Every finding on record at Mountain Ridge Health and Rehabilitation

Based on observation, interview, and facility policy the facility failed to prepare, store, and serve food under sanitary conditions. Observations on 01/13/2026 during initial kitchen tour, foods were not labeled or dated, and steam table pan removed from the dish rack and stacked onto another steamtable pan still wet. Continued observation in the kitchen on 01/13/2026, lunch service, staff changed gloves without preforming hand hygiene, touching clothing with gloved hand and food placed onto the steamtable over 30 minutes before service. Observation of the resident refrigerator at the nurses' station resident food items not labeled or dated and the refrigerator needed cleaning. The findings include:A review of the facility policy titled Ware Washing dated 10/2019 revealed the dining service director ensures that all dishware is air dried and properly stored. A review of the facility flyer titled TCS Foods and 7-day Labeling no date, revealed TCS (Temperature Control for Safety) food label include item, prep date, use by date, and initials. Transfer for rewrite labels with the original Use by date from the first container if you move labeled items to different containers. A review of the facility policy titled Hand Hygiene dated 6/09/2025, revealed clean your hands by hand washing with soap and water. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. A review of the State Operations Manual (SOM) dated 04/25/2025, The temperature of TCS (Temperature Control for Safety) foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures are maintained. If time is being used in place of temperature as a means of ensuring food safety, the facility must have a system in place to track the amount of time a TCS is held out of temperature control and dispose of it accordingly. The temperature danger zone is 41 degrees Fahrenheit to 135 degrees Fahrenheit. Observation of the Dietary staff on 01/13/2026 at 8:56 AM taking steam table pan out of the dishrack, from the clean side of the dishwasher. The pan had a wet appearance with water dripping as the pan placed upside down and stacked onto another steam table pan under the preparation table. Continued observation in the same area of a clear lidded container with the appearance of brown sugar not labeled or dated sitting on the floor and soft tortillas in a zip lock bag not labeled or dated left on top of a tall bin. Observation of the lunch meal preparation service with tour of the dry storage on 01/13/2025 at 11:20 AM to 11:38 AM, revealed clear bag of pancakes, out of the case, with no label or date in the freezer. Dietary Staff actively completing food items and placing them onto the steam table. The steam table had food placed onto the steam table more than 30 minutes prior to meal service at 12:00 PM. Continued observation of Dietary Staff revealed not washing hands between change of task or glove changes. Observation of aide taking a pen out of her pocket with gloves on. Observation of the resident nourishment refrigerator on 01/13/2026 at 12:24 PM a large white plastic bag with several lidded containers with no identification on the bag, date, or resident name. One UnCrustable sandwich with no resident name in the refrigerator drawer and no date. The refrigerator with dry brown substance on the low shelf over the drawers, and in the two drawers. Open can of Mellow Yellow was left in the refrigerator with no open date or resident name. During an interview with Culinary Aide 1 on 01/14/2026 at 1:27 PM, she stated when changing tasks gloves are to be changed to prevent cross contamination. She further stated food is dated with the open date and allow the pans to dry before putting up wet to prevent bacteria from growing.In an interview with Dietary Supervisor on 01/14/2026 at 1:30 PM, she stated it is important to change gloves between tasks and wash hands to prevent cross contamination. She further stated food items should be dated with receive date, open date and use by date. She continued to state that pans are to dry and not have any moisture prior to putting them onto the shelf.In an interview with [NAME] 1 on 01/14/2026 at 1:35 PM, he stated that gloves are to be changed between tasks, wash hands and put on gloves. He further stated that opened food is to be labeled with an open date and dated for discard in 7 days and pans are air dried to not contain chemicals.In an interview with Culinary Aide 2 on 01/14/2026 at 1:38 PM, he stated gloves are to be changed after every task to prevent cross contamination, food dated with received date and open date, and to allow pans to dry and not have water in the container. In an interview with the Dietary Manager on 01/14/2026 at 1:43 PM, he stated food should not be placed on the tray line before 30 minutes prior to service. To hold food at proper temperature. He further stated should wash hands between glove changes to prevent cross contamination and food labeled and dated with receive date, open date, and discard within 7 days. He continued to state that no food containers on the floor to prevent cross contamination and the pans are allowed to air dry, not contain water or bacteria to grow.In an interview with the Environmental Services Manager (EVS) on 01/14/2026 at 2:40 PM, she stated nursing was responsible for cleaning the resident refrigerator.In an interview with Licensed Practical Nurse (LPN) 2 on 01/14/2026 at 2:12 PM, he stated housekeeping was responsible for cleaning the resident refrigerator. He further stated if family brings food for residents the food should be labeled with name and date.In an interview with Director of Nursing (DON) on 01/14/2026 at 2:56 PM, he stated his expectations was for staff to follow state and federal guidelines and he really does not know the kitchen.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping services to ensure a clean and sanitary environment for six (Resident (R) R1, R4, R7, R37, R41 and R54) of 58 sampled residentsThe findings include: Review of the undated facility policy titled, Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment. The facility was not able to give the survey team any other policies for housekeeping or maintenance duties. In an interview with the Director of Nursing (DON), he stated We do not have policies for housekeeping or maintenance.1. On 01/13/2026 at 09:18AM, observation of R4's room revealed a tile cracked in the floor next to the baseboard on the wall, potentially creating a fall hazard.2. On 01/13/2026 at 09:26AM, observation of R7's room revealed two cracked tiles in the floor.3.On 01/13/2026 at 09:39AM, observation of R1's room revealed two cracked tiles in the doorway of the resident's room. Continued observation revealed paint chipped on the wall behind R1's bed. In an interview with R1, they stated I wish they would paint the wall behind my bed. It just makes my room not feel like home. If this was at my house, I would have painted it as soon as it needed it. 4. On 01/13/2026 at 10:04AM, observation of R37's room revealed two cracked tiles in the doorway and paint chipped on the wall behind the bed. 5. On 01/13/2026 at 10:12AM, observation of R41's room revealed the baseboard coming off the wall near the entrance. Further observation revealed a hole in the tile near the center of the room, potentially causing a fall hazard. In an interview with R41 they stated I get in my wheelchair sometimes to go out of my room and my wheel gets stuck in that hole in the tile. I just have to yell for someone to help me get unstuck cuz my call light isn't close. I wish they would fix that so I could go out of my room whenever I wanted to.6. On 01/13/2026 at 10:28AM, observation of R54's room revealed a broken tile near the window of side B. Further observation revealed the door frame was broke and had a piece of metal bulging out which exposed a sharp metal. 7. On 01/13/2026 at 10:46AM, observation of dining room revealed two cracked tiles in the floor in the floor near the entrance. Continued observation revealed a different set of tiles in the floor near the entrance. These tiles are a different size than the others used on the rest of the flooring in the dining room. This use of different tile makes an obvious height difference when walked over creating a fall hazard to residents and staff that frequently walk in that area. 8. On 01/13/2026 at 11:02AM, observation of walls in the dining room revealed several scratches on the wall which chipped paint off. Further observation revealed the door to the kitchen having scratches on it that took the pain off and exposed rust.The Maintenance Director stated in interview on 01/14/2026 at 11:42AM, that they use a system called Tails, and anyone can put a work order in. Everyone knows that they can put a work order in, and we will make sure it gets done. The Maintenance Director further stated there were no active work orders currently and that he has not been made aware of anything that needs fixed. In an interview with the Director of Nursing (DON) on 01/14/2026 at 12:13PM, he stated that he was unaware of any cracked tiles in any of the resident's rooms. The DON further stated that himself, the maintenance director and the housekeeping director all do what they call Eagle Rounds daily. During these rounds they are looking for anything that needs to be fixed. The DON stated that he has not seen any cracked tiles in the building that need fixed at this time. During an interview with the Housekeeping Manager on 01/14/2026 at 1:12PM, she stated, Every resident room gets a deep clean once a daily. The housekeeping manager further revealed that she instructs her staff to report anything that would need to be fixed or repaired to her or to maintenance. They all know we are supposed to report anything that needs repaired, to maintenance. That is my expectation of all my staff in housekeeping. This is also the expectation of the DON and Administrator.The administrator of the building was unavailable due to being out because of illness. No interview was able to be conducted with them.

Based on interview, record review, and review of the facility's policy and documents, the facility failed to ensure that it was administered in a manner to ensure the highest practicable physical, emotional, and psychosocial wellbeing for one (Resident (R) 2) of nine sampled residents reviewed for abuse. Administrative staff, including the Administrator and Director of Nursing (DON) were aware that on 11/21/2024, Certified Nursing Assistant (CNA) 1, and CNA 4 observed R3 naked from the waist down, while in bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. However, the administrative staff failed to make a report of an allegation of sexual abuse to either the State Survey Agency (SSA)/(Office of Inspector General - OIG) or to law enforcement. The facility failed to report the incident of sexual abuse of R2, who did not have the capacity to consent to sexual contact, to either the State Survey Agency or to law enforcement for investigation. The facility's failure to ensure that all allegations of alleged sexual abuse were reported to the appropriate State agencies/law enforcement and failure to comply with regulations designed to prevent/report allegations of abuse has the likelihood to place residents at risk for further potential abuse. Refer to F600, F609, and F835. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated as implemented on 01/20/2020 and revised on 08/01/2024, revealed under the section, Policy Explanation and Compliance Guidelines, the facility would designate an Abuse Prevention Coordinator in the facility who was responsible for reporting allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Further review revealed under the Reporting/Response section, that reporting of alleged violations to the state agency, adult protective services and all other required agencies would occur immediately but not later than two hours after the allegation was made if the event involved abuse or serious bodily injury or not later than twenty-four hours if the events that caused the allegation did not involve abuse and do not involve bodily injury. Review of the facility's document titled, Job Description-Administrator, dated 12/2018, revealed the Administrator's responsibilities included directing the overall operations of the facility in accordance with government regulations. Further review of the document, under the Essential Duties and Responsibilities section, revealed the Administrator maintained a working knowledge of and confirmed compliance with all governmental regulations. Review of the facility's document titled, Job Description-Director of Nursing (DON), updated 12/2011, revealed the DON managed the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations. Review of the Essential Duties and Responsibilities section of the policy revealed the DON's duties included informing the state of any reportable incidents within appropriate timeframes. Interview on 12/03/2024 at 10:45 AM with CNA1 revealed that on 11/21/2024, she and CNA4 heard grunting noises coming from R2's room and, when they went in to see what was happening, they observed R3 on top of R2 in R2's bed. R3 had no clothes on from the waist down. His clothes were on the floor and there was fecal matter on him, the bed, and the floor. R2 was wearing a shirt and her brief, and R3 was trying to undo R2's brief. CNA1 stated R3 told staff to get out of the room, saying they were fucking. Interview on 12/03/2024 at 2:00 PM with CNA4 as well as a review of both CNAs written witness statements confirmed CNA1's description of their first-hand observations. Further interview with CNA1 on 12/03/2024 at 10:45 AM revealed that she believed what she witnessed was abuse which needed to be reported to the state and therefore, she immediately reported what she witnessed to nursing staff. Interview on 12/03/2024 at 2:00 PM with CNA4 confirmed CNA1's statement. Interview on 12/03/2024 with Licensed Practical Nurse (LPN) 1 at 1:31 PM, confirmed that after being informed that the CNAs found R3 on top of R2 in R2's bed, she took the information as an allegation of abuse that needed to be reported and the facility immediately contacted the DON and Administrator. Interviews and review of the written witness statements, revealed direct care staff (CNA1, CNA4, and LPN1) were all aware of and immediately identified a situation which constituted an allegation of abuse. The staff reported the incident as required to administrative staff, including the Administrator and DON. However, review of OIG records revealed no evidence that the Administrator (as Abuse Coordinator) or the DON (whose job responsibilities included informing the state of any reportable incidents within appropriate timeframes) reported the allegation of abuse. Interviews with both the DON on 12/03/2024 at 2:31 PM, and the Administrator at 2:59 PM confirmed that neither the OIG nor law enforcement was contacted for investigation of an allegation of abuse and/or a possible crime. In interview on 12/03/2024 at 2:31 PM with the DON, he stated he had worked at the facility for about two years and had been the DON for about a year. The DON stated he and the Administrator arrived at the facility on 11/21/2024 after being informed of the incident between R2 and R3. After obtaining witness statements from staff and determining that R2 was not physically harmed and appeared at her baseline cognition (diagnosis of dementia and moderative cognitive impairment), they both agreed no allegation of abuse had occurred and the incident did not require reporting to law enforcement or to the state agency. The DON stated he felt due to R3's diagnosis of dementia, he had been confused and was looking for the bathroom. The DON stated he did not feel it was fair to assume R3's behaviors were sexual in nature because he did not have a prior history of inappropriate sexual behaviors. The DON stated that if he had thought the incident was abuse, he would have reported it. However, he did not see this as an allegation of abuse, because he did not feel R3 meant to harm R2. The DON stated the Administrator was the facility's abuse coordinator and she was the person responsible for the reporting of incidents of abuse to the state. The DON stated that the direct care staff who made the report never stated that what was witnessed was an actual abuse allegation. As a result, the Administrator chose not to immediately report the initial allegation in which staff witnessed R3, who was naked from the waist down, on top of R2, pulling at her brief and telling staff that they were fucking. In interview on 12/03/2024 at 2:59 PM with the Administrator, she stated she had worked at the facility for two years and confirmed that she was the facility's abuse coordinator. The Administrator stated she was notified of the incident between R2 and R3 via phone on the night it happened and was told what the CNAs described. The Administrator stated she was aware that all allegations of abuse were to be reported immediately/no more than two hours. However, the allegation that staff made was not immediately reported to either the OIG or to law enforcement. The Administrator stated that instead, staff interviews were conducted, and written statements (which verified staff interviews) were reviewed. After review of this information, the Administrator stated she did not feel like the incident between R2 and R3 was abuse and did not feel it was a reportable event. The Administrator stated that R3, who had a history of wandering into other resident rooms while looking for his wife, did not have an erection, was on all fours, and had had a bowel movement when he was found on top of R2. The Administrator stated that based on her investigation, because she felt R3 had dementia, was confused, and had no history of sexual behaviors, the resident thought he was in the bathroom. The Administrator stated that the direct care staff who made the report never stated that what was witnessed was an actual abuse allegation. The Administrator did not immediately report the initial allegation that staff had witnessed and reported R3. In interview on 12/03/2024 at 3:33 PM with the Regional Director of Operations (RDO), she stated she was made aware of the incident between R2 and R3 by phone on the night it occurred The RDO stated as regional support, they did not give guidance or directive on reportable incidents (Cross Reference to F837.). The RDO stated it was the Administrator's name on the facility license which hung on the wall, the Administrator's responsibility, and ultimately the Administrator's decision to determine whether or not to report an incident or event. In additional interview on 12/04/2024 at 8:20 AM with the DON and Administrator, they confirmed that, after taking witness statements from staff, and speaking with R2's family, they did not feel like the incident was abuse or should have been reported to the state agency or to law enforcement. They stated looking back, they would not have handled the situation any differently.

Based on interview, record review, and facility policy/document review, the facility's Governing Body failed to provide effective oversight to the Administrator to ensure the facility implemented policies, including identifying and reporting an allegation of sexual abuse of one (Resident (R) 2) of nine sampled residents reviewed for abuse. On 11/21/2024, staff observed R3, who was naked from the waist down, in bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. The Administrator and Director of Nursing (DON), who were both members of the Governing Body, reported this incident to additional members of the Governing Body, including the Regional Director of Operations (RDO) and Regional Director of Clinical Services (RDCS). on the same night it occurred. However, the regional members of the Governing Body responsible for ensuring compliance with federal regulations failed to provide regulatory guidance/direction to the Administrator and DON, who made the determination to not report the allegation to either the State Survey Agency (Office of Inspector General - OIG) or appropriate law enforcement staff. The Governing Body's failure to provide oversight and ensure that facility administration comply with regulations designed to prevent/report allegations of abuse has the likelihood to place residents at risk for abuse. Refer to F600, F609, and F835. The findings include: Review of an undated typed document, provided by the DON on 12/10/2024 at 3:35 PM, revealed the members of the Governing Body were the RDO, the RDCS, the Administrator and the DON. Review of the facility's document titled, Job Description-Director of Nursing (DON), updated 12/2011, revealed the DON's responsibilities included managing the overall operations of the Nursing Department in accordance with governmental regulations. Review of the facility's document titled, Job Description-Administrator, dated 12/2018, revealed the Administrator led and directed the overall operations of the facility in accordance with government regulations. Further review of the document under the Essential Duties and Responsibilities section revealed the Administrator maintained a working knowledge of and confirmed compliance with all governmental regulations. Review of the facility's policy titled, Governing Body, effective 10/06/2021 and revised 04/07/2023, revealed the governing body was the corporate entity or licensee responsible for the overall operation of the facility. Per the policy, the governing body ensured compliance with state and federal regulations. Interviews with Certified Nursing Assistant (CNA) 1 on 12/03/2024 at 10:45 AM and CNA4 on 12/03/2024 at 2:00 PM revealed that on 11/21/2024, she and CNA4 heard grunting noises coming from R2's room and, when they went in to see what was happening, they observed R3 on top of R2 in R2's bed. R3 had no clothes on from the waist down. R2 was wearing a shirt and her brief, and R3 was trying to undo R2's brief. Per the CNAs, R3 told staff to get out of the room, adding they were fucking. Further interview with the two CNAs revealed that they believed what they witnessed was abuse which needed to be reported to the state and therefore, they immediately reported it to nursing staff. During interview on 12/03/2024 with Licensed Practical Nurse (LPN) 1 at 1:31 PM, she stated she was informed that the CNAs found R3 on top of R2 in R2's bed. LPN1 stated that she took the information as an allegation of abuse that needed to be reported and immediately contacted the DON and Administrator. Although CNA1, CNA4, and LPN1 were all aware of and immediately reported the allegation up their chain of command, review of OIG records revealed no evidence that the facility reported the allegation of sexual abuse. Interviews with both the DON on 12/03/2024 at 2:31 PM, and the Administrator at 12/03/2024 at 2:59 PM confirmed that neither the OIG nor law enforcement was contacted for investigation of an allegation of abuse and/or a possible crime. During interview on 12/03/2024 at 2:31 PM with the DON and on 12/03/2024 at 2:59 PM with the Administrator they stated that they did not identify the situation between R2 and R3 as possible abuse and did not ensure it was reported to the OIG or law enforcement. The Administrator stated she notified members of the Governing Body on the night of the incident; however, she was not instructed to report it. In interview on 12/03/2024 at 3:33 PM with the RDO, she stated she was made aware of the incident between R2 and R3 on the night it occurred by the Administrator on a three-way call with the RDCS and the Administrator. The RDO stated it was the Administrator's responsibility, and ultimately their decision as to whether or not to report an incident or event. Although the facility's policy stated the governing body's responsibilities included ensuring compliance with federal regulations, the RDO stated it was not their job to guide or direct a facility to report an incident of suspected abuse. During the interview, the RDO refused to answer as to whether the initial allegation of sexual abuse should have been reported to the OIG and law enforcement, stating that she could not speak to the incident because she was not in the facility when it occurred. During interview on 12/05/2024 at 10:46 AM with the RDCS, she stated that the corporate's role was to guide the facility on regulation and policy, but not to make decisions on whether or not to report allegations of abuse. The RDCS stated she was made aware of the incident between R2 and R3 on the night it occurred and understood it was not being reported because the Administrator, who was responsible for reporting, did not feel like there was an allegation of abuse. The RDCS stated that it was the corporate/Governing Body's expectation that staff follow the Centers for Medicare and Medicaid Services' (CMS) guidelines and polices on abuse reporting. The RDCS refused to answer as to whether the initial report of sexual abuse should have been reported to the OIG and law enforcement, stating that she could not speak to the incident because she was not in the facility when it occurred.

Based on interview, record review, and review of the facility's policy, the facility failed to immediately report an allegation of sexual abuse (defined as non-consensual contact of any type with a resident) involving two (Resident (R) 2 and R3) of nine sampled residents reviewed for abuse. On 11/21/2024 at 6:20 PM, Certified Nursing Assistant (CNA) 1 and CNA 4 heard noises coming from R2's room. Upon entering the room, they observed R3, who was naked from the waist down, in the bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. The facility failed to report the incident of sexual abuse of R2, who did not have the capacity to consent to sexual contact, to either the State Survey Agency or to law enforcement for investigation. The facility's failure to ensure that all allegations of alleged sexual abuse were reported to the appropriate State agencies/law enforcement and failure to comply with regulations designed to prevent/report allegations of abuse has the likelihood to place residents at risk for further potential abuse. Refer to F600, F835 and F837. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated as implemented on 01/20/2020 and revised on 08/01/2024, revealed that under the section titled, Policy Explanation and Compliance Guidelines, the facility would designate an Abuse Prevention Coordinator in the facility who was responsible for reporting allegations or suspected abuse to the State Survey Agency and other officials in accordance with state law. Further review of the policy, under the section titled, Reporting/Response, revealed reporting of alleged violations to the Administrator, the state agency, adult protective services, and all other required agencies would occur immediately but not later than two hours after the allegation was made if the event involved abuse or serious bodily injury. Further review of the policy revealed that Sexual abuse is defined at non-consensual sexual contact of any type with a resident. Review of R2's Continuity of Care document revealed the facility admitted R2 on 05/15/2024 with diagnoses including unspecified dementia, cognitive communication deficit, muscle weakness, cerebral infarction with left sided weakness, and anxiety. Review of R2's Minimum Data Set Assessment (MDS), dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired. Further review of R2's electronic medical record (EMR) revealed no evidence that the facility assessed the resident to determine if she was competent to consent to sexual contact. Interview on 12/3/2024 at 10:45 AM with CNA1 revealed she and CNA4 heard grunting noises coming from R2's room and, when they went in to see what was happening, they observed R3 on top of R2 in R2's bed. R3 had no clothes on from the waist down. His clothes were on the floor and there was fecal matter on him, the bed, and the floor. R2 had on a shirt and her brief and R3 was trying to undo R2's brief. CNA1 stated R3 told staff to get out of the room, adding they were fucking. Further interview with CNA1 revealed that she believed what she witnessed was abuse which needed to be reported to the state and therefore, she immediately reported what she witnessed to Licensed Practical Nurse (LPN) 2, who then went and got LPN1. In interview on 12/03/2024 at 2:00 PM, CNA4 stated that she had witnessed R3 on top of R2 in bed, and that R3 told them to leave the room because the residents were fucking. CNA4 stated that she viewed this as an allegation of abuse that would need to be reported to the state and they immediately told the nurse. Interview on 12/03/2024 with LPN1 at 1:31 PM, revealed she was informed that the CNAs found R3 on top of R2 in R2's bed. LPN1 stated that she took the information as an allegation of abuse that needed to be reported and immediately contacted the Director of Nursing (DON) and Administrator. However, review of State Survey Agency (Office of Inspector General - OIG) records revealed no evidence that the facility reported the allegation of sexual abuse. Interviews with both the DON on 12/03/2024 at 2:31 PM, and the Administrator at 2:59 PM confirmed that neither the SSA/OIG nor law enforcement was contacted for investigation of an allegation of abuse and/or a possible crime. In interview on 12/03/2024 at 2:31 PM with the DON, he stated that the allegation of sexual abuse, which CNA1, CNA4, and LPN1 passed on to administrative staff, was not reported to either the SSA/OIG or law enforcement agencies within two hours as required by regulation. The DON stated he and the Administrator arrived at the facility on 11/21/2024 after the incident between R2 and R3 and obtained witness statements from staff. Review of the witness statements revealed the interviews with CNA1 and CNA4 in which they described their observations met the definition of an allegation of sexual abuse. However, the DON stated that after determining that R2 was not physically harmed and appeared at her baseline cognition, both he and the Administrator agreed that no allegation of abuse had occurred, and the incident did not require reporting to law enforcement or to the SSA. The DON stated the Administrator was the facility's abuse coordinator and was responsible for the reporting of incidents of abuse to the state. In interview on 12/03/2024 at 2:59 PM with the Administrator, she stated she was the facility's abuse coordinator. The Administrator stated she was aware that allegations of abuse were to be reported within two hours. The Administrator stated that staff informed her that R3 was found on top of R2 in bed, pulling at R2's brief, and was stating that they were fucking, but There was no allegation of abuse by staff. The Administrator repeatedly stated that R3 was confused and meant no harm; therefore, she did not feel like the incident between R2 and R3 was abuse and as a result, she did not feel it that a reportable event. She stated her investigation found that R3 was on all fours with no erection and had had a bowel movement, so she felt because he had dementia, was confused, and had no history of sexual behaviors, R3 thought he was in the bathroom. Interview on 12/03/2024 at 3:33 PM with the Regional Director of Operations (RDO) revealed that although she was made aware of the incident between R2 and R3 on the night it occurred by the Administrator, as regional support, they did not give guidance or directive on reportable incidents. The RDO stated it was ultimately the Administrator's decision to determine whether or not to report an incident or event. In a follow up interview on 12/04/2024 at 8:20 AM with the DON and the Administrator, they both stated neither they nor facility staff thought the incident between R2 and R3 qualified as abuse, and if the same situation were to happen again, they would not handle it any differently. However, the interviews noted above with CNA1, CNA4, and LPN1 on 12/03/2024 revealed that the DON and Administrator's statement was not accurate, as the direct care staff had viewed the incident between R2 and R3 as abuse which needed to be reported. Interviews with the Medical Director (MD) by telephone on 12/05/2024 at 5:35 PM and on 12/09/2024 at 10:13 AM, revealed she first stated she knew R3 had gotten in R2's bed and kind of scared her but did not really know any other details. Then the Medical Director stated she knew R3 was naked and that R3 had stated he and R2 were fucking. She added that she heard the staff present at the time felt it appeared R3 was assaulting R2. The Medical Director stated the facility notified her of the incident the night it occurred via a texting service, but she was not aware the facility did not report the incident to law enforcement or the state agency until the interview with the State Survey Agency Surveyor. The Medical Director stated if the facility had actually spoken with her on the night of the incident related to reporting, she would have suggested the incident be reported.

Based on observation, interview, record review, review of the facility's policy and review of the facility's investigation documentation, the facility failed to protect the resident's right to be free from sexual abuse. On 11/21/2024 at 6:20 PM Certified Nursing Assistant 1 (CNA1) and CNA 2 heard noises coming from Resident 2's (R2) room. Upon entering the room, they observed Resident 3 (R3) naked from the waist down in the bed on top of Resident 2 (R2). R3 was observed pulling at R2's brief and stated, We are fucking. R2 and R3 were immediately separated and R3 was placed on 1:1 staff observation. The facility's administrative staff failed to identify the incident as an allegation of abuse. The facility did not report the incident to the appropriate state agencies or law enforcement. Refer to F609, F835 and F837. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated as implemented on 01/20/2020 and revised on 08/01/2024 revealed it was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse meant the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm. Pain or mental anguish which could include certain resident to resident altercations and included sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. Additionally, the facility's policy defined an alleged violation as a situation or occurrence that was observed or reported by staff. Review of Resident 2's (R2) facility document titled, Continuity of Care revealed the facility admitted R2 on 05/15/2024 with diagnoses of unspecified dementia, cognitive communication deficit, muscle weakness, cerebral infarction with left sided weakness, and anxiety. Review of R2's Quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero (00) out of fifteen (15). This score indicated severe cognitive impairment. Review of R3's facility document titled, Continuity of Care revealed the facility admitted R3 on 09/03/2024 with diagnoses of unspecified dementia, disorientation, and anxiety. Review of R3's Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed a BIMS score of ninety-nine (99) indicating the assessment was unable to be completed because the resident was rarely or never understood. Review of R3's Comprehensive Care Plan (CCP) dated 09/03/2024 revealed R3 was at risk for elopement related to dementia and wandered into other residents' rooms. Review of R3's Progress Note dated 11/21/2024 at 7:35 PM written by Licensed Practical Nurse 1 (LPN1) revealed R3 was found in a female resident's bed, confused and naked with feces on the bed and both residents. R3 was trying to touch the female resident's breast as he was being removed from the bed. Resident 3 was taken to his room and changed and a CNA was sitting one on one with the resident. Review of R3's Social Services Note, dated 11/22/2024 at 10:25 AM revealed the Admissions/Social Services/Admissions Director ([NAME]) spoke with R3 in regard to his recent behavior and R3 did not recall the incident. In interview on 12/03/2024 at 10:30 AM with Certified Nursing Assistant (CNA) 2, she stated she was at the facility the night of the incident between R3 and R2. CNA2 stated at about 6:20 PM, she and Licensed Practical Nurse 1 (LPN1) were in another room and Licensed Practical Nurse 2 (LPN2) came to get them and told them R3 was in bed with R2. CNA2 stated she went into R2's room and there was fecal matter on the floor and R3 was in the bed with R2 and told staff to get out, they were fucking. CNA2 stated it took three staff to get R3 off of R2 and back in his wheelchair. She stated as they were getting him out of the bed, R3 grabbed R2's breast. CNA2 stated all the aides involved wrote a witness statement and waited until the DON and Administrator returned to the facility which was around 8:00 PM. CNA2 stated the abuse coordinator for the facility was the Administrator and abuse training was offered pretty frequently since the new company had taken over, the most recent being last week. CNA2 stated it was the DON's and the Administrator's responsibility to report incidents like this to the State. In interview on 12/03/2024 at 10:45 AM with CNA1, she stated she and CNA4 had heard grunting noises coming from R2's room and when they went in to see what was happening, they observed R3 on top of R2 with no clothes on from the waist down. R3's clothes were on the floor and there was fecal matter on him, the bed and the floor. R2 had on a shirt and her brief and R3 was trying to undo R2's brief. CNA1 stated R3 told staff to get out of the room, they were fucking. CNA1 stated R3 had been combative before, so she had CNA4 stay in the room, and she went to get LPN1 and LPN2 to assist. CNA1 stated R3 was removed from the room, R2 appeared scared and although she had not been able to speak since her stroke, she was making a grunting noise. CNA1 stated she wrote a witness statement and remained at the facility until the Director of Nursing (DON) and the Administrator returned to the facility. 1:1 supervision of R3 began after the incident that night and the next morning, CNA1 stated she had heard the police came to the facility that night and talked to the DON because R2's family had called them. CNA1 stated she had not received any additional abuse training specific to the incident between R2 and R3. She stated she had been told the facility was trying to find new placement for R3 in an all-male facility but there were no beds available. CNA1 stated there had been other incidents with R3 entering the rooms of female residents (R9 and R10). In interview on 12/03/2024 at 2:00 PM with CNA4 she stated she and another aide were starting their round around 6:20 PM, when they heard a noise coming from R2's room. She stated when they walked in they saw R3 with no brief or pants on, laying on top of R2, with fecal matter on him, the bed and the floor. CNA4 stated R2's blankets and clothes were on, but R2 appeared to be in distress even though she was nonverbal. CNA4 stated staff began to explain to R3 he would have to get up and he began to fight, placing his hand on R2's breast. CNA4 stated R3 was removed from the room and placed on 1:1 staff supervision that night. CNA4 stated LPN2 called the DON and the Administrator but she was not sure if the police came to the facility. In interview on 12/03/2024 at 1:31 PM with LPN1, who was on duty the night of the incident, she stated she was in another resident room with CNA2 when LPN 2 came to get them for assistance. LPN1 stated when they got to R2's room, they observed R3 with his pants and brief off and there was feces everywhere. LPN1 stated R3 told them to shut the door, they were fucking. The LPN stated R3 would not be redirected at that time and as they were trying to get him off R2, he grabbed R2's breast. LPN1 stated R2 could not move her legs and was nonverbal, but she was moving her hands, moaning and appeared visibly distressed. LPN1 stated R2 had on a brief and a shirt but no blankets or sheets were covering her. The LPN stated CNA2 and LPN2 cleaned R2 up and completed skin assessments on both residents with no injuries noted. LPN1 stated she called the DON and the Administrator and waited for them to arrive which took about an hour. She stated she reported any incidents to the DON and/or the Administrator. In a phone interview on 12/02/2024 at 7:06 PM with Resident 2's Daughter #3 (R2D3) and Power of Attorney (POA), she stated she had received a call on 11/21/2024 at 7:47 PM from the DON and was told there had been an incident and a male resident had gone into R2's room, had undressed and was on top of her in her bed. R2D3 stated she lived in Ohio, was R2's POA and was concerned with getting someone from her family to the facility. She stated she called R2D4 who went to the facility to check on R2. Eventually R2D1 and R2D2 (two other family members) also arrived at the facility. R2D3 stated she arrived on Friday 11/22/2024 and spoke with CNA4 who had found R3 on R2. She stated she told R2D3 she had seen R3 at the nurses station in his wheelchair not long before the incident. CNA4 told R2D3 while doing resident rounds, she heard commotion, like yelling and stuff, coming from R2's room and went in to see about it. CNA4 told R2D3 she opened the door and found R3 on top of R2, the blankets were not pulled down but R3 was naked; and when she entered the room, R3 was yelling at her to shut the door. CNA4 told R2D3 she needed help to get R3 off R2 because he was yelling and fighting and R2's eyes were as big as saucers. In interview on 12/02/2024 at 2:56 PM with R2's Daughter 1 (R2D1) and R2's Daughter 2 (R2D2), R2D1 stated she was informed of the incident by R2D3 and immediately drove to the facility. R2D1 went to R2's room where another sister had already arrived and was comforting R2. R2D1 stated R2 was unable to articulate but they could tell she was upset. R2D1 stated the DON told her the facility was trying to move R3 to an all-male facility but had not found one yet. R2D2 stated she and her husband tried to file a police report and a police officer had come to the facility but told them there was nothing he could do. Review of R2's Progress Notes from 11/20/2024-11/22/2024 revealed no documentation or description of the incident. Review of R2's Social Services note dated 11/22/2024 at 10:47 AM written by the Admissions/Social Services Director (ASSD) revealed an interview was conducted with R2 to assess for any mental anguish or signs of distress. R2 had no visible signs of distress, was resting in the bed eating snack and smiled frequently, and monitoring for R2 would continue over the next few days. In interview on 12/03/2024 at 2:31 with the DON, he stated the Administrator was the facility's abuse coordinator. He stated that on the night of the incident between R2 and R3, the Administrator had called him, and he arrived at the facility before her. The DON stated he talked to CNA1, CNA4, LPN1 and LPN2 to try and figure out what happened and made sure R3 was separated from R2. The DON stated staff told him they heard noises coming from R2's room and observed R3 on his hands and knees on the bed without any pants on and he had had a bowel movement. The DON stated he assessed R2 and she was not in any distress and was at her baseline (her condition was unchanged from before the incident). LPN1 completed skin assessments on both R2 and R3 with no injuries noted. The DON stated R3 was placed on 1:1 supervision more to protect him than the other residents because R3 did have a history of being confused, wandering and getting into other resident's beds to sleep. The DON stated he could not be sure R3's behavior was sexually motivated or if he just got confused. The DON stated to say the incident was sexually motivated would be discriminatory against R3 and since the facility could not be sure it was, it was not a reportable event. The DON stated the facility did not call law enforcement. The DON stated he was not sure if a police report was filed and he had not signed one. In interview on 12/03/2024 at 2:59 PM with the Administrator she stated she was the facility's abuse coordinator. The Administrator stated she was notified of the incident between R2 and R3 by LPN2 via phone on the night it happened. The Administrator stated LPN2 told her R3 had gone into R2's room and was found with no pants or briefs on, on his hands and knees on top of R2. She stated staff had reported that when they entered R2's room and turned on the lights, R3 stated we are fucking but no one had mentioned if R2 had an erection or not. The Administrator stated she was told R2 was clothed, there were blankets between R2 and R3, and R3 had a bowel movement on the bed. The Administrator stated she was told R2 was grunting and appeared to be upset, so she called the DON and he arrived at the facility before her. The Administrator stated when she arrived, the DON was talking to the nurses, so she went to R2's room and R2 did not appear to be in any distress. The Administrator stated R3 was placed on 1:1 observation before she and the DON had arrived. She stated she had notified the Regional Director of Operations (RDO) the night of the incident and was not instructed to report it. The Administrator stated she did not feel like the incident between R2 and R3 was abuse and did not feel it was a reportable event. The Administrator stated law enforcement was not notified by the facility, but they came to the facility after the family reported the incident and no report had been filed. The Administrator stated R3 was on a wait list for an all-male facility and would remain on 1:1 supervision until he could be transferred. In a follow up interview on 12/04/2024 at 8:20 AM with the DON and the Administrator they both stated neither they or facility staff thought the incident between R2 and R3 qualified as abuse, and if the same situation were to happen again, they would not handle it any differently. In a telephone interview on 12/05/2024 at 5:35 PM with the Medical Director she stated she was aware that R3 had gotten in her R2's bed and kind of scared her but did not really know any other details. When interviewed related to if she knew R3 was naked, she stated yes. The Medical Director stated she knew R3 had said he and R2 were fucking. She stated that the staff she spoke with who were present at the time felt it appeared R3 was assaulting R2. The Medical Director stated the facility notified her of the incident the night it occurred via a Health Insurance Portability and Accountability Act (HIPPA) compliant texting service but she had not spoken to anyone. She stated in talking to R2's family and to the facility staff, she thought the facility had notified the State agency and law enforcement. She stated she was not aware they had not done either until this interview.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure resident injuries of unknown origin were reported immediately (not later than two hours after the allegation) to the administrator and other officials (including the State Survey Agency), for three of three (Resident (R) 27, R110, and R111) sampled for abuse. The facility failed to report to the administrator and the State Survey Agency when R27 sustained skin tears while receiving care from a male CNA on [DATE], when R110 was diagnosed on [DATE] with a fractured hip which was of unknown origin, and when R111 was noted on [DATE], to have a large bruise to the right upper extremity which was of unknown origin. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation implemented [DATE] revealed the facility would have procedures to assist staff in identifying types of abuse, including injury of unknown source. Further review revealed the facility would report to the state agency immediately, but not later than two hours after the allegation or suspicion of abuse was made if the event involve abuse or result in serious bodily injury, or not later than twenty-four hours if the event does not involve abuse and did not involve serious bodily injury. Further review of the policy revealed the facility would have written procedures to assist staff in identifying the different types of abuse. With possible indicators of abuse including, but not limited to: Resident, staff, or family report of abuse, physical marks such as bruises on a resident's body . and/or injury of an injury of an unknown source. 1. Review of R27's admission record revealed the facility admitted the resident on [DATE] with diagnoses which included fracture of the neck of the right femur, convulsions, anxiety, and cerebral infarction. Review of R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Further review of R27's MDS with an ARD of [DATE] revealed a BIMS score of 7, which indicated severe cognitive impairment. Review of R27's Incident Note, dated [DATE] at 9:00 PM revealed Licensed Practical Nurse (LPN) 4 documented the resident became combative with Activities of Daily Living (ADL's) care and with turning/positioning. Per the note, the resident received a skin tear to the right upper arm (back side) with three steri-strips applied and a skin tear to the right inner wrist with two steri-strips applied. Continued review of the note revealed R27 stated she was upset because a male Certified Nursing Assistant (CNA)(unnamed) was in her room and she refused for any male nurses or male CNAs to be in her room. Per the note, the LPN4 gave an as needed anxiety medication and an as needed pain medication. During an interview with Family Member (FM) 2 on [DATE] at 10:50 AM revealed the incident happened approximately two years ago. The resident had told the facility prior to the incident, she did not want a male caregiver to provide any type of personal care. The family had been notified R27 had sustained the injuries when a male CNA came into the room to provide care and the resident refused. Per FM2, she was told the CNA provided care even when the resident refused. FM2 stated the facility told her that while the CNA was putting the resident's shirt on, the resident was combative and the shirt caused the skin tears. FM2 stated she knew the shirt could not have caused the skin tears. FM2 further stated the facility was aware R27 did not want male staff providing personal care for R27 even before the incident occurred. FM2 stated no male CNA's have provided care since the time of the incident. During an attempted interview with R27 on [DATE] at 10:55 AM, the resident nodded her head yes, when asked if she remembered the incident when a male staff provided care for her. The resident kept nodding her head yes, when FM2 stated R27 was very private and forbid a male to see her private areas. During an interview on [DATE] at 4:01 PM with CNA3, she stated she was not working when the incident with R27 occurred but she was aware that a male CNA from the staffing agency was working when the incident occurred. CNA3 stated she knew he had not been back since the incident happened. Attempts to interview LPN4 were unsuccessful, as she was not in the facility working and was on vacation. There was no documented evidence the injury of unknown origin involving R27 was reported to the State Survey Agency. 2. Review of R110's admission record revealed the facility admitted the resident on [DATE] with diagnoses of diabetes, dementia with behaviors, and psychotic disturbance. Review of R110's quarterly MDS with an ARD of [DATE] revealed a BIMS score of 3 out of fifteen which indicated R110 was severely cognitively impaired. Review of R110's nurse progress notes revealed a communication note dated [DATE] at 12:45 PM by the Assistant Director of Nursing (ADON). Per the note, R110's family told the ADON that R110 did not seem right. R110 would not talk to the daughter or son who were visiting with R110. The daughter also reported that R110 flinched as if in pain when her left leg was moved. Per the note, the ADON informed the resident's nurse of the family concerns and asked her to call for orders. Further review of nurse progress notes on [DATE] at 12:48 PM revealed LPN5 documented she called the resident's physician related to family's concern of R110 having pain to the left hip, and not acting alert today. Per the note, new orders were received for a lab work to include Prothrombin Time, Complete Blood Count, Comprehensive Metabolic Profile, and Urinalysis with culture and sensitivity. The orders also include a x-ray of the left hip and pelvis. Further review of the progress notes revealed on [DATE] at 2:40 PM, LPN5 called for Emergency Medical Service (EMS) to transfer the resident to the hospital for complaints of left hip pain. Review of R110's hospital record and hospital disposition summary dated [DATE] revealed R110 was admitted for a displaced right femur neck fracture. Continued review of the hospital record revealed R110 was transferred to the local hospital then on to another hospital for a higher level of care for the hip fracture. Per the hospital record, R110 was discharged back to the local hospital under hospice care and later expired in ,d+[DATE]. The Administrator who was the Director of Nursing (DON) at the time of the incident provided a typed document dated [DATE] which revealed a bruise was noted to the spine of R110. Per the document, after talking with staff and chart review, no change has been noted to resident's behavior. Continue review revealed the resident fell on [DATE]. The resident was found sitting on the floor by the wheelchair after attempting to get out of bed. Per the document, the resident does have a bony spine and bruise is consistent with back bumping front of wheelchair when falling. She stated the incident was reported to the Administrator. There was no documented evidence R110's injury of unknown origin was reported to the State Survey Agency. 3. Review of R111's admission record revealed the facility admitted R111 on [DATE] with diagnoses of Parkinson's Disease, cognitive communication deficit, diabetes, rheumatoid arthritis, and contractures of hands. Further review of the record revealed R111 expired in ,d+[DATE]. Review of R111's quarterly MDS with a ARD date of [DATE] revealed a BIMS score of fifteen of fifteen which indicated the resident was cognitively intact. Review of the skin assessment dated [DATE] at 6:41 AM documented by LPN6 revealed purpura (red, purple or brown spots on the skin caused by bleeding under the skin) was noted to R111's right upper arm. Further review of the note revealed no documenting of size or shape of the purpura area. Review of R111's nurse progress note dated [DATE] at 5:30 AM documented by LPN7 revealed an aide reported to the nurse that R111 was complaining of her right arm being sore when her shirt was put on. Per the note, LPN7 asked R111 if her arm was sore and she nodded her head forward and whispered, yes. The LPN assessed the resident to have a dark purpura area to her right upper inner arm. LPN7 documented the area was noted and charted on a skin assessment on [DATE]. Per the note, LPN7 took R27's right hand and held her arm out straight in front of her and she denied having pain. LPN7 then held under her elbow and abducted her arm out from her side, and she then complained of pain to her shoulder and upper arm. Further review of the progress note revealed the resident's right shoulder appeared slightly bigger than the left. Per the note, R111 had received routine Tylenol a short while prior to the assessment. Review of R111's Nurse Progress note dated [DATE] at 10:19 AM documented by LPN8 revealed the resident's physician was notified of R111's complaint of being unable to move the right arm without pain, and of the large discoloration to the underside of the upper right arm near her the armpit. Per the note, a new order was received for an x-ray of the humerus and shoulder. Review of a nurse progress note dated [DATE] at 3:30 PM documented by LPN5 revealed there were no fracture or dislocation noted from x-ray. However, further review of resident's record revealed no x-ray report. There was no documented evidence that the bruise to R111's upper arm was reported to the State Survey Agency as an injury of unknown origin. During an interview on [DATE] at 3:15 PM with the prior Administrator, she stated she does not recall the incident regarding R27. The Administrator stated she would have reported the incident immediately to the state agency if she had been made aware. She stated that during her time as the Administrator from ,d+[DATE]-,d+[DATE], she expected to be informed of all injuries of unknown origin and suspected/actual abuse. She stated she always reported to the state agency. The prior Administrator further stated she does not recall any incidents with R110 or R111. She further stated the injuries should have been reported to her and then to the State Survey Agency. Interview with the current Administrator on [DATE] at 5:55 PM revealed her expectation was that all abuse allegations, and injuries of unknown origin be reported immediately to the State Agency. She further stated a complete investigation should be completed. Per the Administrator, all nurses' stations have the investigation forms to initiate when an incident happens. The Administrator stated there had been a change in ownership of the facility and when she had taken over as administrator, the facility had no process in place for reporting and investigating allegations of abuse/injury of unknown origin. Per the Administrator, there was now a abuse prevention policy and process for staff to follow. She further stated she was the Abuse Coordinator and it was her responsibility to ensure all allegations of abuse were reported timely and fully investigated. She further stated that she had no record of the above incidents with the three residents being reported to the State Survey Agency.

Based on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure injuries of unknown origin were investigated thoroughly, after the injury was discovered for three of three residents (Residents (R) 27, R110, and R111) reviewed for abuse. The facility failed to investigate the injury of unknown origin when R27 sustained skin tears while receiving care from a male CNA on ,d+[DATE].2022, when R110 was diagnosed on [DATE] with a fractured hip which was of unknown origin, and when R111 was noted on [DATE], to have a large bruise to the right upper extremity which was of unknown origin. . The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation implemented [DATE] revealed the facility would have procedures to assist staff in identifying types of abuse, including injury of unknown source, and investigate immediately when suspicion of abuse neglect or exploitation, or reports of abuse, neglect or exploitation occur. Further review revealed the facility would identify, and interview all involved persons, who might have knowledge of the allegation and provide complete and thorough documentation of the investigation. 1. Review of R27's admission record revealed the facility admitted the resident on [DATE] with diagnoses which included fracture of the neck of the right femur, convulsions, anxiety, and cerebral infarction. Review of R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Further review of R27's MDS with an ARD of [DATE] revealed a BIMS score of seven which indicated severe cognitive impairment. Review of R27's Incident Note, dated [DATE] at 9:00 PM revealed Licensed Practical Nurse (LPN) 4 documented the resident became combative with Activities of Daily Living (ADL's) care and with turning/positioning. Per the note, the resident received a skin tear to the right upper arm (back side) with three steri-strips applied and a skin tear to the right inner wrist with two steri-strips applied. Continued review of the note revealed R27 stated she was upset because a male Certified Nursing Assistant (CNA)(unnamed) was in her room and she refused for any male nurses or male CNAs to be in her room. Per the note, the LPN4 gave an as needed anxiety medication and an as needed pain medication. During an interview with Family Member (FM) 2 on [DATE] at 10:50 AM revealed the incident happened approximately two years ago. The resident had told the facility prior to the incident, she did not want a male caregiver to provide any type of personal care. The family had been notified R27 had sustained the injuries when a male CNA came into the room to provide care and the resident refused. FM2 stated they were told the CNA provided care even when the resident refused. FM2 stated the facility told them that while the CNA was putting the resident's shirt on, the resident was combative and the shirt caused the skin tears. FM2 stated she knew the shirt could not have caused the skin tears. FM2 further stated the facility was aware R27 did not want male staff providing personal care for R27 even before the incident occurred. FM2 stated no male CNA's have provided care since the time of the incident. During an attempted interview with R27 on [DATE] at 10:55 AM, the resident nodded her head yes, when asked if she remembered the incident when a male staff provided care for her. The resident kept nodding her head yes, when FM2 stated R27 was very private and forbid a male to see her private areas. There is no documented evidence the injury of unknown origin to R27's arm was investigated by the facility. 2. Review of R110's admission record revealed the facility admitted the resident on [DATE] with diagnoses of diabetes, dementia with behaviors, and psychotic disturbance. Review of R110's quarterly MDS with an ARD of [DATE] revealed a BIMS score of three out of 15 which indicated R110 was severely cognitively impaired. Review of R110's nurse progress notes revealed a communication note dated [DATE] at 12:45 PM by the Assistant Director of Nursing (ADON). Per the note, R110's family told the ADON that R110 did not seem right. R110 would not talk to the daughter or son who were visiting with R110. The daughter also reported that R110 flinched as if in pain when her left leg was moved. Per the note, the ADON informed the resident's nurse of the family concerns and asked her to call for orders. Further review of nurse progress notes on [DATE] at 12:48 PM revealed LPN5 documented she called the resident's physician related to family's concern of R110 having pain to the left hip, and not acting alert today. Per the note, new orders were received for a lab work to include Prothrombin Time, Complete Blood Count, Comprehensive Metabolic Profile, and Urinalysis with culture and sensitivity. The orders also include a x-ray of the left hip and pelvis. Further review of the progress notes revealed on [DATE] at 2:40 PM, LPN5 called for Emergency Medical Service (EMS) to transfer the resident to the hospital for complaints of left hip pain. Review of R110's hospital record and hospital disposition summary dated [DATE] revealed R110 was admitted for a displaced right femur neck fracture. Continued review of the hospital record revealed R110 was transferred to the local hospital then on to another hospital for a higher level of care for the hip fracture. Per the hospital record, R110 was discharged back to the local hospital under hospice care and expired in ,d+[DATE]. The Administrator who was the Director of Nursing (DON) at the time of the incident provided a typed document dated [DATE] which revealed a bruise was noted to the spine of R110. Per the document, after talking with staff and chart review, no change has been noted to resident's behavior. Continue review revealed the resident fell on [DATE]. The resident was found sitting on the floor by the wheelchair after attempting to get out of bed. Per the document, the resident does have a bony spine and bruise is consistent with back bumping front of wheelchair when falling. She stated the incident was reported to the Administrator. There was no documented evidence R110's hip fracture was investigated by the facility to attempt to determine the cause of this injury of unknown source. 3. Review of R111's admission record revealed the facility admitted R111 on [DATE] with diagnoses of Parkinson's Disease, cognitive communication deficit, diabetes, rheumatoid arthritis, and contractures of hands. Further review of the record revealed R111 expired in ,d+[DATE]. Review of R111's quarterly MDS with a ARD date of [DATE] revealed a BIMS score of fifteen of fifteen which indicated the resident was cognitively intact. Review of the skin assessment dated [DATE] at 6:41 AM documented by LPN6 revealed purpura (red, purple or brown spots on the skin caused by bleeding under the skin) was noted to R111's right upper arm. Further review of the note revealed no documenting of size or shape of the purpura area. Review of R111's nurse progress note dated [DATE] at 5:30 AM documented by LPN7 revealed an aide reported to the nurse that R111 was complaining of her right arm being sore when her shirt was put on. Per the note, LPN7 asked R111 if her arm was sore and she nodded her head forward and whispered, yes. The LPN assessed the resident to have a dark purpura area to her right upper inner arm. LPN7 documented the area was noted and charted on a skin assessment on [DATE]. Per the note, LPN7 took R27's right hand and held her arm out straight in front of her and she denied having pain. LPN7 then held under her elbow and abducted her arm out from her side, and she then complained of pain to her shoulder and upper arm. Further review of the progress note revealed the resident's right shoulder appeared slightly bigger than the left. Per the note, R111 had received routine Tylenol a short while prior to the assessment. Review of R111's Nurse Progress note dated [DATE] at 10:19 AM documented by LPN8 revealed the resident's physician was notified of R111's complaint of being unable to move the right arm without pain, and of the large discoloration to the underside of the upper right arm near her the armpit. Per the note, a new order was received for an x-ray of the humerus and shoulder. Review of a nurse progress note dated [DATE] at 3:30 PM documented by LPN5 revealed there were no fracture or dislocation noted from x-ray. However, further review of resident's record revealed no x-ray report. There was no documented evidence that the bruise/discoloration to R111's upper arm was investigated by the facility in an attempt to determine the cause of this injury of unknown source. During an interview on [DATE] at 3:15 PM with the prior Administrator, she stated she does not recall the incident regarding R27. The Administrator stated she would have investigated and reported the incident immediately to the state agency if she had been made aware. She stated that during her time as the Administrator from ,d+[DATE]-,d+[DATE], she expected to be informed of all injuries of unknown origin and suspected/actual abuse. She stated she always investigated and reported to the state agency. The prior Administrator further stated she does not recall any incidents with R110 or R111. She further stated the injuries should have been fully investigated and reported to her and then to the State Survey Agency. Interview with the current Administrator on [DATE] at 5:55 PM revealed her expectation was that all abuse allegations, and injuries of unknown origin be reported immediately to the State Agency. She further stated a complete investigation should be completed. Per the Administrator, all nurses' stations have the investigation forms to initiate when an incident happens. The Administrator stated there had been a change in ownership of the facility and when she had taken over as administrator, the facility had no process in place for reporting and investigating allegations of abuse/injury of unknown origin. Per the Administrator, there was now a abuse prevention policy and process for staff to follow. She further stated she was the Abuse Coordinator and it was her responsibility to ensure all allegations of abuse were reported timely and fully investigated. She further stated that she had no record of the above incidents with the three residents being reported to the State Survey Agency or of an investigation of the incidents by the facility.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, distribute and/or serve food in accordance with professional standards for food service safety. Observations revealed uncovered food and drink in the refrigerator on 09/03/2024 and 09/04/2024 potentially affecting 25 of 55 residents of the facility. The findings include: Review of facility policy Food Receiving and Storage, undated, revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated. During the initial kitchen tour on 09/03/2024 at 2:30 PM, eight (8) cups of pureed watermelon were observed in the refrigerator uncovered and undated, as well as, lemonade in a pitcher uncovered and undated. On 09/04/2024 at 3:30 PM, at least twenty-five (25) cups of sliced watermelon were observed in the refrigerator uncovered, without date and time. Observation of meal service on 09/04/2025 at 3:40 PM revealed dietary staff were serving the previously observed uncovered watermelon to residents. According to the Matrix (CMS-802), there were no residents who received tube feeding in the facility. Interview with Dietary Manager on 09/03/2024 at 2:45 PM revealed that the dietary staff had been educated on covering and dating all items placed in the refrigerator for storage. The Dietary Manager stated that the Dietary Aide was aware of this policy and was just in a hurry and forgot to do it. The Dietary Manager stated that it was important to cover items when storing them to prevent anything from falling into it. Per the Dietary Manager, it was her expectation for dietary staff to follow the Storage Policy for the facility kitchen. Interview with Regional Director of Operations on 09/06/2024 at 11:30 AM revealed that it was her expectation that the Dietary Manager and staff would cover and label all items that required protection from harmful bacteria, objects, and chemicals. She stated it was the responsibility of all dietary employees working in the kitchen to ensure all items were covered, labeled, and checked for expiration dates. Additionally, she stated it was her expectation for the Dietary Manager to enforce the policy and to retrain staff as needed. In an interview with the Administrator on 09/06/2024 at 5:55 PM she stated that it was her expectation that all staff followed all policies in place at the facility.

Based on interview and record review, it was determined the facility failed to ensure the services of a Registered Nurse (RN) was utilized for at least eight consecutive hours a day, seven days a week. The facility failed to provide eight consecutive hour RN coverage for 12 days between 05/01/2024 and 08/31/2024. The findings include: Interview with the Director of Nursing (DON), on 09/06/2024 at 10:16 AM, revealed the facility did not have a policy to ensure RN coverage for the facility for at least eight consecutive hours a day, seven days a week. Review of the facility's scheduled staffing sheets for 05/01/2024 to 08/31/2024, revealed, no RN coverage for eight consecutive hours for following dates: 05/04/2024; 05/25/2024; 06/07/2024; 06/16/2024; 06/30/2024; 07/06/2024; 07/20/2024; 07/28/2024; 08/09/2024; 08/16/2024; 08/30/2024; and 08/31/2024. Interview with the DON, on 09/06/2024 at 10:16 AM, revealed, she was aware of the regulation that required a RN eight consecutive hours a day, seven days a week. Continued interview revealed, the facility had not consistently scheduled a RN to work eight consecutive hours a day, seven days a week. Interview on 09/06/2024 at 5:55 PM with the Administrator (who has been the Administrator for approximately 2 years) revealed she was aware the facility was required by regulation to have RN coverage for eight consecutive hours a day, seven days a week. Continued interview revealed that she was an RN and did work some weekends for RN coverage but didn't know if her hours counted toward the regulation coverage. Administrator further stated new ownership started as of 08/01/2024 and they were still getting acclimated to the changes.

45113 Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life, and to recognize each resident's individuality for one of two meals observed. Observations during the noon meal on 09/05/2024 revealed staff used labels to identify residents requiring assistance with meals and called the residents feeders during meal service. Additionally, staff initially set-up Resident (R) 6's lunch meal on 09/05/2024 instead of providing feeding assistance. The findings include: A review of the facility's Policy titled Resident's Rights, updated 02/16/2024, revealed the facility believed residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A continued review of the Policy revealed the facility would ensure that all residents were treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. In addition, the facility would ensure the residents were treated with respect and dignity and promote and facilitate resident self-determination through support of resident choice. Further, the policy review revealed the facility would ensure that all staff members were educated on the rights of residents and the responsibility of the facility to properly care for its residents, including the support each resident required in exercising their rights. Review of the clinical record revealed the facility admitted R6 on 04/07/2017, with diagnoses to include type II diabetes mellitus, cerebral infarction, hemiplegia (condition that causes partial or complete paralysis on one side of the body) affecting right dominant side, contracture right hand, right wrist, right elbow and right shoulder, contracture of muscle, multiple sites, abnormal posture, lack of coordination, muscle weakness and mild cognitive impairment of uncertain or unknown etiology. Review of R6's Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Further review of the Annual MDS Assessment revealed the facility assessed the resident with functional limitation and impairment in a range of motion (ROM) to upper and lower right-side extremities, dependent on staff with a self-care performance of eating, which required the helper to make all the effort. The resident made none of the effort to complete the activity. Further, the resident was also assessed as dependent on staff with a self-care performance of bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of R6's Comprehensive Care Plan (CCP) dated 04/08/2015, with a focus on the resident being at risk for alteration in nutrition-less than body requirements related to the resident's mechanically altered, therapeutic diet, history of cerebral vascular accident (CVA), and right upper extremity paralysis. Continued review of R6's nutrition care plan revealed interventions to ensure tray set-up per staff, built-up/large handle spoon to aid with self-feeding, and staff to provide further ongoing resident observation during meal services for signs and symptoms of problems feeding. Further review of R6's at risk for alteration of nutrition interventions revealed an updated revision on 05/28/2024 for staff to feed resident meals as he will allow related to spilling/dropping food. Observation in the dining room, during noon meal service on 09/05/2024 at 12:27 PM, revealed R6 was placed in front of his set-up meal tray attempting to feed himself. The resident was observed to have difficulty getting food items from his plate, onto the eating utensil and to his mouth related to his dominant right sided paralysis and limited ROM of extremities. The resident was observed to attempt to eat using his left hand and was shaking, spilling, and dropping his food back onto the plate and/or into his lap. Further observations revealed R6 attempted to raise his arm with a glass in hand and attempted to take a drink as he poured the drink down the front of his clothing and the cup fell to the floor. Continued observation revealed R6 with an increased red faced appearance as he looked around the room for assistance. Further, after approximately two full minutes of the resident sitting unattended with food and drink all over his clothing, drinking cup in the floor and signs of defeat as he threw his utensil down, two feeding assistants were observed to note the resident's difficulty feeding himself. The feeding assistants were overheard addressing R6 as a feeder tray with need to remove him from the dining room to provide personal care. Observations during noon meal service on 09/05/2024 at 12:42 PM revealed that CNA5 was overheard in the dining room in front of residents, family members, State Survey Agents (SSAs), and employees referring to resident's as Feeders. An interview was attempted with R6 on 09/05/2024 at 12:55 PM, after the resident received personal care. The resident had a red face and nervous appearance of increased involuntary movement of hands and upper extremities. During the interview attempt with the R6, the resident kept his head down and was not attentive nor verbally responsive to questions as he did not make eye contact, looked away with his head down and shrugged his shoulders. Following SSA interview attempt, CNA5 approached the resident to provide feeding assistance. During an interview with feeding assistant/CNA2 on 09/05/2024 at 5:45 PM, CNA2 stated she had heard staff referring to residents who required feeding assistance as feeders; however, she felt it was unprofessional and a dignity issue per facility policy. CNA2 stated the term feeder could make residents feel insecure and like failures because they need help with feeding. Further observation of tray delivery on A unit hallway, in front of room [ROOM NUMBER], during dinner meal service on 09/05/2024 at 5:10 PM, revealed the Activities Director (AD) interacting with residents and explaining to them that dinner was taking a little longer to be served. SSA asked the AD if she was aware of what the delay was and she stated, They are feeding the feeders first. Continued observation of meal tray delivery on A unit hallway, in front of resident rooms on 09/05/2024 at 5:25 PM, the Administrator stated to the SSA while referring to resident's that required meal assistance as feeders in reference to a procedural change in the meal service process. During an interview with the Regional Director of Dietary Operations (RDDO) on 09/06/2024 at 11:30 AM, she stated that she was aware the facility provided in-service related to resident rights and the correct terminology for residents that required feeding assistance. The RDDO explained the importance of the in-service to ensure the employees were aware of the correct terminology about resident rights and dignity. RDO expects that the staff would respectfully refer to all residents. During an interview with Director of Rehabilitation on 09/06/2024 at 5:00 PM, she stated that a potential negative impact of referring to a resident as a feeder could cause the resident to feel humiliated and embarrassed and violate the resident's dignity. She stated she felt it was a dignity issue that could make those residents feel less than others. During an interview with a Physical Therapist (PT) on 09/06/2024 at 5:15 PM, she stated that referring to a resident as a feeder was demeaning; it is all about the person, not the condition. During an interview with the Environmental Service Director (ESD) on 09/06/2024 at 5:25 PM, she stated that when she heard a resident referenced as a feeder, she felt it was degrading and belittling to them. ESD emphasized the importance of staff education on communicating and referencing the correct terminology to ensure resident rights and dignity are honored. During an interview with the Business Office Manager (BOM) on 09/06/2024 at 5:00 PM, she stated that when staff refers to residents as a feeder, that is degrading, disrespectful, and a dignity concern. BOM further noted that the facility is the residents' home, and staff must respect them. During an interview with the Director of Nursing (DON) on 09/06/2024 at 8:20 AM, state that staff, including the Administrator, knew not to refer to residents as feeders. If a staff member called a resident a feeder in front of the resident, he would implement a teachable moment because that was not how staff should refer to residents. In addition, he had implemented re-education beginning 09/05/2024 for all staff related to Resident Rights and Dignity to ensure staff were using the correct terminology when communicating and providing the appropriate care for the residents. During an interview on 09/06/2024 at 5:55 PM, the Administrator stated that calling the resident a feeder was disrespectful and a dignity issue, and it could upset the residents. Therefore, she expected all staff, to include herself, to be aware of the importance of resident rights and to ensure all policies and procedures are implemented and followed.

Based on observation, interview, record review and facility policy, the facility failed to promote and facilitate the resident 's right to choose not to have a male provide personal care for 1 of nineteen sampled residents (Residents (R) 27). The findings include: Review of the facility policy titled Resident Rights revised 02/16/2024 revealed the resident had the right to be informed in advance, of the care to be furnished and the type of caregive/professional, that would be providing the care. Further review revealed the resident had the right to request, refuse, and or discontinue treatment. Review of R27's admission record revealed the facility admitted the resident on 06/02/2021 with diagnoses which included fracture of the neck of the right femur, convulsions, anxiety, and cerebral infarction. Review of R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/2022 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Further review of R27's MDS with an ARD of 07/22/2024 revealed a BIMS score of sever, which indicated severe cognitive impairment. Review of R27's Incident Note, dated 06/16/2022 at 9:00 PM revealed Licensed Practical Nurse (LPN) 4 documented the resident became combative with Activities of Daily Living (ADL's) care and with turning/positioning. Per the note, the resident received a skin tear to the right upper arm (back side) with three steri-strips applied and a skin tear to the right inner wrist with two steri-strips applied. Continued review of the note revealed R27 stated she was upset because a male Certified Nursing Assistant (CNA)(unnamed) was in her room and she refused for any male nurses or male CNAs to be in her room. Per the note, the LPN4 gave an as needed anxiety medication and an as needed pain medication. Review of R27's Comprehensive Care Plan (CCP) revealed a focus for self-care deficit related to incontinence of bowel and bladder due to impaired mobility and impaired balance which was initiated 06/15/2021 The goal was for R27 to remain free of signs and symptoms of urinary tract infection and skin breakdown and would remain clean, dry and odor free. The interventions included that the resident requested only female staff to provide care and this intervention was documented as initiated on 06/22/2022. There was no intervention noted on the Care Plan prior to 06/22/2022 that R27 did not want a male caregiver. During an interview with Family Member (FM) 2 on 09/04/2024 at 10:50 AM revealed the incident happened approximately two years ago. The resident had told the facility prior to the incident, she did not want a male caregiver to provide any type of personal care. The family had been notified R27 had sustained the injuries when a male CNA came into the room to provide care and the resident refused. FM2 further stated the facility was aware R27 did not want male staff providing personal care for the resident even before the incident occurred. FM2 stated no male CNA's have provided care since the time of the incident. During an attempted interview with R27 on 09/04/2024 at 10:55 AM, the resident nodded her head yes, when asked if she remembered the incident when a male staff provided care for her. The resident kept nodding her head yes, when FM2 stated R27 was very private. The staffing schedule was requested for 06/16/2022; however, interview with the Administrator on 09/06/2024 at 5:55 PM revealed when the ownership changed she lost access to several items and no longer had the schedules for that timeframe. During and interview on 09/06/2024 at 3:15 PM with the prior Administrator revealed she was not aware of any injury of unknown origin, nor does she remember any incident with R27 and a male caregiver. Further interview revealed that if she had known about the incident, she would have reported to the appropriate agencies immediately. During an interview with Certified Medication Tech (CMT) on 09/06/2024 at 4:00 PM, she stated she was unaware of an incident with R27 being injured but was aware that R27 did not want a male caregiver. Per the CMT, she knew residents had the right to refuse care. She stated she had been trained on abuse, abuse types, and reporting. During interview on 09/06/2024 at 7:20 AM with the Administrator, she stated she was aware that R27 did not want a male caregiver and she ensured male staff did not provide care for the resident. The Administrator further stated she was not the Administrator at the time of the incident and does not recall any specifics regarding the incident.

Based on observation, interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, it was determined that the facility failed to prevent the possible spread of COVID-19. On 07/20/2020, one (1) Dietary Aide was observed wearing a face mask that was not covering her nose and one (1) Dietary Aide was observed not wearing a face mask in accordance with CDC guidance. The findings include: According to CDC guidance for Cafeteria Workers, updated on 04/30/2020, employees should limit close contact with others and maintain a distance of at least six (6) feet, when possible. The CDC recommends wearing cloth face coverings where other social distancing measures are difficult to maintain. The CDC further recommended to institute measures to physically separate and increase distance between employees while working. The CDC revealed there is no evidence to support transmission of COVID-19 spread through food. According to CDC guidance for Using PPE, updated on 06/09/2020, when applying a face mask, the nose piece (if the mask has one) should be fitted to the nose with both hands and should be extended under (the) chin. The guidance stated both the mouth and nose should be protected. The guidance also stated that face masks should not be pulled below the chin. The facility produced an e-mail dated 04/07/2020, received from the Wayne County Health Department, Health Environmentalist, that cafeteria workers must practice social distancing, maintaining at least six (6) feet separation from each other when not wearing a face mask. The e-mail further revealed the CDC guidance referenced above. Observation during the initial tour on 07/20/2020 at 11:03 AM revealed Dietary Aide #1 and Dietary Aide #2 standing side by side at a food preparation table in the kitchen. Dietary Aide #1 was wearing a face mask below her nose. Further observation revealed Dietary Aide #2 was not wearing a face mask or face covering. Interview on 07/20/2020 at 12:35 PM, with Dietary Aides #1 and #2 revealed they were standing together at the food preparation table preparing snacks and desserts for the evening meal. Both Dietary Aides revealed they should have not been standing side by side and should have been standing at least six (6) feet apart. Dietary Aide #1 revealed she was in the process of training Dietary Aide #2 who had just recently started working at the facility. Dietary Aide #1 further revealed she had been taught the correct way to wear a face mask and it should have been up over her nose. Both Dietary Aides revealed that when they exit the kitchen into the facility they are required to always wear a mask. Interview on 07/20/2020 at 12:41 PM with the Director of Nursing (DON) revealed the facility had received guidance from the Wayne County Health Department regarding the cafeteria workers in the kitchen. The DON further revealed the guidance indicated the kitchen staff did not have to wear a face mask while in the kitchen working if they could maintain a six (6) foot distance from another employee; however, if the distance could not be maintained then they must wear a face mask. The DON further revealed the kitchen staff had been trained that if they exit the kitchen area and enter the facility they must wear a face mask at all times. Interview on 07/21/2020 at 9:12 AM with the Dietary Manager revealed she had requested guidance from the Wayne County Health Department regarding wearing a face mask while in the kitchen. The Dietary Manager revealed she had received an e-mail on 04/07/2020, indicating the kitchen staff did not have to wear a face mask if they could maintain at least a six (6) foot distance from another employee while working in the kitchen; however, if the distance could not be maintained they would be required to wear a face mask. The Dietary Manager further revealed she in-serviced all kitchen staff concerning the six (6) feet of distance that should be maintained and the wearing of a face mask. The Dietary Manager further revealed Dietary Aide #2 recently began employment at the facility and Dietary Aide #1 was in the process of training her and both had forgotten to don a face mask appropriately for working side by side.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to provide adequate supervision to prevent one (1) of three (3) sampled residents (Resident #1) from exiting the facility. On 04/22/2020 at 11:55 AM, Resident #1 was observed, on video, to exit the facility via the front door. Review of the facility investigation of the incident revealed Housekeeper #1 heard the door alarm, went to the door, looked out but did not see anyone and turned off the alarm. Per the investigation, the resident was brought back inside the facility unharmed and with no injuries at 11:59 AM. The findings include: Review of the facility policy, Elopements, dated December 2007, revealed staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review of the facility policy, Accidents/Incidents, dated 02/21/2017, revealed the facility was to monitor all accidents and incidents that occur with residents in an effort to reduce and/or eliminate injuries and accidents from occurring. Observation of Resident #1 on 04/28/2020 at 10:42 AM, revealed the resident up in a wheelchair in his/her room. Observation also revealed the resident was performing exercises with the therapist, was following directions, and was cooperative. Further observation, at 11:36 AM, revealed the resident in his/her room, sitting on the side of the bed while eating lunch. When asked about lunch, the resident replied his/her lunch was just fine. Review of the medical record revealed the facility admitted Resident #1 on 12/19/2019 and the resident had [DIAGNOSES REDACTED]. Further review of the record revealed on 04/22/2020, the resident was diagnosed with [REDACTED]. This was a decline from the admission assessment BIMS score of twelve (12), which indicated the resident had moderate cognitive impairment. The MDS revealed no behaviors of wandering or elopement on the admission or the 03/05/2020 assessment. Further review of the 03/05/2020 MDS revealed the resident required limited assistance of one (1) person for locomotion on the unit. Review of the Risk for Elopement/Wandering Reviews, dated 12/24/2019, 01/10/2020, 03/05/2020, and 04/22/2020 revealed the first three (3) showed the resident was not at risk for elopement. Those reviews revealed no history of elopement while at home, no wandering behavior in the facility, and no other exit-seeking behaviors. The review, dated 04/22/2020, revealed the resident was at risk for elopement related to a new behavior of exiting via the front door of the facility and going outside on 04/22/2020. Review of the facility investigation related to an allegation of elopement for Resident #1 on 04/22/2020 revealed the incident occurred at 11:51 AM. The investigation further revealed the resident was observed to be sitting outside the front door of the facility on the porch area by the Housekeeping Supervisor at 11:59 AM. Per the facility investigation, on 04/22/2020 Housekeeper #1 heard the front door alarm sounding and stated she had gone to the front door, looked out but did not see anyone, so she turned the alarm off. The investigation conclusion revealed the resident was brought back into the facility by the Housekeeping Supervisor at 11:59 AM and the incident was immediately reported to the Quality Assurance Nurse and the Director of Nursing. Per the investigation, Resident #1 was assessed to have no injury and the weather on 04/22/2020 was sunny and warm. The resident was placed on one-on-one supervision for twelve (12) hours and a code alert bracelet was placed on the resident. The conclusion also included that all residents were reassessed for elopement risks on 04/22/2020, the codes to all doors were changed, and Maintenance ensured all doors were working properly. Observation of exiting the door with the Housekeeping Supervisor on 04/28/2020 at approximately 11:30 AM, revealed a code was required to be entered on the keypad in order to unlock the door and prevent the door alarm from sounding. Further observation revealed the egress bar could be pushed in for fifteen (15) seconds and then the door would release and open but the alarm would sound. Review of the comprehensive care plan for Resident #1 revealed the facility identified the resident to be at risk for elopement on 04/22/2020 and revised the resident's plan of care. The facility added interventions addressing the resident's elopement risk which included the resident was to wear a code alert bracelet at all times, redirect the resident if near an outside exit doorway, and monitor for proper functioning of the code bracelet. Interview with Housekeeper #1 on 04/28/2020 at 11:12 AM, revealed on 04/22/2020 she was cleaning handrails and heard the alarm sounding for the front door. She stated she walked to the front door and looked out the window but did not see anyone so she shut off the alarm. Housekeeper #1 stated she was familiar with Resident #1 and had never observed the resident to go out any of the doors. She further stated the resident would come out of his/her room to ask for something or to use the phone. Per Housekeeper #1, she had received training/instruction on what to do when responding to a door alarm and had taken a posttest. She also stated she had been suspended on 04/22/2020 related to the incident and had just returned to work on 04/27/2020. Interview with the Housekeeping Supervisor on 04/28/2020 at 10:52 AM, revealed on 04/22/2020 she observed a visitor through one of the front windows and pecked on the window, beside the front door, to wave at the visitor. She stated she observed the visitor speaking to someone and looked out the front door to see whom she was speaking with but did not see anyone else. The Supervisor then stated she went to the big window in the lobby area, looked out, and saw Resident #1 sitting on the front porch. The Housekeeping Supervisor stated she immediately went outside, retrieved the resident, and informed the Quality Assurance Nurse and then the DON. She further stated she had never observed the resident to go to the door or display any type of exiting behaviors. Per the Supervisor, the front door was the door the resident normally exited when going to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Interview with State Registered Nurse Aide (SRNA) #1 on 04/28/2020 at 11:38 AM, revealed the staff are knowledgeable of those residents at risk for elopement through the communication book and the care plans, which are in each resident room. She stated if staff hear a door alarm they go to that door and check the outside area for any residents. If no residents are observed, then staff are to return to the facility and check the facility to ensure all residents are present. Interview with Licensed Practical Nurse (LPN) #1 on 04/28/2020 at 11:45 AM, revealed each nurses' station has an elopement binder which lists all residents in the facility which are risk for elopement. She stated if someone new is placed on elopement risk, the name of the resident at risk is verbally communicated to staff and placed in the communication book. She then stated if she heard a door alarm, she would look at the video monitor to determine which door was alarming. The LPN stated she would then go to the alarming door and check the area outside. She added if no resident was found outside, she would then check the facility to ensure all residents were present. She revealed she was familiar with Resident #1 and had never observed the resident to have any exit seeking-behaviors. Interview with LPN #2 on 04/28/2020 at 4:38 PM, revealed he was the nurse assigned to B Hall, where Resident #1 resided, on 04/22/2020. He stated he had not observed Resident #1 display any exit-seeking behavior or any other behaviors. He further stated the resident was able to self-propel a wheelchair with his/her feet and could transfer and toilet himself/herself with some assistance. He then added that once the resident was returned to his/her room after exiting the facility on 04/22/2020, he/she was placed on one-on-one supervision and had no further exit-seeking behaviors that evening. Interview with the Quality Assurance (QA) Nurse on 04/28/2020 at 2:35 PM, revealed she was familiar with Resident #1. The QA Nurse stated Resident #1 had some behaviors since admission, but no exit-seeking behaviors. She stated she had been part of a telehealth conference call on 04/22/2020 with the resident, the resident's son, and a physician from Vanderbilt just prior to the exiting incident. She stated the physician had informed them the resident had [MEDICAL CONDITION] and that medication would be ordered to address the [DIAGNOSES REDACTED].#1's [MEDICAL TREATMENT] schedule had just changed from three (3) days a week to two (2) days a week. Per the QA Nurse, the resident would now go on Monday and Friday only, and 04/22/2020 was the first Wednesday he/she did not have [MEDICAL TREATMENT]. The QA Nurse stated she wondered if the resident thought he/she was going to [MEDICAL TREATMENT]. Per the QA Nurse, all residents are assessed on admission for the risk of elopement. If they are assessed to be at risk for elopement then the risk is care planned and the care plan is located in the resident's room. She further stated there is a note indicating the elopement risk placed in the communication book, which is to be reviewed daily and signed by the staff. The QA Nurse then stated when the resident was returned to the unit after exiting he/she was immediately placed on one-on-one monitoring. Per the QA Nurse, Nursing documented on the resident every fifteen (15) minutes for one (1) hour, then every thirty (30) minutes for one (1) hour, and then hourly until completed at midnight on 04/22/2020. She stated the nurse was to also check to ensure the code alert was working properly and document this as well as any behaviors and mood the resident displayed. Interview with MDS Nurse #1 on 04/29/2020 at 9:10 AM, revealed she viewed the video as part of the investigation of the elopement by Resident #1 on 04/22/2020. She stated she was able to see the resident exiting the front door at 11:55 AM, but stated she could not determine exactly how the door was opened. She further stated she observed Housekeeper #1 walk over to the front door from the lobby area at 11:57 AM. The MDS Nurse stated could not see the housekeeper turn the alarm off but Housekeeper #1 stated this in the interview during the investigation. She revealed the fire doors were closed, between the front door and A Hall, so vision was limited. Per the MDS Nurse, the resident was observed to be brought back into the facility at 11:59 AM. Interview with the Director of Nursing (DON) on 04/29/2020 at 9:15 AM, revealed the staff have been taught to make sure a resident is not outside when a door alarm sounds. She stated the training provided to the staff on 04/22/2020 was to reinforce this. The staff should go outside and check the area to ensure a resident is not outside. She stated Housekeeper #1 failed to go outside and check for the resident. She further stated she was providing another training on 04/29/2020 on door alarms.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to implement the person-centered care plan for one (1) of nineteen (19) sampled residents (Resident #17). The facility had assessed Resident #17 to be at risk for falls and care planned to have a fall mat to the left side of the bed as a fall prevention intervention. However, observations on 11/13/19 and 11/14/19 of Resident #17 while resting in bed revealed there was no fall mat to the left side of the bed. The findings include: Review of the facility policy, Care Plans, Comprehensive Person Centered, dated (MONTH) (YEAR), revealed a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Observation of Resident #17 on 11/13/19 at 8:24 AM revealed the resident was in bed with the head of the bed raised at ninety (90) degrees. Further observation revealed there was not a fall mat in place on the left side of the bed and the right side of the bed was against the wall. Observation of Resident #17 on 11/14/19 at 9:31 AM revealed the resident was in bed and the bed was in the lowest position. Further observation revealed there was not a fall mat to the left side of the bed. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/30/19, revealed a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. The MDS further revealed the resident required extensive assistance of two (2) or more persons for the tasks of bed mobility, transfers, and dressing. The resident was also totally dependent on two (2) or more persons for the task of toilet use. Continued review of the MDS revealed Resident #17 had suffered two (2) or more falls since admission or the last assessment, whichever was first. Review of the fall investigations for Resident #17 revealed the resident had suffered two falls in the last 120 days. The falls occurred on 08/24/19 and 10/29/19. The fall that occurred on 08/24/19 resulted in an update to the care plan for a safety mat to the left side of the bed when the resident is in bed. Review of the care plan for Resident #17 dated 06/26/18 revealed identification of the resident being at risk for falls. Further review revealed an update to this care plan, dated 08/26/19, which stated a fall mat was to be placed to the left side of the bed when the resident was in bed. Interview with State Registered Nurse Aide (SRNA) #1 on 11/14/19 at 2:56 PM, revealed Resident #17 required total assistance and was a fall risk. The SRNA stated the aide care plan would reveal the level of assistance a resident required. He stated the resident should have a fall mat beside the bed and the bed should be in the lowest position. The surveyor accompanied the SRNA to the resident's room and the SRNA stated the fall mat was not in place, but it was placed between the right side of the bed and the wall. The SRNA pulled the mat out and placed it to the left side of the resident's bed as the resident was still in bed. Interview with the Resident Care Supervisor on 11/14/9 at 3:10 PM, revealed she did not monitor to ensure care plans were implemented as written. She further stated the Quality Assurance (QA) Nurse would be the person who probably monitored this. Interview with the QA Nurse on 11/14/19 at 3:52 PM, revealed the Resident Care Supervisor should have made sure fall precautions were in place. She also stated the fall mat should have been at the left side of Resident #17's bed. Interview with the Director of Nursing (DON) on 11/15/19 at 3:23 PM, revealed all fall precautions should be implemented as care planned. She further stated the staff would move the mat when the resident got out of bed.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to provide care consistent with professional standards of practice for pressure ulcers for one (1) of nineteen (19) sampled residents (Resident #14). Resident #14 developed a wound on 07/09/19 to the left thigh that the facility failed to identify as a pressure ulcer. On 11/04/19, the same wound was documented as an unstageable pressure ulcer and on 11/07/19 the pressure ulcer was documented as Stage 3. The resident was provided the same wound treatment from 07/09/19 until 10/31/19 without evidence in documentation of wound improvement or decline, as there were no measurements from 07/09/19 until 11/04/19. The findings include: Review of the facility policy, Pressure Ulcers, dated 04/06/15, revealed pressure ulcers are monitored daily for exudate, odor, wound and surrounding tissue, and pain. The policy further revealed the pressure ulcer would be monitored weekly to determine pressure ulcer stage, location, size (measurements of length, width, and depth), and progress toward healing and any change in treatment. Review of the National Pressure Ulcer Advisory Panel (NPUAP), undated, revealed the definition of a pressure ulcer was a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Review of The Bones of Mine, undated, revealed the ischium is the bone that takes the weight while the person is sitting on a chair. Observation of Resident #14 on 11/12/19 at 2:38 PM, revealed the resident up in a wheelchair. The resident was observed to sit on the edge of the wheelchair and required a lap belt for safety. Further observation revealed the resident self-propels the wheelchair rapidly around the facility for long periods of time. Observation of the wound on Resident #14, on 11/14/19 at 8:34 AM, revealed a pressure ulcer, Stage 3, to the left ischium (lower buttock). Further observation revealed the wound to be without drainage or signs/symptoms of infection. All documentation in the record stated right upper inner thigh; however, the pressure ulcer was observed on the resident's left ischium. Interview with RN #1 on 11/15/19 at 10:37 AM revealed it was the same wound. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), quarterly assessment, dated 08/28/19, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident was at risk for development of pressure ulcers using formal tool assessments and clinical assessment, but at the time of the MDS assessment had no unhealed pressure ulcers at Stage 2 or higher. Review of a skin/wound note, dated 07/09/19, revealed an aide reported an open area to the right inner/upper thigh area that measured 2.5 centimeters (cm) in length, 3.0 cm in width, and no depth recorded. Review of the skin/wound notes from 07/11/19 through 10/31/19 revealed the same wound treatment was provided, which consisted of keeping the wound clean and dry and to apply [MEDICATION NAME] dressing every three (3) days and whenever needed. Documentation in the skin/wound notes revealed the wound was not measured during this time. Further review of the notes revealed no signs or symptoms of infection, no increased drainage, and wound bed would be pale pink to pink. Review of the current physician order summary for Resident #14, dated 11/15/19, revealed a wound care treatment to clean the area to the right upper inner thigh with soap and water, apply [MEDICATION NAME] Ag, and cover with dressing daily, initiated on 10/31/19. Review of the comprehensive care plan for Resident #14 revealed a problem area identified on 07/09/19, detailed as open area to the upper/inner thigh, right. The care plan then revealed to change open area to unstageable pressure ulcer on 11/04/19. Then on 11/07/19, the pressure ulcer was changed to a Stage 3. Further review of the care plan revealed the resident was at high risk for pressure ulcers and skin breakdown. Interview with Registered Nurse (RN) #2 on 11/14/19 at 8:34 AM, revealed wound care was performed before Resident #14 was out of bed in the mornings, as he/she does not like to lie back down after being up in a wheelchair. She further stated the wound was monitored daily and documentation was done in the record. Per the RN, the wound had no complications related to infection and the biggest challenge had been trying to get Resident #14 to stay off the site as he/she likes to be in up the wheelchair. Interview with RN #1 on 11/15/19 at 10:37 AM, revealed she had performed Resident #14's wound care the weekend prior to 11/04/19 and stated the wound looked worse than when she had seen it before (about two weeks earlier). She stated she believed it was now a pressure ulcer. Interview with the Director of Nursing (DON) on 11/15/19 at 3:41 PM, revealed she believed the wound on Resident #4 may have been an abrasion. She stated the resident sits on the edge of the wheelchair and self-propels throughout the facility. She then stated it should have been addressed as a pressure ulcer on 07/09/19 and treatment should have probably been changed related to no improvement noted.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents (Resident #17) was provided the adequate supervision and assistance devices to prevent accidents. Observations of Resident #17 revealed there was no fall mat to the left side of the resident's bed on 11/13/19 and 11/14/19, as care planned for fall prevention. The findings include: Review of the policy, Falls-Clinical Protocol, dated (MONTH) (YEAR), revealed the staff and the physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Observation of Resident #17 on 11/13/19 at 8:24 AM revealed the resident was in bed with the head of the bed raised at ninety (90) degrees. Further observation revealed there was not a fall mat in place on the left side of the bed and the right side of the bed was against the wall. Observation of Resident #17 on 11/14/19 at 9:31 AM, revealed the resident was in bed and the bed was in the lowest position. Further observation revealed there was not a fall mat to the left side of the bed. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/30/19, revealed a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. The MDS further revealed the resident required extensive assistance of two (2) or more persons for the tasks of bed mobility, transfers, and dressing. The resident was also totally dependent on two (2) or more persons for the task of toilet use. Continued review of the MDS revealed Resident #17 had suffered two (2) or more falls since admission or the last assessment, whichever was first. Review of the fall investigation, dated 08/24/19, revealed Resident #17 had suffered a fall in his/her room. The resident reportedly stated he/she had fallen out of bed. The bed was found to be in the low position and bilateral head-of-bed side rails were up. The resident suffered two (2) skin tears to the left hand. Resident #17 also stated he/she had hit his/her head on the floor and was transported to the emergency room for evaluation. As a result of the investigation, the intervention of placing a fall mat to the left side of the bed was added to the care plan. Review of the care plan for Resident #17, dated 06/26/18, revealed identification of the resident being at risk for falls. Further review revealed an update to this care plan, dated 08/26/19, which stated a fall mat was to be placed to the left side of the bed when the resident was in bed. Interview with State Registered Nurse Aide (SRNA) #1 on 11/14/19 at 2:56 PM, revealed Resident #17 required total assistance and was a fall risk. He stated the resident was on the Falling Star Program, which indicated a high fall risk. Per the SRNA, the aide care plan would reveal the level of assistance a resident required. He stated the resident should have a fall mat beside the bed and the bed should be in the lowest position. The surveyor accompanied the SRNA to the resident's room and the SRNA stated the fall mat was not in place, but it was placed between the right side of the bed and the wall. The SRNA pulled the mat out and placed it to the left side of the resident's bed as the resident was still in bed. Interview with the Resident Care Supervisor on 11/14/9 at 3:10 PM, revealed she did not monitor to ensure care plans were implemented as written. She further stated the Quality Assurance (QA) Nurse would be the person who probably monitored this. Interview with the QA Nurse on 11/14/19 at 3:52 PM, revealed the Resident Care Supervisor should have ensured fall precautions were in place. She also stated the fall mat should have been at the left side of Resident #17's bed. Interview with the Director of Nursing (DON) on 11/15/19 at 3:23 PM, revealed staff would move the mat when the resident got out of bed. Per the DON, all fall precautions should be implemented as care planned.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to notify the physician of the Registered Dietitian recommendations for two (2) of seven (7) residents with nutritional concerns out of twenty-one (21) sampled residents. Resident #36 had recommendations to add dietary supplements due to weight loss and there was no evidence that the physician was notified of the recommendations. Resident #14 was assessed to have a significant weight loss. The Registered Dietitian (RD) had written dietary recommendations dated 03/14/19 and 08/12/19 for the resident to have fortified foods and Mighty Shakes two (2) times a day. However, there was no documented evidence that the physician was contacted with the RD recommendations. The findings include: Review of the facility's policy entitled Dietary Assessment Recommendations, dated 08/26/14, revealed upon completion of dietary recommendations, the Registered Dietitian will make at least two (2) copies of the completed recommendation and provide the copies to the Director of Nursing and the Dietary Manager. According to the policy, the charge nurse will be responsible for notifying the physicians of the recommendations. Review of the care plan for Resident #36 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the care plan revealed the resident was at risk for alteration in nutrition, less than body requirements with interventions in place to monitor weight, and notify physician as indicated. Observations of Resident #36 on 11/12/19 at 4:32 PM revealed the staff brought a meal tray to the resident's room and assisted with setup. Further observation revealed the resident had vegetable beef soup, ham sandwich, and dessert. Observation revealed no health shake was noted on the dinner tray. Review of the Nutritional Assessment Recommendations dated 11/04/19 revealed Resident #36 had a dietary recommendation to add Magic Cup with lunch daily and add health shake with dinner daily to aid in increasing protein calorie intake. Review of the Comprehensive Nutritional assessment dated [DATE] revealed Resident #36's weight was 161.8 on 07/10/19 and the resident had a weight loss to 150.2 on 09/12/19. Further review of the Comprehensive Nutritional Assessment revealed Resident #36's weight was 143.8 on 10/30/19. The resident had an 18-pound weight loss in four months. Further review of Resident #36's physician's orders and progress notes revealed no evidence the physician had been notified of the Registered Dietitian's (RD) recommendations for the resident to receive daily dietary supplements at lunch (Magic Cup) and dinner (health shake). Interview with the RD on 11/15/19 at 2:27 PM revealed the RD makes dietary recommendations and gives the Nutritional Assessment Recommendation form to the Dietary Manager. According to the interview, the RD then files the Comprehensive Nutritional Assessment in the resident's chart. Further interview revealed the Dietary Manager gives a copy of the Nutritional Assessment Recommendation form to the Resident Care Manager to contact the physician for orders. Interview with the Resident Care Manager on 11/15/19 at 4:09 PM revealed the Dietary Manager gives her a copy of the RD's recommendations and then she gives them to the Charge Nurse on the unit to contact the physician for the orders. Interview with the Charge Nurse on 11/15/19 at 4:13 PM revealed the RD's recommendations are left at the unit desk for the Charge Nurse working to contact the physician for orders. Further interview revealed the Charge Nurse will fax the recommendations and follow up with a phone call to the physician. According to the interview, when the physician approves the recommendation then an order is written and the dietary change in made on the meal cards. The Charge Nurse revealed she did not recall working on 11/04/19 when the RD made the recommendations. Interview with the Quality Improvement Nurse on 11/15/19 at 9:44 AM revealed there was no physician order for [REDACTED]. Interview with the Director of Nursing on 11/15/19 at 3:30 PM revealed the Charge Nurse should have contacted the physician with the recommendations made by the RD. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/28/19, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident required extensive assistance of one (1) person to eat. Observation of Resident #4 on 11/12/19 at 2:38 PM, revealed the resident up in a wheelchair. The resident was observed to sit on the edge of the wheelchair and required a lap belt for safety. Further observation revealed the resident self-propels the wheelchair rapidly around the facility for long periods of time. Review of the Nutritional Assessment Recommendations (completed by the RD), dated 03/14/19, revealed Resident #14 had recommendations for fortified foods and Mighty Shakes two (2) times a day. Review of the Comprehensive Nutritional Assessments (completed by the RD) dated 03/14/19 and 08/12/19 revealed both had recommendations of fortified foods and Mighty Shakes. The assessment dated [DATE] revealed a significant weight loss in the past six (6) months. The documented weight on 08/07/19 was 112.6 pounds and the resident had a weight six (6) months earlier of 124.4 pounds. Further assessment revealed the resident was consuming greater than 50 percent of meals and snacks were being offered between meals. The RD also reported the resident had been receiving Mighty Shakes and fortified foods when appropriate. Review of the medical record for Resident #14 also revealed a weight of 115.6 pounds on 11/13/19, which indicated less than a pound lost from a weight of 116.4 on 10/17/19. Review of the physician orders for Resident #14, printed 11/15/19, revealed the resident's diet order to be a Regular diet with chopped texture and regular consistency. The orders did not have evidence of fortified foods or Mighty Shakes. Review of the Dietary card for Resident #14 revealed the diet order was Regular/Chopped meats and listed likes as a Magic Cup for lunch and a Health Shake for dinner. Review of the Communication with Physician notes for Resident #14, dated 05/30/19 through 08/09/19, did not reveal communication of the RD recommendations. Interview with Dietary Staff Member #1 on 11/15/19 at 8:34 AM, revealed her responsibility in the kitchen is to plate the food. She stated she goes by the menu and looks at the resident's diet card to ensure the correct diet is provided. The dietary staff stated after looking at Resident #14's diet card that she is on a regular diet. She stated if the resident is on a fortified diet that would be on the diet card. Interview with the Dietary Manager on 11/15/19 at 9:48 AM, revealed that to make a fortified food whipping cream could be added to mashed potatoes, or extra butter added to other foods. She stated Resident #14 had been receiving the fortified foods as recommended and received the Magic Cup at lunch and the Mighty Shake with dinner. Interview with the Registered Dietitian on 11/15/19 at 2:28 PM, revealed fortified foods are ordered to increase calories and protein. She further stated some examples of how to do this would be to use whole milk, offer peanut butter, extra butter, and gravies. She also stated she does not contact the physicians for the orders for recommendations and does not follow up to see if recommendations were obtained.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure a communication process was maintained between the facility and the hospice provider for one (1) of nineteen (19) sampled residents. The medical record for Resident #50 did not contain hospice documentation or a hospice care plan. The findings include: Review of the facility contract, Contract for Services between the Hospice provider and the facility, undated, revealed services to be furnished by the nursing home were to maintain the Hospice plan as part of its care plan for the resident. The Hospice care provider was to ensure copies of Hospice documentation were available to be filed in the resident's medical record. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record also revealed the resident was admitted to the facility under the care of Hospice. The Minimum Data Set (MDS) admission assessment, dated 11/23/18, revealed the resident had received hospice care outside the facility and was going to receive hospice care in the facility. The MDS annual assessment, dated 10/22/19, revealed the resident had received hospice care in the facility. Review of the comprehensive care plan for Resident #50, dated 11/28/18, identified that the resident had potential for decline related to a [DIAGNOSES REDACTED]. Further review of the medical revealed no hospice plan of care and no documentation of hospice visits since admission. Interview with Registered Nurse (RN) #1 on 11/14/19 at 10:57 AM, revealed they received a care plan and documentation from the hospice provider on 11/14/19, after the surveyor had requested to see hospice documentation and the care plan. The visit notes consisted of a social worker visit note on 10/25/19, an aide note dated 11/06/19, and a nurse visit note dated 11/06/19. The RN stated she was not sure if the facility had been receiving documentation from the hospice provider or not. She stated she would check with the medical records personnel to see if any had been thinned. Interview with the Medical Records personnel on 11/14/19 at 12:05 PM, revealed the facility had not received any documentation from Hospice in a long time. She also stated the facility had not received any documentation at all on Resident #50. She stated, I guess I should have called and had them to send it. Interview with the Director of Nursing (DON) on 11/15/19 at 3:20 PM, revealed she was aware the facility was to maintain documentation of the care plan and visit notes on residents who received hospice care. She stated there are binders set up for hospice notes to be placed in. She further stated the Medical Records personnel is responsible for ensuring the hospice notes are filed and is not sure how it fell through the cracks.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure proper storage of insulin in one (1) of two (2) medication carts. The facility failed to ensure an unopened vial of insulin was refrigerated. While auditing the medication storage on B Wing on 11/15/19, an unopened vial of [MEDICATION NAME] was discovered on the cart. The findings include: Review of the facility policy, Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, dated 12/01/17, revealed no specific guidelines for the storage of insulin. Review of the [MEDICATION NAME] vial insulin insert, dated (MONTH) (YEAR), revealed unopened, unused vials should be kept refrigerated. Observation of a medication cart on B Wing on 11/15/19 at 9:05 AM, revealed an unopened vial of [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #3 on 11/15/19 at 9:05 AM, revealed the unopened vial should not have been in the cart but in the refrigerator until opened. Interview with the Director of Nursing (DON) on 11/15/19 at 3:19 PM, revealed unopened insulins are to be kept in the refrigerator. She further stated that once opened the insulin should be dated when opened and the expiration date placed. She stated the contract pharmacist conducts audits of medication rooms and medication carts to check for expired medications and ensure proper storage.

Based on interview and record review it was determined the facility failed to ensure policies and procedures that prohibited neglect, mistreatment, and abuse had been implemented for three (3) of four (4) sampled residents (Residents #7, #5, and #6). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation. Record review and interviews revealed Resident #7 informed Certified Nurse Aides (CNAs) #7 and #8 that CNA #8 hurt the resident when they provided incontinence care to him/her. CNAs #7 and #8 informed Licensed Practical Nurse (LPN) #2 of the resident's complaint when they (CNAs #7 and #8) left the resident's room; however, LPN #2 did not report the incident. On 01/22/14, Resident #7 informed Registered Nurse (RN) #3 that CNA #8 hurt him/her when he provided incontinence care to the resident, and RN #3 reported the allegation to RN #2 and the DON. RN #2 interviewed Resident #7 and informed the DON of her findings. The DON stated in interview on 04/24/14 at 5:05 PM that due to witnesses being present who denied CNA #8 had intentionally hurt Resident #7 (on 01/18/14), she advised staff that CNA #8 could continue to provide care to other facility residents, but that CNA #8 would not be allowed to provide direct care to Resident #7. The DON stated she did not report the allegation to the Administrator of the facility and State agencies as required. In addition, review of the facility's investigation revealed the facility took no action to protect residents from further abuse/potential abuse until 04/24/14 (95 days after the allegation of abuse) when the facility removed CNA #8 from direct patient care. Resident #5 reported to facility staff (around 04/18/14, exact date unknown) that six dollars ($6.00) and a pair of pants were missing from his/her room; and on 02/04/14, Resident #6 reported that thirty-six dollars ($36.00) was missing from his/her room. The facility reimbursed Residents #5 and #6 for the reported missing monies; however, the facility failed to conduct an investigation or report the possible misappropriation of resident property to the appropriate State agencies as required. The facility's failure to implement policies and procedures that prohibited neglect, mistreatment, and abuse that included reporting allegations of abuse, protecting residents during the course of their investigation, and conducting an investigation of an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 01/18/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 04/24/14. On 05/06-07/14, a partial extended survey was conducted. An acceptable Allegation of Compliance was received on 05/05/14 which alleged removal of the Immediate Jeopardy on 05/03/14. The State Agency determined the Immediate Jeopardy was removed on 05/03/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: According to the facility's policy, "Resident Abuse," not dated, the facility would immediately report, and thoroughly investigate, all allegations of mistreatment, neglect, abuse, and misappropriation of resident property, and would immediately report all alleged incidents involving mistreatment, abuse, or misappropriation of resident property to the facility Administrator. The policy revealed the facility would prevent further potential abuse during the course of the investigation, including the removal of alleged staff from the care of all residents. The policy also revealed the Administrator/designee would immediately notify the appropriate State agencies of the allegation. 1. Documentation in Resident #7's medical record revealed the facility admitted the resident on 12/19/12. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #7 to have a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. Based on documentation on a "Complaint of Abuse/Neglect" form, not dated and not signed, on 01/22/14 Resident #7 reported to Registered Nurse (RN) #3 that CNA #8 hurt him/her when he provided incontinence care to the resident (approximately four days earlier), and RN #3 reported the allegation to RN #2 and the DON. RN #2 completed an incident report and interviewed Resident #7. Continued review of the report revealed Resident #7 informed RN #2 that CNA #8 was "always rough" with him/her. The resident further stated he/she "told" the CNA he was hurting him/her and he started "laughing" and said "you are just being a timid (boy/girl)." Resident #7 acknowledged in an interview conducted on 04/24/14 at 10:30 AM that he/she had reported Certified Nurse Aide (CNA) #8 "hurt me." The resident was unable to recall the exact date of the incident and stated CNA #8 intentionally caused pain to the resident by forcibly pulling the resident's legs apart to provide incontinence care. CNA #8 stated in an interview conducted on 04/24/14 at 4:17 PM that he and CNA #7 had provided incontinence care for Resident #7, the resident told them it hurt "down there," and CNA #8 informed LPN #2. Continued interview with CNA #8 revealed he provided incontinence care to Resident #7 the following night and the resident asked him to be careful with his/her legs because he had hurt them the night before. CNA #7 stated in interview on 04/24/14 at 4:17 PM that Resident #7 had complained that CNA #8 had hurt the resident when the CNA "pulled" the resident's legs apart in order to provide incontinence care. CNA #7 stated he did not remember the exact date of the incident, but stated he and CNA #8 informed Licensed Practical Nurse (LPN) #2 of the resident's complaint. LPN #2 confirmed in interview conducted on 04/24/14 at 6:35 PM that CNA #8 reported to her Resident #7 had complained about the care CNA #8 provided; however, LPN #2 could not recall the date of the report. LPN #2 further stated she assessed the resident and that she "think(s)" she "documented" the incident in the Nursing Notes of the resident's medical record. LPN #2 stated there had been a "witness" in the room at the time of the incident and she did not "think" abuse had occurred and she did not remove the alleged perpetrator from direct resident care, did not initiate an investigation of the incident, and did not report the resident's allegation to anyone. RN #2 stated in an interview conducted on 04/25/14 at 11:15 AM she spoke to Resident #7 on 01/22/14 about his/her allegation and reported the allegation to the Director of Nursing (DON) by telephone. Further interview with RN #2 revealed CNA #8 was in the facility at that time and she was instructed by the DON to inform CNA #8 not to provide care to Resident #7, but that he could continue to provide direct care to all other residents in the facility. RN #2 stated that she talked to three residents that CNA #8 had provided care to on 01/18/14, and none of the residents had voiced complaints. RN #2 also stated no further investigation was conducted at that time and the allegation was not reported to the Administrator or other State Agencies as required. According to RN #2 she had the responsibility to complete abuse investigations in the facility and was aware of the reporting requirements, but ultimately all decisions regarding reporting and disciplinary action were made by the Administrator and/or DON. The DON/Co-Owner stated in interview conducted on 04/24/14, at 5:05 PM that because CNA #8 had denied intentionally harming Resident #8 when he provided incontinence care to the resident, and there had been a witness in the room who also denied CNA #8 had intentionally harmed the resident, she did not feel the allegation warranted further investigation. The Administrator/Co-Owner stated in interview on 04/25/14, at 10:55 AM that he or the DON determined the actions to take when an allegation of abuse was made. The Administrator stated to the "best" of his "recollection" he was not informed of Resident #7's allegation of abuse made on 01/18/14, until 04/24/14, 95 days after the resident voiced the allegation. 2. Resident #5's medical record revealed the facility admitted the resident on 01/05/13. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #5 to have a BIMS score of 15, which indicated the resident's cognition was intact. Resident #5 stated in interview on 04/23/14, at 10:15 AM that six dollars ($6.00) had been taken from his/her room during the night approximately one month ago (exact date unknown). Resident #5 reported to the "boss" that the money had been taken, and was reimbursed six dollars ($6.00). Additionally, Resident #5 stated a pair of pants had also disappeared from his/her room two to three days ago (exact date unknown). In interview on 04/23/14, at 2:50 PM the Social Services Director/Activity Director (SSD/AD) stated when a resident reported missing money or items, the money would be reimbursed to the resident or the missing item replaced. However, the SSD/AD stated the Administrator would not be notified unless the money or item was of substantial value. The SSD/AD stated if a "large" amount of money or an "expensive" item was reported missing, Administrative staff would be notified and an investigation initiated. However, the SSD/AD was unable to state how or who in the facility made the decision on what would be reported to the Administrator or warrant an investigation. 3. The facility admitted Resident #6 on 08/30/13. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact with no memory defects. Review of written statements made by facility staff revealed on 02/03/14, Resident #6 reported thirty-six dollars ($36.00) had been "stolen" from him/her. The staff reported the allegation to Resident #6's nurse on 02/03/14. Interview conducted on 04/25/14 at 11:30 AM with LPN #5 revealed she had been notified on 02/03/14 that Resident #6 had reported missing money. LPN #5 stated she searched Resident #6's room but was unable to locate the money. Although LPN #5 wrote a statement detailing the events of the incident, she took no action to initiate an investigation or notify facility Administration about Resident #6's allegations that money had been stolen. LPN #5 stated the only action she took was notifying the Activity Assistant on 02/04/14 that Resident #6 had reported thirty-six dollars ($36.00) had been stolen. In an interview conducted on 04/24/14 at 3:25 PM the Activity Assistant stated when she was notified of Resident #6's allegations, she reimbursed the resident thirty-six dollars ($36.00) from facility funds. The Activity Assistant stated since the facility reimbursed Resident #6 for the missing money the allegation was not reported to the Administrator or other officials. The Activity Assistant was unable to define what specific circumstances would prompt notification of Administration in relation to resident allegations of missing money. In interview on 04/24/14, at 5:05 PM the DON stated when a resident reported missing money or an item, the facility staff would initiate a search for the item, and if it was not located the item or money was replaced by the facility. The DON confirmed the facility did not investigate when a resident reported a small amount of money or inexpensive item missing. The DON stated she was aware that the facility's policy/procedure indicated an investigation would be initiated for all allegations of misappropriation of resident property but stated since it was a "small facility" it was "easier" to reimburse the resident the money or replace inexpensive items. **The facility provided an acceptable Allegation of Compliance (AOC) on 05/05/14. The facility implemented the following actions to remove the Immediate Jeopardy: The allegation of abuse from 01/18/14 was reopened on 04/25/14 with all regulatory agencies being notified. All staff members alleged to be present during the 01/18/14 allegation including State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #2 were removed from the schedule and suspended pending the conclusion of this investigation. To ensure the safety of Resident #7, as well as all other residents residing at this facility, on 04/25/14 residents with a Brief Interview for Mental Status (BIMS) score of 8 and above were interviewed by the Activity/Social Services Director and/or Minimum Data Set (MDS) Coordinator to determine if any had failed to report an allegation of abuse, neglect, misappropriation, or exploitation. No reports of physical abuse were noted from these interviews. These interviews did identify 13 residents who reported missing items/money. Investigations were started immediately by members of the Abuse Committee. The appropriate State agencies were notified of these allegations on 04/28/14. Residents with a BIMS score below 8 had a head to toe skin assessment done on 04/25/14 by nurses. Ten residents were identified with bruises/areas of discoloration/scratches and scabs. These were reviewed by the Director of Nursing (DON) and Consulting Nurses on 04/27/14, and although none were of suspicious nature, investigations were started on 04/27/14 by the Quality Assurance (QA) Nurse and MDS Coordinators. The appropriate State agencies were notified on 04/28/14 by the MDS Coordinator. Investigations were concluded on 04/29/14 with all being unsubstantiated by the facility's QA Abuse Committee. On 05/01/14 and 05/02/14, the ten residents' investigations were reviewed again for possible causes of the injuries and what could be done to protect the resident from the reoccurrence of similar injuries. To ensure facility policy has been followed and the appropriate State agencies notified timely, members of the Abuse Committee, which are the DON, Social Services/Activity Director, MDS staff, QA Nurse, and Assistant Director of Nursing (ADON), reviewed on 05/01/14 all allegation reports from the year 2013 until present. The Abuse Committee reviewed daily all resident allegations, injuries of unknown origin, and any misappropriation of residents' property to ensure facility policy was followed and all notifications had been timely. All staff was interviewed by the ADON and the QA Nurse on 04/29/14 to determine if anyone had failed to report any allegations of abuse, neglect, misappropriation, or exploitation. There were no new allegations reported. The Nursing Home Administrator (NHA), DON, ADON, QA Nurse, Activity/Social Services Director, Resident Care Supervisor, MDS Coordinators, Medical Records Director, Data Compliance staff, and Office Assistant received in-service education by the Nurse Consultant on 04/25/14 regarding the regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. On 05/01/14, additional in-service was provided by the Nurse Consultant on using the handouts provided at a seminar given by the Office of Inspector General on 02/26/14. Staff was in-serviced by the QA Nurse and/or the DON on April 25, April 26, April 27, and April 29, 2014 on the following items: investigating abuse, neglect, misappropriation, when to investigate, reporting abuse, neglect, misappropriation, collecting statements for investigations, performing head to toe assessments on residents when allegations are made to ensure the resident has no injury, notifying the Administrator, DON, ADON, and appropriate State agencies, when to call 911 for on-call Social Worker, resident's physician, and responsible party, protecting residents by removal of accused immediately, and removing resident(s) immediately out of harm's way. In-service was held on 05/01/14 with all LPNs, SRNAs, Certified Medication Technicians (CMTs), office staff, kitchen staff, housekeeping staff, laundry staff, maintenance staff, and janitorial staff attending. In-service was given by the DON. Two employees were not present at either meeting and those two employees were in-serviced on 05/02/14 by the DON. Information for the in-service included the training manual, "Hand in Hand: A Training Series for Nursing Homes." The in-service covered the following listed areas: revised abuse policy, revised investigation form, types of abuse, how to report abuse, protection of resident, preventing abuse, what constitutes abuse, LPNs starting investigation (what to do), allegations of abuse, identifying abuse, screening potential employees, and revised reporting protocol for abuse. A posttest was given on 05/01/14 to all staff after each of the in-services on examples related to abuse issues. The two employees in-serviced on 05/02/14 were given the posttest also. Employees who did not score 100 percent on their test were rein-serviced at the time the posttest was reviewed by the DON. As an ongoing training program, all new hires will be required to go through the abuse training that will include the following: screening, training, prevention, identification, investigation, protection, and reporting/response. Information for these trainings will be taken from the manual, "Hand in Hand: A Training Series for Nursing Homes." After these in-services, the new employee will be required to take a posttest to ensure they understand all issues related to abuse. In-services on abuse will be done monthly for a period of six months. The monthly abuse in-services will be conducted by either the DON or her designated staff member. Posttests will be done after each abuse in-service. All staff will be required to attend the monthly abuse in-services. Payroll Employee #1, the Office Manager, and Accounts Payable were in-serviced on the following revised policies and procedures by the ADON on 04/28/14: screening of potential employees, criminal record background checks, and reference checks on potential employees. Payroll Employee #1, the Office Manager, and Accounts Payable staff have reviewed all current employee files on the following to ensure current employees have no offences that would prevent them from working at this facility: Abuse Registry, Kentucky Court of Justice, local County Police Department, and the OIG Exclusion. The following policies and procedures have been revised by the DON and ADON: screening of potential employees, criminal record background checks, and reference checks on potential employees. The DON and Administrator have reviewed all employee files and signed off on them as of 04/29/14 indicating all current employees have no record that would prevent them from working at a long-term care facility. The facility QA team (DON, ADON, QA Nurse, MDS Coordinator, and Social Services/Activity Director) met with the Medical Director on 04/29/14 to review the circumstances of the allegation and all interventions which had been and will be implemented by the facility. The Administrator or his designee will be responsible for completing a thorough investigation of all allegations including the following: notifying appropriate State agencies timely, notifying residents' family and Physician timely, prevent further potential abuse, review the results of the investigation process and take any corrective action required such as retraining, disciplinary action, faxing information to agencies, and ensuring residents have been and are being protected. Members of the Abuse Committee will meet daily and review the following: all incident reports from the previous 24 hours, all investigations, all injuries of unknown origin, all allegations of misappropriation, and all other allegations. It will be the responsibility of the Abuse Committee to make the determination that an allegation is or is not substantiated. Members of the Abuse Committee will also be responsible for ensuring daily interviews are completed with five residents and five employees. Interviews were conducted with staff and residents seven days a week until the Immediate Jeopardy (IJ) was removed. Employee interviews were done on a random basis and included all shifts and all departments. After the IJ is removed, staff will continue to do staff and resident interviews weekly for six months to ensure all allegations are reported. A log will be maintained by the Abuse Committee to ensure five different residents and five different employees from different departments are interviewed daily. These interviews will be maintained in a log along with any allegations identified from the interviews. Investigations will be initiated immediately on any allegation identified from the interviews. All investigation information will also be maintained in the log. The information from these interviews will be reviewed daily by members of the Abuse Committee for any allegations and related investigations. It is the responsibility of the Abuse Committee to ensure all allegations are handled in a timely manner with all agencies being notified timely. The Continuous Quality Improvement (CQI) indicator for the monitoring of compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized (during and at the conclusion of the investigation) with each allegation of abuse for four weeks, then monthly for four months, and then quarterly thereafter under the supervision of the Administrator and DON. Results of each abuse allegation CQI indicator will be reviewed by the QA team as part of the daily meetings, Monday through Friday, to ensure all allegations were handled correctly. The results of these CQI indicators will also serve as ongoing information to see where the facility's weak areas are with the seven components of abuse and neglect and in-services will be conducted related to these areas. Daily oversight related to the findings of the completed CQI indicators will be reviewed by the contracted Nurse Consultant by e-mail to ensure all allegations are investigated and reported as indicated. Monthly visits to the facility will also be done by the Nurse Consultant. The facility's Abuse policies and procedures have been reviewed and revised by the DON, ADON, and Administrator. Information from the QA Committee and Abuse Committee will be given to the Administrator daily for his review. This information will include the following: all allegations of abuse, all abuse investigations and conclusions, QA findings, all allegations of misappropriation of property, all other allegations, and minutes from the QA Committee and Abuse Committee. It will be the Administrator's responsibility to oversee all aspects of this Allegation of Compliance. The following policies and procedures have been revised with most of the content being changed: resident Abuse Policy, QA Abuse Investigating Team, form for complaint of abuse, form for reporting misappropriation of property, reporting protocol, check list of initial investigation, Nurse's instructions for initial allegations, initial allegation of abuse and neglect form, policy on resident protection during abuse investigation, reporting on injury of unknown origin policy, missing items monitoring form, initial investigation of misappropriation of property, policy on misappropriation of resident's property, and complaint/grievance report form. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interview with the DON on 05/07/14 at 3:45 PM verified the allegation of abuse by Resident #7 had been reopened and SRNA #8 and LPN #2 had been suspended during the investigation. Interview on 05/07/14 at 2:45 PM with the Activity/Social Services Director revealed all alert and oriented residents with a Brief Interview for Mental Status (BIMS) score of 8 and above had been interviewed regarding abuse and staff treatment and no concerns related to physical abuse or neglect were identified. Interview on 05/07/14 with the DON at 3:45 PM and the Activity/Social Services Director at 2:45 PM revealed 13 residents had been identified during interview who reported missing money/items. Interview and review of the facility's Allegation of Compliance binder revealed the items/money had either been found or replaced and the appropriate State agencies had been notified. Interview with Licensed Practical Nurse (LPN) #4 on 05/07/14 at 2:23 PM, and LPN #5 on 05/07/14 at 2:38 PM revealed they completed skin assessments on residents with BIMS scores below 8. Interview revealed some of the residents assessed had bruising/skin tears; however, none of the areas observed were of a suspicious nature. Interview on 05/07/14 at 3:45 PM with the DON and review of the facility's Allegation of Compliance binder revealed during the skin assessments any areas identified on a resident were reviewed by the DON and investigations were initiated, even though they were not of a suspicious nature. Further review revealed the appropriate State agencies had been notified. Interview on 05/07/14 at 3:45 PM with the Director of Nursing (DON), the Quality Assurance Nurse at 2:15 PM, the Assistant Director of Nursing (ADON) at 2:00 PM, and the Minimum Data Set (MDS) Nurse at 1:45 PM revealed they were a part of the Abuse Committee and had met daily and reviewed all allegations of abuse as a team. The Committee reviewed all allegations from the beginning of 2013 until present to ensure they had been investigated, protection had been provided, and they were reported timely to the appropriate agencies. Further, the Committee only identified a problem with one, which was reopened and investigated and no concerns were identified so it was unsubstantiated. Interview on 05/07/14 with LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed they had been interviewed regarding any abuse which may not have been reported. All staff interviewed denied any further knowledge of abuse. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed they did receive in-service by the Nurse Consultant on 04/25/14 regarding regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. Further interview revealed they also received in-service on 05/01/14 on using the handouts provided at a seminar by the Office of Inspector General. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the QA Nurse at 2:07 PM, the DON at 3:45 PM, LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed in-service was conducted for all staff regarding all components of abuse. Further interview with the LPNs, SRNAs, and the DON revealed another in-service was held on 05/01/14 using the training, "Hand in Hand: A Training Series for Nursing Homes." The staff stated they did take a posttest after the in-service. Interview with Payroll Employee #1 on 05/07/14 at 1:00 PM revealed the facility had not hired any new employees since 05/03/14. Review of the facility's Allegation of Compliance binder and interview with the ADON on 05/07/14 at 2:00 PM revealed Payroll Employee #1, the Office Manager, and Accounts Payable staff had been in-serviced regarding revised policies/procedures regarding screening of potential employees, criminal record background checks, and reference checks on potential employees. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 at 1:50 PM with Payroll Employee #1 revealed all current employee files had been reviewed to ensure no current employee had an offence that would prevent them from working at a nursing facility. Interview with the DON on 05/07/14 at 3:45 PM and review of the following policy/procedures revealed they had been revised: screening of potential employees (revision date 04/25/14), criminal record background checks (revision date 04/25/14), and reference checks on potential employees (not dated). Interview with the DON on 05/07/14 at 3:45 PM revealed she and the Administrator had reviewed all current employee files. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed the QA team had met with the Medical Director on 04/29/14 to ensure he was aware of the Immediate Jeopardy (IJ) and the interventions which had been put in place by the facility. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM, who are members of the Abuse Committee, revealed the Committee had met daily and reviewed incident reports each day from the previous 24 hours, all investigations, all injuries of unknown origin, all allegations of misappropriation, and all other allegations. Further interview revealed the Committee was making the final decision on all investigations as to whether it was substantiated or not. Interview and review of the facility's Allegation of Compliance binder further revealed the Abuse Committee had been conducting five interviews daily with residents and staff regarding abuse and staff treatment of [REDACTED]. Interview further revealed the facility was utilizing the CQI tool for all allegations of abuse. Interview on 05/07/14 with the DON at 3:45 PM, and the QA Nurse at 2:07 PM revealed the QA team was meeting daily, Monday through Friday, and the CQI tool was being reviewed during the meeting. Policy review and interview with the DON on 05/07/14 at 3:45 PM revealed the facility's Abuse Policy and Procedure had been reviewed and revised. Interview on 05/07/14 with the DON at 3:45 PM revealed all information from the Abuse Committee and the QA Committee was given daily to the Administrator for his review. Policy review and interview on 05/07/14 at 3:45 PM with the DON revealed the following policy/procedures had been revised: resident Abuse Policy, QA Abuse Investigating Team, complaint of abuse form, form for reporting misappropriation of property, reporting protocol, check list of initial investigation, Nurse's instructions for initial allegations, initial allegation of abuse and neglect form, policy on resident protection during abuse investigation, reporting on injury of unknown origin policy, missing items monitoring form, initial investigation of misappropriation of property, policy on misappropriation of resident's property, and complaint/grievance report form.

Based on interview, record review, and review of policy/procedures it was determined the facility's Administration failed to ensure its resources, including policies related to abuse and neglect, were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) sampled residents (Resident #7). Interviews and review of the incident report (undated) revealed on 01/22/14, Resident #7 informed Registered Nurse #2 that "four" days prior to the date of the interview (01/18/14), Certified Nurse Aide (CNA) #8 hurt the resident when he provided incontinence care to him/her. Interview revealed Resident #7 alleged Certified Nurse Aide (CNA) #8 "broke" his/her "vagina" and hurt her/his legs. CNA #8 and CNA #7, who were also in the room, informed Licensed Practical Nurse (LPN) #2 of the resident's complaints. However, the LPN failed to follow the facility's policies and procedures on receipt of the resident's allegation and failed to ensure an investigation was initialed, failed to ensure that residents were protected during the facility's investigation, and failed to inform the Administrator of the resident's allegation. On 01/22/14, Resident #7 reported the allegation to Registered Nurse (RN) #3, and RN #3 informed RN #2 (who was responsible for abuse investigations) of the allegation. RN #2 interviewed Resident #7 on 01/22/14 and notified the Director of Nursing (DON) of the resident's allegation. The DON informed RN #2 to not allow CNA #8 to provide care to Resident #7; however, the facility did not restrict CNA #8 from providing direct care to other residents in the facility. Interviews and record review revealed Administration failed to ensure abuse policies and procedures were implemented. The facility failed to initiate an investigation of the allegation, failed to protect residents from further abuse, and failed to report the allegation of abuse immediately to State agencies when the allegation was reported to the LPN on 01/18/14 and the DON on 01/22/14. (Refer to F225 and F226.) The Administration's failure to ensure facility policies/procedures related to abuse prevention were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy was determined to exist on 01/18/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 04/24/14. A partial extended survey was conducted on 05/06-07/14. An acceptable Allegation of Compliance was received on 05/05/14 which alleged removal of the Immediate Jeopardy on 05/03/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/03/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F225 and F226.) The findings include: Review of the facility's policy, "Resident Abuse Policy," (not dated) revealed staff was to report all allegations of mistreatment, abuse, or misappropriation of resident property to the Administrator. According to the policy, the facility was to immediately report and thoroughly investigate all allegations of mistreatment, neglect, and abuse of residents, and allegations of misappropriation of resident property. The policy also revealed the Administrator, or his designee, would immediately notify the appropriate State agencies of the allegations. In addition, the policy revealed the facility would prevent further potential abuse during the investigation including the removal of alleged staff from the care of all residents. Interviews and record review revealed Resident #7 informed Certified Nurse Aide (CNA) #8 that he hurt the resident when he and CNA #7 provided incontinence care to the resident. CNA #7 and CNA #8 informed Licensed Practical Nurse (LPN) #2 of the resident's complaint when he and CNA #7 left the resident's room. However, LPN #2 failed to immediately report the allegation to the Administrator of the facility and/or State agencies, failed to initiate an investigation of the allegation, and failed to ensure residents were protected from further abuse during the course of an investigation. Although interview revealed Resident #7, LPN #2, CNA #8, and CNA #7 could not recall the exact date of the incident, interview on 04/24/14 at 5:50 PM with Registered Nurse (RN) #2 revealed she interviewed Resident #7 on 01/22/14 about the incident and the resident reported the incident occurred "four" days prior to the interview (01/18/14). Interview with RN #2 revealed she reported the abuse allegation to the Director of Nursing (DON). Interview with the DON on 04/24/14 at 5:05 PM revealed she advised staff that CNA #8 could continue to provide care to other facility residents, but the CNA would not be allowed to provide direct care to Resident #7. The DON stated she did not report the allegation to the Administrator of the facility and State agencies as required. In addition, the facility failed to take action to protect residents from further abuse/potential abuse until 04/24/14 (95 days after the incident) when the facility removed CNA #8 from direct patient care in the facility. Interview with the Administrator on 04/25/14 at 10:55 AM revealed he was not aware of the allegation of abuse by Resident #7 which occurred on 01/18/14 until 04/24/14. Further interview revealed LPN #2 "should" have informed "all of us" of the allegation made by Resident #7 at the time the resident reported the allegation. **The facility provided an acceptable Allegation of Compliance (AOC) on 05/05/14. The facility implemented the following actions to remove the Immediate Jeopardy: The allegation of abuse from 01/18/14 was reopened on 04/25/14 with all regulatory agencies being notified. All staff members alleged to be present during the 01/18/14 allegation including State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #2 were removed from the schedule and suspended pending the conclusion of this investigation. To ensure the safety of Resident #7, as well as all other residents residing at this facility, on 04/25/14 residents with a Brief Interview for Mental Status (BIMS) score of 8 and above were interviewed by the Activity/Social Services Director and/or Minimum Data Set (MDS) Coordinator to determine if any had failed to report an allegation of abuse, neglect, misappropriation, or exploitation. No reports of physical abuse were noted from these interviews. These interviews did identify 13 residents who reported missing items/money. Investigations were started immediately by members of the Abuse Committee. The appropriate State agencies were notified of these allegations on 04/28/14. Residents with a BIMS score below 8 had a head to toe skin assessment done on 04/25/14 by nurses. Ten residents were identified with bruises/areas of discoloration/scratches and scabs. These were reviewed by the Director of Nursing (DON) and Consulting Nurses on 04/27/14, and although none were of suspicious nature, investigations were started on 04/27/14 by the Quality Assurance (QA) Nurse and MDS Coordinators. The appropriate State agencies were notified on 04/28/14 by the MDS Coordinator. Investigations were concluded on 04/29/14 with all being unsubstantiated by the facility's QA Abuse Committee. On 05/01/14 and 05/02/14, the ten residents' investigations were reviewed again for possible causes of the injuries and what could be done to protect the resident from the reoccurrence of similar injuries. To ensure facility policy has been followed and the appropriate State agencies notified timely, members of the Abuse Committee, which are the DON, Social Services/Activity Director, MDS staff, QA Nurse, and Assistant Director of Nursing (ADON), reviewed on 05/01/14 all allegation reports from the year 2013 until present. The Abuse Committee reviewed daily all resident allegations, injuries of unknown origin, and any misappropriation of residents' property to ensure facility policy was followed and all notifications had been timely. All staff was interviewed by the ADON and the QA Nurse on 04/29/14 to determine if anyone had failed to report any allegations of abuse, neglect, misappropriation, or exploitation. There were no new allegations reported. The Nursing Home Administrator (NHA), DON, ADON, QA Nurse, Activity/Social Services Director, Resident Care Supervisor, MDS Coordinators, Medical Records Director, Data Compliance staff, and Office Assistant received in-service education by the Nurse Consultant on 04/25/14 regarding the regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. On 05/01/14, additional in-service was provided by the Nurse Consultant on using the handouts provided at a seminar given by the Office of Inspector General on 02/26/14. Staff was in-serviced by the QA Nurse and/or the DON on April 25, April 26, April 27, and April 29, 2014 on the following items: investigating abuse, neglect, misappropriation, when to investigate, reporting abuse, neglect, misappropriation, collecting statements for investigations, performing head to toe assessments on residents when allegations are made to ensure the resident has no injury, notifying the Administrator, DON, ADON, and appropriate State agencies, when to call 911 for on-call Social Worker, resident's physician, and responsible party, protecting residents by removal of accused immediately, and removing resident(s) immediately out of harm's way. In-service was held on 05/01/14 with all LPNs, SRNAs, Certified Medication Technicians (CMTs), office staff, kitchen staff, housekeeping staff, laundry staff, maintenance staff, and janitorial staff attending. In-service was given by the DON. Two employees were not present at either meeting and those two employees were in-serviced on 05/02/14 by the DON. Information for the in-service included the training manual, "Hand in Hand: A Training Series for Nursing Homes." The in-service covered the following listed areas: revised abuse policy, revised investigation form, types of abuse, how to report abuse, protection of resident, preventing abuse, what constitutes abuse, LPNs starting investigation (what to do), allegations of abuse, identifying abuse, screening potential employees, and revised reporting protocol for abuse. A posttest was given on 05/01/14 to all staff after each of the in-services on examples related to abuse issues. The two employees in-serviced on 05/02/14 were given the posttest also. Employees who did not score 100 percent on their test were rein-serviced at the time the posttest was reviewed by the DON. As an ongoing training program, all new hires will be required to go through the abuse training that will include the following: screening, training, prevention, identification, investigation, protection, and reporting/response. Information for these trainings will be taken from the manual, "Hand in Hand: A Training Series for Nursing Homes." After these in-services, the new employee will be required to take a posttest to ensure they understand all issues related to abuse. In-services on abuse will be done monthly for a period of six months. The monthly abuse in-services will be conducted by either the DON or her designated staff member. Posttests will be done after each abuse in-service. All staff will be required to attend the monthly abuse in-services. Payroll Employee #1, the Office Manager, and Accounts Payable were in-serviced on the following revised policies and procedures by the ADON on 04/28/14: screening of potential employees, criminal record background checks, and reference checks on potential employees. Payroll Employee #1, the Office Manager, and Accounts Payable staff have reviewed all current employee files on the following to ensure current employees have no offences that would prevent them from working at this facility: Abuse Registry, Kentucky Court of Justice, local County Police Department, and the OIG Exclusion. The following policies and procedures have been revised by the DON and ADON: screening of potential employees, criminal record background checks, and reference checks on potential employees. The DON and Administrator have reviewed all employee files and signed off on them as of 04/29/14 indicating all current employees have no record that would prevent them from working at a long-term care facility. The facility QA team (DON, ADON, QA Nurse, MDS Coordinator, and Social Services/Activity Director) met with the Medical Director on 04/29/14 to review the circumstances of the allegation and all interventions which had been and will be implemented by the facility. The Administrator or his designee will be responsible for completing a thorough investigation of all allegations including the following: notifying appropriate State agencies timely, notifying residents' family and Physician timely, prevent further potential abuse, review the results of the investigation process and take any corrective action required such as retraining, disciplinary action, faxing information to agencies, and ensuring residents have been and are being protected. Members of the Abuse Committee will meet daily and review the following: all incident reports from the previous 24 hours, all investigations, all injuries of unknown origin, all allegations of misappropriation, and all other allegations. It will be the responsibility of the Abuse Committee to make the determination that an allegation is or is not substantiated. Members of the Abuse Committee will also be responsible for ensuring daily interviews are completed with five residents and five employees. Interviews were conducted with staff and residents seven days a week until the Immediate Jeopardy (IJ) was removed. Employee interviews were done on a random basis and included all shifts and all departments. After the IJ is removed, staff will continue to do staff and resident interviews weekly for six months to ensure all allegations are reported. A log will be maintained by the Abuse Committee to ensure five different residents and five different employees from different departments are interviewed daily. These interviews will be maintained in a log along with any allegations identified from the interviews. Investigations will be initiated immediately on any allegation identified from the interviews. All investigation information will also be maintained in the log. The information from these interviews will be reviewed daily by members of the Abuse Committee for any allegations and related investigations. It is the responsibility of the Abuse Committee to ensure all allegations are handled in a timely manner with all agencies being notified timely. The Continuous Quality Improvement (CQI) indicator for the monitoring of compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized (during and at the conclusion of the investigation) with each allegation of abuse for four weeks, then monthly for four months, and then quarterly thereafter under the supervision of the Administrator and DON. Results of each abuse allegation CQI indicator will be reviewed by the QA team as part of the daily meetings, Monday through Friday, to ensure all allegations were handled correctly. The results of these CQI indicators will also serve as ongoing information to see where the facility's weak areas are with the seven components of abuse and neglect and in-services will be conducted related to these areas. Daily oversight related to the findings of the completed CQI indicators will be reviewed by the contracted Nurse Consultant by e-mail to ensure all allegations are investigated and reported as indicated. Monthly visits to the facility will also be done by the Nurse Consultant. The facility's Abuse policies and procedures have been reviewed and revised by the DON, ADON, and Administrator. Information from the QA Committee and Abuse Committee will be given to the Administrator daily for his review. This information will include the following: all allegations of abuse, all abuse investigations and conclusions, QA findings, all allegations of misappropriation of property, all other allegations, and minutes from the QA Committee and Abuse Committee. It will be the Administrator's responsibility to oversee all aspects of this Allegation of Compliance. The following policies and procedures have been revised with most of the content being changed: resident Abuse Policy, QA Abuse Investigating Team, form for complaint of abuse, form for reporting misappropriation of property, reporting protocol, check list of initial investigation, Nurse's instructions for initial allegations, initial allegation of abuse and neglect form, policy on resident protection during abuse investigation, reporting on injury of unknown origin policy, missing items monitoring form, initial investigation of misappropriation of property, policy on misappropriation of resident's property, and complaint/grievance report form. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interview with the DON on 05/07/14 at 3:45 PM verified the allegation of abuse by Resident #7 had been reopened and SRNA #8 and LPN #2 had been suspended during the investigation. Interview on 05/07/14 at 2:45 PM with the Activity/Social Services Director revealed all alert and oriented residents with a Brief Interview for Mental Status (BIMS) score of 8 and above had been interviewed regarding abuse and staff treatment and no concerns related to physical abuse or neglect were identified. Interview on 05/07/14 with the DON at 3:45 PM and the Activity/Social Services Director at 2:45 PM revealed 13 residents had been identified during interview who reported missing money/items. Interview and review of the facility's Allegation of Compliance binder revealed the items/money had either been found or replaced and the appropriate State agencies had been notified. Interview with Licensed Practical Nurse (LPN) #4 on 05/07/14 at 2:23 PM, and LPN #5 on 05/07/14 at 2:38 PM revealed they completed skin assessments on residents with BIMS scores below 8. Interview revealed some of the residents assessed had bruising/skin tears; however, none of the areas observed were of a suspicious nature. Interview on 05/07/14 at 3:45 PM with the DON and review of the facility's Allegation of Compliance binder revealed during the skin assessments any areas identified on a resident were reviewed by the DON and investigations were initiated, even though they were not of a suspicious nature. Further review revealed the appropriate State agencies had been notified. Interview on 05/07/14 at 3:45 PM with the Director of Nursing (DON), the Quality Assurance Nurse at 2:15 PM, the Assistant Director of Nursing (ADON) at 2:00 PM, and the Minimum Data Set (MDS) Nurse at 1:45 PM revealed they were a part of the Abuse Committee and had met daily and reviewed all allegations of abuse as a team. The Committee reviewed all allegations from the beginning of 2013 until present to ensure they had been investigated, protection had been provided, and they were reported timely to the appropriate agencies. Further, the Committee only identified a problem with one, which was reopened and investigated and no concerns were identified so it was unsubstantiated. Interview on 05/07/14 with LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed they had been interviewed regarding any abuse which may not have been reported. All staff interviewed denied any further knowledge of abuse. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed they did receive in-service by the Nurse Consultant on 04/25/14 regarding regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. Further interview revealed they also received in-service on 05/01/14 on using the handouts provided at a seminar by the Office of Inspector General. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the QA Nurse at 2:07 PM, the DON at 3:45 PM, LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed in-service was conducted for all staff regarding all components of abuse. Further interview with the LPNs, SRNAs, and the DON revealed another in-service was held on 05/01/14 using the training, "Hand in Hand: A Training Series for Nursing Homes." The staff stated they did take a posttest after the in-service. Interview with Payroll Employee #1 on 05/07/14 at 1:00 PM revealed the facility had not hired any new employees since 05/03/14. Review of the facility's Allegation of Compliance binder and interview with the ADON on 05/07/14 at 2:00 PM revealed Payroll Employee #1, the Office Manager, and Accounts Payable staff had been in-serviced regarding revised policies/procedures regarding screening of potential employees, criminal record background checks, and reference checks on potential employees. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 at 1:50 PM with Payroll Employee #1 revealed all current employee files had been reviewed to ensure no current employee had an offence that would prevent them from working at a nursing facility. Interview with the DON on 05/07/14 at 3:45 PM and review of the following policy/procedures revealed they had been revised: screening of potential employees (revision date 04/25/14), criminal record background checks (revision date 04/25/14), and reference checks on potential employees (not dated). Interview with the DON on 05/07/14 at 3:45 PM revealed she and the Administrator had reviewed all current employee files. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed the QA team had met with the Medical Director on 04/29/14 to ensure he was aware of the Immediate Jeopardy (IJ) and the interventions which had been put in place by the facility. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM, who are members of the Abuse Committee, revealed the Committee had met daily and reviewed incident reports each day from the previous 24 hours, all investigations, all injuries of unknown origin, all allegations of misappropriation, and all other allegations. Further interview revealed the Committee was making the final decision on all investigations as to whether it was substantiated or not. Interview and review of the facility's Allegation of Compliance binder further revealed the Abuse Committee had been conducting five interviews daily with residents and staff regarding abuse and staff treatment of [REDACTED]. Interview further revealed the facility was utilizing the CQI tool for all allegations of abuse. Interview on 05/07/14 with the DON at 3:45 PM, and the QA Nurse at 2:07 PM revealed the QA team was meeting daily, Monday through Friday, and the CQI tool was being reviewed during the meeting. Policy review and interview with the DON on 05/07/14 at 3:45 PM revealed the facility's Abuse Policy and Procedure had been reviewed and revised. Interview on 05/07/14 with the DON at 3:45 PM revealed all information from the Abuse Committee and the QA Committee was given daily to the Administrator for his review. Policy review and interview on 05/07/14 at 3:45 PM with the DON revealed the following policy/procedures had been revised: resident Abuse Policy, QA Abuse Investigating Team, complaint of abuse form, form for reporting misappropriation of property, reporting protocol, check list of initial investigation, Nurse's instructions for initial allegations, initial allegation of abuse and neglect form, policy on resident protection during abuse investigation, reporting on injury of unknown origin policy, missing items monitoring form, initial investigation of misappropriation of property, policy on misappropriation of resident's property, and complaint/grievance report form.

Based on interview, record review, review of the Incident Report, and review of the facility's policy and procedures, it was determined the facility failed to ensure allegations of resident abuse and misappropriation of resident property were reported immediately to the State Survey Agency and other officials in accordance with state law for three (3) of four (4) sampled residents (Residents #7, #5, and #6). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation. Interviews and record review revealed Resident #7 informed Certified Nurse Aides (CNAs) #7 and #8 that CNA #8 had hurt him/her when they provided incontinence care to him/her. CNAs #7 and #8 informed Licensed Practical Nurse (LPN) #2 of the resident's complaint when they (CNAs #7 and #8) left the resident's room. However, LPN #2 failed to immediately report the allegation to the Administrator and State agencies, failed to initiate an investigation of the allegation, and failed to ensure residents were protected from further abuse during the course of the investigation. Further review revealed Resident #7, LPN #2, CNA #8, and CNA #7 could not recall the exact date of the incident. Interview on 04/24/14 at 5:50 PM with Registered Nurse (RN) #2 revealed she interviewed Resident #7 on 01/22/14 about an incident Resident #7 had reported to RN #3. Interviews and review of the Incident Report revealed on 01/22/14, the resident informed RN #2 that four days prior (01/18/14) Certified Nurse Aide (CNA) #8 hurt him/her when he provided incontinence care to the resident. Interview with RN #2 revealed she reported the abuse allegation to the Director of Nursing (DON). Interview with the DON on 04/24/14 at 5:05 PM revealed that due to witnesses being present who denied that CNA #8 had intentionally hurt Resident #7 (on 01/18/14), she advised staff that CNA #8 could continue to provide care to other facility residents, but CNA #8 would not be allowed to provide direct care to Resident #7. The DON stated she did not report the allegation to the Administrator of the facility and State agencies as required. In addition, the facility failed to conduct interviews with additional staff and residents during the course of the facility's investigation, and failed to take action to protect residents from further abuse/potential abuse until 04/24/14 (95 days after the allegation of abuse) when the facility removed CNA #8 from direct patient care in the facility. Additionally, around 04/18/14 (exact date unknown) Resident #5 reported to facility staff that six dollars ($6.00) and a pair of pants were missing from his/her room; and on 02/04/14, Resident #6 reported that thirty-six dollars ($36.00) was missing from his/her room. Although the facility reimbursed Residents #5 and #6 for the reported missing monies, the facility failed to conduct an investigation or report the possible misappropriation of resident property to the appropriate State agencies as required. The facility's failure to immediately report all allegations of abuse, failure to protect residents during the course of an investigation of abuse, and failure to investigate an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 01/18/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 04/24/14. A partial extended survey was conducted on 05/06-07/14. An acceptable Allegation of Compliance was received on 05/05/14 which alleged removal of the Immediate Jeopardy on 05/03/14. The State Agency determined the Immediate Jeopardy was removed on 05/03/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, "Resident Abuse," (not dated) revealed the facility would immediately report, and thoroughly investigate, all allegations of mistreatment, neglect, abuse, and misappropriation of resident property. Further review revealed all alleged incidents involving mistreatment, abuse, or misappropriation of resident property were to be reported immediately to the Administrator. In addition, the policy revealed the Administrator, or his/her designee, would immediately notify the appropriate State agencies of the allegation. The policy also revealed the facility would prevent further potential abuse during the course of the investigation, including the removal of alleged staff from the care of all residents. 1. Review of Resident #7's medical record revealed the facility admitted the resident on 12/19/12 with [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. Review of a "Complaint of Abuse/Neglect" form, not dated and not signed, revealed on 01/22/14, Resident #7 reported to Registered Nurse (RN) #3 that CNA #8 had hurt him/her while providing incontinence care "four" days ago. Further review of the form revealed RN #3 informed RN #2 of the resident's allegations, and RN #2 completed an incident report and interviewed Resident #7. Continued review of the report revealed Resident #7 informed RN #2 that CNA #8 was "always rough" with him/her. The resident further stated he/she "told" the CNA he was hurting him/her and he started "laughing" and said "you are just being a timid (boy/girl)." Interview with Resident #7 on 04/24/14 at 10:30 AM revealed Certified Nurse Aide (CNA) #8 "hurt me." Resident #7 was unable to recall the exact date of the incident but stated CNA #8 intentionally caused pain by forcibly pulling his/her legs apart to provide incontinence care. The resident stated he/she told the CNA that he had caused pain to him/her and he/she was going to "tell" on him. Interview with CNA #8 on 04/24/14 at 4:17 PM acknowledged he and CNA #7 had provided incontinence care for Resident #7 when the resident said it hurt "down there," referring to the perineal area. CNA #8 stated he did not recall the exact date of the incident related to Resident #7, but he had informed LPN #2 that the resident had complained that he had hurt his/her legs when he left the resident's room. CNA #8 stated he provided incontinence care to Resident #7 the following night and the resident asked him to be careful with his/her legs because he had hurt them the night before. Interview with CNA #7 on 04/24/14 at 4:17 PM revealed he recalled Resident #7 had complained that CNA #8 had hurt him/her when the CNA "pulled" the resident's legs apart in order to provide incontinence care. Although CNA #7 stated he did not remember the exact date of the incident, he stated when they left the resident's room, he and CNA #8 informed LPN #2 of the statement Resident #7 had made when they had provided incontinence care. Interview with LPN #2 on 04/24/14 at 6:35 PM revealed CNA #8 reported to her that Resident #7 stated CNA #8 "broke" his/her "vagina"; however, LPN #2 could not recall the date of the report. LPN #2 further stated she went in Resident #7's room to assess the resident and did not "see anything broken." She stated the resident informed her CNA #8 "broke" his/her "vagina" and the resident was going to "tell" his/her spouse. LPN #2 stated she "think(s)" she "documented" the incident in the Nursing Notes of the resident's medical record at the time the CNA reported the incident to her. However, LPN #2 stated because there had been a "witness" in the room at the time of the incident, she did not "think" of the incident as abuse and did not remove the alleged perpetrator from direct resident care; she did not initiate an investigation of the incident, and did not report the resident's allegation to anyone. Review of Nursing Notes in Resident #7's medical record for January 2014 (the month the incident occurred based on documentation in the incident report) revealed no documentation the resident had made any complaints related to a "broke vagina" or of an incident that involved CNA #8. Interview with RN #2 on 04/25/14 at 11:15 AM revealed she spoke to Resident #7 on 01/22/14 about his/her allegation. According to RN #2, Resident #7 believed that CNA #8 had intentionally hurt him/her while providing incontinence care on 01/18/14. RN #2 stated she contacted the Director of Nursing (DON) by telephone and reported the resident's allegation. RN #2 revealed at that time CNA #8 was in the facility and she was instructed by the DON to inform CNA #8 not to provide care to Resident #7, but CNA #8 could continue to provide direct care to all other residents in the facility. RN #2 stated that she talked to three residents CNA #8 had provided care to on 01/18/14, and none of the residents had complaints. RN #2 also stated no further investigation was conducted at that time and the allegation was not reported to the Administrator or other State Agencies, as required. According to RN #2 she had the responsibility to complete abuse investigations in the facility and was aware of the reporting requirements, but ultimately all decisions regarding reporting and disciplinary action were made by the Administrator and/or DON. Interview with the DON/Co-Owner on 04/24/14, at 5:05 PM revealed that because CNA #8 had denied intentionally harming Resident #8 when he provided incontinence care to the resident, and there had been a witness in the room who also denied CNA #8 had intentionally harmed the resident, she did not feel the allegation warranted further investigation. Interview with the Administrator/Co-Owner on 04/25/14, at 10:55 AM revealed that he or the DON made decisions regarding abuse investigations. The Administrator stated to the "best" of his "recollection" he was not informed of Resident #7's allegation of abuse made on 01/18/14, until 04/24/14, 95 days after the resident voiced the allegation. 2. Review of Resident #5's medical record revealed the facility admitted the resident on 01/05/13. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #5 to have a Brief Interview Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact with no memory deficits. Interview with Resident #5 on 04/23/14, at 10:15 AM revealed he/she had "been robbed" about a month ago (exact date unknown). Resident #5 stated six dollars ($6.00) had been taken out of a drawer in his/her room during the night. Resident #5 stated he/she had reported to the "boss" that the money was missing and the facility reimbursed him/her the six dollars ($6.00). Additionally, Resident #5 stated "two to three days ago" (exact date unknown) a pair of pants had also disappeared from his/her room. Interview on 04/23/14, at 2:50 PM with the Social Services Director/Activity Director (SSD/AD) revealed she generally took care of missing money or items. The SSD/AD stated when a resident reported they had missing money or items, she would replace the money and/or items. The SSD/AD stated at times the Administrator or DON may be aware of the missing items, but that no formal reporting system was in place for "small" amounts of money or "inexpensive" items. The SSD/AD stated that if a "large" amount of money or an "expensive" item was reported missing, Administrative staff would be notified and an investigation initiated. However, the SSD/AD was unable to state how or who in the facility made the decision on what would be considered "large" and what warranted an investigation or was to be reported to Administration. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 08/30/13. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #6 to have a BIMS score of 15, which indicated the resident's cognition was intact with no memory deficits. Review of a facility file containing written statements revealed on 02/03/14, Resident #6 reported to facility staff that thirty-six dollars ($36.00) had been "stolen" from him/her. The staff reported the allegation made by Resident #6 to the nurse caring for the resident at the time. Interview on 04/25/14 at 11:30 AM revealed LPN #5 was notified on 02/03/14 that Resident #6 reported money had been stolen from him/her. LPN #5 stated she spoke to Resident #6 about the missing money and searched the resident's room but was unable to locate the money. LPN #5 stated she wrote a statement detailing the events of the incident, but took no further action to initiate an investigation or notify facility Administration about Resident #6's allegations that money had been stolen. LPN #5 stated the routine procedure in the facility was to notify an Activities staff member of any missing money reported by residents. LPN #5 stated she informed the Activity Assistant on 02/04/14 that Resident #6 reported he/she had thirty-six dollars ($36.00) missing. Interview on 04/24/14 at 3:25 PM with the Activity Assistant revealed she was informed on 02/04/14 that Resident #6 alleged thirty-six dollars ($36.00) had been "stolen" from him/her. The Activity Assistant stated she spoke with Resident #6 about the money and then reimbursed the resident thirty-six dollars ($36.00) from facility funds. The Activity Assistant stated since she had reimbursed Resident #6 for the missing money the allegation was not reported to the Administrator or other officials. The Activity Assistant stated if anyone reported a "large" amount of money was missing, she would notify facility Administration. However, the Activity Assistant was unable to define what specifically constituted a "large" amount of money, or what specific circumstances would prompt notification of Administration. Interview with the DON on 04/24/14, at 5:05 PM revealed when a resident reported missing money or an item, the facility staff would initiate a search for the item, and if it was not located the item or money was replaced by the facility. The DON confirmed the facility did not investigate when a resident reported a small amount of money or inexpensive item missing. The DON also acknowledged facility staff did not always inform her of all items that residents alleged to be missing. She stated the facility did not have a system in place to track or trend missing items in an attempt to determine if there was a pattern of when the incidents occurred, or to identify staff that had worked at the time the incidents had reportedly occurred. **The facility provided an acceptable Allegation of Compliance (AOC) on 05/05/14. The facility implemented the following actions to remove the Immediate Jeopardy: The allegation of abuse from 01/18/14 was reopened on 04/25/14 with all regulatory agencies being notified. All staff members alleged to be present during the 01/18/14 allegation including State Registered Nurse Aide (SRNA) #8 and Licensed Practical Nurse (LPN) #2 were removed from the schedule and suspended pending the conclusion of this investigation. To ensure the safety of Resident #7, as well as all other residents residing at this facility, on 04/25/14 residents with a Brief Interview for Mental Status (BIMS) score of 8 and above were interviewed by the Activity/Social Services Director and/or Minimum Data Set (MDS) Coordinator to determine if any had failed to report an allegation of abuse, neglect, misappropriation, or exploitation. No reports of physical abuse were noted from these interviews. These interviews did identify 13 residents who reported missing items/money. Investigations were started immediately by members of the Abuse Committee. The appropriate State agencies were notified of these allegations on 04/28/14. Residents with a BIMS score below 8 had a head to toe skin assessment done on 04/25/14 by nurses. Ten residents were identified with bruises/areas of discoloration/scratches and scabs. These were reviewed by the Director of Nursing (DON) and Consulting Nurses on 04/27/14, and although none were of suspicious nature, investigations were started on 04/27/14 by the Quality Assurance (QA) Nurse and MDS Coordinators. The appropriate State agencies were notified on 04/28/14 by the MDS Coordinator. Investigations were concluded on 04/29/14 with all being unsubstantiated by the facility's QA Abuse Committee. On 05/01/14 and 05/02/14, the ten residents' investigations were reviewed again for possible causes of the injuries and what could be done to protect the resident from the reoccurrence of similar injuries. To ensure facility policy has been followed and the appropriate State agencies notified timely, members of the Abuse Committee, which are the DON, Social Services/Activity Director, MDS staff, QA Nurse, and Assistant Director of Nursing (ADON), reviewed on 05/01/14 all allegation reports from the year 2013 until present. The Abuse Committee reviewed daily all resident allegations, injuries of unknown origin, and any misappropriation of residents' property to ensure facility policy was followed and all notifications had been timely. All staff was interviewed by the ADON and the QA Nurse on 04/29/14 to determine if anyone had failed to report any allegations of abuse, neglect, misappropriation, or exploitation. There were no new allegations reported. The Nursing Home Administrator (NHA), DON, ADON, QA Nurse, Activity/Social Services Director, Resident Care Supervisor, MDS Coordinators, Medical Records Director, Data Compliance staff, and Office Assistant received in-service education by the Nurse Consultant on 04/25/14 regarding the regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. On 05/01/14, additional in-service was provided by the Nurse Consultant on using the handouts provided at a seminar given by the Office of Inspector General on 02/26/14. Staff was in-serviced by the QA Nurse and/or the DON on April 25, April 26, April 27, and April 29, 2014 on the following items: investigating abuse, neglect, misappropriation, when to investigate, reporting abuse, neglect, misappropriation, collecting statements for investigations, performing head to toe assessments on residents when allegations are made to ensure the resident has no injury, notifying the Administrator, DON, ADON, and appropriate State agencies, when to call 911 for on-call Social Worker, resident's physician, and responsible party, protecting residents by removal of accused immediately, and removing resident(s) immediately out of harm's way. In-service was held on 05/01/14 with all LPNs, SRNAs, Certified Medication Technicians (CMTs), office staff, kitchen staff, housekeeping staff, laundry staff, maintenance staff, and janitorial staff attending. In-service was given by the DON. Two employees were not present at either meeting and those two employees were in-serviced on 05/02/14 by the DON. Information for the in-service included the training manual, "Hand in Hand: A Training Series for Nursing Homes." The in-service covered the following listed areas: revised abuse policy, revised investigation form, types of abuse, how to report abuse, protection of resident, preventing abuse, what constitutes abuse, LPNs starting investigation (what to do), allegations of abuse, identifying abuse, screening potential employees, and revised reporting protocol for abuse. A posttest was given on 05/01/14 to all staff after each of the in-services on examples related to abuse issues. The two employees in-serviced on 05/02/14 were given the posttest also. Employees who did not score 100 percent on their test were rein-serviced at the time the posttest was reviewed by the DON. As an ongoing training program, all new hires will be required to go through the abuse training that will include the following: screening, training, prevention, identification, investigation, protection, and reporting/response. Information for these trainings will be taken from the manual, "Hand in Hand: A Training Series for Nursing Homes." After these in-services, the new employee will be required to take a posttest to ensure they understand all issues related to abuse. In-services on abuse will be done monthly for a period of six months. The monthly abuse in-services will be conducted by either the DON or her designated staff member. Posttests will be done after each abuse in-service. All staff will be required to attend the monthly abuse in-services. Payroll Employee #1, the Office Manager, and Accounts Payable were in-serviced on the following revised policies and procedures by the ADON on 04/28/14: screening of potential employees, criminal record background checks, and reference checks on potential employees. Payroll Employee #1, the Office Manager, and Accounts Payable staff have reviewed all current employee files on the following to ensure current employees have no offences that would prevent them from working at this facility: Abuse Registry, Kentucky Court of Justice, local County Police Department, and the OIG Exclusion. The following policies and procedures have been revised by the DON and ADON: screening of potential employees, criminal record background checks, and reference checks on potential employees. The DON and Administrator have reviewed all employee files and signed off on them as of 04/29/14 indicating all current employees have no record that would prevent them from working at a long-term care facility. The facility QA team (DON, ADON, QA Nurse, MDS Coordinator, and Social Services/Activity Director) met with the Medical Director on 04/29/14 to review the circumstances of the allegation and all interventions which had been and will be implemented by the facility. The Administrator or his designee will be responsible for completing a thorough investigation of all allegations including the following: notifying appropriate State agencies timely, notifying residents' family and Physician timely, prevent further potential abuse, review the results of the investigation process and take any corrective action required such as retraining, disciplinary action, faxing information to agencies, and ensuring residents have been and are being protected. Members of the Abuse Committee will meet daily and review the following: all incident reports from the previous 24 hours, all investigations, all injuries of unknown origin, all allegations of misappropriation, and all other allegations. It will be the responsibility of the Abuse Committee to make the determination that an allegation is or is not substantiated. Members of the Abuse Committee will also be responsible for ensuring daily interviews are completed with five residents and five employees. Interviews were conducted with staff and residents seven days a week until the Immediate Jeopardy (IJ) was removed. Employee interviews were done on a random basis and included all shifts and all departments. After the IJ is removed, staff will continue to do staff and resident interviews weekly for six months to ensure all allegations are reported. A log will be maintained by the Abuse Committee to ensure five different residents and five different employees from different departments are interviewed daily. These interviews will be maintained in a log along with any allegations identified from the interviews. Investigations will be initiated immediately on any allegation identified from the interviews. All investigation information will also be maintained in the log. The information from these interviews will be reviewed daily by members of the Abuse Committee for any allegations and related investigations. It is the responsibility of the Abuse Committee to ensure all allegations are handled in a timely manner with all agencies being notified timely. The Continuous Quality Improvement (CQI) indicator for the monitoring of compliance with the components of the abuse regulation, including but not limited to investigating and reporting of abuse, will be utilized (during and at the conclusion of the investigation) with each allegation of abuse for four weeks, then monthly for four months, and then quarterly thereafter under the supervision of the Administrator and DON. Results of each abuse allegation CQI indicator will be reviewed by the QA team as part of the daily meetings, Monday through Friday, to ensure all allegations were handled correctly. The results of these CQI indicators will also serve as ongoing information to see where the facility's weak areas are with the seven components of abuse and neglect and in-services will be conducted related to these areas. Daily oversight related to the findings of the completed CQI indicators will be reviewed by the contracted Nurse Consultant by e-mail to ensure all allegations are investigated and reported as indicated. Monthly visits to the facility will also be done by the Nurse Consultant. The facility's Abuse policies and procedures have been reviewed and revised by the DON, ADON, and Administrator. Information from the QA Committee and Abuse Committee will be given to the Administrator daily for his review. This information will include the following: all allegations of abuse, all abuse investigations and conclusions, QA findings, all allegations of misappropriation of property, all other allegations, and minutes from the QA Committee and Abuse Committee. It will be the Administrator's responsibility to oversee all aspects of this Allegation of Compliance. The following policies and procedures have been revised with most of the content being changed: resident Abuse Policy, QA Abuse Investigating Team, form for complaint of abuse, form for reporting misappropriation of property, reporting protocol, check list of initial investigation, Nurse's instructions for initial allegations, initial allegation of abuse and neglect form, policy on resident protection during abuse investigation, reporting on injury of unknown origin policy, missing items monitoring form, initial investigation of misappropriation of property, policy on misappropriation of resident's property, and complaint/grievance report form. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interview with the DON on 05/07/14 at 3:45 PM verified the allegation of abuse by Resident #7 had been reopened and SRNA #8 and LPN #2 had been suspended during the investigation. Interview on 05/07/14 at 2:45 PM with the Activity/Social Services Director revealed all alert and oriented residents with a Brief Interview for Mental Status (BIMS) score of 8 and above had been interviewed regarding abuse and staff treatment and no concerns related to physical abuse or neglect were identified. Interview on 05/07/14 with the DON at 3:45 PM and the Activity/Social Services Director at 2:45 PM revealed 13 residents had been identified during interview who reported missing money/items. Interview and review of the facility's Allegation of Compliance binder revealed the items/money had either been found or replaced and the appropriate State agencies had been notified. Interview with Licensed Practical Nurse (LPN) #4 on 05/07/14 at 2:23 PM, and LPN #5 on 05/07/14 at 2:38 PM revealed they completed skin assessments on residents with BIMS scores below 8. Interview revealed some of the residents assessed had bruising/skin tears; however, none of the areas observed were of a suspicious nature. Interview on 05/07/14 at 3:45 PM with the DON and review of the facility's Allegation of Compliance binder revealed during the skin assessments any areas identified on a resident were reviewed by the DON and investigations were initiated, even though they were not of a suspicious nature. Further review revealed the appropriate State agencies had been notified. Interview on 05/07/14 at 3:45 PM with the Director of Nursing (DON), the Quality Assurance Nurse at 2:15 PM, the Assistant Director of Nursing (ADON) at 2:00 PM, and the Minimum Data Set (MDS) Nurse at 1:45 PM revealed they were a part of the Abuse Committee and had met daily and reviewed all allegations of abuse as a team. The Committee reviewed all allegations from the beginning of 2013 until present to ensure they had been investigated, protection had been provided, and they were reported timely to the appropriate agencies. Further, the Committee only identified a problem with one, which was reopened and investigated and no concerns were identified so it was unsubstantiated. Interview on 05/07/14 with LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed they had been interviewed regarding any abuse which may not have been reported. All staff interviewed denied any further knowledge of abuse. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed they did receive in-service by the Nurse Consultant on 04/25/14 regarding regulatory requirements on reporting, investigation, and protection of residents with all allegations of abuse, neglect, misappropriation, and exploitation. Further interview revealed they also received in-service on 05/01/14 on using the handouts provided at a seminar by the Office of Inspector General. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 with the QA Nurse at 2:07 PM, the DON at 3:45 PM, LPN #4 at 2:43 PM, LPN #6 at 2:38 PM, SRNA #16 at 3:00 PM, and SRNA #15 at 3:10 PM revealed in-service was conducted for all staff regarding all components of abuse. Further interview with the LPNs, SRNAs, and the DON revealed another in-service was held on 05/01/14 using the training, "Hand in Hand: A Training Series for Nursing Homes." The staff stated they did take a posttest after the in-service. Interview with Payroll Employee #1 on 05/07/14 at 1:00 PM revealed the facility had not hired any new employees since 05/03/14. Review of the facility's Allegation of Compliance binder and interview with the ADON on 05/07/14 at 2:00 PM revealed Payroll Employee #1, the Office Manager, and Accounts Payable staff had been in-serviced regarding revised policies/procedures regarding screening of potential employees, criminal record background checks, and reference checks on potential employees. Review of the facility's Allegation of Compliance binder and interview on 05/07/14 at 1:50 PM with Payroll Employee #1 revealed all current employee files had been reviewed to ensure no current employee had an offence that would prevent them from working at a nursing facility. Interview with the DON on 05/07/14 at 3:45 PM and review of the following policy/procedures revealed they had been revised: screening of potential employees (revision date 04/25/14), criminal record background checks (revision date 04/25/14), and reference checks on potential employees (not dated). Interview with the DON on 05/07/14 at 3:45 PM revealed she and the Administrator had reviewed all current employee files. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM revealed the QA team had met with the Medical Director on 04/29/14 to ensure he was aware of the Immediate Jeopardy (IJ) and the interventions which had been put in place by the facility. Interview on 05/07/14 with the DON at 3:45 PM, the ADON at 2:00 PM, the QA Nurse at 2:07 PM, and the Activity/Social Services Director at 2:45 PM, who are members of the Abuse Committee, revealed the Committee had met daily and reviewed incident reports each day from the previous 24 hours, all investigations, all injuries of unknown origin, all allegati

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure two of fourteen sampled residents (Residents #9 and #4) with indwelling urinary catheters received care to prevent complications. A review of Resident #9 and Resident #4's admission and quarterly Minimum Data Set (MDS) assessments revealed staff failed to assess risk factors associated with urinary catheter usage and failed to assess the skin condition of the residents' penis. In addition, the facility failed to develop a care plan with interventions that addressed complications/risk factors related to the resident's urinary catheter and failed to develop interventions to ensure the urinary catheter tubing was secured to prevent pulling/pressure as required per the facility's policy. In addition, the facility failed to assess Resident #4's behavior of pulling at/pulling out his urinary catheter and failed to develop interventions to address this behavior. A review of Resident #9's medical record, including the care plan, revealed the resident had the urinary catheter at the time of admission (02/12/13). Observations conducted on 08/22/13 of urinary catheter care revealed Resident #9's penis was swollen and torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis, approximately 3.5 centimeters. Review of Resident #9's medical record, including the care plan, revealed the resident had the urinary catheter at the time of admission (02/12/13). Observations conducted on 08/22/13 of urinary catheter care revealed Resident #4's penis was torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the underside of the shaft of the resident's penis, approximately 4 centimeters. (Refer to F272 and F279.) The findings include: Review of the facility's policy entitled "Foley Catheter Care," not dated, revealed a resident's catheter tubing should be secured to the bottom bed linens. Further review of the policy revealed staff was not to pull or tug on the catheter. However, the policy failed to address how the indwelling urinary catheters were to be secured to prevent excessive tension on the catheter, which could lead to urethral tears or dislodging of the catheter. Review of Resident Assessment Instrument (RAI) User Manual Version 3.0 revealed, "The assessment should include consideration of the risks and benefits of an indwelling (suprapubic or urethral) catheter...and consideration of complications resulting from the use of an indwelling catheter (e.g., urethral erosion, pain, discomfort, and bleeding). The next step is to develop an individualized care plan based directly on these conclusions." 1. Review of Resident #9's medical record revealed the facility admitted the resident on 02/12/13, with [DIAGNOSES REDACTED]. Review of Resident #9's most recent Minimum Data Set (MDS) assessment dated [DATE], and the admission MDS assessment dated [DATE], revealed the facility assessed the resident as being alert and oriented, with a BIMS (Brief Interview for Mental Status) score of 15, which indicated no cognitive impairment. According to the MDS assessments, Resident #9 had a urinary catheter and required extensive assistance from staff with transferring, dressing, hygiene/bathing, and toilet use (which includes managing a catheter). Review of Resident #9's care plan initially dated 02/12/13, and updated on 07/02/13, revealed staff was required to provide routine catheter care for Resident #9. However, the care plan failed to address interventions to prevent complications from the urinary catheter and failed to develop interventions to direct staff to secure the resident's indwelling urinary catheter tubing to prevent pulling. Observations conducted on 08/22/13 at 10:40 AM, of Foley catheter care for Resident #9 revealed the resident's penis was torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis (measured 3.5 centimeters). The resident was turned onto his side and facility staff failed to secure the resident's Foley catheter while care was provided. The resident was observed to have facial grimacing while staff provided care to the resident. Interview with Certified Nurse Aide (CNA) #1 on 08/22/13 at 11:00 AM, revealed the CNA acknowledged she had not secured the resident's catheter when care was provided and stated she had never been trained to secure urinary catheters since employed at the facility. However, the CNA stated it would decrease the resident's discomfort if the catheter was secured. An interview with Resident #9 on 08/22/13 at 12:40 PM, revealed the resident stated, "My penis was not torn when I came here." The resident stated staff had "ripped it by pulling it so much." The resident stated his genitals burned and were painful when care was provided by facility staff. The resident stated staff had been told that it hurt when care was provided, but nothing had been done to keep the catheter from being pulled when care was provided. An interview with Licensed Practical Nurse (LPN) #1 on 08/22/13 at 2:40 PM, revealed she was assigned to provide care to Resident #9 on 08/22/13. According to LPN #1, the resident's penis had been swollen and split/torn since admission to the facility. However, she stated interventions had not been implemented to prevent the resident's indwelling Foley catheter tubing from being pulled. The LPN stated a thorough assessment should have been conducted and interventions should have been implemented to prevent the resident's Foley catheter from being pulled. An interview with the MDS Coordinator on 08/22/13 at 4:50 PM, revealed she acknowledged an assessment, which included consideration of the risks and benefits of an indwelling catheter and consideration of complications which could result from the use of an indwelling catheter (e.g., urethral erosion, pain, discomfort, and bleeding), had not been conducted for Resident #9. The MDS Coordinator stated a thorough assessment and interventions should have been implemented for the resident related to the indwelling catheter. An interview with the Director of Nursing (DON) on 08/22/13 at 5:30 PM, confirmed the facility policy failed to address how indwelling urinary catheters were to be secured to prevent excessive tension on the catheter, which could lead to urethral tears or dislodging of the catheter. Further interview revealed Resident #9 should have been accurately assessed and interventions should have been implemented related to the resident's indwelling urinary catheter. 2. Observation of urinary catheter care for Resident #4 on 08/22/13 at 9:50 AM, conducted by CNA #2, revealed Resident #4's penis was torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis (measured 4 centimeters). Further observation revealed the resident's urinary catheter was not secured and the catheter tubing was routed out the leg of the resident's pants. The resident was transferred to a wheelchair and the catheter bag was covered and attached to the frame of the wheelchair under the seat. An interview conducted with CNA #2 on 08/22/13 at 9:50 AM, revealed the CNA had not been trained to secure the resident's catheter and did not have a means of securing the resident's catheter to prevent pulling or further tearing of the penis. In addition, CNA #2 stated the resident's penis was torn when the resident was admitted to the facility. A review of the medical record for Resident #4 revealed the facility admitted the resident on 01/16/13, with [DIAGNOSES REDACTED]. A review of the admission assessment, admission MDS assessment completed on 01/16/13, and quarterly MDS assessments completed on 04/18/13 and 07/12/13, revealed Resident #4 utilized a urinary catheter; however, according to the assessments, there was no evidence the resident had any tears or damage to the penis. Further record review revealed Resident #4 exhibited behaviors and pulled out the urinary catheter on 01/17/13. According to the record, the urinary catheter was reinserted the same day with no evidence of tears or damage to the penis documented. According to the nurse's notes, the resident was noted to have a small, red tear to the urethral opening with a small spot of red around the urinary catheter on 02/24/13. Review of the treatment sheets revealed the area had resolved on 03/07/13. Additional review of weekly skin assessments and nurse's notes for Resident #4 since admission revealed no evidence of any other additional tears/damage to the resident's penis. A review of the plan of care developed when the facility admitted Resident #4 on 01/16/13 and updated on 4/23/13 and 7/12/13, revealed no interventions to secure the resident's catheter to prevent pulling of the catheter tubing to prevent or reduce the risk of injury to the penis. An interview conducted with LPN #1 on 08/22/13 at 10:47 PM, revealed the facility did secure some residents' urinary catheters but not Resident #4's because the resident was allergic to tape. According to LPN #1, the resident's penis was torn before the resident was admitted to the facility. An interview with the MDS Nurse conducted on 8/22/13 at 5:00 PM, revealed the MDS Nurse was not aware of the tear/damage to the resident's penis and had not developed care plan interventions to secure the catheter for Resident #4 to prevent additional tears/damage and was not aware of behavior of pulling and did not assess risk factors or consider risks when developing the care plan.

Based on observation, interview, and record review it was determined the facility failed to initially and periodically conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for two of fourteen sampled residents (Residents #4 and #9). The facility failed to assess Residents #4 and #9 and consider the risk factors of having an indwelling urinary catheter, including urethral erosion (wearing away of the canal through which urine flows from the bladder resulting in a split/tear in the penis), pain, and discomfort. Observations of urinary catheter care conducted on 08/22/13 revealed Resident #9's penis was swollen and torn/split from the urinary meatus (the opening in the penis from which urine flows) down the shaft of the resident's penis. The resident experienced pain when care was provided. In addition, observations of Resident #4 revealed the resident had a tear of the penis extending from the end of the penis down the shaft of the penis a length of 4 centimeters. Interview with facility staff revealed the resident had pulled out the catheter in the past and at times tugged on the catheter tubing. The facility failed to assess the tear to the penis of Residents #9 and #4. In addition, the facility failed to assess Resident #4's risk for penile tears related to behavior of pulling out the catheter and physical functioning of being up in the wheelchair and moving about the facility. (Refer to F279 and F315.) The findings include: Review of the facility's policy entitled "Foley Catheter Care," not dated, revealed a resident's catheter tubing should be secured to the bottom bed linens and staff was not to pull or tug on the catheter. Review of a facility policy with no title or date noted, revealed staff was to conduct skin assessments upon admission and then weekly. Staff was to assess for red areas, pain, or swelling. If abnormalities were identified, staff was to assess the resident's needs at that time. Further review of the policy revealed it was the responsibility of the treatment nurse to monitor all skin problems to include abrasions, redness, and tears. Review of the Resident Assessment Instrument (RAI) User Manual Version 3.0 revealed, "The assessment should include consideration of the risks and benefits of an indwelling (suprapubic or urethral) catheter...and consideration of complications resulting from the use of an indwelling catheter (e.g., urethral erosion, pain, discomfort, and bleeding)." 1. Review of the medical record for Resident #9 revealed the facility admitted the resident on 02/12/13. The resident's admitting [DIAGNOSES REDACTED]. A review of the resident's admission comprehensive (RAI) assessment dated [DATE] revealed facility staff identified that the resident had a urinary catheter. However, the resident's assessment provided no evidence the facility assessed Resident #9 and considered the risk factors of the indwelling urinary catheter (urethral erosion, pain, and discomfort). According to the 02/18/13 assessment, Resident #9 did not have a penile tear/erosion. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 continued to utilize a urinary catheter; however, there was no evidence Resident #9 had a penile tear/erosion. Further review of the MDS assessment revealed the resident required extensive assistance with bed mobility, bathing, and incontinence care, and was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. A review on 08/22/13, of Resident #9's medical record revealed licensed staff had conducted a head-to-toe skin assessment when the facility admitted the resident on 02/12/13. The resident's admission skin assessment provided no evidence the resident had a penile tear or penile [MEDICAL CONDITION]. Further review of the record revealed staff had conducted Resident #9's skin assessments weekly since admission, with the last skin assessment conducted on 08/22/13. According to the weekly skin assessments, Resident #9 did not have any torn/split areas to the penis. Staff documented on 08/22/13 at 12:01 PM, that the resident had "no areas noted." Observations conducted of urinary catheter care for Resident #9 on 08/22/13 at 10:40 AM, revealed the resident's penis was torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis. The resident was observed to have facial grimacing while care was provided by facility staff and when the resident was turned onto his side. There was no evidence Resident #9's catheter was secured to prevent pulling/relieve pressure of the catheter tubing. Interview with Resident #9 on 08/22/13 at 12:40 PM, revealed the resident's penis was not torn when the facility admitted the resident (was unable to recall when the tear occurred after admission). The resident stated, "They (staff) have ripped and pulled on my catheter so much here." The resident stated his genitals burned and were painful when facility staff provided care. The resident continued to state that he told staff that it hurt when staff provided care; however, the resident stated, "They won't do anything to keep it from pulling." Interview with Licensed Practical Nurse (LPN) #1 on 08/22/13 at 1:15 PM, revealed she had conducted the skin assessment for Resident #9 at 12:01 PM on 08/22/13 (same day observations of catheter care were conducted), and documented that the resident had no skin problems. The LPN acknowledged the resident had swelling and a penile tear; however, she stated she had not documented the abnormalities because this was not a change for this resident. She continued to state that she should have documented an accurate assessment of the resident's skin integrity. Continued interview with the LPN revealed she had conducted the admission assessment for Resident #9 on 02/18/13. LPN #1 stated the resident's penis was torn and swollen upon admission; however, the LPN stated she had not documented an accurate assessment at the time of admission. An interview with the Director of Nursing on 08/22/13 at 5:30 PM, revealed staff was required to conduct and document an accurate skin assessment upon admission and weekly for facility residents. The DON stated she was not aware of the [MEDICAL CONDITION] and penile tear to Resident #9. She continued to state staff should have documented an accurate, thorough assessment of Resident #9's skin. An interview with the MDS Coordinator on 08/22/13 at 4:50 PM, revealed she did not conduct a skin assessment of residents when completing an MDS assessment, but coded the assessment information based on facility staff documentation. The MDS Coordinator stated she was not aware of the [MEDICAL CONDITION] or penile tear to Resident #9's penis. She acknowledged staff should have documented that the resident's penis was torn/split when staff conducted the weekly skin assessments. She stated Resident #9 had not had a comprehensive, accurate MDS assessment due to the facility failure to ensure skin assessments were accurate. 2. Record review conducted for Resident #4 revealed the facility admitted the resident on 01/16/13, with [DIAGNOSES REDACTED]. Review of the new admission information and the admission assessment completed on 01/16/13 revealed the facility admitted Resident #4 with a urinary catheter. According to the assessment there was no evidence the resident had any tears or problems of the penis related to the urinary catheter. Further record review revealed Resident #4 exhibited behaviors and had pulled out the urinary catheter with the bulb inflated on 01/17/13. According to the record, staff reinserted the urinary catheter the same day. Review of the nurse's notes dated 01/20/13 at 2:10 PM, and 01/23/13 at 4:47 AM, revealed Resident #4 was agitated and pulling at his urinary catheter. Additional record review revealed the resident had a small, red tear to the urethral opening with a small, reddened area around the urinary catheter on 02/24/13; however, according to the treatment sheets, the area had resolved on 03/07/13. Review of the comprehensive admission MDS completed for Resident #4, dated 01/24/13, revealed staff assessed the resident to have behaviors (not directed toward others) and to have a urinary catheter. There was no evidence the facility assessed the resident's behavior of pulling out the catheter or attempting to pull out the catheter. Additional review of the quarterly Minimum Data Set assessments completed for Resident #4 on 04/18/13 and 07/12/13 revealed the resident continued to utilize an indwelling urinary catheter; however, there was no evidence the resident had tears to the penis. In addition, review of weekly skin assessments completed for Resident #4 since admission revealed no documented evidence the resident had a tear/split to the penis. Observation of urinary catheter care conducted for Resident #4 on 08/22/13 at 9:50 AM, revealed the resident had an old tear/split of the penis through the urethra to the underside of the penis extending from the end of the penis down the length of the shaft of the penis 4 centimeters long. The resident's urinary catheter was not secure and was observed protruding from the bottom of the tear/split. Interview with LPN #1 on 08/22/13 at 10:45 PM, revealed the resident's penis had always been torn. LPN #1 stated the resident's catheter was not secured to the resident's leg because the resident was allergic to tape. Interview conducted with the facility's Treatment Nurse on 08/22/13, at 4:40 PM, revealed the Treatment Nurse was aware the resident had a tear to the penis in the past, but was not aware the resident's penis had torn to a length of 4 centimeters. According to the treatment nurse, she would not monitor the skin tear to the penis unless the tear was new. Interview conducted with the MDS Nurse on 08/22/13 at 5:00 PM, revealed the MDS assessment was completed by the fourteenth day after a resident was admitted to the facility and then at least quarterly as required. Further interview with the MDS Nurse revealed she had not identified behaviors of Resident #4 pulling at the catheter, nor had she identified the resident's tear/split to the penis.

Based on interview, record review, and a review of facility policies, it was determined the facility failed to assess and consider risk factors of an indwelling urinary catheter (erosion, pain, and discomfort) and develop a care plan based on the assessment for two of fourteen sampled residents (Residents #9 and #4). In addition, the facility failed to develop a care plan that addressed securing residents' indwelling urinary catheter tubing to prevent pulling/pressure per the facility's policy. Observations conducted of urinary catheter care for Resident #9 revealed the resident's penis was swollen and torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis. Resident #9's catheter tubing was not anchored/secured to prevent pulling. Interviews with Resident #9 revealed the injury to his penis resulted from the catheter tubing being pulled. In addition, the facility admitted Resident #4 with no evidence of any tears/damage to the penis on 01/16/13. The resident exhibited behaviors of pulling and dislodging the urinary catheter and was noted to have a tear to the penis on 02/24/13. The facility failed to implement interventions to secure the urinary catheter to prevent further damage to the resident's penis. Observation of the resident's penis on 08/22/13 revealed a tear/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis. (Refer to F272 and F315.) The findings include: An interview conducted with the Director of Nursing on 08/22/13 at 5:35 PM, revealed the facility did not have a specific policy related to completion of the care plans. However, it was facility practice to develop an initial care plan when the resident was admitted . Then the required MDS assessment and care planning process was utilized to develop a comprehensive care plan as required. Review of the facility's policy entitled "Foley Catheter Care," not dated, revealed a resident's catheter tubing should be secured to the bottom bed linens and staff was not to pull or tug on the catheter. Review of the Resident Assessment Instrument (RAI) User Manual Version 3.0 revealed, "The assessment should include consideration of the risks and benefits of an indwelling (suprapubic or urethral) catheter...and consideration of complications resulting from the use of an indwelling catheter (e.g., urethral erosion, pain, discomfort, and bleeding). The next step is to develop an individualized care plan based directly on these conclusions." 1. A review of Resident #9's medical record revealed the facility admitted the resident on 02/12/13, with [DIAGNOSES REDACTED]. A review of Resident #9's admission comprehensive Resident Assessment Instrument (RAI) assessment dated [DATE], revealed facility staff had identified the resident had a urinary catheter. Review of Resident #9's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 15 and utilized an indwelling urinary catheter. There was no evidence the facility assessed and considered the risk factors and complications of having the urinary catheter. Review of Resident #9's care plan initially dated 02/12/13, and updated on 07/02/13, revealed staff was required to provide routine urinary catheter care. However, staff failed to develop individualized care plan interventions that addressed risk factors of an indwelling urinary catheter (urethral erosion, pain, and discomfort). In addition, the facility failed to develop a care plan with interventions to address pulling/pressure of the resident's indwelling urinary catheter tubing per the facility's policy. Observations conducted on 08/22/13 at 10:40 AM, of Foley catheter care for Resident #9 revealed the resident's penis was torn/split from the urinary meatus (the opening in the penis from which urine flows) and down the shaft of the resident's penis (measured 3.5 centimeters). Resident #9 was observed to have facial grimacing while facility staff provided care. Observations revealed the resident's catheter was not secured. An interview with Resident #9 on 08/22/13 at 12:40 PM, revealed the resident's penis was torn after he was admitted to the facility (was unable to recall when the tear occurred after admission). The resident stated staff had "ripped it by pulling it so much." Resident #9 stated his genitals burned and it was painful when staff provided care. The resident stated staff had been told that it hurt when care was provided; however, nothing had been done to keep the catheter from "pulling" when care was provided. An interview with the MDS Coordinator on 08/22/13 at 4:50 PM, confirmed she failed to implement interventions to prevent Resident #9's indwelling urinary catheter tubing from being pulled. She acknowledged a care plan should have been developed to prevent the catheter tubing from being pulled. An interview with the Director of Nursing (DON) on 08/22/13 at 5:30 PM, revealed staff should have developed interventions to prevent Resident #9's indwelling urinary catheter tubing from being pulled. 2. A medical record review conducted for Resident #4 revealed the facility admitted the resident on 01/16/13, with [DIAGNOSES REDACTED]. According to the record, the resident had a urinary catheter upon admission. Review of the admission assessment, the comprehensive MDS admission assessment dated [DATE], quarterly MDS assessments dated 04/18/13 and 07/12/13, and the Care Area Assessment (CAA) Summary dated 01/29/13, revealed the resident was assessed to have a urinary catheter. There was no evidence on the assessments that the resident had any tears or problems of the penis related to the urinary catheter. According to nurse's notes, Resident #4 exhibited behaviors and pulled out the urinary catheter on 01/17/13. Additional review revealed on 01/20/13 at 2:10 PM, and 01/23/13 at 4:47 AM, the resident was agitated and pulling at the urinary catheter. Additional record review revealed the resident had a small red tear to the urethral opening with a small spot of red around the urinary catheter on 02/24/13, and according to the treatment sheets the area had resolved on 03/07/13. Review of Resident 4's Admission Care Plan, Comprehensive Care Plan, and updates to the plan of care from 01/16/13 to 08/22/13 revealed no evidence of interventions developed to prevent the resident from pulling the urinary catheter, or to secure the urinary catheter to prevent pulling and tearing of the penis. Interview conducted with Certified Nursing Assistant (CNA) #2 on 08/22/13 at 9:50 AM, revealed the CNA was not aware of any interventions to stabilize the catheter for Resident #4. According to CNA #2, the resident had a history of [REDACTED]. Interview with the MDS Coordinator on 08/22/13 at 5:00 PM, revealed the MDS Nurse had not assessed the resident's behavior related to pulling at the catheter nor had identified that the resident had a tear/split of the penis. Further interview revealed the MDS Nurse had not developed care plan interventions related to the pulling of the catheter or the torn/split penis because she was not aware of the resident's problems related to the catheter and had not considered problems related to the catheter tears or erosion of the penis. In addition, the MDS Coordinator stated she relied on weekly skin assessments to identify problems; however, she did not look at the resident's skin when completing the MDS and care plan unless the resident had a pressure sore. According to interview conducted with the DON on 08/22/13 at 5:35 PM, the care team reviewed the resident prior to admission to identify care needs and an admission nursing assessment was completed the day the resident was admitted . Based on the initial review and the admission nursing assessment, an initial care plan was put in place to address the resident's immediate care needs. Further interview revealed the MDS Nurse then completed the admission MDS assessment and developed a comprehensive care plan to address needs based on the assessment. Further interview revealed if a resident had a change or a new concern developed, it was discussed in the department head meeting and the MDS Nurse would update the care plan. According to the DON, the resident's torn/split penis should have been monitored and the care plan should have had interventions to prevent further injury.