Every finding on record at PruittHealth - Peake

Based on observations, interviews, record review, and a review of the facility policy titled Discharge Planning, the facility failed to ensure that medically related social services were provided to one of 39 sampled residents (R) (R133) related to arranging for needed mental and psychosocial counseling services after an allegation of staff-to-resident sexual assault. Psychosocial harm was identified to have occurred on 04/04/2026, using the reasonable person concept, when R133 expressed an allegation of sexual assault by a staff member, as evidenced by R133 being tearful when recalling the alleged sexual assault and expressing feelings that she was not being heard or believed. Findings include:Review of the Minimum Data Set (MDS) for R133, dated 04/12/2026, revealed a Brief Interview for Mental Status (BIMS) score of 13 (indicating little to no cognitive impairment). A review of the facility policy titled Discharge Planning, with the last revised date of 2/24/2025 revealed that discharge planning will begin with each resident and the resident's representative upon admission. The process is coordinated by Social Services/Senior Care Partner or designee. The resident, resident representative, and Interdisciplinary Team (IDT) are involved in the planning process. The post-discharge plan of care is developed with the participation of the resident and/or the resident's representative with the resident's consent. The discharge plan will be monitored and revised as necessary throughout the resident's stay. Discharge care plans will be updated after the Post admission Care Conference, reviewed quarterly, before the anticipated discharge date , and as needed. Discharge Summaries will be opened at the time of Admission, and will be edited before the anticipated discharge date by all members of the IDT to reflect the residents' discharge plans and goals.A review of the electronic medical record (EMR) revealed that the resident is a [AGE] year-old female originally admitted to the facility on [DATE] with a diagnosis including, but not limited to, major depressive disorder.A review of the Facility Incident Report (FRI) dated 04/04/2026 revealed that on 04/04/2026, R133 reported to her peers in the restorative room that Certified Nursing Assistant (CNA) FF had inserted his fingers into her vagina while bathing her the previous evening. She stated that she had complained about him before and didn't want him taking care of her any longer. Review of the facility's investigation revealed that the allegation of sexual abuse was investigated and was not substantiated. During an interview on 05/02/2026 at 10:50 AM, R133 was observed coloring in the rehabilitation room by herself. During this interview, R133 was asked how long she had lived at the facility and what it was like to live there. She avoided eye contact and stated in a very low monotone voice that she had lived at the facility for almost five years. The resident was quiet for a short moment, continuing to look down and avoid eye contact, and stated flatly, I don't want to live here anymore. When asked why, she said, in an almost whisper, that she likes everyone except one person who works here. When asked who and why, R133 looked up from her coloring, still avoiding eye contact, and stated CNA FF's name because he violated her. She stated that she knows it was more than once, but she cannot remember that well. Then she stated that he told her that no one would believe her over him. The resident was tearful at this point and asked for a napkin. She then stated, No one believes me, but he did violate me. The resident wiped tears from her eyes and resumed coloring. At this time, the interview was adjusted to ask about other aspects of living at the facility, such as care plans, nursing care and services, visitation rights, and her family. The resident provided very short answers and continued to not make eye contact. She pulled a cell phone from under her shirt and proceeded to scroll through pictures of her family. The conversation continued for another nine minutes, with the topic unrelated to the alleged incident involving CNA FF. The resident was thanked for her time. At the end of the conversation, without looking up from her coloring, the resident stated, I just don't want to live here anymore. No one believes me here. The resident looked up, wiped tears from her eyes, and went back to coloring.During an interview on 05/02/2026 at 11:57 AM, the Social Worker (SW) stated that she has been the SW for the facility since August 2025. She confirmed that she was familiar with the incident that occurred on 04/04/2026 related to R133. She stated that on 04/04/2026, R133 reported to peers that she had been sexually violated. The residents' peers informed the Activities Assistant, who informed the Activities Director. She stated that somewhere in that process or reporting, she received the information on 04/06/2026. She stated that usually, she talks with the person who makes the allegation, offer behavior health counseling, follows up with them, completes a psycho social assessment, and completes interviews with other residents. She stated that once the resident is offered the services and signs the agreement form. She stated that once the process is started, the company that offers the services acts quickly. She stated that the resident is not saying a lot, but that the resident's family reached out to see if the facility could offer counseling. She confirmed that she did not offer counseling to the resident because the resident went out to the hospital shortly after the allegation and did not return until 04/09/2026, and that she just wasn't able to follow up from 04/09/2026 through 05/02/2026 because R133 had a lot of family in and out and I have regular day-to-day stuff I had to do. The SW was then asked if she was aware that the resident and the resident's family had requested assistance with finding another facility. She stated, I heard that they wanted to go to (facility name). She stated that she called the facility, but the facility did not have any available beds. When asked if this discharge planning was documented anywhere, she stated that she usually documents discharge planning, but in this case, she did not document this information, and she could not remember who she spoke to at the facility she called on behalf of R133. She stated that at this point, R133's discharge planing at a standstill and that she had not talked to the family about any other places. She stated that she could follow up with the family today or on Monday. During an interview on 05/02/2026 at 12:14 PM, the Administrator stated that she has been at the facility in the capacity of Administrator for two weeks. She confirmed that she is the abuse coordinator but knows little about the 04/04/2026 incident with R133 because the former Administrator was at the facility during that investigation. She stated that R133 should have been offered mental health services if needed and that the information should be documented in the clinical record.During an interview on 05/02/2026 at 2:07 PM, the SW stated that she spoke with R133 about receiving psychosocial counseling services, and the resident confirmed that she wanted to proceed with receiving the services. During an interview on 05/03/2026 at 9:00 AM, Administrative Assistant KK stated that she has been at the facility for about a year but had little communication with R133 before today. She stated that she was assigned to complete a psychosocial assessment on the resident this morning, so she is waiting for R133 to wake up. During a follow-up interview on 05/03/2026 11:35 AM, Administrative Assistant KK stated that she completed the psychosocial assessment with the resident and that the resident did become teary when discussing the sexual assault allegation. She provided a copy of the assessment dated [DATE] at 9:25 AM. She stated that the resident's personality and temperament were quiet during the assessment. She said when she asked R133 what, if anything, is frightening, the resident replied, being around the person that assaulted her. A review of the assessment dated [DATE] revealed that the discharge planning and goal setting, and the residents' overall goal for discharge were established during the assessment process: discharge to another facility.

Based on observations, staff interviews, and review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to discard expired food items and failed to properly label and date food items. These deficient practices had the potential to place 112 of 118 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include:Review of facility's policy titled Labeling, Dating, and Storage, review dated 11/11/2022, documented in the Procedure section, 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc.During the initial kitchen tour on 05/01/2026 at 7:43 AM, with the Assistant Dietary Manager (ADM), observations revealed:In the dry storage area:One open 2-pound (lb) bag of cereal, without an open date, One open 46 fluid ounce (oz) container of thickened orange juice, without an open date, One open 1-gallon container of hot sauce, without an open date, One 60 fl. oz. bottle of cranberry juice, with an expiration date of 04/28/2026.One 10-gallon white rubber mini trash bag labeled rice, with an expiration date of 04/23/2026. In the walk-in refrigerator:One open 2-lb turkey breast slices without an open date. In the main kitchen:Five 1-lb 4 oz whole wheat bread loaves with an expiration date of 4/29/2026. Observation on 05/02/2026 at 10:32 AM, in the dry storage area revealed five 2-lb bags of tortilla chips with an expiration of 03/22/2026.In an interview on 05/03/2026 at 10:48 AM, the ADM confirmed that the bread suppliers typically rotate the bread upon delivery. She stated she had observed that the expiration date on the bread was approaching, but was instructed to use it before that date, but forgot to discard it. The ADM stated that Dietary Aid BB confirmed leaving the turkey breast sandwich meat open during the night shift and failed to label it. The ADM stressed that all staff members have undergone in-service training and that three dates should be indicated if an item was opened.In an interview on 05/03/2026 at 11:06 AM, the Dietary Manager (DM) stated that she was responsible for labeling the food items; however, all staff members are tasked with verifying dates and disposing of expired items. The DM stated that the 10-gallon containers of rice in the dry storage area contained a date error and should have been swapped for containers with a different year-end date. The DM explained that the Activities Director brought the expired tortilla chips to the kitchen on 05/02/2026, and she did not verify the date. The DM emphasized that the night shift opened the identified food items and failed to label and date them because she completed rounds on 04/30/2026.In an interview on 05/03/2026 at 12:18 PM, the Registered Dietitian (RD) revealed that she was engaged in a leadership meeting during her visit on 04/22/2026, which focused on labeling and dating. RD explained that the meeting included specific clarification on whether an item is open, to ensure that the correct dates are provided. The Registered Dietitian stated that the potential risks associated with unlabeled, undated, and expired items could lead to the residents becoming ill.

Based on observations, staff interviews, and record review, the facility failed to properly label the nutritional formula and flush containers for two of three sampled residents (R) (R139 and R88) who received nutrition through a gastrostomy tube (G-tube) [a tube surgically inserted into the stomach used to deliver nutrition and hydration] from a total sample of 39 residents. This deficient practice had the potential to place R139 and R88 at risk of medical complications and unmet needs. Findings include:1. Review of the electronic medical record (EMR) for R139 revealed admission to the facility on [DATE] with diagnoses including, but not limited to, dysphagia (difficulty swallowing) and esophagitis.Review of the physician's orders for R139 revealed an order dated 4/30/2026 of Jevity 1.5 at 40 (milliliter) mL/hour (hr). Nocturnal feeds (overnight). Turn on at 8 pm, Turn off at 6 am.Review of the care plan revealed R139 received tube feeding for the risk of aspiration, with interventions to receive tube feeding as ordered.Observations on 05/01/2026 at 10:25 AM and 05/02/2026 at 9:22 AM revealed that R139's formula and flush container labels were missing the dates and times of administration initiation.2. Review of the electronic medical record (EMR) for R88 revealed she was admitted to the facility with diagnoses of dysphagia, oropharyngeal phase (difficulty initiating a swallow), and gastroparesis (a chronic disorder of the stomach muscles working poorly).Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Section K (Swallowing/Nutritional Status) documented that R88 received tube feeding.Review of the physician's orders for R88 revealed an order dated 11/29/2023 for G-Tube: Osmolite 1.2 - full strength by G-tube at 65ml/hr x 16 hours (on at 6 am off at 10 pm). Further review revealed an order dated 08/07/2024 for G-Tube: Tube Flush -60 mL/hr for 16 hours.Review of the care plan for R88 documented that the resident was at risk for alteration in nutrition and is at increased risk for dehydration. She has a feeding tube r/t dysphagia and is strictly nothing by mouth (NPO).Observations on 05/01/2026 at 9:46 AM and 05/01/2026 at 2:46 PM revealed that R88's formula and flush containers were not labeled or dated with the administration initiation date and time. During a walk-through observation and interview on 05/02/2026 at 1:17 PM. Licensed Practical Nurse (LPN) CC stated the residents' formula and flush container labels should include the resident name, room number, written time, and date it was administered. LPN CC continued to state nurses should be checking to ensure the labels are fully completed, and she had not been doing rounds as expected. Further, she confirmed R139 and R88 labels were incomplete with missing dates and times on the formula and flush containers.During an interview on 05/02/2026 at 3:09 PM, the Director of Health Services (DHS) stated that tube-feeding formula and flush containers should be labeled with the date and time they were hung and with the nurse's initials.

Based on observation, staff interviews, and record review, the facility failed to ensure a clean homelike environment. Specifically, the facility failed to ensure the Packaged Terminal Air Condition (PTAC) unit filters were free from buildup on four of eight halls (200 Hall, 300 Hall, 600 Hall, and 700 Hall). This deficient practice had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life. Findings include: Review of a facility-provided document revealed Instructions . PTAC: Clean air filters. The Steps' section included 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. The document included documentation of marked done on time by the Maintenance Director (MD) on March 9, 2025. Observations on 3/8/2025 from 8:49 am to 10:26 am on the 200 and 300 Halls revealed an excessive amount of dusty grayish buildup on the PTAC filters in rooms 201, 301, 302, 304, 305, 306, and 310. Observations on 3/8/2025 from 9:09 am to 10:25 am on the 700 Hall revealed an excessive amount of dusty grayish buildup on the PTAC filters in rooms 703, 705, 706, 707, and 708. Observation on 3/9/2025 from 10:00 am to 10:30 am on the 600 Hall revealed an excessive amount of dusty grayish buildup on the PTAC filters in rooms 603, 606, 609, 610, and 611. In an interview on 3/9/2025 at 9:16 am, the MD stated the maintenance department was responsible for cleaning the PTAC units monthly. He further stated the PTAC units had not been cleaned monthly. In an interview on 3/9/2025 at 9:37 am, the Maintenance Assistant (MA) confirmed that the PTACs not being cleaned could be a risk to the residents' breathing. During an observational tour on 3/9/2025 at 9:58 am with the MD, the MD observed the PTAC filters in the identified rooms and verified the dust buildup on the filters.

Based on observations, staff interviews, record review, and a review of the facility policy titled Oxygen Administration, the facility failed to ensure one of 19 residents (R) (R19) with physician's orders for oxygen (O2) was administered O2 therapy in accordance with the physician's orders. The deficient practice had the potential to place R19 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Oxygen Administration, revised date 8/2/2023, revealed the Policy Statement was It is the policy of [Name of Corporation] to provide oxygen safely and accurately to appropriate patients/residents. The Procedure section included, Oxygen will be administered by licensed personnel only when ordered by the physician, PA (physician's Assistant) or NP (Nurse Practitioner). The physician order may be written . or may specify the number of liters, method of administration, and length of time the oxygen is to be administered. Review of R19's Face Sheet revealed diagnoses including, but not limited to, thrombotic pulmonary emboli and chronic obstructive pulmonary disease. Review of R19's Admission Minimum Data Set (MDS), dated [DATE], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 12 (indicating little to no cognitive impairment) and section O (Special Treatments, Procedures, and Programs) documented that R19 received O2. Review of R19's care plan, initiated on 11/22/2024 and revised on 3/8/2025, revealed that the resident required continuous O2 related to disease process (COPD). Approaches included administering O2 as ordered. Review of R19's Physicians Orders revealed an order dated 11/20/2024 for O2 at 2 liters per minute (LPM) via nasal cannula (NC) continuous. Observation on 3/8/2025 at 9:01 am revealed R19's O2 concentrator was set on 4 LPM and was being delivered to R19 via a NC. In an interview on 3/9/2025 at 9:06 am, Licensed Practical Nurse (LPN) AA verified that R19's physician's order was for O2 at 2 LPM via NC. In a concurrent observation and interview on 3/9/2025 at 9:08 am, Registered Nurse (RN) BB confirmed that R19's O2 flow rate was set at 4 LPM, which was higher than the physician's order. In an interview on 3/9/2025 at 9:11 am, LPN AA revealed she made rounds every day to ensure residents were breathing and stated she did not check oxygen flow rates yesterday or today. LPN AA stated she thought R19 oxygen flow rate was correct. LPN AA further stated that R19's oxygen flow rate should not be higher than the physician's order. In an interview on 3/9/2025 at 9:54 am, RN BB stated administering O2 at a flow rate higher than ordered could affect the resident's respiratory status. In an interview on 3/10/2025 at 9:07 am, the Director of Nursing (DON) revealed an audit was conducted on all O2 concentrators, and flow rates had been adjusted/corrected per physician orders.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Documentation: Charting Activities of Daily Living, the facility failed to ensure that Activities of Daily Living (ADL) care was provided, specifically showers and/or bed baths, according to the schedule for one of 36 sampled residents (R) R116. This failure had the potential to place R116 at risk of being unclean and create an environment that could increase the potential for actual infections and cause R116 to feel self-conscious of their appearance. Findings include: Review of the facility policy titled Documentation: Charting Activities of Daily Living, reviewed 1/11/2024, revealed the Procedure section included 1. CNAs (Certified Nursing Assistants) are required to enter documentation at the point of care. The following should be documented in the ADL tracking tool: Daily observation of the patients/resident ADL on each shift. Review of R116's clinical record revealed diagnoses including, but not limited to, urinary tract infection, methicillin-susceptible staphylococcus aureus infection, muscle weakness, cellulitis of left lower, and age-related physical debility. Review of R116's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) revealed the resident required substantial/maximal assistance with shower/bath. Review of R116's Point of Care History dated 1/4/2025 through 3/10/2025 revealed R116 received seven showers/baths in 1/2025 (1/13/2025, 1/16/2025, 1/18/2025, 1/25/2025, 1/27/2025, 1/28/2025), six showers/baths in 2/2025 (2/5/2025, 2/10/2025, 2/11/2025, 2/13/2025, 2/20/2025, 2/24/2024), and one shower/bath from 3/1/2025 to 3/10/2025 (3/8/2025). Review of R116's care plan, initiated on 1/6/2025 and revised on 3/8/2025, revealed that R116 required ADL assistance due to generalized weakness. Interventions included to shower/bath as scheduled and PRN (as needed). In an interview on 3/8/2025 at 10:10 am, R116 stated she did not receive a bath last week. In an interview on 3/10/2025 at 9:13 am, the Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed that R116 had not received showers/baths according to the schedule. The RNC stated that a notation would be located under the progress notes if the resident refused a shower/bath and confirmed there were no notes of refusal of showers/baths. In an interview on 3/10/2025 at 11:54 am, the DON stated R119 was scheduled to receive a shower/bath on Tuesday and Friday of each week, confirmed that R116 had not received the showers/baths as scheduled, and stated she was unsure why she had not received one as scheduled. In an interview on 3/10/2025 at 12:16 pm, Unit Manager (UM)/Licensed Practical Nurse (LPN) CC stated if a resident refuses ADL care, it should be documented in the nurse's notes. She confirmed that R116 should receive a shower/bath each Tuesday and Friday.

Based on observations, staff interviews, and review of the facility policies titled, Handwashing: Dietary Services and Food Temperature, the facility failed to provide an adequate trash can by hand washing sink to dispose of used paper towels to prevent re-contamination after hand washing. The facility also failed to hold one pureed food item on the steam table above 135 degrees to prevent potential bacterial growth. The deficient practice had the potential to affect 113 of 118 residents receiving an oral diet. Findings include: Review of the facility policy titled, Handwashing: Dietary Services dated 1/8/2021 revealed under Procedure: 5. Dry hands with paper towels and discard the paper towel in a foot operated trash can. Review of the facility policy titled Food Temperature dated 2/24/2023 revealed under Procedure: 1. All hot foods served from the steam table must be held at or above 135 degrees. Observation on 11/17/2023 at 8:35 am of the small trash can next to the hand washing sink revealed the trash can had a foot pedal to lift the lid. After hands were washed in the hand washing sink attempts made to use the foot pedal to lift trash can lid and the foot pedal was broken and only way to discard used paper towel was to touch the lid to the can. Observation on 11/18/2023 at 11:00 am revealed the small trash can next to the hand washing sink continued to not function properly and to discard used paper towels the lid needed to be touched by hand. Observation on 11/18/2023 at 11:18 am of two dietary staff washing their hands using the hand washing sink revealed one staff discarded their used paper towel using the small trash can by the hand washing sink using their hand to lift the lid to the trash can. The other dietary staff member discarded their used paper towel in an empty food can on the food prep table. Continued observation revealed that several pieces of discarded paper towels were in the empty food can and staff were getting ready to assemble sandwiches as evidenced by bread and cheese were near the empty food can containing discarded trash items. During an interview on 11/18/2023 at 11:25 am the Dietary Manager (DM) revealed that she did not know that the foot pedal to trash can was broken, dietary staff did not notify her. When it was pointed out to the DM that the trash can foot pedal was not functioning correctly on 11/17/2023 and she was observed using the hand washing sink and trash can she stated that she was too busy to realize that the foot pedal was broken. Continued interview with the DM, confirmed that the empty food can on the food prep table had several pieces of discarded trash, i.e. paper towel. The DM stated that staff should be using trash cans to discard trash not the empty food can on the food prep table. The DM confirmed that there was food on the food prep table near the empty food can that contained trash. Observation on 11/18/2023 at 12:40 pm of the Steam table temperatures revealed the DM assisted with taking temperatures using the facility's calibrated thermometer. All hot food temperatures were appropriate except the puree peas which had a holding temperature of 121 degrees. During an interview on 11/18/2023 at 12:40 pm the DM confirmed that the pureed peas had a holding temperature of 121 degrees. The DM stated that dietary had not completed serving puree diet consistencies, a couple more puree meals are left to be served and the pureed peas needed to be reheated. Observation on 11/18/2023 at 12:45 pm of the open rack/carts with pre-assembled resident lunch trays revealed tray tickets were placed on the trays. Continued observation revealed at least two resident tray tickets indicated pureed consistency yet to be served.

Based on staff and resident interviews, record review, the facility failed to provide medication as ordered by the physician for two of the 24 sampled residents (R#2 and R#10) This failure had the potential to affect the residents' clinical conditions. Findings: Record review for R#2 revealed the resident was admitted with diagnoses including left-sided hemiplegia, malnutrition, diabetes, and seizure disorder. Review of most recent Minimum Data Set (MDS) dated [DATE] for R#2 revealed the resident was coded under section C-cognitive pattern; Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS is also coded under G-functional status; the resident as needing extensive assistance with activities of daily living (ADL). Review of Medication Administration Record (MAR) for R#2 dated 7/1/2022-7/31/2022 revealed there were blanks for the following dates and times: 7/13/2022 at 6 p.m., 7/21/2022 at 6 a.m., 7/30/2022 at 6 a.m., and, 7/31/2022 at 6 a.m. Record review for R#10 revealed diagnoses that included acute kidney failure, muscle weakness, and diabetes. Review of the discharge MDS, dated [DATE], for R#10 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was discharged from the facility on 12/5/2022. Review of the physicians orders revealed the following orders for medications with a start date of 12/3/2022: Aldactone, 25 (milligram) mg once a day, dicyclomine 10 mg. three times every day, Entresto 97-103 mg three times every day, Farxiga 10 mg once a day, furosemide 20 mg twice a day, isosorbide mononitrate extended release once a day, Levemir Flex touch eight units once a day, Norvasc 10 mg once a day, Pepcid 20 mg at bedtime, potassium chloride 10 milliequivalent (meq) once a day, Singular 10 mg at bedtime, Trulicity 1.5mg once a day. Review of the MAR for R#10 dated 12/3/2022 through 12/5/2022, revealed the resident didn't receive any medications until 12/4/2022 (admitted [DATE]). Interview on 1/6/2023 at 10:00 a.m., with the Director of Nursing (DON), revealed that by looking at the MAR, the medications weren't given until 12/4/2022. The DON confirmed that the medications were ordered on 12/3/2022 but were not given out until 12/4/2022. Interview on 1/6/2023 at 11:30 a.m., with R#10 via phone, she stated she didn't recommend the nursing home to anyone. She stated she never got her medications. The resident further revealed that the facility told her the medications would be there the next morning, and they were not available. Interview on 1/6/2023 at 3:00 p.m., with the Corporate Nurse Consultant, revealed that the medications were not available until Sunday, 12/4/2022. She stated that the medications were not common and were not in their emergency supply. Further interview also confirmed that the nurse who worked that night didn't call the pharmacy for backup medication. The Corporate Nurse Consultant stated they used a Cuvex system to order medications. The medications were ordered on 12/3/2022 in the morning, but they wouldn't kick in until the following day, according to their Cuvex system. The Corporate Nurse acknowledged that R#10 did not get medications until 12/4/2022, and this was a concern.

Based on record review and interviews, the facility failed to notify one resident (R) (#28) and resident's family of a room change of 39 sampled residents. Findings include: Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R#28 was in room [ROOM NUMBER]. Review of the Census Detail by Resident for 6/1/22 through 6/30/22 revealed R#28 was in room [ROOM NUMBER] upon hospital return on 6/2/22. During an interview on 6/28/22 at 2:27 p.m., family of R#28 revealed she did not know R#28 was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. An interview on 6/30/22 at 9:59 a.m. with Licensed Practical Nurse (LPN) AA revealed that upon resident's return from [CONDITION(S)], LPN AA notified him that his room was changed, and all his belongings were moved. She stated she assumed the notification to family was already done. During an interview on 6/30/22 at 10:05 a.m., the Director of Health Services (DHS) stated that R#28 was moved from 208 to 404B due to the need for a female bed (208) on the Level III unit. The unit nurse and housekeeping were notified of the move, but the resident was at [CONDITION(S)]. Interview on 6/30/22 at 10:11 a.m. with the Administrator revealed that staff should notify the resident and/or responsible party if there is a change in resident's status or room.

Based on record review and staff interview, the facility failed to notify the ombudsman when residents are transferred to the hospital for one resident (R) (#116) of two residents reviewed for transfer and/or discharge. Findings include: Review of the clinical record revealed R#116 was admitted to the facility on [DATE] and was transferred back to the hospital on the same day, 4/19/22. There was no documented evidence that the ombudsman was notified of the transfer back to the hospital. Interview with the Social Services Director (SSD) on 6/30/22 at 1:28 p.m. revealed she did not know she needed to notify the ombudsman for the residents that are transferred out of the facility. Continued interview at 2:00 p.m. revealed that the resident was in the facility for 20 minutes, tested positive for COVID-19 and was sent back to the hospital due to lack of Level I beds to accept the resident.

Based on interviews, record reviews and policy review, the facility failed to ensure that COVID-19 testing of employees was consistently documented for eight of eight staff reviewed. Findings include: The facility had a COVID-19 Testing and Re-Testing in Healthcare Centers policy, effective 5/8/20 and revised 8/9/21. The policy included that (COVID-19) testing would include all partners, providers, contractors, and consultants per the center's adjusted County Positivity Rate but no less than weekly. The policy documented that during an outbreak, vaccinated and unvaccinated partners, providers, contractors, and consultants would be tested twice weekly. The adjusted County Positivity Rates were designated as follows: counties with test percent positivity <5.0% or with <20 tests in the past 14 days: green; test percent positivity > or = to 5.0% to < or = to 10.0% or with <500 tests and <2000 tests/100,000 and >10% positive over 14 days: yellow; and > 10.0% and not meeting the criteria for green or yellow: red. A review of county positive rate information, provided by the Administrator, revealed county positive rates for June 2021 through August 2021 as follows: from 6/2/21- 6/15/21: green; 6/9/21-6/22/21: green; 6/15/21-6/28/21: green; 6/23/21-7/6/21: green; 6/30/21-7/13/21: yellow; 7/7/21-7/20/21: red; 7/21/21-8/3/21: red; 7/28/21-8/10/21: red; 8/4/21-8/17/21: red; 8/18/21-8/31/21: red; 8/11/21-8/24/21: red; and 8/25/21-9/7/21: red. 1. A review of facility COVID-19 testing logs revealed that Dietary staff AA tested positive for COVID-19 on 7/28/21. His positive COVID-19 test was the beginning of the facility's COVID outbreak on 7/28/21. Prior to the 7/28/21 positive test log, a review of facility testing logs from June 2021 through July 2021 only revealed AA's name included in the logs as having been tested for COVID-19 on 7/7/21 and 6/14/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and July 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and dietary staff AA's timeclock record revealed multiple weeks between June and July 2021 that he worked at the facility, but with no documentation of COVID testing other than on 6/14/21, 7/8/21 and 7/28/21. During an interview on 9/15/21 at 12:05 p.m. Dietary staff AA was asked, prior to him being COVID-19 positive on 7/28/21, how often was he tested for COVID at the facility. Dietary staff AA responded that he was tested twice a week. He stated that they call it (testing time) on the intercom and want you to come twice a week, so he'd go Monday and Friday, depending on his schedule. He was asked if, when COVID testing was announced, did he always go or did he work some weeks without getting tested for COVID-19? Dietary staff AA responded no, that his supervisor made sure he went. 2. A review of facility COVID-19 testing logs revealed that Licensed Practical Nurse (LPN) DD tested positive for COVID-19 on 8/9/21, during the COVID-19 outbreak that began on 7/28/21. Prior to the 8/9/21 COVID-19 positive test, a review of facility documentation from June 2021 through August 2021 revealed LPN DD's name included in the logs as having been tested for COVID on 6/5/21, 6/23/21, 7/8/21 and 7/21/21. A review of the county's positivity rates information revealed that for June and July the positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. Therefore, the COVID-19 testing logs should have included LPN DD for testing between 7/21/21 and 8/9/21. A cross reference of the COVID-19 testing logs, county positivity rate and LPN DD's timeclock record revealed multiple weeks between June and July 2021 that she worked at the facility, but without documentation of COVID-19 testing other than on 6/5/21, 6/23/21, 7/8/21, 7/21/21 and 8/9/21. In addition, LPN DD's positive COVID-19 test on 8/9/21 was after the COVID-19 outbreak that began on 7/28/21. After the outbreak started on 7/28/21, LPN DD worked 7/30/21, 7/31/21, 8/1/21, 8/4/21, 8/5/21, and 8/6/21 but with no documentation of her being tested until 8/9/21. During an interview on 9/15/21 at 11:00 a.m. LPN DD stated that when she tested positive (for COVID-19) on 8/9/21, it was a routine facility test. LPN DD indicated that prior to the 8/9/21 test, she was tested for COVID-19 at the facility once to twice weekly, depending on the county rate. She stated they would announce COVID testing (over the intercom) and you were supposed to go get tested . She stated that sometimes she missed going because she was busy but would go and get tested later in the day, that there was always someone available to complete the COVID-19 test. LPN DD denied working a week without being tested for COVID. She stated she knew she had to be tested , that she works with the COVID-19 residents. 3. A review of facility COVID-19 testing logs revealed that Certified Nursing Assistant (CNA) HH tested positive for COVID-19 during the facility's COVID-19 outbreak on 8/24/21. Prior to the 8/24/21 positive COVID-19 test, a review of facility documentation from June 2021 through August 2021 revealed no documentation of CNA HH's name included in the logs as having been tested for COVID in June 2021. A review of facility policy and county positivity rates for June 2021 revealed at least weekly testing would have been indicated in June 2021. CNA HH was included in the July and August logs as being tested on [DATE], 7/21/21, 8/2/21, 8/9/21, and 8/17/21, prior to her positive COVID-19 test result on 8/24/21. 4. A review of facility COVID-19 testing logs revealed that Housekeeper BB tested positive for COVID-19 on 8/1/21. Prior to the 8/1/21 positive test log, a review of facility testing logs from June 2021 through July 2021 only revealed BB's name included in the logs as having been tested for COVID-19 on 6/30/21, 7/8/21, 7/16/21, 7/21/21 and 7/28/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and July 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and Housekeeper BB's timeclock record revealed multiple weeks between June and July 2021 that they worked at the facility, but with no documentation of COVID testing other than on 6/30/21, 7/8/21, 7/16/21, 7/21/21 and 7/28/21. During an interview with Housekeeper BB on 9/15/21 at 11:47 a.m., she stated she was tested two times per week but was uncertain about the dates; however, she would go for testing when they used the intercom in the facility to call staff to be tested . 5. A review of facility COVID-19 testing logs revealed that Floor Tech CC tested positive for COVID-19 on 8/6/21. Prior to the 8/6/21 positive test log, a review of facility testing logs from June 2021 through July 2021 only revealed CC's name included in the logs as having been tested for COVID-19 on 6/25/21 and 7/15/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and July 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and Floor Tech CC timeclock record revealed multiple weeks between June and July 2021 that they worked at the facility, but with no documentation of COVID testing other than on 6/25/21 and 7/15/21. During an interview on 9/15/21 at 11:16 a.m., Floor Tech CC stated he could not remember how many times a week the facility was testing him, but he felt like it was two to three times per week. He indicated the facility would call the staff into the lab to be tested and he went when they were called. He stated if you missed the call, you could be tested later. 6. A review of facility COVID-19 testing logs revealed that CNA EE tested positive for COVID-19 on 8/12/21. Prior to the 8/12/21 positive test log, a review of facility testing logs from June 2021 through July 2021 only revealed EE's name included in the logs as having been tested for COVID-19 on 7/15/21, 7/20/21, and 7/30/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and July 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and CNA EE's timeclock record revealed multiple weeks between June and July 2021 that they worked at the facility, but with no documentation of COVID testing other than on 7/15/21, 7/20/21, and 7/30/21. During an interview on 9/15/21 at 2:23 p.m., CNA EE stated that the facility did not have any positive COVID-19 cases in the facility during the months of June or July 2021. She stated that the facility would make announcements over the intercom for staff to come to the lab to get tested . She stated that she would go every time the announcement was made. 7. A review of facility COVID-19 testing logs revealed that CNA FF tested positive for COVID-19 on 8/14/21. Prior to the 8/14/21 positive test log, a review of facility testing logs from June 2021 through July 2021 only revealed FF's name included in the logs as having been tested for COVID-19 on 6/22/21 and 7/1/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and July 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and CNA FF's timeclock record revealed multiple weeks between June and July 2021 that they worked at the facility, but with no documentation of COVID testing other than on 6/22/21 and 7/1/21. 8. A review of facility COVID-19 testing logs revealed that Maintenance Staff GG tested positive for COVID-19 on 8/17/21. Prior to the 8/17/21 positive test log, a review of facility testing logs from June 2021 through August 2021 only revealed GG's name included in the logs as having been tested for COVID-19 on 7/9/21, 7/16/21, 7/27/21, 8/4/21, and 8/10/21. A review of the county's positivity rates information, provided by the Administrator, revealed that for June 2021 and August 2021, the county positivity rate ranged from green to red, indicating testing of once to twice weekly, depending on the week. A cross referencing of the COVID-19 testing logs, county positivity rate, and Maintenance Staff GG's timeclock record revealed multiple weeks between June and August 2021 that they worked at the facility, but with no documentation of COVID testing other than on 7/9/21, 7/16/21, 7/27/21, 8/4/21, and 8/10/21. During an interview on 9/15/21 at 10:38 a.m., Maintenance Staff GG stated he was tested prior to his positive COVID-19 findings, in the facility, once or twice a week depending on the facility positivity rate. He stated they can get a test any time they want one. He also stated that the facility would page department by department to come to the lab to get the testing, and that announcements were posted on the lab door. During an interview on 9/9/21 at 2:00 p.m. the Director of Health Services (DHS) stated it had been a challenge keeping track of employee COVID-19 testing. She stated she was working on a new individualized form to implement (along with COVID-19 testing logs).

Based on staff interview, record review, and policy review, the facility failed to ensure that the influenza vaccine was administered to one resident (#7), from a total sample of 12 residents. Findings include: The facility had an Influenza (Flu) Vaccinations for Healthcare Center Patients policy, revised [DATE]. The policy documented that all patients who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza. The policy included that current and newly admitted patients will be offered the influenza vaccine beginning on [DATE]st of each year and will be offered for as long as the influenza viruses are circulating and unexpired vaccine is available. During an interview on [DATE] at 11:05 a.m., when the Director of Health Services (DHS) was asked who assessed the vaccination status of residents, she stated that she does and the last time she assessed was March of this year (2021). The DHS stated vaccination status was previously assessed last influenza season, around September or [DATE]. Resident (R)#7 resided at the facility from [DATE] through [DATE]. A review of his clinical record revealed no evidence that the resident was offered the influenza vaccine during the time he resided at the facility. Additionally, a review of the facility's Influenza Immunization Log Worksheets, which included residents who were educated on the influenza vaccine on [DATE] and received the influenza vaccine on [DATE], revealed R#7 was not included on the logs as having received influenza information or the influenza vaccine. The facility did not provide additional information to show that R#7 was offered the flu vaccine after surveyor requests on [DATE] at 11:05 a.m. and 3:20 p.m. and on [DATE] at 4:20 p.m.

Based on staff interview, record review and policy review, the facility failed to ensure that one resident (#2) received a second dose of the COVID-19 vaccine in a timely manner, from a total sample of 12 residents. Findings include: The facility had a COVID-19 Vaccinations Clinics policy, effective 3/27/21 and revised 7/19/21. The policy included that all residents who have no medical contraindications to the vaccine will be offered the COVID-19 vaccine per CDC recommendations to encourage and promote the benefits associated with the vaccinations against COVID-19. Resident (R)#2 received the first dose of COVID-19 vaccine on 1/8/21. A review of the clinical record revealed that she received the Pfizer COVID-19 vaccine to the right deltoid on 1/8/21. The clinical record documented that the next scheduled dose would be 1/29/21. Further review of the clinical record revealed a 1/21/21 nurse's note entry that documented R#2 had tested positive for COVID-19. She was subsequently hospitalized from 1/24/21 through 1/27/21 and returned to the facility. Following R#2's return to the facility on [DATE], there was no evidence in the clinical record that she received the second dose of COVID-19 vaccine, as scheduled on 1/29/21 or that facility nursing staff followed up with R#2's practitioner regarding if and/or when the second dose of COVID-19 vaccine could be given, until after surveyor inquiry on 8/25/21. During an interview on 8/25/21 at 3:55 p.m. the Director of Health Services (DHS) confirmed that R#2 had not received the second dose of the COVID-19 vaccine. Following surveyor inquiry, an 8/27/21 nurse's note entry in R#2's clinical record documented that the DHS spoke with R#2's Nurse Practitioner (NP) regarding the second dose of the COVID vaccine. The NP responded that it was okay to proceed with the second dose.

Based on record review, review of the facility procedure titled Lippincott Procedures-SBAR (situation, background, assessment, recommendation) Communication, and staff/family interviews, the facility failed to notify the Physician and responsible party (RP) of a new and worsening pressure ulcer for one resident (R)(#1) of 10 sampled residents. On 3/4/21 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020. The IJ is outlined as follows: R#1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers (F686 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. An Acceptable IJ Removal Plan was received on 3/8/21. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/7/21. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and resident's with pressure ulcers. Findings include: Review of facility procedure titled Lippincott Procedure-SBAR Communication dated 8/24/2020 read: SBAR, an acronym that stands for situation, background, assessment, and recommendation, is a communication tool that can be adapted for use in various situations. It's useful for framing a conversation in a neutral way, setting expectations for the content of the conversation, and ultimately improving communication among caregivers. SBAR facilitates effective, efficient, consistent, and focused communication. SBAR communication provides a systematic approach to communication during care transitions and in situations in which communication information about the patient's condition to other multidisciplinary team is necessary. Using this tool helps to reduce the risk of patient care errors that commonly occur with transitions in care. Review of the facility procedure titled Lippincott Procedures-Pressure Injury Prevention, Long-term Care with a review date of 7/5/16 revealed: If pressure injury develops, note changes in the condition or size of the pressure injury and elevations of skin temperature. Document when you notified the practitioner of pertinent abnormal observations. Document resident and family teaching and their comprehension of your teaching. The facility had no other policies related to change of condition or notification of change. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] (a quarterly was done even though the resident was admitted on [DATE], an admission assessment was done on 11/19/2020) revealed R#1 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section G- Functional Status documented R#1 required two-person assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Section M - Skin Conditions documented one unstageable pressure ulcer that was not present on admission. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Observation Report dated 11/12/2020 revealed under skin section, no alterations in skin. Braden assessment dated [DATE], completed on admission, indicated at risk for pressure ulcers. Review of Focused Observation document dated 12/3/2020 noted a change in skin to right buttocks. Stage 2 pressure ulcer to right buttocks measured 2 cm x 3 cm. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks combined to be 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. There is no documented evidence in the medical record that the Physician or responsible party were notified of the residents wound prior to 2/2/21. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation further stated that resident's pressure ulcer to sacrum is unstageable and has a foul odor, with drainage, and necrotic tissue. Me and NP were not notified. Physician gave an order to send R#1 to the acute care hospital emergency room for further evaluation. Review of hospital documentation dated 2/2/21 revealed R#1 was admitted with [CONDITION(S)] and large sacral wound; wound and blood cultures positive for heavy growth proteus mirabilis (bacteria). Interview on 2/24/21 at 1:35 p.m. with LPN DD, part time treatment nurse, revealed she implemented all R#1's treatments while she was in the facility. LPN DD stated she did not get the order from Physician and she did not notify him of the pressure ulcers. LPN DD stated when she worked the weekends, she would leave a note for the weekday nurses so they would know about the new wounds. LPN DD also confirmed she did not fill out the SBAR communication tool. Interview on 3/1/21 at 11:19 a.m. with Family of R#1 revealed she was notified by the hospital that the resident had a severe pressure ulcer to her sacrum. Family of R#1 stated she was unaware of the pressure ulcer prior to the resident's hospitalization on [DATE]. Family of R#1 called the facility almost daily to receive updates and identified several staff she had spoken with. Family of R#1 stated that the resident is currently in another nursing home receiving palliative care. Interview on 3/2/21 at 10:42 a.m. with the Administrator and DHS revealed Family of R#1 notified them of concerns about the resident's care on 2/2/21. The Administrator and DHS looked in the medical record of R#1 and were unable to locate documentation of family notification of R#1's pressure ulcer. They did education on SBAR, as the primary tool to be used to make sure the family and Physician are notified timely. The DHS further stated the facility wants to make sure all notifications are properly made. Interview on 3/2/21 at 11:32 a.m. with Nurse Practitioner (NP) NN revealed she was not notified of R#1's wound until 2/2/21, a few hours prior to the resident going to the hospital. NP NN stated she is in the facility five days per week for at least eight hours per day and can be reached via phone 24 hours per day, seven days per week when a resident has a change in condition. Interview on 3/3/21 at 3:27 p.m. with the Physician revealed that he saw the resident on 2/2/21 for [CONDITION(S)] and a change in mental status. The resident also had COVID. He entered the room and smelled a foul odor and then looked at the wound. The wound was draining and there was necrotic tissue in the wound. The Physician stated he knew, upon observation, that it was unstageable. He expected them to call him any time there is a change in condition, especially when they have a wound, so that they can evaluate if the treatment was appropriate. The Physician stated he feels that R#1 fell through the cracks and the decline in her wound could have possibly been prevented with proper treatment and care. Cross refer to F686. The facility implemented the following actions to remove the IJ: 1. On 2/2/21, Resident #1 was hospitalized for a sacral wound infection and [CONDITION(S)]. Resident #1 was transferred from hospital to another nursing home on 2/18/21 and is receiving palliative care. 2. It was identified that the Physician was not notified timely for new and worsening pressure injuries, so that prompt treatment could be initiated. 3. The week of 2/22/21, a 100% body audit was completed by the charge nurses. All identified pressure injuries were reported to Medical Director (MD) and responsible party (RP) by 3/1/21. New orders were obtained as indicated for new and worsening pressure injuries. Documentation of the MD/RP notification was placed in the resident's EMR (electronic medical record). MD is aware of all current/new/worsening pressure injuries with all in-house residents. The DHS completed the body audit tool checklist to verify 100% compliance of body audits and MD/RP notification. 4. On 3/4/21, the Director of Health Services (DHS) and Unit managers (UM) completed 100% chart audit on 10 of 10 in-house residents with documented pressure injuries to verify documentation of MD/RP notification. Per the audit, 10 of 10 residents' documentation was noted. 5. Ongoing, the DHS/UM/Skin integrity coordinator (SIC) will utilize the daily body audit schedule to verify completion of body audits of all new and worsening wounds on a daily basis. Any missing or incomplete body audits will be addressed and completed immediately. DHS/UM/SIC will review for SBAR completion for change of condition due to new and worsening wound, verify notification to MD/RP. Audits forms that will be used are Daily Body Audit Form and Daily Audit for Change of Condition for new or worsening wounds. 6. On 3/4/21, the DHS, Clinical Competency Coordinator (CCC), and UM started in¿-services for licensed nurses on in-service titled Notification of Wounds and INTERACT'S SBAR Communication to address documentation and notification to Medical Director (MD) and responsible party (RP) for new and worsening pressure injuries. As of 3/5/21, 100% of the licensed nurses, which included 11 Registered Nurses (RNs), 24 LPNs, and 3 Agency nurses (agency contract expires 3/6/21). In-service was completed on 3/5/21. 7. On 3/4/21, the DHS, CCC (Clinical Care Coordinator), and UM started in-services for certified nursing assistants on completion of INTERACT Stop & Watch (an early warning communication written tool) to notify nurse of any new or worsening wounds. As of 3/5/21, 96.22% of the Certified Nursing Assistants (CNA) which included 51 of 53 CNAs. In-service was completed on 3/5/21. CNA's not in-serviced will be educated prior to working their shift. 8. Education on in-service titled Notification of Wounds and INTERACT'S SBAR Communication to address documentation and notification was added to licensed nurse's new partner orientation. Education for in-services on the INTERACT Stop and Watch was added to certified assistants' new partner orientation. 9. All corrective actions were completed on 3/6/21. 10. The immediacy of the IJ was removed on 3/7/21. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of Census Records documentation revealed Hospital Leave dated 2/2/21 at 11:45 a.m. for R#1. Interview with Family of R#1 on 3/1/21 at 11:19 a.m. revealed the resident is at another nursing home receiving palliative care. 2. It was identified, through interview, that the Physician was not notified timely for new and worsening pressure injuries, so that prompt treatment could be initiated. 3. Review of the Midnight Census dated 2/23/21 revealed a 100% body audit was completed by 2/25/21. This was signed as completed by the DHS on 3/1/21. Eighty-seven Body Audit Forms were reviewed with two residents being currently hospitalized . Review of the Observation Details dated 2/24/21 revealed R#11 had a reddened small open area to the left buttocks the size of a quarter. The Physician and RP were notified on 2/24/21 at 6:39 p.m. 4. Review of the document signed by the DHS revealed 100% Chart Audit was completed for 10 residents with pressure ulcers. Review of Progress Notes revealed: a. On 2/25/21, NP NN was present during the body audit and gave new treatment orders for R#7. The resident representative was already aware of the wound. b. On 3/5/21, the Physician was notified and assessed the left hip and sacrum area for R#8 and continued current treatment orders. R#8's representative was also notified on 3/5/21. c. On 3/5/21, newly opened area was noted to the sacrum for R#12. The Physician was called into the room and assessed the wound as Stage 2. Treatment orders were initiated, and the resident's representative was notified at 1:38 p.m. The SBAR Communication Form was completed. 5. Review of the documents titled Daily Body Audit Form and Daily Change of Condition (COC) Audit Tool for New or Worsening Wounds revealed tools being utilized daily to verify completion of body audits. The Daily Body Audit Form revised 3/6/21 revealed columns for: Resident Room Number, Resident Name, Date Body Audit Scheduled, Completed (yes/no). The Daily COC Audit Tool for New or Worsening Wounds revealed columns for: Resident name, SBAR reviewed: new worsening wound (yes/no), if new or worsen, date MD notified, treatment orders verified (yes/no), RP notification (yes/no), care plan updated (yes/no), referred (name - wound specialist) (yes/no), MD notified of result of referral (yes/no). Audits documented from 3/4/21 through 3/10/21 with corrections noted for identified issues. Daily Skin Assessment schedules were reviewed and were observed on 3/8/21 at each nurse's station. 6. Review of the in-service records dated 3/4/21 confirmed 11 RN's, 24 LPN's, and 3 agency nurses received education regarding SBAR Communication pertaining to notification of wounds. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 9:53 a.m. with LPN BB, 10:21 a.m. with LPN PP, 10:27 a.m. with LPN QQ, 10:29 a.m. with LPN RR, 10:32 a.m. with LPN SS, 10:38 a.m. with LPN TT, 11:23 a.m. with LPN UU, 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, 12:20 p.m. with RN GG, and 12:31 p.m. with LPN WW. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 7. Review of the in-service records dated 3/4/21 confirmed 51 CNA's received education on the use of the Stop and Watch Tools and the importance of communication. One CNA received education via phone on 3/6/21 and one CNA is on leave. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 10:04 a.m. with CNA XX, 10:09 a.m. with CNA YY, 10:15 a.m. with CNA ZZ, 10:20 a.m. with CNA AAA, 10:26 a.m. with CNA BBB, 10:30 a.m. with CNA CCC, 10:40 a.m. with CNA DDD, and 10:50 a.m. with CNA EEE The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 8. Review of the New Hire Education Packet revealed the following items added: for licensed nurse's: Notification of Wounds and Interacts SBAR Communication; for CNAs: Interact Stop and Watch. As of 3/8/21, no new licensed nurses or CNAs were hired. 9. All corrective actions were completed on 3/6/21. 10. The immediacy of the IJ was removed on 3/7/21.

Based on record review, review of facility policy titled Care Plans, and staff interviews, the facility failed to follow the care plan for one of 10 residents (R) (#1) related to weekly skin assessments and Physician notification for a new and worsening pressure ulcer. On 3/4/21 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020. The IJ is outlined as follows: R#1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers (F686 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. An Acceptable IJ Removal Plan was received on 3/8/21. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/7/21. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and resident's with pressure ulcers. Findings include: Review of facility policy titled Care Plans last revised 10/5/17 revealed: Policy Statements- It is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) . Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#1 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section G- Functional Status documented R#1 required two-person assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Section M - Skin Conditions documented one unstageable pressure ulcer that was not present on admission. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan initiated 11/24/2020 and last reviewed/revised on 2/12/21 revealed R#1 is at risk for skin breakdown related to bowel and bladder incontinence and impaired physical mobility. Resident has pressure ulcers to sacrum and right buttock. Interventions included but not limited to notify the MD (Physician), skin audit per protocol, and treatment as ordered. Review of Focused Observation document dated 12/3/2020 noted a change in skin to right buttocks. Stage 2 pressure ulcer to right buttocks measured 2 cm x 3 cm. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks combined to be 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. There is no evidence in the medical record that a weekly skin audit was completed between 11/18/2020 to 12/3/2020, 12/4/2020 to 12/14/2020, and 1/24/21 to 2/2/21. There is no evidence in the medical record that the Physician was notified for the new and worsening pressure ulcers to the right buttocks and sacrum. Review of hospital documentation dated 2/2/21 revealed R#1 was admitted with [CONDITION(S)] and large sacral wound; wound and blood cultures positive for heavy growth proteus mirabilis (bacteria). Interview on 2/22/21 at 2:25 p.m. with DHS revealed she expects the nursing staff to follow the interventions on the care plan and update the care plan as needed. Interview on 2/24/21 at 1:35 p.m. with Licensed Practical Nurse (LPN) DD, part time treatment nurse, revealed she did not notify the Physician of the new and worsening pressure ulcers on R#1. Interview on 3/2/21 at 10:42 a.m. with DHS and Administrator revealed the intervention on the care plan for R#1 stating notify the MD was not followed. The Physician was not notified of the new and worsening of the pressure ulcer until 2/2/21. Interview on 3/2/21 at 11:32 a.m. with Nurse Practitioner (NP) revealed she was not notified R#1 has a new and worsening pressure ulcer until 2/2/21 when resident was transferred to an acute care hospital. Interview on 3/2/21 at 1:44 p.m. with LPN CC revealed the care plans have interventions on how to care for residents and should be followed. Interview on 3/3/21 at 2:20 p.m. with Registered Nurse (RN) GG revealed she is the Case Mix Director. She stated her role is to coordinate the completion of the MDS assessments and care plans. RN GG stated that all members of the Interdisciplinary Team give input into the MDS and care plans. It is the responsibility of the Interdisciplinary Team to ensure proper care plan and interventions are in place for each resident. Each department head is responsible to ensure partners in their department are following care plan interventions. Interview on 3/3/21 at 3:27 p.m. with the Physician revealed he was not notified of R#1's wounds until 2/2/21 during his record review when he was making facility rounds. Interview on 3/5/21 at 9:36 a.m. with Administrator confirmed that all nursing staff and any person providing direct care to residents should follow the care plans. The intervention for R#1 to notify MD of changes was not followed. Cross refer to F686. The facility implemented the following actions to remove the IJ: 1. On 2/2/21, Resident # 1 was hospitalized for a sacral wound infection and [CONDITION(S)]. Resident # 1 was transferred from hospital to another nursing home on 2/18/21 and is receiving palliative care. 2. It was identified that the facility failed to follow the care plan related to Physician notification for a new and worsening pressure ulcer and weekly skin audits. 3. On 3/4/21, Case Mix Directors (CMD) were given a list of all pressure injuries for care plans to be updated with appropriate interventions. CMDs were instructed by the Senior Nurse Consultant to complete by the end of business day on 3/5/21. 4. On 3/5/21, the DHS/UM (Unit Manager) completed 100% care plan review audit on 10 of 10 in¿ house residents with documented pressure injuries to verify skin integrity care plans are complete and accurate. Per the audit, 10 of 10 residents' care plans were updated appropriately. 5. Ongoing, the DHS/UM will complete a daily care plan audit tool to verify new and/or worsening wounds are noted on the care plan with appropriate interventions. This will be documented on the Daily COC (Change of Condition) Audit Tool for new or worsening wounds. 6. On 3/4/21, the DHS, Clinical Competency Coordinator (CCC) in-serviced 100% of all licensed nurses on the Care plans policy to address updating, reviewing, and following care plan interventions. Education was completed for 100% of the licensed nurses that includes 11 Registered Nurses (RN's) and 24 LPN' s and 3 agency nurses. Inservice was completed 3/5/21. 7. All new licensed nurses will be educated during orientation on in-service titled Care Plan Policy. 8. On 3/4/21, education with the CNAs was completed on the residents' profile and care plan approaches to view for pressure injuries interventions. As of 3/5/21, 96.22% of the Certified Nursing Assistants (CNA), which included 51 of 53 CNAs have been completed. Two CNA's could not be in-serviced as one is on FMLA and one could not be reached. The CNA will be educated prior to working the next scheduled shift. 9. All new CNA's will be educated during new partner orientation on the residents' profile and care plan approaches to view for pressure injuries interventions. 10. During admission, readmission, significant change, and quarterly care plan meetings, the Skin integrity nurse (SIC), DHS, UM, and Case Mix (CMD) coordinator(s) will review skin integrity care plan for identification of pressure injuries and appropriate interventions. 11. All corrective actions were completed on 3/6/21. 12. The immediacy of the IJ was removed on 3/7/21. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of Census Records documentation revealed Hospital Leave dated 2/2/21 at 11:45 a.m. for R#1. Interview with Family of R#1 on 3/1/21 at 11:19 a.m. revealed the resident is at another nursing home receiving palliative care. 2. It was identified, through interview, that the Physician was not notified timely for new and worsening pressure injuries, so that prompt treatment could be initiated. 3. Review of the Midnight Census Worksheet dated 3/4/21 signed by the DHS revealed a 100% audit on 10 residents with pressure ulcers. The residents were checked off as completed. 4. Review facility documentation dated 3/4/21 revealed 100% care plan review audit on 10 of 10 in¿ house residents with documented pressure injuries to verify skin integrity care plans are complete and accurate. R#12, R#14, and R#15 care plan were reviewed with no concerns. 5. Review of the Daily COC Audit Tool for New or Worsening Wounds dated 3/6/21 through 3/9/21 revealed SBAR was reviewed, date of Physician notification, verification of treatment orders, RP (Responsible Party) notification, and care plan update. On 3/8/21, an SBAR was completed for two residents with non-pressure related skin concerns. Physician and RP were notified, and care plan was updated. 6. Review of the in-service records dated 3/4/21 confirmed 11 RN's, 24 LPN's, and 3 agency nurses received education regarding SBAR Communication pertaining to notification of wounds; and Care Plan Policy and Process for updating, reviewing, and following care plan interventions. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 9:53 a.m. with LPN BB, 10:21 a.m. with LPN PP, 10:27 a.m. with LPN QQ, 10:29 a.m. with LPN RR, 10:32 a.m. with LPN SS, 10:38 a.m. with LPN TT, 11:23 a.m. with LPN UU, 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, 12:20 p.m. with RN GG, and 12:31 p.m. with LPN WW. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 7. Review of the New Hire Education Packet revealed the following items added for licensed nurse's: Notification of Wounds and Care Plan Policy and Procedure. As of 3/9/21, no new licensed nurses were hired. This was confirmed by interview with RN AA, CCC, on 3/9/21 at 12:08 p.m. 8. Review of the in-service records dated 3/4/21 confirmed 51 CNA's received education resident profile and viewing care plan actions/ interventions in (Electronic Medical Record). One CNA received education via phone on 3/6/21 and one CNA is on leave. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 10:04 a.m. with CNA XX, 10:09 a.m. with CNA YY, 10:15 a.m. with CNA ZZ, 10:20 a.m. with CNA AAA, 10:26 a.m. with CNA BBB, 10:30 a.m. with CNA CCC, 10:40 a.m. with CNA DDD, and 10:50 a.m. with CNA EEE. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 9. Review of the New Hire Education Packet revealed the following items added for CNA's: viewing resident's profile including care plan interventions for residents with pressure ulcers. As of 3/9/21, no new CNA's were hired. This was confirmed by interview with RN AA, CCC, on 3/9/21 at 12:08 p.m. 10. R#7 had an MDS Quarterly Assessment on 2/25/21 with one DTI (Deep Tissue Injury) noted on the assessment. R#7 noted with updated care plan with appropriate interventions. 11. All corrective actions were completed on 3/6/21. 12. The immediacy of the IJ was removed on 3/7/21.

Based on observation, record review, review of the facility's Lippincott Procedure and staff interviews, the facility failed to ensure that wound assessments were completed weekly for three of 10 sampled residents (R) (#1, #2, and #4) with pressure ulcers; and failed to conduct consistent weekly skin assessments and failed to notify the Physician for appropriate wound treatment orders for R#1. On 3/4/21 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020. The IJ is outlined as follows: R#1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers (F686 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. An Acceptable IJ Removal Plan was received on 3/8/21. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/7/21. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and resident's with pressure ulcers. Findings include: Review of the procedure titled Lippincott Procedures-Wound Observation and Assessment Documentation, with a review date of January 2015 revealed - Critical Note: Wound Observations are documented weekly in the Electronic Health Record. At least every 7 days a comprehensive nursing assessment is completed by the registered nurse that includes a review of the current plan of care, current wound status (based on assessment and review of all documentation), and the patient/resident's response to the treatment plan. Review of the procedure titled Lippincott Procedures-Pressure Injury Prevention, Long-term Care with a review date 7/5/16 revealed - If pressure injury develops, note changes in the condition or size of the pressure injury and elevations of skin temperature. Document when you notified the practitioner of pertinent abnormal observations. Document resident and family teaching and their comprehension of your teaching. The facility had no other policies related to wound care or skin integrity. 1. Review of the Face Sheet revealed R#1 was admitted to the facility on [DATE]. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#1 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section G- Functional Status documented R#1 required two-person assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Section M - Skin Conditions documented one unstageable pressure ulcer that was not present on admission. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Observation Report dated 11/12/2020 revealed under skin section, no alterations in skin. Braden assessment dated [DATE], completed on admission, indicated at risk for pressure ulcers. Review of Focused Observation document dated 12/3/2020 noted a change in skin to right buttocks. Stage 2 pressure ulcer to right buttocks measured 2 centimeters (cm) x 3 cm. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks combined to be 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. There is no documented evidence in the medical record that the Physician was notified for proper treatment prior to 2/2/21. There is no evidence in the medical record that a weekly skin audit was completed between 11/18/2020 to 12/3/2020, 12/4/2020 to 12/14/2020, and 1/24/21 to 2/2/21. Weekly wound assessments for those wounds were completed on 12/3/2020, 1/17/21, and 1/23/21 only. No other weekly wound assessments were completed during the nursing home stay from 11/12/2020 through 2/2/21. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/3/20-Treatments Non-RX: Cleanse wound to right buttocks with NS/WC (normal saline/ wound cleanser). Blot dry. Apply skin protectant to surrounding skin, Cover wound with Puracol and a foam dressing Once A Day on Tue, Thu, Sat (d/c 1/17/21). 1/17/21-Treatments Non-RX: Cleanse wound to sacrum with NS/WC. Blot dry. Apply skin protectant to surrounding skin, Cover wound with Calcium Alginate and a foam dressing Special Instructions: monitor for signs and symptoms of infection Once A Day Every Other Day (d/c 1/25/21). 1/25/21- Treatments Non-RX: Cleanse wound to sacrum with Dakins solution. Blot dry. Apply skin protectant to surrounding skin, Cover wound with Santyl, NS moisten gauze and a foam dressing. Special Instructions: monitor for signs and symptoms of infection, Once A Day. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation further revealed that resident's pressure ulcer to sacrum is unstageable and has a foul odor, with drainage, and necrotic tissue. Me and NP (Nurse Practitioner) were not notified. Physician gave an order to send R#1 to the acute care hospital emergency room for further evaluation. Review of hospital documentation dated 2/2/21 revealed R#1 was admitted with [CONDITION(S)] and large sacral wound; wound and blood cultures positive for heavy growth proteus mirabilis (bacteria). During an interview on 2/24/21 at 11:54 am., the Administrator revealed that the Physician does not give standing orders for wound care treatments. Wound care treatments should be initiated by the Physician. Interview on 2/24/21 at 1:35 p.m. with LPN DD, part time treatment nurse working on the weekends, revealed she implemented all R#1's treatments while she was in facility. LPN DD stated she did not get the order from Physician and she did not notify him of the pressure ulcers. LPN DD stated when she worked the weekends, she would leave a note for the weekday nurses so they would know about the new wounds and the NP is in the facility to look at the wound first thing on Monday morning. LPN DD also confirmed she did not fill out the SBAR (situation, background, assessment, and recommendation) communication tool. Interview with NP NN on 3/2/2021 at 11:32 a.m. revealed she did not see R#1 and did not know about her wounds until the resident went to the hospital. NP NN stated that she felt like R#1 fell through the cracks when she was moved from one wing to another because of COVID. NP NN stated, typically, they will notify her, and she will go first thing and assess that resident. She is in the facility on Monday through Friday and is available by phone on the weekends. NP NN revealed that for a really bad or worsening wound, the nurse should call the Physician or NP for orders. NP NN stated that what happened to R#1 usually does not happen. NP NN stated that LPN DD is so used to treating wounds and she initiated a treatment that she has seen for a similar wound. Interview with the Physician on 3/3/2021 at 3:27 p.m. revealed that he seen the resident that day for [CONDITION(S)] and a change in mental status. The resident also had COVID. He entered the room and smelled a foul odor and then looked at the wound. The wound was draining and there was necrotic tissue in the wound. He knew, upon observation, that the wound was unstageable. He knew by her other symptoms that she had some sort of infection. He did not feel that the wound got infected overnight, and was most likely infected for several days, likely when they found it 1/25/2021 (sic, 1/23/21). He expected them to call him any time there is a change in condition, especially when they have a wound, so that they can evaluate if the treatment was appropriate. The Physician stated he expects the nurses to do body audits and weekly wound assessments so they can review them and determine if the wound is healing or if the order needs to be changed. He has not been able to do that (review documentation) and has had to rely on communication with the nurses for wound status. He stated R#1 fell through the cracks and this could have been prevented. 2. Review of Face Sheet revealed R#2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS assessment dated [DATE] revealed R#2 with a BIMS score of nine out of 15 indicating mild cognitive impairment. R#2 required two-person extensive assistance with bed mobility and total dependence for transfers. Section M-Skin Condition documented R#2 at risk for pressure injury and had one unstageable pressure ulcer with slough and/or eschar and three unstageable pressure injuries with suspected deep tissue injury (DTI). During an observation on 2/23/21 at 12:53 p.m., R#2 received treatment to the right and left heel and right ankle. There were no concerns identified during wound care. Review of the Wound Management Reports revealed the right heel was newly identified on 2/12/21 as a DTI. The left heel was identified on 9/23/2020 as a DTI measuring 3 cm x 3.5 cm. There was no evidence of a weekly wound assessment since 11/12/2020. The wound was assessed again on 2/12/2020 to be 4 cm x 4 cm x 0.1 cm, stable DTI. The right ankle was identified on 9/23/2020 as unstageable with slough and/or eschar measuring 3 cm x 3.2 cm. There was no evidence of a weekly wound assessment since 10/8/2020. The wound was assessed again on 2/12/2020 to be 2 cm x 1.5 cm x 0.2 cm, improving. Review of the (name - wound specialists) Evaluation and Management Report dated 2/26/21 revealed R#2 with wounds to the right heel (2.1 cm x 2 cm x 0.2 cm), left heel (4 cm x 3.7 cm x 0.1 cm), and right lateral malleolus (outer ankle - 2.1 cm x 1.2 cm x 0.2 cm) . arterial and pressure with onset in the past months. 3. Review of Face Sheet revealed R#4 was admitted to the facility 12/29/16 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Quarterly MDS assessment dated [DATE] revealed R#4 with a BIMS score of nine out of 15 indicating mild cognitive impairment. R#4 required one-person extensive assistance with bed mobility and activity did not occur for transfers. Section M-Skin Condition documented R#4 at risk for pressure injury and had one unstageable pressure ulcer with slough and/or eschar and one unstageable pressure injuries with suspected DTI. Review of the (name - wound specialists) Evaluation and Management Report dated 2/25/21 revealed R#4 with pressure ulcer to the left heel (6 cm x 2 cm x 0.3 cm), unstageable and right foot, fourth digit (0.1 cm x 1.2 cm x 0.1 cm), Stage 3. Wound has been present for a couple of months. Review of the Wound Management Reports for R#4 revealed the left heel was identified on 10/22/2020 as a pressure ulcer with necrotic tissue measuring 2 cm x 1.7 cm, no stage. There was no evidence of a weekly wound assessment since 12/17/2020. The wound was assessed again on 2/13/2020 to be 2 cm x 3.5 cm, stable Stage 2. There is no evidence of weekly wound assessments for the right foot, fourth digit. Interview on 2/23/21 at 10:50 a.m. with RN AA revealed the treatment nurse is responsible to complete weekly wound assessments on residents with wounds. She stated that if a nurse finds a wound when the treatment nurse is not working, that nurse is responsible to complete a wound assessment. The wound care specialist has been seeing certain residents with wounds but will begin seeing any resident with Stage 2 or greater pressure ulcer weekly beginning 2/25/21. Interview on 2/23/21 at 10:53 a.m. with LPN BB revealed the treatment nurse is responsible for completing weekly wound assessments on residents with wounds. Interview on 2/24/21 at 11:54 a.m. with the DHS revealed wound assessments are to be completed weekly on all residents with wounds by the skin integrity coordinator (SIC) (treatment nurse). The facility only has one part time treatment nurse who works on the weekends. The other treatment nurses went on leave several months ago and did not return. Further interview on 2/24/21 at 1:35 p.m. with LPN DD, part time treatment nurse on the weekends, revealed she is responsible to do wound assessments on new wounds and worsening wounds. LPN DD stated she does not do weekly wound assessments. Continued interview on 3/2/21 at 11:55 a.m. with LPN DD revealed she does not do any documentation on the wounds except the MDS assessment. When asked who is responsible to do the weekly wound assessment, she stated I don't know. The facility implemented the following actions to remove the IJ: 1. On 2/2/21, Resident # 1 was hospitalized for a sacral wound infection and [CONDITION(S)]. Resident # 1 was transferred from hospital to another nursing home on 2/18/21 and is receiving palliative care. 2. It was identified that the facility failed to provide necessary treatment and services to prevent the development of new pressure ulcers, to promote healing of existing pressure ulcers and to prevent wound infection. 3. The week of 2/22/21, a 100% body audit was completed by the charge nurses. All identified pressure injuries were reported to medical director (MD) and responsible party (RP) by 3/1/21. Current orders were obtained as indicated for new and worsening pressure injuries. Documentation was placed in the resident's EMR (electronic medical record) to document notification. Audit revealed no new pressure wounds. Audit also revealed that a stage 1 had worsened to a stage 2. Nurses note on 3/4/21 reveals the area on the left buttocks is reddened. On 3/5/21 SNC (Senior Nurse Consultant) and CMD (Case Mix Director) assessed wound and found it to be scarring from a previously healed wound skin tact. 4. On 3/5/21, the DHS/UM (Unit Manager) completed 100% chart audit on 10 of 10 in-house residents with documented pressure injuries to verify documentation of MD/RP notification. Per the audit, 10 of 10 residents' documentation was noted. 5. On 3/5/21, the DHS/UM completed 100% chart audit on 89_in-house residents to verify weekly body audit was completed the week of 2/28/21. DHS verified completion of all body audits. 6. On 3/4/21, the DHS, Clinical Competency Coordinator (CCC), and UM started in-services for licensed nurses on Relias procedure's Wound Care Assessment and Guidelines for Cleansing and Observing a Wound to address wound identification and documentation. As of 3/4/21, 100% of the licensed nurses. As of 3/5/21, 100% of the licensed nurses, which included 11 RNs, 24 LPNs, and 3 Agency nurses (agency contract expires 3/6/21). In-service was completed on 3/5/21. 7. On 3/4/21, CNAs were in-serviced on the residents' profile and care plan approaches to view for pressure injuries interventions. As of 3/5/21, 96.22% of the Certified Nursing Assistants (CNA), which included 51 of 53 CNAs. In-service was completed on 3/5/21. CNA will be educated prior to working her shift. 8. All new CNA's will be educated during new partner orientation on the residents' profile and care plan approaches to view for pressure injuries interventions. 9. On 3/6/21 the DHS educated all licensed nurses on the following process: The charge nurse utilizes the body audit schedule which is assigned by room numbers to an associated day of the week for Day and Evening shifts, Monday through Saturday. If a charge nurse finds a new area, they will complete a SBAR, with a wound assessment and notify MD for orders and notify RP. DHS/UM/SIC will review SBAR completion each day for new and worsen wounds. 91.66% of the education was completed. That includes 11 out of 11 RN's and 22 out of 24 LPN's. 10. SIC Nurse/RN will do weekly wound assessment including measurements on all patients with pressure injuries every 7 days or less. An audit will be performed weekly by the DHS, UM's or CCC. Results will be documented on the Weekly Wound Assessment Audit Tool. 11. SIC Nurse/RN/UM will contact RP for consent to refer to (name - wound specialists) for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. (name - wound specialists) will provide evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 13. The SIC/DHS/UM will review all SBAR's daily for change of condition due to new and worsening wounds, verify notification to MD/RP is documented, verify care plans are updated, and verify treatment orders are noted. Any areas identified that are incomplete from the audit will be completed immediately. The DHS or designee will provide appropriate disciplinary actions to the licensed nurse if tasks are incomplete. This will be documented on the Daily Audit for Change of Condition for new or worsening wounds. 14. Ongoing, the DHS/UM/SIC will utilize the daily body audit schedule to verify completion of body audits of all new and worsening wounds on a daily basis. Any missing or incomplete body audits will be addressed and completed immediately. Results will be documented on the Daily Audit for Change of Condition for new or worsening wounds. 15. On 2/9/21, the treatment nurse that was responsible for the care of Resident # 1 received one on one education and written disciplinary action by the DHS. 16. On 3/2/21, a new treatment nurse was hired. She completed her orientation on 3/4/21. During orientation she reviewed and acknowledge her job description. She also received education on Wound Care Assessment and Guidelines for Cleansing and Observing a Wound. On 3/4/21 the DHS completed 1:1 education on the Wound Action Plan. 17. All corrective actions were completed on 3/6/21. 18. The immediacy of the IJ was removed on 3/7/21. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of Census Records documentation revealed Hospital Leave dated 2/2/21 at 11:45 a.m. for R#1. Interview with Family of R#1 on 3/1/21 at 11:19 a.m. revealed the resident is at another nursing home receiving palliative care. 2. Through investigation, it was identified that the facility failed to provide necessary treatment and services to prevent the development of new pressure ulcers, to promote healing of existing pressure ulcers and to prevent wound infection. Review of facility documentation and email correspondence with the Medical Director confirmed he reviewed the policies: Notification of Wounds, Interact SBAR Communication, Interact Stop/Watch to address documentation and notification, Wound Care Assessment, and Cleansing and Observing Wound during the 3/4/21 QAPI meeting. No revisions were needed. 3. Review of the Midnight Census dated 2/23/21 revealed a 100% body audit was completed through 2/25/21. This was verified with DHS signature on 3/1/21. Eighty-seven Body Audit Forms were reviewed with two residents being currently hospitalized . Review of the Observation Details dated 2/24/21 revealed R#11 had a reddened small open area to the left buttocks the size of a quarter. The Physician and resident representative were notified on 2/24/21 at 6:39 p.m. A treatment was ordered by the Physician. Review of Resident Progress Note dated 3/5/21 revealed resident reddened area on sacrum with skin to sacrum and buttocks intact and easily blanchable. The Physician and resident representative were notified of the resolved area. 4. Review of the document signed by the DHS revealed 100% Chart Audit was completed for 10 residents with pressure ulcers. Review of Progress Notes revealed: On 2/25/21, NP NN was present during the body audit and gave new treatment orders for R#7. The resident representative was already aware of the wound. On 3/5/21, the Physician was notified and assessed the left hip and sacrum area for R#8 and continued current treatment orders. R#8's representative was also notified on 3/5/21. On 3/5/21, open area was noted to the sacrum for R#12. The Physician was called into the room and assessed the wound as Stage 2. Treatment orders were initiated, and the resident's representative was notified at 1:38 p.m. The SBAR Communication Form was completed. 5. Review of the Body Audit Complete document revealed the following: 3/1/21 - 13 resident body audits were completed as scheduled. 3/2/21 - 17 resident body audits were completed as scheduled. 3/3/21 - 15 resident body audits were completed as scheduled. 3/4/21 - 24 resident body audits were completed as scheduled. 3/5/21 - 23 resident body audits were completed as scheduled. All residents in the facility received a weekly skin assessment. Review of the clinical record revealed a Focused Observation was completed on 3/1/21 and 3/8/21 for R#16, 3/1/21 and 3/8/21 for R#17, and 3/1/21 and 3/9/21 for R#18. No concerns were identified. 6. Review of the in-service records dated 3/4/21 confirmed 11 RN's, 24 LPN's, and 3 agency nurses received education on Guidelines for Cleaning and Observing and Wound; and Wound Care: Assessment policies and procedures. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 9:53 a.m. with LPN BB, 10:21 a.m. with LPN PP, 10:27 a.m. with LPN QQ, 10:29 a.m. with LPN RR, 10:32 a.m. with LPN SS, 10:38 a.m. with LPN TT, 11:23 a.m. with LPN UU, 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, 12:20 p.m. with RN GG, and 12:31 p.m. with LPN WW. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 7. Review of the in-service records dated 3/4/21 confirmed 51 CNA's received education resident profile and viewing care plan actions/ interventions in EMR. One CNA received education via phone on 3/6/21 and one CNA is on leave. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 10:04 a.m. with CNA XX, 10:09 a.m. with CNA YY, 10:15 a.m. with CNA ZZ, 10:20 a.m. with CNA AAA, 10:26 a.m. with CNA BBB, 10:30 a.m. with CNA CCC, 10:40 a.m. with CNA DDD, and 10:50 a.m. with CNA EEE The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 8. Review of the New Hire Education Packet revealed the following items added for CNAs: education on viewing resident's profile and care plan interventions for residents with pressure ulcers. As of 3/8/21, no new CNAs were hired. 9. Review of the in-service records dated 3/6/21 confirmed 11 RN's and 22 LPN's received education on the body audit schedule and actions to take when identifying a new skin concern, including completing an SBAR, wound assessment and Physician/ RP notification. There have been no new hires. Also verified via the following staff interviews on 3/9/21: 9:53 a.m. with LPN BB, 10:21 a.m. with LPN PP, 10:27 a.m. with LPN QQ, 10:29 a.m. with LPN RR, 10:32 a.m. with LPN SS, 10:38 a.m. with LPN TT, 11:23 a.m. with LPN UU, 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, 12:20 p.m. with RN GG, and 12:31 p.m. with LPN WW. The staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Review of documentation revealed the skin assessment schedule verifying all residents will be assessed weekly. 10. Review of the Weekly Wound Assessment Audit Tool dated 3/6/21 completed by the DHS revealed 10 residents were identified as having wounds. Review of the audit revealed each resident was reviewed completion of weekly wound assessment: treatment orders, measurements, and documentation. Review of the clinical record revealed an accurate weekly wound assessment was completed for: R#12, on 3/5/21 - Stage 2 to the sacrum measuring 1 cm x 2 cm x 0.2 cm; referred to (name - wound specialists). R#14, on 3/4/21 - Stage 2 to left heel measuring 3 cm x 2 cm x 0.2 cm; and unstageable to right heel measuring 1 cm x 0.9 cm x 0.2 cm; (name - wound specialists) following for wound care. R#15, on 3/6/21- DTI to the right heel measuring 5 cm x 4 cm; referred to (name - wound specialists). 11. Review of documentation from (name - wound specialists) Evaluation and Management Report revealed R#14 was seen on 3/4/21. Consents were obtained and results of the referral for R#12 and R#15 were communicated to the Physician. 12. (name - wound specialists) scheduled to return to the facility on Thursday, 3/11/21. Interview with NP OO with (name - wound specialists) team on 3/10/21 at 11:12 a.m. revealed they will be evaluating any newly identified wounds and treating pressure injuries weekly on Thursdays at the facility in accordance with the contract. 13. Review of the Daily Change of Condition Audit Tool from 3/5/21 through 3/10/21 revealed SBAR's were completed for four residents including R#12. The Physician and RP were notified, treatment orders obtained, and care plan was updated. This was confirmed by interview with LPN BB, Unit Manager. She ensures all skin assessments have been completed from the previous day and verified Physician/ RP notification with any changes found. 14. Review of the Daily Body Audit Form and Daily Change of Condition Audit Tool from 3/5/21 through 3/10/21 revealed all scheduled skin assessments were completed. 15. Review of the employee file for LPN DD revealed in-service documentation on notifying the Physician/ NP and family upon finding new wounds and/or change/decline in wounds (2/9/21). The file revealed written disciplinary action dated 2/9/21 with a 30-day performance improvement plan. Interview on 3/10/21 at 11:25 a.m. with the Administrator revealed LPN DD received ongoing education in addition to education that was previously provided. Interview with LPN DD on 3/10/21 at 11:30 a.m. revealed she received education and disciplinary action regarding R#1. 16. Review of documentation revealed LPN WW was hired for full time employment, on 3/2/21, as the Skin Integrity Coordinator. LPN WW acknowledgement her job description on 3/2/21 and received all in-service education on 3/4/21 including the Wound Care Action Plan. This was confirmed by interview with LPN WW on 3/9/21 at 12:31 p.m. 17. All corrective actions were completed on 3/6/21. 18. The immediacy of the IJ was removed on 3/7/21.

Based on record review, review of the 2/26/21 Performance Improvement Plan (PIP), review of the Administrator and Director of Health Services (DHS) Position Description, and staff interviews, Administration failed to ensure the staff were performing weekly skin assessments and weekly wound assessments; and failed to provide oversight and monitoring of the skin integrity program. The census was 87. On 3/4/21 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020. The IJ is outlined as follows: Resident (R) #1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers (F686 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. An Acceptable IJ Removal Plan was received on 3/8/21. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/7/21. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and resident's with pressure ulcers. Findings include: Review of document titled Position Description Job Title: Administrator revealed - Job Purpose: Directs day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for our patients/residents. Key Responsibilities: 1. Current knowledge of state and federal laws governing the operation of nursing facilities. 2. Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long term care and services, and environmental health and safety relevant to nursing facility operations. 5. Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. 7. Ability to develop and implement administrative policies and procedures that reflect the center's philosophy and mission in compliance with federal and state laws and regulations. Review of document titled Position Description Job Title: Director of Health Services revealed - Job Purpose: Plans, organizes, develops and directs the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. The facility failed to provide oversight and monitoring of skin integrity program. The system failure included not ensuring weekly skin assessments and weekly wound assessments were completed routinely by licensed nurses on residents at risk for impaired skin integrity. 1. Administration failed to ensure the Physician and Responsible Party were notified of the identification and deterioration of pressure ulcers for R#1. 2. Administration failed to ensure the care plan was being followed related to Physician notification for a new and worsening pressure ulcer and weekly skin assessments for R#1. 3. Administration failed to provide necessary treatment and services to prevent the development of new pressure ulcers, to promote healing of existing pressure ulcers and to prevent a wound infection for R#1. Specifically, the facility failed to ensure that skin and wound assessments were completed weekly and failed to notify the Physician for a new and deteriorating wound for R#1. 4. Administration failed to ensure adequate monitoring and services to prevent new and worsening pressure ulcers for R#1. Review of the PIP titled Wound Care Action Plan initiated on 2/17/21(15 days after R#1 was hospitalized for wound infection) revealed the overall goal of this improvement project was to ensure that all clinical components of wound care are followed through when there is a patient being admitted with a wound and if one is acquired in house. The PIP documented a lack of oversight, lack of education on wound care clinical process, and lack of dedicated staff in wound care. Random wound care audits were going to start on 3/1/21, during the survey. A baseline body audit for all residents was completed the week of 2/22/21 (during the survey). Interview on 2/24/21 at 11:54 a.m. with the DHS revealed wound assessments are to be completed weekly on all residents with wounds by the skin integrity coordinator (SIC) (treatment nurse). The facility only has one part time treatment nurse who works on the weekends. The other treatment nurses went on leave and did not return. Interview on 3/2/21 at 10:42 a.m. with the Administrator and DHS revealed the family of R#1 notified them of concerns about the resident's care on 2/2/21. The facility then looked in the medical record of R#1. The Administrator confirmed there was no documentation of notifying the family and could not determine if the family was notified. The Administrator and DHS discussed a Wound Care Action Plan which was started on 2/17/21. They believed a lack of education on the wound care process, lack of dedicated staff, and lack of oversight of the program is what lead to the breakdown of the program. The Administrator confirmed the facility did fail to ensure adequate monitoring of services to prevent and treat pressure ulcers. Interview with Nurse Practitioner (NP) NN on 3/2/21 at 11:32 a.m. revealed that she thinks R#1 fell through the cracks and that facility staff need more education. The facility had a change in DHS on 3/9/21. Cross refer to F686. The facility implemented the following actions to remove the IJ: 1. On 3/4/21, Area Vice President (AVP) reviewed job description with Administrator and DHS. 2. On 3/4/21, The Senior Nurse Consultant completed an in-service on the policy Care Plans and procedures SBAR Communication, Wound Care Assessment, and Cleansing and Observing Wounds with 1of 1 DHS and 1of 1 Administrator. The in-service included identification of change of conditions related to new or worsening pressure injuries, INTERACT Stop & Watch (an early warning communication written tool) and MatrixCare (electronic health record software) process for residents' profile review. a. Review of the identified FTAGS and the accompanying policies i. FTAG 580 Notify of Change: Review of INTERACT'S SBAR Communication ii. FTAG 656 Care Plans: Review of policy, Care Plan; updating and following of care plan with admission, readmission, significant change, quarterly, and as needed. iii. FTAG 686: Review of body audit completion, Relias Procedures for Wound care assessment, Cleansing and Observing Wounds, and INTERACT'S SBAR communication and Stop & Watch. iv. FTAG 835 Administration: reviewed all deficiencies, RCA (root cause analysis), and interventions. 3. On 3/4/21, the Administrator and DHS were educated by the Area Vice President the Quality Assurance and Performance Improvement (QAPI) policy: a. QAPI, Policy, Quality Assurance and Performance Improvement which included: i. The administrator role in QAPI ii. Identifying issues iii. Conducting RCA iv. Development action plans v. Bring back data from the actions plans for feedback from the team vi. Monthly meeting to discuss plan agendas vii. Participation of Medical Director in QAPI 4. The Area Vice President or a member of the corporate region team will be onsite daily until the immediate jeopardies are removed. 5. The Administrator/DHS/ADHS (Assistant Director of Health Services) will continue to complete QAPI weekly or as needed until the immediate jeopardies are removed. The Area Vice President or Senior Nurse Consultant (SNC) will monitor compliance and outcomes of the QAPI weekly until the center is placed back in compliance. This will be documented on the AVP/SNC Weekly QAPI Audit form. 6. The DHS will review the body audits daily to assure they are completed per schedule. At the end of each week, the facility Administrator will verify that all body audits scheduled for the week were completed. This will be documented on the Administrator Weekly Body Audit Tool. 7. The QAPI committee will return to monthly meetings with IDT team members and address any new areas of concerns with the appropriate PIP. 8. All corrective actions were completed on 3/6/21. 9. The immediacy of the IJ was removed on 3/7/21. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of in-service record and Position Description Acknowledgement form dated 3/4/21 revealed the administrator and the DHS received education and review of their position descriptions. This was confirmed by interview with the Area Vice President, DHS, and Administrator on 3/9/21 at 9:44 a.m. 2. Review of in-service record dated 3/4/21 revealed the Administrator and DHS received education on Interacts SBAR Communication, Care Plans, Wound Care Assessments and Procedures, and developing root cause analysis' and interventions. This was confirmed by interview with the Administrator on 3/9/21 at 9:44 a.m. 3. Review of in-service record dated 3/4/21 revealed the Administrator and DHS received education on the QAPI Policy and Procedures. This was confirmed by interview with the Administrator on 3/9/21 at 9:44 a.m. 4. Daily observation from 3/8/21 through 3/10/21 revealed corporate staff present in the facility. Review of the Corporate Leadership Sign Sheet revealed corporate staff signatures daily from 3/4/21 through 3/10/21. This was also confirmed by interview with the Area Vice President on 3/9/21 at 9:45 a.m. 5. Review of document titled AVP and/or SNC Weekly QAPI Audit revealed a meeting held on 3/4/21 and 3/8/21, with Medical Director present. This was signed off by the Area Vice President and indicated that outcomes were met. 6. Review of document titled Administrator Weekly Body Audit Tool revealed the Administrator reviewed the Body Audit Tool on 3/5/21 and all body audits were completed. This was confirmed by interview with the Administrator on 3/9/21 at 9:44 a.m. 7. Interview with the Area Vice President on 3/9/21 at 9:45 a.m. revealed that QAPI meetings are still being held weekly and will return to monthly when appropriate. Review of the Quality Assessment and Assurance/ QAPI Committee Meeting Attendance Sheet revealed meetings held on 3/4/21, 3/6/21, 3/7/21, and 3/8/21 with the Administrator and DHS, along with other members, in attendance. 8. All corrective actions were completed on 3/6/21. 9. The immediacy of the IJ was removed on 3/7/21.

Based on staff interviews, record review, and review of the Facility Assessment and Quality Assurance and Performance Improvement (QAPI) Policy, the facility failed to have an effective Quality Assurance process that identified concerns related to the care and management of residents with pressure ulcers and impaired skin integrity, including failure to ensure skin and wound assessments were completed weekly. The facility census was 87. On 3/4/21 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 3/4/21 at 11:18 a.m. The noncompliance related to the IJ was identified to have existed on 12/3/2020. The IJ is outlined as follows: Resident (R) #1 was admitted to the facility on [DATE] with no alterations in skin and was assessed as at risk for pressure ulcers. On 12/3/2020, a Stage 2 pressure ulcer was observed on the right buttocks measuring 2 centimeters (cm) x 3 cm. A wound treatment was started. However, the Physician and family were not notified. On 1/17/21, a Stage 3 pressure ulcer to the sacrum was identified measuring 3 cm x 4 cm. On 1/23/21, the sacrum and right buttocks pressure ulcers combined and measured 10.5 cm x 7.5 cm. A wound observation assessment was completed indicating that the wound was declining. The wound treatment was changed. However, the Physician and family were not notified. The Physician became aware of the pressure ulcer on 2/2/21 when making rounds. He identified an unstageable pressure ulcer to the sacrum with a foul odor, drainage, and necrotic tissue. R#1 was hospitalized due to wound infection and [CONDITION(S)]. R#1 was transferred to another nursing home and is receiving palliative care. There was no evidence that skin assessments were consistently done weekly and only three wound assessments were completed from November 2020 through January 2021. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers (F686 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. An Acceptable IJ Removal Plan was received on 3/8/21. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/7/21. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and resident's with pressure ulcers. Findings include: Review of the document titled Facility Assessment last updated 11/16/21 revealed the facility records a high frequency of wound infections and a very high frequency of one or more unhealed pressure ulcers/injuries. Acuity-Care requirements revealed the facility provides the services required for skilled care of wound/pressure ulcer treatments. Review of the Quality Assurance and Performance Improvement Policy reviewed 9/20/19 revealed: Purpose: The purpose of the Quality Assurance and Performance Improvement (QAPI) Program at (name of facility) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Process: Each center, must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care, quality of life and resident choice. A review of regularly scheduled Quality Assurance (QA) committee meeting sign in sheets revealed that the members of the committee included but were not limited to the Administrator, Medical Director (MD) (also the only Physician), DHS, Infection Control Preventionist, Activities, Admissions, Business Office, Clinical Competency Coordinator, Case Mix Directors, Dietary Services, Environmental Services, Maintenance, Human Resources, Medical Records, Senior Care Partners, Unit Managers, and Social Services. Review of the Process Improvement Plan with a start date listed as 2/17/21 and a target date of 5/31/21 revealed a Wound Care Action Plan was created after R#1 was hospitalized with wound infection and [CONDITION(S)]. Root cause and factors identified were lack of oversight on program, lack of education on the wound care clinical process, and lack of dedicated staff in wound care. Interview on 3/2/21 at 10:42 a.m. with Administrator and DHS revealed the facility first identified they had a problem about wounds on 2/3/21 when contacted by the family of R#1. An investigation was started on 2/3/21 or 2/4/21 by interviewing residents and staff about neglect. The investigation concluded no issues with neglect but identified a concern about the wound care program when reviewing R#1's medical record. It was documented on the treatment administration record that R#1 was getting wound care. The Administrator confirmed there was no documentation of notifying the family or the Physician. A 100% body audit was started on the 2/10/21 or 2/11/21 and completed on 2/17/21. Once completed, DHS had a concern because nursing leadership did not believe the validity of the audits, so another audit was done on 2/22/21 or 2/23/21 (during the survey). A list of residents with Stage 2 or higher-pressure ulcers was submitted to outside wound care company to come in and assist with the assessment, treatment, and staging of pressure ulcers. During the week of 2/15/21 contact was made with the wound care company to provide support for the treatment team. The wound care company said they could see any resident with wounds. The company came in on 2/25/21 to assess and will make rounds weekly. A Wound Care Action Plan was developed on 2/17/21. A root cause analysis revealed lack of education on the wound care process, lack of dedicated staff, and lack of oversight of the program. There is an issue with the body audits being completed consistently and accurately, a slight issue with the wound audit form. The wound audit tool is a form used to document wound and notification. The form had not been used correctly. Cross refer to F686. The facility implemented the following actions to remove the IJ: 1. ADHOC QAPI was held on March 4, 21. In which the QAPI committee, the Administrator, Medical Director, Dietary manager, Social Worker, Activity Director, Unit Mangers (UM), Admission Director, Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, Certified Nursing Assistant (CNA), and Financial Counselor, AVP and SNC met and reviewed the noncompliance with F 580 Notify of Change, F 656 Care plans, F 686 Treatment/ Services to Prevent/ Heal Pressure Ulcers, F 835 Administration, and F 867 QAPI. This represented 94.44% of the department heads. The QAPI committee was led by the Administrator/DHS's root cause analysis and actions plans were created for each F tag the findings were as followed: a. F 580 Notify of Change: the RCA (root cause analysis) was determined to be the facility failed to notify MD and responsible party (RP) regarding worsening wound. The action plan for the F Tag 580 included a 100% body audits to identify new and/or worsening wounds and 100% documentation audit to verify MD/RP notification. The Director of Health Services educated the licensed nurses on MD/RP notification and documentation for all new and worsening wounds. 100% of the licensed nurses were educated on in-service titled Notification of Wounds and INTERACT'S SBAR Communication b. F656 Care Plans: the RCA was determined to be the facility failed to update the care plan with new and worsening pressure injuries. The action plan for the F Tag 656 included a 100% audit of all care plan to ensure accuracy of all current care plan with identification of pressure injuries. The Director of Health Services educated the Case Mix Director and licensed nurses on making sure care plans were updated. 100% of the licensed nurses were educated on policy Care Plans and updating care plans with new and worsening wounds. The DHS/CCC/UM educated the CNAs on how to review the care plan approaches in MatrixCare. 96.22% of the certified nursing assistants were educated on the MatrixCare (electronic health record software) review process. c. F686 Treatment/Services to Prevent/Heal Pressure Ulcers: the RCA was determined to be the facility failed to ensure skin audits were completed weekly and MD notification for new and worsening wounds. The action plan for the F Tag 686 included a 100% body audits to identify new and/or worsening wounds and 100% documentation audit to verify MD/RP notification. An audit to verify completion of the body audits were completed. The Director of Health Services educated the licensed nurses on MD/RP notification and documentation for all new and worsening wounds and completion of weekly body audits. 100% of the licensed nurses were educated on in-service titled Notification of Wounds, body audits completion, and INTERACT'S SBAR Communication. The DHS/CCC/UM educated the C.N.A.s on completion of INTERACT'S Stop and Watch to notify nurses of new and worsening wounds. 96.22% of the certified nursing assistants were educated on the INTERACT process. d. F 835 Administration: the action plan for F 835 included education from the Senior Nurse Consultant on INTERACT process- SBAR Communication and Stop and Watch, Procedures- Wound Care Assessment and Cleansing and Observing wounds, and policy, Care Plan. The Area Vice President in-serviced the Administrator on the policy, Quality Assurance and Performance Improvement Policy. The Administrator will be monitored by the Area Vice President weekly to review audits from the plan of correction, QAPI minutes and to mentor the administrator. e. F 867 QAPI: the RCA was determined to be the facility failed to identify the issues that were cited. The action plan for F 867 included education for the QAPI team. The region team will review the monthly notes and will attend either in person or via virtual monthly meeting to ensure the process is maintained per policy. 2. On 3/4/21 the Medical Director reviewed the following policies during QAPI meeting: Notification of wounds, INTERACT SBAR Communication, INTERACT stop and watch, Care plan policy, Wound care assessment and cleansing and observing wounds. The Medical Director did not recommend any changes to the policies at this time. 3. On 3/4/21, the interdisciplinary team and Department Managers to include the following: Dietary Manager, Social Worker, Activity Director, Unit Managers, Admission Director, Director of Health Services, Case Mix Director, Clinical Competency Coordinator, Maintenance Director, C.N.A, and Financial Counselor this represented 94.44% of the department heads. The Administrator educated on the QAPI requirements and policy Quality Assurance and Performance Improvement Policy''. The education focused but not limited to: * Identifying issues * Conducting RCA * Development action plans * Monthly meeting to discuss plan agendas 4. The QAPI committee will continue to meet weekly until the deficiencies are corrected. The results of all audits completed will be brought to the weekly QAPI meetings. 5. All Corrective actions were completed on 3/6/21. 6. The Immediacy of the IJ was removed on 3/7/21. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the Quality Assessment and Assurance/ QAPI Committee Meeting Attendance Sheet dated 3/4/21 revealed the Administrator, DHS, Medical Director, Area Vice President, Senior Nurse Consultant, and multiple other attendees developed a root cause analysis regarding: * staff failure to conduct weekly body audits according to schedule provided to nursing staff * lack of supervision of the compliance for weekly resident skin assessments * failure of facility staff to follow policy for a change of condition for skin concerns * failure to follow and update care plan consistently regarding new and worsening wounds This was verified with the following QAPI committee members on 3/9/21: 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, and 12:20 p.m. with RN GG. 2. Review of facility documentation and email correspondence with the Medical Director confirmed he reviewed the policies: Notification of Wounds, Interact SBAR Communication, Interact Stop/Watch to address documentation and notification, Care Plan Policy, Wound Care Assessment, Cleansing and Observing Wound, and the QAPI Policy during the 3/4/21 QAPI meeting. No revisions were needed. 3. Review of in-service record dated 3/4/21 revealed 22 staff members including the 94.44 percent of department heads were educated on the Quality Assurance and Performance Improvement Policy which included information on Standardized QAPI Tools and Performance Improvement Projects. This was verified with the following QAPI committee members on 3/9/21: 12:08 p.m. with RN AA, 12:12 p.m. with RN VV, and 12:20 p.m. with RN GG. 4. Review of the Quality Assessment and Assurance/ QAPI Committee Meeting Attendance Sheet dated 3/6/21, 3/7/21, and 3/8/21 revealed a QAPI Meeting with discussions including residents with newly identified wounds, 10 patients in-house with pressure ulcers, results from DHS audits, corrective action for failure to initiate SBAR with change of condition, revision of daily body audit schedule and expectation for nurses, weekly wound assessment will be done every Thursday, referral process for (name - wound specialists), and Corporate Leadership oversight. Interview with the Area Vice President on 3/9/21 at 9:45 a.m. revealed that QAPI meetings are still being held weekly and will return to monthly when appropriate. 5. All Corrective actions were completed on 3/6/21. 6. The Immediacy of the IJ was removed on 3/7/21.

Based on record review, review of the facility policy titled Infection Prevention and Control Surveillance and staff interviews, the facility failed to provide evidence that infection control surveillance data was collected and analyzed from (MONTH) (YEAR) through (MONTH) 2019. The census was 111. Findings include: Review of the facility's policy titled Infection Prevention and Control Surveillance dated (MONTH) (YEAR) revealed the facility will maintain a surveillance program for the tracking, prevention, and follow-up of all resident's infections including tracking and analysis of outbreaks of infections as well as implementing and documenting actions to resolve related problems. Review of the facility's monthly infection control reports for tracking and trending of infections revealed no documentation of infection control surveillance for the months of (MONTH) (YEAR) through (MONTH) 2019. During an interview on 3/20/2019 at 11:15 a.m. with the current Director of Health Services (DHS), she revealed that the previous DHS was responsible for the infection control program during that time but she left the position. DHS stated the responsibility of infection control was then designated to the Clinical Care Coordinator (CCC). The DHS confirmed that the infection control reports were not done for the months of (MONTH) (YEAR) through (MONTH) 2019. During an interview on 3/20/19 at 12:30 p.m. with the CCC, she stated the DHS was completing the infection control reports but left the facility; and that is when it was determined that the infection control reports had not been completed. The CCC stated she is now responsible for infection control and has completed the report for (MONTH) 2019. The CCC stated she will be going to training next month and she also confirmed that the infection control data collection and reports for (MONTH) (YEAR) through (MONTH) 2019 were not done. During an interview on 3/20/2019 at 2:30 p.m. with the Administrator, she revealed her expectations are for the infection control reports to be completed as per the facility's policy. She confirmed that the infection control information was not completed for the months of (MONTH) (YEAR) through (MONTH) 2019 and this will be taken care of immediately.

Based on resident interviews, and staff interviews, the facility failed to provide resident trust fund account quarterly statements. Two (2) residents (A and B) of two (2) residents reviewed. Ninety-three (93) fund trust accounts managed by the facility. Findings include: Interview conducted on 3/6/18 at 8:00 a.m. with resident B revealed has not receive quarterly statement of the trust fund account. Interview conducted on 3/6/18 at 8:29 a.m. with resident A revealed has not received a quarterly statement of the trust fund account in a year. An interview was conducted on 03/08/18 at 03:34 p.m. with the Administrator revealed that his expectations were that each resident receive a statement within 30 days, at the end of the quarter. The person that is responsible for sending the statements is the financial manager of the facility although the pervious financial manger last day working was (MONTH) 9th, (YEAR). The Administrator revealed he has no evidence that the residents received the quarterly statement of the trust fund account. The Administrator confirmed that the resident A and B did not get a quarterly statement for (MONTH) through (MONTH) (YEAR). The Administrator revealed that he takes full responsibility for the resident not receiving the trust fund account quarterly statements.

Based on record review, review of the facility policy titled, Reporting, Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, review of the policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, resident and staff interviews, the facility failed to immediately report to the State Survey Agency and thoroughly investigate allegations of staff to resident abuse for one of 44 sampled residents (R#112). Refer F223 and F226: On 2/11/16 R#112 reported to the facility that LPN KK had been verbally and mentally abusing her. Additionally, on 10/28/16 R#112 reported that a heavyset woman, who provided her care, had been verbally, mentally, and physically abusive. In an interview with R#112 on 3/21/17 at 12:37 p.m., she stated that she had reported this to the people over the facility. R#112 could not name the nurse, but could describe her appearance, knew that she worked during the day and administered her medications. R#112 stated that she was afraid of this nurse and that the nurse was not working today (3/21/17). Additional interviews were conducted on 3/24/17 with residents who reside on the 300 hall. On 3/24/17 at 1:18 p.m., R#80 stated he was sort of afraid of a nurse, who he was unable to name and who worked on the 300 hall and provided his care. In addition, on 3/24/17 at 2:00 p.m., R A alleged verbal and physical abuse by LPN KK, however, she did not report the allegation to the facility. R A stated she was afraid of LPN KK and afraid of retaliation for telling on her. This failure to thoroughly investigate the alleged incidents reported on 2/11/16 and 10/28/16 by R#112 contributed to the increased likelihood of abuse to other residents in care of LPN KK. The facility suspended LPN KK on 3/22/17 during the survey and she was officially terminated on 3/27/17. The facility's failure to immediately report to the State Survey Agency and thoroughly investigate allegations of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 3/23/17 and determined to have existed on 2/11/16. The facility's former Administrator and former Director of Health Services (DHS) were informed of the Immediate Jeopardy on 3/23/17 at 6:50 p.m. An acceptable Allegation of Compliance (AoC) was received on 3/25/17 and the State Survey Agency validated the Immediate Jeopardy which was removed on 3/28/17 as alleged. The Scope and Severity was lowered to a D while the facility developed and implemented the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The facility's Administrator and Director of Health Services (DHS) were informed of the immediate jeopardy on 3/23/17 at 6:50 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 2/11/16. The immediate jeopardy continued through 3/27/17 and was removed on 3/28/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 3/25/17. Findings include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 2/24/17 documented; Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, should immediately be reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 11/21/16 documented: The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed. If there is an occurrence of or allegation involving patients abuse (including injuries of unknown source), neglect, exploitation, mistreatment or misappropriation of patient property, the following investigation and reporting procedures will be followed: Documentation of the investigation should include, but not limited to; names of accused and any witnesses, any physical evidence and description of emotional state of patient(s), signed statements from pertinent parties, cognitive status of victim and patients who are witnesses (whether they are alert, oriented, and able to answer questions appropriately, information gathered from the investigation, action taken by the provider (safeguarding the patient and preventing a reoccurrence). Information gathering should include, but not limited to; written signed statements from any involved parties: the suspect, the person(s) making accusation(s), the patient(s) involved, reliable witnesses and any other person who may have information. All investigative information should be kept on file in a secured location. An interview with R#112 on 3/21/17 at 12:37 p.m., revealed that a heavy set, black nurse on first shift has a history of verbally, mentally and physically abusing her. She stated that the nurse has also threatened to stick her with needles. R#112 stated that she told the people over the facility. Upon further interview with the resident on 3/21/17 at 12:37 p.m., the resident stated that she was afraid of this nurse. R#112 stated that this occurred about three weeks ago. R#112 could not provide details of an exact date or name of the nurse but she was able to describe the nurse, knew she worked during the day and administered her medications. R#112 stated that the nurse was not working today (3/21/17). Record review for R#112 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderate cognitive impairment. A quarterly MDS assessment dated [DATE] documented a BIMS summary score of seven, indicating severe cognitive impairment. A quarterly MDS assessment dated [DATE] documented a BIMS summary score of 10, indicating moderate cognitive impairment. All three MDS assessments indicated that R#112 did not exhibit behaviors of hallucinations or delusions (section E). Review of the Reportable Occurrence Log Form revealed an allegation of abuse-physical reported by R#112 on 10/28/16. Further review of the Reportable Occurrence Log Form failed to reveal any additional allegation of abuse reported by R#112. During a second interview with R#112 on 3/22/17 at 11:43 a.m., she stated that the nurse who abused her was working today. R#112 stated it was the nurse who had administered her medications this morning. R#112 stated that the nurse came in today and said Get up! R#112 stated she tried to sit up. and the nurse said Get up! If you don't sit up, I'm going to give you a shot! I don't suppose to get shots so I just sat up! The Licensed Practical Nurse (LPN KK) was observed at the medication cart outside of R#112's room. LPN KK confirmed that she was assigned to care for residents on this hall (300 hall, on which R#112 resides). LPN KK fit the description provided by R#112 as the alleged perpetrator. The facility's former Administrator was immediately informed of this incident by the surveyor. During an interview with the former Administrator on 3/22/17 at 11:47 a.m., she confirmed that she was the facility abuse coordinator. The former Administrator stated that on 10/28/16 at 5:00 p.m., CNA/Central Supply Scheduler (CNA SS) reported to her that R#112 had made an allegation of abuse by staff. The resident alleged that she had been pushed by a heavy set woman but could not communicate when this occurred or by whom. The former Administrator stated that the family was in the room at the time CNA SS was interviewing R#112 about the abuse. The former Administrator stated that a thorough investigation was conducted. She stated the investigation did include speaking with other staff that cared for R#112 and speaking with R#112 about the incident. The former Administrator stated she did not interview all staff that fit the resident's description of the perpetrator. The former Administrator repeatedly stated that R#112 had a BIM score of seven, and therefore, was not credible. The former Administrator stated that she did report the incident to the State Survey Agency and provided a fax cover sheet dated 10/28/16, but no fax confirmation. The former Administrator confirmed that she did not have any evidence or documentation of the information gathered for this investigation. The former Administrator provided the documents she had on file for the incident of 10/28/16. Review of documents provided revealed a plain white paper with no letterhead, dated 11/3/16, addressed to: Georgia Department of Health-LTC-Complaint unit. The document stated that during a quarterly resident interview, R#112 answered yes when asked about ever being abused. R#112 did not know the name but that she was a very heavy woman. R#112 did not know the time or date of the occurrence. The section titled The immediate protection revealed an initiation of immediate investigation. The investigation documented the resident's diagnoses, her BIMS score of seven, and that R#112 reported that she was pushed by a very heavy set woman but did not know who she was. The daughter was present in the room and was not aware of an incident of her mom being pushed. The findings documented that based on the investigation, there was not any supporting evidence that this incident occurred. The conclusion stated that after a thorough investigation, the exact nature of the allegation was unfounded and unsubstantiated. The Administrator was unable to provide any gathered investigative documents to support that a thorough investigation had been conducted or to support the conclusion. The second document was a Facility Incident Report Form dated 10/28/16 which documented staff to resident and physical abuse. No injury, no treatment required. The physician was not notified, the police were not notified and other agencies involved were not notified. Review in the State Survey Agency Complaint and Incident Tracking System during the survey revealed no evidence of an entity self-report related to this incident of 10/28/16. Review of the employee file for LPN KK, revealed a Grievance Complaint Form dated 2/11/16, which was stapled to a Record of Partner Corrective Action Form dated 2/15/16. The Grievance stated R#112 informed the Senior Care Partner (SCP) Registered Nurse (RN) that When I turn on my call light, LPN KK won't answer. When she comes in, she always talking loudly and when I tell her that my leg hurts, she tells me to Shut up! and there is nothing wrong with my leg. The way she talks to me hurts my feeling and nobody else here talks to me that way or hurt my feelings. The SCP RN noted that R#112 began to cry at this point during the conversation. Action Taken documented on 2/15/16 by the SCP; discussed findings with the Administrator. Nurse will be disciplined for poor deportment as reported by resident who is alert and oriented x 3 (People, Place and Time). The Record of Partner Corrective Action Form indicated no investigation conducted and that LPN KK received a written warning related to violation of discourtesy to the patients/residents and was allowed to continue working with the resident until she was suspended on 3/22/17 and officially terminated on 3/27/17. An interview with the Interim Administrator on 3/28/17 at 4:15 p.m. revealed the incident involving LPN KK and R#112 documented on the Performance Corrective Action dated 2/15/16 should have been investigated as an allegation of verbal abuse. During an interview with the Senior Care Partner on 3/28/17 at 4:24 p.m., she confirmed that R#112 began to cry during the interview for the grievance of 2/11/16. She stated that she reported this to the former Administrator because the nature of the grievance was an allegation of abuse. She stated that she was not sure what the former Administrator did after she reported the allegation of abuse to her. Review of the State Survey Agency Complaint and Incident Tracking System during the survey revealed no evidence of an entity self-report related to this incident of 2/11/16. The facility implemented the following actions to remove the Immediate Jeopardy: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? Nurse in question was immediately suspended pending the investigation on March 22 2017, Administrator is conducting an internal investigation related to this event Investigation was started on March 22 , 2017 and is on-going. 24 hour report was completed and submitted to state on March 22, 2017. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? On March 22, 2017 the Nurse Management and Senior Care Partner interviewed 11 residents with a BIMS score of 10 or above on the unit where the accused nurse worked (this was 100% of residents on this unit with a BIMS of 10 or above). On March 24, 2016 the center expanded our sample to an additional 46 residents with a BIMS score of 10 or above (this was 100% of all residents in the center with a BIMS of 10 or above). The center performed a 100% body audit of all residents with a BIMS score of 9 or below with no adverse findings on 3/26/2017. Staff has also been in-serviced on the identification of injuries or events that are suspicious and may constitute abuse in patients of all levels of cognition. Based on our interviews the following allegations were reported. On March 22, 2017 we had one allegation (of abuse) which was reported for an allegation on a CNA. This was reported and the CNA was suspended. On March 27, 2017 interviews revealed we had one additional allegation (of abuse) which was reported from a resident on an unnamed CNA which was stated to have happened twice over the last 8 months. This allegation was also reported to the state. On additional interviews with this patient she stated that CNA doesn't work here any longer. We had two allegations (of abuse) brought to us by the survey team regarding the nurse in the original complaint, These two alllegations were also reported to the state agency. We have filed a police report based on the allegations against the LPN. We have had 3 total allegations against the LPN, The investigation on the LPN will be completed resulting in the termination of the LPN. We have had a total of 7 [MEDICATION NAME] (3 from the survey team; 2 from interviews; 2 presented to staff). Of the four [MEDICATION NAME] (self reports) submitted by the center 3 had a BIMS of 10 or greater and 1 had a BIMS of 99, During this time frame we have suspended 7 staff members. What measures will be put in place or systematic changes will be made to ensure that the deficient practice will not reoccur? Education began on March 22, 2017 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The in-service included types of abuse that must be reported, how and who to report to, and the time frame for reporting. The center has 90% staff in-service completed as of 3/25/17. Any staff not receiving the in-service after 3/26/2017 related to FMLA, PRN status, or paid time off will be educated before the next schedule shift for that staff member. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. On March 24, 2017 the Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. The resident council was educated on who to report to and will continue to be reassured that they can report without fear of retaliation. On 3/27/2017 the Administrator posted his personal contact information in the front lobby and at both nursing stations. In addition, the Administrator distributed the reporting phone numbers for the Ombudsman, Department of Community Health reporting, and the Pruitt Health Customer Service Hot Line to all residents with a BIMS score of 10 or above. These numbers are also posted in common areas for all visitors and families to see. How will the corrective action be monitored to assure that the deficient practice will not reoccur? Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. The center will continue to follow new hire policy and procedure which includes checking the applicant's background, licensure/certification, and two reference checks. The center will also begin checking all licensed and certified staff on a quarterly bases. All RNs, LPNs, CNAs, and therapist have been completed with no other findings. (Other than the one LPN who was terminated on 3/28/2017) Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate and thorough investigations were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Review of Records revealed a Notice dated 3/26/17 documented the following: LPN KK was suspended 3/22/17. As of 3/26/17 employee is still suspended pending investigation. Continued record review revealed a Separation Notice dated 3/27/17 for LPN KK documenting that LPN KK was terminated from employment on 3/27/17. Reason for separation documented to be: Serious Rule Violation - Resident Abuse. Record review revealed that investigation conducted and incident reported. Record review revealed forms titled, Resident Interview Question Alleged Abuse Investigation which revealed on 3/22/17 10 residents with BIMs greater than 10 were interviewed with no adverse findings noted. Further review revealed that on 3/24/17 46 residents with BIMS 10 or greater were interviewed. Alleged Abuse Investigation forms for the 10 residents interviewed on 3/22/17 and for the 46 residents interviewed on 3/24/17 revealed the following questions were investigated: Have you ever been treated roughly by staff? Have staff injured you on purpose? Have you ever had an injury that you did not know how it happened? Do you ever feel afraid because of the way you or some other resident is treated? All forms reviewed for each resident. Record review revealed Body audit forms were reviewed for all residents with BIMS score less than 9. No adverse findings documented. Review of In-service Program Attendance Record Form dated 3/22/17 for Abuse revealed 113 staff members signed in for attendance. Review of Resident Interview Question Alleged Abuse Investigation revealed the following questions documented on the questionnaire: Have you ever been treated roughly by staff? Have staff injured you on purpose Have you ever had an injury that you did know how it happened? Do you ever fee afraid because of the way your or some other resident is treated? Review of Staff list compared to In-service sign in sheets educated revealed 140 staff members signed in for and attended the Abuse in-service. Review of the facility self reports and investigations revealed allegations were investigated and reported. Review of Resident Council Minutes/Report Form dated 3/24/17 and 3/26/17 revealed that Resident Council meeting was called The Resident Council president (BIMS 15) and 11 other residents. Information discussed included Abuse. Any allegations, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment and misappropriation of property, reported. Area Vice President informed the residents that he will be the administrator at this time, and you need anything to let him know. Residents said they would. 3/25/17 Resident Council meeting - Discussed retaliation. - The provider will provide emotional support and assurance to patients and their families or representatives following the reporting of discovery. AVP explained to the residents that if any staff mistreated, including talked ugly to , abuse of any kind, mistreat them, to report it as soon as possible to the Charge Nurse, Administrator, nurse or anyone you see. Please report if you, or you anyone abuses you, neglects you, mistreats you or anyone you know. We are here to keep you all safe. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse on 3/22/17. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Abuse in-services were provided by the DHS, Clinical Competency Coordinator, RN Restorative Nurse on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore, that if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: 11:00 p.m. to 7:00 a.m., shift: On 3/26/17 at 12:46 p.m., with Housekeeper BBB, on 3/26/17 at 12:49 p.m., with Activities Director/CNA, 3/26/17 at 12:56 p.m., with CNAZZZ, 3/26/17 at 1:07 p.m. with CNA YYY (Restorative), 3/26/17 at 1:13 p.m. with CNA XXX, 3/26/17 at 1:47 p.m. with CNA WWW, 3/26/17 at 1:53 p.m. with CNA VVV, Interview on 3/27/17 at 6:47 a.m., with CNA UUU, On 3/27/17 at 7:00 a.m., with CNA TTT, On 3/27/17 at 7:10 a.m., with CNA SSS, On 3/27/17 at 7:15 a.m., with CNA RRR, On 3/27/17 at 7:20 a.m. with CNA QQQ, On 3/28/17 at 9:30 a.m. with CNA PPP, On 3/28/17 at 9:41 a.m. with CNA PP On 3/28/17 at 10:04 a.m., with CNA OOO, On 3/28/17 at 10:35 a.m., with CNA NNN, On 3/28/17 at 10:45 a.m., with CNA MMM, On 3/28/17 at 10:55 a.m., with CNA SS, Central Supply, CNA scheduler, On 3/28/17 at 11:03 a.m. with CNA LLL, 3:00 p.m. to 11 p.m. shift 3/26/17 at 3:24 p.m., with CNA KKK, 3/26/17 at 4:20 p.m. with CNA JJJ, On 3/26/17 at 4:53 p.m. LPN JJ, 7pm - 7AM On 3/27/17 at 6:55 a.m. (11p.m. - 7 a.m.) LPN III, 3/27/17 at 6:57 a.m., with LPN HHH, 3/27/17 at 7:03 a.m., with LPN GGG, 3/28/17 at 9:25 a.m. with RN EE (Infection control, Restorative nurse), 3/28/17 at 10:52 a.m. with LPN FFF, 3/26/17 at 12:52 p.m., with Maintenance Director EEE, 3/28/17 at 3:15 p.m., with Housekeeping DDD Interviews with the following residents revealed: Interview 3/26/17 at 1:27 p.m. with R#1, the Resident Council President, on 3/26/17 at 12:45 p.m., with R#77, on 3/28/17 at 10:50 a.m., with R87, on 3/28/17 at 11:00 a.m,, with R#88, on 3/28/17 at 11:13 a.m., R#73, on 3/28/17 at 11:20 a.m., with R#120, on 3/28/17 at 11:28 a.m., with R#66 revealed that the Area Vice President (AVP), that is currently the Interim Administrator, called a Resident Council meeting Friday night (3/24/17) and spoke with the Resident Council members and staff regarding abuse. That the residents were instructed to tell the staff CNA, Charge Nurse, any staff, and the Administrator and tell them if they have any problems. Residents were educated that they can call the Ombudsman and how to call the Ombudsman. Residents able to verbalize who they would report abuse to, who was the Abuse Coordinator, and how to report abuse themselves. Residents revealed that the AVP and Interim DHS have encouraged them to report abuse to them. Residents revealed that they (AVP and Interim DHS) want us to tell them if we have any concerns. R#1 revealed that the Ombudsman comes to facility pretty frequently and that the facility announces the resident rights over the loud speaker every morning. Information sheets were given to cognitive residents and included the phone number to the Ombudsman, HFRD, and the facility's corporate office. Review of Abuse Policy's revealed: revealed all seven components addressed. Review of the facility self reports and investigations revealed allegations were reviewed by the AVP, were investigated by the AVP, Interim DHS and were reported by the AVP. Interventions of QAPI for abuse are documented to be: All allegations of abuse will be reported to the Administrator or DHS immediately. The Administrator or DHS will report the allegation to the state agency within a 2 hour time frame. The Ombudsman will be notified. Law enforcement will be notified if deemed appropriate. A complete investigation will be completed. Staff will be in-serviced related to the abuse allegations. Review of notice regarding QAPI meeting on 3/26/17 revealed the following: On 3/26/17 the AVP educated all department heads on QAPI process, policy and procedures, their roles and responsibilities, current action plans, and how write Performance Improvement plans. AVP discussed QAPI review with Medical Director on 3/26/17. Medical Director signature observed to be on 5th page as reviewed and dated 3/26/17.

Based on record review, review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of property, resident and staff interviews, the facility failed to ensure that three of 44 sampled residents (R) (R#112, R#80 and R A) were free from verbal and physical abuse by a Licensed Practical Nurse (LPN) (LPN KK). On March 23, 2017, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's former Administrator and former Director of Health Services (DHS) were informed of the immediate jeopardy on 3/23/17 at 6:50 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 2/11/16. The immediate jeopardy continued through 3/27/17 and was removed on 3/28/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 3/25/17. The Immediate Jeopardy is outlined as follows: Review of the clinical record revealed that R#112 had reported to the facility on [DATE] that Licensed Practical Nurse (LPN) (LPN KK) had verbally abused her. The facility failed to thoroughly investigate, and failed to report, this allegation of abuse. The facility failed to follow their abuse policy and failed to protect other residents, from LPN KK. The facility continued to allow LPN KK to continue to work with R#112, and other residents, after the facility was aware of the abusive behavior on 2/11/16. The facility's failure to thoroughly investigate, and report, the allegations of abuse, and by continuing to allow LPN KK to continue to work in the facility R#112, and other residents, continued to be subjected to abusive behavior from LPN KK. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12(a)(1) Free from Abuse/Involuntary Seclusion (F223 S/S: J), 483.12(a)(3)(4)(c)(1) Investigate/report allegations/individuals (F225 S/S: J), 483.12(b)(1)-(3) Develop/implement abuse/neglect etc. policies (F226 S/S: J), and 483.70 Effective Administration/resident wellbeing (F490 S/S: J) Additionally, Substandard Quality of Care was identified with requirements at 42 C.F.R. 42 C.F.R. 483.12(a)(1) Free from Abuse/Involuntary Seclusion (F223 S/S: J), 483.12(a)(3)(4)(c)(1) Investigate/report allegations/individuals (F225 S/S: J), 483.12(b)(1)-(3) Develop/implement abuse/neglect etc. policies (F226 S/S: J). In addition Harm was identified at 483.21(b)(3)(ii) Services by qualified persons/ per care plan 483.25(e)(1)-(3) and No catheter, prevent UTI, restore bladder (F315). A Credible Allegation of Compliance (AOC) was received on 3/25/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/28/17. The facility remained out of compliance at a lower scope and severity at F223 S/S: D, F225 S/S: D, F226 S/S: D and F490 S/S: D, while the facility continued management level staff oversight of the facility's abuse policy, recognizing allegations of abuse, investigating abuse, and reporting abuse. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing abuse. Findings include: Review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised 11/21/16 documented: It is the policy of Pruitthealth and its affiliated entities (Collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment and misappropriation of property, referred collectively in this policy as abuse, mistreatment and exploitation. The organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect and exploitation. 1. Record review for R#112 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment. The MDS assessment revealed the resident did not exhibit hallucinations or delusions. Review of the resident's clinical record revealed [DIAGNOSES REDACTED]. During an interview with R#112 on 3/21/17 at 12:37 p.m. she alleged that a black nurse on first shift has a history of verbally and physically abusing her. The nurse yells and hollers at her and has also threatened to stick her with needles. She stated that she told the people over the facility and when she told the people over the facility the nurse went crazy, hit her across the back and shoved her. The resident stated she did not report when the nurse went crazy, hit her across the back and shoved her. Upon further interview with the resident on 3/21/17 at 12:37 p.m., the resident stated that she was afraid of this nurse. R#112 stated that this occurred about three weeks ago. R#112 could not provide details of an exact date or name of the nurse but she was able to describe the nurse, knew she worked during the day and administered her medications. R#112 stated that the nurse was not working today (3/21/17). Review of the Reportable Occurrence Log Form failed to reveal an allegation made by R#112 during the past several weeks. Further review of the Reportable Occurrence Log Form revealed an allegation was made by R#112 on 10/28/16. Review of the allegation dated 10/28/16, revealed that at approximately 5:00 p.m. during a internal facility survey process, the resident was interviewed and alleged that a heavy set female staff employee pushed her. During an interview with R#112 on 3/22/17 at 11:43 a.m., she stated that the nurse who abuses her was working today. R#112 stated it was the nurse who had administered her medications this morning. R#112 stated that the nurse came in today and said Get up! R#112 stated she tried to sit up. And the nurse said Get up! If you don't sit up, I'm going to give you a shot! I don't suppose to get shots so I just sat up! The Licensed Practical Nurse (LPN) (LPN KK) was observed at the medication cart outside of R#112's room, just after the interview with R#112. LPN KK confirmed that she was assigned to care for residents on this hall (300 hall, for which R#112 resides). LPN KK fit the description provided by R#112 as the alleged perpetrator. The facility former Administrator was informed of this incident by the surveyor at this time. During an interview with the former Administrator on 3/22/17 at 11:47 a.m., who is also the facility's abuse coordinator, revealed on 10/28/16 at 5:00 p.m. the Certified Nursing Assistant (CNA)/Central Supply Scheduler (CNA SS) reported to her that R#112 had made an allegation of abuse by staff. She stated that the resident alleged that she had been pushed by a heavy set woman, but could not communicate when this occurred or by whom. She stated that R#112 was unable to give any further description of the staff member. She stated that R#112's family member was in the room at time of the interview with CNA SS. The Administrator stated that a thorough investigation had been conducted and that the incident was reported to the State Agency. The former Administrator repeatedly stated R#112 had a BIMS score of seven and therefore the allegation was not credible and was unsubstantiated. The former Administrator provided an untitled document dated 11/3/16, which was addressed to the Georgia Department of Health - LTC- Complaint unit. The document stated that during a quarterly resident interview, R#112 answered yes when asked about ever being abused. R#112 did not know the name of their staff member, but reported that she was a very heavy woman. R#112 did not know the time or date of the occurrence. The former Administrator was not able to provide any additional relevant information that the allegation of abuse was investigated and only that the allegation was unsubstantiated (refer to F225). Review of the State Agency Complaint and Incident Tracking System during the survey revealed no evidence of an entity self-report related to this incident of 10/28/16. During an interview with LPN KK on 3/22/17 at 12:13 p.m., she revealed that she has worked at the facility for two years and has a set assignment on the 300 Hall (where R#112 resides). LPN KK stated that she was assigned to care for R#112. LPN KK stated she was not aware of any concerns R#112 may have had related to verbal abuse, physical abuse or mistreatment. During an interview with a family member of R#112 on 3/22/17 at 12:37 p.m., the family member stated that she was in the room when R#112 told staff that she was pushed by an employee at the facility. The family member stated R#112 said the person who pushed her was a large black woman. Review of the employee file for LPN KK, revealed a Grievance Complaint Form dated 2/11/16, which was stapled to a Record of Partner Corrective Action Form dated 2/15/16. Review of the grievance report revealed R#112 informed the Senior Care Partner (SCP) Registered Nurse (RN) that When I turn on my call light, LPN KK won't answer. When she comes in, she's always talking loudly and when I tell her that my leg hurts, she tells me to 'Shut up!' and there is nothing wrong with my leg. The way she talks to me hurts my feeling and nobody else here talks to me that way or hurt my feelings. The SCP RN noted that R#112 began to cry at this point during the conversation. The Record of Partner Corrective Action Form dated 2/15/16 indicated there was no investigation conducted and LPN KK received a written warning related to a violation of discourtesy to the patients/residents. Review in the State Agency Complaint and Incident Tracking System during the survey revealed no evidence of an entity self-report related to the 2/11/16 incident. An interview with the Interim Administrator on 3/28/17 at 4:15 p.m., who replaced the previous Administrator on 3/24/17, revealed the incident involving LPN KK and R#112, which was documented on the Grievance Complaint Form dated 2/11/16 and the Record of Partner Corrective Action Form dated 2/15/16, should have been investigated as an allegation of verbal abuse. An interview with the Senior Care Partner (SCP) on 3/28/17 at 4:24 p.m., confirmed that she filled out the Grievance Complaint Form dated 2/11/16 at 5:50 p.m. The SCP reviewed the form and confirmed that R#112 began to cry during the interview. The SCP stated that she reported this to the Administrator because the nature of the grievance was an allegation of abuse. She stated that she was not sure what the former Administrator did after she reported it to her. 2. During an interview with R#80 on 3/24/17 at 1:18 p.m., (who resided on the 300 hall) he stated that a nurse comes around and curses him and makes him mad. This same nurse threatened to beat the hell out of him. R#80 stated that she has shoved him in the past and that he was sort of afraid of her R#80 did not know the name of the nurse but described her as a black female nurse weighing about 250 pounds. He stated that he could identify her if he saw her but he had not seen her today. R#80 further stated that he did not report this and did not know who the abuse coordinator was. Record review for R#80 revealed a quarterly MDS assessment dated [DATE], which documented a BIMS summary score of four, indicating severe cognitive impairment. [DIAGNOSES REDACTED]. The MDS revealed the resident did not exhibit hallucinations or delusions. Despite a BIMS score of four, the resident was able to accurately describe his nurse and knew that he had not seen LPN KK on the day of his interview on 3/24/17. (Although R#80 had a BIMS score of four, on 3/24/16 at 1:16 p.m., LPN XXX included R#80 on a list of residents who, were in her professional opinion candidates for resident interviews.) 3. During an Interview on 3/24/17 at 2:00 p.m., with R A(who resided on the 300 hall), R A reported a nurse would make her wait for her medications. R A stated the nurse was overly aggressive with words and always had an attitude when speaking to her. R A was fearful to name the nurse initially, but stated the nurse wore green and worked on Tuesday (3/21/17). R A eventually named the nurse as LPN KK and was visibly upset when talking about her. R A had never reported this to the facility. R A was crying throughout the interview and was afraid that she would be retaliated against if others knew that she was telling about the treatment from LPN KK. Record review for R A revealed an annual MDS assessment dated [DATE] which documented a BIMS summary score of 15, indicating no cognitive impairment. The resident was not assesed to have exhibited behaviors of hallucinations or delusions. A post survey interview with the Interim Administrator was conducted, via the telephone, on 4/7/17 at 10:04 a.m. The interview revealed that LPN KK was terminated on 3/27/17 and was reported to the Nursing Board on 3/29/17 by the Interim DHS. The facility implemented the following actions to remove the Immediate Jeopardy: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? Nurse in question was immediately suspended pending the investigation on March 22 2017, Administrator is conducting an internal investigation related to this event Investigation was started on March 22 , 2017 and is on-going. 24 hour report was completed and submitted to state on March 22, 2017. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? On March 22, 2017 the Nurse Management and Senior Care Partner interviewed 11 residents with a BIMS score of 10 or above on the unit where the accused nurse worked (this was 100% of residents on this unit with a BIMS of 10 or above). On March 24, 2016 the center expanded our sample to an additional 46 residents with a BIMS score of 10 or above (this was 100% of all residents in the center with a BIMS of 10 or above). The center performed a 100% body audit of all residents with a BIMS score of 9 or below with no adverse findings on 3/26/2017. Staff has also been in-serviced on the identification of injuries or events that are suspicious and may constitute abuse in patients of all levels of cognition. Based on our interviews the following allegations were reported. On March 22, 2017 we had one allegation (of abuse) which was reported for an allegation on a CNA. This was reported and the CNA was suspended. On March 27, 2017 interviews revealed we had one additional allegation (of abuse) which was reported from a resident on an unnamed CNA which was stated to have happened twice over the last 8 months. This allegation was also reported to the state. On additional interviews with this patient she stated that CNA doesn't work here any longer. We had two allegations (of abuse) brought to us by the survey team regarding the nurse in the original complaint, These two alllegations were also reported to the state agency. We have filed a police report based on the allegations against the LPN. We have had 3 total allegations against the LPN, The investigation on the LPN will be completed resulting in the termination of the LPN. We have had a total of 7 [MEDICATION NAME] (3 from the survey team; 2 from interviews; 2 presented to staff). Of the four [MEDICATION NAME] (self reports) submitted by the center 3 had a BIMS of 10 or greater and 1 had a BIMS of 99, During this time frame we have suspended 7 staff members. What measures will be put in place or systematic changes will be made to ensure that the deficient practice will not reoccur? Education began on March 22, 2017 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The in-service included types of abuse that must be reported, how and who to report to, and the time frame for reporting. The center has 90% staff in-service completed as of 3/25/17. Any staff not receiving the in-service after 3/26/2017 related to FMLA, PRN status, or paid time off will be educated before the next schedule shift for that staff member. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. On March 24, 2017 the Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. The resident council was educated on who to report to and will continue to be reassured that they can report without fear of retaliation. On 3/27/2017 the Administrator posted his personal contact information in the front lobby and at both nursing stations. In addition, the Administrator distributed the reporting phone numbers for the Ombudsman, Department of Community Health reporting, and the Pruitt Health Customer Service Hot Line to all residents with a BIMS score of 10 or above. These numbers are also posted in common areas for all visitors and families to see. How will the corrective action be monitored to assure that the deficient practice will not reoccur? Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. The center will continue to follow new hire policy and procedure which includes checking the applicant's background, licensure/certification, and two reference checks. The center will also begin checking all licensed and certified staff on a quarterly bases. All RNs, LPNs, CNAs, and therapist have been completed with no other findings. (Other than the one LPN who was terminated on 3/28/2017) Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate and thorough investigations were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Review of Records revealed a Notice dated 3/26/17 documented the following: LPN KK was suspended 3/22/17. As of 3/26/17 employee is still suspended pending investigation. Continued record review revealed a Separation Notice dated 3/27/17 for LPN KK documenting that LPN KK was terminated from employment on 3/27/17. Reason for separation documented to be: Serious Rule Violation - Resident Abuse. Record review revealed that investigation conducted and incident reported. Record review revealed forms titled, Resident Interview Question Alleged Abuse Investigation which revealed on 3/22/17 10 residents with BIMs greater than 10 were interviewed with no adverse findings noted. Further review revealed that on 3/24/17 46 residents with BIMS 10 or greater were interviewed. Alleged Abuse Investigation forms for the 10 residents interviewed on 3/22/17 and for the 46 residents interviewed on 3/24/17 revealed the following questions were investigated: Have you ever been treated roughly by staff? Have staff injured you on purpose? Have you ever had an injury that you did not know how it happened? Do you ever feel afraid because of the way you or some other resident is treated? All forms reviewed for each resident. Record review revealed Body audit forms were reviewed for all residents with BIMS score less than 9. No adverse findings documented. Review of In-service Program Attendance Record Form dated 3/22/17 for Abuse revealed 113 staff members signed in for attendance. Review of Resident Interview Question Alleged Abuse Investigation revealed the following questions documented on the questionnaire: Have you ever been treated roughly by staff? Have staff injured you on purpose Have you ever had an injury that you did know how it happened? Do you ever fee afraid because of the way your or some other resident is treated? Review of Staff list compared to In-service sign in sheets educated revealed 140 staff members signed in for and attended the Abuse in-service. Review of the facility self reports and investigations revealed allegations were investigated and reported. Review of Resident Council Minutes/Report Form dated 3/24/17 and 3/26/17 revealed that Resident Council meeting was called The Resident Council president (BIMS 15) and 11 other residents. Information discussed included Abuse. Any allegations, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment and misappropriation of property, reported. Area Vice President informed the residents that he will be the administrator at this time, and you need anything to let him know. Residents said they would. 3/25/17 Resident Council meeting - Discussed retaliation. - The provider will provide emotional support and assurance to patients and their families or representatives following the reporting of discovery. AVP explained to the residents that if any staff mistreated, including talked ugly to , abuse of any kind, mistreat them, to report it as soon as possible to the Charge Nurse, Administrator, nurse or anyone you see. Please report if you, or you anyone abuses you, neglects you, mistreats you or anyone you know. We are here to keep you all safe. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse on 3/22/17. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Abuse in-services were provided by the DHS, Clinical Competency Coordinator, RN Restorative Nurse on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore, that if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: 11:00 p.m. to 7:00 a.m., shift: On 3/26/17 at 12:46 p.m., with Housekeeper BBB, on 3/26/17 at 12:49 p.m., with Activities Director/CNA, 3/26/17 at 12:56 p.m., with CNAZZZ, 3/26/17 at 1:07 p.m. with CNA YYY (Restorative), 3/26/17 at 1:13 p.m. with CNA XXX, 3/26/17 at 1:47 p.m. with CNA WWW, 3/26/17 at 1:53 p.m. with CNA VVV, Interview on 3/27/17 at 6:47 a.m., with CNA UUU, On 3/27/17 at 7:00 a.m., with CNA TTT, On 3/27/17 at 7:10 a.m., with CNA SSS, On 3/27/17 at 7:15 a.m., with CNA RRR, On 3/27/17 at 7:20 a.m. with CNA QQQ, On 3/28/17 at 9:30 a.m. with CNA PPP, On 3/28/17 at 9:41 a.m. with CNA PP On 3/28/17 at 10:04 a.m., with CNA OOO, On 3/28/17 at 10:35 a.m., with CNA NNN, On 3/28/17 at 10:45 a.m., with CNA MMM, On 3/28/17 at 10:55 a.m., with CNA SS, Central Supply, CNA scheduler, On 3/28/17 at 11:03 a.m. with CNA LLL, 3:00 p.m. to 11 p.m. shift 3/26/17 at 3:24 p.m., with CNA KKK, 3/26/17 at 4:20 p.m. with CNA JJJ, On 3/26/17 at 4:53 p.m. LPN JJ, 7pm - 7AM On 3/27/17 at 6:55 a.m. (11p.m. - 7 a.m.) LPN III, 3/27/17 at 6:57 a.m., with LPN HHH, 3/27/17 at 7:03 a.m., with LPN GGG, 3/28/17 at 9:25 a.m. with RN EE (Infection control, Restorative nurse), 3/28/17 at 10:52 a.m. with LPN FFF, 3/26/17 at 12:52 p.m., with Maintenance Director EEE, 3/28/17 at 3:15 p.m., with Housekeeping DDD Interviews with the following residents revealed: Interview 3/26/17 at 1:27 p.m. with R#1, the Resident Council President, on 3/26/17 at 12:45 p.m., with R#77, on 3/28/17 at 10:50 a.m., with R87, on 3/28/17 at 11:00 a.m,, with R#88, on 3/28/17 at 11:13 a.m., R#73, on 3/28/17 at 11:20 a.m., with R#120, on 3/28/17 at 11:28 a.m., with R#66 revealed that the Area Vice President (AVP), that is currently the Interim Administrator, called a Resident Council meeting Friday night (3/24/17) and spoke with the Resident Council members and staff regarding abuse. That the residents were instructed to tell the staff CNA, Charge Nurse, any staff, and the Administrator and tell them if they have any problems. Residents were educated that they can call the Ombudsman and how to call the Ombudsman. Residents able to verbalize who they would report abuse to, who was the Abuse Coordinator, and how to report abuse themselves. Residents revealed that the AVP and Interim DHS have encouraged them to report abuse to them. Residents revealed that they (AVP and Interim DHS) want us to tell them if we have any concerns. R#1 revealed that the Ombudsman comes to facility pretty frequently and that the facility announces the resident rights over the loud speaker every morning. Information sheets were given to cognitive residents and included the phone number to the Ombudsman, HFRD, and the facility's corporate office. Review of Abuse Policy's revealed: revealed all seven components addressed. Review of the facility self reports and investigations revealed allegations were reviewed by the AVP, were investigated by the AVP, Interim DHS and were reported by the AVP. Interventions of QAPI for abuse are documented to be: All allegations of abuse will be reported to the Administrator or DHS immediately. The Administrator or DHS will report the allegation to the state agency within a 2 hour time frame. The Ombudsman will be notified. Law enforcement will be notified if deemed appropriate. A complete investigation will be completed. Staff will be in-serviced related to the abuse allegations. Review of notice regarding QAPI meeting on 3/26/17 revealed the following: On 3/26/17 the AVP educated all department heads on QAPI process, policy and procedures, their roles and responsibilities, current action plans, and how write Performance Improvement plans. AVP discussed QAPI review with Medical Director on 3/26/17. Medical Director signature observed to be on 5th page as reviewed and dated 3/26/17.

Based on record review, review of the facility policy titled Governing Body review of the Administrator Position Description, resident and staff interviews, the facility failed to ensure that it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and/or psychosocial wellbeing of each resident. The facility administration was aware on 2/11/16 that allegations had been reported by resident (R) #112 that Licensed Practical Nurse (LPN) KK was verbally and physically abusive. Additionally, on 10/28/16 R#112 reported that a heavyset woman, who provided her care, had been verbally, mentally, and physically abusive. The administration failed to thoroughly investigate the allegations of abuse and report the alleged abuse to the appropriate State Survey Agency in accordance with the facility's policies. During interviews with other residents that reside on the 300 Hall, for which LPN KK is regularly assigned, there was one resident (RA) that alleged she had been verbally abused by LPN KK. This failure had the potential to affect all residents in care of LPN KK. Refer F223, F225 and F226 The facility's failure to use its resources effectively and efficiently in accordance with the facility's policies related to Governing Body and Abuse, has caused or is likely to cause serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified on 3/23/17 and determined to exist on 2/11/16. The facility's former Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on 3/23/17 at 6:50 p.m. An acceptable Allegation of Compliance (AoC) was received on 3/24/17 and the State Survey Agency validated the Immediate Jeopardy which was removed on 3/28/17, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy titled Governing Body revised 11/29/16 revealed that it is the policy of this healthcare center to have in place a governing body pursuant to 42 C.F.R 483.70. A designated group of people that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The governing body of this healthcare center is the Administrator and Area Vice President. Review of the Administrator Position Description created 6/26/16 documented the Job Purpose- Directs the day to day functions of the nursing center in accordance with federal, state and local regulations that govern long term care centers, and as may be directed by the Area Vice President, to provide appropriate care for our patients/residents. Key Responsibilities include but not limited to; Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality, Ability to develop and implement administrative policies and procedures, Demonstrates competency in the protection and promotion of residents' rights. During an interview with R#112 on 3/21/17 at 12:37 p.m., she stated that her nurse, who she described as a heavy set black woman, had a history of [REDACTED]. R#112 stated that the nurse hollers and yells at her and she was afraid of her. R#112 further stated that the nurse yells and hollers at her and has also threatened to stick her with needles. R#112 stated that when she told the people over the facility the nurse went crazy and hit her across her back and shoved her. In a subsequent interview on 3/22/17 at 11:43 a.m., R#112 stated that the nurse that abused her was her nurse that gave her medication this morning (3/22/17). R#112 stated that the nurse told her that if she didn't get up, she was going to give her a shot. R#112 sated that she doesn't get shots so she tried her best to sit up. Licensed Practical Nurse (LPN) KK was at the medication cart outside of R#112's room and confirmed that she was the nurse for the 300 hall for which R#112 resides. Review of the Reportable Occurrence Log Form revealed an allegation of abuse (physical) reported by R#112 on 10/28/16. In an interview with the former Administrator on 3/22/17 at 11:47 a.m., she stated that she had conducted a thorough investigation of the incident but was unable to provide evidence or documentation of the investigative information gathered to support that the incident was unfounded and unsubstantiated. The former Administrator further stated that the incident was reported to the State Survey Agency. The former Administrator provided a plain white piece of paper with no letterhead, dated 11/3/16, addressed to: Georgia Department of Health-LTC-Complaint unit. The document stated that R#112 had reported that a very heavy set woman had pushed her, but she did not know who she was or the date or time of the occurrence. The section titled Immediate protection implemented indicated initiation of immediate investigation. The conclusion stated that after a thorough investigation, the exact nature of the allegation was unfounded and unsubstantiated. The former Administrator stated that she conducted interviews with staff members but she could not remember who she spoke with. The former Administrator confirmed that the only documentation she had on file for this incident was the letter addressed to the Georgia Department of Health-LTC-Compliant Unit dated 10/28/16 and a Facility Incident Report Form dated 10/28/16, which documented staff to resident physical abuse, revealed no injury and no treatment required. The physician was not notified, the police were not notified and other agencies involved were not notified. Although the former Administrator claimed to have reported this incident to the State Survey Agency, the facility incident report form dated 10/28/16 reflected no such report was filed. In addition, review of the State Survey Agency Complaint and Incident Tracking System duing the survey revealed no evidence of an entity self-report related to the allegations of abuse made by R#112. The former Administrator repeatedly stated that R#112's Brief Interview of Mental Status (BIMS) score was a seven; therefore, she was not credible. Review of her employee file was conducted. The employee file revealed a previous Grievance Complaint Form dated 2/11/16 stapled to a Record of Partner Corrective Action Form dated 2/15/16, with a complaint made by R#112 indicated that LPN KK talks loudly to her and tells her to shut up. LPN KK received a written warning related to violation of discourtesy to the patients/residents. Additional interviews on the 300 hall revealed one resident (R A) alleged LPN KK had verbally and/or physically abused her. During an interview with R#80 on 3/24/17 at 1:18 p.m., (who resided on the 300 hall) he stated that a nurse comes around and curses him and makes him mad. This same nurse threatened to beat the hell out of him. R#80 stated that she has shoved him in the past and that he was sort of afraid of her R#80 did not know the name of the nurse but described her as a black female nurse weighing about 250 pounds. He stated that he could identify her if he saw her but he had not seen her today. R#80 further stated that he did not report this and did not know who the abuse coordinator was. Record review for R#80 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which documented a BIMS summary score of four, indicating severe cognitive impairment. The resident was assessed as not having exhibited behaviors of hallucinations or delusions. Despite a BIMS score of four, the resident was able to accurately describe his nurse and knew that he had not seen LPN KK on the day of his interview on 3/24/17. (Although R#80 had a BIMS score of four, LPN XXX provided a list of residents (which included R#80) who were in her professional opinion candidates for resident interviews on 3/24/17 at 1:16 p.m.). During an interview on 3/24/17 at 2:00 p.m., with R A(who resided on the 300 hall), R A reported a nurse would make her wait for her medications. R A stated the nurse was overly aggressive with words and always had an attitude when speaking to her. R A was fearful to name the nurse initially, but stated the nurse wore green and worked on Tuesday (3/21/17). R A eventually named the nurse as LPN KK and was visibly upset when talking about her. R A had never reported this to the facility. R A was crying throughout the interview and was afraid that she would be retaliated against if others knew that she was telling about the treatment from LPN KK. Record review for R A revealed an Annual MDS assessment dated [DATE] which documented a BIMS summary score of 15, indicating no cognitive impairment. The MDS assessment revealed the resident did not exhibit behaviors of hallucinations or delusions. The former Administrator and DHS were terminated before an interview could be conducted regarding the Grievance Complaint Form dated 2/11/16 in LPN KK's employee file. An interview with the Interim Administrator on 3/28/17 at 4:15 p.m., revealed this incident should have been investigated as an allegation of verbal abuse. In an interview with the Senior Care Partner (SCP) Registered Nurse (RN) on 3/28/17 at 4:24 p.m., she confirmed that R#112 began to cry during the interview for the grievance of 2/11/16. She stated that she reported this to the former Administrator because the nature of the grievance was an allegation of abuse. She stated that she was not sure what the Administrator did after she reported it her. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 2/24/17 documented; Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, should immediately be reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies). Review of the policy titled No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 11/21/16 documented: Any suspicion of abuse, neglect, exploitation, mistreatment or misappropriation of patient property, a suspected partner should not have direct care contact with the patient at issue until the investigation is completed and the issue resolved. For example, a partner suspected of committing any such act should be suspended without pay pending the outcome of the investigation. The facility implemented the following actions to remove the Immediate Jeopardy: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? PruittHealth Peake will be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. Based upon the alleged deficient practice cited on F 490. The Administrator of record during the survey is no longer at the facility. The Area Vice President is now the interim administrator of the center. We are now in the process of securing a permanent administrator. The healthcare center conducted a Performance Improvement Committee meeting on March 24, 2017 to review the findings of the following: Regulatory survey tags cited - F223, F224, F225, F226, F281, F315, F490, F498, F520 Audit findings conducted as a result of the survey tags cited Reviewed in-servicing that was conducted relating to the survey tags cited which included: Abuse and Neglect How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The Area Vice President is the acting administrator. If an allegation is brought forward the following procedure will be followed: Accused person will be suspended pending investigation per policy Reports will be filed to appropriate agency in the allotted time frame Investigation will be conducted by the Administrator and/or Director of Health Services The healthcare center's Performance Improvement Committee developed new performance improvement action plans on the areas noted during regulatory survey and other areas identified during monitoring/ audit findings. The healthcare center's Performance Improvement Committee was in-serviced on March 26, 2017 by the Area Vice President on the following: Action plan development related to abuse and catheter care. Action plan revision, utilizing monitoring/audit findings Action plan evaluation AVP educated Department heads on QAPI process and their roles and responsibilities on March 26, 2017. What measures will be put in place or systematic changes will be made to ensure that the deficient practice will not reoccur? For the abuse tag education began on March 22, 2017 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and 1 Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The center has 90% staff in-service completed as of 3/25/17. Any staff not receiving the in-service by 3/26/2017 related to FMLA, PRN status, or paid time off will be educated before the next schedule shift. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. On March 24, 2017 Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council meeting. The healthcare center's Performance Improvement Committee will meet bi-monthly for three months, then monthly thereafter. The Performance Improvement Committee will review, but not be limited to the following, at each meeting: Action plan monitoring/auditing results Evaluation of current action plans Revisions of current action plans as a result of the audit findings submitted to the Performance Improvement Committee on a monthly basis Resolution of current action plans Development of new action plans The Administrator will monitor compliance to the Performance Improvement action plans bi-monthly for three months and monthly thereafter. If issues are discovered the plan will be re-assessed and new intervention put into place. How will the corrective action be monitored to assure that the deficient practice will not reoccur? Area Vice President will chair the initial Performance Improvement Committee meeting and will attend or review minutes thereafter. Any issues or identified deficiencies to be reviewed with full Performance Improvement team. Once an Administrator is secured for the building the following will occur: Area Vice President Monitoring; The AVP will monitor compliance to the following bi-monthly and document findings in a checklist report format: Review Job Description Review all allegations of abuse to ensure the policy was followed Review and/or observation of Performance Improvement Committee Team meetings/minutes The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Record review revealed the Administrator and the DHS were both terminated on 3/27/17. The Area Vice President is the acting Interim Administrator. Record review revealed that all areas of abuse and Administration were reviewed. Record review of the Quality Assessment and Assurance/QAPI Committee Meeting Attendance sheet for 3/25/17 at 5:30 p.m. revealed the Area Vice President, Interim DHS were in attendance, and reviewed all finding with the Medical Director on 3/26/17. Medical Director documented reviewed and signed on 3/26/17. The healthcare centers Performance Improvement Committee new Improvement Action Plans related to abuse and Administration. Action Plans included: Abuse: all allegations have to be investigated and reported, review of the types of abuse including: verbal abuse, sexual abuse, physical abuse, mental abuse, involuntary seclusion. Must report all allegations of abuse immediately - The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator of the facility. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. Screening: screen potential employees for a history of abuse, neglect or mistreating residents. Checking with previous employers, background checks, checking appropriate licensing boards and registries. How staff should report their knowledge related to allegations without fear of reprisal. Training: through orientation and on-going sessions related to abuse prohibition practices. Prevention: Provide families and staff information on how and to whom they can report concerns incidences and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identification - identify events, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. Investigate different types of incidents and identify the staff member responsible for the initial investigation. Protect residents from harm during the investigation. Federal Regulations were reviewed with what requirements are to be met to meet the Federal Regulations related to each tag including Abuse: F223, F224, F225, F226, F490. Audit findings revealed 7 facility [MEDICATION NAME] that were investigated and reported. Education began on March 22, 2017 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. On March 24, 2017 the Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. The resident council was educated on who to report to and will continue to be reassured that they can report without fear of retaliation. On 3/27/2017 the Administrator posted his personal contact information in the front lobby and at both nursing stations. In addition, the Administrator distributed the reporting phone numbers for the Ombudsman, Department of Community Health reporting, and the(NAME)Health Customer Service Hot Line to all residents with a BIMS score of 10 or above. These numbers are also posted in common areas for all visitors and families to see. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse on 3/22/17. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Abuse in-services were provided by the DHS, Clinical Competency Coordinator, RN Restorative Nurse on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore, that if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: 11:00 p.m. to 7:00 a.m., shift: On 3/26/17 at 12:46 p.m., with Housekeeper BBB, on 3/26/17 at 12:49 p.m., with Activities Director/CNA, 3/26/17 at 12:56 p.m., with CNAZZZ, 3/26/17 at 1:07 p.m. with CNA YYY (Restorative), 3/26/17 at 1:13 p.m. with CNA XXX, 3/26/17 at 1:47 p.m. with CNA WWW, 3/26/17 at 1:53 p.m. with CNA VVV, Interview on 3/27/17 at 6:47 a.m., with CNA UUU, On 3/27/17 at 7:00 a.m., with CNA TTT, On 3/27/17 at 7:10 a.m., with CNA SSS, On 3/27/17 at 7:15 a.m., with CNA RRR, On 3/27/17 at 7:20 a.m. with CNA QQQ, On 3/28/17 at 9:30 a.m. with CNA PPP, On 3/28/17 at 9:41 a.m. with CNA PP On 3/28/17 at 10:04 a.m., with CNA OOO, On 3/28/17 at 10:35 a.m., with CNA NNN, On 3/28/17 at 10:45 a.m., with CNA MMM, On 3/28/17 at 10:55 a.m., with CNA SS, Central Supply, CNA scheduler, On 3/28/17 at 11:03 a.m. with CNA LLL, 3:00 p.m. to 11 p.m. shift 3/26/17 at 3:24 p.m., with CNA KKK, 3/26/17 at 4:20 p.m. with CNA JJJ, On 3/26/17 at 4:53 p.m. LPN JJ, 7pm - 7AM On 3/27/17 at 6:55 a.m. (11p.m. - 7 a.m.) LPN III, 3/27/17 at 6:57 a.m., with LPN HHH, 3/27/17 at 7:03 a.m., with LPN GGG, 3/28/17 at 9:25 a.m. with RN EE (Infection control, Restorative nurse), 3/28/17 at 10:52 a.m. with LPN FFF, 3/26/17 at 12:52 p.m., with Maintenance Director EEE, 3/28/17 at 3:15 p.m., with Housekeeping DDD Interview on 3/28/17 at 2:21 p.m., with the Senior Nurse Consultant revealed that the previous Director of Health Services (DHS) was terminated on 3/24/17 and that she is the Senior Nurse Consultant and she has stepped in as the Interim DHS and will be the Interim DHS until a new DHS is hired. The Interim DHS further revealed that the former DHS was not reporting what was occurring in the facility accurately and that there was a lack of follow up and that the former DHS was not following the facility's policies and procedures regarding abuse. The Interim DHS revealed that the facility has a System Checklist but that the checklist had not been completely correctly recently but she is going to ensure that the Systems Checklist is re-implemented and that the System Failure such as failure to assess, investigate, report are corrected. The Interim DHS revealed that they have vigorously started in-servicing the staff regarding abuse, neglect, recognizing abuse, investigating, and reporting abuse. She further revealed that they had found that the facility had a very hateful nurse but that nurse (LPN KK) had been terminated and that they have a zero tolerance for abuse of any kind. Interview on 3/28/17 at 3:49 p.m., with the facility's Area Vice President (AVP) revealed that he is the Interim Administrator until a new Administrator is hired. What he found was that the former Administrator did not report the instances of abuse, but that during their (his and the Interim DHS) investigation they substantiated the verbal abuse and that the nurse responsible (LPN KK) was terminated on 3/27/17 and that the former Administrator was terminated on 3/24/17 and the former DHS was terminated on 3/24/17. The AVP revealed that he will be responsible for reporting investigating and reporting all allegations of abuse. Interventions of QAPI for abuse are documented to be: All allegations of abuse will be reported to the Administrator or DHS immediately. The Administrator or DHS will report the allegation to the state agency within a 2 hour time frame. The Ombudsman will be notified. Law enforcement will be notified if deemed appropriate. A complete investigation will be completed. Staff will be in-serviced related to the abuse allegations. Review of notice regarding QAPI meeting on 3/26/17 revealed the following: On 3/26/17 the AVP educated all department heads on QAPI process, policy and procedures, their roles and responsibilities, current action plans, and how write Performance Improvement plans. AVP discussed QAPI review with Medical Director on 3/26/17. Medical Director Signature observed to be on 5th page as reviewed and dated 3/26/17.

Based on observation, record review, review of facility policy titled No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, staff and resident interviews, the facility failed to implement and follow its policy related to employee training, identifying abuse, conducting thorough investigations of alleged abuse, immediately reporting suspected abuse to the State Survey Agency, and providing protection from staff to resident abuse for one of 44 sampled residents (R#112). This failure increased the likelihood of staff to resident abuse of all residents in care of the alleged perpetrator, Licensed Practical Nurse (LPN KK). LPN KK continued to work in the facility for over one year after it was first reported by R#112 on 2/11/16, that she was abusive. Refer F223 and F225 The facility's failure to implement its policies related to allegations of abuse, has caused or is likely to cause serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified on 3/23/17 and determined to have existed on 2/11/16. The facility's former Administrator and former Director of Health Services (DHS) were informed of the Immediate Jeopardy on 3/23/17 at 6:50 p.m. An acceptable Allegation of Compliance (AoC) was received on 3/24/17 and the State Survey Agency validated the Immediate Jeopardy which was removed on 3/28/17, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the policy titled No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 11/21/16 documented: It is the policy of PruittHealth and its affiliated providers (collectively, the Organization) that there should be no retaliation against PruittHealth partners, patients, patients' families, or others for good faith reporting of occurrences or allegations of patient abuse, neglect, exploitation, mistreatment, or misappropriation of patient property. Any suspicion of abuse, neglect, exploitation, mistreatment or misappropriation of patient property, a suspected partner should not have direct care contact with the patient at issue until the investigation is completed and the issue resolved. For example, a partner suspected of committing any such act should be suspended without pay pending the outcome of the investigation. 1. During an interview with R#112 on 3/21/17 at 12:37 p.m., she alleged that a heavy set black nurse on first shift has a history of verbally and physically abusing her. R#112 stated that a few weeks ago, she reported to the facility that her nurse was hollering at her and threatening to stick her with needles. R#112 stated that after she reported it, the nurse went crazy and hit her across the back and shoved her. The resident did not report this incident to the facility. R#112 stated that she was afraid of this nurse. R#112 could not provide details of an exact date or name of the nurse but she was able to describe the nurse, knew she worked during the day and administered her medications. R#112 stated that the nurse was not working today. In a subsequent interview with R#112 on 3/22/17 at 11:43 a.m., she stated that the nurse who abused her was working today (3/22/17). R#112 stated it was the nurse who had administered her medications this morning (3/22/17). R#112 stated that the nurse came in today and said Get up! R#112 stated she tried to sit up. And the nurse said Get up! If you don't sit up, I'm going to give you a shot! I don't suppose to get shots so I just sat up! R#112's eyes were open very wide as she described this incident and she was visibly frightened. LPN KK was observed at the medication cart outside of R#112's room, just after the interview with R#112. LPN KK confirmed that she was assigned to care for residents on this hall (300 Hall, on which R#112 resides). The former facility Administrator was immediately informed of this incident by the surveyor. Record review for R#112 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderate cognitive impairment. A quarterly MDS assessment dated [DATE] documented a BIMS summary score of seven, indicating severe cognitive impairment. A quarterly MDS assessment dated [DATE] documented a BIMS summary score of 10, indicating moderate cognitive impairment. All three MDS assessments indicated that R#112 did not exhibit behaviors of hallucinations or delusions (section E). During an interview with the former Administrator on 3/22/17 at 11:47 a.m., she stated that she is the abuse coordinator. On 10/28/16 at 5:00 p.m., the Certified Nursing Assistant (CNA) Central Supply Scheduler (CNA SS) reported to her that R#112 made an allegation of abuse by staff. She stated that the resident alleged that she had been pushed by a heavy set woman but could not communicate when this occurred or by whom. The former Administrator stated that she had not interviewed all staff that fit R#112's description. She stated that R#112's family member was in the room at time of the interview with CNA SS. The Administrator stated that a thorough investigation had been conducted and that the incident was reported to the State Survey Agency. The former Administrator repeatedly stated R#112 had a BIMS score of seven and therefore the allegation was not credible and was unsubstantiated. The former Administrator provided a plain white paper with no letterhead, dated 11/3/16, addressed to: Georgia Department of Health-LTC-Complaint unit. The document stated that R#112 had reported that a very heavy set woman pushed her but she did not know who she was or the date or time of the occurrence. The section titled Immediate protection implemented indicated initiation of immediate investigation. The conclusion stated that after a thorough investigation, the exact nature of the allegation was unfounded and unsubstantiated. The former Administrator was unable to provide any gathered investigative documents to support that a thorough investigation had been conducted or to support the conclusion. There was no documentation that any staff caring for R#112, who fit the description, had been removed from her care until the investigation was completed. The second document was a Facility Incident Report Form dated 10/28/16 which documented: staff to resident physical abuse. No injury, no treatment required. The physician was not notified, the police were not notified and other agencies involved were not notified. The following interviews with direct care staff revealed they were not able to identify the facility's Abuse Coordinator: On 3/22/17 at 6:29 p.m., CNA PP revealed that she has worked in the facility four years. CNA PP was not able to identify the facility Abuse Coordinator. On 3/22/17 at 6:37 p.m., CNA DDD revealed she has worked in the facility one year. CNA DDD was not able to identify the facility Abuse Coordinator. On 3/22/17 at 6:55 p.m., CNA EEE revealed she has worked in the facility for 8 months. CNA EEE was not able to identify the facility Abuse Coordinator. An interview with the Resident Council President on 3/24/17 at 10:14 a.m., revealed she did not know who the facility's Abuse Coordinator was. During an interview with the Clinical Competency Coordinator (CCC) on 3/24/17 at 11:00 a.m., she stated that she was responsible for staff education under the direction of the former Director of Health Services (DHS). She stated that the most recent in-house training on abuse was 2/23/17 with only 26 employees signed as attending this in-service. The CCC stated that the in-services related to abuse are targeted for all employees of the facility. She was trying to do abuse in-services monthly because she was having difficulty getting staff to attend and was not getting cooperation from the DHS. The CCC stated she did not know why all staff did not attended the abuse in-service. Review of the in-service dated 11/3/16 titled Abuse Prevention revealed a signature indicating LPN KK was in attendance. Review of the in-service dated 2/23/17 titled Hand in Hand 2 Abuse revealed no signature indicating attendance by LPN KK. Further review of the in-service revealed only 26 employee signatures were in attendance. Review of the employee file for LPN KK, revealed a Grievance Complaint Form dated 2/11/16 which was stapled to a Record of Partner Corrective Action Form dated 2/15/16. The Grievance stated R#112 informed the Senior Care Partner (SCP) Registered Nurse (RN) that When I turn on my call light, LPN KK won't answer. When she comes in, she always talking loudly and when I tell her that my leg hurts, she tells me to Shut up! and there is nothing wrong with my leg. The way she talks to me hurts my feeling and nobody else here talks to me that way or hurt my feelings. The SCP RN noted that R#112 began to cry at this point during the conversation. Action Taken documented on 2/15/16 by the SCP; discussed findings with the Administrator. Nurse will be disciplined for poor deportment as reported by resident who is alert and oriented x 3 (People, Place and Time). The Record of Partner Corrective Action Form indicated no investigation conducted and that LPN KK received a written warning related to violation of discourtesy to the patients/residents. There was no evidence or documentation that LPN KK had been removed from resident care or that an investigation had been conducted. Review of the nursing license for LPN KK revealed it was due to expire on 3/31/17. Additional interviews were conducted on 3/24/17 with residents who reside on the 300 hall. In an interview with R#80 on 3/24/17 at 1:18 p.m., he expressed that he was sort of afraid of the nurse and she had threatened to beat the hell out of him. R#80 was not able to name the nurse but described her as a black female nurse weighing about 250 pounds. R#80 further stated that the nurse curses at him and makes him mad. In addition, on 3/24/17 at 2:00 p.m., an interview with R A (who wished to remain anonymous) revealed that she had been verbally abused by a nurse. R A was hesitant to name the nurse that verbally abused her, but stated the nurse was overly aggressive with words and always had an attitude when speaking to her. R A did finally identify the nurse as LPN KK. The resident was crying as she spoke about LPN KK. R A alleged verbal and physical abuse by LPN KK; however, she did not report the allegation to the facility. R A stated she was afraid of LPN KK and afraid of retaliation for telling on her. Record review for R#80 revealed a quarterly MDS assessment dated [DATE], which documented a BIMS summary score of four, indicating severe cognitive impairment. [DIAGNOSES REDACTED]. The resident did not exhibit hallucinations or delusions. Despite a BIMS score of four, the resident was able to accurately describe his nurse and knew that he had not seen LPN KK on the day of his interview on 3/24/17. (Although R#80 had a BIMS score of four, on 3/24/16 at 1:16 p.m., LPN XXX included R#80 on a list of residents who, were in her professional opinion candidates for resident interviews.) During an interview with the Interim Administrator on 3/28/17 at 4:15 p.m., he stated the incident involving LPN KK and R#112 that was documented on a Grievance Complaint Form dated 2/11/16 and the Record of Partner Corrective Action Form dated 2/15/16, should have been investigated as an allegation of verbal abuse. During an interview with the Registered Nurse (RN) Senior Care Partner (SCP) on 3/28/17 at 4:24 p.m., she confirmed that she had filled out the Grievance Complaint Form dated 2/11/16 at 5:50 p.m. The RN SCP stated that she reported this to the former Administrator and the nature of the grievance was that of abuse and that R#112 was crying during the interview. A post survey interview with the Interim Administrator was conducted, via the telephone, on 4/7/17 at 10:04 a.m. The interview revealed that LPN KK was terminated on 3/27/17 and was reported to the Nursing Board on 3/29/17 by the Interim DHS. A telephone interview conducted 3/28/17 at 3:54 p.m., with a representative of the Georgia State Board of Licensing, revealed LPN KK was on probation status and that any additional questions needed to be directed in an e-mail to the Licensing Board. On 3/29/17 at 9:56 a.m., a representative for the State Board of Licensing called the surveyor and stated that LPN KK had failed to comply with Board recommendation to provide a copy to her employer of her probationary status and provide quarterly reports by her employer. The representative further stated LPN KK's license was on the calendar for review. Review of the Georgia Secretary of State public website dated 8/31/16 under Findings of Fact revealed on or about September of 2011, the Respondent (LPN KK) had signed out 59 narcotics and failed to enter documentation on the medication administration records. On or about July 2012, the Board issued a Confidential Order for Mental/Physical Examination (MPE 2012). The results of the July MPE revealed the Respondent had been receiving treatment for [REDACTED]. On or about August 2014, the Board issued a second Order for Mental/Physical examination (2014 MPE) in order to determine Respondent's [DIAGNOSES REDACTED]. The 2014 MPE results contained a [DIAGNOSES REDACTED]. On or about June 19, 2015, after finding that the 2014 examination did not comply with the Board's 2014 MPE, because it was not performed by a licensed physician who is Board Certified in Addiction Medicine or Addiction Psychiatry, the Board entered a third Confidential Expedited Order for Mental/Physical Examination (2015 MPE). The results of the 2015 MPE included an Opioid Use Disorder, controlled with [MEDICATION NAME]. The 2015 MPE recommended that Respondent enter a treatment program and gradually be tapered off the [MEDICATION NAME]; that she enters a nurses' recovery group; and undergo random drug screens. The former Administrator had been terminated from the facility after the Immediate Jeopardy was called on 3/23/17. The surveyor was unable to attain an interview related to whether she was aware of LPN KK's probationary status and restrictions on her license. The facility implemented the following actions to remove the Immediate Jeopardy: What Corrective action will be accomplished for the residents found to have been affected by the deficient practice? Nurse in question was immediately suspended pending the investigation on March 22 2017, Administrator is conducting an internal investigation related to this event Investigation was started on March 22 , 2017 and is on-going. 24 hour report was completed and submitted to state on March 22, 2017. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? On March 22, 2017 the Nurse Management and Senior Care Partner interviewed 11 residents with a BIMS score of 10 or above on the unit where the accused nurse worked (this was 100% of residents on this unit with a BIMS of 10 or above). On March 24, 2016 the center expanded our sample to an additional 46 residents with a BIMS score of 10 or above (this was 100% of all residents in the center with a BIMS of 10 or above). The center performed a 100% body audit of all residents with a BIMS score of 9 or below with no adverse findings on 3/26/2017. Staff has also been in-serviced on the identification of injuries or events that are suspicious and may constitute abuse in patients of all levels of cognition. Based on our interviews the following allegations were reported. On March 22, 2017 we had one allegation (of abuse) which was reported for an allegation on a CNA. This was reported and the CNA was suspended. On March 27, 2017 interviews revealed we had one additional allegation (of abuse) which was reported from a resident on an unnamed CNA which was stated to have happened twice over the last 8 months. This allegation was also reported to the state. On additional interviews with this patient she stated that CNA doesn't work here any longer. We had two allegations (of abuse) brought to us by the survey team regarding the nurse in the original complaint, These two alllegations were also reported to the state agency. We have filed a police report based on the allegations against the LPN. We have had 3 total allegations against the LPN, The investigation on the LPN will be completed resulting in the termination of the LPN. We have had a total of 7 [MEDICATION NAME] (3 from the survey team; 2 from interviews; 2 presented to staff). Of the four [MEDICATION NAME] (self reports) submitted by the center 3 had a BIMS of 10 or greater and 1 had a BIMS of 99, During this time frame we have suspended 7 staff members. What measures will be put in place or systematic changes will be made to ensure that the deficient practice will not reoccur? Education began on March 22, 2017 for all staff (to include Nursing, CNAs, Housekeeping, Dietary, Laundry, Maintenance, Administrative, Therapy and Respiratory Therapy) conducted by the Clinical Competency Coordinator, on abuse and reporting abuse per policy. The in-service included types of abuse that must be reported, how and who to report to, and the time frame for reporting. The center has 90% staff in-service completed as of 3/25/17. Any staff not receiving the in-service after 3/26/2017 related to FMLA, PRN status, or paid time off will be educated before the next schedule shift for that staff member. Education on abuse is reviewed in new partner orientation by the Clinical Competency Coordinator. Any staff members not receiving the in-service will be unable to return to work until they have completed the in-service. On March 24, 2017 the Administrator met with Resident Council to review abuse and reporting of abuse. There were no allegations reported during resident council. The resident council was educated on who to report to and will continue to be reassured that they can report without fear of retaliation. On 3/27/2017 the Administrator posted his personal contact information in the front lobby and at both nursing stations. In addition, the Administrator distributed the reporting phone numbers for the Ombudsman, Department of Community Health reporting, and the Pruitt Health Customer Service Hot Line to all residents with a BIMS score of 10 or above. These numbers are also posted in common areas for all visitors and families to see. How will the corrective action be monitored to assure that the deficient practice will not reoccur? Administrator will notify the Area Vice President immediately of any alleged reports of abuse or neglect. The center will continue to follow new hire policy and procedure which includes checking the applicant's background, licensure/certification, and two reference checks. The center will also begin checking all licensed and certified staff on a quarterly bases. All RNs, LPNs, CNAs, and therapist have been completed with no other findings. (Other than the one LPN who was terminated on 3/28/2017) Administrator and Area Vice President will review all allegations of abuse and neglect. To ensure accurate and thorough investigations were completed and reporting is completed per current policy. Abuse policy is reviewed yearly by the compliance officer at the corporate office and was updated on [DATE] to include the new requirements of participation. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: Review of Records revealed a Notice dated 3/26/17 documented the following: LPN KK was suspended 3/22/17. As of 3/26/17 employee is still suspended pending investigation. Continued record review revealed a Separation Notice dated 3/27/17 for LPN KK documenting that LPN KK was terminated from employment on 3/27/17. Reason for separation documented to be: Serious Rule Violation - Resident Abuse. Record review revealed that investigation conducted and incident reported. Record review revealed forms titled, Resident Interview Question Alleged Abuse Investigation which revealed on 3/22/17 10 residents with BIMs greater than 10 were interviewed with no adverse findings noted. Further review revealed that on 3/24/17 46 residents with BIMS 10 or greater were interviewed. Alleged Abuse Investigation forms for the 10 residents interviewed on 3/22/17 and for the 46 residents interviewed on 3/24/17 revealed the following questions were investigated: Have you ever been treated roughly by staff? Have staff injured you on purpose? Have you ever had an injury that you did not know how it happened? Do you ever feel afraid because of the way you or some other resident is treated? All forms reviewed for each resident. Record review revealed Body audit forms were reviewed for all residents with BIMS score less than 9. No adverse findings documented. Review of In-service Program Attendance Record Form dated 3/22/17 for Abuse revealed 113 staff members signed in for attendance. Review of Resident Interview Question Alleged Abuse Investigation revealed the following questions documented on the questionnaire: Have you ever been treated roughly by staff? Have staff injured you on purpose Have you ever had an injury that you did know how it happened? Do you ever fee afraid because of the way your or some other resident is treated? Review of Staff list compared to In-service sign in sheets educated revealed 140 staff members signed in for and attended the Abuse in-service. Review of the facility self reports and investigations revealed allegations were investigated and reported. Review of Resident Council Minutes/Report Form dated 3/24/17 and 3/26/17 revealed that Resident Council meeting was called The Resident Council president (BIMS 15) and 11 other residents. Information discussed included Abuse. Any allegations, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment and misappropriation of property, reported. Area Vice President informed the residents that he will be the administrator at this time, and you need anything to let him know. Residents said they would. 3/25/17 Resident Council meeting - Discussed retaliation. - The provider will provide emotional support and assurance to patients and their families or representatives following the reporting of discovery. AVP explained to the residents that if any staff mistreated, including talked ugly to , abuse of any kind, mistreat them, to report it as soon as possible to the Charge Nurse, Administrator, nurse or anyone you see. Please report if you, or you anyone abuses you, neglects you, mistreats you or anyone you know. We are here to keep you all safe. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse on 3/22/17. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Abuse in-services were provided by the DHS, Clinical Competency Coordinator, RN Restorative Nurse on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore, that if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: 11:00 p.m. to 7:00 a.m., shift: On 3/26/17 at 12:46 p.m., with Housekeeper BBB, on 3/26/17 at 12:49 p.m., with Activities Director/CNA, 3/26/17 at 12:56 p.m., with CNAZZZ, 3/26/17 at 1:07 p.m. with CNA YYY (Restorative), 3/26/17 at 1:13 p.m. with CNA XXX, 3/26/17 at 1:47 p.m. with CNA WWW, 3/26/17 at 1:53 p.m. with CNA VVV, Interview on 3/27/17 at 6:47 a.m., with CNA UUU, On 3/27/17 at 7:00 a.m., with CNA TTT, On 3/27/17 at 7:10 a.m., with CNA SSS, On 3/27/17 at 7:15 a.m., with CNA RRR, On 3/27/17 at 7:20 a.m. with CNA QQQ, On 3/28/17 at 9:30 a.m. with CNA PPP, On 3/28/17 at 9:41 a.m. with CNA PP On 3/28/17 at 10:04 a.m., with CNA OOO, On 3/28/17 at 10:35 a.m., with CNA NNN, On 3/28/17 at 10:45 a.m., with CNA MMM, On 3/28/17 at 10:55 a.m., with CNA SS, Central Supply, CNA scheduler, On 3/28/17 at 11:03 a.m. with CNA LLL, 3:00 p.m. to 11 p.m. shift 3/26/17 at 3:24 p.m., with CNA KKK, 3/26/17 at 4:20 p.m. with CNA JJJ, On 3/26/17 at 4:53 p.m. LPN JJ, 7pm - 7AM On 3/27/17 at 6:55 a.m. (11p.m. - 7 a.m.) LPN III, 3/27/17 at 6:57 a.m., with LPN HHH, 3/27/17 at 7:03 a.m., with LPN GGG, 3/28/17 at 9:25 a.m. with RN EE (Infection control, Restorative nurse), 3/28/17 at 10:52 a.m. with LPN FFF, 3/26/17 at 12:52 p.m., with Maintenance Director EEE, 3/28/17 at 3:15 p.m., with Housekeeping DDD Interviews with the following residents revealed: Interview 3/26/17 at 1:27 p.m. with R#1, the Resident Council President, on 3/26/17 at 12:45 p.m., with R#77, on 3/28/17 at 10:50 a.m., with R87, on 3/28/17 at 11:00 a.m,, with R#88, on 3/28/17 at 11:13 a.m., R#73, on 3/28/17 at 11:20 a.m., with R#120, on 3/28/17 at 11:28 a.m., with R#66 revealed that the Area Vice President (AVP), that is currently the Interim Administrator, called a Resident Council meeting Friday night (3/24/17) and spoke with the Resident Council members and staff regarding abuse. That the residents were instructed to tell the staff CNA, Charge Nurse, any staff, and the Administrator and tell them if they have any problems. Residents were educated that they can call the Ombudsman and how to call the Ombudsman. Residents able to verbalize who they would report abuse to, who was the Abuse Coordinator, and how to report abuse themselves. Residents revealed that the AVP and Interim DHS have encouraged them to report abuse to them. Residents revealed that they (AVP and Interim DHS) want us to tell them if we have any concerns. R#1 revealed that the Ombudsman comes to facility pretty frequently and that the facility announces the resident rights over the loud speaker every morning. Information sheets were given to cognitive residents and included the phone number to the Ombudsman, HFRD, and the facility's corporate office. Review of Abuse Policy's revealed: revealed all seven components addressed. Review of the facility self reports and investigations revealed allegations were reviewed by the AVP, were investigated by the AVP, Interim DHS and were reported by the AVP. Interventions of QAPI for abuse are documented to be: All allegations of abuse will be reported to the Administrator or DHS immediately. The Administrator or DHS will report the allegation to the state agency within a 2 hour time frame. The Ombudsman will be notified. Law enforcement will be notified if deemed appropriate. A complete investigation will be completed. Staff will be in-serviced related to the abuse allegations. Review of notice regarding QAPI meeting on 3/26/17 revealed the following: On 3/26/17 the AVP educated all department heads on QAPI process, policy and procedures, their roles and responsibilities, current action plans, and how write Performance Improvement plans. AVP discussed QAPI review with Medical Director on 3/26/17. Medical Director signature observed to be on 5th page as reviewed and dated 3/26/17.

Based on record review and staff interview the facility failed to ensure that the care plan was followed to check proper positioning of the indwelling urinary catheter tubing for one (1) resident (R) (R#239) of four (4) residents with urinary catheters. This failure resulted in harm for R#239 who was hospitalized for [REDACTED].) coli Urinary Tract Infection [MEDICAL CONDITIONS] (MRSA) bacteremia . The sample was forty-four (44) residents. Findings include: 1. Review of the Comprehensive Care Plan for R#239 dated 9/21/16 revealed that the resident had a Foley catheter related to [MEDICAL CONDITION] due to Benign Prostate Hypertrophy ([MEDICAL CONDITION]) with a goal that he would have no complications related to the catheter in three (3) months. Interventions included nursing staff to check the catheter every shift for patency and proper position of the tubing and bag. Continued review of the Comprehensive Care Plan revealed that the resident was at risk for skin breakdown related to bowel incontinence, limited mobility and use of a Foley catheter with an intervention for nursing staff to perform skin assessments per facility protocol and as needed (PRN). Review of the medical record revealed that there was no indication that nursing staff checked the proper positioning of the Foley catheter tubing from the resident's admission on 8/25/16 to his discharge to the hospital on [DATE] with [DIAGNOSES REDACTED].) coli Urinary Tract Infection [MEDICAL CONDITIONS] bacteremia and placement of a suprapubic urinary catheter. Interview with the Regional Nurse Consultant/Interim Director of Health Services (DHS) on 3/27/17 at 11:30 a.m. revealed that she expected licensed nursing staff to monitor a resident's intake and output (I/O) if ordered, to monitor the color/clarity of the urine and to monitor for any complications such as breakdown. Continued interview revealed that she expected licensed nursing staff to document any abnormalities that they identified, with the resident, in the Nurses Notes. She stated that she expected the Certified Nursing Assistants (CNA'S) to provide catheter care daily and to notify the nurse of any breakdown related to the catheter. Cross refer to F315

Based on record review, review of the Wound, Ostomy and Continence Nurses Society ' s Care and Management of Patients With Urinary Catheters: A Clinical Resource Guide and staff interviews, the facility failed to ensure that nursing staff monitored one (1) resident (R) (R#239) with an indwelling urinary catheter for possible complications related to the use of the catheter of four (4) residents reviewed for indwelling/suprapubic catheters . This failure resulted in harm for R#239 who was hospitalized for [REDACTED].) coli Urinary Tract Infection [MEDICAL CONDITIONS] bacteremia (bacterial infection, in the blood, that is resistant to many of the antibiotics used to treat ordinary staph infections) and R#239 had to get a suprapubic urinary catheter placed (a cut in the abdominal wall that allows a hollow tubing to be inserted into the bladder to drain urine). The sample size was 44 residents Findings include: Review of the Wound, Ostomy and Continence Nurses Society ' s Care and Management of Patients With Urinary Catheters: A Clinical Resource Guide (2016) (pages 29-30) revealed that irritation or skin breakdown may occur in the periurethral/perineal area and/or in areas where the catheter and drainage tubing are placed or secured. Causes and contributive factors to breakdown include positioning of the drainage tubing or catheter straps on the skin. Prevention of breakdown includes securing the catheter and drainage tubing in areas that will not cause pressure or tension when changing position. Continued review revealed that documentation of catheter care can be completed using a checklist or hand written progress notes. Complete, accurate, and timely documentation is essential to evaluate the clinical effectiveness of nursing interventions. Routine documentation should include the type/location of anchoring device and the presence/absence of problems. Review of the medical record for R#239 (a closed record) revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was alert and oriented; required the assistance of two staff for bed mobility and transfer; had an indwelling urinary catheter; was frequently incontinent of bowel; had an admission weight of 247 pounds; and had no skin breakdown on admission. Review of the resident's Admission Interim Care Plan dated 8/26/16 revealed that the resident had a urinary catheter related to [MEDICAL CONDITION] with a goal that the resident would not develop any complications associated with catheter usage within the next thirty (30) days. Interventions included nursing staff to provide catheter care per policy, keep catheter tubing free of kinks, keep drainage bag below level of the bladder and prevent tension on the urinary meatus from the catheter. Review of the Comprehensive Care Plan dated 9/21/16 revealed that the resident had a Foley catheter related to [MEDICAL CONDITION] due to Benign Prostate Hypertrophy ([MEDICAL CONDITION]) with a goal that he would have no complications related to the catheter in three (3) months. Interventions included nursing staff to check the catheter every shift for patency and proper position of the tubing and bag. Continued review of the Comprehensive Care Plan revealed that the resident was at risk for skin breakdown related to bowel incontinence, limited mobility, and use of a Foley catheter with an intervention for nursing staff to perform skin assessments per facility protocol and as needed (PRN). Review of the medical record for R#239 revealed that the resident was admitted to the facility on [DATE] for skilled therapy after hospitalization for cervical spinal surgery. Continued review revealed that the resident had [MEDICAL CONDITION] while hospitalized and was admitted to the facility with a Foley catheter. The resident had a physician's orders [REDACTED].) for [MEDICAL CONDITION] and for staff to provide catheter care nightly and PRN and to change the catheter PRN for leakage/occlusions/sediment. Review of the Admission/Nursing Observation Form dated 8/25/16 revealed that the resident had a Foley catheter and no skin breakdown. Review of the Braden Scale For Predicting Pressure Sore Risk dated 8/25/16 revealed that the resident scored 14 indicating that he was at moderate risk for pressure sore development. Review of the Skilled Daily Nurses Notes dated 9/1/16 on the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift revealed that staff failed to document that the resident had a catheter and failed to document the color and consistency of the resident's urine. Review of the SBAR Communication Form dated 9/2/16 at 6:20 p.m. revealed that the resident's urine was very concentrated and a dark yellowish-orange in color and he complained of feeling bad. Continued review revealed he verbalized his pain as a 7 on a scale of 1 to 10 and that he was grimacing. His vital signs were within normal limits. Review of the Skin Evaluation section of the form revealed that the resident did not have any skin tears, ulcers or wounds. Continued review revealed that the resident's family wanted staff to send him to the hospital. The physician was notified and the resident was sent to the emergency room (ER) on 9/2/16 at 7:30 p.m. Review of the Hospital Discharge Summary dated 9/7/16 revealed that the resident's Foley catheter had been changed during his admission to the hospital 9/2/16 to 9/7/16 but did not specify the actual date. Continued review revealed final diagnoses, for the resident being admitted to the hospital on [DATE], was Escherichia (E) coli Urinary Tract Infection [MEDICAL CONDITIONS] and acute kidney injury. There was no indication in the Hospital History and Physical dated 9/2/16 or the Hospital Discharge Summary dated 9/7/16 that the resident had any skin breakdown related to the catheter. Review of the Admission/Nursing Observation Form dated 9/7/16 revealed that the resident was readmitted to the facility without any skin breakdown. The resident was readmitted with a physician's orders [REDACTED]. Review of the medical record revealed that the resident had a follow-up appointment with the Urologist on 9/15/16. Review of the Urologist Progress Note dated 9/15/16 revealed that the resident was in a wheelchair and was unable to transfer. Continued review revealed that the Urologist was unable to place the resident on a stretcher in order to change his Foley catheter at that time. Continued review revealed that a physical examination of the resident's genitals was deferred so there was no documentation that the resident had breakdown. Further review revealed that the Urologist ordered facility nursing staff to change the resident's Foley catheter in two weeks (9/29/16) and then change every four weeks afterwards. Although the resident had a care plan intervention for staff to check the catheter every shift for proper position of the tubing, there was no indication in his medical record that staff had checked the position of the catheter tubing to ensure that it was positioned properly to prevent skin breakdown and erosion of the resident's penis. Continued review of the Skilled Daily Nurses Notes revealed that licensed nursing staff did not assess the resident's urine on 9/10/16, 9/13/16, 9/20/16, and 9/28/16. Review of the Skilled Daily Nurses Note dated 9/28/16 at 1:20 a.m. revealed that the resident had confusion and was yelling at times. However, there was no indication that licensed nursing staff assessed the resident's Foley catheter or the color and consistency of his urine on 9/28/16 on the 7:00 a.m. to 7:00 p.m. shift or the 7:00 p.m. to 7:00 a.m. shift. Review of the SBAR dated 9/29/16 revealed that the Licensed Practical Nurse (LPN) was to change the resident's Foley catheter as ordered by the Urologist and noted an open area on the underside of his penis. Continued review revealed that LPN WW inserted a new Foley catheter, notified the Unit Manager who notified the physician of the open area at 4:30 p.m. The physician ordered staff to send the resident to the emergency room (ER). Continued review of the SBAR revealed that the resident had increased confusion, appeared to have discomfort, verbalized the intensity of his pain as a 7 on a scale of 1 to 10 and had dark urine. Further review revealed that the LPN had administered pain medication to the resident at 2:30 p.m. for complaints of pain to his back and to the Foley insertion site. Review of the Hospital Discharge Summary dated 10/6/16 revealed that the resident presented with pelvic discomfort and was found to have traumatic [DIAGNOSES REDACTED] secondary to mucosal erosion from the Foley catheter, scrotal [MEDICAL CONDITION], E. coli UTI, [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) bacteremia and placement of suprapubic urinary catheter. The resident did not return to the facility after discharge from the hospital. Although the resident had a care plan intervention for nursing staff to perform skin assessments per facility policy and as needed (PRN) there was no indication that the Treatment Nurse had identified any slits or open areas on the resident's penis on the Admission Nursing Observation Form dated 8/25/16 and on his readmission from the hospital on [DATE]. Review of the Body Audits performed by Licensed Nursing Staff on 8/25/16, 8/30/16, 9/7/16, 9/13/16, 9/21/16 and 9/27/16 revealed no indication that staff had identified any breakdown related to the resident's Foley catheter at those times. Review of the Medication Administration Records (MARS) revealed that the resident received [MEDICATION NAME] twice in 8/2016 for throat pain, one time in 9/2016 for generalized pain and one time in 9/2016 for tooth pain. There was no indication that the resident requested or received pain medication for genital or groin pain. Interview with the previous Director of Health Services (DHS) on 3/23/17 at 12:25 p.m. revealed that the resident had a penile abscess that had burst during his hospitalization prior to his admission to the facility. Continued interview revealed that he was admitted with two slits on the head of his penis related to the abscess. The DHS was unable to provide Hospital documentation regarding the abscess or any facility documentation that the resident was admitted with the slits. Interview with LPN VV on 3/23/17 at 1:45 p.m. revealed that she had performed a skin assessment for the resident on 9/27/16 on the 7:00 p.m. to 7:00 a.m. shift, two days prior to his hospitalization for traumatic [DIAGNOSES REDACTED] and had not seen any open areas or slits on his penis. Continued interview with LPN VV revealed that she would have lifted up the resident's penis and scrotum to assess for any breakdown on his genitals. Further interview revealed that she would have ensured the catheter tubing was secured to his leg to prevent tension. Interview with the previous DHS on 3/23/17 at 4:50 p.m. revealed that the resident was obese and would frequently push his genitals between his thighs possibly causing pressure on his genitals instead of allowing his genitals to rest on top of his thighs as encouraged by staff. However, the DHS was unable to provide any documentation of the resident's behavior. There was no indication that staff had developed a plan of care to address the resident's behaviors. During a telephone interview on 3/23/17 at 4:56 p.m. with LPN WW who was the nurse who assessed R#239 with an open area on his penis on 9/29/16, revealed that the resident was admitted to the facility with two slits on his penis. However, LPN WW was unable to provide documentation that the resident had slits on his penis on admission to the facility or at any time prior to 9/29/16 when she assessed him with an open area. Continued interview revealed that when she had removed the old Foley catheter to replace it with a new one on 9/29/16, the slits had worsened and were larger. She stated that the open area was noted prior to the insertion of the new Foley catheter. Continued interview revealed that there was no bleeding, swelling or redness from the open area. Further interview revealed that she did not remember if the resident complained of pain at the insertion site but, that she would have assessed the catheter to see if the tubing was secured to his leg and not pulling on his penis. Interview with LPN WW on 3/26/17 at 11:50 a.m. revealed that when she lifted up the resident's penis to change his Foley catheter on 9/29/16, that the catheter tubing was coming out of the bottom of his penis about mid-shaft. Continued interview revealed that the resident complained of pain during his stay at the facility related to his surgical site but, she did not remember that he complained of groin pain or pain at the insertion site until 9/29/16. Interview with Registered Nurse (RN) Nurse Manager (RN XX) on 3/26/17 at 12:25 p.m. revealed that LPN WW had notified her on 9/29/16 of the open area on the resident's penis. Continued interview revealed that she found that the physician had not been notified of any open area prior to LPN WW identifying the area on 9/29/16. Continued interview revealed that she notified the physician who ordered staff to send the resident to the hospital. Continued interview revealed that she did not assess the open area on the resident's penis at that time. Further interview revealed that she interviewed the CNAs who cared for the resident and CNA AAA told her that he was aware of an open area on the resident's penis prior to 9/29/16 but did not know when he first noticed the area. She stated that she did not know if he had notified the nurse. Further interview revealed that she had spoken with the treatment nurses who told her that they had not been notified about the open area. Interview with CNA YY on 3/26/17 at 12:35 p.m. revealed that she was aware of a slit under the resident's penis that was about ½ inch long but could not remember the date that she noticed it. She stated that she notified the nurse who no longer works at the facility. Continued interview revealed that when the resident was readmitted from the hospital (on 9/7/16) the slit was longer and extended about 1/3 the length of the resident's penis. Continued interview revealed that she notified the nurse at that time but, she could not remember who. Continued interview revealed that she provided catheter care for the resident every day during the provision of bowel incontinence care and the resident did not complain of genital pain at those times. Further interview revealed that she did not document her assessment of the slit and its deterioration or the supervisory nursing staff she notified. Interviews with LPN/Treatment Nurse ZZ and RN/Treatment Nurse OO on 3/26/17 at 12:55 p.m. revealed that they had not been notified of slits or open areas on the resident's penis. Continued interview revealed that if staff had notified them they would have notified the physician for treatment orders, treated the area and documented their treatments and assessment of the wound. LPN/Treatment Nurse ZZ stated at that time that she performed a head to toe skin assessment on the resident when he was readmitted from the hospital on [DATE] and that the resident did not have any slits/open areas on his penis at that time. Further interview with LPN/Treatment Nurse ZZ revealed that the resident did not complain of pain at that time but, expressed discomfort at having to spread his legs apart during the assessment because he was so obese. During a telephone interview with CNA AAA on 3/26/17 at 1:23 p.m., he stated that he provided catheter care for the resident but was not aware of any slits or open areas on the resident's penis. Continued interview revealed that the resident's family notified him one afternoon that they had pulled on the resident's catheter while repositioning the resident in the bed. Continued interview revealed that the resident's catheter was intact and the tubing secured with a leg strap. Continued interview revealed that the resident complained of pain in his private area at that time and he notified the nurse. However, he was unable to say who he notified. Further interview with CNA AAA revealed that he provided catheter care for the resident after this incident and the resident did not have any slits or open areas. Interview with the resident's attending physician on 3/26/17 at 5:15 p.m. revealed that he was not aware of any abscess on the resident's penis that had ruptured prior to his admission to the facility on [DATE]. He stated that if the resident had a ruptured abscess, he would have been notified by hospital staff and would have monitored the abscess during his stay at the facility. Continued interview revealed that he was not aware of any slits or open areas on the resident's penis until 9/29/16 when he ordered the resident sent to the hospital. Continued interview revealed that he expected nursing staff to notify him promptly of any slits or open areas or other breakdown so that he could assess the area and possibly order an antibiotic to prevent infection. He stated that he expected staff to notify him if the area had deteriorated. Continued interview revealed that he expected nursing staff to monitor a resident's indwelling urinary catheter for any complications, monitor the resident's genitals for breakdown and thoroughly document their assessments in the Nurse Notes every shift. Further interview revealed that he had expressed concerns to the previous DHS and Administrator about some nursing staff's failure to notify him that laboratory tests had not been done as ordered and the lack of thorough documentation by nursing staff. During a telephone interview with the family of R#239 on 3/27/17 at 10:44 a.m., she stated that staff had not notified the family of any abscess or slits in the resident's penis during his stay at the facility. Further interview revealed that the family were not aware of the [DIAGNOSES REDACTED] until 9/29/16 when the emergency room physician notified them. Although interviews with several nursing staff revealed that R#239 was admitted with several slits at the head of his penis, there was no indication in his medical record that the slits were assessed, that the physician was notified of the slits for possible treatment to prevent infection and that the slits were monitored for deterioration. Although nursing staff documented that daily catheter care was provided for R#239, there was no indication that nursing staff monitored the resident's catheter insertion site for breakdown and for the consistent proper positioning of the catheter tubing. There was no indication that nursing staff monitored the resident for possible complications related to the use of the Foley catheter until 9/29/16 when LPN WW identified an open area on the resident's penis and the resident was admitted to the hospital with [REDACTED]. During the Quality Assurance process, additional interviews and record reviews were conducted as follows: A post telephone interview was conducted with the attending physician on 4/3/17 at 12:20 p.m. The physician stated that although he is not an expert in the field of penile [DIAGNOSES REDACTED], this is a condition most commonly present from childhood and a younger population. The attending physician stated that he could not say based on the [DIAGNOSES REDACTED]. The physician stated that this [DIAGNOSES REDACTED]. Typically this develops over several months as opposed to several weeks. Chronic catheter use causes small micro trauma. Repeated trauma turns to fibrosis then to [DIAGNOSES REDACTED]. A post telephone interview with CNA RRR on 4/3/17 at 12:51 p.m. revealed he had cared for Resident #239 on a regular basis. CNA RRR stated that the resident wore a brief and he had never seen any discharge or blood in the residents brief. CNA RRR further stated that he performed catheter care for R#239 and never noticed any discharge or bleeding from his penis. A post telephone interview with CNA PP on 4/3/17 at 1:04 p.m. revealed that she had care for R#239 on several occasion. CNA PP stated that she had never seen a discharge or blood in the resident's brief and had never seen a discharge or blood form the resident's penis when she conducted catheter care. The resident had a catheter during the hospital stay prior to admission to the facility. Hospital records showed that he had a catheter inserted 8/15/16 which was removed on 8/22/16 and reinserted 8/24/16 due to [MEDICAL CONDITION]. During the hospital stay, it was noted on the GU consultation report dated 8/15/16 that R#239 complained of pain with the catheter the entire time he had a catheter. The resident was cognitively intact with a BIMS of 15 and never complained of any trauma or pain to his penis while in the nursing facility. Further review revealed that the resident was returned to the hospital on [DATE] with a UTI and the catheter was changed during that hospital stay of 9/2/16 - 9/7/16.