . Employee (CNA #5) stated resident (RI #101) was in the dining area watching TV with other residents she was monitoring the dining area . (RI #101) was given a snack and placed at a table near (RI #21) shortly after being place there (he/she) had moved from the table in (his/her) wheel chair towards (RI #21) which (he/she) then was pulling at (RI #21's) wheelchair to help roll (his/her) self Employee stated she heard (RI #21) saying stop and realize (RI #101) moved from the table so she went and redirected (him/her) after several minutes of (him/her) staying put she was tending to other residents when she heard (RI #21) yell out to stop again she turned to see what was going on and (RI #101) was standing up and swung (his/her) hand at (RI #21) she hurried over to redirect both resident . On 10/17/2024 at 3:33 PM an interview was conducted with CNA #5 who was working with RI #101 on 10/05/2024. CNA #5 said, upon arriving to work that day around 2:00 PM, RI #101 was assisted out of bed and taken to the activity room. CNA #5 said, RI #101 was calm initially however, started getting agitated and cursing, getting up and down. CNA #5 said, RI #101 was at his/her own table, then rolled over to RI #21's wheelchair and she redirected RI #101 back to the table area, provided a snack, offered to take RI #101 back to bed, and RI #101 said, no and cursed at CNA #5. CNA #5 said, RI #101 ate the snack, and she went to assist another resident. Soon after, CNA #5 said, she heard RI #101 cursing, getting agitated, heard RI #21 say stop, and CNA #5 saw RI #101 pulling up on RI #21's wheelchair. CNA #5 said, before she could get back over to intervene, RI #101 had hit #21 on the right side of the face. CNA #5 said, it was not a hard hit, however, it could have been painful to be hit in the face. CNA #5 said, she jumped between them to keep RI #21 from hitting RI #101 back, because RI #21 wanted to fight back. The two residents were immediately separated and CNA #5 assisted RI #101 back to his/her room to lie down and calm down. A WITNESS INTERVIEW RECORD dated 10/09/2024 and signed by Activity Assistant (AA) #7 documented: . (RI #101) hit (RI #21) in the face . A more detailed handwritten statement signed by AA #7 dated 10/11/2024 documented: We was all watching the football game in the back dining area. (RI #101) was trying to stand up the entire day. (He/she) rolled forward behind (RI #21's) chair and used the hand-rail on the back of (RI #21's) chair to stand up. (He/she) was told by the CNA to sit back down in (his/her) chair. (He/she) sat back down in (his/her) chair and was rolled back to the table. (RI #21) didn't know at the time that (RI #101) was on the back of (his/her) chair. We continued to watch the football game and (RI #101) did the same thing in regards to standing up using . (RI #21's) chair. This time (RI #21) asked (RI #101) to get off the back of (his/her) chair. (RI #101) then slapped (RI #21) on the side of (his/her) face. We then separated the (RI #21 and RI #101). On 10/17/2024 at 9:10 AM a telephone interview was conducted with AA #7 who was conducting an activity on 10/05/2024 and witnessed the incident. AA #7 said, RI #101 was sitting at a table by him/herself approximately four feet away from RI #21. AA #7 said, RI #101 was agitated, cursing, rolling over to try and pull him/herself up on RI #21's wheelchair, and CNA #5 redirected RI #101 back to the table and provided a snack. AA #7 said, CNA #5 then went to assist another resident and shortly after she heard RI #21 say stop, and RI #101 was pulling up on RI #21's wheelchair again. AA #7 said, RI #101 cursed RI #21 called him a (SOB) (son of a bitch) and hit RI #21 on the face before staff could intervene. AA #7 said, this incident would be considered physical and verbal abuse. On 10/17/2024 at 4:30 PM, an interview was conducted with the DON. She said, a physician's order for every 15-minute checks for 24 hours was written for the protection of residents from an aggressor. The DON said, the every 15-minute checks for 24 hours started on 10/04/2024 at 12:50 PM and ended 10/05/2024 at 12:50 PM, less than three hours before RI #101 hit RI #21. The DON said, being hit in the chest could cause pain, and a person in that situation would become upset, and the incident of RI #22 being hit in the chest was physical abuse. The DON said, being hit in the face would cause someone to become startled and she would not like to be hit in the face, and the incident of RI #21 being hit in the face was physical abuse. On 10/17/2024 at 5:04 PM an interview was conducted with Registered Nurse (RN) #6 who was the unit manager/on call when the incident occurred on 10/04/2024. RN #6 said, she was notified by LPN #4 that RI #101 had hit RI #22 in the dining room. RN #6 said, they immediately separated the two, assessed for injuries, made notifications, notified the physician and new orders were received to place RI #101 on 15-minute checks for 24 hours for the protection of other residents. When asked what would happen when the 24 hours lapsed, RN #6 said, the staff remained on high alert to watch and observe for any behaviors and if behaviors continued, the staff would notify the physician. RN #6 was asked what could have been done to prevent the incident from occurring when RI #101 was observed becoming agitated on 10/05/2024 during the activity. RN #6 said, staff could have intervened earlier and moved RI #101 away from the area and to a calmer environment or less stimulating area. RN #6 stated this incident would be considered physical abuse and someone watching a football game in their home would feel scared and unsafe if they were hit and this was the resident's safe space. On 10/17/2024 at 6:15 PM an interview was conducted with the Administrator (ADM). When the ADM was asked what was determined from the facility's investigation, he said, staff had moved RI #101 from the area once where RI #101 was pulling on the wheelchair of RI #21. The ADM said, staff went to assist another resident, and RI #101 rolled back over to RI #21 and this was when the incident occurred on 10/05/2024. When asked what could have been done to prevent the incident from occurring, ADM said, intervening sooner and removing RI #101 from the vicinity where RI #21 was located. When asked what type of abuse this would be considered, the ADM said, physical abuse. The ADM stated someone who was hit in their own home would not feel too happy about it. RI #101's comprehensive care plan that was initiated on 07/09/2024, just after RI #101 was admitted to the facility, contained a focus area of Resident/patient exhibits, or has the potential to exhibit physical behaviors . 7/4/24 -noted in progress notes trying to hit staff & (and) throwing dinner tray; 7/3/24 -cursing at staff, . RI #101's care plan had interventions added on 10/04/2024 such as to do a body audit to check for injury, call law enforcement, notify the doctor/family, and separate the resident from the other resident when it happens. There were not any new interventions or approaches on RI #101's plan of care that would instruct staff on how to prevent occurrences of abuse perpetrated by RI #101 or the level of supervision RI #101 required to prevent residents in the facility from being abused by RI #101.

Based on interviews, record review, review of the facility's investigative file, review of the facility's abuse policy titled Abuse Prohibition, and review of the job responsibilities of the Administrator (ADM), the ADM failed to ensure the Abuse Policy was implemented, failed to investigate abuse thoroughly, failed to identify abuse, and take appropriate action for prevention of abuse. On 07/01/2023, Certified Nursing Assistant (CNA #14) reported that she grabbed Resident Identifier (RI) #398's wrists to keep RI #398 from hitting her to Licensed Practical Nurse (LPN) #17. The incident was not reported to the Administrator (ADM) and no protective measures were implemented until 07/06/2023. On 07/06/2023 red and purple discolorations were noted on RI #398 's bilateral arms and wrists. The ADM failed to substantiate the allegation of physical abuse despite the CNA stating that she grabbed RI #398's wrists. The facility's investigation did not determine the cause of the bruising. The facility allowed CNA #14 to return to work at the facility. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 08/30/2024 at 7:32 PM, the ADM and the Director of Nursing (DON) were provided the IJ templates and notified of the findings at the immediate jeopardy level in the area of Administration at F835-Administration. The IJ began on 07/01/2023 and continued until 09/01/2024 when the facility implemented corrective actions. On 09/02/2024, the immediate jeopardy was removed, F 835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. The failure of the Administrator to ensure the Abuse Policy was implemented to ensure allegations of abuse were investigated thoroughly and identified as abuse to ensure appropriate actions were implemented to prevent further potential abuse had the potential to affect all residents of the facility. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number AL00044697. Findings Include: Cross Reference F 607, F 610, and F 867. 48195 Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse, mistreatment . for all patients . PROCESS 1. The Administrator . is responsible for operationalizing policies and procedures that prohibit abuse . Review of the Administrator's Job Description, with an effective date of 06/01/2022, revealed the following: . POSITION SUMMARY . Responsible for assuring that the center operates in full compliance with Federal and State regulations . Accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Investigation: The investigation consisted of interviews with residents and staff. Also included were skin assessments of residents. Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating he/she had bruising on his/her wrists and that a CNA was rough during care on the previous Saturday . (RI #398) had some reddened areas on his/her wrist . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab his/her wrist in order to stop him/her from striking her . On 08/29/2024 at 3:24 PM, an interview was conducted with the facility's ADM. The ADM said his responsibilities were to oversee the facility operations, ensure policies were being followed, staff were properly trained, investigate abuse allegations, and report timely. The ADM said investigating abuse allegations entailed gathering all needed information to determine what actually occurred through interviews, obtaining clinical input, and putting corrective action in place to ensure safety of the resident. The ADM was asked about an allegation of physical abuse that alleged Certified Nursing Assistant (CNA) #14 grabbed Resident Identifier (RI) #398's wrist to stop the resident from striking her. The ADM said he did not substantiate the allegation because CNA #14 said she was stopping RI #398 from hitting her and the ADM was thinking that there was no intent to harm. The ADM said the allegation should have been substantiated and CNA #14's employment should have been terminated. 21055 ************************************************************** On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 F-835- Administration On 7/6/23 Center Social Worker informed Center Administrator that RI#398 family informed her that RI#398 told them that a CNA had been rough with RI# 398 during care. On 7/6/23 it was discovered during DON interviews that CNA #14 had reported to LPN #17 that she had had an incident on 7/1/24 where she had grabbed the wrists of RI#398. LPN #17 failed to report this occurrence to the Administrator which delayed interventions and investigation from occurring to ensure RI#398 was protected. On 7/6/23 Administrator failed to document interview with RI #398. This resulted in the investigation failing to be completed thoroughly. The failure of a thorough investigation resulted in a failure to substantiate the allegation of physical abuse RI #398 was discharged on [DATE], from Merry wood Lodge Center. On August 30, 2024, the Market President educated the Nursing Home Administrator on implementing Abuse policies and procedures, reporting alleged violations timely, thoroughly investigating alleged incidents, and center's response to the results of the investigations to include identifying abuse and taking appropriate action for prevention of abuse. Education emphasized the Administrator's responsibility of operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. Education, on August 30, 2024, included ensuring the Administrator understands his role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy. The Administrator plays a vital role in ensuring staff are properly trained on the Abuse Prohibition Policy including identification of abuse, protection of the residents, and reporting. Administrator will lead in the investigation process, he will follow up with outstanding activities needed for a thorough investigation. The Administrator will also ensure that each reportable event is taken to the QAPI committee for thorough review of completion, deliberation on investigation findings, and development of appropriate actions to take regarding elimination of future recurrence. Education of the Administrator, on August 30, 2024, also included training the Administrator to notify Market Clinical Lead of each occurrence and keeping them abreast of the progress of the investigation and protection of the resident. Also that the complete investigation is reviewed by the Market Clinical Lead to collaborate on the thoroughness of the investigation, any additional steps that still need to occur and that correct determinations are made based on the details of the investigation. On August 31st, 2024, the Market Clinical Advisor and Market Clinical Lead reviewed allegations of Abuse and Neglect in the last 60 days to ensure written Abuse Prohibition policies and procedures were implemented and allegations were reported timely, thoroughly investigated, and residents were protected. No concerns were identified. On August 31, 2024, the Market President and Market Clinical Advisor hosted an AD HOC Quality Assurance Performance Improvement meeting with key personnel. Key personnel included Administrator, DON, Social Worker, Admissions coordinator, maintenance director, business office manager, environmental services supervisor, dietary department manager, recreation director, and memory care program director. This was also done in collaboration with the Medical Director to review the Abuse Prohibition policy and procedure to ensure residents are free from Abuse and Neglect, Abuse policies and procedures are implemented, alleged violations are reported timely, a thoroughly investigation is completed, and center's response to the results of the investigations to include identification of abuse and appropriate actions to prevent abuse. The Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator met on 9/1/24 at 12:45 pm to discuss staff on resident incidents after the incident occurring on 7/1/2023. Two were identified reviewed to determine if correct determination was made and if appropriate corrective action has been taken the findings are as follows: RI# 81 event dated 1/2/24- Based on QAPI review, thorough investigation was not completed, the determination remains appropriate, the actions taken at the time were appropriate however QAPI committee determines that additional actions needed to be taken these additional actions taken include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. RI# 48-Event dated 3/10/24- Based on QAPI review, a thorough investigation was not completed, the determination was incorrect, the corrective actions taken at the time were appropriate however the QAPI committee has determined additional actions necessary to be taken. These actions include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken On 09/01/2024 at 4:25 pm the Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator reviewed the remaining incidents that were previously unverified/unsubstantiated since 07/10/2023. 12 incidents were reviewed. 8 were verified during the review. The corrective actions were reviewed for the 8 incidents verified. The review determined the appropriate corrective action had been implemented for 8 incidents, despite being initially unverified/unsubstantiated. It was determined that the 8 incidents required additional corrective actions to include: Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. Compliance Date: September 1, 2024 ********************************************************* After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

Based on interviews, record review, review of facility policies titled Abuse Prohibition and Center Quality Assurance Performance Improvement Process, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee reviewed and analyzed an allegation of abuse in a manner to analyze causes and implement preventative actions. The committee failed to identify physical abuse against Resident Identifier (RI) #398 and failed to identify concerns with identification, reporting, investigation, and protection for an allegation of physical abuse reported to the State Agency (SA) on 07/06/2023. It was determined the facility's non compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.75-Quality Assurance and Performance Improvement. On 08/30/2024 at 7:32 PM, the ADM and the Director of Nursing (DON) were provided the IJ template and notified of the findings at the immediate jeopardy level in the area of Quality Assurance and Performance Improvement at F867-QAPI/QAA Improvement Activities. The IJ began on 07/01/2023 continued until 09/01/2024 when the facility implemented corrective action to prevent reoccurrence. On 09/02/2024, the immediate jeopardy was removed, F 867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. The failure of the QAPI committee to review allegations of abuse to analyze causes and implement preventative actions has the potential to affect all residents of the facility. This deficient practice was cited as a result of the investigation of a Facility Reported Incident, complaint/report number AL00044697. Findings Include: Cross Reference F 607 and F 610. 29671 Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse . for all patients . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral. written language that willfully includes disparaging and derogatory terms to patients . Examples of verbal abuse includes, but are not limited to: threats of harm; saying things to frightened a patient . Physical Abuse includes hitting slapping, pinching, kicking, etc.Mistreatment is defined as inappropriate treatment . of a patient . 10. At monthly Quality Assurance and Performance Improvement (QAPI) meetings, review all allegations of abuse, neglect, misappropriate of patient property, and exploitation that were reported to the state to: 10.1 Analyze occurrences to determine what changes are needed, if any, to prevent further occurrences; 10.2 Identify situations which have a potential for risk; and 10.3 Determine what preventive measures will be implemented by staff . A review of the facility policy titled Center Quality Assurance Performance Improvement Process with a revision date of 10/24/2022 documented: POLICY Centers are committed to incorporating the principles of Quality Assurance and Performance Improvement (QAPI) into all aspects of the Center work processes, service lines, and departments. QAPI activities will be integrated across all care and service areas and include clinical care, quality of life, and patient/resident .choice. PURPOSE To standardize the Center's approach to QAPI culture and processes by implementing the following key elements. QAPI principles will drive the decision making within each Center. The administrator leads the Center's QAPI process and involves all departments, staff and stakeholders-balancing a culture of safety, quality, and patient centeredness. The QAPI process and improvements are based on evidence, drawing data from multiple sources, prioritizing improvement opportunities, and benchmarking results against developed targets. Improvement Activities (IAs) and Performance Improvement Projects (PIPs) are the structure and means through which identified problem areas are addressed with data analysis, process improvements, and ongoing monitoring whenever necessary using an indiscipline team. Focus areas will include all systems that affect patient, family, and staff satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in the Center. Successful implementation of QAPI Center-wide enables sustainability of QAPI and Quality Assessment and Assurance (QAA) during periods of transitions of staff and Center leadership . On 08/30/2024 at 4:58 PM an interview was conducted with the DON regarding QAPI. The DON described the facility's process for QAPI coordination regarding abuse allegations. The DON said abuse was not discussed in each QAPI meeting and it depended on whether an issue of abuse had occurred. The DON said once there was an allegation the QAPI team met to see there was an issue that was not managed to the facility's standards, and they used the opportunity to improve on that. The DON said the ADM went over each abuse allegation and went over each opportunity where the facility could improve. The DON said the ADM presented each allegation of abuse that was received during that period. The DON said the incident involving RI #398 was reviewed during QAPI. The DON said the ADM stated the Social Worker was contacted by RI #398's daughter. The QAPI team discussed the bruising of RI #398's wrist. The DON was asked, regarding the incident with RI #398, were all QAPI members in agreement to not substantiate the allegation of abuse that the CNA grabbed RI #398's arm. The DON said, no, the ADM made the decision to substantiate or not. The DON said the ADM asked the QAPI members their input on his decision and no member disagreed with him. He stood firm on his decision to not substantiate the allegation. The DON said based on regulations, abuse did occur when CNA #14 stated she grabbed RI #398's arm and reported to Licensed Practical Nurse (LPN) #17 that she grabbed RI #398's arm. The DON said the QAPI committee's concern with LPN #17's actions was her lack of caring for the residents and not following the company guidelines including reporting the allegation. An interview was conducted with the ADM on 08/29/2024, at 3:24 PM. During the interview, the ADM reported his responsibilities, which included managing the daily operations of the facility and ensuring staff adherence to established policies and procedures. He said that his duties as the abuse coordinator involved preventing abuse, training staff on abuse-related issues, following up on allegations, and conducting prompt investigations and reporting. The Administrator said that the facility's policy mandated a review of all reported abuse allegations through the QAPI process. He said that the QAPI review of abuse allegations included an assessment of the appropriateness of interventions, the execution of investigations, and an evaluation of the effectiveness of those interventions to determine whether new measures were warranted. He also said that the facility's written policies and procedures required that monthly QAPI meetings were held to review all allegations concerning abuse, neglect, and misappropriation of patient property. He said that while the Governing Body oversaw the QAPI process related to allegations, no information regarding abuse allegations had been communicated to the Governing Body from QAPI. 21055 ************************************************************ On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 F-867 - QAPI Program/Plan, disclosure/good faith attempt On 7/28/23 a QAPI meeting was held which included a review of reportables for the month of July 2023, Center QAPI committee failed to thoroughly review and analyze the allegation of abuse in a manner to identify all concerns and address appropriateness of actions On August 31st, 2024, the Market Clinical Advisor and Market Clinical Lead reviewed allegations of Abuse in the last 60 days and the Quality Assurance Performance Improvement Committee meeting minutes to ensure allegations of abuse were analyzed; Abuse Prohibition policies and procedures were implemented; allegations were reported timely; thorough investigation were completed, residents were protected, and appropriate actions were taken to identify and prevent abuse. No concerns were identified. The Market President educated the Nursing Home Administrator on the Quality Assurance Performance Improvement process to include systematic identification, reporting, investigation, analysis, and prevention of abuse or allegations of abuse; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities related to abuse on August 30, 2024. On August 31, 2024, the Market President and Market Clinical Advisor educated the Quality Assurance Performance Improvement Committee on the Abuse Prohibition policy and procedure to ensure residents are free from Abuse and Neglect, Abuse policies and procedures are implemented, alleged violations are reported timely, a thoroughly investigation is completed, and center's response to the results of the investigations with emphasis on identification of abuse and appropriate actions to prevent abuse. The Quality Assurance Performance Improvement Committee includes the Nursing Home Administrator, Director of Nursing, Medical Director, and any other key personnel of at least 3 members. Members present for the education were the Administrator, DON, admissions coordinator, business office manager, recreation director, medical records, social services, memory care program director, recreation director, maintenance director, environmental service supervisor, and dietary services supervisor. Education on August 31, 2024 included emphasizing the importance of analyzing as a team the reportable events of the Center. This analysis should include review of all investigative information, conclusions made, and actions taken. Committee educated that this analysis is important in ensuring all details have been identified and that all necessary and potentially any further actions are implemented to eliminate the risk of event recurrence and resident continued safety. Governing body to include Market President, Market Clinical Advisor, Clinical Lead, Nursing Home Administrator, and Director of Nursing reviewed the Quality Assurance Performance Improvement process and discussed success/barriers for all improvement activities and performance improvement projects to ascertain support, resources, and breakthrough ideas on August 31, 2024. The Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator met on 9/1/24 at 12:45 pm to discuss staff on resident incidents after the incident occurring on 7/1/2023. Two were identified reviewed to determine if correct determination was made and if appropriate corrective action has been taken the findings are as follows: RI# 81 event dated 1/2/24- Based on QAPI review, thorough investigation was not completed, the determination remains appropriate, the actions taken at the time were appropriate however QAPI committee determines that additional actions needed to be taken these additional actions taken include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. RI# 48-Event dated 3/10/24- Based on QAPI review, a thorough investigation was not completed, the determination was incorrect, the corrective actions taken at the time were appropriate however the QAPI committee has determined additional actions necessary to be taken. These actions include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. On 09/01/2024 at 4:25 pm the Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator reviewed the remaining incidents that were previously unverified/unsubstantiated since 07/10/2023. 12 incidents were reviewed. 8 were verified during the review. The corrective actions were reviewed for the 8 incidents verified. The review determined the appropriate corrective action had been implemented for 8 incidents, despite being initially unverified/unsubstantiated. It was determined that the 8 incidents required additional corrective actions to include: On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. Compliance Date: September 1, 2024 ******************************************************* After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

Based on interviews, residents' record review, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect residents right to be from abuse perpetrated by staff of the facility. On 07/01/2023 Resident Identifier (RI) #398 was physically abused by Certified Nursing Assistant (CNA) #14. This deficiency was cited as the result of the investigation of complaint /report #AL00044697. The facility further failed to ensure RI #48 was free from abuse perpetrated by CNA #10. On 03/10/2024 RI #48 was physically abused by CNA #10. The facility further failed to substantiate the allegations as abuse. These deficient practices affected RI #48 and RI #398, two of four sampled residents reviewed for employee to resident abuse. This deficiency was cited as a result of the investigation of FRI/complaint/report numbers AL00044697 and AL00047200. After retrospective Quality Assurance review and at the direction of Centers for Medicare and Medicaid (CMS) Services Atlanta Location, the Statement of Deficiencies (FORM CMS-2567) was amended on 11/27/2024 to reflect facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/27/2024 at 2:40 PM, the Administrator was provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed through implemented removal plans for F 607 and F 610, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings include: Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Centers prohibit abuse, mistreatment, neglect . for all patients . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their ability to comprehend, or disability . Examples of verbal abuse includes, but are not limited to: threats of harm; saying things to frightened a patient . Physical Abuse includes hitting slapping, pinching, kicking, etc. Mistreatment is defined as inappropriate treatment . of a patient . 1) RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Affecting Right Dominant Side, and Anxiety Disorder,. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/26/2023, identified RI #398 as scoring a five of 15 on the Brief Interview of Mental Status (BIMS) indicating RI #398 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . Describe any injury to the alleged victim . bruising on wrist . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Investigation: The investigation consisted of interviews with residents and staff. Also included were skin assessments of residents. Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating he/she had bruising on his/her wrists and that a CNA was rough during care on the previous Saturday . (RI #398) had some reddened areas on his/her wrist . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab his/her wrist in order to stop him/her from striking her . On 08/24/2024 at 4:25 PM a telephone interview was conducted with RI #398's Responsible Party (RP). When asked what she could tell the surveyor about an incident occurring on 07/01/2023, involving bruising to RI #398's wrists. The RP said when her sister visited the facility on 07/01/2023, RI #398 mentioned a lady that had not been nice to him/her. The RP said RI #398 said the staff member was always ugly to him/her and told him/her to ''shut up and threw his/her arms down. The RP said when she visited RI #398 on 07/02/2023, she noticed the dark red/purple to black bruises on RI #398's wrists. The RP said she notified the social worker. On 08/24/2024 at 4:45 PM, the surveyor conducted a telephone interview with RI #398's daughter. RI #398's daughter said RI #398 informed her the CNA was always mean to him/her, and they called that CNA big trouble. RI #398's daughter said RI #398 informed her the CNA grabbed him/her and was hurting him/her, and would not let him/her go. RI #398's daughter said on 07/02/2023 when she went to visit RI #398, she noticed the bruises on RI #398's wrist. RI #398's daughter said RI #398's RP reported the incident to facility staff. On 08/24/2024 at 5:13 PM, an interview was conducted with the SW. When asked what she could tell the surveyor about an incident involving RI #398 and CNA #14 occurring on 07/01/2023, the SW said RI #398's daughter called and stated a CNA was rough with RI #398. The SW said she reported this to the ADM. The SW said the CNA being rough with RI #398 would be consider physical abuse if it occurred. The facility's investigative file was reviewed and a typed statement signed by the DON on 07/06/2023, revealed the following: A resident (RI #398) . called his/her Sponsor (name of responsible party) on Saturday, July 1, 2023 with his/her cellphone and told her that Big Trouble grabbed his/her wrist and was rough with him/her. (He/She) stated she (the CNA) said . Don't call me anymore either. The Sponsor called the Social Worker (name of SW) and reported it to her on July 5, 2023 . The Social Worker went to the resident's room and she returned and stated the resident said that someone grabbed his wrist but (he's/she's) not telling her who it was. I then went to the resident's room with the charge nurse (LPN #22) . I observed red bruises to both forearms .The resident went on to say he/she was getting good care at the facility and proceeded to hug his assigned CNA (CNA #14) . Witness statements were obtained . One of the employees (CNA #14) that worked with the resident on the evening of July 1, 2023, stated during my investigation that the resident was fighting her that night and she had to hold his/her wrist to block him/her from hitting her. She stated she went and immediately reported to Charge Nurse (LPN #17) and another Nurse was standing there . Both Nurses were interviewed and they corroborated the story from (CNA #14) . The abuse allegation cannot be substantiated. On 08/25/2024 at 5:46 PM, an interview was conducted with the DON. The DON said she was made aware, by the ADM, of the incident involving RI #398 and CNA #14 on 07/06/2023. The DON said she was informed that CNA #14 had grabbed RI #398's wrist. The DON said when she did a head-to-toe assessment on RI #398, there were discolorations on RI #398's arms. When asked could CNA #14 have just walked away from RI #398 and reported the incident, the DON said CNA #14 could have but according to her statement she was trying to stop RI #398 from hitting her. The DON said RI #398 could sit up in the bed independently, but required a mechanical lift for transfer out of the bed and was not ambulatory or able to walk. The DON said the facility was not aware RI #398 nicknamed CNA #14 big trouble until after the ADM interviewed RI #398. The DON said CNA #14 resigned in October of 2023 due to personal reasons. Unsuccessful telephone attempts were made to contact CNA #14 on 08/24/2024 at 5:42 PM and on 08/25/2024 at 3:02 PM. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by LPN #17 on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . This nurse went into room to assess the resident. Resident was calm . On 08/27/2024 at 12:25 PM, a telephone interview was conducted with LPN #17. LPN #17 said she did make the late entry concerning the incident involving RI #398. LPN #17 said she would consider the incident to be abuse. LPN #17 said she should have reported the incident to the abuse coordinator. On 08/28/2024 at 5:45 PM, an interview was conducted with the Registered Nurse/Nurse Practice Educator (NPE). The NPE said a CNA grabbing a resident by the wrist to keep the resident from hitting the CNA would be considered physical abuse. On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report, he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that on Saturday night (07/01/2023) an unnamed staff member was rough during care. The ADM said he reported the incident to ADPH (Alabama Department of Public Health) and initiated an investigation to identify the unnamed staff member. The ADM said during the investigation, CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. The ADM said he categorized the incident as physical abuse because the allegation was physical in nature. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. When asked how it would make a reasonable person feel if someone grabbed them by the wrist and left bruising on them, the ADM said he would want it to stop. 2) RI #48 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease and Dementia. A Quarterly MDS assessment with an ARD of 01/02/2024 identified RI #48 had a BIMS score of 03 of 15 which indicated RI #48 had severe cognitive impairment. The Alabama Department of Public Health Online Incident Reporting System form, dated 03/10/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #48) . Name of alleged perpetrator(s): (CNA #10) What was reported . It is alleged that (RI #48) grabbed (CNA #10) collar and (CNA #10) pushed (RI #48) back into the bed . Action(s) taken by the facility in response to the incident. Resident asses for injury, none noted, CNA #10 placed on administrative leave . The facility's incident summary, documented that the facility's investigation determined: Allegation Summary: On March 10, 2024 . Center Conclusion: This investigation is unable to substantiate abuse. (CNA #10) in attempting to remove (RI #48's) hand did result in (RI #48) losing his/her balance. The witnessing staff felt this situation could have been handled better and felt that frustration did play a factor in the interaction . An interview was conducted with Activity CNA #8 on 08/24/2024, at 11:59 AM. During this interview, CNA #8 recounted an incident that occurred on 03/10/2024, in which CNA #21, CNA #10 and she, were providing care to RI #48. CNA #8 stated that while they were providing care to RI #48, the resident pulled away from CNA #10. In response, CNA #10 placed both hands on RI #48's arms, turned the resident around, and shook him/her two to three times, resulting in RI #48's body hitting the footboard of the bed. CNA #8 indicated that she removed CNA #10's hands from RI #48 and then left the room to report the incident to Licensed Practical Nurse #11. An interview was conducted with LPN #11 on 08/24/2024, at 1:17 PM. During the interview, LPN #11 said that on 03/10/2023 CNA #8 reported that she felt CNA #10 was rough while attempting to provide care to RI #48. LPN #11 said she immediately went in the room and completed a body audit with no negative results found. LPN #11 then reported the incident to the weekend supervisor, administrator, responsible party, and medical doctor. LPN #11 reported that CNA #10 was sent home and did not return to work. LPN #11 said RI #48 had normal behavior the remainder of the day. LPN #11 said when a resident was combative, staff should leave the room and look for ways such as providing snacks to calm the resident. A telephone interview was conducted with CNA #10 on 08/26/2024, at 2:50 PM. During the interview, CNA #10 recalled that on 03/10/2024, she was assigned to care for RI #48 and sought assistance from CNA #8 and CNA #21. CNA #10 described an incident in which RI #48 grabbed her shirt, prompting her to grab RI #48's hand and wrist. She said that RI #48 was pulling on her shirt, and she had to tug twice before RI #48 released his/her grip. CNA #10 indicated that when she removed RI #48's hand from her shirt, it resulted in RI #48 falling over the bed. When questioned about her training for managing resistant residents, she stated that the protocol was to leave the room and return later. CNA #10 explained that she did not leave the room because RI #48 required a change, so she continued to provide care. When asked if she believed her actions were appropriate, she admitted that she could have left and returned later, which could have de-escalated the situation. CNA #10 said she did not consider her actions to be physical abuse, as RI #48 was examined and no redness or marks were observed. She acknowledged that she could have approached the situation differently. Following the incident, CNA #10 said she provided a verbal statement after the incident and clocked out for the day. A telephone interview was conducted with CNA #21 on 08/26/2024, at 3:18 PM. During the interview, CNA #21 recalled an incident from 03/10/2024, when she was requested to assist CNA #10 and CNA #8 in providing care to resident #48. CNA #21 said that resident #48 was upset and resisting care at that time. CNA #21 said RI #48 grabbed CNA #10's shirt collar and CNA #10 removed RI #48's hand. CNA #21 said CNA #10 turned RI #48 around and RI #48 fell on to the bed. CNA #21 said it was upsetting the way that CNA #10 handled RI #48 and reported the incident to the unit manager. When asked if she believed the actions she witnessed constituted abuse, she said yes, stating that this was the reason for her reporting the incident. In response to a question about her training for managing residents who resist care, she indicated that the guidance was to leave them alone and return at a later time. An interview was conducted with the ADM on 08/24/2024, at 4:54 PM. During the interview, the ADM said that he became aware of the incident involving RI #48 on 03/10/2024. He reported that an investigation was initiated, a report was submitted to the State Agency, and the employee, CNA #10, was suspended. The ADM noted that CNA #10 denied any allegations of being rough with RI #48, asserting that she was attempting to prevent the resident from hitting the bed. When questioned whether a staff member grabbing and placing a resident onto the bed could be classified as abuse, the ADM said that such an action would be considered abusive. He also mentioned that the resident was evaluated following the incident and found to have no injuries. Upon being asked if he believed RI #48 had been abused, he stated that he could not make a determination, as the accounts he received during the investigation were inconsistent. **************************************** 29671 2) RI #48 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease and Dementia. A Quarterly MDS assessment with an ARD of 01/02/2024 identified RI #48 had a BIMS score of 03 of 15 which indicated RI #48 had severe cognitive impairment. The Alabama Department of Public Health Online Incident Reporting System form, dated 03/10/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #48) . Name of alleged perpetrator(s): (CNA #10) What was reported . It is alleged that (RI #48) grabbed (CNA #10) collar and (CNA #10) pushed (RI #48) back into the bed . Action(s) taken by the facility in response to the incident. Resident asses for injury, none noted, CNA #10 placed on administrative leave . The facility's incident summary, documented that the facility's investigation determined: Allegation Summary: On March 10, 2024 . Center Conclusion: This investigation is unable to substantiate abuse. (CNA #10) in attempting to remove (RI #48's) hand did result in (RI #48) losing his/her balance. The witnessing staff felt this situation could have been handled better and felt that frustration did play a factor in the interaction . An interview was conducted with Activity CNA #8 on 08/24/2024, at 11:59 AM. During this interview, CNA #8 recounted an incident that occurred on 03/10/2024, in which CNA #21, CNA #10 and she, were providing care to RI #48. CNA #8 stated that while they were providing care to RI #48, the resident pulled away from CNA #10. In response, CNA #10 placed both hands on RI #48's arms, turned the resident around, and shook him/her two to three times, resulting in RI #48's body hitting the footboard of the bed. CNA #8 indicated that she removed CNA #10's hands from RI #48 and then left the room to report the incident to Licensed Practical Nurse #11. An interview was conducted with LPN #11 on 08/24/2024, at 1:17 PM. During the interview, LPN #11 said that on 03/10/2023 CNA #8 reported that she felt CNA #10 was rough while attempting to provide care to RI #48. LPN #11 said she immediately went in the room and completed a body audit with no negative results found. LPN #11 then reported the incident to the weekend supervisor, administrator, responsible party, and medical doctor. LPN #11 reported that CNA #10 was sent home and did not return to work. LPN #11 said RI #48 had normal behavior the remainder of the day. LPN #11 said when a resident was combative, staff should leave the room and look for ways such as providing snacks to calm the resident. A telephone interview was conducted with CNA #10 on 08/26/2024, at 2:50 PM. During the interview, CNA #10 recalled that on 03/10/2024, she was assigned to care for RI #48 and sought assistance from CNA #8 and CNA #21. CNA #10 described an incident in which RI #48 grabbed her shirt, prompting her to grab RI #48's hand and wrist. She said that RI #48 was pulling on her shirt, and she had to tug twice before RI #48 released his/her grip. CNA #10 indicated that when she removed RI #48's hand from her shirt, it resulted in RI #48 falling over the bed. When questioned about her training for managing resistant residents, she stated that the protocol was to leave the room and return later. CNA #10 explained that she did not leave the room because RI #48 required a change, so she continued to provide care. When asked if she believed her actions were appropriate, she admitted that she could have left and returned later, which could have de-escalated the situation. CNA #10 said she did not consider her actions to be physical abuse, as RI #48 was examined and no redness or marks were observed. She acknowledged that she could have approached the situation differently. Following the incident, CNA #10 said she provided a verbal statement after the incident and clocked out for the day. A telephone interview was conducted with CNA #21 on 08/26/2024, at 3:18 PM. During the interview, CNA #21 recalled an incident from 03/10/2024, when she was requested to assist CNA #10 and CNA #8 in providing care to resident #48. CNA #21 said that resident #48 was upset and resisting care at that time. CNA #21 said RI #48 grabbed CNA #10's shirt collar and CNA #10 removed RI #48's hand. CNA #21 said CNA #10 turned RI #48 around and RI #48 fell on to the bed. CNA #21 said it was upsetting the way that CNA #10 handled RI #48 and reported the incident to the unit manager. When asked if she believed the actions she witnessed constituted abuse, she said yes, stating that this was the reason for her reporting the incident. In response to a question about her training for managing residents who resist care, she indicated that the guidance was to leave them alone and return at a later time. An interview was conducted with the ADM on 08/24/2024, at 4:54 PM. During the interview, the ADM said that he became aware of the incident involving RI #48 on 03/10/2024. He reported that an investigation was initiated, a report was submitted to the State Agency, and the employee, CNA #10, was suspended. The ADM noted that CNA #10 denied any allegations of being rough with RI #48, asserting that she was attempting to prevent the resident from hitting the bed. When questioned whether a staff member grabbing and placing a resident onto the bed could be classified as abuse, the ADM said that such an action would be considered abusive. He also mentioned that the resident was evaluated following the incident and found to have no injuries. Upon being asked if he believed RI #48 had been abused, he stated that he could not make a determination, as the accounts he received during the investigation were inconsistent. ****************************************************************************** On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 On 7/6/23 RI #398's family reported to Center Social Worker that an unnamed CNA had been rough with RI #398 On 7/6/23 immediately after speaking with family, Center Social Worker notified the Administrator Administrator spoke with RI #398 on 7/6/23, administrator failed to document interview with resident which resulted in resident not being protected from potential further abuse During the interviews, on 7/6/23, DON discovered that CNA #14 had reported to LPN #17 that she had an instance on 7/1/23, in which she had grabbed RI #398's wrist in order to stop the resident from striking her. LPN #17 failed to notify the Administrator on 7/1/23 of the occurrence which delayed interventions to ensure the alleged staff member was removed from the situation and caused a failure to ensure resident safety during the intervening time. On 7/6/23 CNA #14 was placed on administrative leave pending the results of the investigation. RI #398 was discharged on [DATE], from Merry wood Lodge Center. Certified Nursing Assistant #14 is no longer employed at Merry wood Lodge Center. CNA #14's last day worked was 10/14/23 Licensed Practical Nurse #17 is no longer employed at Merry [NAME] Lodge Center. LPN #17's last day worked was 7/20/23. On August 30, 2024, The Social Services Director and/or designee interviewed 47 residents deemed as interviewable with a BIMs score ranging from 8-15 regarding Staff being rough with the residents. No concerns were identified On August 30, 2024, Licensed Nurses completed skin assessment on 42 residents identified with severe cognitive impairment with a BIMs score ranging from 0-7 to identify suspicion of Abuse. No additional concerns were identified. On August 30, 2024, the Nurse Practice Educator and/or designee initiated 100% re-education with employees (full-time, part-time) in all disciplines (Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities, and Administration) on Abuse Prohibition policy and procedure, including but not limited to, the definition, types of Abuse (Physical, Mental/Emotional, Neglect, Sexual, and Financial), prevention and supervision, identification, reporting of abuse, and trauma. Identification includes knowing the types of abuse, recognizes deliberate acts, noticing suspicious behaviors, suspicious events, suspicious injuries, trends or patterns. Additionally, education emphasized immediately protecting the resident when abuse is identified and that anyone can be a perpetrator of abuse. The primary method for protecting residents, following staff involved abuse allegations or incidents, will be immediately placing the accused staff member on administrative leave pending the results of investigation. Education included protocols for employees having knowledge of an alleged abuse incident for reporting abuse immediately including first reporting to their Supervisor, the Supervisor will report to the Director of Nursing and Administrator. Employees with knowledge may also report directly to the Administrator as well. Education was completed on August 31, 2024, with all staff present in the Center and for all staff available via telephone communication. The total number of employees educated was 110. The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. New hires (full-time, part-time) will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services. On 8/31/24 110 staff members were educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations. Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual. Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation. Education on August 30, 2024 also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI. Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment. Compliance Date: September 1, 2024 *********************************************************** After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

Based on interviews, record review, review of the facility's investigative file and review of the facility's abuse policy titled Abuse Prohibition, the facility failed to ensure the abuse policy was implemented following an incident of staff to resident physical abuse. The facility failed to ensure the incident was identified by licensed staff as abuse and protective measures were immediately implemented to prevent further potential abuse. The facility further failed to ensure the incident was reported to the Administrator (ADM) within two hours and thoroughly investigated to identify that abuse occurred and to ensure appropriate actions were taken to prevent further potential abuse. On 07/01/2023, Certified Nursing Assistant (CNA #14) reported to Licensed Practical Nurse (LPN) #17 that she grabbed Resident Identifier (RI) #398's wrists to keep RI #398 from hitting her. The incident was not reported to the ADM and no protective measures were implemented until the family reported the incident on 07/06/2023. On 07/06/2023 red and purple discolorations were noted on RI #398 's bilateral arms and wrists. The ADM failed to substantiate the allegation of physical abuse despite the CNA stating that she grabbed RI #398's wrists. The facility allowed CNA #14 to return to work at the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 08/30/2024 at 7:32 PM, the ADM and Director of Nursing (DON) were provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 607- Develop/Implement Abuse/Neglect, etc. Policies. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed, F 607 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report #AL00044697. Findings include: Cross-Reference F 610, F 835 and F 867. Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse . for all patients . The Center will implement an abuse prohibition program through the following: . Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting slapping, pinching, kicking, etc. as well as controlling behavior through corporal punishment . Mistreatment is defined as inappropriate treatment . of a patient . PROCESS . 6. Staff will identify events- such as . occurrences . that may constitute abuse . 6.1 Anyone who witnesses an incident of suspected abuse . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator . RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Affecting Right Dominant Side, and Anxiety Disorder. RI #398's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 06/26/2023, identified RI #398 as scoring 5 of 15 on the Brief Interview of Mental Status, which indicated that RI #398 had severely impaired cognition. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by LPN #17, an agency/contract staff member, on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . This nurse went into room to assess the resident. Resident was calm . On 08/27/2024 at 12:25 PM, a telephone interview was conducted with LPN #17. LPN #17 said she did make the late entry concerning the incident involving RI #398; and she would consider the incident to be abuse. LPN #17 said she should have reported the incident to the abuse coordinator. Review of the assignment sheets for the unit RI #398 resided on revealed CNA #14 continued to provide care to RI #398 on 07/02/2023 on the 2 PM to 10 PM shift, on 07/03/2023 on the 2 PM to 10 PM shift, on 07/04/2023 on the 2 PM to 10 PM and 10 PM to 6 AM shifts and on 07/05/2023 on the 6 PM to 2 PM shift. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . Describe any injury to the alleged victim . bruising on wrist . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Investigation: The investigation consisted of interviews with residents and staff. Also included were skin assessments of residents. Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating he/she had bruising on his/her wrists and that a CNA was rough during care on the previous Saturday . (RI #398) had some reddened areas on his/her wrist . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab his/her wrist in order to stop him/her from striking her . On 08/28/2024 at 5:45 PM, an interview was conducted with the Registered Nurse/Nurse Practice Educator (NPE). The NPE said grabbing a resident by the wrist would be considered physical abuse. The NPE said when the incident was reported to LPN #17, she should have ensured the resident was safe, even if that meant sending the CNA home. The NPE said this incident should have been reported to the ADM immediately. On 08/25/2024 at 5:46 PM, an interview was conducted with the DON. The DON said CNA #14 was suspended for six days after the allegation. The DON said CNA #14 resigned in October of 2023 due to personal reasons. On 08/30/2024 at 4:58 PM, an interview was conducted with the DON. The DON said the facility's concern with LPN #17 was she had a lack of caring for residents and violated company policy. The DON said LPN #17 did not complete an assessment on RI #398 at the time of the incident. On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that on Saturday night (07/01/2023) an unnamed staff member was rough during care. The ADM said he reported the incident to ADPH (Alabama Department of Public Health) and initiated an investigation to identify the unnamed staff member. The ADM said during the investigation CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. On 08/28/2024 at 11:00 AM, a follow-up interview was conducted with the ADM. The ADM said LPN #17 should have reported the incident to him. When asked how RI #398 was protected from further potential harm from 07/01/2023 until 07/06/2023, the ADM said RI #398 was not protected. The ADM said he did not investigate how RI #398 obtained the bruises to his/her wrist because he was not aware of the bruising at the time of the investigation. The ADM said he did not have a documented interview with CNA #14 or LPN #17. ************************************************************ On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: F-607-Development and implementation of written Abuse Prohibition policies. On 7/6/23 RI #398's family reported to Center Social Worker that an unnamed CNA had been rough with RI #398 On 7/6/23 immediately after speaking with family, Center Social Worker notified the Administrator Administrator spoke with RI #398 on 7/6/23, administrator failed to document interview with resident which resulted in resident not being protected from potential further abuse During the interviews, on 7/6/23, DON discovered that CNA #14 had reported to LPN #17 that she had an instance on 7/1/23, in which she had grabbed RI #398's wrist in order to stop the resident from striking her. LPN #17 failed to notify the Administrator on 7/1/23 of the occurrence which delayed interventions to ensure the alleged staff member was removed from the situation and caused a failure to ensure resident safety during the intervening time. On 7/6/23 CNA #14 was placed on administrative leave pending the results of the investigation. RI #398 was discharged on [DATE], from Merry wood Lodge Center. Certified Nursing Assistant #14 is no longer employed at Merry wood Lodge Center. CNA #14's last day worked was 10/14/23 Licensed Practical Nurse #17 is no longer employed at Merry [NAME] Lodge Center. LPN #17's last day worked was 7/20/23. On August 30, 2024, The Social Services Director and/or designee interviewed 47 residents deemed as interviewable with a BIMs score ranging from 8-15 regarding Staff being rough with the residents. No concerns were identified On August 30, 2024, Licensed Nurses completed skin assessment on 42 residents identified with severe cognitive impairment with a BIMs score ranging from 0-7 to identify suspicion of Abuse. No additional concerns were identified. On August 30, 2024, the Nurse Practice Educator and/or designee initiated 100% re-education with employees (full-time, part-time) in all disciplines (Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities, and Administration) on Abuse Prohibition policy and procedure, including but not limited to, the definition, types of Abuse (Physical, Mental/Emotional, Neglect, Sexual, and Financial), prevention and supervision, identification, reporting of abuse, and trauma. Identification includes knowing the types of abuse, recognizes deliberate acts, noticing suspicious behaviors, suspicious events, suspicious injuries, trends or patterns. Additionally, education emphasized immediately protecting the resident when abuse is identified and that anyone can be a perpetrator of abuse. The primary method for protecting residents, following staff involved abuse allegations or incidents, will be immediately placing the accused staff member on administrative leave pending the results of investigation. Education included protocols for employees having knowledge of an alleged abuse incident for reporting abuse immediately including first reporting to their Supervisor, the Supervisor will report to the Director of Nursing and Administrator. Employees with knowledge may also report directly to the Administrator as well. Education was completed on August 31, 2024, with all staff present in the Center and for all staff available via telephone communication. The total number of employees educated was 110. The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. New hires (full-time, part-time) will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations. Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual. Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation. Education on August 30, 2024 also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI. Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment. Compliance Date: September 1, 2024 *********************************************************** After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

Based on interviews, record reviews, review of the facility's abuse policy titled, Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative files, the facility failed to ensure an allegation of staff to resident physical abuse was thoroughly investigated to identify that abuse occurred, determine if bruising was a result of the abuse, and take appropriate action to prevent further potential abuse. On 07/01/2023, Certified Nursing Assistant (CNA #14) reported to Licensed Practical Nurse (LPN) #17 that she grabbed Resident Identifier (RI) #398's wrists to keep RI #398 from hitting her. The incident was not reported to the Administrator (ADM) and no protective measures were implemented until 07/06/2023. On 07/06/2023 red and purple discolorations were noted on RI #398 's bilateral arms and wrists. The ADM failed to substantiate the allegation of physical abuse despite the CNA stating that she grabbed RI #398's wrists. The facility's investigation did not determine the cause of the bruising. The facility allowed CNA #14 to return to work at the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 08/30/2024 at 7:32 PM, the ADM and Director of Nursing (DON) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 610-Investigate/Prevent/Correct Alleged Violations. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed, F 610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report #AL00044697. Further the facility failed to thoroughly investigate three allegations of resident on resident abuse and two incidents of injury of unknown origin. These failures did not rise to the level of immediate jeopardy and included the following allegations: 2) On 04/19/2023 RI #148 hit RI #25. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00043994. 3) On 08/22/2023 RI #51 hit RI #600. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00045350. 4) On 10/30/2023 RI #198 was observed with bruising around the right eye and was complaining of left hip pain. The facility identified the allegation as injury of unknown origin and failed to thoroughly investigate. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00046026. 5) On 11/14/2023 RI #598 alleged she/he was experiencing back pain from being pushed down to the floor. The facility failed to thoroughly investigate the injury of unknown origin involving RI #598. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00046185. 6) On 06/25/2024 RI #60 slapped RI #9. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00048245. Findings Include: Cross-Reference F 600, F 835, and F 867. Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse, mistreatment . for all patients. This includes, . any physical . restraint not required to treat the patient's medical symptoms . The Center will implement an abuse prohibition program through the following: . Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting slapping, pinching, kicking, etc. (etcetera) . Injuries of unknown source are defined as an injury with both of the following conditions. The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and The injury is suspicious because of the intent of the injury or the location of the injury (e.g., (for example) the injury is located in an area not generally vulnerable to trauma) . Mistreatment is defined as inappropriate treatment . of a patient . PROCESS . 6. Staff will identify events - such as suspicious bruising of patients, occurrences, patterns. and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse . 7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included . 1) RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Unspecified, Hemiplegia, Unspecified Affecting Right Dominant Side and Anxiety Disorder. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/26/2023, identified RI #398 as scoring a 5 of 15 on the Brief Interview of Mental Status (BIMS) indicating RI #398 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating (he/she) had bruising on (his/her) wrists and that a CNA was rough during care on the previous Saturday . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab (his/her) wrist in order to stop (him/her) from striking her . The facility's investigative file was reviewed and a WITNESS INTERVIEW RECORD statement dated 07/06/2023, signed by CNA #14 documented the following: . I worked with (him/her) Saturday. When I was changing (him/her) (he/she) begin to hit me and I Told (him/her) to stop and (he/she) didn't And I When (went) and got the nurse And Told her what (he/she) was doing And When you try To give (him/her) patient care (he/she) begin to fight. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by an agency staff member, LPN #17 on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that an unnamed staff member on Saturday night (07/01/2023) was rough during care. The ADM said he reported the incident to ADPH and initiated an investigation to started to try to identify the unnamed staff member. The ADM said the investigation revealed CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. When asked how it would make a reasonable person feel if someone grabbed them by the wrist and left bruising on them, the ADM said he would want it to stop. On 08/28/2024 at 11:00 AM, a follow-up interview was conducted with the ADM. When asked how he investigated the alleged abuse occurring with RI #398 on 07/01/2023, the ADM said he interviewed any staff that worked from 07/01/2023 to 07/06/2023. The ADM said he was not aware RI #398 had bruises until the surveyor informed him on 08/25/2024. The ADM said he interviewed CNA #14, LPN #17 and LPN #7, but did not document they had been interviewed. When asked if he should have kept a record of the staff being interviewed, the ADM said yes. 2) RI #25 was admitted to the facility on [DATE]. A Quarterly MDS assessment with an ARD date of 01/28/2023, identified RI #25 as scoring a 10 of 15 on the BIMS, indicating RI #25 had moderate impaired cognition. RI #148 was admitted to the facility on [DATE]. A Quarterly MDS assessment with an ARD date of 03/10/2023, identified RI #148 as scoring a 6 of 15 on the BIMS, indicating RI #148 had severe impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 04/19/2023 documented: . Incident Type . Other Facility Incidents . Incident Detail . Name(s) of resident(s) involved: (RI #25 and RI #148) . Narrative summary of how injury was discovered: Reportedly RI #148 hit RI #25 on his/her arm while in the dining area. When asked why RI #148 states that RI #25 was in his way . A review of the facility's investigation summary documented: .On April 19, 2023, it was reported that RI #148 had struck the arm of RI #25. When asked RI #148 stated he/she needed him/her to move out of his/her way. RI #148 was attempting to exit the dining area and from his/her perspective RI #25 was impeding his/her route out of the dining room . At this time we are unable to substantiate abuse occurred based on the fact that RI #148 had no intent to harm RI #25 but to merely compel him/her to relocate . Review of the facility's investigative file revealed no documentation of interviews completed during the investigation. An interview was conducted with the ADM on 08/26/2024, at 4:20 PM. During the interview, the ADM was asked about the documentation of any interviews related to the investigation involving RI #148 and RI #25. The ADM said that he had conducted interviews with RI #148, as well as with witnesses and other residents present in the dining room. When questioned about the location of these interviews, he stated that he typically retained and submitted them with the investigation; however, he was unable to locate any interviews associated with this case. The ADM said the importance of documenting all statements was to ensure sufficient information was available for a thorough assessment of the situation and the formulation of an appropriate action plan. 3) RI #51 was admitted to the facility on [DATE] with a Diagnosis to include but not limited to: Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. A review of RI #51's Quarterly MDS ARD of 07/20/2023, indicated RI #51 had a Brief Interview of Mental Status BIMS score of 15 of 15, which indicated intact cognition. RI #51 ambulated independently with assistance of a walker on the unit. RI #600 was originally admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with Diagnosis of Dementia with Behavioral Disturbance. A review of RI #600's care plan revealed he/she had the potential to exhibit physical behaviors and noted a prior physical altercation with a resident on 07/07/2023. A review of RI #600's Quarterly MDS with an ARD of 08/8/2023, indicated a BIMS score of 4 of 15 which indicated RI #600's cognition was severely impaired. He/she ambulated independently on the unit with no assistive device. On 08/22/2023 at 8:10 PM, the Alabama Department of Public Health (ADPH) Incident Reporting System documented RI #51 alleged RI #600 hit him/her on the upper back when he/she tried to redirect. Review of the facility's investigation summary revealed: . On 08/22/2023 it was alleged by RI #51 that RI #600 had struck him/her back and arm after he/she had tried to direct RI #600 to change directions in the hall. Center Investigation: The Center investigation included interviews with staff on the unit at the time of alleged event and interview with RI #51. RI #600 is not able to be interviewed. Center Findings: This event was unwitnessed and only reported by RI #51 . According to RI #51 he/she was attempting to redirect RI #600 in the hallway. During this interaction it was alleged at RI #600 struck RI #51 in the back twice and arm once .both assessed for injury. None noted. RI #600 was monitored and assessed for aggressive behavior . Center Actions Taken: . Allegation reported to ADPH Resident RPs and MD notified of occurrence RI #600 monitored for aggressive behavior, none noted RI #51 and RI #600 assessed for injury, none noted RI #51 educated regarding to inform staff if another resident is to be redirected . The facility investigative file was reviewed and revealed no documented evidence of where RI #51 was interviewed. No documented evidence where education was provided to RI #51. Further, the facility investigative file revealed no documented evidence that RI # 600's behavior was monitored to ensure no physically aggressive behavior occurred after the alleged incident. On 08/24/2024 at 4:16 PM, RI #51 was interviewed and recalled the incident on 08/22/2023 when he/she was hit by RI #600. RI #51 said that RI #600 had wandered into his/her room and attempted to take a personal item. When RI #51 provided redirection, RI #600 hit him/her on the back. On 08/24/2024 at 5:10 PM CNA #12 was interviewed and revealed RI #600 exhibited behaviors towards others. CNA #12 said she was working down the hall when she heard RI #51 talking to RI #600 saying do not go in his/her room. CNA #12 said RI #600 was a firecracker, and his/her behavior was unpredictable. When he/she heard the argument, he/she went down the hall quickly to intervene. This was when RI #51 reported that RI #600 hit him/her when redirected. CNA #12 said RI #51 was initially upset, but did calm down. On 08/25/2024 at 4:55 PM, the ADM was interviewed about the allegation between RI #51 and RI # 600 on 08/22/2023. The ADM noted the incident was reported by RI# 51, investigated by the facility, and actions put in place. When asked about documentation from resident interviews and behavioral monitoring for RI #600 for aggressive behavior, the ADM said there was unfortunately no documented evidence of the above actions. The ADM agreed there should be more documentation for a thorough investigation. 4) RI #198 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Anoxic Brain Damage, Expressive Language Disorder, Parkinson's, Vascular Dementia, Long Term (current) use of Aspirin and History of Falling. An Annual MDS assessment with an ARD date of 09/14/2023, identified RI #198 as scoring a 3 of 15 on the BIMS, indicating RI #198 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 10/30/2023 documented: . Incident Type . Injuries of Unknown Source . Date and time of when staff became aware of the incident: . 10/30/2023 .Time: 04:00 PM . Incident Detail . Name(s) of resident(s) involved: (RI #198) . Narrative summary of how injury was discovered: Resident discovered with bruising over . (his/her) right eye and complaining of pain in (his/her) left hip. Resident unable to state how injuries occurred and no incidence have been reported explaining how injuries occurred . Review of the facility's investigation summary revealed: . On 10/30/23 it was reported that (RI #198) had bruising around his/her eye and was complaining of hip pain. The origin of these concerns were not known . Center Investigation: The Center investigation included interviews with staff providing care for (RI #198). X-rays were also taken. Center Findings: At the time X-rays did not show a fracture . At this time staff do not report having seen or witnessed any incident that would have explained the injury and pain noted . Resident is unable to provide any information as to the origin of the discoloration over (his/her) eye . Center Actions Taken: . Injuries reported to MD (Medical Doctor) and RP (Representative) Injury reported to ADPD Resident assessed for additional injury; none noted Xray obtained, no acute fractures noted Investigation completed . Review of the facility's investigative file revealed a WITNESS INTERVIEW RECORD statement had not been obtained from CNA #10, the CNA providing care for RI #128 on the 6 AM to 2 PM shifts, on 10/28/2023, 10/29/2023, and 10/30/2023. On 08/26/2024 at 12:50 PM, a telephone interview was conducted with CNA #10, the CNA providing care for RI #198 on the 6 AM to 2 PM shifts, on 10/28/2023, 10/29/2023 and 10/30/2023. CNA #10 said she did recall RI #198 having a bruise to one of his/her eyes back in October of last year but could not remember which eye it was and could not describe how the bruise looked. CNA #10 said she got RI #198 out of bed around 10:30 AM on 10/29/2023, because RI #198 was becoming fidgety. CNA #10 said when she got RI #198 out of bed she placed RI #198 in his/her geriatric chair and left RI #198 in his/her room. CNA #10 said probably around lunch time she went back to check on RI #198 and noticed RI #198 had the bruise. CNA #10 said she took RI #198 to the nurse to show the nurse the bruise. When asked did she write a statement about what she had observed, CNA #10 said no one asked her to write a statement about what she witnessed. On 08/28/2024 at 9:38 AM, an interview was conducted with the ADM. The ADM said RI #198's bruise was considered an injury of unknown origin because the bruise was from an unknown source. When asked how an investigation was conducted to determine if abuse or neglect occurred, the ADM said staff who had provided care for RI #198 a couple of days before the bruise was identified were interviewed. The surveyor showed the ADM the assignment sheet for 10/28/2023 and 10/29/2023 and asked the ADM which CNA provided care to RI #198 on the 6 AM to 2 PM shift. The ADM said CNA #10. The ADM said looking at the interviews collected during his investigation he did not see where CNA #10 completed a Witness Interview. The ADM said since CNA #10 provided care for RI #198 during the time frame the bruise was observed, she should have completed a Witness Interview Record form. The ADM said since CNA #10's statement was not obtained, this was probably not a thorough investigation. 5) RI #598 was admitted to the facility on [DATE] with a Diagnosis of Dementia with Behavioral Disturbance. A review of RI #598's Quarterly MDS with an ARD of 06/15/2023 revealed he/she scored a 10 of 15 on the BIMS which indicated RI #598's cognition was moderately impaired. He/she ambulated on the unit independently with assistance of a walker. RI # 598's balance during transitions was coded as not steady, but able to stabilize without staff assistance. RI #598 was care planned for the potential to demonstrate verbal outburst towards others. A review of RI #598's care plan documented 11/08/2023 he/she exhibited verbal outbursts toward staff. A review of RI #598's medical record documented that on 11/13/2023 at 7:35 PM RI #598 started an argument with another resident, became agitated, cursing, and required staff intervention. On 11/14/2023 at 7:11 AM, the Alabama Department of Public Health Online Incident Reporting System form documented . RI #598 of our memory care unit stated to nurse that he/she had back pain because he/she was pushed down to the floor last night. He/she was unable to state by whom. Review of the facility's investigation summary revealed: . On 11/14 2023 RI #598, a resident in our memory care unit, claimed that he/she was having back pain. Nurse treated for pain and RI #598 claimed he/she was pushed down to the floor on the night before. Unable to state who or where. Center Investigation: Investigation included interviews with staff that had worked with RI # 598. Center Findings: RI # 598 is unable to state how, why or who pushed him/her down on the night shift. X-ray were taken, no fractures noted. Some mild osteoarthritis was noted. No other signs of injury were found. Staff interviewed stated they did not witness a fall, nor any incident of RI #598 being pushed. They did not find him/her on the floor at any point on the shifts. Center Actions Taken: . ADPH notified MD and RP notified Resident assessed for injury, none noted Resident treated for pain with good effect X-Ray of back taken, no fracture noted Resident monitored for change in behaviors or interactions with others, none noted Social Services provided as needed . A review of the facility investigative file revealed no staff or resident interviews were conducted prior to 11/14/2023 when RI #598 complained of back pain from being pushed down the night before. Further, the facility file revealed no documentation from staff that witnessed the altercation on 11/13/2023. No documentation that the incident on 11/13/2023 was investigated. On 08/26/2024 at 2:54 PM, the ADM was interviewed and said the facility investigation concluded there were no witnesses to a fall, or incident of RI #598 being pushed down the night before. When the ADM was asked if staff/resident witness statements were conducted days prior to 11/14/2023 to assist in determining if abuse did or did not occur, the ADM said no. The ADM agreed that more interviews should have been completed and documented. The ADM said he was not aware of an incident that occurred on 11/13/2023; therefore, no witness statements obtained nor investigated. When asked if the incident on 11/13/2023 should have been investigated further, the ADM said yes. 6) RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Schizoaffective Disorder, Depressive Type. An Admission MDS assessment with an ARD date of 04/04/2024, identified RI #9 had a BIMS of 5 of 15 which indicated that RI #9 had severely impaired cognition. RI #60 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Adjustment Disorder. A Quarterly MDS assessment with an ARD date of 06/20/2024, identified RI #60 as scoring a 12 of 15 on the BIMS, indicating RI #60 had moderate impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 06/25/2024 documented: . Incident Type . Other Facility Incidents . Incident Detail . Name(s) of resident(s) involved: (RI #9 and RI #60) . Narrative summary of how injury was discovered: RI # 9 was in another residents room, RI #60 came by and attempted to redirect RI #9 out of the room. RI #60 allegedly slapped RI #9's hand and told him/her they should not be in this room. RI #60 denies slapping RI #9 . A review of the facility's five day summary documented: . On June 25, 2024 it was alleged that RI #60 pinched the hand of RI #9 . This was a witnessed resident to resident altercation. Staff witnessing the incident were interviewed. Residents were also interviewed . At this time abuse cannot be substantiated in this instance. RI #60 simply did not understand that RI #9 was an invited guest in the room and . did not intend to cause harm to RI #9 . Both residents were assessed for injury, none noted . Review of the facility's investigative file revealed no documentation of interviews completed during the investigation. An interview was conducted with the ADM on 08/27/2024, at 12:13 PM. During the interview, the ADM was asked about the documentation of any interviews related to the investigation involving RI #60 and RI #9. He acknowledged that he spoke with those involved in the investigation but had not documented the interviews. He said that he should have documented the interviews. The ADM said the importance of documenting statements would be to provide an accurate and clear understanding of the events, which was essential for formulating an accurate action plan. *************************************************************** On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 F-610-Investigate/Prevent/Correct Alleged Violation On 7/6/23 Center Social Worker was notified by RI#398's family regarding resident RI#398 stating a CNA had been rough during care. On 7/6/23 Center Social worker notified Center Administrator of the allegation Center administrator on 7/6/23 spoke with RI#398 regarding the occurrence. The Administrators failure to obtain the resident's statement, statements from other residents, and potential witness statements resulted in the facility not investigating thoroughly to include determining the cause of the injury to RI# 398 wrist/forearms and implement appropriate corrective actions to prevent further potential abuse. RI #398 was discharged on [DATE], from Merry wood Lodge Center. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; notifying and reviewing each investigation with the Market Clinical Lead before completion; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations to include identifying abuse and taking appropriate action for prevention of abuse. Administrator has been trained and understands his role and responsibility in ensuring a thorough investigation is completed. Administrator has been trained on the steps to a thorough investigation. These include identification of an alleged occurrence, ensure all alleged occurrences are reported to the Administrator, protect the resident(s),reporting the event, assess resident for injury, perform and document interviews with all Interviewable residents, interviewing all witnesses and all staff in the Center at the time, reviewing pertinent chart documentation such as progress notes, care plans, physician's order, diagnoses and any other clinical documentation appropriate to the investigation. Investigating bruises and injuries are also a key component to investigation. Developing appropriate conclusions, including substantiation or not correctly, and also developing appropriate actions to take in order to prevent future occurrences from occurring. The Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator met on 9/1/24 at 12:45 pm to discuss staff on resident incidents after the incident occurring on 7/1/2023. Two were identified reviewed to determine if correct determination was made and if appropriate corrective action has been taken the findings are as follows: RI# 81 event dated 1/2/24- Based on QAPI review, thorough investigation was not completed, the determination remains appropriate, the actions taken at the time were appropriate however QAPI committee determines that additional actions needed to be taken these additional actions taken include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. RI #48-Event dated 3/10/24- Based on QAPI review, a thorough investigation was not completed, the determination was incorrect, the corrective actions taken at the time were appropriate however the QAPI committee has determined additional actions necessary to be taken. These actions include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. On 09/01/2024 at 4:25 pm the Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office as [TRUNCATED]

Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and a facility's policy titled Environment, the facility failed to ensure the kitchen floor was maintained in a clean and sanitary manner. This had the potential to affect all residents who received meals from the facility's kitchen. Findings Include: A review of 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, documented: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . A review of policy titled Environment Revised 9/2017 documented: .The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation . On 08/20/2024 at 10:16 AM, the Surveyor along with the Dietary Manager conducted an initial inspection of the kitchen. During the tour, it was noted that the kitchen floor was sticky, and an unidentified black substance was present in both the center and corners of the floor. On 08/22/2024 at 11:52 AM, a follow up kitchen inspection was conducted. The kitchen floor was observed to be unclean and sticky, with an unidentified black substance on various sections of the floor. On 08/28/2024 at 5:09 PM, and interview was conducted with the Director of Operations. The Director acknowledged the issue of sticky floors in the kitchen. He explained that the floors were old and a monthly deep clean was being considered. He was unsure the last time the floors had been deep cleaned. When asked about the black substance observed on the floor, the Director said it could be resolved through the deep cleaning process, as mopping and sweeping had proven ineffective in addressing those areas. The Director said the floors required attention and a new cleaning schedule would be implemented. He said it was important to maintain clean, non-sticky floors to prevent the attraction of insects, pests, and rodents.

Based on observation, interview, review of a facility policy titled, Environmental Services Policies and Procedures and review of the 2017 U.S. (United States) Public Health Service Food Code, the facility failed to ensure the grounds around the dumpster's were free of a burn pile with an accumulation of discarded cardboard boxes piled on top of the burn pile. This had the potential to attract rodents and pests and affect all 98 residents living in the facility. Findings Include: A review of the the 2017 U.S. (United States) Public Health Service Food Code revealed: . 5-501.110 Storing Refuse, Recyclables, and Returnable's. REFUSE, . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, . shall be maintained free of unnecessary items . and clean . The facility manual entitled Environmental Services Policies and Procedures included a policy titled ENV207 with a revision date of 03/01/2024 which documented: .Trash is removed from the Center/Community on a scheduled basis. Purpose To prevent accumulation of trash . The facility policy titled Environment with a revision date of 03/01/2024 documented: . 7. All trash will be disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. On 08/20/2024 at 10:16 AM the outside dumpster area of the facility was observed with the Dietary Manager. During the inspection a burn pile in close proximity of the dumpster area was observed. The burn pile contained multiple discarded cardboard boxes stacked on the burn pile. On 08/20/2024 at 10:20 AM an interview was conducted with the Dietary Manager. The Dietary Manager confirmed the presence of the burn pile and did not know how long it had been there. She said cardboard should not be stacked on the burn pile, as it may attract animals, pests or snakes. She said that cardboard was typically disposed of in the dumpster's. On 08/24/2024 at 11:49 AM an interview was conducted with the Administrator (ADM). The ADM said the burn pile located near the dumpster's was used by maintenance to burn old furniture and some debris. The ADM confirmed that discarded cardboard boxes were observed by the surveyor on 08/20/2024 and said cardboard should not be burned but rather disposed of in the dumpster's. The ADM said the concern of a burn pile near the outside dumpsters and the facility would be the possibility of a fire.

Based on interviews and review of the Payroll Based Journal (PBJ) Staffing Data Report, the facility failed to report accurate staffing data to the Centers for Medicare & (and) Medicaid Services (CMS). This affected the second quarter of the PBJ Staffing Data Report for 2024 (January 1, 2024 - March 31, 2024). Findings include: Review of the CMS PBJ Staffing Data Report for the second quarter of 2024 revealed the following: . Excessively Low Weekend Staffing . Result . Triggered . Definition . Triggered = Submitted Weekend Staffing data is excessively low . On 08/29/2024 at 12:18 PM, an interview was conducted with the former Staffing Manager (SM). The former SM said when she was the SM her job was to make sure the floors were staffed with the right amount of Certified Nursing Assistants (CNAs) and Nurses according to the census. The surveyor shared with the former SM that according to the PBJ Staffing Data Report from CMS, the facility triggered for Excessively Low Weekend staffing for the second Quarter ( January 1 - March 31, 2024). The former SM said the assignment sheets would accurately tell who worked. Review of the weekend assignment sheets for the second quarter of 2024 (January 1 - March 31) did not show the facility had low staffing on the weekends. On 08/29/2024 at 2:08 PM, the surveyor conducted a telephone interview with the [NAME] President of Product Management (VPPM), the person responsible for submitting the facility's PBJ information to CMS. The VPPM said she submitted the PBJ electronically, once a quarter. The VPPM said she submits the hours for all employees punching in on the time clock. The surveyor shared with the VPPM that according to the CMS Staffing Data Report, the facility triggered for Excessively Low weekend staffing for the 2nd Quarter of 2024 (January 1 - March 31); and asked the VPPM why would that be. The VPPM said when sending in staffing information to CMS, she does not determine who are nursing staff or not she just sends in the amount of staff who have worked or punched in on the time clock for that quarter. The VPPM said low weekend staffing may have triggered because staff who work during the week would not punch in as working on weekends. On 09/01/2024 at 10:33 AM, in interview was conducted with the Administrator (ADM). The ADM said the VPPM was responsible for submitting PBJ information to CMS and it was based off of the timecards punched for that quarter. The surveyor shared with the ADM that according to the CMS Staffing Data Report, the facility triggered for Excessively Low weekend staffing for the second Quarter of 2024 (January 1 - March 31). When asked was the facility short of staff at this time, the ADM said not to his knowledge. The ADM said it may have been that salaried staff, who did not have to punch in, worked on some of the the weekends. The ADM said when this happened the staff actually working the weekend might not have been actually counted as working the weekend on the PBJ Staffing Data Report. The surveyor asked, why would CMS need accurate information for the PBJ report. The ADM said basically to show the facility had adequate staff working on weekends.

Based on observations, interviews and a review of a facility policy titled, Food Storage: Cold Foods, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler, and 2. food items were labeled with a received date or use by date prior to storage in the walk-in cooler/reach-in freezer. These failures had the potential to affect 89 residents receiving meals from the kitchen out of 92 total residents residing in the facility. Findings Include: The facility policy titled, Food Storage: Cold Foods, with a revised date of 4/2018, included . Procedures . 5. All foods will be stored . labeled and date, and arranged . to prevent cross contamination . On 02/29/20 at 01:18 p.m., the surveyor observed food items in the walk-in cooler. There was one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one container of Prepared Yellow Salad Mustard with an opened date of 12/25/19 and labeled with a use by date of 01/25/20, and one bag of turkey with an open date of 02/15/20 and labeled with a use by date of 02/25/20. On 02/29/20 at 01:31 p.m., the surveyor observed food items in the reach-in freezer. The following items were observed: one bag of Spinach with an open date of 0[DATE] and no use by date, one bag of pepperoni slices with no open date and a use by date of 12/09/20, and one unopened roll of Ground Turkey with a received date of 12/13/19 and labeled with a use by date of 01/13/19. On 03/02/20 at 09:08 a.m., the surveyor conducted an interview with EI (Employee Identifier) #1, the Lunch Cook. The surveyor asked EI #1, what does a use by date mean. EI #1 stated, use it by that date or throw it away the next day. The surveyor asked EI #1 why the following items were observed in the walk-in cooler on 02/29/20 at 01:18 p.m.: one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one container of Prepared Yellow Salad Mustard with an opened date of 12/25/19 and labeled with a use by date of 01/25/20, and one bag of turkey with an opened date of 02/15/20 and labeled with a use by date of 02/25/20. EI #1 stated the items had been overlooked by staff. The surveyor asked EI #1 why the following items were observed in the reach-in freezer on 02/29/20: one bag of Spinach with an opened date of 0[DATE] and no use by date, one bag of pepperoni slices with no open date and a use by date of 12/09/20, and one unopened roll of Ground Turkey with a received date of 12/13/19 and a use by date of 01/13/19. EI #1 again stated these items had been overlooked by staff. EI #1 was asked, what was the facility's policy on labeling food items prior to storage. EI #1 stated all food items should be dated and labeled with open and use by date before placing in proper storage areas. The surveyor asked EI #1, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #1 stated it could cause food borne illness or contamination, which could lead to sickness. On 03/02/20 at 09:36 a.m., the surveyor conducted an interview with EI #2, the Dietary Manager. The surveyor asked EI #2, who was responsible for ensuring the food items were discarded when out of date in the walk-in cooler/refrigerator/freezer. EI #2 stated, all staff. The surveyor asked EI #2, what was the potential concern of storing foods not labeled with use by dates and storing items past their use by dates. EI #2 stated, it could cause food borne illness, which could lead to sickness.

Based on interview, record review and review of a facility policy titled Change in Condition: Notification of the facility failed to contact Resident Identifier (RI) # 24's resident representative when his/her diet was changed to pureed in August 2019. This affected 1 of 20 sampled residents. Findings Include: A review of policy titled Change in Condition: Notification of, with an effective date of 11/28/16, documented: .A Center must immediately inform the patient's Health Care Decision Maker (HCDM) where there is:.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. RI # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 24 also had a [DIAGNOSES REDACTED]. A review of RI # 24's diet orders documented the following: 8/13/19.Resident's diet downgraded to pureed due to coughing when eating. Resident appearing at times to have trouble swallowing regular tray. Speech Therapy (ST) was alerted and to see resident. On 03/02/20 at 2:53 p.m. the Surveyor reviewed RI # 24's medical record. A Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 documented the following: . Patient/Caregiver Education = Family/caregiver expressed understanding of evaluation and agreement with goals and treatment plan; Does patient/family agree w/ (with) Diet Recommendation? = Yes. On 3/2/20 at 9:38 a.m. an interview was completed with Employee Identifier (EI) # 3, Speech Therapist. EI # 3 stated she had RI # 24 on her case load on and off in 2019 for swallowing and cognitive problems. EI # 3 was asked what type of diet she recommended for RI # 24. EI # 3 stated she recommended a pureed diet in August of 2019 and RI #24 received that diet after the recommendation. A follow-up telephone interview was completed with EI # 3, Speech Therapist, on 3/2/20 at 2:47 p.m. EI # 3 was asked if she contacted RI # 24's family when he/she went on pureed diet in August. EI # 3 stated no. EI # 3 further stated she had a conversation with RI # 24's daughter but did not call her about the diet change. EI # 3 was asked what the statement on the Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 meant when it documented the Family/Caregiver expressed understanding of the evaluation and agreement with goals and treatment plan to include the diet recommendation. EI # 3 stated it meant she spoke with the facility about the resident's diet, not the family. EI # 3 was asked if she normally called family regarding a diet change. EI # 3 stated no. An interview was completed with EI # 4, Registered Nurse (RN), on 3/3/20 at 9:35 a.m. EI # 4 was asked if nursing staff called RI # 24's daughter when his/her diet was downgraded in August of 2019. EI # 4 stated there was a note about downgrading the diet on 8/13/19, but it was not documented the daughter was called and informed. EI # 4 further stated it should be documented. EI # 4 was asked what was the potential negative outcome of not notifying family of changes. EI # 4 stated the family not knowing about the change.

Based on record review, interviews, review of the consultant pharmacist's February 2020 Medication Regimen Review reports, and review of policies titled 9.1 Medication Regimen Review and 3.8 [MEDICAL CONDITION] Medication Use, the facility failed to ensure the consultant pharmacist identified concerns during the February 2020 medication review with Resident Identifier (RI) #24's [MEDICATION NAME], an antipsychotic medication, that was ordered on [DATE] without adequate justification for use. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 9.1 Medication Regimen Review, dated 11/28/16, revealed the following: .PROCEDURE . 1.1 The drug regimen of each skilled nursing facility resident must be reviewed at least once a month by a licensed pharmacist. Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/16, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was previously discontinued on 11/02/2018. Further, review of RI #24's current comprehensive care plans revealed no care plan for any behaviors. Review of the Pharmacy Consultation Reports indicated monthly Medication Regimen Reviews had been conducted from 2/16-2/18/20. RI #24's recommendation reports indicated the pharmacist had not identified a concern with the order for [MEDICATION NAME]. On 3/03/20 at 3:18 PM, a consultant Pharmacist (Pharmacist #1) was asked to explain the [MEDICAL CONDITION] Medication Use policy and the reference to a clinically indicated use and rationale. Pharmacist #1 stated there were a number of psychiatric disorders, as well as behaviors with intention for harm, that would warrant the use of antipsychotic medication. Pharmacist #1 stated he had not reviewed the policy in some time and did not realize it was so vague. When asked about [MEDICATION NAME] and whether Dementia or Alzheimer's would be an appropriate [DIAGNOSES REDACTED].#1 said no, unless there were documented behaviors or other diagnoses. Pharmacist #1 stated he filled orders for medications, but Pharmacist #2 was in the facility each month to conduct the medication reviews. Pharmacist #2 was interviewed on 3/03/2020 at 3:35 PM. Pharmacist #2 stated RI #24 had been prescribed [MEDICATION NAME] once daily for Alzheimer's. When asked what types of [DIAGNOSES REDACTED].#2 said dementia with associated behaviors. He further stated Alzheimer's was not the best [DIAGNOSES REDACTED].#24's [MEDICATION NAME]. After reviewing the information he had available on RI #24, Pharmacist #2 said he had notes indicating he had recommended a dose reduction on RI #24's [MEDICATION NAME] on 7/2/18 and it had been completely discontinued as of his note on 12/4/18. Pharmacist #2 also indicated another pharmacist (Pharmacist #3) made a note on 1/28/2020 that indicated RI #24 was receiving [MEDICATION NAME] 25 mg daily for Dementia. When asked what was an adequate rationale for use of an antipsychotic, Pharmacist #2 said [MEDICAL CONDITION]'s, [MEDICAL CONDITION], or Dementia with behaviors; He further stated dementia without behaviors would not be a reason to warrant use of [MEDICATION NAME]. As far as making a recommendation regarding the rationale and [DIAGNOSES REDACTED].#24's [MEDICATION NAME], Pharmacist #2 said he must have missed it when doing his February 2020 review.

Based on record review, interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Use, the facility failed to ensure Resident Identifier (RI) #24 was not given [MEDICATION NAME], an antipsychotic medication, without a [DIAGNOSES REDACTED]. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/2016, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 3. [MEDICAL CONDITION] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was discontinued on 11/02/18. Further, review of RI #24's current comprehensive care plans revealed no care plan addressing any behaviors. RI #24's January and February 2020 Medication Administration Record [REDACTED]. A telephone interview was completed on 3/2/20 at 3:37 p.m. with Employee Identifier (EI) # 7, Nurse Practitioner. EI # 7 was asked if she was aware RI #24 was readmitted to the facility on [DATE] with [MEDICATION NAME]. EI # 8 stated she was not aware and that EI # 8, the Medical Director, would be the one to sign off on it. An interview was completed on 3/3/20 at 2:48 p.m. with EI # 5, Licensed Practical Nurse (LPN), the nurse that processed RI #24's readmission on [DATE]. When asked how familiar she was with RI #24, EI # 5 said she was very familiar because RI #24 was her resident from the time of his/her original admission. EI # 5 said she was the nurse at the time RI #24 was readmitted on [DATE] and she had completed the admission. When asked what her responsibility was as the admitting nurse for reviewing the resident's medications. EI # 5 said she was responsible for making sure the orders were transcribed into the computer. When asked what the rationale for use of the [MEDICATION NAME] was when RI #24 returned from the hospital, EI # 5 said she had no idea, nor did she know if RI #24 was receiving the [MEDICATION NAME] before going to the hospital. EI # 5 further stated [MEDICATION NAME] was an antipsychotic medication. When asked why she had not questioned the order for the [MEDICATION NAME], EI # 5 said she did not know; she just assumed RI #24 was taking it before going out to the hospital. EI # 5 said she should have compared the medication orders RI #24 was taking prior to going to the hospital with the ones listed after RI #24's return, but she had not done that. When asked why it was important to have a rationale for the use of an antipsychotic medication, EI # 5 said the resident should not be on the medication if he/she does not need it. EI # 5 was then asked if RI #24 had any sort of behaviors prior to going out to the hospital, EI # 5 said RI #24 would sometimes have some anxiety, but they would get RI #24 and his/her roommate together and RI #24 would calm down. When asked if RI #24 displayed any behaviors after returning from the hospital, EI # 5 said he/she would complain of chest pain. When asked about the facility's policy regarding the use of antipsychotic medications, EI # 5 said anyone with orders for an antipsychotic should have a behavior sheet on their Medication Administration Record [REDACTED]. During a follow-up interview with EI # 5 on 3/03/20 at 5:24 p.m., EI # 5 stated she faxed the Medical Director, EI # 7, a copy of RI #24's admission orders [REDACTED]. EI # 5 said she had called the Medical Director and discussed pain medication orders but she did not recall asking about the [MEDICATION NAME]; she had just assumed RI #24 had been receiving it before going to the hospital. On 3/03/20 at 3:18 p.m., a consultant Pharmacist (Pharmacist #1) was asked to explain the Use of [MEDICAL CONDITION] Medications policy and the reference to a clinically indicated use and rationale. Pharmacist #1 stated there were a number of psychiatric disorders, as well as behaviors with intention for harm, that would warrant the use of antipsychotic medication. Pharmacist #1 stated he had not reviewed the policy in some time and did not realize it was so vague. When asked about [MEDICATION NAME] and whether Dementia or Alzheimer's would be an appropriate [DIAGNOSES REDACTED].#1 said no, unless there were documented behaviors or other diagnoses. Pharmacist #1 stated he filled medication orders, but Pharmacist #2 was in the facility each month to review medication orders. Pharmacist #2 was interviewed on 3/03/20 at 3:35 p.m. Pharmacist #2 stated RI #24 had been prescribed [MEDICATION NAME] once daily for Alzheimer's. When asked what types of [DIAGNOSES REDACTED].#2 said dementia with associated behaviors. He further stated Alzheimer's was not the best [DIAGNOSES REDACTED].#24's [MEDICATION NAME]. After reviewing the information he had available on RI #24, Pharmacist #2 said he had notes indicating he had recommended a dose reduction on RI #24's [MEDICATION NAME] on 7/2/18 and it had been completely discontinued as of his note on 12/4/18. Pharmacist #2 also indicated another pharmacist (Pharmacist #3) made a note on 1/28/20 that indicated RI #24 was receiving [MEDICATION NAME] 25 mg daily for Dementia. When asked what was an adequate rationale for use of an antipsychotic, Pharmacist #2 said [MEDICAL CONDITION]'s, [MEDICAL CONDITION], or Dementia with behaviors; He further stated dementia without behaviors would not be a reason to warrant use of [MEDICATION NAME]. Pharmacist #2 also said he had met with the facility in February to discuss psychoactive medications, but he was not sure if RI #24's [MEDICATION NAME] had been discussed. He indicated EI # 9, the Director of Nursing (DON), would have the notes from that meeting. Pharmacist #3, that completed the admission medication review, was interviewed on 3/03/20 at 4:28 p.m. When asked what types of [DIAGNOSES REDACTED].#3 stated any psychiatric [DIAGNOSES REDACTED]. When questioned whether RI #24 should have received [MEDICATION NAME] after coming back from the hospital (after it had been discontinued since 2018), Pharmacist #3 said if there was no indication of harmful behaviors, she would hope the facility would consider getting the resident off of the medication. Pharmacist #3 further stated there have to be behaviors and dose reductions when residents are on antipsychotic medications. On 3/3/20 at 4:15 p.m., EI # 9, the DON, was asked about the February meeting referenced by Pharmacist #2, in which psychoactive medications were discussed, and whether RI #24's [MEDICATION NAME] had been addressed. EI # 9 stated they had discontinued another one of RI #24's medications, but had continued with the [MEDICATION NAME]. When asked what the [DIAGNOSES REDACTED].#24's [MEDICATION NAME], EI # 9 said Alzheimer's and [MEDICAL CONDITION]. When asked if those [DIAGNOSES REDACTED].# 9 said she did not know that those [DIAGNOSES REDACTED]. When questioned why RI #24 required the [MEDICATION NAME] after it had been discontinued for over a year, EI # 9 stated she would need to review the information in RI #24's chart to discuss the concern any further. On 3/3/20 at 4:39 p.m., EI # 9 returned and stated she had reviewed the information in RI #24's chart. When asked what information she had that justified the use of [MEDICATION NAME] for RI #24, EI # 9 said RI #24 had come back from the hospital with orders for it. EI # 9 went on to say that she did see notes that RI #24 had exhibited a few behaviors after returning from the hospital. When asked if the [MEDICATION NAME] was being used to address any specific target behaviors, EI # 9 said they had not attached any specific behaviors to the order for [MEDICATION NAME]. When asked where RI #24's behavior monitoring tools could be located, EI # 9 said they were captured in the nurses' notes. EI # 9 said in her review of RI #24's medical record, she found two instances of behaviors since RI #24's readmission on [DATE]: on [DATE] exit seeking was noted and there was another episode of the resident undressing. When asked if there had been any repetitive behaviors noted, EI # 9 said those were the only two instances she saw since [DATE]. When asked if that was enough to justify the use of the [MEDICATION NAME] for RI #24, EI # 9 said she could not just discontinue the medication. EI # 9 went on to say she did not know if anyone had specifically asked the Nurse Practitioner or Medical Director why RI #24 was back on the [MEDICATION NAME]. EI # 9 said the facility was responsible for ensuring they are in compliance with the requirements for antipsychotic usage. EI # 7, the Medical Director, was interviewed on 3/03/20 at 5:00 p.m. EI # 7 was asked if he recalled the MEDICATION ORDERS FOR [REDACTED]. EI # 7 said, yes, facility staff had called him and he was frustrated because RI #24 had been readmitted to the facility with an order for [REDACTED].# 7 said the order for the [MEDICATION NAME] never should have been entered/transcribed for RI #24 to continue. When asked what [DIAGNOSES REDACTED].# 7 said none in a dementia patient, only uncontrolled [MEDICAL CONDITION]. When asked how the facility had justified continuing the [MEDICATION NAME] for RI #24 after it had been discontinued for over a year, EI # 7 stated he does not use [MEDICATION NAME] for dementia, and the medication had been ordered for RI #24 in error.

Based on record review, interview and review of a facility policy titled Medication: Administration: General, the facility failed to ensure nursing staff documented administration of Resident Identifier (RI) #24's [MEDICATION NAME] on 01/28/20 and 01/30/20 on the Medication Administration Record (MAR). This affected 1 of 20 sampled residents whose MARs were reviewed. Findings Include: A review of a facility policy titled Medication: Administration: General, revised [DATE], documented: .11. Document: 11.1 Administration of medication on Medication Administration Record (MAR). RI # 24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #24's physician's orders [REDACTED]. A review of RI # 24's Narcotic Record for January 2020 documented one dose of [MEDICATION NAME] was taken out on 1/28/20 and another on 1/30/20. However, review of RI # 24's January 2020 MAR did not reflect [MEDICATION NAME] was administered on [DATE] or 1/30/20. On 3/1/20 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 5, the Licensed Practical Nurse (LPN) that signed out the [MEDICATION NAME] on 1/28/20. EI # 5 was asked if she gave RI # 24 a [MEDICATION NAME] on 1/28/20. EI # 5 stated yes, it was documented on the narcotic book that she had signed one out. EI # 5 was asked if she marked the MAR when the [MEDICATION NAME] was given on 1/28/20. EI # 5 stated no, she forgot, but she should have signed it off on the MAR as adminsitered. EI # 5 was asked why she should mark it on the MAR. EI # 5 stated the next shift needed to know what was given. EI # 5 was asked how many doses of the [MEDICATION NAME] RI # 24 received. EI # 5 stated a total of two doses: one on 1/28/20 at 6:00 p.m. and one on 1/30/20 at 12:00 p.m. EI # 5 stated she did not give the the dose on 1/30/20. EI # 5 was asked if the nurse from 1/30/20 marked on the MAR that the [MEDICATION NAME] was given. EI # 5 stated no. An interview was completed with EI # 4, Registered Nurse/Unit Manager, on 3/3/20 at 9:40 a.m. When questioned about RI #24's Narcotic Record reflecting doses of [MEDICATION NAME] were signed out on 1/28/20 and 1/30/20 but administration was not documented on the MAR, EI # 4 stated it should have been documented in both places. EI #4 further explained the Narcotic Record reflected the medication was taken out, and the MAR should reflect the medication was administered. EI # 4 was asked if nurses should document on the MAR when they give medications. EI # 4 replied yes. EI # 4 was asked why nurses should document on the MAR. EI # 4 replied, to show the medication was given.

Based on observation and interview, the facility failed to ensure Nurse Staffing information was posted on Saturday, 2/29/20, when the survey team entered the building. This was observed on 2/29/20 and had the potential to affect all 92 residents residing in the facility, as well as family and visitors in the facility. Findings include: On 2/29/20 at 1:00 p.m., the survey team entered the facility and observed the Nurse Staffing information posted; the posting was dated for the previous day, 2/28/20, instead of for the current date and shift. On 3/03/20 at 3:17 p.m., Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN), was interviewed. EI # 6 was asked who was responsible for ensuring Nurse Staffing information was posted daily on the weekends. EI # 6 said the first hall nurse was responsible. EI # 6 further stated she had been the nurse working on the 1st hall on 2/29/20. When asked if she had posted the Nurse Staffing information that day, EI # 6 said no, she forgot. EI # 6 said she should have posted the staffing information for 2/29/20 that morning. EI # 6 was asked the purpose of posting the Nurse Staffing information daily in the facility. EI # 6 said it should be posted because it shows the public how many people are working, shows the number of employees in the building, as well as the number of residents.

Based on interviews, medical record review and review of the facility's policy titled OPS300 Abuse ProhibitionAbuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure a Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) reported an allegation of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not reported timely to the State Survey Agency (Reporting); 3) protect Resident Identifier (RI) #2 and potentially other residents from abuse perpetrated by RI #1 (Protection); and 4) investigate an allegation of physical abuse (Investigation). On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation and physical abuse did occur. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. These deficient practices affected RI #2, RI #3, RI #4 and RI #5, four of five sampled residents reviewed for resident to resident altercations; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F607. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY . The Center will implement an abuse prohibition program through the following: . * Prevention of occurrences; . * Investigation of incidents and allegations; * Protection of patients during investigations; and * Reporting of incidents, investigations, and Center response to the results of their investigations . PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . PREVENTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 4. Actions to prevent abuse . will include: . 4.2 identifying, correcting, and intervening in situations in which abuse . is more likely to occur . Contained within the facility's investigation file were the following: On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. Before staff could intervene, RI #5 fell to the floor and struck the back of his/her head against the floor or wall. Both residents sent to the local hospital for evaluation and returned back to the facility. Law enforcement, the residents' families and physician were notified. RI #5 was sent to acute Geri-Psych on 4/20/2018. RI #1 had a medical condition that delayed transfer to Geri-Psych; he/she remained on close monitoring by staff until sent. The facility concluded that physical abuse did occur; however, they could not determine the aggressor or the victim. As a result of the incident, the staff was provided education on proactive identification and response to possible resident aggression; position residents in common areas to respect personal space and freedom of movement. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. The facility concluded that no physical abuse occurred - the contact was deemed accidental. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. Neither resident could account for how they ended up on the floor or what happened. The staff did not hear or otherwise observe any interactions between the two residents. RI #1 had been walking around the Memory Care (Dementia) Unit and RI #3 was in the bed, with the bed in the lowest position. RI #3 was sent to the local hospital for evaluation. The facility was unable to substantiate that abuse occurred or who the victim or aggressor was. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. This allegation was reported to the SA on 2/15/2019 at 8:50 PM. The five-day report concluded RI #1 struck RI #2 with no warning or provocation. While neither resident was injured, physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was provided 1:1 oversight during the resident's waking hours. On 2/21/2019, RI #1 was transferred to an acute Geri-psychiatric facility. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked what intervention(s) was put in place after the 4/19/2018 incident. EI #2 said there were none for that time period. When asked what intervention(s) were put in place after the 11/23/2018 incident, EI #2 said RI #1 was assisted to his/her room and gotten ready for bed. EI #2 was asked about the 12/26/2018 incident. According to EI #2, after the incident, RI #3 was sent to the hospital and when RI #3 returned to the facility the resident was placed in a room by himself/herself for the remainder of the night to avoid any further confrontations. When asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. EI #2 was asked what interventions were put in place after the 2/15/2019 incident between RI #1 and RI #2. She explained there were no interventions for RI #2 other than the assessment for injury; however, RI #1 was placed on 1:1 until discharge or other placement could be found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. EI #5 stated she didn't know RI #1 was 1:1 when the second incident on 2/20/2019 happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he was asked what intervention(s) were put in place after the 4/19/2018 incident. EI #1 said RI #5 was discharged to the hospital for evaluation and subsequently sent to a mental health setting, while RI #1 was placed on close monitoring while out of bed. When asked what was done to deter the 11/23/2018 from reoccurrence, EI #1 said RI #5 was assigned to another room outside of the Memory Care Unit. According to EI #1, the 12/16/2018 incident between RI #1 and RI #3 was treated as a fall. When asked what interventions were put in place after the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #1 said RI #1 was placed on 1:1 until discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. RI #1's care plan titled Resident/patient exhibits, or has the potential to exhibit physical behaviors such . Physical aggression toward others . initiated 2/6/2018 had the following interventions: redirect and offer rest periods if resident becomes agitated was initiated on 5/4/2018 by EI #2; a medication review by the psychiatrist was initiated on 11/24/2018 by EI #2; a roommate change was initiated on 1/30/2019 by EI #12, a LPN; supervision to and from activity was initiated on 1/30/2019 by EI #12; medication adjustment was created on 2/5/2019 by EI #11, a Registered Nurse (RN); an attempt to keep RI #1 in populated areas and provide redirection as needed was initiated on 1/30/2019 by EI #12 and revised on 2/7/2019 by EI #2; 1:1 supervision with escalation of behaviors as needed was initiated on 2/7/2019 by EI #2; an activity board for 1:1 entertainment was initiated on 2/7/2019 by EI #2; monthly psychiatrist visits were initiated on 2/7/2019 by EI #2; and 1:1 supervision was initiated on 2/18/2019 by EI #11, a RN. REPORTING/RESPONSE The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff stated she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. INVESTIGATION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, was asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no notification to sponsors/physicians; documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . PROTECTION The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . 5.2 If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. 5.2.1 The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected. 5.2.2 The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. 5.2.3 The family and physician will be notified . PR[NAME]ESS . 7. The Center will protect patients from further harm during an investigation. 7.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 7.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, was asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to the facility's investigative summary submitted to the Alabama State Survey dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * The 1:1 supervision of (RI #1) by Center staff, put into place on (MONTH) 15, 2019, was not maintained through (RI #1's) discharge date of (MONTH) 21, 2019, enabling (RI #1) to strike (RI #2) on (MONTH) 20, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F607, which documented: F-607 J-Development and implementation of written Abuse Prohibition policies. Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the implementation of Abuse Prohibition policy and procedure to include protection of the resident. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the implementation of Abuse Prohibition policy and procedure to include protection of residents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F607 was lowered to a E level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.

Based on interviews, review of the facility's policy titled OPS138 Staffing/Center Plan, the Facility's Assessment Tool, the facility's daily census, staffing and assignment report, the facility failed to ensure sufficient staff was assigned to work during the evening shift on 2/20/2019 on the Homestead Memory Care (Dementia) Unit. The facility had determined the staffing needs for the evening shift was one direct care staff per nine residents. The daily census for the Dementia Unit for 2/20/2019 was 34, which indicated two direct care staff were assigned to care for 11 residents and one direct care staff was assigned to care for 12 residents. During the evening shift on 2/20/2019 around supper time, Resident Identifier (RI) #1, a resident identified as being physically aggressive towards others, was found by staff standing over RI #2, punching RI #2 in the head. RI #1 had previously been identified to physically abuse RI #2 on 2/15/2019. After this physical altercation, RI #1 was to be placed on 1:1 until discharge from the facility. This intervention was not implemented, thus RI #1 was found again physically abusing RI #2, five days later. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the Administrator, Director of Nursing Service and Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Nursing Services, F725. Findings include: The facility's policy titled OPS138 Staffing/Center Plan with a revision date of 9/1/2013, documented POLICY Genesis HealthCare Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. PURPOSE To assure that appropriate staff levels are scheduled and maintained. PR[NAME]ESS . 4. The Center maintains appropriate staff levels, with qualified personnel, 24 hours/day, seven days/week on each shift to assure that patients are safe and their needs are met. Inquiries concerning nursing staffing should be referred to the Nursing Director . The facility's FACILITY ASSESSMENT TOOL for the Homestead Memory Care Unit dated (MONTH) (YEAR), indicated the direct care staff for the evening shift was one staff per nine residents. On 2/22/2019, anonymous callers reported to the Alabama State Survey Agency that RI #1 had repeatedly physically abused other residents on the Dementia Unit. According to the callers, earlier in the week during the second shift, RI #1 punched RI #2 in the chin. Then during the second shift on 2/20/2019, RI #1 was seen punching RI #2 in the face. The callers stated it was impossible for someone to watch RI #1 1:1 during the second shift because they were understaffed. The Merry Wood Lodge Daily Census for 2/20/2019 indicated there were a total of 34 residents who resided on the Homestead Memory Care (Dementia) Unit. The daily staffing sheet for 2/20/2019 indicated there were a total of three Certified Nursing Assistants (CNAs) scheduled to work during the evening shift, 2:00 PM to 10:00 PM; however, one CNA was listed as working 2:30 PM to 8:30 PM. The CNAs were listed as Employee Identifier (EI) #5, EI #6 and EI #7. The Homestead Assignment Sheet for the evening shift on 2/20/2019 revealed EI #5, CNA was assigned to care for 11 residents; EI #6 was assigned to care for 12 residents; and EI #7 was assigned to care for 11 residents. In a telephone interview on 2/27/2019 at 9:31 PM, EI #5, a CNA, said normally three CNAs work the unit. EI #5 said three was not an adequate number of CNAs to work the unit and she had told the person who does scheduling (EI #10, the Staffing Coordinator) that four CNAs were needed. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA confirmed there were three CNAs working the Homestead Unit on 2/20/2019. EI #7 stated it was very seldom four CNAs worked the unit. In an interview on 3/1/2019 at 9:34 AM, EI #10, the Staffing Coordinator was asked how the Dementia unit was staffed. EI #10 stated normally there are three CNAs, one male and two female CNAs. EI #10 explained that the male CNA only cared for the eight male residents that resided on the unit, leaving the other two female CNAs to split the other female residents. When asked about the 2/20/2019 incident, EI #10 stated the census on the Homestead Unit was 34 residents. When asked how many staff were scheduled, EI #10 said three females. EI #10 was asked how many residents each staff member had. EI #10 replied that two CNAs had 11 and one CNA had 12. When asked what the facility's assessment indicated the staffing pattern should be for evening shift on the Homestead Unit, EI #10 said one CNA per nine residents. When asked if staffing levels during the evening shift on 2/20/2019 reflected the assessed needs of the unit per the Facility's Assessment, EI #10 said no ma'am. EI #10 was asked if anyone had reported staffing concerns to her related to the facility's Dementia unit. EI #10 said EI #5 had. On 3/1/2019 at 10:25 AM, an interview was conducted with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS). EI #2 said she was involved in staffing by helping to make sure the facility had adequate staff for each unit. EI #2 said according to the Daily Staff sheet for the Homestead Unit on 2/20/2019, the census was 34. EI #2 confirmed there were three CNAs scheduled to work and two of the CNAs were assigned to care for 11 residents and one CNA was assigned to care for 12 residents. EI #2 said according to the Facility's Assessment, the ratio was to be one staff to care for nine residents. EI #2 said that staff on that shift did not meet the Facility Assessment's guideline. During an interview with EI #1, the Center Executive Director, also known as the Administrator, on 3/1/2019 at 3:10 PM, he confirmed the facility's Assessment ratio of one staff to care for nine residents was not followed on 2/20/2019, on the Homestead unit for the 2:00 PM to 10:00 PM shift. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F725, which documented: F-725 J- Nursing Services; sufficient nursing staff On (MONTH) 20, 2019, on the 2-10 pm shift 3 Certified Nursing Assistants were assigned to the Homestead Unit. Effective (MONTH) 1, 2019, the first and second shifts in the Homestead memory care unit were scheduled with four (4) CNAs. This level of staffing of the Homestead unit will be continued until revised per the Facility Assessment. On (MONTH) 1, 2019, the Nurse Practice Educator validated the employees assigned to the Homestead Unit met the Dementia training education requirements. On (MONTH) 1, 2019, the Center Executive Director (CED) educated the Center Nurse Executive (CNE) and Center Scheduler on ensuring proper direct-care staffing is available on the Homestead unit, per the Facility Assessment. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F725 was lowered to a E level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.

Based on interview and review of the Center Nurse Executive's job description, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), responsible for the overall operations associated with direct patient care, failed to ensure staff was provided written education on when and how to provide 1:1 supervision of Resident Identifier (RI) #1 and further failed to ensure the 1:1 supervision was implemented from 2/15/2019 until 2/21/2019. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS and was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During interview on 2/28/2019, Employee Identifier (EI) #2 stated she now realized that she should have provided written education and had the staff to document that the 1:1 supervision intervention was being implemented for RI #1. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: Refer to F600 and F607 The GENESIS HEALTHCARE JOB DESCRIPTION: CENTERS for the position titled Center Nurse Executive with a revision date of 6/16/2017, documented . POSITION SUMMARY: The Center Nurse Executive leads the Center clinical team to fulfill the organization's mission, vision and value. This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities . RESPONSIBILITIES/ACCOUNTABILITIES: . Clinical Leadership: . 2.8 Monitors nursing care to ensure positive clinical outcome . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignment sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred, and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied, I don't know. I would never do that. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F 835, which documented: F-835 J- Administration On (MONTH) 1, 2019, the Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on ensuring residents are free from Abuse and Neglect, implementing Abuse policies and procedures, reporting alleged violations timely, and investigating alleged incidents. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be the Center Executive Director, who is the Abuse Prevention Coordinator. On (MONTH) 1, 2019, Director of Clinical Operations reviewed allegations of Abuse and Neglect in the last 30 days to ensure written Abuse Prohibition policies and procedures were implemented and allegations were reported timely, thoroughly investigated, and residents were protected. No concerns were identified. On (MONTH) 1, 2019, the Director of Clinical Operations hosted a Quality Assurance Performance Improvement meeting with selected Department Managers and reviewed the Abuse Prohibition policy and procedure to ensure residents are free from Abuse and Neglect, Abuse policies and procedures are implemented, alleged violations are reported timely, and thoroughly investigated. ************************** After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a E level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.

Based on interviews, review of Resident Identifier (RI) #1, RI #2's medical record, RI #3's medical record, the facility's policy titled OPS300 Abuse Prohibition and the facility's investigative file, the facility failed to ensure RI #2 and RI #3 were free from abuse perpetrated by RI #1, a resident who resides on the Homestead Memory Care (Dementia) Unit. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1, a resident identified as being physically aggressive toward others, struck RI #2 with no warning or provocation and physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the evening shift on 2/20/2019, around supper time, the intervention of 1:1 supervision/oversight was not implemented and RI #1 was found by staff standing over RI #2, punching RI #2 in the head. This deficient practice affected RI #2 and RI #3, two of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled, OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY Genesis HealthCare Centers will prohibit abuse . for all residents . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting, slapping, pinching, kicking, etc., . 1) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #2 was admitted to the facility on [DATE]. RI #2 has a medical history to include [DIAGNOSES REDACTED]. RI #2's Quarterly MDS with an assessment reference date of 11/28/2018, indicated RI #2 was severely impaired in cognitive skills for daily decision making, with a BIMS score of 4. For one to three days during this assessment period, RI #2 displayed verbal behavior symptoms directed toward others. On 2/15/2019, the facility reported an allegation of physical abuse to the Alabama State Survey Agency. According to the report, . (RI #1) and (RI #2) were ambulating in hallway toward one another. (RI #1) struck (RI #2) with (his/her) R (right) fist on (RI #2's) chin . Action(s) taken by the facility in response to the incident: . (RI #1) placed on 1:1 observation until referral to geri-psychiatric services . The facility's investigative summary dated 2/22/2019, documented . On (MONTH) 15, 2019, at approximately 7:45 PM, LPN (Licensed Practical Nurse) (EI (Employee Identifier) #4) was exiting Resident room [ROOM NUMBER] when she observed (RI #1) and (RI #2) walking towards one another. (EI #4) observed (RI #1) say something towards (RI #2), and then strike (RI #2) on (his/her) chin with a closed fist. The Nurse intervened to prevent further contact . Center Conclusions. RI #1 struck RI #2 with no warning or provocation . physical abuse did occur. From (MONTH) 15, 2019 until (MONTH) 21, 2019, RI #1 was provided 1:1 oversight during (his/her) waking hours. On (MONTH) 21, 2019, (he/she) was transferred to the acute geri-psychiatric setting . On 2/22/2019, anonymous callers reported to the Alabama State Survey Agency that RI #1 had repeatedly physically abused other residents on the Dementia Unit. According to the callers, earlier in the week during the second shift, RI #1 punched RI #2 in the chin. Then during the second shift on 2/20/2019, RI #1 was seen punching RI #2 in the face. The callers stated it was impossible for someone to watch RI #1 1:1 during the second shift because they were understaffed. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. When asked what she did observe, EI #5 stated as she was walking down hall she looked over in RI #2's room and saw RI #1 punching RI #2 in the head. When asked where RI #2 was, EI #5 said RI #2 was sitting on the bed and RI #1 was standing over RI #2 hitting him/her. According to EI #5, another CNA (EI #6) came over and asked what was going on. Also, EI #7, a CNA and EI #4, the LPN responded when EI #4 called for help. EI #5 stated she removed RI #1 from the room and asked the resident what was wrong. EI #5 replied, RI #1 told her that's ok I have taken care of the problem it has been going on 14 days. EI #5 was asked if she observed any injuries to either resident. EI #5 replied, she didn't see any injuries to RI #2 but RI #1's knuckles were red. EI #5 stated the nurse, EI #4, was made aware of what occurred. When asked if RI #1 was ever on 1:1, EI #5 stated before RI #1 hit RI #2 the second time (2/20/2019), RI #1 was on 1:1 for about a day. EI #5 stated she didn't know RI #1 was 1:1 when the second incident (2/20/2019) happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if she was familiar with RI #1, EI #7 said yes. EI #7 described RI #1 as being alert but very confused. EI #7 was asked, who was assigned to care for RI #1 during the second shift on 2/20/2019. EI #7 replied, EI #6 was. When asked if she witnessed RI #1 hitting RI #2 on 2/20/2019, EI #7 replied no. EI #7 was asked when she became aware of the altercation. EI #7 explained that the nurse, EI #4, had asked her to take a resident to the bathroom, when she heard EI #7 holler help or something to that nature. EI #7 stated she stopped what she was doing and went to RI #2's room; however, EI #6 was already there. According to EI #7, EI #5 said she went into the room and noticed RI #1 on top of RI #2 beating RI #2 with his/her fist. When asked if the nurse, EI #4, was notified of the altercation, EI #7 said yes. EI #7 stated the nurse told her that she had contacted the Director of Nursing Service (DNS), who stated to not do anything that she (DNS) would take care of it in the morning. EI #7 was asked if RI #1 was supposed to be on 1:1 on 2/20/2019. EI #7 replied, she wasn't sure. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but EI #7 said she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on it to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. EI #6 was asked if there was altercation between RI #1 and RI #2 on 2/20/2019. EI #6 answered, yes. When asked what happened, EI #6 said it was during supper time and she was in the middle of feeding another resident when EI #5 observed RI #2 sitting on the bed and RI #1 punching RI #2 in the face. EI #6 stated when she entered RI #2's room she could tell that RI #1 had hit RI #2 because RI #1's knuckles on both of his/her hands were red and RI #1 was sweating. Also, EI #6 stated the left side of RI #2's face looked bruised. According to EI #6, the nurse, EI #4, notified the DNS, who told her not to call RI #2's family, that the staff was going to be written up because they were not watching RI #1 and that she (DNS) would take care of things the next day. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. When asked if she was familiar with RI #1, EI #4 said yes. EI #4 stated RI #1 was a nice resident most of the time. According to EI #4, RI #1 did have a problem where he/she hit two residents. EI #4 explained on 12/16/2018, RI #1 knocked RI #3's tooth out. Then on 2/15/2019, EI #4 explained that she was coming out of room [ROOM NUMBER] and saw RI #1 hit RI #2 under the chin. EI #4 stated she yelled and got in between both residents. Afterwards, EI #4 stated she notified the Director of Nursing Service (DNS). When asked if she had been told to place RI #1 on 1:1, EI #4 said yes. When asked what 1:1 meant, EI #4 said that someone is with the resident at all times. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. When asked if she documented the 2/20/2019 altercation, EI #4 said she did not. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. RI #1's Merry Wood Lodge Progress Notes written by EI #4, a LPN and dated 2/15/2019 at 9:48 PM, documented the following: . Note: A change in condition has been noted. The symptoms include: Other change in condition Hit another resident 02/15/2019 in the afternoon . A review of RI #1's medical record revealed no documentation regarding the 2/20/2019 incident in which RI #1 was observed punching another resident, RI #2, in the head. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. EI #2 was asked if resident-to-resident altercations were reportable to the State Survey Agency and she said yes. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred, and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied, I don't know. I would never do that. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. 2) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #3 was admitted to the facility on [DATE]. RI #3 has a medical history to include [DIAGNOSES REDACTED]. RI #3's Quarterly MDS with an assessment reference date of 11/30/2018 indicated RI #3 was severely impaired in cognitive skills for daily decision making with a BIMS of 2. During this assessment period, RI #3 was not identified as displaying any behaviors. According to the facility's investigative file, on 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. In an interview with RI #3 on 2/26/2019 at 11:03 AM, the resident was asked if he/she had ever been in a fight or had someone hit him/her while in the facility. RI #3 replied, We both hit each other. When asked why each resident hit each other, RI #3 stated the other resident had hit him/her. When asked who hit first, RI #3 replied the other resident hit him/her first. RI #3 was asked where was he/she hit and the resident replied, on my head. When RI #3 was asked if he/she was hurt, the resident stated no we just hit each other. ************************* On 03/02/19 at 7:15 p.m., the facility submitted an Allegation of Credible Compliance for F 600, which documented: F-600J-Freedom from Abuse and Neglect * Licensed Nurse discharged RI #1 to (local geri-psychiatric facility) on (MONTH) 21, 2019. * As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. * Interdisciplinary Team interviewed 7 of 7 residents deemed as interviewable on Homestead and/or with BIMs score ranging from 8-15 regarding Abuse and Resident to Resident altercations on the Homestead Unit on (MONTH) 2, 2019. No other resident to resident altercations were voiced by the residents. * Licensed Nurses completed skin assessment on 24 of 31 residents on Homestead identified with severe cognitive impairment to identify suspicion of Abuse and/or Neglect on the Homestead Unit. The skin assessments were completed (MONTH) 2, 2019. No concerns were identified. * The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) (2019) on the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations. Employees on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires are educated on Abuse Prohibition policy during orientation. * The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. * Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure on (MONTH) 1, 2019. * Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.

Based on interviews and review of the facility's policy titled OPS Abuse Prohibition the Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) failed to report an allegation of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not timely reported to the Alabama State Survey Agency. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the LPN, she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F609. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) Licensed Practical Nurse (LPN) assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F609, which documented: F-609 J- Reporting of Alleged Violations Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. Center Executive Director submitted an online report with the State Agency on (MONTH) 27, 2019 related to the resident to resident altercation occurrence on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include reporting of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to reporting during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure to reporting of incidents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F609 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.

Based on interviews and review of the facility's policy titled OPS300 Abuse Prohibition, the facility failed to immedately investigate an allegation of physical abuse perpetrated by Resident Identifier (RI) #1, a cognitively impaired resident who resides on the facility's Homestead Memory Care (Dementia) Unit. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the Director of Nursing Service (DNS); however, she was told to not document anything that the DNS, would take care of everything in the morning. There was no documentation or investigation of this allegation of physical abuse until 2/27/2019. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who reside on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F610. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS (Risk Management System). Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . In an interview with Employee Identifier (EI) #1, the Center Executive Director, also known as the Administrator, on 2/28/2019 at 12:25 PM, he was asked what he expected the staff to do when they became aware of the incident. EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have been completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey Agency dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no . documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F610, which documented: F-610 J-Investigate/Prevent/Correct Alleged Violation Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. Center Executive Director initiated an investigation on (MONTH) 27, 2019 related to the resident to resident altercation on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include investigation of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to investigating incidents during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure to include investigation of incidents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F610 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156.