Every finding on record at NHC Healthcare, Glasgow

Based on observation, interview, record review, and review of facility policy, the facility failed to provide a safe, clean, comfortable, and homelike environment inside the facility for its residents. The findings include: Review of the facility policy titled, NHC Healthcare Glasgow Environment Policy, dated March 2026, revealed the facility strived to maintain a comfortable, safe environment in the facility. Per review, all partners (staff) worked together to identify maintenance issues that needed to be addressed. Further review revealed maintenance partners had the responsibility to ensure . all areas are free of safety hazards. 1. Observation on 03/06/2026 at 2:41 PM, of the hallway to the right of the reception desk, revealed metal wall anchors which had been left exposed, protruding out of the wall approximately two inches at a height of approximately 33 inches off the floor. Continued observation revealed the metal anchors had been left exposed when the handrails were removed to paint the walls. Further observation revealed there were four metal anchors on the right side of the hallway and two on the left side of the hallway. Observation on 03/02/2026 through 03/10/2026, at various times, revealed the residents using the hallway walls, where the exposed metal anchors were, to assist in propelling themselves in their wheelchairs. Further observation revealed ambulatory residents were also using the hallway walls to balance when walking. In interview with the facility's Maintenance staff person, on 03/09/2026 at 3:35 PM, he stated he would re-install the handrail, after the State Survey Agency (SSA) Surveyor brought the exposed metal anchors to his attention. He reported however, he did not see how the exposed metal anchors would be harmful to residents. In interview with the Director of Nursing (DON) on 03/10/2025 at 5:56 PM, she stated the facility provided a safe environment for residents by staff being available to provide care 24 hours a day, seven (7) days a week. She said she was unsure when the handrails had been removed leaving the metal anchors exposed. The DON stated she had not noticed the anchors being exposed prior to the SSA Surveyor bringing it to her attention. She further stated she saw no more safety risk to residents than door handles would be. In interview with the Administrator on 03/10/2026 at 6:40 PM, she stated she made daily rounds throughout the building, along with other leadership and maintenance staff. She said the rail had been removed approximately at the end of the week prior to the SSA's arrival. The Administrator reported the metal anchors protruding from the wall presented no safety issue for residents in her opinion. She explained the reason the rails had not been replaced in that area already was because the facility was waiting on the new handrails to arrive. The Administrator further stated she saw the exposed metal anchors as similar to door handles, and it was her belief the anchors were smooth. 2. Observation of station 2 on 03/04/2026 at 2:31 PM, revealed discolored ceiling tiles, in the dining room, which had stains, hand and fingerprints, and there was an exposed cable wire suspended from the ceiling to the lower outer wall. Continued observation revealed one corner of the ventilation screen door was not completely engaged into the ceiling, and there were hoyer sling pads hung against the wall in the dining area. Further observation revealed there were medication carts left in the dining room, and a rollator walker with a seat was left unlocked in dining area. An additional observation of station 2 on 03/07/2026 at 11:24 AM, revealed the crash cart was obstructed by equipment making it not easily accessible in the event of a medical emergency. Observation from 3/3/2026 through 3/10/2026, at various times, revealed the station 4 restorative dining had two exercise machines, cornhole gaming activity, and a wheelchair scale stored along the perimeter of the dining room. Further observation revealed residents dining with the equipment stored in the room. In interview with the Unit Manager (UM), of station 4, on 03/06/2026 at 2:45 PM, she stated her description of a homelike environment was when staff provided residents with their meal off the trays, interacted with residents, and providing a well-lit environment. She stated she realized the NuStep (recumbent cross trainer) and arm ROM exercise machines could be stored elsewhere out of the dining room. The UM said however, the dining room was used for restorative dining and activities. She further stated the wheelchair scale located in the dining room, was only used by one resident. In interview with Licensed Practical Nurse (LPN (2), on Station 2 on 03/07/2026 at 10:47 AM, she stated she had not observed anything that would raise concerns in the dining room. She said she was unsure if the cable hanging from the ceiling, was a big concern. The LPN explained staff were usually in the dining room when the residents were dining. She stated they did have one resident, who wandered that staff had to monitor. LPN 2 reported the dining room used to be where they stored their wheelchairs; however, had been converted to a dining room after so many residents were wanting to eat in there. She said she could see the ventilation cover being a possible concern and she would contact maintenance to take care of it. The LPN stated the medication carts were usually stored in the dining room area, but were not usually in the dining room when meals were being served, as staff were using them out in the hallway to pass medications. She further stated the hoyer slings hanging on the wall were where they had always stored prior to the room becoming a dining area. LPN 2 additionally said, the wheelchairs were also stored there and had never been moved. In interview with the maintenance staff person on 03/09/2026 at 3:35 PM, he stated he was concerned about the wire suspended from the ceiling in the station 2 resident lounge/ dining area. He said the dirty handprints on the ceiling tiles were due to a technician doing a repair on the sprinklers. The maintenance staff person stated the work order for the sprinklers had been provided to the Life Safety Surveyor. He reported the handrails had been recently removed for painting, and the new handrails had been ordered, but had not arrived yet. The maintenance staff person said he would re-install the previous handrails until the new ones arrived. He explained however, he did not see how the missing handrails would be harmful to the residents, even though, it was brought to his attention the protruding metal support could potentially cause harm. The maintenance staff person stated he was informed of repairs throughout the facility, as each nursing station had a maintenance logbook that was checked periodically throughout the day. He further stated for any emergencies or immediate attention, staff were able to reach maintenance by phone 24/7. In interview with DON on 03/10/2026 at 5:56 PM and 6:00 PM, she stated the facility ensured residents were provided with a safe homelike environment; however, that was subjective to interpretation, as all homes were different. She stated there were no concerns with the exposed wall mounts, nor with the exercise equipment being stored in the restorative dining area. The DON reported she expected crash carts to be easily accessible, and should not have anything in front of it. In interview with the Administrator on 03/10/2026 at 6:42 PM and at 6:51 PM, she stated our goal as the facility was to provide a safe and comfortable setting for all residents. When concerns were brought to her attention regarding wire suspended from the ceiling, She stated she did find concern with the wire suspended from the ceiling; however, said the call lights residents used were also cables. The Administrator explained the handrails had been removed a week prior to the State Survey Agency's (SSA's) arrival to the facility. She reported there was no harm with the protruding metal mounts being exposed. The Administrator said she expected her staff to log any maintenance repairs in the maintenance book which was checked periodically throughout the day. She stated all 4 nursing stations had their own maintenance logbooks. The Administrator said depending on the nature of the repair, they all should be documented in the logbook, unless it presented an immediate concern which maintenance should be contacted to immediately take care of. She said regular walk throughs and facility rounds on daily basis was how leadership evaluated whether the environment continued to feel homelike. The Administrator reported she expected the crash carts to be kept in an area near residents, appropriately checked and maintained. She further stated, in the event of an emergency that required the crash cart, I would run in there and move stuff out of the way.

Based on interview, record review, pharmacy audit reports, and review of facility policy, the facility failed to maintain medical records for each resident that were complete and accurately documented for 5 of 35 sampled residents, (Residents (Rs)4, R22, R30, R70, R102). The findings include: Review of the facility's, Network Pharmacy Policy, titled, Preparation and General Guidelines - Medication Administration - General Guidelines, revised 01/01/2019, revealed the individual who administered a medication dose was to record the administration on the resident's Medication Administration Record (MAR) directly after the medication was given. Further review revealed at the end of each medication pass, the person who administered the medications was to review the MAR to ensure necessary doses were administered and documented. Review of the facility's Network Pharmacy Policy, titled, Preparation and General Guidelines - Controlled Substances, revised 02/25/2025, revealed accurate accountability of all controlled drugs was maintained at all times. Per review, when a controlled substance was administered, the licensed nurse/medication technician who administered the medication immediately entered the following information on the Accountability Record (AR) and the MAR: Date and time of administration (MAR and AR), amount administered (AR), remaining quantity (AR), and initials of the nurse/medication technician who administered the dose, completed after the medication was actually administered (MAR and AR). 1. Review of the Facesheet revealed the facility admitted R70 on 11/01/2022, with diagnoses which included Alzheimer's disease, dementia, and Parkinson's disease. Review of the comprehensive Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/11/2025, revealed the facility assessed R70 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognitive function. Review of the Network Pharmacy's PRN (as needed) Controlled Substance Audit completed 10/10/2025 revealed R70's AR for Norco 5-325 milligrams (mgs) documented removal of a dose on 09/29/2025 at 7:30 PM. Continued review revealed however, the Norco dose was not documented on the resident's corresponding Medication Administration Record (MAR). Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025 revealed R70's AR for Norco 5-325 mg documented a removal of a dose on 09/30/2025 at 7:30 PM. Additional review revealed however, the Norco dose was not documented on the resident's corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025, revealed R70's AR for Norco 5-325mg documented removal of a dose on 10/02/2025 at 9:30 PM. Further review revealed however, the Norco dose was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025, revealed R70's AR for Norco 5-325mg documented removal of a dose on 10/03/2025 at 7:15 PM. Per continued review however, the Norco dose was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025, revealed R70's AR for Norco 5-325mg documented removal of a dose on 10/04/2025 at 7:30 PM. Additional review revealed however, the Norco was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025, revealed R70's AR for Norco 5-325 mg documented removal of a dose on 10/05/2025 at 7:30 PM. Continued review revealed however, the Norco dose was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 10/10/2025, revealed R70's AR for Norco 5-32 5 mg documented removal of a dose on 10/06/2025 at 7:50 PM. Further review revealed however, the Norco dose was not documented on the corresponding MAR. 2. Review of the Facesheet revealed the facility admitted R102 on 04/18/2025 with diagnoses which included: osteomyelitis, Alzheimer's disease, and dementia. Review of the Quarterly MDS Assessment with an ARD of 12/24/2025, revealed the facility assessed R102 to have a BIMS score of 5 out of 15, indicating severe cognitive impairment. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/02/2025 at 7:45 PM. However, continued review revealed however, the narcotic medication dose was not documented on the resident's corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/10/2025 at 8:00 PM. Per review however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/11/2025 at 8:00 PM. Further review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/14/2025 at 6:58 AM. Review further revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/14/2025 at 6:00 PM. Continued review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/15/2025 at 6:30 AM. Additional review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/16/2025 at 8:00 PM. Per review however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/19/2025 at 8:00 PM. Continued review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/20/2025 at 8:07 PM. Further review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/24/2025 at 4:00 PM. Review further revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/27/2025 at 8:55 AM. Per review however, the narcotic medication dose was not documented on the corresponding MAR. Review of R102's AR for hydrocodone - APAP (acetaminophen) 5 - 325 mg documented removal of a dose on 11/30/2025 at 7:43 PM. Additional review revealed however, the narcotic medication dose was not documented on the corresponding MAR. 3. Review of the Facesheet revealed the facility admitted R22 on 07/14/2024, with an admission diagnosis of fracture of head of right femur. Per review, other diagnoses included: dementia, primary hypertension, and anxiety disorder. Review of the Quarterly MDS with an ARD of 09/26/2025, revealed the facility assessed R22 to have a BIMS score of 6 out of 15, indicating severe cognitive impairment. Review of R22's MAR revealed on 11/21/2025, oxycodone-acetaminophen 5-325 mgs was administered to the resident at 8:30 AM and 3:13 PM. Review of the MAR revealed on 11/22/2025, the oxycodone-acetaminophen 5-325 mgs narcotic medication was noted as administered at 8:26 AM and 2:54 PM. Review of the MAR further revealed on 11/23/2025, the oxycodone-acetaminophen 5-325 mg narcotic medication was documented as administered at 8:43 AM and 2:41 PM. Review of an email, provided by the facility, dated 11/24/2025 at 3:44 PM, revealed the laboratory results dated [DATE] at 1:20 PM, noted a value of negative, with a Normal Reference Range of Negative, for Opiate Screen of Urine for R22. (The negative results indicated R22 had not received the documented administrations of the oxycodone-acetaminophen 5-325mg narcotic pain medication on 11/21/2025 through 11/23/2025.) 4. Review of the Resident Face Sheet for R30, revealed the facility admitted the resident on 11/13/2025, with a primary diagnosis of mild unspecified dementia with anxiety. Further review revealed additional diagnoses included: a displaced fracture of the left femur, Type 2 Diabetes Mellitus, and other chronic pain. Review of the Controlled Substance Inventory Record (CSIR), dated 12/30/2025 - 01/27/2026, for R30's Oxycodone 5 mg tab one by mouth every four (4) hours as needed for pain, Review of R30's MAR for the same time period, revealed documentation of four doses having been removed on the CSIR; however, not documented as having been administered to the resident on the MAR. Continued review revealed doses of the narcotic medication were noted as removed from the stock, but not documented until later on, sometimes hours later, on the MAR. In addition, there were doses noted as removed from stock; however, not documented as administered on the resident's MAR. 5. Review of the Facesheet revealed the facility admitted R4 on 12/10/2021, with diagnoses which included: unspecified displaced fracture of surgical neck of right humerus, unspecified dementia, and hypertensive chronic kidney disease. Review of the Comprehensive MDS Assessment with an ARD of 01/21/2026, revealed the facility assessed R4 to have a BIMS score of 14 out of 15, indicating intact cognitive function. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 01/20/2026, revealed R4's AR for Norco 5 mg documented removal of a dose on 01/14/2026 at 12:00 AM. Per review however, the narcotic medication dose was not documented on the resident's corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 01/20/2026 revealed R4's AR for Norco 5 mg documented removal of a dose on 1/16/2026 at 8:30 PM. Continued review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 01/20/2026 revealed R4's AR for Norco 5 mg documented removal of a dose on 1/17/2026 at 8:20 AM. Further review revealed however, the narcotic medication dose was not documented on the corresponding MAR. Review of the Network Pharmacy's PRN Controlled Substance Audit completed 01/20/2026 revealed R4's AR for Norco 5 mg documented removal of a dose on 1/19/2026 at 9:00 PM. Additional review revealed however, the narcotic medication dose was not documented on the corresponding MAR. In interview with Licensed Practical Nurse (LPN) 6 on 03/05/2026 at 3:06 PM, she stated when a narcotic medication was administered, it must be signed out on both the narc sheet (AR) as well as on the resident's MAR. She further stated if there was a discrepancy on the narcotic counts, the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) were to be notified. In interview with LPN 7 on 03/05/2026 at 4:08 PM, she stated she documented on the MAR when any medication was given. In interview with the Pharmacist on 03/09/2026 at 2:20 PM, she stated there were audits performed PRN to compare narcotic sign-outs to what was documented as administered on the MAR. She further stated those audits were usually quarterly and done by pharmacy techs (technicians) and then she reviewed their findings. In an additional interview with Pharmacist on 03/09/2026 at 4:10 PM, she stated a pharmacy tech checked documentation, observed a medication pass monthly and checked medication storage quarterly. She reported the audits were performed of at least two completely random residents from each nursing station. Additionally, she further stated the results of those audits caused concern because of poor documentation and that information had been shared with the DON. In interview on 03/10/2026 at 10:05 AM, the Staff Educator stated her role was staff education, orientation, and involvement in nursing hiring. She said once new hires were in the facility, they went over power-points presentations and videos. The Staff Educator explained the Department heads went over over policies related to their specific areas with new hires. She reported she was not sure if anyone went over documenting on the MARS, she thought the nurse preceptors did that; however, was unsure. The Staff Educator further stated she was also unsure if there were ever any chart audits completed by anyone in the facility. In interview on 03/10/2025 at 5:56 PM, the DON stated the Pharmacist had made her aware of concerns related to documentation of narcotics. She reported however, she had not seen concerns with inconsistencies. The DON said the topic had been discussed with nurses in partner (staff) meetings and possibly during in-services. She further stated audits were completed at times, but nothing was documented on paper. She also stated the Pharmacist's concerns were never presented to the facility's Quality Assessment and Process Improvement (QAPI) Committee. In interview on 03/10/2026 at 6:40 PM, the Administrator stated she was unaware of the Pharmacist's concern. She said she would have considered an inconsistency between the AR and MAR a medication error. Additionally, she stated in the past several days there had been many discussions about narcotic wastes and documentation inconsistencies.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were treated with respect and dignity and provided care in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life for one of 31 sampled residents, (Resident (R)14). The findings include: Review of the facility policy titled, Patient Rights Booklet (Section J), revised 09/2024, revealed the facility was to provide residents with privacy to maintain a dignified existence. Per policy review, privacy was to be maintained during toileting, bathing, and other activities of personal hygiene. Record review revealed the facility admitted R14 on 11/11/2022, with diagnoses to include atherosclerotic heart disease, lymphedema, anxiety disorder, and history of other venous thrombosis and embolism. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/19/2025, revealed the facility assessed R14 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. In interview with R14, on 03/03/2026 at 3:43 PM, she stated she recalled an incident about two weeks ago when a Certified Nurse Aide (CNA) left her lying on her bed in her room and never returned to assist her with getting dressed, and left her wearing only a brief. She stated she could not identify who the CNA had been, but believed it was a male staff member. R14 further stated she believed she informed a nurse; however, was not certain. In interview with R129 (R14's roommate), on 03/09/2026 at 4:30 PM, she stated she recalled a few weeks ago she had been awakened by a male walking out of their room. She said she turned over and observed R14 lying on her bed without any clothing on. R129 stated she believed R14 had been naked. She further stated she was unable to identify who the male had been; however, thought it was a staff member providing R14 with toileting assistance. In interview with CNA 7, on 03/06/2026 at 10:39 AM, she stated she worked on station 4, which included R14's hallway. She said she worked weekends only, Saturday through Monday at night, 7:00 PM to 11:00 PM. The CNA explained she always checked on her residents when she first arrived for her shift. She reported R14 liked to sleep in only a brief and t-shirt or gowns, with a blanket on. CNA 7 stated she recalled one night a few weeks ago when she arrived at the facility and found R14 with her blanket off; however, could not remember what the resident had on, but she had not been naked. The CNA further stated if R14 had voiced concerns to her (CNA 7) about how she (R14) had been left undressed, she would have taken that information to the nurse. In addition, she said she believed R14's blanket had just fallen off of her. During an additional interview with R14, on 03/10/2026 at 8:35 AM, she stated she remembered the night she had been left lying on her bed wearing only a brief. The resident said even though she had no blanket at the time, she had not been naked. She explained she still could not recall the CNA who had been assisting her that night, but denied the CNA being a male. R14 reported she had not liked being left wearing only a brief and she had been very cold. She stated she had not seen the CNA in her room anymore, and later that evening, CNA 7 had arrived for her shift, and assisted her into her night clothes and provided her with a blanket. In interview with CNA14, on 03/10/2026 at 8:45 AM, she stated when R14 pressed the call light for assistance with toileting the staff were to use a sit-to-stand chair with two staff members present. She said call lights were to be answered timely and if they were not then R14 might have potential concerns with infections, skin issues, and constipation. CNA 14 explained R14 preferred to sleep in a brief and gown or sometimes a t-shirt. She stated she had not worked the evening of the incident, so she had not been aware of a concern with R14 having been left wearing only a brief on her bed. CNA 14 further stated the staff on the 3:00 PM to 11:00 PM shift generally helped R14 to bed. In interview with CNA15, on 03/10/2026 at 9:00 AM, she stated she worked on R14's hall and often assisted the resident with toileting. She said she observed R14 lying on her bed wearing only a brief and her blanket lying on the floor. The CNA explained she had reported that information to Licensed Practical Nurse (LPN) 13. She reported the incident had occurred about two weeks ago and had only happened that once that she was aware of. She further stated she was certain that would be a dignity concern for R14, and could affect the resident psychosocially. A telephonic (phone) interview was attempted with LPN 13, on 03/10/2026 at 4:20 PM; however, was unsuccessful. In interview with the Director of Nursing (DON), on 03/10/2026 at 6:07 PM, she stated one staff person could use the sit-to-stand chair to assist a resident with toileting. She said if staff were assisting a resident with their activities of daily living (ADLs), such as getting them dressed after toileting, her expectation was for the staff member to meet all the resident's needs before leaving the room. In interview with the Administrator, on 03/10/2026 at 6:47 PM, she stated her expectations for resident care was for staff to provide adequate privacy when assisting residents. She further stated she also expected staff to maintain the dignity of the resident in all circumstances.

Based on interview, record review, and facility policy review, the facility failed to comply with the requirements to inform and provide written information to all residents concerning the right to, at the resident's option, formulate an advance directive for 1 of 31 sampled residents (Resident (R)113). The findings include: Review of the facility policy Do Not Resuscitate (DNR) Order, revised March 2012, showed the interdisciplinary care planning team was to review advance directives with residents during quarterly care planning sessions to see if any changes were desired. Review of R113's Face Sheet showed admission on [DATE] with diagnoses of hemiplegia and hemiparesis post-cerebral infarction on the left non-dominant side. The 01/20/2026 Quarterly Minimum Data Set (MDS) Assessment noted a BIMS score of 15/15, indicating intact cognition. The last quarterly care conference on 02/09/2026 showed no documentation that advance directives were discussed. In an interview on 03/05/2026 at 9:00 AM, the Social Services Director (SSD) stated that advance directives were addressed upon admission, but she was unsure about follow-up timing or documentation for R113 during quarterly care planning. During an interview on 03/05/2026 at 9:30 AM, the admission Coordinator stated that admission paperwork asked about advance directives, but was unsure of follow-up procedures. If residents or families had questions, they were given state legal aid contact information, and advance directive documents were attached to the medical chart if provided. During an interview with R113 on 03/05/2026 at 4:14 PM, the resident stated he did not remember the facility addressing advance directives upon admission or any follow-up afterward. He added that his brother knew his preferences, and he wanted to appoint him as his power of attorney (POA). During the interview on 03/10/2026 at 5:55 PM, the Director of Nursing (DON) stated the Social Services staff had not initially understood advance directives, and she was unfamiliar with when directives were to be revisited. She said she would need to check with Social Services to confirm the timing and could not recall if directives had been discussed in care plan meetings she attended or when she last participated in one. During an interview with the Administrator on 03/10/2026 at 6:37 PM, she stated that advance directives were reviewed at admission, but had not been discussed in care planning meetings she attended. She expected copies of legal documents to be provided at the earliest opportunity.

Based on interview, record review, and review of the facility's investigation reports and policies, the facility failed to implement a written policy to ensure abuse allegations were reported as required to the State Survey Agency (SSA) per Federal and State Law for 1 of 31 sampled residents, (Resident (R)22).The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, revealed any patient (resident) event reported was to be considered an allegation of either abuse, neglect, misappropriation of patient (resident) property or exploitation. Per review, the facility was to ensure all alleged violations .were reported immediately, . or not later than 24 hours (if the events that caused the allegation did not involve abuse and did not result in serious bodily injury) to the Administrator of the facility. Further review revealed all alleged violations were to be reported to other officials (including the State Survey Agency (SSA) in accordance with State law through established procedures. In addition, external reporting of the investigation to the SSA and all other state required agencies following Federal, individual State laws, and licensure regulations. Review of the Face Sheet for R22 revealed the facility admitted the resident on 07/14/2024, with a diagnosis of fracture of head of right femur, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/26/2025, revealed the facility diagnosed R22 to have a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating severe cognitive impairment. The facility provided an untitled hand-written undated document as its investigation into an incident that occurred on 11/04/2025. Review of that document revealed the Station 3 Unit Manager (UM) reported a concern to the Director of Nursing (DON) related to Registered Nurse (RN) 4 wasting a (narcotic) medication for R22 that was witnessed by Licensed Practical Nurse (LPN) 3. Continued review revealed it was noted R22 takes her pills whole; however, what RN 4 asked LPN 3 to witness was a spilled crushed med. Further review revealed the DON notified the Administrator of the concern on 11/05/2025, the DON informed the Administrator, and a call to Values Line about this concern on 11/10/2025. (The Values Line was a company hotline which allowed employees to voice concerns or complaints anonymously). Review of the untitled typed document, undated, provided by the facility and signed by the DON, revealed on 11/10/2025, Regional Nurse 2 called to inform the DON that an anonymous call had been placed to the Values Line related to RN 4 and narcotics. Per review, after Regional Nurse 2's telephone (phone) call an investigation regarding the concern was initiated. Review revealed the DON, Assistant Director of Nursing (ADON), RN 5, and the Administrator were all aware of the concerns and subsequent investigation. Continued review revealed the Administrator and ADON received another phone call on 11/24/2024, from Regional Nurse 1 to discuss the suspicion of diversion (of narcotic medication). Review of Regional Nurse 1's documentation revealed on 11/21/2025, 11/22/2025, and 11/23/2025, RN 4 documented administering a total of six doses of R22's narcotic pain medication, oxycodone-acetaminophen 5 - 325 milligrams (mg). Continued review revealed based on those previous days documentation, the Medical Director was notified and an order for a drug screen was obtained for R22. In interview on 03/10/2026 at 9:55 AM, Regional Nurse 1 stated the expectation for investigations after a suspicion was reported would depend on what the suspicion was about. She said they would always find out what the concern was, what the facts of the concern was, and who was involved. Regional Nurse 1 explained the next steps were extremely situational and depended on what had been reported. She stated reporting was extremely situational. She stated reporting to law enforcement or the SSA was done if: the concern was deemed abuse or misappropriation following the guidelines; if it was found to be true; and in some other situations. The Regional Nurse further stated the incident involving R22 had been reported to the Kentucky Board of Nursing, and had not met misappropriation so no, it should not have been reported. She also said therefore we (the facility) had done as we should. In interview on 03/10/2025 at 5:56 PM, the Director of Nursing (DON) stated she believed all had been handled correctly during due process for the nurse (RN 4) involved in the incident, of wasting a narcotic that had been split or crushed (Even though the LPN who witnessed the wasting knew R22 took her medications whole). She said she did not feel in any way, shape, or form that a wrong decision had been made (in not investigating further). The DON stated she saw no potential outcome for residents because they had not seen the concern (incident involving R22) as a reasonable suspicion as it had appeared all documentation was in order and there was no proof of any actual wrong doing until the drug screen was obtained for R22 and the results were negative for the narcotic. She said it was felt it was just one nurse complaining about another. In interview on 03/10/2026 at 6:40 PM, the Administrator stated she believed, in retrospect, there were actions that could have been taken quicker. She said the original suspicion had been brought forth on 11/04/2025. She did believe the facility conducted a complete and thorough investigation related to the diversion of R22's narcotic medication. The Administrator reported she rounded on residents daily and claimed there had been no abuse that occurred, so there had been no reason to report the incident to anyone else. She said, to her knowledge at that time, all required reporting had been made, which was to the Kentucky Board of Nursing (KBN). The Administrator stated it was her belief in the situation (involving R22's narcotic medication) it had been appropriate to report to KBN after there was irrefutable proof the resident had not received the narcotic medication documented as administered by RN 4. She further stated at that time it was her understanding that was the only reporting requirement.

Based on interview, record review, facility document review, and review of facility policy, the facility failed to report suspected misappropriation of resident property to the State Survey Agency (SSA) within 24 hours for 1 of 31 sampled residents, (Resident (R)22). The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, revealed any (resident) event reported to (staff) by patient (resident) was to be considered an allegation of abuse, neglect, misappropriation of (resident) property or exploitation. Per policy review, the allegation was to be considered misappropriation if it met the following criteria: .the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's (resident's) belongings or money without the patient's (resident's) consent. Continued review revealed the facility was to ensure all alleged violations involving . misappropriation of resident property, were reported immediately, . or not later than 24 hours, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. Further review revealed all alleged violations involving the above were to be reported to the Administrator of the facility and to other officials (including the SSA) in accordance with State law through established procedures, and Federal and licensure regulations. In addition policy review revealed the confidential internal investigative file was to be kept in the Administrator's office and maintained as a working document of the Quality Improvement (QI) Committee. Record review revealed the facility admitted R22 on 07/14/2024, with diagnoses of anxiety disorder, fracture of head of right femur, and dementia. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/26/2025, revealed the facility assessed R22 was assessed as having a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. Review of an untitled, undated hand-written document, provided by the facility as its Investigation, revealed on 11/04/2025 the Station 3 Unit Manager (UM) reported a concern regarding wasting of a (narcotic) medication to the Director of Nursing (DON). Per review, the medication waste had been witnessed by Licensed Practical Nurse (LPN) 3 with Registered Nurse (RN) 4 for R22. Continued review revealed the concern regarding the medication waste was that R22 took her pills whole and what RN 4 asked to be witnessed as waste was a spilled crushed med. Further review revealed on 11/05/2025, the DON informed the Administrator, and on 11/10/2025, a telephone (phone) call was placed to Values Line about this concern. (The Values Line was a company hotline which allowed employees to voice concerns or complaints anonymously). Review of an untitled, undated typed document, signed by the DON, revealed on 11/10/2025, revealed a phone call had been received from Regional Nurse 2. Per review, the phone call was to inform the DON a call had been placed anonymously to the Values Line concerning RN 4 and narcotics. Continued review of the document revealed after the phone call an investigation related to the concerns was started. Additionally, review revealed the people aware of the concerns and subsequent investigation were the DON, Assistant Director of Nursing (ADON), Administrator, and RN 5. Review of the DON's typed document revealed the Administrator and ADON received a phone call on 11/24/2025, from Regional Nurse 1, to discuss the suspicion of diversion. Review of documentation, noted by Regional Nurse 1 revealed on 11/21/2025, 11/22/2025, and 11/23/2025, RN 4 documented she administered a total of six doses of oxycodone-acetaminophen 5 - 325 milligrams (mg). Per continued review of Regional Nurse 1's documentation, based on RN 4's noted administration of R22's oxycodone-acetaminophen, the Medical Director was notified and an order received for a drug screen to be obtained on the resident. Further review of the facility's typed documentation revealed after the drug screen results were received on 11/24/2025 (and were negative for opiates), the Administrator requested an in-person meeting with RN 4. Review revealed RN 4 had been notified she would not be allowed to work until the in-person meeting took place. In review of the typed documentation it was noted on 11/25/2025, RN 4 met with the Administrator and DON, and the findings of the investigation were discussed. Review further revealed RN 4 was notified there was definitive proof that medication had not been administered to R22 as she had documented, and the RN stated I quit, I'm done and exited the building. However, additional review of all the facility's untitled, undated documentation presented by the facility, revealed no evidence of documentation noting the SSA or other state agencies having been notified. In interview on 03/10/2026 at 9:55 AM, Regional Nurse 1 stated after a suspicion was reported they always found out what the concern was, what the facts of the concern was and who was involved in it. She said the next steps were extremely situational and depended on what had been reported as well. The Regional Nurse explained reporting to law enforcement or the Office of Inspector General (OIG) was done if the concern was deemed abuse or misappropriation following the guidelines, if the concern was found to be true, and in some other situations. She stated the situation in this instance (incident involving RN 4) was reported to the Kentucky Board of Nursing; however, It had not met misappropriation. Regional Nurse 1 further stated so no, the incident should not have been reported to other state agencies and therefore, the facility had done as we should. In interview on 03/10/2025 at 5:56 PM, the DON stated she believed all was handled correctly during due process for the nurse. She reported she did not feel in any way, shape, or form that a wrong decision was made (regarding reporting). The DON additionally stated she saw no potential (negative) outcome because they (the facility) had not seen the concern as reasonable suspicion. In interview on 03/10/2026 at 6:40 PM, the Administrator stated she believed in retrospect there were actions that could have been taken quicker. She reported she did believe the facility had performed a complete and thorough investigation related to the diversion of narcotics.(Even though the facility failed to report to the state agencies as required. The Administrator said to her knowledge at that time (of the incident involving RN 4), all required reports had been made. She reported It was her belief in that situation it was appropriate for the facility to report to the KBN, after there was irrefutable proof (of diversion of narcotics). She further stated that at that time it was her understanding that was the only requirement.

Based on interview, facility policy and document review, the facility failed to thoroughly investigate an allegation of misappropriation of narcotic medications for 1 of 31 sampled residents, (Resident (R)22). The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, revealed the patient (resident) had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Further policy review revealed all events reported as possible (resident) abuse, neglect, or misappropriation of patient (resident) property was to be investigated and when there was a question as to whether to conduct an investigation, it was best to do so. Review of R22's Facesheet revealed the facility admitted the resident on 07/14/2024, with diagnoses of right femur head fracture, anxiety disorder, and dementia. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/26/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status score of 6 out of 15, indicating severely impaired cognition. Review of the untitled hand-written document, undated, provided by the facility as its investigation revealed on 11/04/2025, the Station 3 Unit Manager (UM) reported a concern to the Director of Nursing (DON) regarding wasting of a medication, witnessed by Licensed Practical Nurse (LPN) 3 with Registered Nurse (RN) 4 for R22. Per review, the concern noted was that R22 takes her pills whole and what RN 4 asked LPN 3 to witness was a spilled crushed med. Further review revealed on 11/05/2025, the DON informed the Administrator, and on 11/10/2025, it was noted a call to Values Line about this concern was made. (The Values Line was a company hotline that allowed employees to voice complaints or concerns anonymously). Review of the untitled typed document, undated, included with the documentation provided by the facility, and signed by the DON, revealed on 11/10/2025, a telephone (phone) call was received from Regional Nurse 2. Per review, the phone call was to inform the DON a phone call had been placed anonymously to the Values Line concerning RN 4 and narcotics. Review of the untitled document revealed after the phone call an investigation related to the concern was initiated, and those (staff) aware of the concerns and subsequent investigation were the DON, Assistant Director of Nursing (ADON), Administrator, and RN 5. Additional review of the DON's typed document revealed the Administrator and ADON received a phone call on 11/24/2025, from Regional Nurse 1 to discuss the suspicion of diversion. Review of Regional Nurse 1's documentation, included in the facility's documentation, revealed on 11/21/2025, 11/22/2025, and 11/23/2025, RN 4 documented administering a total of six doses of R22's narcotic pain medication, oxycodone-acetaminophen 5 - 325 milligrams (mg). Further review of Regional Nurse 1's documentation based on RN 4's documented days of administering R22's narcotic pain medication, the Medical Director was notified and an order for a drug screen was obtained for the resident. However, further review of all the facility's documentation provided as their investigation revealed no documented evidence a thorough investigation was performed, to include notifying all state agencies as required. In interview on 03/06/2026 at 10:40 AM, the Station 3 Unit Manager (UM) stated she reported, several months ago, a concern to the DON and showed her (the DON) a narcotic sheet she had the concern about. She reported she was not sure of the exact date; however, noticed on the narcotic sheet RN 4 appeared to be the only one administering the narcotic pain medication to R22. The UM said she was not involved in the investigation of her reported concern. She further stated she had not heard of any mention of medication diversion although had considered it (when she reported the concern). The Station 3 UM further stated misappropriation was a form of abuse and that could have been what was occurring at that time. In interview on 03/07/2026 at 11:04 AM, the Administrator stated a suspicion was presented to her on 11/04/2025, regarding the wasting of one tablet of a narcotic pain medication. She reported the DON initiated review of the residents' Medication Administration Records (MARs) and the narcotic sheets for all residents on that hallway (Station 3). The Administrator said additional rounding had also been conducted. Per the Administrator in interview, neither the additional rounding or review of residents' narcotic sheets and MARs had raised red flags. She stated the facility considered the concern as just one employee versus another and did not want to accuse someone without proof. The Administrator said no one else had said anything and they had not wanted to be accused of discrimination. She reported no staff interviews were conducted and the facility had no documentation of residents' interviewed (as part of their investigation). She explained on 11/10/2025, an anonymous call had been placed to the facility's Values Line, and the phone call concern was routed to the Regional Nurse who ramped up an investigation. She (The Administrator) reported, had the anonymous phone call not been made, and the Regional Nurse not called the facility, they would have considered the matter over as no proof to back up the suspicion had been found. The Administrator further stated a drug screen was not conducted on RN 4 because, based on the facility's corporation's past experience, it would be inconclusive and would not prove anything. In interview on 03/09/2026 at 2:20 PM, the Pharmacist stated the DON asked her to help the facility investigate a concern of medication diversion. She said her own investigation involved auditing the narcotic sheets present on the cart at that time (November 2025). The Pharmacist reported the audited narcotic sheets presented a concern to her because of a lot of wasting and a trend of using PRN (as needed) medications. She stated her audit raised concern of one particular nurse and a select few residents. The Pharmacist further stated she voiced her concerns to the DON on 11/11/2025. In interview on 03/10/2026 at 9:55 AM, Regional Nurse 1 stated the expectation for the facility to initiate an investigation after a suspicion was reported, was related to what the suspicion was about. The Regional Nurse said they always found out what the concern was, what the facts were related to the concern, and who was involved. Regional Nurse 1 further stated the next steps were extremely situational and depended on what had been reported. In additional interview on 03/10/2026 at 6:40 PM, the Administrator stated she believed in retrospect there were actions that could have been taken quicker. She confirmed the original suspicion had been brought forth on 11/04/2025. The Administrator further stated she believed the facility's investigation had been a complete and thorough investigation related to the diversion of narcotics. The facility did not conduct staff interviews, and the facility had no documented evidence of residents' having been interviewed or all state agencies notified as required.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 31 sampled residents, (Resident (R)3 and R22). The findings include: Review of the facility's Pharmacy policy titled, Medication Administration - General Guidelines, revised 01/01/2019, revealed medications were administered as prescribed in accordance with good nursing principles and practices. Per review, the individual who administered the medication dose was to record the administration on the resident's Medication Administration Record (MAR) directly after the medication was given. Further review revealed at the end of each medication pass, the person administering the medications was to review the MAR to ensure the necessary doses were administered and documented. Review of the Facesheet for R22 revealed the facility admitted the resident on 07/14/2024, with diagnoses that included: dementia, fracture of the right femur head, and anxiety disorder. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/26/2025, revealed the facility assessed R22 as having a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating the resident had severely impaired cognition. Review of R22's MAR dated 11/10/2025 - 11/23/2025, revealed the following: a). On 11/21/2025 at 8:30 AM, one tablet of oxycodone - acetaminophen 5 - 325 milligrams (mg), a schedule II narcotic medication. Continued review of the MAR revealed the 11/21/2025, dose of R22's narcotic medication was administered by Registered Nurse (RN) 4. Further review of the 11/21/2025 MAR revealed an additional dose of the same narcotic medication was administered to R22 at 3:13 PM, by RN 4. b). On 11/22/2025 at 8:26 AM, one tablet of the oxycodone - acetaminophen 5 - 325 mg narcotic medication was administered to R22 by RN 4. Per review, RN 4 administered another dose of the same medication to R22 at 2:54 PM. c). On 11/23/2025 at 8:43 AM, one tablet of oxycodone - acetaminophen 5-325 mg was administered to R22 by RN 4. Further review revealed an additional dose of the same medication was administered to R22 by RN 4 at 2:41 PM. Review of the laboratory (lab) test results dated 11/24/2025 at 1:20 PM, for the urine opiate screen performed for R22 revealed the value was noted as negative, meaning no opiates were detected in the sample. Review of the facility's untitled typed document, undated, revealed on 11/24/2025, it was determined, based on the lab results, R22 had no oxycodone in her system despite RN 4's documentation on the MAR indicating she had administered the resident's doses of the narcotic pain medication. In interview on 03/09/2026 at 11:10 AM, the Lab Technician stated the drug test performed on R22 on 11/25/2025 would have been sensitive for synthetic opiates, including oxycodone. She further stated had the oxycodone been administered a total of six times in the previous three days the drug test would have indicated positive results. In interview on 03/10/2026 at 3:36 PM, the Medical Director stated when informed the drug screen (lab test performed on 11/24/2025) was negative, he concluded R22 had not received the narcotic medication (as ordered). 2. The State Survey Agency (SSA) Surveyor requested the facility's policy related to the staff responsible for tube feeding (TF) management three times; however, no such policy was presented. Review of the facility's job description for a Registered Nurse (RN), reviewed 11/07/2022, revealed current standards of practice as well as local, state, and federal regulations related to nursing services were to be integrated into the care of patients' (residents). Review of the facility's job description for a Licensed Practical Nurse (LPN), reviewed 11/07/2022, also revealed the current standards of practice as well as local, state, and federal regulations related to nursing services were to be integrated into the care of patients. Review of the Kentucky Administrative Regulations, 201 [NAME] 20:400 specifically, revealed delegation of nursing tasks, effective 01/03/2025, was to be a task that a reasonable and prudent nurse would find was within the scope of sound nursing judgment and practice to delegate (to others). Review of the facility's Resident Face Sheet for R3 revealed the facility admitted the resident on 07/16/2024, with diagnoses that included: gastrostomy, dysphagia, abnormal weight loss, and traumatic brain compression without herniation, subsequent encounter - with bilateral craniotomy and revision. Review of the current MDS assessment dated [DATE] for R3 revealed the facility assessed the resident as having a BIMS score of 99, indicating the resident was unable to complete the interview. In interview with Certified Nursing Assistant (CNA) 11 on 03/09/2026 at 3:27 PM, she stated R3 was mostly in bed during her shifts. She said she turned R3 every two hours and paused the TF on the pump when she got the resident up and down. In interview with LPN 7 on 03/10/2026 at 9:18 AM, she revealed she was aware the CNA's paused R3's TF pump. She further stated however, she was not sure about whether pausing the TF pump was in the scope of practice of a CNA. In interview with LPN 6 on 03/10/2026 at 9:20 AM, she stated pausing TF was not within the scope of practice for a CNA. In interview with the Station 3 Unit Manager (UM) on 03/10/2026 at 11:15 AM, revealed licensed nurses were responsible for managing the TF pump for R3. She reported no caregivers other than nurses were authorized to touch the TF pump at any time. The Station 3 UM stated if a CNA was providing care requiring a position change and the TF pump needed to be paused, the CNA should go get a licensed nurse to pause the pump. In interview with the Director of Nursing (DON) on 03/10/2026 at 5:56 PM, she stated the licensed nurse was responsible for controlling the TF pump and it was out of the scope of practice for a CNA to pause and/or restart a TF pump. She said if a CNA determined a resident needed to be repositioned, the CNA should notify the nurse to pause the TF pump. When the SSA Surveyor asked the DON what could occur if an unqualified person paused and/or restarted a TF pump, the DON stated it would be the same as the nurse doing it and could not identify any possible negative outcomes (though she said the licensed nurse was responsible for the TF pump and CNA's should notify the nurse to pause the pump). In interview with the Administrator on 03/10/2026 at 6:38 PM, she stated her expectation for CNA staff employed by the facility was for them to act within their scope of practice.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 155 of the facility's 155 residents who consumed food from the kitchen. The findings include: Review of the facility policy titled, Dry Storage, revised 06/2025, revealed food items stored in the original packaging and had been opened, were to be closed securely to protect the product. Per review, all items were to be checked at the time of delivery and any severely dented cans or damaged products were to be returned. Continued review revealed questionable dented cans were to be placed in a designated area for thorough review soon after delivery. Additionally, any non-Time/Temperature Controlled for Food Safety (TCS) food product was to be stored in a clean and dry location; not exposed to splash, dust, or other contamination. Review of the facility policy titled, Refrigerator and Freezer Storage, revised 06/2025, revealed food containers were to be clearly labeled with their contents and with the use-by date and/or the date opened. Further review revealed leftover foods were to be stored in an approved container, covered, labeled, and dated and stored in the refrigerator or freezer at the correct temperature. Observation during the initial tour of the kitchen on 03/03/2026, revealed the following: a. Observation of the kitchen's dry pantry storage at 4:00 PM, revealed the #10 can storage shelf had five (120 ounce (oz) cans of apple pie filling, and two (120 oz cans) of mushroom stems and pieces that were dented and damaged, but were still in rotation to serve residents. Continued observation revealed graham cracker crumbs stored on the shelf in a box with the flaps and plastic packaging inside unsealed and exposed to air. Further observation revealed a (97 oz) cannister of hot chocolate, opened and undated. In interview with the Food Service Director (FSD) on 03/03/2026 at 4:20 PM, she stated all dented cans were to be stored in her office until they were returned to the food supplier and credited or replaced. She said she had missed the damaged cans that were stored on the active rotation shelf. The FSD reported she had been told by the health department if cans only had dented rims, they were still usable. She further stated she believed the whole box of the apple pie filling cans must have been received at the facility damaged. The FSD additionally said however, she was aware any dented cans should never have been placed in rotation for use. b. Observation of the kitchen's 3-door refrigerator at 4:40 PM, revealed a large, unsealed plastic container of leftover tomato soup exposed to air. 2. During additional tour of the kitchen on 03/04/2026 revealed the following: a. Observation of the 3-door refrigerator at 11:10 AM, revealed the individual rubber seal around the perimeter of the three doors had a dark colored substance in multiple areas. In interview with the FSD, on 03/04/2026 at 11:20 AM, she stated she was aware of the dark colored substance on the 3-door refrigerator seals. She reported however, she and another dietary partner cleaned the inside and outside of the refrigerators weekly with a product containing bleach. The FSD explained even after cleaning with the bleach cleaner the discoloration remained. She further stated she should have reported the issue to maintenance in order to have the seals replaced as there was no way to know what caused the discoloration. b. Observation of two large storage bins in the kitchen at 11:40 AM, revealed one labeled flour and one labeled sugar were located in between the 3-door refrigerator and a staff accessible sink. Continued observation revealed large white pipes entering and exiting the wall above where the two storage bins were kept. Further observation revealed the storage bin that contained flour was located next to the sink and had dried liquid droplets on the lid near the opening of the bin. In an additional interview with the FSD, on 03/04/2026 at 11:50 AM, she stated she was not aware the location of the flour and sugar storage bins was a concern, but after observing the soiled top of the flour bin she said she was aware of the potential for contamination. She further stated space was limited in the kitchen for storage bins that size; however, she would ensure they were moved immediately. In interview with the Administrator, on 03/10/2026 at 6:44 PM, she stated her expectations for food safety were for staff to ensure no food was served to residents from dented cans. She stated it was the FSD's responsibility to ensure cans were inspected and removed from rotation if dented. The Administrator reported dented cans were to be returned to the food supplier for credits. She said her expectations for the dietary staff was for them to ensure every food item was stored in an appropriate container and sealed to prevent contamination. The Administrator further stated all food items were to be labeled and dated and anything that had possibly been contaminated was to be discarded.

Based on staff interviews, policy, and record review, the facility failed to ensure it developed, implemented, and maintained an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) system that focused on the development, implementation, and evaluation of adverse events to ensure necessary corrective action was taken regarding its pharmacy program. The findings include: Review of the undated facilities policy document with identification at the bottom of the page, as follows: Quality Assurance Performance Improvement (QAPI) Policy, Page 32, R/3-2025, revealed that the QAPI program committee was responsible for implementing and maintaining an ongoing systemwide process of quality improvement. In an interview with the Director of Health Information Management (HIM) on 03/10/2026 at 4:21 PM, she stated she had been in her position for the last two and a half years. She said the facility's QAPI committee met monthly unless an emergency meeting was needed. The Director of HIM explained that the last QAPI meeting was an emergency meeting held in January related to a resident's fall. She reported she did not recall controlled substances having been brought up in QAPI meetings. The Director of HIM stated the facility's current performance improvement plan (PIP), which is being worked on now, was for Medicare certification and inventory sheets. She further stated she had not been aware of the pharmacy issues found in October and November of 2025, and January of 2026. In an interview with the Director of Nursing (DON) on 03/10/2026 at 6:18 PM, she stated concerns with medication were never brought to the QAPI meetings. She stated the internal facility audit, where extra narcotic sheets had been checked, was a concern; however, those checks were not documented. The DON reported things brought to QAPI meetings were: mealtime delivery, falls, and pressure ulcers. She stated that if the medication issues were not being addressed by nursing, it would then be sent to QAPI for the team to help work on the issues. The DON further stated she expected policies to be followed. In an interview with the Administrator on 03/10/2026 at 7:00 PM, she stated wasted medication was a concern to her as the Administrator; however, she reported the facility did not track wasted medications. She stated she attended the QAPI meetings where reports of medication errors were brought up, as well as other issues. The Administrator said a medication error to her would be considered giving a wrong medication to a patient, or a medication pulled from the controlled substance record and not documented in the facility's electronic medication administration record (eMAR). She explained that wasted medication issues should have been brought to the attention of the QAPI team, and the Medical Director should have been notified. The Administrator further stated that if medication problems (such as wasted medication issues) had been brought to the QAPI team, they could have helped in solving the issues. She additionally said the current QAPI problems included fall rates, weight loss, and decreasing hospital emergency visits. In an interview with the Medical Director on 03/10/2026 at 5:21 PM, he stated he had not been made aware of pharmacy audit concerns in October and November 2025. He reported he would want to be made aware of discrepancies if they affected the residents he cared for in the facility. The Medical Director further stated that issues such as this should be brought to the QAPI meetings to find the root cause and implement corrective action.

Based on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. The deficient practice had the potential to affect all residents residing the facility. The findings include: Review of the facility's policy titled, Mail Distribution to Patients, revised 09/01/2014, revealed mail would be distributed to the patient within 24 hours of delivery by the postal service. The policy further stated if the recreation department was not routinely at the center on weekends, the task must be assigned to another department head or responsible partner. During the Resident Council meeting on 12/10/2024 at 2:02 PM , Resident (R) 26 stated residents did not receive or send mail on Saturdays at the facility. R26 stated she did receive mail on Monday through Friday when the activities department was working in the facility. The remainder of the resident attendees confirmed there was no Saturday mail delivery. During an interview with the Activities Director (AD) on 12/11/2024 at 1:37 PM, she stated mail was not passed out to the residents on Saturdays due to the activities department not having weekend staff. She further stated, We are short handed and don't have anyone here every weekend to pass out the mail. During an interview with the Administrator on 12/13/2024 at 2:37 PM, she stated the activity/recreation department was responsible for delivering resident mail Monday through Friday. The Administrator further stated she was aware there had been a lapse of residents not having their mail delivered on Saturdays. She stated the receptionist would begin delivering mail on Saturdays. She stated she expected the mail to be delivered to the residents on the weekends.

Based on observation, interview and review of facility policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Review of the facility Matrix (CMS-802) received on 12/10/2024 revealed 147 of 149 residents received their meals from the kitchen. Observation on 12/09/2024 revealed food items stored in the three-door refrigerator were open to air, not labeled, and/or undated. Observations on 12/12/2024 and 12/13/2024 revealed dietary staffs' hair and/or beards were not properly secured under a hairnet and/or beard guard. The findings include: Review of the facility policy titled, Refrigerator and Freezer Storage, dated with a reviewed/revised date of 11/2017, revealed refrigerated and frozen goods will be stored properly for optimal product safety. Further review of the policy revealed foods will be stored in their original container or an approved contain or wrapped tightly in moisture-proof film, foil, etc. and clearly labeled with the contents and the use by date. Additionally, per the policy, The use by date is determined by a 7-day period that includes the day the food was prepared plus the 6 days following. Review of the facility policy titled, Hygienic and Safety Practices, with a reviewed/revised date of 11/2017 revealed effective personal hygienic and safety practices are essential in preventing food contamination. The guidelines included that hair restraints should be worn and were worn to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Observation during the initial tour of the kitchen on 12/09/2024 at 6:40 PM revealed the three door refrigerator cabinet contained the following food items: one open box with an unsealed plastic bag of hot dogs which was open to air; one container of sliced raw carrots with a use by date of 12/08/2024; one plastic container with a snap-on lid of sliced pineapple in juice with a preparation date of 11/26 and a D/C date of 12/15 which, on the date of inspection, 12/09/2024, would have exceeded the seven day storage period; one undated plastic container with a snap-on lid that was unlabeled and appeared to contain pickles; and one mislabeled container of vegetable soup with a preparation date of 12/09/2024 and D/C date of 12/19 which would exceed the seven day storage guideline per the facility policy. Ongoing initial tour of the kitchen on 12/09/2024 at 6:40 PM revealed a single door heating cabinet that contained one undated container of oatmeal and one undated container of gravy. The Food Service Manager (FSM) stated these portions were made earlier today and were to be sent out to a resident this evening. Observation of the single door cooling cabinet on 12/09/2024 at 6:40 PM revealed multiple individual green salads that were labeled and dated; however, two of the salads were not labeled or dated. Observation on 12/12/2024 at 11:40 AM of the kitchen staff during meal service revealed the cook Cook1 with a hair restraint improperly worn and not fully covering the hair with all of the bangs out from under the hairnet. Observation on 12/13/24 9:52 AM revealed the Assistant Cook, who had a beard, was observed not wearing a beard restraint while putting chocolate pudding into individual serving size bowls. The Assistant [NAME] stated he had not been asked to wear a beard guard. He stated would put one on and proceeded to obtain and apply a beard guard. During an interview on 12/09/2024 at 6:55 PM, during the initial tour of the kitchen the Food Service Manager (FSM) stated the hot dogs should have been inside a zip lock bag and sealed. The FSM removed the sliced carrots, pineapple in juice, and stated all items should be labeled and dated. In an interview with the FSM on 12/12/2024 at 11:40 AM, when the cook Cook1 was observed improperly wearing the hair restraint with all bangs out of the net. The FSM stated the hair net was being worn improperly and said, I will talk to her. The FSM stated it was her expectation that all the hair was covered. In an interview on 12/13/2024 at 09:50 AM with the Dietary Aide, she stated it was the expectation to cover all the hair when wearing a hair net to prevent food from getting into people's food. She stated if she saw another employee improperly wearing a hair net, she would tell the co-worker and expected them to fix it. In an interview with the FSM at 12/13/2024 at 11:00 AM, she stated it was her expectation that staff with beards wear beard guards to prevent hair from getting into food. In an interview with the Director of Nursing (DON) on 12/13/2024 at 2:09 PM, she stated it would be her expectation for dietary staff to label and store food according to policy to prevent food related illness. The DON also stated she would expect dietary staff to properly wear hair nets and beard guards to prevent hair from getting into the food. In an interview with the Administrator on 12/13/2024 at 2:53 PM, she stated it was her expectation for dietary staff to label and date all food items in the refrigerator and that staff properly wear hair and beard restraints to ensure that the food we feed and deliver to our residents and are safe for consumption guidelines.

Based on interview, record review and facility policy review, it was determined the facility failed to report an allegation of verbal abuse of one (1) of three (3) sampled residents (Resident #2). Resident #1 reported Resident #2 was verbally abused by Certified Nurse Aide (CNA) #1 and #2. The facility failed to report the allegation to the appropriate state agencies within two (2)hours of receiving the allegation per facility policy. The findings include: Review of facility policy titled Patient Protection and Response Policy for Allegations/Incident of Abuse, Neglect, Misappropriation of Property and Exploitation, revision date 09/14/17 revealed .The definition of verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy reveals under the Policy Table of Contents, #6 .Reporting Policy; Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploration must report the event immediately, but not later than two (2) hours after forming the suspicion, if the events that cause suspicion results in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the suspicion do not result in serious bodily injury.It is the policy that abuse are reported to Federal and State Law. The facility will ensure that all alleged violations be reported to the Administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Record review revealed the facility admitted Resident #1 on 10/19/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Heart Failure, and [CONDITION(S)], and [CONDITION(S)] following a Cerebral Infarction. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/03/19 revealed the facility assessed the resident's cognition to be intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Record review revealed the facility admitted Resident #2 on 02/31/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #1 on 01/07/2020 at 10:30 AM revealed he/she was laying in the bed and heard CNA #1 and #2, while assisting his/her roommate (Resident #2) with care, make the comment You get in the bed, you are a pain in the ass, you're getting[OBSCENITY]all over me. Resident #1 stated his/her roommate cannot do anything, just has to lay in bed, but he/she can hear but just not talk. The resident stated the CNA's should not be talking like that around him/her. Resident #1 further revealed he/she told CNA #3 when she came on shift that morning. The resident stated the people in the office came to talk with him/her and he/she told them the same thing, and they asked him/her not to tell anyone else. Interview with CNA #3 on 01/08/2020 at 10:20 AM revealed she had come in to work the morning of the event and Resident #1 told her CNA #1 and #2 made the comment to Resident #2 that he/she was getting[OBSCENITY]all over them and had become a pain in the ass. CNA #3 revealed she reported the event to Licensed Practical Nurse (LPN) #1 immediately. Interview with LPN #1 on 01/07/2020 at 11:30 AM revealed the event was reported to her that morning by CNA #1 and she reported it to LPN #2 directly after it was reported to her. She stated LPN #2 reported it to the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator. Interview with LPN #2 on 01/08/2020 at 11:15 AM revealed the event was reported to her by CNA #3 and #4, and she called the Unit Manager, and the Director of Nursing (DON) that morning after it was reported to her. Interview with the Assistant Director of Nursing (ADON) on 01/08/2020 at 10:45 PM revealed her and the DON talked with Resident #1 after the event had been reported to them. She stated Resident #1 had said he/she had heard one of the CNA's say something about ass, but nothing was said about[OBSCENITY] She stated she first thought Resident #1 was trying to cause drama because he/she did not want to be a resident at the facility, or maybe just misunderstood what was said. She revealed when she interviewed CNA #2, CNA #2 stated she did say pain in the ass but was referring to Resident #2's tight pants, only jokingly. The ADON revealed they counseled CNA #2 for using inappropriate language. She further revealed the Administrator was made aware early that morning along with herself and the DON, but did not feel it was necessary to notify the state officials after CNA #2 had admitted to saying pain in the ass. Interview with the DON on 01/07/2020 at 2:45 PM revealed she and the ADON had spoken to CNA #1 and #2 individually on the morning of 11/21/19 and CNA #1 denied saying anything to Resident #2. The DON stated when interviewing CNA #2, the CNA stated Resident #2's pants were too tight and she laughed and told Resident #2 his/her pants were a pain in the ass. Further interview on 01/09/2020 at 11:20 PM revealed; I stayed up all night thinking about this and I agree this should have been investigated and reported. This has been a learning experience for me and I want to thank you. Interview with the Administrator on 01/08/2020 at 3:05 revealed the incident was reported to her by the ADON and the DON. She stated after interviewing Resident #1, and determining the CNA had used the word[OBSCENITY]but it was not directed toward the resident, so she did not feel the need to call it into state.

Based on interview, record review, review of the facility's internal investigation, and facility policy review, it was determined the facility failed conduct a complete investigation of an allegation of verbal abuse of one (1) of three (3) sampled residents (Resident #2). Resident #1 alleged Certified Nurse Aides #1 and #2 verbally abused Resident #2 on 11/20/19. The facility failed to interview all staff involved in the alleged incident. The findings include: Review of facility policy titled Patient Protection and Response Policy for Allegations/Incident of Abuse, Neglect, Misappropriation of Property and Exploitation, revision date 09/14/17 revealed verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Further review of the policy revealed all events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether abuse, neglect, misappropriation of property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. Record review revealed the facility admitted Resident #1 on 10/19/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Heart Failure, and [CONDITION(S)], and [CONDITION(S)] following a Cerebral Infarction. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 11/03/19 revealed the facility assessed the resident's cognition to be intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Record review revealed the facility admitted Resident #2 on 02/31/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #1 on 01/07/2020 at 10:30 AM revealed he/she was laying in the bed and heard CNA #1 and #2, while assisting his/her roommate (Resident #2) with care, make the comment You get in the bed, you are a pain in the ass, you're getting[OBSCENITY]all over me. Resident #1 stated he/she told CNA #3 when she came on shift that morning. Interview with Licensed Practical Nurse (LPN) #2 on 01/08/2020 at 11:15 AM revealed the event was reported to her by CNA #3 and #4, and she called the Unit Manager, and the Director of Nursing (DON) that morning after it was reported to her. Review of the facility Internal Investigation Form, dated 11/21/19 at 730 AM revealed Certified Nurse Aides #1 and #2 were talked to separately after they interviewed Resident #1 and the findings revealed: CNA #2 made the statement, in a joking manner, to Resident #2 that his/her pants were a pain in the ass due to them being to tight while pulling them up. CNA #2 was up front regarding what she stated and was counseled on her language. CNA #2 stated she was not upset or irritated at all and that she was making a joke to initiate a laugh from Resident #2. Further review of the investigation revealed no other staff were interviewed or asked to write a statement on what they were told or observed related to the alleged allegation of verbal abuse. Interview with the Assistant Director of Nursing (ADON) on 01/08/2020 at 10:45 PM revealed her and the DON talked with Resident #1 after the event that had been reported to them. She stated Resident #1 had said he/she had heard one of the CNA's say something about ass, but nothing was said about[OBSCENITY] She stated she interviewed CNA #2, and the CNA stated she did say pain in the ass but was referring to Resident #2's tight pants, only jokingly. The ADON stated they counseled CNA #2 for using inappropriate language. Interview with the DON on 01/07/2020 at 2:45 PM revealed she and the ADON had spoken to CNA #1 and #2 individually on the morning of 11/21/19 and CNA #1 denied saying anything to Resident #2. The DON stated when interviewing CNA #2, the CNA stated Resident #2's pants were too tight and she laughed and told Resident #2 his/her pants were a pain in the ass. Further interview on 01/09/2020 at 11:20 PM revealed the DON stated, I stayed up all night thinking about this and I agree this should have been investigated with written statement taken by all staff that was involved. This has been a learning experience for me and I want to thank you.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 06/25/19 , revealed food stored in the walk-in refrigerator was not covered. Review of the facility Census and Condition, dated 06/25/19, revealed one-hundred and sixty-one (161) of one-hundred and sixty-six (166) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Refrigerator and Freezer Storage, revision date 11/2017, revealed refrigerated and frozen foods will be stored properly for optimal product safety. Further review of the policy revealed foods will be stored in their original container or an approved container or wrapped tightly in moisture-proof film, foil, etc. and clearly labeled with the contents and the use by date. Observation of the walk-in refrigerator during initial tour, on 06/25/19 at 1:48 PM, revealed four (4) pans of biscuit were uncovered and open to air. Interview with Dietary Manager, on 06/25/19 at 1:59 PM, revealed all items stored in the refrigerator should be covered, dated, and labeled. She further stated they normally have plastic bags covering the pans of biscuits and they should be covered and not open to air. Interview with Regional Nutritional Services Manager, on 06/27/19 at 3:54 PM, revealed she would expect items to be dated and covered per the facility policy.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure health information was maintained in a private and confidential manner for one (1) resident. On 06/28/19, a resident information form containing medical information, was observed unattended and exposed to public view on top of a medication cart in the hallway. The findings include: Review of the facility policy, Confidentiality of Information and Personal Privacy, last revised (MONTH) (YEAR), revealed the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The facility will strive to protect the resident's privacy regarding his or her accommodations, medical treatments, and personal care. Further review of the policy revealed access to resident personal and medical records wilt be limited to authorized staff and business associates. Observation, on 06/28/19 at 9:45 AM, revealed an unattended medication cart on, in front of a resident's room. Further observation revealed the form was visible and in plain view. Continued observation revealed two (2) visitors and five (5) staff members, pass by the medication cart. Interview with Licensed Practical Nurse (LPN) #1 on 06/28/19 at 9:55 AM, revealed she should have turned the page over to ensure privacy because it can be considered a Health Insurance Portability and Accountability Act (HIPPA) violation. Interview with the Assistant Director of Nursing (ADON), on 06/28/19 at 2:22 PM, revealed she would expect health information to be kept private. She further stated all staff are inserviced upon hire and annually on HIPPA.

Based on interview, record review and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure a discharge assessment was completed for one (1) of three (3) closed records reviewed (Resident #55). The findings include: Review of the RAI version 3.0 User Manual revealed Discharge Assessments must be completed when the resident is discharged from the facility and the resident is not expected to return within thirty (30) days. Closed record review revealed the facility admitted Resident #55 on 03/16/19 with [DIAGNOSES REDACTED]. Review of the Nurses Notes, dated 04/29/19, revealed the resident was sent out to the hospital and admitted . However, further record review revealed the staff failed to complete a discharge Minimum Data Set (MDS) assessment after the resident was discharged from the facility. Interview with the MDS Coordinator, on 06/28/19 at 10:34 AM, revealed she expected a discharge MDS to be completed on all resident's who were discharged and the facility should have completed a discharge MDS assessment on Resident #55. She stated she was not sure why it had not been completed. Interview with the Assistant Director of Nursing (ADON) on 06/28/19 at 2:22 PM, revealed she would have expected Resident #55 to have a discharge MDS assessment completed by the MDS Coordinator per the RAI guidelines and timeframe's.

Based on observation, interview, record review, facility policy review, and review of the facility Haz Com Program, it was determined the facility failed to ensure four (4) of four (4) residents identified as residents who wandered remained as free of accident hazards, and risks as possible (Residents #162, #113, #132, and #95). Observation revealed there were four (4) vials of essential oils sitting on the nursing station out of eyesight of staff, and where residents would have access to them. Interview with Registered Nurse/400 hall Unit Manager on 6/27/19 at 11:35 AM revealed the unit housed four (4) wandering residents (Residents #162, #113, #132, and #95). The findings include: Review of the facility's Haz Com Program policy, revealed Copies of SDS's (Safety Data Sheets) for all hazardous chemicals to which workers are exposed or are potentially exposed will be kept in Maintenance Office. Workers can access SDS's by logging into Center Share. The Maintenance Director is responsible for reviewing the SDS's received for safety and health implications and initiating any needed changes in workplace practices. A list of ALL known hazardous chemicals in the workplace is attached to (this) program. This list includes the name of each chemical, and the work area(s) in which each of the chemicals is used. To ensure that any new chemical is added in a timely manner, the following procedures shall be followed: The new chemical will be clearly labeled in accordance with requirement of HazCom 212, including a product identifier, pictogram, hazard statement, signal word, and precautionary statement, as well as the supplier's contact information (name and address). Review of the facility Haz Com Program revealed the following substances were included in the assessment: Clorox Toilet Bowl Cleaner, Heavy Duty Low Odor Floor Stripper, Shineline Baseboard Stripper, Shineline Emulsifier Plus, Aero Curveball, Aero Orange Works, and Pure Brite Germicidal Bleach. Further review revealed there were no essential oils included in the program. Review of copies of essential oils labels brought by the Administrator, revealed the Tea Tree Essential oil clearly stated Keep out of Reach of Children, and not to use internally unless directed by a licensed radiotherapist or physician. The(NAME)label revealed Do not ingest oil and Due to the potency of the oil . dilute with a carrier oil. The(NAME)oil label also stated Do not ingest oil, avoid contact with eyes and other sensitive areas. Due to the potency of the oil, dilution with a carrier oil is recommended. Keep out of the reach of children. Review of the Brief Interview of Mental Status (BIMS) scores revealed Resident #162 scored five (5)' on 06/05/19 and Resident #132 scored a three (3) on 05/28/19, which indicted the residents had severely impaired cognation and, Resident #113 scored a nine (9) on 05/13/19 and Resident #95 scored an eight (8) on 05/04/19, which indicated the resident had moderately impaired cognition. Observation on 06/26/19 at 9:45 AM revealed four (4) vials of essential oils:(NAME)(almost empty),(NAME)(full vial), Tea Tree (full vial), and Christmas (full vial); sitting on the nurses station. The nearly empty vial of(NAME)sat beside a white mesh bag which contained the other three (3) vials. The vials were on the desk near an entrance from the hall to the nurses station. The nurses station was located in a unit on which cognitively impaired and mobile residents resided. The desk was accessible to residents on the unit. Observations on 06/26/19 at 2:30 PM and at 4:00 PM revealed the essential oils were still located on the desk in the same location as the earlier observation. Residents were seen ambulating/self-propelling up and down the hall where the desk was located and staff nurses were attending other residents. Observation on 06/27/19 at 9:00 AM revealed the essential oils were still located on the desk in the same location as observed on 06/26/19. One resident, identified as at risk for wandering, was seated near the desk with an overbed table in front of him/ her. Observation on 06/27/19 at 11:40 AM revealed the essential oils were still located on the desk in the same location by the entrance to the nurses' station. Residents were seen in the hallway and nursing staff were in and out of the station. Observation on 06/27/19 at at 4:05 PM revealed the essential oils were still located on the desk in the same location, and residents were noted in the hall. The Nursing staff were engaged in patient care and the Unit Manager was in the small room behind the station. Further interview with Registered Nurse/400 hall Unit Manager, on 06/27/19 at 4:05 PM revealed the essential oils belong to the facility and were on the nurses station to refill the essential oil diffuser on the unit. She stated the diffuser sits behind the nurses station, however, when she looked for the diffuser, it was not there. She stated the diffuser may be in the Unit Four (4) day room and confirmed the diffuser was there. She further revealed the oils usually stay in the drawer at the nurses' station, and the station occasionally/briefly lacks a staff member to monitor the security of the oils. Interview with the Assistant Director of Nursing (ADON), who was in charge of the nursing department while the DON was on vacation, on 06/28/19 at 2:05 PM revealed the oils were not dangerous compared to hand sanitizer, which was readily available throughout the unit. She stated the oils would not cause harm, then conceded she would not allow a child to consume the essential oils. Interview with the Administrator on 06/28/19 at 2:20 PM revealed the facility had not obtained a SDS for the essential oils, and the oils were not included in the Haz Com Program assessment of the facility due to the labels not having a hazardous symbol. She stated the facility used the essential oils in diffusers as a behavior intervention. Further interview with the Administrator on 06/28/19 at 4:00 PM revealed the facility did not have a chemical storage policy. After review of the oil label, the Administrator acknowledged the oils should be kept in a secure location.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1) to include the assessed needs of the resident related to bed mobility and incontinent care. On 07/12/18, the facility assessed Resident #1 had [MEDICAL CONDITION] (paralysis right side), and required extensive assistance of two (2) staff for bed mobility; however, review of the Comprehensive Care Plan revealed the facility care planned the resident required the assistance of one to two (1-2) staff for incontinent care, leaving it to the CNA's to assess the resident on a daily basis to determine if the resident required one or two assist. On 07/28/18, a CNA (without the assistance of another staff member) provided incontinent care to Resident #1 in bed, and when the resident threw his/her good leg over to the right side to assist, the momentum of the resident's leg caused the resident to roll off the bed on to the floor resulting in a fractured right femur. Resident #1 had emergency surgery on 07/29/18. The findings include: Review of facility policy titled, Care Plan, Comprehensive Person-Centered, last revised (MONTH) (YEAR), revealed a Comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being, incorporate identified problem areas, incorporate risk factors associated with identified problems, aide and preventing or reducing decline in the resident's functional status and/or functional levels, reflect currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required comprehensive assessment (MDS). Record review revealed the facility admitted Resident #1 on 11/01/04 with [DIAGNOSES REDACTED]. Review of the annual Minimum Date Set (MDS) assessment, dated 07/12/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Further review revealed the facility assessed Resident #1 to require extensive assistance (staff providing weight bearing support and resident participating in activity) of two (2) staff for bed mobility, dressing, and toileting; and he/she had functional limitation in range of motion (limitation that interfered with daily functions or placed resident at risk for injury) on both sides for upper and lower extremities. In addition the resident had Active [DIAGNOSES REDACTED]. However, review of Resident #1's Complete Patient Care Plan for Self Care deficits, dated 05/21/18 and Patient Information Certified Nurse Aide (CNA) Care Guide, not dated, revealed to provide the assist of one (1) to two (2) staff for incontinent care instead of the two (2) staff per the MDS assessment which left it up to the CNA to assess the resident to determine the amount of assistance needed. In addition, the care plan did not address the extensive assistance the resident was assessed to require. Further review revealed the care plan was updated on 08/02/18 and the CNA Care Guide was updated on 07/28/18 after the fall, to provide two (2) assist for incontinent care. Review of Resident #1's Initial Note, dated 07/28/18 on on 08/31/18 at 3:47 PM revealed CNA #2 was changing resident per plan of care (one to two {1-2} assist) for incontinent care, and had the resident on his/her right side. The resident swung his/her leg, fell out of the bed, and landed on his/her right side on the fall mat. Physician and family notified, ordered sent to emergency room (ER) to evaluation. Review of the hospital Discharge Summary, dated 08/02/18, revealed the resident was discharged with a [DIAGNOSES REDACTED]. Interview with Certified Nurse Aide (CNA) #2 on 08/31/18 at 3:47 PM revealed she was changing Resident #1 and the bed linens at the same time, with the bed raised. She stated she had Resident #1 roll over on to his/her right side, she tucked the dirty linen under the resident, and then to assist the resident grabbed the bed rail with his/her good hand (left hand), and threw his/her good leg (left) over toward the right side of the bed, as the resident has always done in the past but the momentum caused the resident to go over the side of the bed, and the resident landed on the floor. She revealed she tried to grab Resident #1's leg; however, the resident was dead weight and it happened to fast to catch the resident. Further interview revealed she was hired in (MONTH) (YEAR) and Resident #1's care plan had always read one (1) to two (2) assist with turning, bathing, and hygiene. She stated she always provided care for Resident #1 by herself and there were several residents with care plans that read one (1) to two (2) assist. She revealed she generally tried to take care of the resident by herself and then if she determined she could not provide care by herself at that time she would go get help. She stated it was up to the nurse aide to decide how many people was needed to provide care for the resident if the care plan read one (1) to two (2) assist. Interviews with CNA #1, on 08/31/18 at 1:28 PM, CNA #6 on 09/01/18 at 2:48 PM, CNA #7 on 09/01/18 at 3:00 PM, CNA #8 on 09/01/18 at 3:30 PM, and CNA #9 on 09/02/18 at 8:46 AM, revealed when a resident is care planned for one (1) to two (2) assistance, the CNA's have to make the decision on how many people it would really take to care for the resident. Interview with Licensed Practical Nurse (LPN) #1, on 08/31/18 at 2:16 PM, revealed Resident #1 has been a one (1) to two (2) assist for as long as she could remember. She revealed the care plan was a guide on how to provide care for the residents and if it read one (1) to two (2) assist, it would be up to the CNA to decide how many staff was needed to provide the care for the resident at that specific time. She stated sometimes it takes one (1) and sometimes it takes two (2), depending on the time and the situation. Interview with MDS Coordinator #2, on 08/31/18 at 4:15 PM revealed according to the most recent annual MDS assessment completed on 7/12/18, Resident #1 was coded three (3) for self-performance and coded three (3) for support for bed mobility, which indicated extensive assistance of two (2) person for physical assist for bed mobility. She stated the resident's care plan should be a reflection of the MDS assessment; however; the facility developed the care plan as person-centered, specific to the individual resident. She revealed the whole team discusses the individual resident, and a CNA takes part in the care plan meetings, because they are who provide the bulk of the care to the resident. She stated the care plan was also developed based on the seven (7) day look back period which showed how many staff were required to provide the care during that period. She revealed the seven (7) day look back period for 07/06/18 to 07/12/18, revealed Resident #1 required an assist of two (2) staff for bed mobility nine (9) times; and required one (1) staff for bed mobility ten (10) times. She stated that was why the resident was care planned for one (1) to two (2) assist with turning and repositioning. She revealed some resident's may require more assistance at various times of the day, depending on how they are doing for the day. She stated it was up to the CNA who is providing the care at that time to decide how much care the resident is going to require. She revealed the facility does not actually base the care on the MDS Assessment, the facility looks back at the seven (7) day look back period and then develops the care plan as a team, based on the information the CNAs entered into the ADL system. She stated the team tries to make the care plans person-centered, and not the same across the board for all the residents. Interview with Resident #1's Primary Care Provider, on 08/31/18 at 12:50 PM revealed the fall was an unfortunate event, and in her opinion it was not neglect or malice intent. She stated Resident #1 has a history of right sided [MEDICAL CONDITION], and used his/her left good arm and leg to help turn him/herself over with assistance. She revealed due to the resident's history it may have been helpful to have two (2) people in the room, as it may have helped to prevent the resident from falling out of the bed, when the resident swung his/her leg over the side of the bed. She stated after the fall, the facility has changed the resident's care plan to always have (2) assist with all care. She stated, the resident sustained [REDACTED]. Interview with the Director of Nursing (DON) on 08/31/18 at 1:52 PM revealed Resident #1's fall was an accident, accidents do happen, and the resident has lived in this facility for fourteen (14) years with no prior history of falls. The DON stated the staff to include CNA's sit down as a team to develop the care plan, She revealed the facility reviewed all the information about the individual residents and developed individual care plans that are not based on specific numbers. She stated the staff take the MDS information into consideration; however, that is not what we base the entire person-centered care plan around. She stated the CNA's do not assess the resident. She stated the CNAs go by the resident care plan and the information they received from the off going shift on how the resident has been doing on the previous shift. She revealed if the CNA determined the resident was having a bad day, or not feeling well, then the CNA would know the resident required more care.

Based on observation, interview, record review, and hospital record review it was determined the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was diagnosed with [REDACTED]. However, the facility failed to ensure the adequate amount of supervision/assistance was provided when they care planned the resident to need one to two staff for incontinent care. On 07/28/18, one (1) CNA provided incontinent care for Resident #1 and when the resident threw his/her good leg (left) to the right side to assist with turning, the resident's momentum caused the resident to roll off the right side of the bed on to the floor resulting in a fractured right femur. Resident #1 had emergency surgery on 07/29/18. The findings include: Review of facility policy titled, Falls and Fall Risk, Managing, last revised (MONTH) 2007, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Record review revealed the facility admitted Resident #1 on 11/01/04 with [DIAGNOSES REDACTED]. Review of Fall Risk Evaluation for Resident #1, dated 05/02/18 revealed a total score of fourteen (14) which indicated the resident was at high risk for falls due to level of consciousness/mental status, ambulation/elimination status, gait/balance, medications, and predisposing disease. Review of the annual Minimum Date Set (MDS) Assessment, dated 07/12/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Further review revealed the facility coded Section G0110 Functional Status for bed mobility as self performance (3) and support (3), which indicated extensive assistance (staff providing weight bearing support and resident participating in activity) of two (2) person physical assist for bed mobility. In addition, the facility coded Section G0400 Functional Limitation in Range of Motion {limitation that interfered with daily functions or placed resident at risk for injury} revealed impairment on both sides for upper and lower extremities. Review of Section I Active Diagnoses, revealed [MEDICAL CONDITION] [MEDICAL CONDITION], or Stroke; [MEDICAL CONDITION] or [MEDICAL CONDITION], and contracture of right hand. Review of Complete Patient Care Plan for Self Care Deficits present related to history of [MEDICAL CONDITIONS], joint stiffness, communication deficits, Dementia, [MEDICAL CONDITIONS], Depression, inability to provide own care independently, and requires assist with ADL's, dated 05/21/18, and the Patient Information Certified Nurse Aide (CNA) Care Guide, not dated, revealed an intervention for the assist of one (1) to two (2) for incontinent care even though the MDS assessment identified two staff were needed for adequate assistance and supervision. Further review revealed the Complete Patient Care Plan was updated on 08/14/18 and the CNA Care Guide was updated on 07/28/18, to two assist with incontinent care. Review of Resident #1's Alert Charting Initial Note, dated 07/28/18 revealed a CNA was changing resident per plan of care (1-2 assist), had resident on his/her right side, resident swung his/her leg over, fell out of the bed and landed on his/her right side on the fall mat. Physician and family notified, ordered sent to emergency room (ER) for evaluation. Review of nursing home to hospital transfer form, dated 07/28/18 revealed Resident #1 was transferred out to the local emergency room (ER) for fall and pain in the right hip and leg, most recent pain level was yelling related to pain of right hip and leg. Review of hospital History and Physical dated 07/28/18 revealed Resident #1 presented to the hospital with a Right Femur Fracture. The resident was in a tremendous amount of pain and was yelling and very agitated. The Physician prescribed pain medications, but did not see any other route except to surgically fix the fracture due to the resident's severity of pain and the pain would be extremely hard to control without surgical fixing. Review of hospital Discharge Summary dated 08/02/18, revealed Resident #1 was discharged with a [DIAGNOSES REDACTED]. Observation of Resident #1 on 08/31/18 at 11:20 AM revealed the resident was lying in a low bed with eyes open, positioned on his/her backside, with pillow between knees, covered with white sheet. There were quarter (1/4) rails attached at the top on both sides of the bed, a gray fall mat in the floor on each side of the bed. The resident was no interviewable but the resident smiled at the surveyor and pointed at his/her leg. Interview with Certified Nurse Aide (CNA) #2 on 08/31/18 at 3:47 PM revealed she was changing Resident #1 and the bed linens with the bed raised up to her belly button level (she stated she was five (5) foot three (3) inches tall). She stated she assisted Resident #1 to roll over on to his/her right side, then tucked the dirty linen under the resident. She further stated the resident grabbed the bed rail with his/her good hand (left hand), and then threw his/her good left leg over toward the right side of the bed to assist with turning as he/she always had done. CNA #2 revealed the resident had so much momentum with his/her good left leg, the resident just kept rolling over the side of the bed, and landed on the floor. She stated she tried to grab Resident #1's leg; however, the resident was going way too fast for her to catch the resident, and the resident was dead weight. She stated she immediately went and notified the charge nurse to come assess the resident, and it took several nurses to use the really long sling device to place the resident back in the bed. CNA #2 further revealed she was hired in (MONTH) (YEAR) at the facility and Resident #1's care plan had always read one (1) to two (2) assist with turning, bathing, and hygiene. She stated she had always provided care for Resident #1 by herself and there were several residents with care plans that read one (1) to two (2) assist. She stated generally she tries to take care of the resident by herself at first, and if she see's at that time she can not provide care by herself then she will go get help. She stated sometimes the resident is tired, sick, not feeling well and they can not help much, then it would take two (2) people instead of one (1) person. She stated if the care plan reads one (1) to two (2) assist it would be up to her to decide how much care the resident actually needed. Interview with Licensed Practical Nurse (LPN) #1, on 08/31/18 at 2:16 PM, revealed CNA #2 came and notified her that Resident #1 had fallen out of the bed, and was lying on the right side of the bed on the floor. She stated she assessed Resident #1 and at that time Resident #1 did complain of some pain with the right leg. She revealed several nurse's came to assist and we placed Resident #1 back in the bed, and she immediately called the physician and the family. She stated the resident was sent out to the local emergency room for evaluation and treatment. She revealed Resident #1 has been a one (1) to two (2) assist for as long as she can recall. She revealed the care plan was a guide to provide care for the residents and if it reads one (1) to two (2) assist, it would be up to the CNA to decide how much help they are going to need to provide care for that resident, based on the resident at that specific time. She stated Resident #1 has been a two (2) assist with all care at all times, since he/she returned from the hospital. Interview with Resident #1's Primary Care Provider, on 08/31/18 at 12:50 PM revealed the facility made her aware of the resident's fall, and she ordered Resident #1 sent out to treatment and evaluation. She stated it was unfortunate event, and in her opinion it was not neglect or malice intent. She revealed the resident does have a history of Right sided [MEDICAL CONDITION], and does have use of his/her left good arm and leg to help turn her/himself over. However; with the resident's history it may have been helpful to have two (2) people in the room, as it may have helped prevent the resident from falling out of the bed, when the resident swung his/her leg over the side of the bed. She stated the facility changed the resident's care plan after the fall to always have (2) assist with all care. She stated the resident sustained [REDACTED]. Interview on 08/31/18 at 1:52 PM with the Director of Nursing (DON) revealed she was made aware of the fall on 07/28/18 at 7:45 PM, by the House Supervisor. She stated the House Supervisor informed her CNA #2 was providing incontinent care and turning Resident #1 while in the raised bed, and Resident #1 was holding onto the right side of the rail with his/her good left hand. She stated the House Supervisor said while CNA #2 was trying to tuck a sheet under the resident, the resident lifted his/her good left leg to help assist CNA #2 and when the resident swung his/her left leg toward the right side of the bed the momentum of swinging the left leg toward the right side of the bed caused the resident to slide off the right side of the bed on to the floor. She stated the resident was sent out to the emergency room for evaluation and treatment and required surgery to the Right femur. She revealed on Monday {7/30/18} the team (DON, falls prevention nurse, Unit Manager, Staff Development Coordinator {SDC}, and the Administrator} did a root cause analysis regarding the fall, interviewed CNA #2 , and looked at the resident's care plan. She stated the root cause of the fall was the resident slinging his/her left leg at a fast momentum causing him/her to slide off the right side of the bed. She revealed the resident has lived in the facility with no history of falls, and this was just an accident, accidents do happen and she does not feel the facility failed the resident in any way. She stated she did not consider Resident #1 a high risk for falls, just because he/she scored a fourteen (14) on the fall risk assessment, as it is just a number and we do not look at our resident's as a number we look at them as individuals. She stated when you look at that number on the fall risk assessment what does that really tell you about that individual resident, its just a number, it does not tell you anything specific to that individual resident. She stated nurse's assess the resident and add what is needed to the resident care plan, and the CNAs do not assess the resident. She stated the CNA's go by the resident care plan and the information they receive from the off going shift on how the resident has been doing on the previous shift. She stated if the CNA determines the resident was having a bad day, or not feeling well, then the CNA would know the resident would require more care, and at that point the CNA would have to determine if the resident required one or two assist, based on the shift report.

Based on interview, record review, facility policy review and review of the Hospital History of Present Illness and Acute Care Hospital (ACH) Record, it was determined the facility failed to revise a care plan for one (1) of fourteen (14) sampled residents (Resident #2) that addressed the resident's assessed need of two (2) staff for bathing and bed mobility. Resident #2 was assessed by the facility as requiring the assistance of two (2) staff for bathing and bed mobility: However, the facility failed to revise the care plan to reflect the need for two (2) assist with bathing or bed mobility. On 06/21/15, Certified Nurse Aide (CNA) #1 was providing a bed bath to Resident #2 without the assistance of another staff. When she turned to obtain a washcloth, Resident #2 turned over and fell out of bed. Resident #2 sustained bilateral nasal bone fractures, a bilateral subarachnoid hemorrhage, and a subdural hematoma along the right temporal frontal region. The findings include: Review of the facility's Medical Record Manual, last revised 06/10/11, revealed resident problems should be identified -- with time limited goals and specific approaches to reach each goal. The care plan should be individualized to meet the needs of the resident with the discipline responsible for each approach identified. Review of the facility's Documentation Guidelines, Care Plan Development, last revised 07/03/08, revealed nursing staff as close to the resident care as possible, Social Worker, Recreation, Dietary, and other disciplines as appropriate for the particular resident were responsible for developing the resident's care plan. The problem should be determined by how does the condition affected the resident's well-being (not their partner's ability to do their work). The care plan goals may be short-term, long-term, or intermediate goals that should lead to a reasonable attainable objective. The timeframes should be set according to the needs of each individual. Care plan approaches should be specific, individualized steps staff and residents will take together to assist the resident to achieve the goal. Further review revealed the care plans should be updated as needed. In addition, new problems should be handled as they arise, and should be added to the current care plan even if the change in condition is not considered significant enough for a complete revision. Record review revealed the facility admitted Resident #2 on 06/30/08 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 04/23/15, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. In addition, the facility assessed the resident as requiring total assistance of two (2) for bathing and bed mobility. Bed mobility was defined as how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #2's Comprehensive Care Plan for Activities of Daily Living (ADLs), dated 05/07/15, revealed interventions for staff assistance with bathing, dressing and grooming. However, the care plan did not specify the number of staff needed for bathing, dressing and grooming. In addition, review of Resident #2's August 2015 CNA Care Plan revealed the resident required the assist of two (2) staff for turning and positioning in bed. The CNA care plan did not address how many staff was needed for a bed bath which would require turning and positioning the resident. Review of a Nursing Note, dated 06/21/15 at 10:30 AM, and review of a Post Fall Nursing Assessment and Post Fall Investigation, dated 06/22/15, revealed Registered Nurse (RN) # 8 was called to Resident #2's room by CNA #1. CNA #1 told the nurse that Resident #2 had fallen from the bed during his/her bed bath. Resident #2 was laying on the floor on his/her right side with his/her right side of face to the floor; there was blood on the floor coming from the resident's nose. The resident had a laceration to the right side of the forehead under his/her right eye and the nose was visibly disfigured. The resident rated his/her pain as four (4) out of ten (10). Review of Hospital History of Present Illness, dated 06/21/15, and Computerized Axial Tomography Scan (CT Scan) without contrast, of Resident #2's head, dated 06/21/15, revealed Resident #2 sustained bilateral nasal bone fractures, a small amount of bilateral subarachnoid hemorrhage, and a small subdural hematoma extending along the right temporal frontal region. Review of Acute Care Hospital (ACH) Record, dated 06/21/15, revealed Resident #2's final [DIAGNOSES REDACTED]. Interview with Resident #2, on 08/12/15 at 10:30 AM, revealed he/she was being given a bed bath by CNA #1 when he/she fell from the bed. The resident stated CNA #1 was standing on the left side of the bed. When the CNA turned him/her over, he/she went over the right side of the bed, and hurt his/her face so bad he/she had to go to an acute care hospital and stayed for a week. Interview with CNA #1, on 08/22/15 at 1:16 PM, revealed Resident #2 was two person (2) assist with activities of daily living but the resident was able to wash the upper part of his/her body. CNA #1 stated the day of Resident #2's fall she did not remember if she set him/her up for the bath or if she gave the whole bath. She stated while she was getting the wash cloth off the bedside table to rinse Resident #2 off, the resident started to roll to his/her back and she told him/her she was not done. Continued interview revealed the resident rolled back over and his/her head went up and over the 1/4 side rail, hit the nightstand, and hit his/her eye and nose on the floor and landed on the right side. CNA #1 stated the other CNA was giving Resident #2's room mate a bed bath and was not assisting her with the bed bath at the time. Interview with CNA #18, on 08/24/15 at 12:18 PM, revealed she was giving Resident #2's roommate a bed bath with the curtain around the bed and CNA #1 was giving Resident #2 a bed bath. CNA #18 stated CNA #1 had the bed at waist level (three to four {3-4} feet high), and she heard CNA #1 tell Resident #2 to hold on, she was getting a cloth to wash his/her back. CNA #18 stated after that she heard the resident fall. Interviews (Post Survey) on 09/04/15 with CNA #21 at 3:07 PM and CNA #27 at 3:08 PM, revealed CNAs looked at the CNA Care Plan to determine the amount of staff needed to provide care for each resident. She stated the CNA care plans were updated daily. Interview with MDS Staff #2, on 08/24/15 at 4:33 PM, revealed the MDS assessment was used as a guide to develop and revise the comprehensive care plan, and the CNA care plan was made from the Comprehensive Care Plan and they should match at all times. MDS Staff #2 stated the floor nurse attended the care plan meeting and MDS Staff #2 reads the interventions and the floor nurse verifies if they are accurate or not. MDS Staff #2 also stated there were several new nurses and there have been issues with the care plans not being updated until the meeting. Interview with the Director of Nursing (DON), on 08/25/15 at 6:00 PM, revealed the MDS staff and nurses developed and updated the care plan and it should be updated/revised at any point that the Plan of Care changed for a resident. Interview with the Interim Administrator, on 08/25/15 at 5:40 PM, revealed she expected staff to follow facility guidelines, policies, and standards of practice related to the care and interventions provided to the residents.

Based on interview, record review, facility policy review, review of the facility Post Investigation of Incidents and Post Fall Investigation review and review of the Emergency Medical System (EMS) Patient Care Record, Hospital History of Present Illness, and Acute Care Hospital (ACH) Record, it was determined the facility failed to provide adequate supervision to prevent accidents for two (2) of fourteen (14) sampled residents (Resident #1 and Resident #2). The facility assessed Resident #2 as requiring the assistance of two (2) staff for bathing and bed mobility; however, the care plan did not specify the amount of staff supervision needed for bathing and bed mobility. On 06/21/15, Certified Nurse Aide (CNA) #1 was providing a bed bath for Resident #2 without the adequate supervision of two (2) staff and when CNA #1 turned to obtain a washcloth the resident turned over and fell out of the bed. Resident #2 sustained bilateral nasal bone fractures, a bilateral subarachnoid hemorrhage, and a small subdural hematoma extending along the right temporal frontal region. The facility assessed and care planned Resident #1 as requiring extensive assistance of two (2) staff for bed mobility and total assistance of two (2) staff with bathing; however, on 06/12/15, CNA #2 provided a bed bath for Resident #2 without the assistance of another staff as care planned. Resident #1 fell from the bed when left unattended by CNA #2. Resident #2 sustained bruises and lacerations to hands and knees bilaterally. The findings include: Review of the facility's Incident and Accident Process, dated 03/01/01, revealed an accident or incident was defined as any occurrence that is outside the norms of any happening that is not consistent with the routine operation of the center or care of a particular resident. Falls, found on floor, and medication variances were listed as examples of incidents/accidents. Further review revealed when any incident/accident results in an injury, and/or there is evidence of negligence it must be reported to clinical risk management. Injury was defined as any condition requiring medical treatment outside the center that is inconsistent with the routine management of the resident's preexisting condition(s), or any event resulting in the resident's admission to the hospital. Further review revealed staff should report the incident/accident; complete an incident report, timeliness is of the essence; report on the shift report, when giving report; on the 24 hour report; and the care plan may require a change/update. Occurrences of an unusual nature will be reported as required by facility policy, and state law. Review of the facility's Documentation Guidelines, Care Plan Development, last revised 07/03/08, revealed Nursing staff as close to the resident care as possible, Social Worker, Recreation, Dietary, and other disciplines as appropriate for the particular resident were responsible for developing the resident's care plan. The problem should be determined by how the condition affect the resident's well-being (not their partners ability to do their work). The care plan goals may be short-term, long-term, or intermediate goals that should lead to a reasonable attainable objective. The timeframes should be set according to the needs of each individual. Care plan approaches should be specific, individualized steps staff and residents will take together to assist the resident to achieve the goal. Further review revealed the care plans should be updated as needed. In addition, new problems should be handled as they arise, and should be added to the current care plan even if the change in condition is not considered significant enough for a complete revision. 1. Record review revealed the facility admitted Resident #2 on 06/30/08 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 04/23/15, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment, dated 04/23/15, revealed the facility assessed the resident as requiring total assistance of two (2) for bathing and bed mobility which was defined as how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Review of Resident #2's Comprehensive Care Plan for Activities of Daily Living (ADL's), dated 05/07/15, revealed interventions for staff assistance with bathing, dressing and grooming; however, the care plan did not specify the number of staff needed for bathing, dressing and grooming. Review of Resident #2's August 2015 CNA Care Plan revealed the resident required the assist of two (2) staff for turning and positioning in bed. However, the CNA care plan did not address how many staff was needed for a bed bath which would require turning and positioning the resident. Interview with MDS Staff #2, on 08/24/15 at 4:33 PM, revealed the MDS assessment was used as a guide to develop and revise the comprehensive care plan, and the CNA care plan was made from the Comprehensive Care Plan and they should match at all times. MDS Staff #2 stated the floor nurse comes to the care plan meeting and MDS Staff reads off the interventions and the floor nurse reveals if accurate or not. MDS Staff #2 also stated there were several new nurses and there have been issues with the care plans not being updated until the meeting. Review of a Nursing Note, dated 06/21/15 at 10:30 AM, and review of a Post Fall Nursing Assessment, dated 06/22/15, revealed Registered Nurse (RN) #9 was called to the room by CNA #1 and the CNA told the nurse Resident #2 had fallen from bed during his/her bath. The Nurse documented the resident was on his/her right side with his/her right side of face to the floor and there was blood on the floor coming from the resident's nose. Further review of the nursing note revealed when the nurse moved the resident she noted a laceration to the right side of the resident's forehead under the right eye and the nose was visibly disfigured. The resident had a pain rating of four (4) out of ten (10). Review of the Post Investigation of Incidents, dated 06/20/15 (should be 06/21/15) revealed when receiving ADL care the resident used the side rail to roll over during bath and rolled to far and the resident fell in floor. Review of a Post Fall Investigation, dated 06/22/15, revealed Resident #2 fell from bed, with head injury and the new intervention put in place was for two (2) to assist with bed bath. However, according to the MDS assessment the resident was assessed as needing two (2) assist with bathing and turning /repositioning in bed prior to the fall. Review of Emergency Medical System (EMS) Patient Care Record for Resident #2, dated 06/21/15 at 10:50 AM, revealed Resident #2 was being given a bath by staff and fell from bed. The resident had a two to three (2-3) inch laceration over the right eye and a two (2) inch laceration under the right eye. Review of Hospital History of Present Illness, dated 06/21/15, revealed Resident #2 received a blow (getting a bath and staff rolled patient on to side and resident continued over striking face on bedside table). Review of a Hospital Computerized Axial Tomography Scan (CT scan) without contrast of Resident #2 head, dated 06/21/15, revealed the resident sustained [REDACTED]. Review of the Acute Care Hospital (ACH) Record, dated 06/21/15, revealed Resident #2's final [DIAGNOSES REDACTED]. The resident was discharged back to facility on 06/22/15 at 10:10 AM. Interview with Resident #2, on 08/12/15 at 10:30 AM, revealed he/she was being given a bath by CNA #1. The resident stated CNA #1 was standing on his/her left side, and no one was touching him/her and when she turned, he/she went over the right side of the bed, and hurt his/her face so bad he/she had to go to an acute care hospital and stayed for a week. Interview with CNA #1, on 08/22/15 at 1:16 PM, revealed Resident #2 was two (2) assist with activities of daily living but the resident was able to wash the upper part of the body. CNA #1 stated she would get the supplies and fill the basin, then pull the curtains while the resident washed the top part of his/her body and she would give the roommate a bed bath. She stated she would then complete Resident #2's bath by washing the resident's lower body. CNA #1 further stated the day of Resident #2's fall she did not remember if she set her up for the bath or if she gave the whole bath. She stated while she was getting the wash cloth off the bedside table to rinse Resident #2, the resident started to roll to his/her back and she told him/her she was not done and the resident rolled back over and his/her head went up and over the side rail, hit the nightstand, and hit his/her eye and nose on the floor and landed on the right side. Interview with CNA #18, on 08/24/15 at 12:18 PM, revealed she was giving Resident #2's roommate a bed bath with the curtain around the bed and CNA #1 was giving Resident #2 a bed bath. CNA #18 stated CNA #1 had the bed at waist level (three to four {3-4} feet high), and she heard CNA #1 tell Resident #2 to hold on, she was getting a cloth to wash his/her back. CNA #18 stated after that she heard the resident fall. Interview with Licensed Practical Nurse (LPN) #2, on 08/23/15 at 8:07 PM, revealed when she entered Resident #2's room CNA #1 stated she was bathing Resident #2 and soaped up the resident and when she rolled the resident over to his/her back, the resident's top leg went over the side of the bed and the rest of the resident went too. She stated she was new to the floor and did not know how many staff should be providing a bed bath for Resident #2. Interview with Registered Nurse (RN) #9, on 08/24/15 at 10:40 AM, revealed she was told by CNA #1 that she was giving Resident #2 a bed bath at the time of fall on 06/21/15 and the resident's legs were off the bed. RN #9 stated the CNA said she tried to catch the resident but the resident fell to the floor. RN #2 stated the resident had a nose bleed, and a laceration above and below the eye. Interview with the former Assistant Director of Nursing, on 8/15/15 at 7:36 PM, revealed CNA #1 was the only CNA attending to the resident and had raised the bed up, turned the resident to his/her side, and had turned sideways to retrieve a wash cloth when Resident #2 fell from the bed and received a brain bleed. The former ADON stated she could not remember if Resident #2 required one (1) or two (2) staff for a bed bath. 2. Record review revealed the facility admitted Resident #1 on 07/10/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 04/07/15, revealed the facility assessed Resident #1's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility and total assistance of two with bathing. Review of the Comprehensive Care Plan for ADLs, dated 04/15/15, revealed Resident #1 required total care with most ADLs, and to help the resident to bathe, groom, and dress the portions of his/her body that he/she was unable to do; but, it did not specify the number of staff needed for a bed bath that would involve turning and repositioning in bed. Review of the CNA ADL Care Plan revealed the resident required two (2) person care for bathing. Review of the Post Fall Assessment, dated 06/12/15 at 9:50 AM, revealed Resident #1 was turned on his/her right side by CNA#2. The resident fell out of the bed when the CNA left the resident unattended to obtain a wet wash cloth to clean the resident. CNA #2 was providing the bed bath without another staff, which was not per the care plan. Resident #1 was found up on his/her forearms and knees, with bruises to his/her bilateral knees and skin tears to bilateral hands and arms. Review of a Nurse's Notes, dated 06/12/15 at 2:24 PM, revealed staff documented the resident was lying in bed alert with a dressing to the left elbow and right hand. Further review revealed a Nurse's Note, dated 06/12/15 at 10:00 PM, which documented the resident had an ace wrap to the left knee from a fracture due to the fall. Review of the X-ray Report for Resident #1's left knee, dated 06/12/15, revealed there was a non-displaced fibular neck fracture identified. Review of the Physician's Consultation Report, dated 06/17/15, revealed the resident did not have a fracture but was required to wear a ace bandage and was able to return to normal activities. Interview with Resident #1, on 08/20/15 at 5:00 PM, revealed only one (1) staff had been providing his/her bath at the time of the fall. Attempts to interview CNA #2, who was the staff providing care to Resident #1 at the time of fall, on 08/23/15 at 4:40 PM and 08/24/15 at 2:00 PM, were unsuccessful. However, review of a written statement for CNA #2 completed by the prior DON, dated 06/12/15, revealed the CNA was providing a bed bath for Resident #1 without any assistance from other staff. When she turned to obtain a washcloth the resident's legs slipped off the bed resulting in the resident falling out of the bed. Interview with LPN #6, on 08/13/15 at 2:30 PM, revealed Resident #1 fell when CNA #2 rolled the resident over then stepped away to get a wash cloth and the resident's leg flopped over and he/she fell off the bed. LPN #6 stated the resident landed on knees and elbows. Interviews with Unit Manager #2, on 08/12/15 at 2:40 PM and on 08/13/15 at 3:10 PM, revealed Resident #1 was care planned for two (2) assist because he/she can not roll by himself/herself and the CNA was providing care with no assistance. When the CNA went to get a wash cloth, the resident fell out of bed. Interview with the Director of Nursing (DON), on 08/25/15 at 6:00 PM, revealed the nurses update the care plan and it should be updated/revised at any point that the Plan Of Care changes for a resident. The DON stated the care provided should match the care plan. Further interview with the DON revealed staff should follow the care plan and should not leave residents unattended with bed elevated to ensure the resident's safety. Interview with the Interim Administrator, on 08/25/15 at 5:40 PM, revealed there should be interventions for falls and they should be placed on the care plan. The Interim Administrator stated she expected staff to follow facility guidelines, policies, and standards of practice related to the care and interventions provided to the residents. The Interim Administrator further stated she expected staff to act in a manner that ensures the safety and well being of residents.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of five (5) sampled residents (Resident #1). Staff removed Resident #1 from his/her wheelchair with a gel cushion which had been assessed by Occupational Therapy (OT) for positioning and safety. The resident was placed in another wheelchair without the gel cushion. The staff failed to consult with OT and failed to supervise the resident while in the other chair to ensure the resident's safety. The resident's positioning device (lap buddy) was loose on his/her wheelchair due to the wheelchair being a different size which enabled the resident to remove the lap buddy. Resident #1 removed the lap buddy and had a fall which resulted in a fractured pelvis on 05/04/14. Resident #1 returned to the facility the same day on bedrest; and, on 05/08/14 the resident was able to be in the wheelchair as tolerated. The findings include: Review of the facility's policy and procedure titled "Incident and Accident Process", dated 03/01/01, revealed "Injury is defined for reporting purposes as: A. Fracture or dislocation of bones and joints; B. Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s); C. Any event resulting in the patient's admission to the hospital." Review of the Patient Care Policies regarding Resident Rights, revised 03/06/13, revealed "Safety precautions are taken to prevent, whenever possible, patient accidents and infections." Record review revealed the facility admitted Resident #1 on 06/22/13 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 03/19/14, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. He/She required extensive assistance of two (2) staff for transfers and bed mobility; and, was non-ambulatory. Review of the Comprehensive Care Plan, titled "Falls", dated 04/02/14, revealed the facility assessed and care planned Resident #1 to have a lap buddy while up in the wheel chair for positioning due to the resident's leaning forward. However, further review revealed there were no interventions to address the resident's gel cushion until 05/06/14; after the fall, when interventions were added to ensure the resident was in his/her wheelchair. Staff was to monitor for self removal of the lap buddy; and, to ensure the cushion recommended by Occupational Therapy was in the wheel chair. Review of the Occupational Therapist (OT) Evaluation, dated 08/28/13, revealed the family requested the evaluation by OT for wheel chair positioning. OT completed the evaluation and determined Resident #1 was using a standard wheel chair with a cushion that was too large to fit the chair which caused the resident to sit in a posterior pelvic tilt with hips in extension and adduction. The cushion was changed to a pressure relieving cushion (gel cushion with cut out) to decrease pain and to promote an upright posture for Resident #1. Interview with the Therapy Program Director and Occupation Therapist, on 05/29/14 at 10:43 AM, revealed Resident #1 was evaluated for a wheelchair/and cushion per his/her family's request for positioning. They stated the resident had a standard one (1) inch foam cushion that he/she had when he/she was admitted to the facility. They stated after evaluating the resident they recommended a new cushion that would put the resident's pelvis and hips in a neutral and functional position. Further interview revealed the resident was having pain and the cushion helped place the resident's pelvis in a comfortable position. Review of the facility's Investigation Report, dated 05/04/14 at 10:25 AM, revealed Resident #1 was found on the floor with a skin tear and yelling for help. He/She had removed the lap buddy from the wheel chair that staff had changed him/her into, and attempted to self transfer. Resident #1 had sustained a skin tear to the right hand and had pain in the right hip. The resident was transferred to the emergency room for evaluation on 05/04/14 at 11:14 AM. Documentation revealed the root cause of the fall was determined to be related to a trial assessment of a more comfortable wheel chair with a concave back and the trial was unsuccessful. The resident was moved back into his/her own wheel chair due to complaints of pain. Review of the Final X-ray Report, emergency room Report, and Nurse's Note, dated 05/04/14, revealed Resident #1 was seen in the emergency room and sent back to the facility with orders to follow up with the physician as needed. The facility received a phone call from the hospital and was made aware the resident had a fractured left superior pubic ramus (pelvis) and orders were received for bedrest until seen by physician. Further review of the physician's orders [REDACTED].#1 could be up in wheelchair as tolerated. Interview with Resident #1's daughter, on 05/30/14 at 3:36 PM, revealed the fall occurred on 05/04/14. She stated her other parent had gone into the facility two (2) days prior to visit the resident and he/she was in a wheel chair that wasn't his/hers and the special cushion that OT had recommended was missing as well. She stated her father told her the chair the resident was in was larger and the lap buddy did not fit properly. When he asked staff where the resident's wheel chair and cushion were, no one knew. Further interview revealed the resident's spouse explained to the staff that if the resident was not placed in his/her own wheel chair, he/she was going to fall. She further stated interview with the resident's spouse revealed he/she went through the wheel chair storage closet and found Resident #1's wheel chair that had his/her name on it. Additionally, another daughter came to visit Resident #1 and inquired as to why the resident was in a different wheel chair and was told it was because the resident was complaining of pain in his/her buttocks. Interview with Licensed Practical Nurse (LPN) #1, on 05/29/14 at 3:46 PM, revealed on 05/01/14 or 05/02/14 a Certified Nurse Aide (CNA) came to her and asked if the resident could be switched out to a wheel chair with a rounded back as she thought it would be more comfortable for her. The LPN stated the resident was transferred to the other wheelchair, and at that time the resident did not attempt to remove the lap buddy from the new chair. She stated the lap buddy was looser but she was not aware of this resident ever trying to remove the lap buddy. She revealed the resident should have been evaluated before the wheelchair was changed. Interview with Certified Nursing Assistant (CNA) #1, on 05/29/14 at 1:41 PM, revealed the resident was able to remove the lap buddy from the wheelchair Resident #1 was changed to because the wheelchair was not as wide as the other wheelchair so the lap buddy was loose. Interview with CNA #2, on 05/29/14 at 2:25 PM, revealed she was told in report from the midnight shift that Resident #1's chair had been changed for comfort to the resident's back. She stated she was unaware of any issues with the other chair and was not sure why it was changed. Additionally, she stated the lap buddy was loose in the new chair. Interview with LPN #2, on 05/29/14 at 2:00 PM, revealed LPN #1 told her in morning report that a trial for a different wheel chair was initiated because Resident #1's old wheel chair was not as soft. The LPN stated the resident was able to move the lap buddy in the new wheelchair; however, she did not take any action to ensure the resident's safety. Interview with Registered Nurse (RN) #1, on 05/29/14 at 3:22 PM, revealed there were no issues to warrant changing the wheelchair. She stated LPN #1 should have gotten an order for [REDACTED]. Interview with the Unit Manager (UM), on 05/29/14 at 10:00 AM, revealed staff tried a different wheelchair on 05/02/14 because the CNAs thought it might be more comfortable for the resident because it was softer. The UM stated the wheelchair the resident was in when OT assessed him/her was the resident's wheelchair and it was smaller in height and width. The UM stated the lap buddy was used as a positioning device for Resident #1. Interview with the Administrator, on 05/30/14 at 5:55 PM, revealed he did not feel the Charge Nurse, who removed the resident's wheel chair and cushion, should have obtained an OT Consultation prior to removing the wheel chair and cushion OT had recommended.

Based on review of video recordings, interviews, record reviews and review of the facility's "Abuse/Neglect and Misappropriation of Resident Property" policy and procedure, it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #1), was free from abuse. The facility failed to have an effective system in place to ensure residents were free from abusive treatment by staff; and, failed to ensure staff reported the observed mistreatment of [REDACTED]. The facility's Certified Nurse Aides (CNA) were video recorded by a "Nanny Cam" placed in Resident #1's and #2's shared room by a family member. The video recordings revealed the CNAs, who were providing care to Resident #1, were displaying inappropriate behaviors. The CNAs were video recorded on different dates, restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing their finger at the resident in a threatening manner just inches from his/her face after care had been provided. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist on 01/15/14. The findings include: Review of the facility's policy and procedure, titled "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property", dated 09/24/09, revealed the policy and procedures shall be in place to prevent resident abuse. The policy defined the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish as abuse. The policy listed controlling behavior through corporal punishment as physical abuse. Mental abuse was listed as including, but not limited to, humiliation, harassment and threats of punishment or deprivation. Record review revealed the facility admitted Resident #1 on 08/13/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/20/14, revealed the facility staff's assessment of Resident #1's cognitive status was severely impaired and the resident required extensive assistance with transfers, hygiene and bathing and was incontinent at times of bowel and bladder. In addition, the resident had behaviors of being resistive to care at times. An attempt on 04/15/14 at 9:00 AM to interview Resident #1 was unsuccessful due to the Resident's severe cognitive impairment. Review of the video recording, on 04/14/14, revealed the following: 1. On 01/10/14 at 10:02 PM, two (2) CNAs provided care for Resident#1 (one on the side of the bed by the door and the other one was on the side by the window). Resident #1 was resistive and attempting to pinch the CNA nearest the window of the room. The CNA, not smiling, appeared to be saying something to Resident #1 and then pointed her finger in Resident #1's face in a threatening manner 2. On 01/11/14 at 4:10 AM, two (2) CNAs entered the resident's room, closed the hall door and while standing in view of Resident #1 at the foot of Resident #1's bed, one of the CNAs bent over and bit or kissed the buttocks of the other CNA. The CNAs then provided care to Resident #1. 3. On 01/15/14 at 10:56 PM, two (2) CNAs provided care to Resident #1 and when the resident was resistive, his/her hands were restrained on the resident's chest and one of the CNAs (nearest the window) moved to the head of the bed leaning forward into the resident's face in a threatening manner. 4. On 01/17/14 at 4:00 AM, two (2) CNAs provided care to Resident #1 and one (1) of the CNAs (nearest the door) picked up a banana off the resident's bed side table and made an inappropriate sexual gesture like she was going to stick the banana between the resident's legs. 5. On 02/03/14 at 1:18 AM, two (2) CNAs provided care to Resident #1. The resident was kicking out and being resistive. One of the CNAs was restraining Resident #1's hands at the wrist. The CNAs finished care and moved to exit from the room when one of the CNAs (nearest the door) turned and returned to the head of the resident's bed pointing a finger at the resident's face and then reached toward the resident's face, leaving her hands in the resident's face for several seconds. The video did not reveal where the CNA's hands went. 6. On 02/03/14 at 4:21 AM, two (2) CNAs entered the resident's room and stood over Resident #1. One CNA (nearest the door) showed the other CNA (nearest the window) her left breast and the other CNA (nearest the window) performed a breast exam on herself in front of Resident #1. Both CNAs then stood over Resident #1 and talked on their cell phones. The CNAs left the room without providing any care for Resident #1. 7. On 03/12/14 at 9:00 PM, two (2) CNAs entered the resident's room. Resident #1 repeatedly pushed the cover back from his/her face and one (1) of the CNAs (nearest the window) flipped the cover back over the resident's face five (5) different times. The CNA pointed a finger near the resident's face and then made a taunting gesture of holding her hands by her ears while waving her fingers. Interview with a family member of Resident #1, on 04/14/14 at 9:45 AM, revealed she had placed a "Nanny Cam" in the room on 01/10/14 to monitor Resident #1's care after facial bruising was identified to Resident #1's face the first week of January. She further stated the facility had determined the bruising was self-inflicted; however, the family member was certain the bruising was not self-inflicted. Interview with the DCBS Representative, on 04/17/14 at 8:30 AM, revealed she had been to the facility on [DATE] in conjunction with an investigator from the OAG office as the family had taken the video recordings to the OAG. She stated interviews were conducted and schedules and assignment sheets were used to identify which CNAs were providing care on the days in question. The CNAs were identified as CNA #1, CNA #2 and CNA #3. Attempts to contact CNA #1 and CNA #3 on 04/16/14 were unsuccessful because their telephone numbers were disconnected. An interview by phone with CNA #2 was conducted on 04/21/14 at 12:15 PM. CNA #2 revealed she had been suspended and questioned about rough handling of Resident #1. CNA #2 stated she had told the Administrator she did not do it (treat the resident roughly). Interview with the Administrator and Director of Nursing (DON), on 04/14/14 at 3:15 PM, revealed the facility was made aware of the allegation on 03/19/14 when the OAG Investigator and a DCBS Representative were at the facility. The Administrator stated he was told by the DCBS Representative to suspend three (3) people that included CNA #1, CNA #2 and CNA #3. The Administrator stated he was not informed of any details of the allegation at the time and was told by DCBS the facility could not conduct an investigation. The Administrator stated on 04/08/14, the OAG Investigator revealed eight (8) to ten (10) video clips to the Administrator. The Administrator stated the OAG Investigator stated the CNAs' behavior was unprofessional and poor technique but did not rise to criminal. The Administrator felt one of the videos could have been "rough handling" and that CNA #1 was terminated. He further stated the facility reported her to the Nurse Aide Abuse Registry. Further interview revealed the Administrator and DON stated there had not been any allegations of mistreatment of [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/19/14, the facility suspended and then terminated CNAs #1, #2, #3 and #4. CNA #1 was reported to the Nurse Aide Abuse Registry by the Administrator. On 04/21/14, the Regional Nurse provided oversight as Unit Managers assisted by other licensed staff (total of ten) and the RN Supervisor conducted physical assessments for signs/symptoms of possible abuse on all residents including Resident #1; no injuries were found. The care plans for Resident #1 were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. On 04/22/14, the Regional Nurse in-serviced the Administrator and Director of Nursing regarding the facility's abuse/neglect policy. Together they reviewed and revised the policy to include specific assessment of non-interviewable residents for potential abuse during investigations. The Medical Director was informed of the policy revision. Beginning 04/22/14, all facility employees were inserviced regarding the revision in the policy and employees on leave or unavailable would have the inservice prior to working their next shift; this was completed on 04/23/14. Inservice training was provided to licensed staff by the DON, RNs and Unit Managers and Nurse Supervisors on recognizing and managing Alzheimer type dementia and emphasized the nurses' and CNAs' understanding of person centered interventions when caring for residents with dementia, specifically combative behaviors. This was initiated on 03/20/14 and completed on 03/21/14. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy including the types of abuse and interviewing residents. An additional four (4) weeks of monitoring was added following the 04/22/14 revision that included the assessment of non-interviewable residents for potential signs and symptoms of abuse. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Ten (10) random care plans will be reviewed weekly for six (6) weeks by the RN/Unit Managers for appropriate interventions related to specific behavior care plan. The monitors will be completed 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The State Survey Agency validated the Corrective action taken by the facility as follows: Record review for Resident #1 and Resident #2, on 05/01/14, revealed Resident #1 and Resident #2 were assessed by their physician on 03/20/14 and no new orders were given. On 05/01/14, record reviews for Residents #3, #4 and #5 revealed they had been assessed for injuries of unknown injuries and none were found. RN Unit Managers and Supervisors had assessed them. Interview with RN #6 on 05/01/14 at 11:45 AM revealed she and other Unit Managers had completed skin assessments on all residents in the facility on 04/23/14. Review of the inservice logs, on 05/01/14, revealed the Administrator and Director of Nursing were inserviced by the Regional Nurse related to the "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property". Interview with the Administrator and Director of Nursing on 05/01/14 at 10:00 AM verified the inservicing was completed. Review of the policy revision for the Abuse/Neglect and Misappropriation of Resident property, on 05/01/14, verified the revision regarding the assessment of non-interviewable patients for potential abuse during investigations. Review on 05/01/14 of the inservice logs, dated 04/22/14 and 04/23/14, revealed all staff was inserviced related to the revision of the policy on 04/23/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff from different shifts to include five (5) LPNs, an RN and eight (8) CNAs revealed the in-servicing had been provided by the DON, RNs/Unit Managers and Nurse Supervisors for Licensed Nurses and CNAs on "Recognizing and Managing Alzheimer's Type Dementia and was completed on 03/21/14. Review on 05/01/14 of inservice logs dated 03/22/14 and 03/23/14, revealed all staff was provided in-service training by the DON, RNs/Unit Managers and Nurse Supervisors on "Caregiver Stress and Burnout" and was completed on 03/22/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff which included five (5) LPNs, an RN and eight (8) CNAs from all shifts, revealed the inservicing had been provided. On 05/01/14 at 11:35 AM, CNA #10 verified through interview that she had received the inservice training by the DON and Unit Manager. The inservice training included the revision of the abuse/neglect policy which included the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:40 AM, LPN #2 verified through interview that she had received the inservice training by the DON. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview at 11:45 on 05/01/14 with RN #2 revealed she had received inservice training by the DON and she had also provided some of the training to the CNAs. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:05 PM and interview with LPN #3 revealed the DON had provided inservice training on the abuse/neglect policy changes, the types of abuse, stress and staff burnout and managing behaviors of residents with Alzheimer's type behaviors. Care plans for residents with behaviors were also included in the training. An interview on 05/01/14 at 12:05 PM with CNA #11 revealed she had been provided inservice training by the Unit Manager. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. Interview with CNAs #12 and #13 on 05/01/14 at 12:10 PM revealed they had received lots of inservicing by the DON and Unit Managers that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:27 PM CNA #14 revealed in interview that she had received inservice training by the Administrative Nurses related to burnout, behaviors of residents, the changes in the abuse policy including residents that were not interviewable. Interview with CNA #15 on 05/01/14 at 12:45 PM revealed she had been provided inservice training by a nurse and the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:48 PM, an interview with LPN #5 revealed she had been provided numerous inservice trainings recently that included the policy, resident behaviors and appropriate interventions, staff burnout and what to do. Review of inservice records revealed inservice training had been provided to the DON, RNs, Unit Managers and Clinical Social Workers by the Regional Nurse and Regional Director of Social Service related to Care Planning that covered ensuring interventions related to resident behaviors were care planned as needed. Interviews on 05/01/14 (between 11:15 AM and 4:00 PM) with the DON, RN, Unit Managers and three (3) Licensed Social Workers revealed they had been provided the inservicing which was completed on 04/23/14. Interview on 05/01/14 at 11:15 AM with the Social Service Director revealed she had received inservice training from the Regional Nurse and Regional Director of Social Service related to resident behavior care plans on 04/24/14. The Social Service Director stated she had also received the inservice training that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:45 AM, an interview with RN #2 revealed she had received inservice training by the Regional Director of Social Service related to resident care plans for behaviors of residents and she had received training by the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview with LPN #2 on 05/01/14 at 11:40 AM revealed she had received inservice training by the Regional Nurse and Regional Director of Social Service on 04/24/14. The training was related to resident care plans for residents with behaviors. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy and additional four (4) weeks following the 04/22/14 revision. This will be completed by 05/30/14. On 05/01/14, Quality Assurance Monitors dated for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14, 04/22/14 and 04/29/14 were reviewed by the Survey Agency and verified as being completed. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Review of documented interviews for the weeks of 03/23/14, 04/01/14, 04/15/14, 04/22/14 and 04/29/14 were verified completed. Review of the Quality Assurance Monitors were reviewed by the State Survey Agency on 05/01/14 and included the interviews of fifteen (15) CNAs and five (5) nurses had been completed for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14 and 04/29/14. Ten (10) random care plans will be reviewed weekly for six weeks by RN/Unit Managers for appropriate interventions related to specific behavior care plan. This was verified 05/01/14 per interview with the Director of Nursing and review of the monitors already completed. The monitors will be completed on 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. This was verified on 05/01/14 by interview and review of in-service records as completed on 03/20/14 by the RNs/Unit Managers/Nurse Supervisors and Department Heads.

Based on observation of video recordings, interview, record review and review of the facility's Abuse/Neglect and Misappropriation of Property policy and procedure, it was determined the facility failed to ensure staff reported observed incidents of abuse/mistreatment and assess non-interviewable residents for symptoms of abuse/neglect for one (1) of five (5) sampled residents (Resident #1). Certified Nurse Aides (CNA) were video recorded by a "Nanny Cam" placed in Resident #1's and #2's shared room by a family member. The video recordings revealed inappropriate behaviors of CNAs #1, #2 and #3 (determined by schedule and assignment sheet), who were providing care for Resident #1. The video recordings revealed there were two (2) staff present at all times when care was being rendered to Resident #1 and none of the CNAs reported the recorded events to the Administrator. CNAs were video recorded on different dates, restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing a finger at the resident in a threatening manner after care had been provided. The facility was made aware of the allegations of abuse and neglect on 03/19/14 when the Office of Attorney General and the Department for Community Based Services (DCBS) entered the facility to investigate the allegations; however, the facility failed to assess residents who were unable to speak for themselves for signs/symptoms of abuse/mistreatment. The facility's failure to ensure staff reported observed incidents of abuse/neglect/mistreatment and assess non-interviewable residents for signs/symptoms of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist 01/15/14. The facility was notified of the Immediate Jeopardy on 04/22/14. The findings include: Review of the facility's policy and procedure, titled Policy Regarding Abuse/Neglect and Misappropriation of Resident Property, dated 09/24/09, revealed the policy and procedures shall be in place to prevent resident abuse and neglect. The policy revealed staff observing or hearing about such events will report the event immediately, either verbally or in writing, to their immediate supervisor and any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event to the facility Administrator or their designee immediately. 1. Record review revealed the facility admitted Resident #1 on 08/13/09, with [DIAGNOSES REDACTED]. Interview with a family member of Resident #1, on 04/14/14 at 9:45 AM, revealed she had placed a "Nanny Cam" in the resident's room on 01/10/14 to monitor Resident #1's care after facial bruising was identified to the resident's face the first week of January. He/she stated staff was making faces at Resident #1, gesturing like they were going to stick a banana between the resident's legs; pointing their finger in the resident's face; and, holding Resident #1 down while laughing. Further interview revealed the Office of the Attorney General had viewed the video recordings on 03/19/14 and identified the CNAs as CNA #2 and CNA #3 by the schedule and assignment sheets. The SSA Surveyor's review of the video recordings provided by the family member, on 04/16/14, dating from 01/10/14 through 03/12/14 revealed inappropriate behaviors by CNAs #1, #2 and #3 (determined by schedule and assignment sheet), who were providing care for Resident #1. The video recordings revealed there were two (2) staff present at all times when care was being rendered to Resident #1. CNAs were video recorded on different days restraining Resident #1's hands during care, getting in the resident's face and pointing their finger at the resident in a threatening manner after care had been provided. One of the CNAs was observed bending over and biting or kissing the buttocks of the other CNA. Further observation of the video revealed one (1) of the CNAs picked a banana up off the resident's bed side table and made an inappropriate sexual gesture like she was going to stick the banana between the resident's legs; one CNA showed the other CNA her left breast and the other CNA performed a breast exam on herself in front of Resident #1; and, on another occasion Resident #1 repeatedly pushed the cover back from his/her face and one (1) of the CNAs flipped the cover back over the resident's face five (5) different times. The CNA pointed a finger near the resident's face and then made a taunting gesture as the CNA held her hands by her ears while waving her fingers. Interview with the Administrator and Director of Nursing (DON), on 04/14/14 at 3:15 PM, revealed no staff or residents had reported any abuse/neglect/mistreatment of [REDACTED]. Interview with the Director of Nursing (DON), on 04/16/14 at 3:45 PM, revealed their investigation after being made aware of the allegation of abuse/neglect/mistreatment did not include assessments of non-interviewable residents to determine if any residents had sign/symptoms of abuse/mistreatment. Attempts to contact CNA #1 and CNA #3 on 04/16/14 were unsuccessful due to their telephone numbers were disconnected. A telephone interview with CNA #2, on 04/21/14 at 12:15 PM, revealed CNA #2 revealed she had been suspended and questioned about rough handling of Resident #1. CNA #2 stated she had told the Administrator she did not do it (treat the resident roughly). **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/19/14, the facility suspended and then terminated CNAs #1, #2, #3 and #4. CNA #1 was reported to the Nurse Aide Abuse Registry by the Administrator. On 04/21/14, the Regional Nurse provided oversight as Unit Managers assisted by other licensed staff (total of ten) and the RN Supervisor conducted physical assessments for signs/symptoms of possible abuse on all residents including Resident #1; no injuries were found. The care plans for Resident #1 were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. On 04/22/14, the Regional Nurse in-serviced the Administrator and Director of Nursing regarding the facility's abuse/neglect policy. Together they reviewed and revised the policy to include specific assessment of non-interviewable residents for potential abuse during investigations. The Medical Director was informed of the policy revision. Beginning 04/22/14, all facility employees were inserviced regarding the revision in the policy with employees on leave or were unavailable would have the inservice prior to working their next shift; this was completed on 04/23/14. Inservice training was provided to licensed staff by the DON, RNs and Unit Managers and Nurse Supervisors on recognizing and managing Alzheimer type dementia and emphasized the nurses' and CNAs' understanding of person centered interventions when caring for residents with dementia, specifically combative behaviors. This was initiated on 03/20/14 and completed on 03/21/14. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy including the types of abuse and interviewing residents. An additional four (4) weeks of monitoring was added following the 04/22/14 revision that included the assessment of non-interviewable residents for potential signs and symptoms of abuse. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Ten (10) random care plans will be reviewed weekly for six (6) weeks by the RN/Unit Managers for appropriate interventions related to specific behavior care plan. The monitors will be completed 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The State Survey Agency validated the Corrective action taken by the facility as follows: Record review for Resident #1 and Resident #2, on 05/01/14, revealed Resident #1 and Resident #2 were assessed by their physician on 03/20/14 and no new orders were given. On 05/01/14, record reviews for Residents #3, #4 and #5 revealed they had been assessed for injuries of unknown injuries and none were found. RN Unit Managers and Supervisors had assessed them. Interview with RN #6 on 05/01/14 at 11:45 AM revealed she and other Unit Managers had completed skin assessments on all residents in the facility on 04/23/14. Review of the inservice logs, on 05/01/14, revealed the Administrator and Director of Nursing were inserviced by the Regional Nurse related to the "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property". Interview with the Administrator and Director of Nursing on 05/01/14 at 10:00 AM verified the inservicing was completed. Review of the policy revision for the Abuse/Neglect and Misappropriation of Resident property, on 05/01/14, verified the revision regarding the assessment of non-interviewable patients for potential abuse during investigations. Review on 05/01/14 of the inservice logs, dated 04/22/14 and 04/23/14, revealed all staff was inserviced related to the revision of the policy on 04/23/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff from different shifts to include five (5) LPNs, an RN and eight (8) CNAs revealed the in-servicing had been provided by the DON, RNs/Unit Managers and Nurse Supervisors for Licensed Nurses and CNAs on "Recognizing and Managing Alzheimer's Type Dementia and was completed on 03/21/14. Review on 05/01/14 of inservice logs dated 03/22/14 and 03/23/14, revealed all staff was provided in-service training by the DON, RNs/Unit Managers and Nurse Supervisors on "Caregiver Stress and Burnout" and was completed on 03/22/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff which included five (5) LPNs, an RN and eight (8) CNAs from all shifts, revealed the inservicing had been provided. On 05/01/14 at 11:35 AM, CNA #10 verified through interview that she had received the inservice training by the DON and Unit Manager. The inservice training included the revision of the abuse/neglect policy which included the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:40 AM, LPN #2 verified through interview that she had received the inservice training by the DON. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview at 11:45 on 05/01/14 with RN #2 revealed she had received inservice training by the DON and she had also provided some of the training to the CNAs. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:05 PM and interview with LPN #3 revealed the DON had provided inservice training on the abuse/neglect policy changes, the types of abuse, stress and staff burnout and managing behaviors of residents with Alzheimer's type behaviors. Care plans for residents with behaviors were also included in the training. An interview on 05/01/14 at 12:05 PM with CNA #11 revealed she had been provided inservice training by the Unit Manager. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. Interview with CNAs #12 and #13 on 05/01/14 at 12:10 PM revealed they had received lots of inservicing by the DON and Unit Managers that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:27 PM CNA #14 revealed in interview that she had received inservice training by the Administrative Nurses related to burnout, behaviors of residents, the changes in the abuse policy including residents that were not interviewable. Interview with CNA #15 on 05/01/14 at 12:45 PM revealed she had been provided inservice training by a nurse and the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:48 PM, an interview with LPN #5 revealed she had been provided numerous inservice trainings recently that included the policy, resident behaviors and appropriate interventions, staff burnout and what to do. Review of inservice records revealed inservice training had been provided to the DON, RNs, Unit Managers and Clinical Social Workers by the Regional Nurse and Regional Director of Social Service related to Care Planning that covered ensuring interventions related to resident behaviors were care planned as needed. Interviews on 05/01/14 (between 11:15 AM and 4:00 PM) with the DON, RN, Unit Managers and three (3) Licensed Social Workers revealed they had been provided the inservicing which was completed on 04/23/14. Interview on 05/01/14 at 11:15 AM with the Social Service Director revealed she had received inservice training from the Regional Nurse and Regional Director of Social Service related to resident behavior care plans on 04/24/14. The Social Service Director stated she had also received the inservice training that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:45 AM, an interview with RN #2 revealed she had received inservice training by the Regional Director of Social Service related to resident care plans for behaviors of residents and she had received training by the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview with LPN #2 on 05/01/14 at 11:40 AM revealed she had received inservice training by the Regional Nurse and Regional Director of Social Service on 04/24/14. The training was related to resident care plans for residents with behaviors. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy and additional four (4) weeks following the 04/22/14 revision. This will be completed by 05/30/14. On 05/01/14, Quality Assurance Monitors dated for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14, 04/22/14 and 04/29/14 were reviewed by the Survey Agency and verified as being completed.. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Review of documented interviews for the weeks of 03/23/14, 04/01/14, 04/15/14, 04/22/14 and 04/29/14 were verified completed. Review of the Quality Assurance Monitors were reviewed by the State Survey Agency on 05/01/14 and included the interviews of fifteen (15) CNAs and five (5) nurses had been completed for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14 and 04/29/14. Ten (10) random care plans will be reviewed weekly for six weeks by RN/Unit Managers for appropriate interventions related to specific behavior care plan. This was verified 05/01/14 per interview with the Director of Nursing and review of the monitors already completed. The monitors will be completed on 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. This was verified on 05/01/14 by interview and review of in-service records as completed on 03/20/14 by the RNs/Unit Managers/Nurse Supervisors and Department Heads.

Based on interview, record review, and review of video recordings and the facility's "Abuse/Neglect and Misappropriation of Property" policy and procedure, it was determined the facility failed to implement the facility's Abuse/Neglect policy and procedure for one (1) of five (5) sampled residents (Resident #1). Certified Nurse Aides were video recorded by a "Nanny Cam" placed in Resident #1's and #2's shared room by a family member. The video recordings revealed inappropriate behaviors of CNAs #1, #2 and #3 (determined by schedule and assignment sheet), who were providing care for Resident #1. The video recordings revealed there were two (2) staff present at all times when care was being rendered to Resident #1 and none of the CNAs reported the recorded events to the Administrator. CNAs were video recorded on different dates, restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing a finger at the resident in a threatening manner after care had been provided. The facility was made aware of the allegations of abuse and neglect on 03/19/14 when the Office of the Attorney General and the Department for Community Based Services (DCBS) entered the facility to investigate the allegations. However, the facility failed to assess residents who were unable to speak for themselves for signs/symptoms of abuse. In addition, the facility failed to identify that Resident #1 had behaviors that might lead to conflict with staff or other residents and failed to develop a care plan with interventions to address the resident's aggressive behaviors with care that placed the resident at an increased risk for abuse. The facility's failure to implement the procedures in their abuse/neglect policy to protect residents from abuse and misappropriation of property has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist on 01/15/14. The facility was notified of the Immediate Jeopardy on 04/22/14. The findings include: Review of the facility's policy and procedure, titled "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property", dated 09/24/09, revealed the policy and procedures shall be in place to prevent resident abuse, neglect and misappropriation of resident property. Further review revealed staff observing or hearing about such events will report the event immediately, either verbally or in writing, to their immediate supervisor and any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event to the facility Administrator or their designee immediately. The policy also stated residents with needs and behaviors that might lead to conflict with staff or other residents will be identified by the Care Planning Team and will follow through with interventions designed to minimize the risk of conflict or neglect, such as: Residents with a history of aggressive behaviors, residents with communication disorders, and residents who require heavy nursing care, or are totally dependent on nursing care, will be considered as potential victims of abuse. The interventions designed to meet the needs of such residents will include, but will not be limited to identification of residents whose personal histories render them at risk for abusing other residents or staff, assessments of appropriate intervention strategies to prevent occurrences, monitoring the resident for any changes that would trigger abusive behavior and reassessment of the protective strategies on a regular basis. 1. Record review revealed the facility admitted Resident #1 on 08/13/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/20/14, revealed the staff assessed Resident #1's cognition as severely impaired; and, the resident had behaviors of being resistive to care at times with behaviors of kicking, screaming, hitting and smacking at staff during direct care. Review of the Care Plan for Activities of Daily Living, dated 04/02/14, revealed an intervention to "Allow me time to calm down" if (I) become agitated/aggressive. Further review revealed there was no care plan or interventions to address the resident's combative and resistive behaviors to care at times which could place the resident at an increased risk for abuse. Review of the video recordings provided by Resident #1 and Resident #2's family member on 04/16/14 revealed Certified Nursing Aides (CNA) were recorded on different dates (01/10/14 through 03/12/14, on eight different events) with at least two (2) CNAs in the room, restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing a finger at the resident in a threatening manner just inches from his/her face after care had been provided. Interview with the Administrator and Director of Nursing (DON), on 04/14/14 at 3:15 PM, revealed there had not been any allegations of mistreatment of [REDACTED]. The Administrator stated he was told by the DCBS representative to suspend three (3) people that included CNA #1, CNA #2 and CNA #3. The Administrator revealed on 04/08/14, the OAG investigator revealed eight (8) to ten (10) video clips to him. The Administrator stated the OAG investigator stated the CNAs behavior was unprofessional and poor technique but did not rise to criminal. The facility suspended those staff and initiated an investigation. Interview with the Director of Nursing (DON), on 04/16/14 at 3:45 PM, revealed when the facility was made aware of the allegations on 03/19/14, the facility did not perform assessments of residents that were not interviewable to assess for any signs or symptoms of possible abuse during their investigation. Interview with the Administrator and DON, on 04/17/14 at 10:15 AM, revealed they ensured compliance with policies by relying on the residents, nurses and staff to report allegations of abuse/neglect. They stated Administrative staff conducted room checks three days a week and abuse and neglect were discussed in care plan meetings and family meetings. They revealed the Unit Managers were also scheduled for surprise visits one (1) time a week which would be a way of ensuring compliance. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/19/14, the facility suspended and then terminated CNAs #1, #2, #3 and #4. CNA #1 was reported to the Nurse Aide Abuse Registry by the Administrator. On 04/21/14, the Regional Nurse provided oversight as Unit Managers assisted by other licensed staff (total of ten) and the RN Supervisor conducted physical assessments for signs/symptoms of possible abuse on all residents including Resident #1; no injuries were found. The care plans for Resident #1 were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. On 04/22/14, the Regional Nurse in-serviced the Administrator and Director of Nursing regarding the facility's abuse/neglect policy. Together they reviewed and revised the policy to include specific assessment of non-interviewable residents for potential abuse during investigations. The Medical Director was informed of the policy revision. Beginning 04/22/14, all facility employees were inserviced regarding the revision in the policy with employees on leave or were unavailable would have the inservice prior to working their next shift; this was completed on 04/23/14. Inservice training was provided to licensed staff by the DON, RNs and Unit Managers and Nurse Supervisors on recognizing and managing Alzheimer type dementia and emphasized the nurses' and CNAs' understanding of person centered interventions when caring for residents with dementia, specifically combative behaviors. This was initiated on 03/20/14 and completed on 03/21/14. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy including the types of abuse and interviewing residents. An additional four (4) weeks of monitoring was added following the 04/22/14 revision that included the assessment of non-interviewable residents for potential signs and symptoms of abuse. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Ten (10) random care plans will be reviewed weekly for six (6) weeks by the RN/Unit Managers for appropriate interventions related to specific behavior care plan. The monitors will be completed 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The State Survey Agency validated the Corrective action taken by the facility as follows: Record review for Resident #1 and Resident #2, on 05/01/14, revealed Resident #1 and Resident #2 were assessed by their physician on 03/20/14 and no new orders were given. On 05/01/14, record reviews for Residents #3, #4 and #5 revealed they had been assessed for injuries of unknown injuries and none were found. RN Unit Managers and Supervisors had assessed them. Interview with RN #6 on 05/01/14 at 11:45 AM revealed she and other Unit Managers had completed skin assessments on all residents in the facility on 04/23/14. Review of the inservice logs, on 05/01/14, revealed the Administrator and Director of Nursing were inserviced by the Regional Nurse related to the "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property". Interview with the Administrator and Director of Nursing on 05/01/14 at 10:00 AM verified the inservicing was completed. Review of the policy revision for the Abuse/Neglect and Misappropriation of Resident property, on 05/01/14, verified the revision regarding the assessment of non-interviewable patients for potential abuse during investigations. Review on 05/01/14 of the inservice logs, dated 04/22/14 and 04/23/14, revealed all staff was inserviced related to the revision of the policy on 04/23/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff from different shifts to include five (5) LPNs, an RN and eight (8) CNAs revealed the in-servicing had been provided by the DON, RNs/Unit Managers and Nurse Supervisors for Licensed Nurses and CNAs on "Recognizing and Managing Alzheimer's Type Dementia and was completed on 03/21/14. Review on 05/01/14 of inservice logs dated 03/22/14 and 03/23/14, revealed all staff was provided in-service training by the DON, RNs/Unit Managers and Nurse Supervisors on "Caregiver Stress and Burnout" and was completed on 03/22/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff which included five (5) LPNs, an RN and eight (8) CNAs from all shifts, revealed the inservicing had been provided. On 05/01/14 at 11:35 AM, CNA #10 verified through interview that she had received the inservice training by the DON and Unit Manager. The inservice training included the revision of the abuse/neglect policy which included the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:40 AM, LPN #2 verified through interview that she had received the inservice training by the DON. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview at 11:45 on 05/01/14 with RN #2 revealed she had received inservice training by the DON and she had also provided some of the training to the CNAs. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:05 PM and interview with LPN #3 revealed the DON had provided inservice training on the abuse/neglect policy changes, the types of abuse, stress and staff burnout and managing behaviors of residents with Alzheimer's type behaviors. Care plans for residents with behaviors were also included in the training. An interview on 05/01/14 at 12:05 PM with CNA #11 revealed she had been provided inservice training by the Unit Manager. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. Interview with CNAs #12 and #13 on 05/01/14 at 12:10 PM revealed they had received lots of inservicing by the DON and Unit Managers that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:27 PM CNA #14 revealed in interview that she had received inservice training by the Administrative Nurses related to burnout, behaviors of residents, the changes in the abuse policy including residents that were not interviewable. Interview with CNA #15 on 05/01/14 at 12:45 PM revealed she had been provided inservice training by a nurse and the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:48 PM, an interview with LPN #5 revealed she had been provided numerous inservice trainings recently that included the policy, resident behaviors and appropriate interventions, staff burnout and what to do. Review of inservice records revealed inservice training had been provided to the DON, RNs, Unit Managers and Clinical Social Workers by the Regional Nurse and Regional Director of Social Service related to Care Planning that covered ensuring interventions related to resident behaviors were care planned as needed. Interviews on 05/01/14 (between 11:15 AM and 4:00 PM) with the DON, RN, Unit Managers and three (3) Licensed Social Workers revealed they had been provided the inservicing which was completed on 04/23/14. Interview on 05/01/14 at 11:15 AM with the Social Service Director revealed she had received inservice training from the Regional Nurse and Regional Director of Social Service related to resident behavior care plans on 04/24/14. The Social Service Director stated she had also received the inservice training that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:45 AM, an interview with RN #2 revealed she had received inservice training by the Regional Director of Social Service related to resident care plans for behaviors of residents and she had received training by the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview with LPN #2 on 05/01/14 at 11:40 AM revealed she had received inservice training by the Regional Nurse and Regional Director of Social Service on 04/24/14. The training was related to resident care plans for residents with behaviors. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy and additional four (4) weeks following the 04/22/14 revision. This will be completed by 05/30/14. On 05/01/14, Quality Assurance Monitors dated for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14, 04/22/14 and 04/29/14 were reviewed by the Survey Agency and verified as being completed.. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Review of documented interviews for the weeks of 03/23/14, 04/01/14, 04/15/14, 04/22/14 and 04/29/14 were verified completed. Review of the Quality Assurance Monitors were reviewed by the State Survey Agency on 05/01/14 and included the interviews of fifteen (15) CNAs and five (5) nurses had been completed for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14 and 04/29/14. Ten (10) random care plans will be reviewed weekly for six weeks by RN/Unit Managers for appropriate interventions related to specific behavior care plan. This was verified 05/01/14 per interview with the Director of Nursing and review of the monitors already completed. The monitors will be completed on 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. This was verified on 05/01/14 by interview and review of in-service records as completed on 03/20/14 by the RNs/Unit Managers/Nurse Supervisors and Department Heads.

Based on observation, interview, record review and review of the facility's "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property" and "Care Plan Development" policy, it was determined the facility failed to revise the care plan for one (1) of five (5) sampled residents (Resident #1). Resident #1 had behaviors of being resistive and combative toward staff during care but the facility failed to revise the care plan to include interventions to try to decrease the risk for abuse due to these behaviors. Resident #1 was assessed and identified to have behaviors of resisting care and being combative with staff during care which placed the resident at an increased risk for abuse. The facility failed to revise the care plan to include interventions to address these behavior to try to decrease the risk for abuse. Review of the video recordings, on 04/16/14, provided by the family revealed two (2) CNAs providing care to Resident #1 on eight (8) occasions from 01/10/14 through 03/12/14 while the resident was showing behaviors of resistance to care. The CNAs were observed restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing their finger at the resident in a threatening manner. The facility's failure to revise the care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist on 01/15/14. The facility was notified of the Immediate Jeopardy on 04/22/14. The findings include: Review of the facility's policy, titled, Care Plan Development, last revised 07/03/08, revealed the staff responsible for the development of the care plan was the "Nursing staff as close to the patient's care as possible and the problems were patient conditions, needs, or weaknesses which currently do or potentially could prevent the patient from achieving or maintaining the highest practicable level of well being". The policy also revealed the "Problems should be stated using simple language that any center partner can understand". Review of the facility's policy and procedure, titled "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property", dated 09/24/09, revealed the policy and procedures shall be in place to prevent resident abuse, neglect and misappropriation of resident property. The policy also stated residents with needs and behaviors that might lead to conflict with staff or other residents will be identified by the Care Planning Team and will follow through with interventions designed to minimize the risk of conflict. Record review revealed the facility admitted Resident #1 on 08/13/09, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/20/14, revealed the facility assessed Resident #1's cognition as severely impaired (unable to complete Brief Interview for Mental Status interview) and had behaviors of being resistive to care at times with behaviors of kicking, screaming, hitting and smacking at staff during direct care. Review of Resident #1's Comprehensive Care Plan for "Activities of Daily Living (ADLs)", dated 04/02/14, revealed an intervention to "Allow me time to calm down if (I) become agitated/aggressive". Further review of the Comprehensive Care Plan revealed there was no care plan or other interventions to address the resident's combative and resistive behaviors to care at times which could place the resident at an increased risk for abuse. Interview with a family member of Resident #1, on 04/14/14 at 9:45 AM, revealed she had placed a "Nanny Cam" in the room on 01/10/14 to monitor Resident #1's care after facial bruising was identified to Resident #1's face the first week of January. Review of the video recordings, on 04/16/14, provided by the family revealed two (2) CNAs providing care to Resident #1 from 01/10/14 through 03/12/14. There were eight (8) different events on different dates that revealed Resident #1 being resistive and/or combative with care. The CNAs were recorded restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing their finger at the resident in a threatening manner. Interview, on 04/15/14 at 3:00 PM with CNA #9, revealed when any resident becomes resistant or combative toward caregivers, staff should get somebody else and try again. Interviews, on 04/15/14 at 10:30 PM with CNA #5 and CNA #9, revealed when a resident becomes combative during care they stop, try again and report to the nurse. Interview with Registered Nurse #1, on 04/21/14 at 1:20 PM, revealed she would expect staff to walk away when a resident was displaying resistive and combative behaviors and to report those behaviors to the nurse. Interview with the Social Service Worker (SSW), on 05/16/14 at 5:30 PM (post survey interview), revealed she did not think residents with behaviors were at a higher risk for abuse. She stated the facility would develop a care plan around what triggers the resident's behavior and would try to find the root cause of the behavior. The Social Worker stated to her knowledge Resident #1 never had any overt behaviors. Interview with the MDS Coordinator, on 05/16/14 at 3:30 PM (post survey interview), revealed the residents' care plans were developed from the information they received from the chart, resident and family as well as the staff. She stated the care plan was reviewed by everyone on the Interdisciplinary Team (MDS Coordinator, Dietary, SSW, Activities and Nursing). She stated there was no care plan in place to address Resident #1's combative or resistive behavior; however, she said there was a care plan, dated 04/02/14, with an intervention to "allow the resident to calm down if became agitated or aggressive". Interview with the Director of Nursing (DON), on 04/17/14 at 9:00 AM, revealed she felt interventions to manage Resident #1's resistive and combative behaviors could be pulled from all the different care plans that were in place for the resident in the "Complete Care Plan". The DON stated a "Behavior" care plan was not developed until 04/11/14 and prior to that date the intervention to "allow time to calm" was the only intervention in place. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/19/14, the facility suspended and then terminated CNAs #1, #2, #3 and #4. CNA #1 was reported to the Nurse Aide Abuse Registry by the Administrator. On 04/21/14, the Regional Nurse provided oversight as Unit Managers assisted by other licensed staff (total of ten) and the RN Supervisor conducted physical assessments for signs/symptoms of possible abuse on all residents including Resident #1; no injuries were found. The care plans for Resident #1 were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. On 04/22/14, the Regional Nurse in-serviced the Administrator and Director of Nursing regarding the facility's abuse/neglect policy. Together they reviewed and revised the policy to include specific assessment of non-interviewable residents for potential abuse during investigations. The Medical Director was informed of the policy revision. Beginning 04/22/14, all facility employees were inserviced regarding the revision in the policy with employees on leave or were unavailable would have the inservice prior to working their next shift; this was completed on 04/23/14. Inservice training was provided to licensed staff by the DON, RNs and Unit Managers and Nurse Supervisors on recognizing and managing Alzheimer type dementia and emphasized the nurses' and CNAs' understanding of person centered interventions when caring for residents with dementia, specifically combative behaviors. This was initiated on 03/20/14 and completed on 03/21/14. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy including the types of abuse and interviewing residents. An additional four (4) weeks of monitoring was added following the 04/22/14 revision that included the assessment of non-interviewable residents for potential signs and symptoms of abuse. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Ten (10) random care plans will be reviewed weekly for six (6) weeks by the RN/Unit Managers for appropriate interventions related to specific behavior care plan. The monitors will be completed 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The State Survey Agency validated the Corrective action taken by the facility as follows: Record review for Resident #1 and Resident #2, on 05/01/14, revealed Resident #1 and Resident #2 were assessed by their physician on 03/20/14 and no new orders were given. On 05/01/14, record reviews for Residents #3, #4 and #5 revealed they had been assessed for injuries of unknown injuries and none were found. RN Unit Managers and Supervisors had assessed them. Interview with RN #6 on 05/01/14 at 11:45 AM revealed she and other Unit Managers had completed skin assessments on all residents in the facility on 04/23/14. Review of the inservice logs, on 05/01/14, revealed the Administrator and Director of Nursing were inserviced by the Regional Nurse related to the "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property". Interview with the Administrator and Director of Nursing on 05/01/14 at 10:00 AM verified the inservicing was completed. Review of the policy revision for the Abuse/Neglect and Misappropriation of Resident property, on 05/01/14, verified the revision regarding the assessment of non-interviewable patients for potential abuse during investigations. Review on 05/01/14 of the inservice logs, dated 04/22/14 and 04/23/14, revealed all staff was inserviced related to the revision of the policy on 04/23/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff from different shifts to include five (5) LPNs, an RN and eight (8) CNAs revealed the in-servicing had been provided by the DON, RNs/Unit Managers and Nurse Supervisors for Licensed Nurses and CNAs on "Recognizing and Managing Alzheimer's Type Dementia and was completed on 03/21/14. Review on 05/01/14 of inservice logs dated 03/22/14 and 03/23/14, revealed all staff was provided in-service training by the DON, RNs/Unit Managers and Nurse Supervisors on "Caregiver Stress and Burnout" and was completed on 03/22/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff which included five (5) LPNs, an RN and eight (8) CNAs from all shifts, revealed the inservicing had been provided. On 05/01/14 at 11:35 AM, CNA #10 verified through interview that she had received the inservice training by the DON and Unit Manager. The inservice training included the revision of the abuse/neglect policy which included the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:40 AM, LPN #2 verified through interview that she had received the inservice training by the DON. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview at 11:45 on 05/01/14 with RN #2 revealed she had received inservice training by the DON and she had also provided some of the training to the CNAs. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:05 PM and interview with LPN #3 revealed the DON had provided inservice training on the abuse/neglect policy changes, the types of abuse, stress and staff burnout and managing behaviors of residents with Alzheimer's type behaviors. Care plans for residents with behaviors were also included in the training. An interview on 05/01/14 at 12:05 PM with CNA #11 revealed she had been provided inservice training by the Unit Manager. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. Interview with CNAs #12 and #13 on 05/01/14 at 12:10 PM revealed they had received lots of inservicing by the DON and Unit Managers that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:27 PM CNA #14 revealed in interview that she had received inservice training by the Administrative Nurses related to burnout, behaviors of residents, the changes in the abuse policy including residents that were not interviewable. Interview with CNA #15 on 05/01/14 at 12:45 PM revealed she had been provided inservice training by a nurse and the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:48 PM, an interview with LPN #5 revealed she had been provided numerous inservice trainings recently that included the policy, resident behaviors and appropriate interventions, staff burnout and what to do. Review of inservice records revealed inservice training had been provided to the DON, RNs, Unit Managers and Clinical Social Workers by the Regional Nurse and Regional Director of Social Service related to Care Planning that covered ensuring interventions related to resident behaviors were care planned as needed. Interviews on 05/01/14 (between 11:15 AM and 4:00 PM) with the DON, RN, Unit Managers and three (3) Licensed Social Workers revealed they had been provided the inservicing which was completed on 04/23/14. Interview on 05/01/14 at 11:15 AM with the Social Service Director revealed she had received inservice training from the Regional Nurse and Regional Director of Social Service related to resident behavior care plans on 04/24/14. The Social Service Director stated she had also received the inservice training that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:45 AM, an interview with RN #2 revealed she had received inservice training by the Regional Director of Social Service related to resident care plans for behaviors of residents and she had received training by the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview with LPN #2 on 05/01/14 at 11:40 AM revealed she had received inservice training by the Regional Nurse and Regional Director of Social Service on 04/24/14. The training was related to resident care plans for residents with behaviors. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy and additional four (4) weeks following the 04/22/14 revision. This will be completed by 05/30/14. On 05/01/14, Quality Assurance Monitors dated for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14, 04/22/14 and 04/29/14 were reviewed by the Survey Agency and verified as being completed.. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Review of documented interviews for the weeks of 03/23/14, 04/01/14, 04/15/14, 04/22/14 and 04/29/14 were verified completed. Review of the Quality Assurance Monitors were reviewed by the State Survey Agency on 05/01/14 and included the interviews of fifteen (15) CNAs and five (5) nurses had been completed for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14 and 04/29/14. Ten (10) random care plans will be reviewed weekly for six weeks by RN/Unit Managers for appropriate interventions related to specific behavior care plan. This was verified 05/01/14 per interview with the Director of Nursing and review of the monitors already completed. The monitors will be completed on 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. This was verified on 05/01/14 by interview and review of in-service records as completed on 03/20/14 by the RNs/Unit Managers/Nurse Supervisors and Department Heads.

Based on interview, record review and review of the Administrator's job description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of five (5) sampled residents (Resident #1). The facility failed to have an effective system in place to ensure residents were safe and free from abusive treatment. The facility failed to ensure staff reported observed mistreatment of [REDACTED]. Facility "Certified Nurse Aides (CNAs) were video recorded by a "Nanny Cam" placed in Resident #1's and Resident #2's room by a family member. The video recordings revealed inappropriate behaviors of CNAs, who were providing care for Resident #1. CNAs were recorded on different dates, restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing a finger at the resident in a threatening manner. Additionally, Resident #1 was not identified as a potential victim of abuse, as per the facility's policy and no interventions specific to meet his/her needs were in place in the plan of care. The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist on 01/15/14. The facility was notified of the Immediate Jeopardy on 04/22/14. The findings include: Review of the facility's "Job Description for the Administrator", last revised 06/01/09, revealed "The Administrator has complete administrative and managerial responsibilities within the health care center, acting as liaison, motivator, coordinator and support person for Department Directors, other partners, patients, families, visitors, physicians and the local community". The job description included: "Must be able to make administrative decisions, Ability to interpret and implement regulations (State and Federal) and Assures compliance with State and Federal Regulations and Center policies." Review of the video recordings provided by Resident #1 and Resident #2's family member on 04/16/14 revealed Certified Nursing Aides (CNA) were recorded on 01/10/14 through 03/12/14, on eight (8) occasions with at least two (2) CNAs in the room, displaying some of the following behaviors: restraining Resident #1's hands during care, making inappropriate gestures, getting in the resident's face and pointing a finger at the resident in a threatening manner just inches from his/her face and not providing incontinent care several hours (six hours and forty minutes). Interviews with the Administrator and Director of Nursing (DON) on 04/14/14 at 3:15 PM; and, on 04/17/14 at 10:15 AM revealed the facility was made aware of the allegation on 03/19/14 by the Office of Attorney General's (OAG) Investigator and a Department of Community Based Services (DCBS)Representative. The Administrator was told by the DCBS representative to suspend three (3) people that included CNA #1, CNA #4 and CNA #3. On 04/08/14, the OAG Investigator revealed eight (8) to ten (10) video clips to the Administrator. The Administrator stated the OAG Investigator stated the CNAs behavior was unprofessional and there was poor technique but it did not rise to criminal. The OAG Investigator informed the Administrator that CNA #1 had admitted to stealing money from Resident #2 and would be charged with a criminal offense. Further interview with the DON, on 04/16/14 at 3:45 PM, revealed no assessments had been completed by the facility to identify any signs and symptoms of possible abuse of residents who could not speak for themselves. Interview with the Administrator, on 04/17/14 at 10:15 AM, revealed he would have expected staff to report any observed abuse or neglect and that he relied on the residents, nurses and staff to report any alleged abuse or neglect. Three (3) days a week room checks with administrative staff were done weekly and Unit Managers were scheduled for surprise visits one time a week. However, no assessments of non-interviewable residents had been completed as the facility relied on staff to report. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/19/14, the facility suspended and then terminated CNAs #1, #2, #3 and #4. CNA #1 was reported to the Nurse Aide Abuse Registry by the Administrator. On 04/21/14, the Regional Nurse provided oversight as Unit Managers assisted by other licensed staff (total of ten) and the RN Supervisor conducted physical assessments for signs/symptoms of possible abuse on all residents including Resident #1; no injuries were found. The care plans for Resident #1 were reviewed and updated with focus on interventions specific to the resident's behaviors. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. On 04/22/14, the Regional Nurse in-serviced the Administrator and Director of Nursing regarding the facility's abuse/neglect policy. Together they reviewed and revised the policy to include specific assessment of non-interviewable residents for potential abuse during investigations. The Medical Director was informed of the policy revision. Beginning 04/22/14, all facility employees were inserviced regarding the revision in the policy with employees on leave or were unavailable would have the inservice prior to working their next shift; this was completed on 04/23/14. Inservice training was provided to licensed staff by the DON, RNs and Unit Managers and Nurse Supervisors on recognizing and managing Alzheimer type dementia and emphasized the nurses' and CNAs' understanding of person centered interventions when caring for residents with dementia, specifically combative behaviors. This was initiated on 03/20/14 and completed on 03/21/14. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy including the types of abuse and interviewing residents. An additional four (4) weeks of monitoring was added following the 04/22/14 revision that included the assessment of non-interviewable residents for potential signs and symptoms of abuse. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Ten (10) random care plans will be reviewed weekly for six (6) weeks by the RN/Unit Managers for appropriate interventions related to specific behavior care plan. The monitors will be completed 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The State Survey Agency validated the Corrective action taken by the facility as follows: Record review for Resident #1 and Resident #2, on 05/01/14, revealed Resident #1 and Resident #2 were assessed by their physician on 03/20/14 and no new orders were given. On 05/01/14, record reviews for Residents #3, #4 and #5 revealed they had been assessed for injuries of unknown injuries and none were found. RN Unit Managers and Supervisors had assessed them. Interview with RN #6 on 05/01/14 at 11:45 AM revealed she and other Unit Managers had completed skin assessments on all residents in the facility on 04/23/14. Review of the inservice logs, on 05/01/14, revealed the Administrator and Director of Nursing were inserviced by the Regional Nurse related to the "Policy Regarding Abuse/Neglect and Misappropriation of Resident Property". Interview with the Administrator and Director of Nursing on 05/01/14 at 10:00 AM verified the inservicing was completed. Review of the policy revision for the Abuse/Neglect and Misappropriation of Resident property, on 05/01/14, verified the revision regarding the assessment of non-interviewable patients for potential abuse during investigations. Review on 05/01/14 of the inservice logs, dated 04/22/14 and 04/23/14, revealed all staff was inserviced related to the revision of the policy on 04/23/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff from different shifts to include five (5) LPNs, an RN and eight (8) CNAs revealed the in-servicing had been provided by the DON, RNs/Unit Managers and Nurse Supervisors for Licensed Nurses and CNAs on "Recognizing and Managing Alzheimer's Type Dementia and was completed on 03/21/14. Review on 05/01/14 of inservice logs dated 03/22/14 and 03/23/14, revealed all staff was provided in-service training by the DON, RNs/Unit Managers and Nurse Supervisors on "Caregiver Stress and Burnout" and was completed on 03/22/14. Interviews conducted on 05/01/14 (between 11:15 AM and 4:00 PM) with staff which included five (5) LPNs, an RN and eight (8) CNAs from all shifts, revealed the inservicing had been provided. On 05/01/14 at 11:35 AM, CNA #10 verified through interview that she had received the inservice training by the DON and Unit Manager. The inservice training included the revision of the abuse/neglect policy which included the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:40 AM, LPN #2 verified through interview that she had received the inservice training by the DON. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview at 11:45 on 05/01/14 with RN #2 revealed she had received inservice training by the DON and she had also provided some of the training to the CNAs. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:05 PM and interview with LPN #3 revealed the DON had provided inservice training on the abuse/neglect policy changes, the types of abuse, stress and staff burnout and managing behaviors of residents with Alzheimer's type behaviors. Care plans for residents with behaviors were also included in the training. An interview on 05/01/14 at 12:05 PM with CNA #11 revealed she had been provided inservice training by the Unit Manager. The inservice training included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. Interview with CNAs #12 and #13 on 05/01/14 at 12:10 PM revealed they had received lots of inservicing by the DON and Unit Managers that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:27 PM CNA #14 revealed in interview that she had received inservice training by the Administrative Nurses related to burnout, behaviors of residents, the changes in the abuse policy including residents that were not interviewable. Interview with CNA #15 on 05/01/14 at 12:45 PM revealed she had been provided inservice training by a nurse and the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 12:48 PM, an interview with LPN #5 revealed she had been provided numerous inservice trainings recently that included the policy, resident behaviors and appropriate interventions, staff burnout and what to do. Review of inservice records revealed inservice training had been provided to the DON, RNs, Unit Managers and Clinical Social Workers by the Regional Nurse and Regional Director of Social Service related to Care Planning that covered ensuring interventions related to resident behaviors were care planned as needed. Interviews on 05/01/14 (between 11:15 AM and 4:00 PM) with the DON, RN, Unit Managers and three (3) Licensed Social Workers revealed they had been provided the inservicing which was completed on 04/23/14. Interview on 05/01/14 at 11:15 AM with the Social Service Director revealed she had received inservice training from the Regional Nurse and Regional Director of Social Service related to resident behavior care plans on 04/24/14. The Social Service Director stated she had also received the inservice training that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. On 05/01/14 at 11:45 AM, an interview with RN #2 revealed she had received inservice training by the Regional Director of Social Service related to resident care plans for behaviors of residents and she had received training by the DON that included the revision of the abuse/neglect policy to include the types of abuse/neglect, assessment of non-interviewable residents for signs and symptoms of potential abuse. The training also included training on caregiver stress and burnout, recognizing and managing Alzheimer's type behaviors. An interview with LPN #2 on 05/01/14 at 11:40 AM revealed she had received inservice training by the Regional Nurse and Regional Director of Social Service on 04/24/14. The training was related to resident care plans for residents with behaviors. Quality Assurance Monitors began the week of 03/23/14 and included twenty (20) random employees to be interviewed per week for six (6) weeks to determine their understanding of the abuse policy and additional four (4) weeks following the 04/22/14 revision. This will be completed by 05/30/14. On 05/01/14, Quality Assurance Monitors dated for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14, 04/22/14 and 04/29/14 were reviewed by the Survey Agency and verified as being completed.. Fifteen (15) random CNAs and five (5) random nurses to be interviewed for understanding of care and interacting with residents with dementia. Fifteen (15) random CNAs and five (5) nurses per week to be interviewed for understanding of care giver burnout. Review of documented interviews for the weeks of 03/23/14, 04/01/14, 04/15/14, 04/22/14 and 04/29/14 were verified completed. Review of the Quality Assurance Monitors were reviewed by the State Survey Agency on 05/01/14 and included the interviews of fifteen (15) CNAs and five (5) nurses had been completed for the weeks of 03/23/14, 04/01/14, 04/08/14, 04/15/14 and 04/29/14. Ten (10) random care plans will be reviewed weekly for six weeks by RN/Unit Managers for appropriate interventions related to specific behavior care plan. This was verified 05/01/14 per interview with the Director of Nursing and review of the monitors already completed. The monitors will be completed on 05/30/14 and overseen by the Regional Nurse. All Quality Assurance monitors to be reviewed by the Regional Nurse with the Director of Nursing and will be reported to the Quality Assurance Committee. The facility began interviewing employees on 03/19/14 as part of their in-service training on the facility's abuse policy. This was verified on 05/01/14 by interview and review of in-service records as completed on 03/20/14 by the RNs/Unit Managers/Nurse Supervisors and Department Heads.