Every finding on record at Ridgewood Terrace Health and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 sampled residents, (Resident (R)79). The findings include: Review of a facility policy titled Enhanced Barrier Precautions (EBP), undated, revealed EBP were used in conjunction with standard precautions. Per review, EBP expanded the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDRO) to staffs' hands and clothing. Further review of the policy revealed EBP precautions were indicated for residents with wounds and/or indwelling medical devices such as urinary catheters, even if the resident was not known to be infected or colonized with a MDRO. Observation of the facility's 600-hall on 05/20/2025 at 10:00 AM, revealed two enhanced barrier carts located in hallway against the walls in between every other door on one side of the hallway, resident rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS]. Continued observation revealed enhanced barrier and contact precaution signs lying on top of the carts. In interview with Hydration Aide 1 on 05/20/2025 at 10:02 AM, she stated the (EBP) carts in the hallway stored the PPE supplies for the aides and nurses. She reported the yellow stickers on the name plates outside of the residents' rooms meant the resident was either on contact precautions or EBP. The Hydration Aide further stated she was not sure how to differentiate whether a resident was on contact precautions or EBP. In interview with CNA 1 on 05/20/2025 at 10:29 AM, she stated there were usually signs on the residents' doors indicating if the resident was on EBP, contact precautions or not. She stated she did not know if there were any residents currently on the 600-hall who were on contact precautions or EBP. In interview with Licensed Practical Nurse (LPN) 1 on 05/20/2025 at 10:52 AM, she stated residents had yellow dots by their names outside of their doors if they were on EBP. She said only certain wounds were placed on EBP. LPN 1 reported for residents on contact precautions, they had pouches with supplies hanging outside the residents' doors. She further stated she did not know if there was anyone on contact precautions or EBP. 1. Review of the facesheet for R79 revealed the facility admitted the resident on 03/06/2025, with diagnoses that included chronic obstructive pulmonary disease, emphysema, acute respiratory failure with hypoxia, and urinary tract infection. Review of Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/01/2025, revealed the facility assessed R79 to have a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident had moderate cognitive impairment. Review of R79's physician orders revealed the resident was to be on EBP related to an indwelling urinary catheter. Observation of the 600-hall on 05/22/2025 at 11:00 AM, revealed a yellow dot beside R79's name outside the room door, with PPE in an EBP cart located between rooms [ROOM NUMBERS]. Continued observation revealed Certified Nurse Aide (CNA) 7 and CNA 4 providing direct care for R79 in the resident's room (603-A), at bedside without wearing the necessary personal protective equipment (PPE) required for the resident's enhanced barrier precautions. In interview with CNA 4 on 05/21/2025 at 8:30 AM, she stated the yellow stickers beside residents' names meant the resident was on EBP. She reported if the resident was on contact precautions there would be a bag with supplies and a sign that said see the nurse hanging outside of the resident's door. In additional interview with CNA 4 on 05/22/2025 at 11:05 AM, she stated she typically wore a gown and other PPE when required and she should have done so this time, but, she stated I honestly forgot. She said R79 was on EBP possibly because he had a catheter. CNA 4 reported residents were usually on EBP because they had a catheter and/or wounds. She stated she had received training on how to wear PPE and on infection control through monthly meetings and if there was anything that needed to be addressed. The CNA further stated a negative outcome of not following proper EBP was the spread of a harmful infection. In interview with CNA 7 on 05/22/2025 at 11:10 AM, she stated she knew the yellow dot on the outside of the residents' doors by their name indicated the resident was on EBP. She said she normally worked on the 400-hall and stated she was not very familiar with R79 and did not pay attention to whether he was on EBP or not. CNA 7 reported she had received training on proper PPE use and how to put on PPE; however, did not know how often she had received those trainings. She stated it was important to follow the facility's policy related to EBP and contact precautions to protect the resident from their germs and the germs of other residents. The CNA further stated negative outcomes of not following the facility's infection control and EBP policies could be swapping infections between residents. In interview with the Infection Preventionist (IP) on 05/22/2025 at 9:00 AM, she stated she and the unit managers (UMs) did audits of staff for surveillance of appropriate handwashing and appropriate use of PPE once per week and more often than that if there were more residents on precautions. She reported for residents with chronic wounds that required a dressing, those residents should be on EBP. The IP said EBP was indicated by a yellow dot by the resident's name outside of their door. She additionally stated contact precautions were indicated by the supply bag hanging right outside of the resident's door and a sign placed on the door. In interview with the Director of Nursing (DON) on 05/23/2025 at 1:01 PM, she stated her expectation of her staff regarding the use of EBP was to use it appropriately and follow the facility's policy. She reported examples of high contact care were changing linens, bathing residents, changing their briefs, and performing their catheter care. The DON said using EBP properly was important to prevent the spread of disease. She stated everyone that worked in the facility received infection control training upon hire and yearly thereafter. The DON further stated the training included return demonstration of donning and doffing PPE and the difference between the different types of transmission-based precautions. In interview with the facility's Administrator on 05/23/2025 at 1:33 PM, she stated she expected staff to wear appropriate PPE according to the facility's EBP policy. She stated a negative outcome of her staff not using appropriate PPE per the EBP policy was the spread of infection from staff to residents and staff possibly taking infections home with them.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to implement a resident specific Plan of Care for each resident that meets the resident's nursing, and mental and psychosocial needs for one (1) of three (3) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] with diagnoses to include: Paraplegia, Thoracic Vertebrae (T2-T6) injury of Thoracic Spinal Cord, Multiple fractures of Ribs bilateral and Type 2 Diabetes. Resident #1's Self-Care Deficit Plan of Care, dated [DATE], revealed an intervention for two (2) staff to assist with a bath. Further, the resident's at Risk for Cardiac Dysfunction Plan of Care, dated [DATE], revealed interventions for staff to observe for signs and symptoms of respiratory distress on every shift; and contact the charge nurse when changes in the resident's condition was observed and notify the physician. On [DATE], at approximately 9:00 AM, Certified Nursing Assistant (CNA) #6, gave Resident #1 a bed bath by herself as she was unaware the resident was care planned for two (2) assist with baths. The resident becameshort of breath following the bath from rolling around. Shortly afterwards, CNA #6 answered Resident #1's call light and the resident stated he/she had passed out and requested to see the nurse. At 10:20 AM, Licensed Practical Nurse (LPN) #1 documented in Resident #1's Nurse's Progress Note, the resident had obvious respiratory distress. However, review of the clinical record revealed there was no documented evidence LPN #1 conducted a thorough respiratory assessment, or monitored the resident for respiratory distress, as per the Plan of Care. Further, although the Nurse's Note documented at 10:20 AM, revealed the resident was in respiratory distress and the on call Doctor and Emergency Medical Services (EMS) were notified of the resident's transfer to the Hospital emergency room (ER), interview with LPN #1 revealed the physician was not immediately contacted related to the resident's condition as per the Plan of Care. LPN #1 stated she called the on call physician, and EMS at approximately 11:26 AM, about sixty-six (66) minutes after the resident reported he/she wanted to be transported to the hospital. The EMS record revealed EMS was notified of the need to transport the resident at 11:26 AM. EMS arrived at the facility at 11:32 AM, and observed the resident to be alone, unresponsive, with cyanosis to his/her lips and gray in color. EMS initiated Cardiopulmonary Resuscitation (CPR) and the resident was transferred to the hospital where he/she expired. The facility's failure to ensure the Plan of Care was implemented to provide effective and person-centered care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE], at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F695. The facility was notified of Immediate Jeopardy on [DATE]. An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy, on [DATE]. The Immediate Jeopardy was verified by the State Survey Agency to be removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F695 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F695) The findings include: Review of the facility policy titled Comprehensive Care Plan, revised [DATE] and reviewed on [DATE], revealed the purpose of this form was to ensure each residents' daily care needs were provided by the nursing staff in accordance with the guidelines of the Resident Assessment Instrument (RAI) process and in keeping with the Medicare/Medicaid Service requirements. Residents receive care and treatment on an assessment of their needs, the severity of their diagnosis or disease, condition, and impairment of disability. The data obtained from the assessment was used to determine and prioritize the resident's Comprehensive Plan of Care. The development, implementation and maintenance of a resident's care plan as initiated by the admitting licensed nurse, was an interdisciplinary process. Closed medical record review revealed the facility admitted Resident #1 on [DATE] with diagnoses to include: Paraplegia, Thoracic Vertebrae (T2-T6) injury of Thoracic Spinal Cord, Multiple fractures of Ribs bilateral and Type 2 Diabetes. There was no Admission Minimum Data Set (MDS) Assessment completed due to the resident being newly admitted to the facility. Review of the Nurse Admission/Re-Admission Note, dated [DATE] at 12:54 PM, revealed the resident was alert and oriented and capable of making his/her own decisions. Resident #1's At Risk for Cardiac Dysfunction Plan of Care, dated [DATE], revealed a goal to be free of signs and symptoms of cardiac dysfunction through next review. Interventions included: staff to observe for signs and symptoms of respiratory distress on every shift; and contact the charge nurse when changes in the resident's condition was observed and notify the physician. Continued review of the Plan of Care, dated [DATE], revealed Resident #1 had Self-Care Deficit related to Thoracic Spine Fracture, and Spinal Cord Injury T4 with Paraplegia. The goals included: would continue to assist with Activities of Daily Living (ADLs) daily through next review; and would have all needs met daily through next review as evidenced by the resident being clean dry and odor free with a neat appearance. The interventions included the assistance of two (2) staff with bathing, bed mobility, and dressing and assist of two (2) staff and gait belt for transfers. Post Survey phone interview on [DATE] at 3:59 PM, with the Administrator, revealed the CNA Care plan (Kardex) had been canceled/deactivated and was not available for review. Review of Resident #1's Nurse's Progress Note, dated [DATE] at 10:20 AM, written by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was in obvious respiratory distress. Vital signs were documented as Blood Pressure ,d+[DATE] (normal B/P for adults less than ,d+[DATE]), heart rate 84 (normal heart rate in adults (,d+[DATE] beats per minute). Further review revealed blood sugar was documented at 92 (normal blood glucose range in adults ,d+[DATE] milligrams per deciliter) and oxygen saturation was documented at ninety-eight percent (98%) (normal oxygen saturation in adults ,d+[DATE] percent) on room air. Continued review of the Note, revealed EMS, Power of Attorney (POA), Doctor on call and Administrator were notified of the resident's transfer to the hospital emergency room (ER). Additional review of Resident #1's medical record, revealed there was no documented evidence LPN #1 conducted a thorough respiratory assessment to include respiratory rate, effort and pattern; skin color to check for cyanosis (bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) or auscultation of the lungs in order to observe for respiratory distress as per the Plan of Care. Additionally, there was no documented evidence the nurse monitored Resident #1 after the initial assessment. Further, the nurse failed to contact the physician for a change in condition as per the Plan of Care after the resident was identified to be in respiratory distress. Moreover, LPN #1 did not immediately contact EMS. Review of the Emergency Medical Services (EMS) record, revealed LPN #1 called at 11:26 AM to transport Resident #1 to the hospital. Per the EMS record, EMS arrived at the facility at 11:32 AM and the resident was observed in his/her room alone, unresponsive, with cyanosis to his/her lips and was observed to be gray in color. EMS initiated Cardiopulmonary Resuscitation (CPR) and Resident #1 was transferred to the hospital where he/she expired. Interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 2:05 PM, revealed on [DATE] at approximately 9:00 AM she had given Resident #1 a bed bath by herself. She stated Resident #1 became short of breath following the bath from rolling around. Per interview, she was unaware the resident was care planned for two (2) assist. She further stated, shortly after the bath, she answered Resident #1's call light. CNA #6 stated the resident told her he/she had passed out and requested to see the nurse. Per interview, she reported this right away to LPN #1 who immediately went to Resident #1's room to check his/her oxygen level and vital signs. CNA #6 stated LPN #1 then exited the resident's room and stated she was sending Resident #1 to the hospital. Further interview revealed CNA #6 did not return to Resident #1's room and she was not asked by LPN #1 to check on the resident. Further, she witnessed LPN #1 checking other residents' blood sugars at the nurse's station after assessing Resident #1. Interview with LPN #1, on [DATE] at 11:07 AM, [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed on [DATE] at approximately 10:20 AM, Certified Nursing Assistant (CNA) #6 reported Resident #1 had requested to see her and was complaining of difficulty breathing. Per interview, LPN #1 immediately checked Resident #1's oxygen level and it was 98% on room air and his/her vital signs and blood sugar were within normal limits. Further interview revealed the resident was short of breath, was in respiratory distress and was sweating a little; however, she admitted she did not check the resident's respiratory rate, effort or pattern nor did she auscultate his/her lungs. She stated she did not administer oxygen (02) as the resident's oxygen saturation was 98%, and she checked the resident's fingers and toes and he/she was not cyanotic. Further interview with LPN #1, on [DATE] at 11:07 AM, on [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed she decided to send Resident #1 to the emergency room (ER) because of respiratory distress and further stated, It looked like respiratory distress, but it was more anxiety. Per interview, she calmed Resident #1 and stayed in the room with him/her for a period of time in order to convince him/her to go to the hospital and also repositioned the resident and he/she seemed calmer when she left the room. Additional interview with LPN #1, on [DATE] at 11:07 AM, [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed she did not immediately contact the physician to notify him of the Resident #1's change in condition. She stated she called the on call physician, the resident's significant other and EMS all at approximately 11:26 AM, about sixty-six (66) minutes after the resident reported he/she wanted to be transported to the hospital. Per interview, she did not stay with Resident #1 while waiting for EMS to arrive nor did she re-assess the resident. Additional interview revealed she was not familiar with Resident #1 as it was her first day caring for him/her. She stated she did not have time to look at the resident's medical record/chart or his/her Plan of Care. LPN #1 stated she was unaware Resident #1 was paralyzed from the chest down or that he/she had bilateral rib fractures. Interview with Minimum Data Set (MDS) Nurse #2, on [DATE] at 9:48 AM, revealed the Interdisciplinary team (IDT) would know if residents required assessment and increased monitoring or had special needs before admission and also the hospital records should indicate if there were precautions that needed to be followed. Per interview, the Plan of Care should be person centered related to diagnoses and problems and care plan interventions should be implemented. Interview with the Director of Nursing (DON), on [DATE] at 09:48 AM, revealed she initiated Resident #1's Plan of Care. She stated CNA #6 should have ensured she followed the Plan of Care related to ensuring there were two (2) staff to assist the resident with bathing. Further, the Plan of Care should have been followed related to assessing and monitoring for respiratory distress. Per interview, LPN #1 should have completed a thorough respiratory assessment to include respiratory rate and effort, oxygen saturation (O2 Sat), use of ancillary muscles, nasal flaring, and listening to lungs. Continued interview revealed LPN #1 should have followed the Plan of Care related to contacting the physician immediately when the resident had a change in condition. She stated it was her expectation that the Plan of Care be implemented at all times. Interview with the Administrator, on [DATE] at 3:18 PM, revealed she expected the Plan of Care to address necessary care concerns for the resident. She further stated she expected the Plan of Care to be implemented. **The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]: 1. Resident #1 is no longer a resident of the facility as of [DATE]. The facility terminated Licensed Practical Nurse (LPN) #1's employment as of [DATE]. Certified Nursing Assistant (CNA) #6 was suspended on [DATE] pending further education related to failure to follow Resident #1's plan of care. 2. The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Quality Assurance Nurse and Resident Care Coordinator, completed a root cause analysis on [DATE] to identify causation of LPN #1's failure to provide appropriate care to Resident #1 and CNA #6's failure to follow the resident's plan of care. Utilizing the root cause analysis, the facility identified immediate actions should be completed including implementation of policy, education, review of records and monitoring. All Licensed/Registered nurses were educated regarding the causation and identification of deficient practice on [DATE]. 3. The root cause analysis completed on [DATE], by the Quality Assurance Team, determined the need for a new respiratory policy to be developed and implemented. The Administrator, DON and Medical Director developed and implemented a new Respiratory Policy on [DATE], with emphasis on assessment response, timeliness of response and response care for a resident in respiratory distress. 4. The Administrator, DON, Assistant Director of Nursing/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding the results of the root cause analysis, audits and the need to review Comprehensive and CNA care plans. 5. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding the newly implemented Respiratory Policy, Code Blue Policy, Advance Directives/Code Status Policy, Comprehensive Care Plan Policy, and Cardiopulmonary Resuscitation and Basic Life Support Policy. In addition, the facility provided education to include assessment response, timeliness of response, response care for a resident in respiratory distress, change in condition, immediate notification of physician and procedures for resident in respiratory distress. Licensed nurses completed a post-test after the training and a physical observation was completed of Licensed/Registered nurses related to the delivery of respiratory care per the Comprehensive Care Plan. All Licensed/Registered nurses off work, including agency staff and new hires were not permitted to work until all of the education and post-testing had been completed. 6. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding Comprehensive Care Plan review, revisions and updates. 7. The root cause analysis completed on [DATE] by the Quality Assurance Team identified all residents with a respiratory diagnosis or respiratory need requiring a Comprehensive Care Plan review and/or update. The Administrator, DON, ADON/Quality Assurance Nurse, Minimum Data Set (MDS) Coordinator, Resident Care Coordinator, and Unit Manager, completed the review of the Comprehensive Care Plans on [DATE] and [DATE], to assure the appropriate respiratory care and services were care planned for each resident. 8. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor, and Weekend House Supervisor developed an audit process on [DATE] to observe the care the resident received and to ensure the care was per the individualized Care Plan. 9. The Administrator, DON, ADON/Quality Assurance Nurse, MDS Coordinator, Unit Manager, and Resident Care Coordinator, reviewed and/or updated the CNA Care Plan with the Comprehensive Care Plan on [DATE] and [DATE]. The Administrator, DON, ADON, Unit Manager, Resident Care Coordinator, and MDS Coordinator, completed a one hundred percent (100%) audit to ensure that each resident CNA Care Plan (Kardex) and Comprehensive care plan was consistent with care. 10. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses and all State Registered Nursing Assistants (including agency staff) on [DATE] to [DATE] regarding the review and/or update of the CNA Care Plan (Kardex). The education also included providing care and following the Kardex consistent with the Comprehensive Care Plan for each resident. Post-testing was given after the education and there was also physical observation of the CNAs providing care per the CNA Care Plan (Kardex). All CNA's that were off work, including agency staff and new hires were not permitted to work until all the education and post- testing had been completed on providing care and following the CNA Care Plan (Kardex). 11. Results of all CNA Care Plan audits and the related Comprehensive Care Plans are reviewed each day by the Quality Assurance Committee and the Interdisciplinary Team. Members of the Quality Assurance Committee and Interdisciplinary Team include the Medical Director, Administrator, DON, ADON/Quality Assurance Nurse, MDS Nurse, Resident Care Coordinator, Weekend House Supervisor/Registered Nurse, Night Shift House Supervisor, Unit Nursing Manager/Registered Nurse, Medical Records Director and Social Services Director. The Quality Assurance Committee reviews and makes recommendations related to the information. 12. The Administrator and Director of Nursing developed an observation audit form on [DATE] to be completed by Licensed/Registered nurses that are assigned by the Director of Nursing. Ten percent (10%) of the resident population will be audited. The audits will be completed throughout each day (seven [7] days a week) and will cover the respiratory care plan that is consistent with the care the resident receives. Any identified issues are reported to the DON for immediate correction. The facility will continue the audits seven (7) days per week for a minimum of four (4) weeks. The Quality Assurance Committee and the Interdisciplinary Team will evaluate progress for potential decrease in audit number of days. 13. Results of all respiratory care audits and the related Comprehensive Care Plans are reviewed each day by the Quality Assurance Committee and the Interdisciplinary Team. The Quality Assurance Committee reviews and makes recommendations related to the information. 14. The Administrator and DON developed an observation audit form on [DATE] to be completed by Licensed/Registered nurses that are assigned by the Director of Nursing. Ten percent (10%) of the resident population will be audited seven (7) days each week to ensure the CNA care plan (Kardex) was consistent with the Comprehensive Care Plan. Any identified issues are reported to the DON for immediate correction. The facility will continue audits seven (7) days a week for a minimum four (4) weeks. The Quality Assurance Committee and the Interdisciplinary Team will evaluate progress for potential decrease in audit number of days. 15. The Social Services Director and Social Services staff interviewed all residents and/or their representatives to solicit any concerns regarding care and treatment of residents including respiratory services on [DATE]. **The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] as follows: 1. Review of Resident #1's medical record revealed the resident expired on [DATE]. Review of the employee record documentation revealed LPN #1's employment at the facility was terminated on [DATE]. Review of the employee record documentation for CNA #6 revealed the CNA was suspended on [DATE] for two (2) days. Further review revealed CNA #6 received education on [DATE] on the CNA Care Plan (Kardex), Advance Directive policy and a review of the recent deficient practice. Continued review of the record revealed CNA #6 received education on [DATE] on how to access the resident Kardex, and on the actual resident Kardex related to assistance and care needs. Further review revealed the education was provided by the Administrator and DON with return demonstration of how to access CNA Kardex and a Kardex post-test was completed by the CNA #6 on [DATE]. Interview with CNA #6 on [DATE] at 6:19 PM, revealed she had received the above education, and completed a post-test with a return demonstration regarding the required education. Interview with the DON, on [DATE] at 10:45 AM, revealed she had provided education for CNA #6. The DON stated CNA #6 was required to perform a return demonstration and post-test. She further stated LPN #1's employment was terminated. Interview with the Administrator, on [DATE] at 5:15 PM and [DATE] at 12:25 PM, revealed CNA #6 was suspended and received education prior to return to the facility. Per interview, CNA #6 was required to complete return demonstration of education material and complete a post-test. The Administrator further stated CNA #6 was placed back in training with another staff member upon return to work for thirty (30) days. Continued interview revealed LPN #1's employment was terminated on [DATE]. 2. Interview with the ADON, on [DATE] at 12:34 PM, Administrator on [DATE] at 10:02 AM, and DON on [DATE] at 10:45 AM, revealed the facility completed a root cause analysis to identify the root causation and identification of facility steps to address the identified root cause. Review of the facility records revealed a root cause analysis was completed on [DATE]. Interview with LPN #5 on [DATE] at 6:07 PM; LPN #2 on [DATE] at 4:22 PM; LPN #6 on [DATE] at 5:44 PM; RN #1 on [DATE] at 3:07 PM; and RN #2 on [DATE] at 5:37 PM, revealed they received education on the root analysis, and causation and identification of deficient practice on [DATE] which was completed by the facility administration. 3. Review of the new facility Respiratory policy, dated [DATE], revealed the physician (attending practitioner) was to be notified immediately of significant changes in resident's condition, notify the family or legal representative immediately of significant changes and call EMT's (Emergency Medical Technicians)/911 when a respiratory medical emergency exists and the resident needs to be transferred. The policy directed staff when a respiratory medical emergency exists, do not leave resident unattended and to check advance directive/code status of the resident. Per policy, nursing staff were required to document the physician notification, response and interventions implemented to address the resident's condition. Interview with the Administrator, on [DATE] at 10:02 AM; DON on [DATE] at 10:45 AM; and the Medical Director on [DATE] at 2:53 PM, revealed the need was identified to develop and implement a respiratory care policy. Further interview revealed a new respiratory policy was developed on [DATE] with emphasis on assessment response, timeliness of response and response care for a resident in respiratory distress. 4. Review of the facility training documentation revealed all Licensed/Registered nurses (including agency staff) received education on [DATE], [DATE], or prior to the beginning of their shift. Interview with the ADON on [DATE] at 12:34 PM, and DON on [DATE] at 10:45 AM, revealed the facility provided education to staff including agency staff regarding the results of the root cause analysis, audit processes implemented and review of Comprehensive Care Plans and CNA Care Plans (Kardex). Interview with the Administrator, on [DATE] at 10:02 AM, revealed the facility provided education to staff including agency staff regarding the results of the root cause analysis, audit processes implemented and review of Comprehensive Care Plans and CNA Care Plans (Kardex). Further, all staff including agency must be educated prior to beginning his/her shift. Interview with LPN #5 on [DATE] at 6:07 PM; RN #1 on [DATE] at 3:07 PM; LPN #2 on [DATE] at 4:22 PM; and LPN #6 on [DATE] at 5:44 PM, revealed they received education on the root cause analysis, audit processes implemented, and on reviewing the resident Comprehensive Care Plan and CNA Care Plan (Kardex). 5. Review of the facility documentation revealed all Licensed/Registered nurses (including agency staff) received education on [DATE], [DATE] or prior to beginning of their shift regarding the newly implemented respiratory policy, code blue policy, advance directives/code status policy, comprehensive care plan policy, and cardiopulmonary resuscitation and basic life support policy. In addition, the facility provided education to include assessment response, timeliness of response, response care for a resident in respiratory distress, change in condition, immediate notification of physician and procedures for resident in respiratory distress. Further review of the facility documentation revealed Licensed/Registered nurses completed a post-test after the training and a physical observation was completed of Licensed/Registered nurses related to the delivery of respiratory care per the Comprehensive Care Plan. Interview with LPN #5 on [DATE] at 6:07 PM; RN #1 on [DATE] at 3:07 PM; LPN #2 on [DATE] at 4:22 PM; RN #2 on [DATE] at 5:37 PM, and LPN #6 on [DATE] at 5:44 PM, revealed they received education on the newly implemented Respiratory Policy, Code Blue Policy, Advance Directives/Code Status Policy, Comprehensive Care Plan Policy, and Cardiopulmonary Resuscitation and Basic Life Support Policy. In addition, the nurses revealed the facility provided education to include assessment response, timeliness of response, response care for a resident in respiratory distress, change in condition, immediate notification of physician and procedures for resident in respiratory distress which included post testing. Further, the nurses revealed there was physical observation of Licensed/Registered nurses regarding the delivery of respiratory care per the Comprehensive Care Plan. Interviews revealed the education was provided by the Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse. 6. Review of the facility documentation revealed all Licensed/Registered nurses (including agency staff) received education regarding Comprehensive Care Plan review, revisions and updates on [DATE], [DATE] or prior to the beginning of their shift. Interview with the ADON on [DATE] at 12:34 PM; Administrator on [DATE] at 10:02 AM; and DON on [DATE] at 10:45 AM, revealed the facility provided education to staff including agency staff regarding Comprehensive Care Plan review, revisions and updates and all staff including agency must be educated prior to beginning his/her shift. Interview with LPN #5 on [DATE] at 6:07 PM; RN #1 on [DATE] at 3:07 PM; LPN #2 on [DATE] at 4:22 PM; and LPN #6 on [DATE] at 5:44 PM, revealed they received education related to Comprehensive Care Plan review, revisions and updates. 7. Review of the facility documentation revealed all ninety-one (91) residents' Care Plans were reviewed on [DATE] or [DATE]. No identified concerns were identified regarding the respiratory Comprehensive Care Plan review. The facility census was 91 on [DATE]. Review of the medical records for Residents #5, #7, #8, #9 and #10, revealed five (5) out of the five (5) residents with respiratory diagnoses and/or respiratory need had been audited by the facility staff. Further review revealed respiratory care and services were care planned for each resident with no identified concerns. Interview with the Unit Manager on [DATE] at 5:28 PM; ADON on [DATE] at 12:34 PM; MDS Nurse on [DATE] at 4:11 PM; and DON on [DATE] at 10:45 AM, revealed all residents with a respiratory status/respiratory diagnosis received a Comprehensive Care Plan review. Interview with the Administrator, on [DATE] at 8:15 AM, revealed all residents with a respiratory status/respiratory diagnosis received a Comprehensive Care Plan review. The Administrator stated the facility identified sixty-seven (67) residents with a respiratory diagnosis. However, she stated administrative staff reviewed all resident comprehensive care plans to ensure each resident had a Comprehensive COVID-19 Care Plan due to potential respiratory concerns with COVID-19. 8. Interview with the ADON on [DATE] at 12:34 PM and the DON on [DATE] at 10:45 AM, revealed the Interdisciplinary team developed an audit process on [DATE] to observe and compare the care the resident received with the individualized Care Plan. Interview with the Administrator, on [DATE] at 10:02 AM, revealed the Interdisciplinary team developed an audit process on [DATE] to observe and compare the care the resident received with the individualized Care Plan. Further, the facility utilized the audit tool to make physical observations of facility staff providing care and ensuring the care provided aligned with the resident Comprehensive Care Plan and care needs. She denied any concerns at this time; however, stated the facility staff would provide education to staff if the need was identified. 9. Review of the facility audits revealed all ninety-one (91) residents were audited by facility staff to ensure the CNA Care Plan (Kardex) was consistent with the Comprehensive Care Plan. Review of the census on [DATE] revealed 91 residents in the facility. Review of Residents #5, #7, #8, #9 and #10's CNA Care Plan (Kardex), revealed the documentation was consistent with the comprehensive care plan. Review of Resident #5's comprehensive care plan and CNA care plan (Kardex), revealed the resident required two (2) person assist for bed mobility. Observation of care on [DATE] at 2:41 PM, revealed staff provided appropriate level of assistance with care (per the resident's care plan) during a skin assessment and repositioning in bed. Resident #9's Comprehensive Care Plan and CNA care plan (Kardex), revealed the resident required two (2) person assist for toileting and bed mobility. Observation of care on [DATE] at 3:27 PM, revealed staff provided appropriate level of assistance per the care plan during incontinence care. Review of Resident #10's Comprehensive Care Plan and CNA care plan (Kardex), revealed t [TRUNCATED]

Based on interview, record review, review of facility policy, and review of the Lippincott Manual of Nursing Practice, 11th edition, it was determined the facility failed to provide the necessary respiratory care and services consistent with professional standards of practice for one (1) of three (3) sampled residents, Resident #1. Licensed Practical Nurse (LPN) #1 documented a Nurse's Progress Note, dated [DATE] at 10:20 AM, which stated Resident #1 had obvious respiratory distress, with documented vital signs that had been obtained which included his/her blood pressure, and heart rate. Further, Resident #1's blood glucose level and oxygen saturation were documented as checked. However, there was no documented evidence of a thorough respiratory assessment performed by a nurse for Resident #1. Additionally, there was no documented evidence the resident was further monitored for the obvious respiratory distress he/she was experiencing. Furthermore, the physician was not immediately contacted when the resident experienced a change in his/her respiratory status. Although LPN #1's Nurse's Note documented on [DATE] at 10:20 AM, the physician and Emergency Medical Services (EMS) had been notified of the resident's need to be transferred to the Hospital emergency room (ER), interview with the LPN revealed she had not contacted the physician and EMS until approximately 11:26 AM, over an hour after noting Resident #1's being in respiratory distress. The EMS record revealed EMS had been notified at 11:26 AM, and arrived at the facility at 11:32 AM. Per the EMS record, EMS staff observed Resident #1 unresponsive and alone in his/her room, with cyanosis (lack of adequate oxygenation) to his/her lips and was gray in color. EMS initiated Cardiopulmonary Resuscitation (CPR) and transferred Resident #1 to the hospital where he/she was pronounced as expired. In addition, the facility failed to ensure there were policies and procedures in place for staff to reference related to providing respiratory care for residents. The facility's failure to ensure residents received respiratory care as per professional standards of care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE], at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, Respiratory/Tracheostomy Care and Suctioning, F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F695. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy, on [DATE]. The Immediate Jeopardy was verified by the State Survey Agency to be removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F695 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F656) The findings include: Interview with the Administrator, on [DATE] at 10:18 AM, revealed the facility had no policy related to respiratory care of residents available. The Administrator stated Med-Pass was utilized as the facility's Standard of Practice and a new Med-Pass manual had been ordered. However, the Med Pass Standards of Practice information referenced as what the facility was using was not provided to the State Survey Agency Representative. Further interview on [DATE] at 3:18 PM with the Administrator, revealed the facility was utilizing Lippincott as the facility's Standard of Practice and not Med Pass. Review of the Lippincott Manual of Nursing Practice, 11th edition, copyright 2019, revealed clinical assessment in respiratory care included: assessing respiratory rate, depth, and pattern; assessing if accessory muscles were being used; assessing if the patient was breathing through the mouth or pursing lips during exhalation. Continued review revealed the clinical assessment was to also include: checking if sputum was being expectorated, appearance and odor of sputum; assessing for central cyanosis indicating possible hypoxemia; assessing if mucous membranes and nail beds were pink. Further review revealed the assessment was also to include assessing if breath sounds were present and equal bilaterally; assessing if lung fields were clear or if there was rhonchi, wheezing, crackles, stridor, or pleural friction rub . Review of the facility policy titled, Change In Resident Condition or Status, revised [DATE], revealed the nurse supervisor/charge nurse or designee would notify the resident's attending physician or on-call physician when there had been a significant change in the resident's physical/emotional/mental condition, and/or a need to transfer the resident to a hospital/treatment center. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included: Multiple fractures of Ribs, bilateral; Paraplegia; Thoracic Vertebrae (T2-T6) injury of Thoracic Spinal Cord; and Type 2 Diabetes. Review revealed no Minimum Data Set (MDS) Assessment had been completed due to the resident being newly admitted . Review of the Nurse Admission/Re-Admission Note, dated [DATE] at 12:54 PM, revealed the facility assessed Resident #1 to be alert and oriented and capable of making his/her own decisions. Review of Resident #1's hospital Discharge Summary, dated [DATE], revealed the resident had been hospitalized with a Fracture to his/her back and was being admitted to the skilled nursing facility for further rehabilitation with the plan of returning home. Review of Resident #1's Advance Directive, dated [DATE], revealed he/she had not executed an Advance Directive. Review of the Physician's orders dated [DATE], revealed orders for Full Code Status. Review of the facility's Investigation document, dated [DATE], revealed it was reported to the Administrator that Resident #1 had a significant change in status on [DATE]. LPN #1 was noted to check on Resident #1 at 10:20 AM and notified EMS at 11:27 AM. EMS arrived at the facility at 11:30 AM. LPN #1 left Resident #1 to check another resident's blood sugar. Further review of the investigation, revealed the facility felt LPN #1 should have stayed with Resident #1 while awaiting the arrival of EMS. LPN #1 failed to frequently monitor the critical resident until EMS arrived and was terminated from employment on [DATE]. Review of Resident #1's Nurse's Progress Note, dated [DATE] at 10:20 AM, revealed LPN #1 documented the resident was in obvious respiratory distress. Vital signs were obtained to include, Blood Pressure ,d+[DATE] (normal B/P for adults less than ,d+[DATE]), and heart rate 84 (normal heart rate in adults (,d+[DATE] beats per minute). Further, blood sugar was documented at 92 (normal blood glucose range in adults ,d+[DATE] milligrams per deciliter) and oxygen saturation at ninety-eight percent (98%) (normal oxygen saturation in adults ,d+[DATE] percent) on room air. Further review of the Note, revealed EMS, Power of Attorney (POA), Doctor on call and Administrator were notified of resident's transfer to the hospital emergency room (ER). Although the Nurse's Progress Note, dated [DATE] at 10:20 AM, revealed Resident #1 was in respiratory distress, there was no documented evidence LPN #1 conducted a thorough respiratory assessment to include respiratory rate, effort and pattern, auscultation of lung sounds, or assessment for cyanosis (bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood). Additionally, there was no documented evidence the resident was further monitored and no documented evidence of a Physician's order to transport the resident to the hospital on [DATE]. Furthermore, although the Nurse's Progress Note, dated [DATE] at 10:20 AM, revealed the Doctor on call and EMS were notified of Resident #1's transfer to the hospital ER at 10:20 AM, the EMS record revealed EMS did not receive the call until 11:26 AM, which was over an hour later. Review of the EMS record, revealed LPN #1 called EMS and stated Resident #1 wanted to go to the hospital on [DATE] at 11:26 AM and his/her vital signs were normal. Further review revealed EMS arrived at the facility at 11:32 AM. Per the EMS record, the resident was observed in his/her room alone, unresponsive, with cyanosis to his/her lips and was observed to be gray in color. EMS initiated Cardiopulmonary Resuscitation (CPR) and the resident was sent to the hospital where he/she expired. Review of the Hospital emergency room (ER) record, dated [DATE], revealed Resident #1 arrived by EMS and was unresponsive. When placed on the monitor at the facility, the resident was in asystole and EMS initiated chest compressions. The Advanced Cardiovascular Life Support (ACLS) protocol was followed, and Resident #1 received epinephrine, sodium bicarb, calcium gluconate and fluid bolus. Continued review revealed Resident #1 was intubated during the code and the code was continued for a total of thirty (30) minutes and was unsuccessful. Resident #1 was pronounced dead by 12:18 PM, with cause of death noted as Cardiac Arrest. Interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 2:05 PM, revealed she had given Resident #1 a bed bath on [DATE] at approximately 9:00 AM by herself. She stated Resident #1 was short of breath following the bath from rolling around. She further stated, shortly after the bath, she answered Resident #1's call light. CNA #6 stated the resident told her he/she had passed out and requested to see the nurse. Per interview, she reported this right away to LPN #1 who immediately went to Resident #1's room to check his/her oxygen level and vital signs. CNA #6 stated LPN #1 then exited the resident's room and stated she was sending Resident #1 to the hospital. Further interview revealed CNA #6 did not return to Resident #1's room and she was not asked by LPN #1 to check on the resident. Further, she witnessed LPN #1 checking other residents' blood sugars at the nurse's station after assessing Resident #1. Interview with CNA #1, on [DATE] at 11:00 AM, revealed she was returning from lunch on [DATE] at approximately 10:45 AM, when LPN #1 told her she was calling EMS and sending Resident #1 to the emergency room because the resident was short of breath. CNA #1 stated she later saw LPN #1 on her phone at the treatment cart and thought she was calling EMS. CNA #1 further stated LPN #1 did not ask her to check on Resident #1 and she (CNA #1) did not enter the resident's room until EMS arrived and she (CNA #1) led EMS to the resident's room. Further, upon entering the room CNA #1 observed Resident #1 to take his/her last breath. She stated she then went to the resident's door and yelled for a nurse. Continued interview revealed LPN #1 came to the room as EMS was performing chest compressions and transferring the resident to the stretcher. Interview with Resident #1's significant other, on [DATE] at 6:13 PM, revealed Resident #1 was admitted to the facility on [DATE] for short term rehab and died on [DATE]. She stated the resident had phoned her on [DATE] at 8:16 AM and he/she did not seem to be in any distress. She further stated LPN #1 called her at 11:25 AM and told her Resident #1 was saying he/she was short of breath and wanted to go to the hospital. Further interview revealed she asked LPN #1 why she was calling her instead of the ambulance. Per interview, LPN #1 phoned her again at 11:38 AM and told her Resident #1 was unresponsive and was going to the hospital. Interview with LPN #1, on [DATE] at 11:07 AM, [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed she had been a nurse for two (2) years and during those two (2) years she had worked at the facility. She stated she was the charge nurse and had provided care for Resident #1 on [DATE]. She further stated that morning, at approximately 10:20 AM, CNA #6 reported Resident #1 had requested to see her and was complaining of difficulty breathing. LPN #1 stated she immediately checked Resident #1's oxygen level and it was 98% on room air and his/her vital signs were normal. She stated she also checked the resident's blood sugar which was within normal limits. Further, LPN #1 stated the resident was short of breath, was in respiratory distress and was sweating a little; however, she did not check the resident's respiratory rate or pattern nor did she auscultate his/her lungs when the resident had the change in condition. Per interview, she did not administer oxygen (02) as the resident's oxygen saturation was 98%, but stated she would have applied 02 if the resident's oxygen levels were 92% or lower. She stated she checked the resident's fingers and toes and he/she was not cyanotic. Further interview with LPN #1, on [DATE] at 11:07 AM, on [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed she decided to transfer the resident to the emergency room (ER) because of respiratory distress. She stated, It looked like respiratory distress, but it was more anxiety. She further stated she calmed Resident #1 and stayed in the room with him trying to convince him/her to go to the hospital and also repositioned him/her and he/she seemed calmer when she left the room. LPN #1 stated she stepped out of Resident #1's room and told CNA #1 and CNA #6 that she was sending Resident #1 to the hospital. LPN #1 stated Resident #1 was a full code, but he/she was not at that point. Continued interview with LPN #1, on [DATE] at 11:07 AM, [DATE] at 3:22 PM, and [DATE] at 8:13 PM, revealed she did not immediately contact the physician related to the resident's change in condition. She stated she called the on call physician, the resident's significant other and EMS all at approximately 11:26 AM, about sixty-six (66) minutes after the resident reported he/she wanted to be transported to the hospital. Per interview, she did not stay with Resident #1 while waiting for EMS to arrive nor did she re-assess the resident because she needed to check other residents' blood sugars and she asked CNA #1 and CNA #6 to periodically check on the resident. She stated she was not in Resident #1's room when EMS arrived. She further stated after EMS arrived at 11:30 AM, CNA #1 yelled for her that Resident #1 had stopped breathing. Interview with Registered Nurse (RN) # 1, on [DATE] at 1:54 PM, revealed she received a text message from LPN #1 on [DATE] at 11:20 AM, telling her that she was sending Resident #1 to the ER. She stated Resident #1 was gone when she arrived for her shift at 11:38 AM. Further, she did not speak to LPN #1 about Resident #1 and she was not aware of his/her condition at the time of transfer. Interview with the Medical Director, on [DATE] at 11:19 AM, and on [DATE] at 9:18 AM, revealed a basic respiratory assessment should consist of respiratory rate and effort, checking of blood oxygen level and simple auscultation. He further stated it was his expectation that a resident in respiratory distress or any kind of distress would be sent to the ER immediately. Per interview, he did not expect a nurse to leave a resident unattended if having significant distress. He stated it would be his expectation that the nurse would stay with the resident until EMS arrived. Further interview revealed it was probably impossible to find out exactly what time LPN #1 called the on call physician on [DATE] as the on call physician takes call for five (5) nursing homes and receives up to fifty (50) calls a day. An article entitled Incidence of respiratory complications following Spinal Cord Injury from the Archives of Physical Medicine and Rehabilitation 75, pages ,d+[DATE] - [DATE]. Authors: [NAME] B. Jackson, MD and [NAME] Legroom, MD was sent to the State Survey Agency Representative via email on [DATE] from the facility Medical Director. Per the Article, The possible complications that can arise secondary to paraplegia include the following and can differ based on the level of the injury itself. Not listed in any particular order Pressure sores (decubitus), Thrombosis (Blood clot), Depression and anxiety, Bladder and bowel incontinence/recurrent Urinary tract infections, Circulation disorders, Autonomic dysreflexia, Muscle Atrophy and Spasticity, Phantom Pain, Chronic Pain syndrome, Pneumonia, Difficulty Breathing, and clearing respiratory secretions, Respiratory Failure, Orthostatic hypotension, Osteoporosis. Interview with the Director of Nursing (DON), on [DATE] at 3:10 PM, and on [DATE] at 9:48 AM, revealed she was not aware of any issues with LPN# 1's job performance or documentation skills prior to the incident involving Resident #1. She stated on Saturday, [DATE] at 11:57 AM, she received a phone call from LPN #1 telling her that Resident #1 was not doing well and was complaining of difficulty breathing and she had sent him/her to the ER. Continued interview with the DON, on [DATE] at 3:10 PM, and on [DATE] at 9:48 AM, revealed after looking into the situation, It was a complete failure across the board. She stated LPN #1 failed to do a thorough respiratory assessment. Per interview, a thorough assessment should include respiratory rate and effort, oxygen saturation (O2 Sat), use of ancillary muscles, nasal flaring, and listening to lungs. She stated LPN #1 should have assessed the resident as a person, figured out what changed or what happened to him/her, fixed it, or sent him out to the hospital ER. Further, LPN #1 showed a lack of understanding of the urgency of the situation and checking routine blood sugars was not a reason to leave the resident unattended. Per interview, LPN #1 was not responsive to Resident #1's needs and left him/her unattended when he/she was having respiratory distress. Additional interview with the DON, on [DATE] at 3:10 PM, and on [DATE] at 9:48 AM, revealed she did not believe LPN #1 made any calls, including to the physician and EMS at 10:20 AM, as indicated in the Nurse's Progress note, but those calls should have been made at the resident's first sign of distress. The DON stated she was not made aware of Resident #1's death until she returned to work on Monday. Further interview revealed she and the Administrator had a phone interview with LPN #1 and the nurse admitted to leaving Resident #1 to go check other residents' blood sugars and the nurse had no other excuses for leaving the resident alone. She stated LPN #1 was terminated on [DATE] for failing to provide care, and abandoning a patient when he/she was in distress. Further interview with the DON on [DATE] at 3:10 PM, and on [DATE] at 9:48 AM, revealed she became aware in [DATE] that the facility did not have a policy on Respiratory Care and the facility did work on a policy during this survey. She stated Lippincott was used as the standard of practice. Interview with the Administrator, on [DATE] at 3:18 PM, revealed she expected the nurses to thoroughly assess and monitor a resident who was in respiratory distress. She stated an assessment should include blood pressure, heart rate, respiratory rate, oxygen saturation, listening to the lungs, using nursing judgement and following up with the physician immediately. She further stated she would not expect a nurse to leave a resident unattended if they were unstable and if Resident #1 was in distress the nurse should have stayed with him/her until EMS arrived. Further interview revealed she was not notified by LPN #1 that the resident was being sent to theER on [DATE] as per the Nurse's Progress Note, dated [DATE] at 10:20 AM. Further interview revealed there should have been a policy related to respiratory care in place and available to staff prior to the incident with Resident #1, and a new policy dated [DATE], was developed. **The facility implemented the following actions to remove the Immediate Jeopardy on [DATE]: 1. Resident #1 is no longer a resident of the facility as of [DATE]. The facility terminated Licensed Practical Nurse (LPN) #1's employment as of [DATE]. Certified Nursing Assistant (CNA) #6 was suspended on [DATE] pending further education related to failure to follow Resident #1's plan of care. 2. The Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Quality Assurance Nurse and Resident Care Coordinator, completed a root cause analysis on [DATE] to identify causation of LPN #1's failure to provide appropriate care to Resident #1 and CNA #6's failure to follow the resident's plan of care. Utilizing the root cause analysis, the facility identified immediate actions should be completed including implementation of policy, education, review of records and monitoring. All Licensed/Registered nurses were educated regarding the causation and identification of deficient practice on [DATE]. 3. The root cause analysis completed on [DATE], by the Quality Assurance Team, determined the need for a new respiratory policy to be developed and implemented. The Administrator, DON and Medical Director developed and implemented a new Respiratory Policy on [DATE], with emphasis on assessment response, timeliness of response and response care for a resident in respiratory distress. 4. The Administrator, DON, Assistant Director of Nursing/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding the results of the root cause analysis, audits and the need to review Comprehensive and CNA care plans. 5. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding the newly implemented Respiratory Policy, Code Blue Policy, Advance Directives/Code Status Policy, Comprehensive Care Plan Policy, and Cardiopulmonary Resuscitation and Basic Life Support Policy. In addition, the facility provided education to include assessment response, timeliness of response, response care for a resident in respiratory distress, change in condition, immediate notification of physician and procedures for resident in respiratory distress. Licensed nurses completed a post-test after the training and a physical observation was completed of Licensed/Registered nurses related to the delivery of respiratory care per the Comprehensive Care Plan. All Licensed/Registered nurses off work, including agency staff and new hires were not permitted to work until all of the education and post-testing had been completed. 6. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses (including agency staff) on [DATE] to [DATE], regarding Comprehensive Care Plan review, revisions and updates. 7. The root cause analysis completed on [DATE] by the Quality Assurance Team identified all residents with a respiratory diagnosis or respiratory need requiring a Comprehensive Care Plan review and/or update. The Administrator, DON, ADON/Quality Assurance Nurse, Minimum Data Set (MDS) Coordinator, Resident Care Coordinator, and Unit Manager, completed the review of the Comprehensive Care Plans on [DATE] and [DATE], to assure the appropriate respiratory care and services were care planned for each resident. 8. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor, and Weekend House Supervisor developed an audit process on [DATE] to observe the care the resident received and to ensure the care was per the individualized Care Plan. 9. The Administrator, DON, ADON/Quality Assurance Nurse, MDS Coordinator, Unit Manager, and Resident Care Coordinator, reviewed and/or updated the CNA Care Plan with the Comprehensive Care Plan on [DATE] and [DATE]. The Administrator, DON, ADON, Unit Manager, Resident Care Coordinator, and MDS Coordinator, completed a one hundred percent (100%) audit to ensure that each resident CNA Care Plan (Kardex) and Comprehensive care plan was consistent with care. 10. The Administrator, DON, ADON/Quality Assurance Nurse, Night Shift House Supervisor/Registered Nurse, and/or Weekend House Supervisor/Registered Nurse, provided education to all Licensed/Registered nurses and all Certified Nursing Assistants (including agency staff) on [DATE] to [DATE] regarding the review and/or update of the CNA Care Plan (Kardex). The education also included providing care and following the Kardex consistent with the Comprehensive Care Plan for each resident. Post-testing was given after the education and there was also physical observation of the CNAs providing care per the CNA Care Plan (Kardex). All CNA's that were off work, including agency staff and new hires were not permitted to work until all the education and post- testing had been completed on providing care and following the CNA Care Plan (Kardex). 11. Results of all CNA Care Plan audits and the related Comprehensive Care Plans are reviewed each day by the Quality Assurance Committee and the Interdisciplinary Team. Members of the Quality Assurance Committee and Interdisciplinary Team include the Medical Director, Administrator, DON, ADON/Quality Assurance Nurse, MDS Nurse, Resident Care Coordinator, Weekend House Supervisor/Registered Nurse, Night Shift House Supervisor, Unit Nursing Manager/Registered Nurse, Medical Records Director and Social Services Director. The Quality Assurance Committee reviews and makes recommendations related to the information. 12. The Administrator and Director of Nursing developed an observation audit form on [DATE] to be completed by Licensed/Registered nurses that are assigned by the Director of Nursing. Ten percent (10%) of the resident population will be audited. The audits will be completed throughout each day (seven [7] days a week) and will cover the respiratory care plan that is consistent with the care the resident receives. Any identified issues are reported to the DON for immediate correction. The facility will continue the audits seven (7) days per week for a minimum of four (4) weeks. The Quality Assurance Committee and the Interdisciplinary Team will evaluate progress for potential decrease in audit number of days. 13. Results of all respiratory care audits and the related Comprehensive Care Plans are reviewed each day by the Quality Assurance Committee and the Interdisciplinary Team. The Quality Assurance Committee reviews and makes recommendations related to the information. 14. The Administrator and DON developed an observation audit form on [DATE] to be completed by Licensed/Registered nurses that are assigned by the Director of Nursing. Ten percent (10%) of the resident population will be audited seven (7) days each week to ensure the CNA care plan (Kardex) was consistent with the Comprehensive Care Plan. Any identified issues are reported to the DON for immediate correction. The facility will continue audits seven (7) days a week for a minimum four (4) weeks. The Quality Assurance Committee and the Interdisciplinary Team will evaluate progress for potential decrease in audit number of days. 15. The Social Services Director and Social Services staff interviewed all residents and/or their representatives to solicit any concerns regarding care and treatment of residents including respiratory services on [DATE]. **The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] as follows: 1. Review of Resident #1's medical record revealed the resident expired on [DATE]. Review of the employee record documentation revealed LPN #1's employment at the facility was terminated on [DATE]. Review of the employee record documentation for CNA #6 revealed the CNA was suspended on [DATE] for two (2) days. Further review revealed CNA #6 received education on [DATE] on the CNA Care Plan (Kardex), Advance Directive policy and a review of the recent deficient practice. Continued review of the record revealed CNA #6 received education on [DATE] on how to access the resident Kardex, and on the actual resident Kardex related to assistance and care needs. Further review revealed the education was provided by the Administrator and DON with return demonstration of how to access CNA Kardex and a Kardex post-test was completed by the CNA #6 on [DATE]. Interview with CNA #6 on [DATE] at 6:19 PM, revealed she had received the above education, and completed a post-test with a return demonstration regarding the required education. Interview with the DON, on [DATE] at 10:45 AM, revealed she had provided education for CNA #6. The DON stated CNA #6 was required to perform a return demonstration and post-test. She further stated LPN #1's employment was terminated. Interview with the Administrator, on [DATE] at 5:15 PM and [DATE] at 12:25 PM, revealed CNA #6 was suspended and received education prior to return to the facility. Per interview, CNA #6 was required to complete return demonstration of education material and complete a post-test. The Administrator further stated CNA #6 was placed back in training with another staff member upon return to work for thirty (30) days. Continued interview revealed LPN #1's employment was terminated on [DATE]. 2. Interview with the ADON, on [DATE] at 12:34 PM, Administrator on [DATE] at 10:02 AM, and DON on [DATE] at 10:45 AM, revealed the facility completed a root cause analysis to identify the root causation and identification of facility steps to address the identified root cause. Review of the facility records revealed a root cause analysis was completed on [DATE]. Interview with LPN #5 on [DATE] at 6:07 PM; LPN #2 on [DATE] at 4:22 PM; LPN #6 on [DATE] at 5:44 PM; RN #1 on [DATE] at 3:07 PM; and RN #2 on [DATE] at 5:37 PM, revealed they received education on the root analysis, and causation and identification of deficient practice on [DATE] which was completed by the facility administration. 3. Review of the new facility Respiratory policy, dated [DATE], revealed the physician (attending practitioner) was to be notified immediately of significant changes in resident's condition, notify the family or legal representative immediately of significant changes and call EMT's (Emergency Medical Technicians)/911 when a respiratory medical emergency exists and the resident needs to be transferred. The policy directed staff when a respiratory medical emergency exists, do not leave resident unattended and to check advance directive/code status of the resident. Per policy, nursing staff were required to document the physician notification, response and interventions implemented to address the resident's condition. Interview with the Administrator, on [DATE] at 10:02 AM; DON on [DATE] at 10:45 AM; and the Medical Director on [DATE] at 2:53 PM, revealed the need was identified to develop and implement a respiratory care policy. Further interview revealed a new respiratory policy was developed on [DATE] with emphasis on assessment response, timeliness of response and response care for a resident in respiratory distress. 4. Review of the facility training documentation revealed all Licensed/Registered nurses (including agency staff) received education on [DATE], [DATE], or prior to the beginning of their shift. Interview with the ADON on 01/ [TRUNCATED]

Based on observation, interview, review of the facility's policy, and review of the Centers for Disease and Prevention (CDC) Guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, including COVID-19. Observation on 12/28/2021, on the West Unit, revealed Licensed Practical Nurse (LPN) #1 and the Medical Records Director at the nurse's station. LPN #1 was observed to wear her face mask below her nose and the Medical Records Director's face mask was hanging below her chin. Additionally, observation on 01/03/2022, on the West Unit, revealed Hydration Aide (HA) #1 was at the nurse's station drinking from a cup with her face mask below her chin. On the same day, HA #1 was observed on the East Unit, with her face mask below her nose in the hall. Furthermore, observation on 01/03/2022, revealed the Rehab Technician was walking around the therapy room and was not wearing a face mask while other staff and residents were present. The findings include: Review of the facility policy titled, COVID-19 Plan, dated July 9, 2021, under the section titled Hazard Assessment and Worker Protection, revealed face masks were required to be worn in the building at all times in the healthcare setting unless in defined areas away from the patient care areas. (Defined areas in which a facemask would not need to be worn included: when an employee was alone in a room or while an employee was eating or drinking at the workplace, provided each employee was at least six (6) feet away from any other person, or separated from other people by a physical barrier). Review of CDC Infection Control Guidelines, updated 02/18/2021, revealed Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps. 1. Observation on 12/28/2021 at 8:50 AM, on the West Unit, revealed LPN #1 and the Medical Records Director engaged in conversation at the nurse's station. LPN #1 was observed to wear her face mask below her nose and the Medical Records Director's face mask was hanging below her chin. Interview with LPN #1, on 12/28/2021 at 9:15 AM, revealed she was aware face masks were to be worn covering the mouth and nose when in a resident area. She further stated the nurse's station was not considered a resident area. Interview with the Medical Records Director, on 12/28/2021 at 9:18 AM, revealed the facility's policy required face masks to be worn covering the mouth and nose at all times unless in an office area. She stated she should have had her face mask up covering her mouth and nose while sitting at the nurse's station. 2. Observation on 01/03/2022 at 10:20 AM, on the West Unit, revealed Hydration Aide (HA) #1 at the nurse's station drinking from a cup with her face mask below her chin. Again, observation on 01/03/2022 at 10:44 AM, on the East Unit, revealed HA #1 was wearing her face mask below her nose in the hall. Interview with Hydration Aide #1, on 01/03/2022 at 10:44 AM, revealed staff was supposed to wear a face mask covering the nose and mouth at all times except while on their breaks in the employee break room. She stated she should have had her mask covering her nose and mouth while sitting at the nurse's station. 3. Observation on 01/03/2022 at 10:38 AM, revealed the Rehab Technician was walking around the therapy room with no mask in place while other staff and residents were present. Interview with the Rehab Technician, on 01/03/2022 at 10:39 AM, revealed he was in his office and had stepped out for a minute into the therapy room, and did not think about putting a face mask on when he left his office. He further stated he did wear a face mask when he was providing one on one (1:1) therapy to the residents. Continued interview revealed per facility policy, face masks were to be worn covering the mouth and nose. However, the Rehab Tech had his face mask below his nose during the interview with the State Survey Agency (SSA) Representative. Interview with the Director of Nursing (DON), on 01/11/2022 at 2:38 PM, revealed staff was expected to wear face masks covering their nose and mouth at all times while in the facility except when in an office area. She stated she expected staff to wear all appropriate PPE (personal protective equipment) properly, per the CDC guidelines and facility policy, to prevent the spread of infectious diseases such as COVID-19. Further interview revealed the Infection Control Preventionist was out of the building and unavailable for interview. Interview with the Administrator, on 01/25/2022 at 3:18 PM, revealed she expected all staff to follow the facility's policy as well as CDC guidelines on wearing face masks to prevent the potential spread of infection.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement interventions on the Comprehensive Person-Centered Care Plan for two (2) of five (5) sampled residents, Resident #1 and Resident #9. The facility failed to implement the care plan intervention to observe for signs of [CONDITION(S)] (CHF) for both residents. The findings include: Review of the facility's policy entitled, Comprehensive Care Plan, reviewed [DATE], revealed the purpose of the Comprehensive Care Plan was to note each resident's daily care needs which were to be provided by nursing staff in accordance with the guidelines of the Resident Assessment Instrument, (RAI) process and in keeping with the Medicare/Medicaid Services requirements. Per review, residents received their care and treatment based on the assessment of their needs, and the severity of their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the facility's Interdisciplinary Team (IDT) and the Minimum Data Set (MDS) Coordinator were to review and finalize the resident's Care Plan form in the facility's computer portal to ensure continued provision of care for the resident. Continued review revealed the initial Comprehensive Care Plan was to be completed within twenty-one ( 21) days and updated as necessary. Per the policy, the development, implementation, and maintenance of a resident's care plan as initiated by the admitting license nurse, was an interdisciplinary process. Further review revealed all disciplines involved in the care of a resident collaborated to develop the Comprehensive Plan of Care, with the resident, his/her family or representative included to the extent possible. Review of the clinical record for Resident #1 revealed the facility admitted Resident #1 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set Assessment, dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of of twelve (12) out of a total of fifteen (15), which indicated he/she was moderately cognitively impaired. Review of Resident #1's Comprehensive Care Plan Plan initiated on [DATE], revealed the facility had care planned the resident for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review, staff were to check Resident #1's breath sounds; monitor and document any shortness of breath, congestion, dry cough, crackles and/or wheezing upon auscultation (listening) of the lungs. Further review revealed the interventions also included for staff to monitor and document any dependent [CONDITION(S)] in Resident #1's legs and feet, weakness or fatigue, increased heart rate, lethargy (lack of energy), disorientation or cool skin. (Was there an intervention in place to obtain the resident's weight daily or at least every few days or weekly?) There was an intervention in place to monitor for weight gains unrelated to intake initiated on [DATE]. There was no indication as to how often, although the resident did have a standing order for weights to be done weekly and as needed. Weights had been done weekly and when the facility readmitted the resident after hospitalization s. Review of Resident #1's Nursing Progress Notes revealed a Note for [DATE] at 8:28 PM documenting an ambulance arrived to transfer the resident to the hospital's Emergency Department (ED) related to difficulty breathing. Review of the Hospital Records for Resident #1 revealed the resident was seen in the ED on [DATE] at 09:15 PM by the Emergency Medicine Physician for respiratory distress and was admitted to the hospital. Per review, the hospital discharged Resident #1 back to the facility on [DATE] with final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Was there any type of testing performed to indicate the resident was experiencing an exacerbation of his/her CHF? Such as, Chest x-rays? EKG's? MRI's? Blood testing (BNP)? Or any documentation noting this, maybe in the nurses' or Physicians' Notes?) Hospital records revealed on [DATE] at 10:32 PM the residents's Brain Natriuretic Peptide (BN)) test was elevated to 1123.0 (a test highy sensitive for the detection of acute [CONDITION(S)]. BPN is a blood test that measures levels of proteins that is made by the heart and blood vessels. BNP are higher than normal when one has heart failure). Chest xray (CXR) results [DATE] (no time) Narative: EXAM Front and lateral views of the chest. COMPARISON: Prior chest xray [DATE]. FINDINGS: LUNGS: Chronic coarse intersititiial prominence with superimposed bibasilar atelectasis versus scarring similiar to prior exam. No defiinite acute focal lung consolidation. 1.2 cm nodular density in the right lung base similiar to prior exam. PLEURAL SPACE: Unremarkable. Impresssion:1. Chronic coarse interstitial prominence with superimposed bibasilar atelectasis verus scarring similar to prior exam.No definite acute focal lung consolidation. 2. 1.2 cm nodular density in the right lung base similar to prior exam. Electronically signed by MD pm [DATE] at 9:45 PM. Continued review of Resident #1's Nursing Progress Notes for [DATE] at 4:09 PM, signed by Licensed Practical Nurse (LPN) #2, revealed the resident arrived back to the facility at 4:09 PM on [DATE] via a private vehicle and escorted by his/her daughter. Per review, Resident #1's lung sounds were documented as clear and diminished in the bases on the nursing readmission assessment dated [DATE] at 4:09 PM. Review of Resident #1's Nursing Progress Notes dated [DATE] at 7:42 PM, revealed an ambulance had arrived at the facility to transfer the resident to the hospital ED again related to difficulty breathing. Review of the Hospital Records for Resident #1 revealed the resident was seen by the Hospitalist on [DATE] at 12:25 AM, for Acute/Chronic Respiratory Failure with [CONDITION(S)] and Acute/Chronic [CONDITION(S)]. Per review, the resident was once again admitted to the hospital, and discharged back to the facility on [DATE] with final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Was there any type of testing performed to indicate the resident was experiencing an exacerbation of his/her CHF? Such as, Chest x-rays? EKG's? MRI's? Blood testing (BNP)? Or any documentation noting this, maybe in the nurses' or Physicians' Notes?) CXR on [DATE] at 10:57 PM revealed: Pulmonary vascularity is indistinct. More severe bilateral groundglass airspace disease greatest with the lung bases. Pleura: Both costophrenic sulci are blunted. No pneumothorax is present. Findings suggestive of [CONDITION(S)] with pulmonary [CONDITION(S)] and bilateral effusions. Underlying pneuumonia is not excluded. Review of Hospitalist's consult, dated [DATE] at 12:25 AM reveald the residient's BNP on [DATE] was 2197. Patient was noted to have pulmonary [CONDITION(S)] with bilteral pleural effuson on chest x-ray. Was given IV diuresis and dropped eight (8) pounds. Patient was weaned back to his/her normal 2 L oxygen. Continued review of Resident #1's Nursing Progress Notes revealed a Note signed by the Director of Nursing (DON) on [DATE] at 3:05 PM, which noted the resident had arrived back to the facility at 3:05 PM on that date via private car transfer. Per review, Resident #1's lung sounds had been documented as diminished in all fields by the DON. Further review of Resident #1's Nursing Progress Notes for the time period of [DATE] through [DATE], revealed no documented evidence of further assessment and auscultation of the resident's lungs to assess for depth and quality of his/her breath sounds as per the care plan interventions, except for the two (2) Progress Notes dated [DATE] and [DATE], documented after the resident's return from the two (2) hospital stays. 2. Clinical record review revealed the facility admitted Resident #9 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #9 continued to have the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident with a BIMS score of eleven (11) out of fifteen (15), indicating the resident had moderately impaired cognition. Review of the facility's Plan of Care for Resident #9, initiated on [DATE], revealed the facility had care planned the resident for his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the interventions additionally included for staff to observe Resident #9 for dependent [CONDITION(S)] of legs/feet, cool skin, weakness or fatigue, increased heart rate, lethargy and/or disorientation. (Was there an intervention to obtain the resident's weight daily or at least every few days or weekly?) Intervention was to monitor weight gain. There was no indication of how often. The facility was monitoring weekly and more often for resident #9 because of the the readmissions from the hospital. The facility had a standing order to do weekly weights and more often if needed. Review of the Hospital Records for Resident #9 revealed the resident was admitted to the hospital for the time period of [DATE] through [DATE]. Per review, Resident #9 presented with a Lung Nodule, [CONDITION(S)], and Altered Mental Status on admission. Further review revealed the final discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Nursing Progress Notes revealed a Note dated [DATE] at 4:27 PM, signed by the Registered Nurse (RN) #4 which documented the resident arrival back to the facility via an ambulance. (Did this Note have any documentation of assessment of Resident #9's heart and lung sounds?) There was no documentation at 4:27 PM r/t assessment of heart and lung sounds. There was documentation in a Nursing Progress Noted dated [DATE] at 5:34 PM. Lungs clear with no resp distress noted. signed by RN #4. Review of the facility's Re-admit 72 Hour Charting documentation for [DATE] at 3:15 AM and at 9:29 AM, which was located in the Nursing Progress Notes, for Resident #9 revealed no documented evidence nursing staff had assessed the resident's lung sounds as per the care plan. Review of the Hospital Records for Resident #9 dated [DATE] through [DATE], revealed the resident had been admitted again to the hospital. Per review, on admission Resident #9 had presented with Metabolic [CONDITION(S)] (a condition which disturbs brain function either temporarily or permanently due to different diseases or toxins in the body), Renal Artery Stenosis, Urinary Tract Infection and [CONDITION(S)] of Liver with Ascites. Further review revealed Resident #9's final discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Nursing Progress Notes [DATE] at 3:20 PM which had been signed by the Assistant Director of Nursing (ADON) revealed the resident had arrived back to the facility via ambulance and was readmitted to the facility. Review of the Re-admit 72 Hour Charting located in the Nursing Progress Notes for Resident #9 on [DATE] at 1:01 AM, on [DATE] at 1:09 PM and at 10:43 PM, revealed no documented evidence staff had assessed the resident's lung sounds as per the care plan. Review of the Hospital Records for the time period of [DATE] through [DATE], for Resident #9 revealed the resident had been admitted to the hospital again. Per review, on admission Resident #9 had presented with an Upper Gastrointestinal (GI) Bleed, [CONDITION(S)] of Liver with Ascites and [CONDITION(S)]. Further review revealed Resident #9's final discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Nursing Progress Notes dated [DATE] at 5:20 PM, signed by the ADON revealed the resident had arrived back to the facility via ambulance for readmission. Review of the Re-admit 72 Hour Charting located in the Nursing Progress Notes for Resident #9 revealed no documented evidence nursing staff had assessed the resident's lung sounds as per the care plan on [DATE] at 11:02 AM, on [DATE] at 11:04 PM, and on [DATE] PM at 8:04 AM. Interview with the MDS Coordinator on [DATE] at 3:10 PM in the Conference Room revealed Resident #1's care plan related to his/her CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, Resident #9's CHF care plan was active and the interventions were ongoing. The MDS Coordinator stated Resident #1's and Resident #9's CHF care plans should have been followed. A telephonic (phone) interview on [DATE] at 11:10 AM with LPN #3 revealed she would assess lung sounds on a resident if there were any signs or symptoms of distress such as shortness of breath, cyanosis (bluish discoloration of the skin), or increased confusion. Also, if a resident was on 72 Hour Alert Charting for a Pneumonia diagnosis, an incident or a new admission/readmission, the lungs of the resident should be auscultated and documented. A phone interview on [DATE] at 11:50 AM with LPN #4 revealed she charted by exception (a method of medical notation in which nurses only provide notes if there are deviations from a patient's norm or baseline). Per interview, LPN #4 revealed she was the Charge Nurse for the West Wing of the facility. which included three (3) resident room halls. She stated she did not usually assess a resident's lung sounds during her rounds of the residents under her care. Interview revealed during her rounds if she observed any concerns with a resident, such as increased confusion or shortness of breath, she assessed the resident further and documented her findings. LPN #4 revealed she had not assessed Resident #1 for [CONDITION(S)] on her rounds on the evening of [DATE]. Further interview revealed the LPN stated, I did not look at Resident #1's ankles on my rounds about midnight. ([NAME], what happened to Resident #1 that made the LPN state this? I asked the nurse if she assessed resident's extremities when making her rounds. I saw where you noted the resident passed away on [DATE], so was it related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? No I asked the question. During an Interview with the Medical Director on [DATE] at 5:00 PM the Medical Director stated, The resident's death was likely related to the natural progression of his/her Chronic Obstructive Pulmonay Disease ([CONDITION(S)]). His/her Coronary Artery Disease (CAD) and [CONDITION(S)] put additonal strain on his/her cardiac situation. Patients with CAD have very little tolerance of [CONDITION(S)] excerbation episodes. The resident's daughter told me the dealth certificate said the cause of death was Cardiac Failure, [CONDITION(S)] excerbation, Diabetes, CAD, and [CONDITION(S)], signed by the Medical Director. Did the resident die from CHF or some other reason? Cardiac Failure r/t excerbation of [CONDITION(S)]. I assumed it was CHF. I cannot assume that. The MD said it was cardiac failure. Did the resident pass away at the facility or hospital? At the facility on [DATE]. Per Nursing Progress Note dated [DATE] at 10:57 AM signed by RN #1 the time of death was 10:50 AM. Can you put a little more of that record review information in under Resident #1's example above please? Thanks!) Hope this infor helps. No sure where you want it. Interview, on [DATE] at 10:05 AM with the DON revealed a resident's lungs should be auscultated and documented on the 72 Hour Charting in the Nursing Progress Notes. (Did she say how often the nurses should assess and document during the 72 Hour Charting?) NO . I did not ask, but I should have good question. It appears it is done every 24 hours for three days. The DON stated the 72 Hour Alert Charting occurred whenever a resident was admitted or readmitted to the facility or if an incident had occurred. Per interview, nursing staff should have followed Resident #1's and Resident #9's care plans. According to the DON, nursing staff should have assessed the residents' lung sounds and documented their assessment on each resident's nursing readmission assessment and on the 72 Hour Alert Charting. Further interview revealed when the Surveyor inquired of the DON what could happen if a resident with [CONDITION(S)] had fluid in their lungs, which the DON refused to answer. Interview with the Administrator on [DATE] at 1:30 PM, revealed she expected all her nursing staff to implement the interventions on each resident's care plans. Per interview, the facility utilized current standards of nursing practice for documentation of the nurse's monitoring of residents, and for Respiratory Services documentation. When the Surveyor inquired of the Administrator of how often staff were to monitor the breath/lung sounds of a resident, the Administrator's responded, We eyeball the resident every shift when performing pulse oximetry testing (test for measuring oxygen saturation in the blood). Further interview revealed the Administrator stated the facility assessed and charted by exception, and if a concern was identified during the pulse oximetry test, nursing staff would go further with their assessment of the resident's lungs. (Did he/she not feel nursing staff should have been assessing the lungs of residents after their readmission to the facility, or as per their care plan interventions in order to determine if a resident was experiencing an exacerbation of their CHF?) The Administrator did reveal that lung sounds should have been documented on the 72 hours charting. Other than that she continued to say the nursing staff is to chart by exception.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) was able to exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. On [DATE], staff failed to honor Resident #1's right to refuse care when staff held the resident's arms, legs, and ankles to provide incontinent care and change his/her brief. Resident #1 was resistive, combative, and crying, and had previously told the staff no when the staff attempted incontinent care at 2:00 AM and 4:30 AM; however, at 5:,[DATE]:00 AM, Registered Nurse (RN) #1 held Resident #1's right arm/hand down on the bed by using her hand and knee, causing a skin tear on his/her right forearm, and right hand near his/her thumb/forefinger. Certified Nurse Aide (CNA) #1 held the resident's left hand and Nurse Aide (NA) #1 held the resident's ankles. The findings include: Review of the facility's policy titled, Resident Rights, dated [DATE], revealed a resident has the right to refuse treatment. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Observation and interview of Resident #1, on [DATE] at 2:30 PM, revealed there was a quarter-sized area, slightly torn open in a U or V shape, with no active bleeding and steri-strips in place to the resident's forearm and a small open area, darkened around it, with no active bleeding to the resident's right hand between his/her right thumb and forefinger. Resident #1 stated the injuries occurred on [DATE], when she (RN #1) pushed on it. The resident spoke in a low tone and became tearful frequently during our conversation. Review of a Nurse's Note documented by RN #1, dated [DATE] at 5:45 AM, revealed signee and three (3) aides attempting to change resident's wet brief - resident had refused multiple times when asked by aides to perform personal hygiene - resident trying to hit, scratch, kick staff - while changing brief, signee noticed small skin tear to hand and forearm where resident had apparently bumped (himself/herself) while trying to hit staff. Interview with CNA #1, on [DATE] at 2:55 PM, revealed, on [DATE], she and NA #2 (orientee) did rounds around 2:00 AM and Resident #1 was combative and did not want to be changed. CNA #1 stated when they went back to change the resident during rounds at 4:30 AM to 4:45 AM, the resident still refused to be changed, so they decided to finish their rounds and knew dayshift would be there shortly and they had a better rapport with the resident. CNA #1 revealed when they finished their rounds, RN #1 asked if they had changed the resident, and they told her no but RN #1 did not listen to her fully and said it was unacceptable and the resident had to be changed. CNA #1 stated RN #1 told them to grab a few people, and then RN #1, NA #1, NA #2, and herself went to the resident's room. She stated the staff put gloves on, and when they went to change the resident the resident said no and became combative. She stated RN #1 then grabbed the resident's right forearm and put her knee on the resident's hand. CNA #1 revealed RN #1 had the resident with one hand and the other hand trying to get the resident's brief off, and she was on the resident's left side, holding the resident's left hand, and was trying to help with the brief. She stated when we rolled the resident, NA #1 slid the brief underneath the resident, and fastened it. She revealed at that time, the resident saw his/her hand was bleeding and asked what happened. RN #1 told the resident that he/she hit it on the siderail and the resident said to get out and stop touching him/her. CNA #1 stated NA #1, NA #2 and herself stayed in the room while RN #1 went to get supplies for the skin tears on the resident's right arm/hand. She stated Resident #1 had a big area on his/her hand where RN #1's knee was placed, which was about half-dollar size with the skin pulled back; and, an area on his/her right forearm, where RN #1's fingernails dug into the resident's skin, and was bleeding. She revealed the resident was combative and resistive the whole time they were in there, which was not normal for the resident. She stated while the RN was gone out of the room, the resident was crying and saying she broke my heart, and when the RN came back, the resident stated look what you did to my hand, and RN #1 denied it stating the resident hit it on the siderail. CNA #1 added they left the room after RN #1 bandaged the resident's right hand and arm, and the resident was still crying. She stated CNA #2 (dayshift staff) met her in the hallway, and asked the resident what was wrong. The resident was crying and told CNA #2, look what the nurse did showing CNA #2 his/her right arm/hand. Interview with NA #1, on [DATE] at 11:05 AM, revealed on [DATE], she was walking down another hall when CNA #1 and NA #2 came up to RN #1 and told her that the resident would not let them change him/her. She stated RN #1 asked her to come along because we're going to need some help. That's unacceptable, (he/she) has to be changed. NA #1 revealed they went to the resident's room, turned the light on, and the resident started crying and talking about his/her deceased spouse. She revealed RN #1 told the resident that they were going to change his/her brief, and the resident said to leave him/her alone. She revealed CNA #1 held the resident's left arm, RN #1 held his/her right arm/hand with both hands and one (1) knee, and she held the resident's ankles, or right above that, which were crossed. NA #1 stated they changed the resident but the resident was combative. She stated the resident had blood on his/her right wrist or a little below it, and blood between his/her right fingers near the thumb. She revealed the resident tried to blame the nurse, and stated you did this, but the nurse denied it and told the resident, we had to change you, but we have to patch you up now. She stated RN #1 left the room to get bandages and the resident started crying about his/her deceased spouse and got hysterical. She stated the RN came back, patched him/her up and left the room. Interview with NA #2 (orientee), on [DATE] at 4:06 PM, revealed on [DATE], she and CNA #1 made rounds throughout the shift, and each time Resident #1 was resistive to being changed, so we decided to try again later. She stated they told RN #1 that they would change the resident later and RN #1 stated no we're not, that's not acceptable, (he/she's) got be changed. NA #2 stated there were four (4) staff in the resident's room, and RN #1 immediately grabbed the resident's right arm, holding her knee on his/her forearm, and her hands on his/her right wrist. She also revealed the nurse had long acrylic nails. NA #2 recalled the resident had a cut on the top part of his/her right forearm and the resident said look what you did, but RN #1 blamed it on the resident. She revealed the resident was combative and crying the whole time, thinking (his/her) spouse was cheating on (him/her). She stated the resident was still crying when all of them left the room. She revealed she left the shift afterward, and added that RN #1 had been in a bad mood, hateful and rude to staff all night, not sure about any other residents. Interview with CNA #2, on [DATE] at 12:25 PM, revealed she worked dayshift and received report from the third shift CNA (#1) regarding the [DATE] incident, which had just ended when she clocked in. She revealed they did a walk through during report and when CNA #1 told her about Resident #1, she checked on the resident, and he/she was upset/crying, saying that mean nurse hurt my hand. She added the resident's right hand had blood on it. Interview with RN #1 (alleged perpetrator), on [DATE] at 2:23 PM, revealed I prefer not to make a statement at this time. Interview with the Administrator, on [DATE] at 6:00 PM, revealed RN #1's, CNA #1's, NA #1's and NA #2's actions were not appropriate, and they did not follow the Resident Rights policy. She stated CNA #1 was re-inserviced on [DATE]; and, NA #1 and NA #2 were re-inserviced on [DATE], on Abuse and Dealing with a combative resident; to include stop, re-approach, try a different method, different person, offer a snack, blanket, and Never force a resident or hold them down. She stated RN #1 was terminated on [DATE]. The Administrator revealed no other action was taken.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse (Resident #1). On [DATE], Resident #1 refused incontinent care at approximately 2:00 AM and 4:30 AM when Certified Nurse Aide (CNA) #1 and Nurse Aide (NA) #2 (orientee) made their rounds. When Registered Nurse (RN) #1 became aware of this, she told CNA #1, NA #1, and NA #2 that was unacceptable and the resident had to be changed. RN #1, CNA #1, NA #1, and NA #2 attempted to provide incontinent care to Resident #1 and the resident refused, was crying, and became combative. RN #1 grabbed Resident #1's right arm and held it to the bed with her hands and knee, while CNA #1 held the resident's left arm, and NA #1 held the resident's ankles with them crossed. RN #1 caused a skin tear on the resident's right forearm with her nails and on his/her right hand near his/her thumb/forefinger with her knee. Resident #1 stated she broke my heart and told RN #1 look what you did referring to his/her hand/arm, while still crying. CNA #1 reported the incident to the oncoming dayshift CNA; however, CNA #1, NA #1 and NA #2, failed to protect residents from any further abuse when they failed to report the incident to a supervisor prior to leaving the facility. The findings include: Review of the facility's policy related to Resident Abuse, Neglect, and Exploitation, last revised [DATE], revealed it is the goal of the facility to have a process in place to protect the health and welfare of each resident; to assure that each resident is free from verbal, sexual, physical and mental abuse; corporal punishment, neglect, involuntary seclusion, exploitation and injuries of unknown origin. All staff are trained to identify and report inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care. Any incidents of suspected abuse involving staff toward a resident shall immediately be reported to the employee's immediate supervisor and the Administrator and/or designee, at which time an investigation will begin. Allegations will be thoroughly investigated by the Abuse/Neglect Coordinator, Administrator and/or designee. The resident's safety and protection will first be assured. Employees witnessing an incident of resident abuse must report the incident immediately. The employee(s) witnessing the abuse may be considered as an accessory to the abuse if they do not report the incident. As such, they will be subject to disciplinary action in the form of warnings, or discharge from employment, and if appropriate, legal action. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS revealed the resident required limited to extensive assistance with activities of daily living (ADLs), only supervision while eating. Interview with Resident #1, on [DATE] at 2:30 PM, revealed the areas on his/her right forearm and right hand happened, on [DATE], when she (RN #1) pushed on it. Resident #1 spoke in a low tone and became tearful frequently during the conversation. Observations with RN #2 at this time revealed there was a quarter-sized area, slightly torn open in a U or V shape, with no active bleeding and steri-strips in place, on the resident's right forearm. Further observation revealed a small open area, darkened around it, with no active bleeding, on the resident's right hand, between his/her right thumb and forefinger. Review of a Nurse's Note documented by RN #1, dated [DATE] at 5:45 AM, revealed signee and three (3) aides attempting to change resident's wet brief - resident had refused multiple times when asked by aides to perform personal hygiene - resident trying to hit, scratch, kick staff - while changing brief, signee noticed small skin tear to hand and forearm where resident had apparently bumped (himself/herself) while trying to hit staff. Interview with RN #1 (alleged perpetrator), on [DATE] at 2:23 PM, revealed I prefer not to make a statement at this time. Interview with CNA #1, on [DATE] at 2:55 PM, revealed on [DATE], she and NA #2 (orientee) did rounds around 2:00 AM and 4:,[DATE]:45 AM and Resident #1 was being combative and did not want to be changed. CNA #1 stated they decided dayshift would be there by the time they finished the 4:30 AM round so they would wait to change the resident because dayshift had a better rapport with the resident. She revealed when they finished their rounds, RN #1 asked if they had changed Resident #1 and they told her no but before they could explain they were waiting for dayshift, RN #1 stated it was unacceptable and the resident had to be changed. CNA #1 said RN #1 told them to grab a few people, and then RN #1, NA #1, NA #2 and herself went to the resident's room, put their gloves on, and when they went to change the resident, the resident said no. CNA #1 further revealed that was when RN #1 grabbed the resident's right forearm, put her knee on the resident's right hand, and used the other hand to get the resident's brief off. CNA #1 stated she was on the resident's left side holding his/her left hand, and was trying to help with the brief, and NA #1 was next to RN #1. She stated when they rolled the resident, NA #1 slid the clean brief underneath the resident, and fastened it. She stated at that time, the resident saw his/her hand was bleeding and asked what happened and RN #1 told him/her that he/she hit it on the siderail. The resident then said to get out and stop touching him/her. CNA #1 stated the resident had a half dollar size area with skin pulled back on his/her hand where RN #1's knee was placed, and, an area that was bleeding on his/her right forearm where RN #1's fingernails dug in to his/her skin (RN #1 had long fake (acrylic) fingernails). CNA #1 revealed the resident was combative and resistive the whole time, which was not normal for him/her. She stated while the RN was gone out of the room to get supplies for the skin tears, the resident starting crying and saying she broke my heart, and when the RN came back, the resident stated look what you did to my hand, and RN #1 denied it saying he/she hit it on the siderail. CNA #1 added they left the room after the resident hand and arm were bandaged and the resident was still crying. She stated the dayshift CNA (#2) met her in the hallway, and asked the resident what was wrong and the resident aid look what the nurse did showing her (his/her) right arm/hand. The resident was still crying. She stated when she gave report to CNA #2, CNA #2 told her she needed call the Director of Nursing (DON) or the Administrator to let them know about it. She said she left the facility at 6:00 AM; however, the Administrator, who was the Weekend Manager, called her when she got home, after CNA #2 had reported the incident to her. In addition, review of CNA #1's written statement revealed the resident was being combative, and the Charge Nurse grabbed his/her hand and put her knee with full force on the resident's hand, with her fingernails digging into his/her arm, which caused two (2) skin tears. Further review of the statement revealed CNA #1 reported the Charge Nurse had no reason to do what she did. The resident was panicking and becoming more combative when the Charge Nurse was on his/her arm/hand. Interview with NA #2, on [DATE] at 4:06 PM, revealed she and CNA #1 made rounds throughout the shift, and each time Resident #1 was resistive to being changed, so we decided to try again later. She stated they told RN #1 they were going to change the resident later and she stated no we're not, that's not acceptable, (he/she's) got be changed. NA #2 revealed there were four (4) staff in the resident's room, and RN #1 immediately grabbed his/her right arm, holding her knee on his/her right forearm, and had her hands on his/her right wrist. NA #2 recalled the resident had a cut on the top part of his/her right forearm and the resident said look what you did, but RN #1 blamed it on the resident. She revealed the resident was combative and crying the whole time,thinking (his/her) spouse was cheating on (him/her). and the resident was still crying when all of them left the room. She revealed RN #1 had been in a bad mood, hateful and rude to staff all night, not sure about any other residents. Further interview with NA #2, on [DATE] at 5:35 PM, revealed she did not report the incident because CNA #1 and NA #1 said they'd report it. She revealed the Administrator called her a few minutes after she got home, about 6:20 AM or 6:30 AM, on [DATE]; and the incident had occurred around 5:50 AM or 6:00 AM that morning. She stated she should have reported to another nurse before she left the building. In addition, review of NA #2's statement revealed the nurse held the resident down very roughly with her knee and dug her nails in (his/her) arm, which caused (him/her) to bleed. Nobody else acted that way, it was her anger. Interview with NA #1, on [DATE] at 11:05 AM, revealed on [DATE], she was walking down another hall when CNA #1 and NA #2 came up to RN #1 and told her that the resident would not let them change him/her. She stated RN #1 asked her to come along because we're going to need some help. That's unacceptable, (he/she) has to be changed. She stated they went to the resident's room, turned the light on, and the resident was still awake and he/she started crying and talking about his/her deceased spouse. She revealed, altogether, there were four (4) staff in the room. She stated RN #1 told the resident that they were going to change his/her brief, and the resident said to leave him/her alone. She revealed CNA #1 was holding the resident's left arm, RN #1 was holding his/her right arm/hand with both hands and one (1) knee, and she was holding the resident's ankles, or right above that, which were crossed. She stated they changed the resident but he/she was combative and they told him/her not to hit or kick us. She revealed the resident had blood on his/her right wrist or a little below it, and blood between his/her right fingers near his/her thumb. She stated the resident tried to blame the nurse, and stated you did this, but the nurse denied it and told the resident, we had to change you, but we have to patch you up now. She stated RN #1 left the room to get bandages and the resident started crying about his/her deceased spouse and got hysterical. She stated the RN came back, patched him/her up and left the room. She revealed she thinks CNA #1 texted the DON after they left the room, and then she went back to work, gave report to dayshift, and clocked out. Further interview with NA #1, on [DATE] at 5:24 PM, revealed she did not have phone numbers to report what happened at that time. She stated she should have reported to the other nurse there. In addition, review of NA #1's written statement revealed I saw the Charge Nurse apply way too much force on the resident's right arm, and jerk (him/her). At one of those points, her nails must've dug into (his/her) skin, which caused two (2) skin tears. She did not need to put that much force on (him/her). (He/she) also started to get more combative after the fact. Interview with CNA #2, on [DATE] at 12:25 PM, revealed she worked dayshift and received report from the third shift CNA (#1) regarding the [DATE] incident, which had just ended when she clocked in. She revealed they did a walk through during report. She stated as soon as CNA #1 told her about Resident #1, she checked on the resident and the resident was upset/crying, saying that mean nurse hurt my hand and she observed blood on the resident's right hand. She revealed she reported to the Administrator, who was the Weekend Manager, and in the building that morning. She stated after she reported the incident, the Administrator took it over. In addition, review of CNA #2's written statement revealed in report, (CNA #1) told me that (RN #1) and the three (3) aides were told that they had to change (Resident #1). (Resident #1) was upset and (RN #1) held (his/her) hand down with her knee, causing a skin tear. Interview with RN #2, on [DATE] at 6:38 PM, revealed she came in at 6:00 AM on [DATE] (Saturday) and received report from RN #1. She stated RN #1 stated the resident was being combative and got a skin tear on his/her right arm. She revealed she had never had an issue with the resident; however, when she saw the resident after report, he/she was still upset and yelling/crying, and she observed steri-strips on the top of the resident's right arm. Interview with the SSD/Abuse Coordinator, on [DATE] at 1:40 PM and [DATE] at 9:35 AM, revealed she and the Administrator conducted a joint investigation. She stated the Administrator had come in as Weekend Manager on [DATE], early that morning. She stated the Administrator spoke to CNA #2, CNA #1, and NA #1 , and the Administrator then called her, and she came to the facility. She revealed the three (3) staff gave their written statements to the Administrator; however, RN #1 refused to give a statement, and was escorted out of the building. She stated the resident recalled the incident and what the nurse was wearing, but did not remember her name. Further interview with the SSD/Abuse Coordinator revealed the appropriate notifications (Physician, family, police) were made, and stated we felt it was abuse. Interview with the Director of Nursing (DON), on [DATE] at 10:25 AM, revealed looking at her phone, she did not have a text message from (CNA #1) or any other of the other staff involved, on [DATE]. The DON stated the staff should have immediately reported to the nurse on the other unit (LPN #1), before ever leaving the building. She revealed CNA #1 and NA #1 should have told LPN #1 when they first saw RN #1 was angry. She stated she did not get to speak to RN #1 after the incident on [DATE], but she was usually very attentive to the residents. Review of the facility's final investigation, dated [DATE], completed by the Social Services Director (SSD)/Abuse Coordinator, revealed Staff was attempting to change the resident when the resident became combative with staff. Resident has had confusion during the process of recovering from COVID-19. Staff attempted to redirect the resident with the resident continuing to be combative. Staff stopped trying to change the resident at this time to let (him/her) calm down. It is likely that the RN took her knee and pressed it onto the resident's right hand holding (him/her) down to prevent further combative behavior. In the process of this, it appears that the resident obtained skin tears and bruising to (his/her) right hand and arm. Skin assessments were completed and the skin tear was cleansed and dressed. Families and MD were notified as well as the local police department. The resident continues to have some confusion, but expresses no concerns from the incident. The RN is no longer an employee with the facility. Witness statements from CNA #1, CNA #2, NA #1, and NA #2 (orientee) were included in the investigation. Interview with the Administrator, on [DATE] at 10:20 AM, revealed she came in about 5:00 AM on [DATE] due to being the Weekend Manager. She stated CNA #2, who was a dayshift CNA, came to her after CNA #1 reported to CNA #2 about Resident #1. Further interview with the Administrator revealed CNA #2 reported to her that CNA #1 said the resident received a skin tear on his/her right hand, as well as bruising. She stated she called CNA #1, NA #1 and NA #2, who had already left the building from working nightshift. She revealed RN #1 was giving report to the dayshift RN (#2) and she spoke to RN #1 in the clean utility room, with RN #2 as a witness. She stated RN #1 was angry and upset, but she did not see any blood on her. She further revealed she gave RN #1 an opportunity to write a statement; however, she chose not to. She stayed with RN #1 until she finished charting, and walked her out. She revealed the investigation was completed on [DATE] and she called RN #1 and terminated her on [DATE]. Further interview with the Administrator, at 6:00 PM, revealed she did not know if CNA #1, NA #1 and NA #2 felt uncomfortable to say anything to RN #1, because she was their supervisor; but, their actions were not appropriate, and they did not follow the policy related to Abuse/Neglect related to reporting.

Based on interview, record review, facility final report of allegation, and facility policy review, it was determined the facility failed to ensure an allegation of abuse was reported immediately for one (1) of three (3) sampled residents (Resident #1). On 06/20/2020, Resident #1 refused incontinent care during rounds at approximately 2:00 AM and 4:30 AM. When Certified Nurse Aide (CNA) #1 and Nurse Aide (NA) #2 made Registered Nurse (RN) #1 aware of this, she told CNA #1, NA #1, and NA #2 (orientee) that was unacceptable and the resident had to be changed. RN #1 told NA #1 to accompany her, CNA #1, and NA #2 to the resident's room. When they attempted to provide incontinent care to Resident #1, the resident refused, was crying, and became combative. RN #1 then proceeded to grab Resident #1's right arm and hold it to the bed with her hands and knee, while CNA #1 held the resident's left arm, and NA #1 held the resident's ankles with them crossed. RN #1 caused a skin tear on the resident's right forearm with her nails and on his/her right hand near his/her thumb/forefinger with her knee. Resident #1 stated she broke my heart and told RN #1 look what you did referring to his/her hand/arm, while still crying. CNA #1 reported the incident to CNA #2 (dayshift CNA) during report; however, CNA #1, NA #1 and NA #2 failed to report the incident to a supervisor. CNA #2 reported the incident to the Administrator, who was the Weekend Manager, and had been in the building since 5:00 AM on 06/20/2020. The findings include: Review of the facility's policy related to Resident Abuse, Neglect, and Exploitation, last revised 07/08/17, revealed all staff are trained to identify and report inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care. Any incidents of suspected abuse involving staff toward a resident shall immediately be reported to the employee's immediate supervisor and the Administrator and/or designee, at which time an investigation will begin. Employees witnessing an incident of resident abuse must report the incident immediately. The employee(s) witnessing the abuse may be considered as an accessory to the abuse if they do not report the incident. As such, they will be subject to disciplinary action in the form of warnings, or discharge from employment, and if appropriate, legal action. Record review revealed the facility admitted Resident #1 on 01/29/2020 with [DIAGNOSES REDACTED]. Interviews on 06/24/2020 with CNA #1 at 2:55 PM and NA #2 (orientee) at 4:06 PM; and on 06/25/2020 with NA #1 at 11:05 AM, revealed Resident #1 refused incontinent care at approximately 2:00 AM and 4:30 AM when CNA #1 and NA #2 made their rounds. The CNA and Aides stated CNA #1 and NA #2 decided to wait for day shift due to them having a better rapport with the resident. The CNA and Aides revealed when Registered Nurse (RN) #1 was made aware the resident refused, RN #1 told NA #1 to come with her, CNA #1, and NA #2 (orientee), and stated that was unacceptable and the resident had to be changed. The CNA and Aides further stated when they and RN #1 attempted to provide incontinent care to Resident #1, the resident refused, was crying, and became combative; and, RN #1 proceeded to grab Resident #1's right arm and hold it to the bed with her hands and knee. They stated RN #1 caused a skin tear with her nails on the resident's right forearm and on his/her right hand near his/her thumb/forefinger with her knee. The CNA and Aides revealed Resident #1 stated she broke my heart and told RN #1 look what you did referring to his/her hand/arm, while still crying. Interview with CNA #2, on 06/26/2020 at 12:25 PM, revealed she received report from CNA (#1) regarding the 06/20/2020 incident. She stated they were doing a walk through during report, and CNA #1 told her about Resident #1. She stated she checked on the resident and the resident was was upset/crying, saying that mean nurse hurt my hand. She revealed the resident's right hand had blood on it. She stated she reported this immediately to the Administrator, who was the Weekend Manager, and in the building that morning. Review of the facility's final investigation, dated 06/22/2020, completed by the Social Services Director (SSD)/Abuse Coordinator, revealed the allegation was initially reported to the Administrator by CNA #2 (dayshift aide) on 06/20/2020, after receiving report from CNA #1 (nightshift aide) that morning. However, there was no documented evidence the facility identified and took action related to CNA #1, NA #1 and NA #2 failing to report the allegation to an immediate supervisor. Further interview with CNA #1 on 06/24/2020 at 2:55 PM revealed she made the day CNA (#2) aware of the incident when she met her in the hallway after leaving the room. She stated when she gave report to CNA #2, CNA #2 told her she needed call the Director of Nursing (DON) or the Administrator to let them know about it. She said she left the facility at 6:00 AM; however, the Administrator, who was the Weekend Manager, called her when she got home, after CNA #2 had reported the incident to the Administrator. Further interview with NA #2, on 06/28/2020 at 5:35 PM, revealed she did not report the incident because CNA #1 and NA #1 said they'd report it. She revealed the Administrator called her a few minutes after she got home, about 6:20 AM or 6:30 AM, on 06/20/2020; and the incident had occurred around 5:50 AM or 6:00 AM that morning. She stated she should have reported to another nurse before she left the building. Further interview with NA #1, on 06/28/2020 at 5:24 PM, revealed she did not have phone numbers to report what happened at the time and she thinks CNA #1 texted the DON, and the DON said to report to the other facility nurse. She stated she should have reported to the other nurse there. Interview with the DON, on 06/29/2020 at 10:25 AM, revealed she was not notified by the staff about RN #1 on 06/20/2020. She revealed the staff involved should have immediately reported to the nurse on the other unit, before ever leaving the building, and CNA #1 and NA #1 should have notified the other nurse when they first saw RN #1 was angry. Interview with the Administrator, on 06/25/2020 at 10:20 AM, revealed she came in about 5:00 AM on 06/20/2020 due to being the Weekend Manager. She stated CNA #2 reported to her that CNA #1 said the resident had received a skin tear on his/her right hand, as well as bruising, during the incident. She stated she called CNA #1, NA #1 and NA #2, who had already left the building from working nightshift. Further interview with the Administrator, at 6:00 PM, revealed she did not know if CNA #1, NA #1 and NA #2 felt uncomfortable to say anything to RN #1, but their actions were not appropriate, and they did not follow the policy related to Abuse/Neglect related to reporting.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned on 05/27/2020 to allow the resident to calm down then re-approach later, or try another staff member to provide care, if resident refuses to be change and becomes combative. On 06/20/2020, Resident #1 refused incontinent care and became combative during rounds at approximately 2:00 AM and 4:30 AM and Certified Nurse Aide (CNA) #1, and Nurse Aide (NA) #2 (orientee), followed the care plan and were going to let day shift try to provide incontinent care because the resident had better rapport with them, However, at 5:50 AM-6:00 AM, when Registered Nurse (RN) #1 was made aware the resident had refused incontinent care; she stated it was unacceptable and the resident had to be changed. RN #1 instructed CNA #1, NA #2, and NA #1 to accompany her to the resident's room. Resident #1 refused and was crying and combative and RN #1 proceeded to hold Resident #1 right arm down with her knee and hand which resulted in a skin tear on his/her right forearm and on his/her right hand near his/her thumb/forefinger. CNA #1 held the resident's left hand and NA #1 held the resident's ankles. The findings include: Review of the facility's Comprehensive Care Plan Policy, dated 01/2020, revealed residents receive care and treatment based on an assessment of their needs, the severity of their [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #1 on 01/29/2020 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/07/2020, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's Care Plan Focus, Resident exhibits socially inappropriate/disruptive behavior, refuses to be changed, hits/scratches/kicks staff at times, pseudolrellar effect (uncontrollable episodes of crying and/or laughing, or other emotional displays}, dated 05/27/2020, revealed an intervention if resident is combative, allow resident to calm down, then re-approach later, or try another staff member to provide care. However, interviews on 06/24/2020 with CNA #1 at 2:55 PM and NA #2 (orientee) at 4:06 PM; and on 06/25/2020 with NA #1 at 11:05 AM, revealed on 06/20/2020, when Registered Nurse (RN) #1 was made aware Resident #1 had refused incontinent care, she told CNA #1, NA #2 and NA #1, that was unacceptable and the resident had to be changed. RN #1 had CNA #1, NA #2, and NA #1 assist her to provide incontinent care but Resident #1 refused and was crying and became combative. RN #1 proceeded to grab Resident #1 right arm and hold it down on the bed with her hands and knee causing a skin tear on his/her right forearm and on his/her right hand near his/her thumb/forefinger. CNA #1 and NA #1 also helped change the resident. Observation and interview with Resident #1, on 06/25/2020 at 2:30 PM, revealed the areas on his/her right forearm and right hand happened, on 06/20/2020, when RN #1 pushed on it. The resident spoke in a low tone and became tearful frequently during the conversation. Observation revealed a quarter-sized area, slightly torn open in a U or V shape, with no active bleeding on resident's right forearm and a small open area, darkened around it, with no active bleeding on right hand between his/her right thumb and forefinger. Interview with RN #1 (alleged perpetrator), on 06/30/2020 at 2:23 PM, revealed I prefer not to make a statement at this time. Interview with the MDS Coordinator (RN #3), on 06/29/2020 at 3:20 PM, revealed residents have the right to refuse any care, but staff should try to find out why the resident refused care, or maybe try to find someone who has a good rapport with the resident. Interview with the Director of Nursing (DON), on 06/29/2020 at 10:25 AM, revealed she expected staff to follow residents' care plans when providing care. Interview with the Administrator, on 06/29/2020 at 4:05 PM, revealed staff should try to reapproach a resident if combative.

Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The State Surveyor entered the front entrance to the facility on [DATE] to conduct a complaint survey related to Infection Control during Coronavirus Disease 2019 (COVID-19). However, the surveyor was not screened related to COVID 19 per facility policy until three (3) hours after she entered the facility. The findings include: Review of the facility policy titled, Concord Health Systems, Coronavirus Surveillance, dated 03/31/2020, revealed increased surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening all visitors (including essential vendors), staff, and residents. Observation on 04/29/2020 at 9:45 AM, revealed the surveyor entered the facility front entrance for a complaint related to Infection Control during COVID-19. The Assistant Administrator was already inside the front entrance and greeted the surveyor at that time. She informed the surveyor that the conference room near the front entrance of the facility was available for use and lead the surveyor directly to this area. There was already a person set up in the conference room, but she was relocated to another area of the building. The Assistant Administrator then went to find the Administrator. The Assistant Administrator did not screen the surveyor related to COVID-19 until 1:00 PM, over three (3) hours later. Interview with the Assistant Administrator, on 05/04/2020 at 2:20 PM, revealed she did not understand the deficient practice when the surveyor was not in a resident care area on 04/29/2020. Interview with the Administrator, on 04/29/2020 at 10:00 AM, revealed there was only one (1) entrance/exit for the facility's employees at the back of the building, and all staff get screened upon entrance. She stated that any other people who use the front door get screened there as well. However, further interview wit the Administrator on 05/01/2020 at 1:13 PM, revealed she stated, we have a person at the front desk; however, we don't have a screening site set up at the front door, and the door to the front lobby has a keypad. She stated they do have the means to screen at the front entrance of the building.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of two (2) sampled residents (Residents #49). Resident #49 was care planned to administer Oxygen (O2) at four (4) liters per nasal cannula (N/C); however, observations revealed the O2 was being administered at three (3) liters per N/C. The findings Include: Review of facility policy titled, Comprehensive Care Plan, last revised 01/02/2020, revealed it is the purpose of this form to document how each residents' daily needs are provided by the nursing staff in accordance with the guidelines of the RAI process and in keeping with the Medicare/Medicaid requirements. Residents receive care and treatment based on an assessment of their needs, the severity of their [DIAGNOSES REDACTED]. The data obtained from the assessment is used to determine and prioritize the residents Comprehensive Plan of Care. The nurse overseeing the resident's care will complete and implement the initial form. The development, implementation, and maintenance of a resident's care plan as initiated by the admitting licensed nurse, and it is an interdisciplinary process. All disciplines involved in the care of the resident collaborate to develop a comprehensive plan of care. The resident/family or resident's representative is included to the extent possible in the implementation, maintenance, and evaluation of the care provided. Record review revealed the facility admitted Resident #49 on 12/02/2019 with the [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/17/2019 revealed the facility assessed Resident #49's cognition as intact with a Brief Interview for Mental Status (BI[CONDITION]) score of twelve (12) which indicated the resident was interviewable. Review of Resident #49's Comprehensive Care Plan for at risk for Respiratory Distress with use of O2, dated 01/21/2020 revealed an intervention to administer O2 as ordered. Review of Resident #49's February 2020 physician's orders [REDACTED].#49's 02 concentrator was set at four (4) liters per N/C. Interview with the Administrator on 02/07/2020 at 3:15 PM revealed she expected staff to follow the resident's care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents received respiratory care that was consistent with professional standards of practice, and the comprehensive person-centered care plan ( Residents #[AGE] and #49). Resident #49 and #[AGE] were physician ordered and care planned to receive Oxygen (O2) at three (3) and two (2) liters respectively, per nasal cannula (N/C). However, observations revealed Resident #49 was receiving O2 at four (4) liters per N/C and Resident #[AGE] was found not to be wearing wearing his/her O2. In addition, the nurse failed to obtain the Resident's [AGE]'s O2 sat, even though the resident was stating he/she could not breath. The findings include: Review of facility policy titled, Oxygen Policy and Procedure, last revised 02/01/2020, revealed the purpose of oxygen is to supplement oxygen supply when insufficient oxygen is being carried by the blood to the tissue. Responsibility: Licensed Nurse a. Procedure - Check physician's orders [REDACTED]. Note Physician order [REDACTED]. If at any time the oxygen saturation (O2 sat.) below [AGE]%, initiate oxygen and notify the physician. b. Oxygen saturations are to be checked every shift and documented on the Treatment Administration Record (TAR). c. If oxygen saturations fall below [AGE]%, check O2 sat's every two hours until oxygen reaches [AGE]% or greater and record on the TAR. 1. Record review revealed the facility admitted Resident #49 on 12/02/2019 with the [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 11/17/2019 revealed the facility assessed Resident #49's cognition as intact with a Brief Interview for Mental Status (BI[CONDITION]) score of twelve (12) which indicated the resident was interviewable. Review of Resident #49's Comprehensive Care Plan for at risk for Respiratory Distress with use of oxygen (O2), dated 01/21/2020 revealed to administer O2 as ordered. Review of Resident #49's February 2020 physician's orders [REDACTED]. Observation on [DATE]20 at 9:09 AM revealed Resident #49's 02 concentrator was set at four (4) liters per N/C. Further observations on 02/07/2020 revealed the 02 setting was at 3 liters at 10:00 AM, then at 2:23 PM observed the 02 to now to be on 4 liters again. Interview with Resident #49, on 02/07/2020 at 2:30 PM revealed a Certified Nurse Aide (CNA) was in the room earlier and I asked her to turn it up, and she went to ask the nurse and the nurse told her she could turn it up a little. The CNA was identified to be CNA #4. Interview with CNA# 4 on 02/07/2020 at 2:45 PM revealed she had asked the nurse, Licensed Practical Nurse (LPN) #2, and she said go make it look as though you turn the 02 up to keep the resident happy. Interview with LPN #2 on 02/07/2020 at 3:00 PM revealed she told the CNA to go in the resident's room and check it out, but told the CNA not to touch it. When questioned the LPN if the CNA should have been assessing the need to turn up the O2, she stated no. Further interview at 3:36 PM revealed, she should have assessed the resident, and when asked why she didn't she stated just scatter brained, I guess. Interview with Registered Nurse (RN) #2 on 02/07/2020 at 3:10 PM revealed CNA's are never to assess or adjust the O2, but should report it to the nurse for the nurse to assess. Interview with the Administrator on 02/07/2020 at 3:15 PM revealed she expected the nurse only, to a assess a resident's 02 needs, and if needed to be turned up or down, to call the physician and get an order. 2. Record review revealed the facility admitted Resident #[AGE] on 03/12/19 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 12/03/19 revealed the facility assessed Resident #[AGE]'s cognition as severely impaired with a BI[CONDITION] score of three (3), which indicated the resident was not interviewable. Review of Resident #[AGE]'s Comprehensive Care Plan for at risk for Respiratory Distress, dated 01/15/19, revealed an intervention to administer 02 as ordered and desat weekly on room air. Review of Resident #[AGE]'s February 2020 Physician order [REDACTED]. Observation on 02/07/2020 at 10:20 AM revealed Resident #[AGE] was sitting on the side of bed with his/her head down. Further observation revealed the 02 tubing was laying on the floor and not connected to the concentrator, and the water bottle was also laying on the floor. CNA #3, who was in the room at the time, got the assistance of RN #2, who got a portable 02 tank to use while getting new tubing and humidity. Observation on 02/07/2020 at 10:25 AM revealed Registered Nurse (RN) #2 hooked up the resident to the portable 02 tank to replace the dirty tubing that had been on the floor, but did not check the resident's 02 sat (the amount of oxygen in the blood) even though it was not known how long the 02 had been off, and the resident was complaining of not being able to breath. When the RN was asked to check the resident's 02 SAT's, the resident's O2 sat was 89%. Interview with RN #2 on 02/07/2020 at 4:58 PM revealed she visually assessed the resident and did not see a concern with the resident and, also, was desating the resident, which required 02 to be off for fifteen (15) minutes only. However, it was unknown how long the 02 had been off and the resident was complaining of not being able to breath. Interview with the Assistant Director of Nursing (ADON) on 02/07/2020 at approximately 5:10 PM revealed a CNA was never to assess a resident on 02, or alter the administration of 02 in any way. She stated it was the licensed nurse's responsibility. The interview further revealed anytime a resident was off 02 for an unknown amount of time, and the order is for continuous, she expected the resident to be assessed including checking the 02 saturation of the resident.

Based on observation, interview, record review and facility policy review, it was determined the facility failed maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-two (22) sampled residents (Resident #[AGE]). The Certified Nurse Aide (CNA) failed to wash his/her hands during pericare and handle linen properly to prevent the spread of infection. The findings include: Review of facility policy titled, Precautions for Managing Infection, last revised 03/09/10 revealed: 1. Hand washing a. Wash hands after touching body fluids secretions, excretions and contaminated items, whether or not gloves are worn. b Wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Wash hands between task and procedures on the same resident to prevent cross-contamination of different body sites. 2. Gloves: a. Wear gloves (clean, non sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and non-intact skin. c. Change gloves between task and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environment. 3. Linen: transport, and process linen soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents. Record review revealed the facility admitted Resident #[AGE] on 03/12/19 with [DIAGNOSES REDACTED]. Observation of Resident #[AGE]'s incontinent care provided by CNA #3 and #4, on 02/07/20 at 10:50 AM revealed the two (2) CNA's prepared for incontinent care by washing their hands and applying gloves and obtaining a bath basin of water with multiple washcloths and towels. Further observation revealed CNA #3 removed the resident's soiled brief and washed the resident's peri area, and CNA #4 completed perineal (peri) care by cleaning the buttocks and rectal area. Further observation revealed after CNA #4 washed the resident, the resident was incontinent of stool. The CNA washed the resident and laid the soiled washcloth on the bed side tray (BST), touching the resident's water picture. The two CNA's then provided occupied bed care due to the sheets being soiled. The soiled sheets were removed and since there was no bag in place to place the dirty linen in, CNA #3 attempted to hold the linen in her hands while applying the clean linen. CNA #3 then placed the dirty linen at the foot of the bed on the clean linen to free up both hands, and a clean brief applied. Further observation revealed at no time did either CNA wash hands or change gloves after going from a dirty area and prior going to a clean area. CNA #4 then removed the tub from the BST without cleaning off the BST, took a trash bag and placed the soiled laundry inside the bag, and removed it out of the room, still with the same dirty gloves on. CNA #4 was observed, a few minutes later, without gloves, preparing to transfer another resident in the wheel chair. When asked where she had washed her hands, she stated to tell the truth, I did not wash them. Interview with CNA #3 on 02/07/2020 at 11:15 AM revealed she should have came better prepared, by having a bag ready for the soiled linen. She stated she realized she should have washed her hands and changed gloves after giving peri care and prior to applying clean linen and clothing, but failed to do so. Interview with CNA #4 on 02/07/2020 at 11:20 AM revealed she had not been a CNA very long, but did realize she should have washed hands and changed gloves before applying clean linen and clothing, and should have cleaned off the BST after laying dirty linen on the table. She also stated she should have washed her hands after disposing of the soiled linen, and before assisting another resident. Interview with the Assistant Director of Nursing (ADON) on 02/07/2020 at approximately 5:00 PM revealed CNA #4 had been certified only a short time so may need more education, but she expected all CNA's to follow the facility policy of proper hand hygiene, glove use, handling of linen, and the cleaning of dirty surfaces after exposure to soiled items, to ensure good infection control.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of three (3) sampled residents related to falls (Resident #1). Resident #1 was identified by staff to be removing his/her tag alarm and to get up and walk; however, the facility failed to revise the care plan to address the resident's behavior. In addition, Resident #1 was care planned to have a bowel and bladder pattern completed on 11/25/19, however, the facility failed to revise the care plan with a toileting schedule until 12/03/19 (five{5} days after the pattern should have been completed). The findings include: Review of facility policy titled, Comprehensive Care Plan, last revised 03/07/10, revealed the purpose is to document how each residents' daily care needs are provided by the nursing staff in accordance with the guidelines of the RAI process and in keeping with the Medicare/Medicaid Services requirements. Residents are to receive care and treatment based on an assessment of their needs, the severity of their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT and or the MDS Coordinator will review and finalize the care plan form in the resident portal as updates are completed. Record review revealed the facility admitted Resident #1 on 10/29/19 with diagnoses, which included fracture of Unspecified Part of Neck of Left Femur, Symbolic Dysfunction, Dementia without Behaviors, Unsteadiness on feet, Need for Assistance with Personal Care, [CONDITION(S)]-Right Ankle/Joints of Right Foot, Cervical Disc Degeneration C4-C7, and Spondylolisthesis-Cervical Region. Review of Admission Minimum Data Set (MDS) assessment, dated 11/05/19 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment, revealed the facility assessed the resident required extensive assistance with 1-2 person, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility Fall Investigation dated 11/01/19 at 12:15 AM revealed Resident #1 fell in room with tag alarm placed for increased safety awareness related to intermittent confusion as an intervention. Further review revealed Resident #1 stated he/she was going to bathroom. Observation on 12/03/19 at 12:55 PM revealed Resident #1 was observed walking from room to hallway with no alarm sounding and no staff assistance. Interviews on 12/03/19 with Resident #1's roommate at 12:55 PM, Certified Nursing Assistant (CNA) #1 at 12:57, and the Unit Manager at 4:00 PM; and, on 12/04/19 with Licensed Practical Nurse (LPN) at 1:13 PM revealed Resident #1 would remove his/her tag alarm all the time and get up and walk. LPN #2 stated MDS nurses were responsible for ensuring interventions were on the care plans of the residents. Review of Resident #1's Comprehensive Care Plan for at risk for falls/injury, last revised on 11/13/19 revealed an intervention for tag alarm placed on bed and wheelchair; however, further review revealed there was no documented evidence the care plan was revised to address the resident's ability to remove the alarm. Review of facility Fall Investigation dated 11/23/19 at 6:50 AM revealed Resident #1 was found sitting on floor in the door on buttocks with tag alarm unattached/not sounding and no call light on in room. Resident #1 stated he/she had been to the bathroom and lost balance on the way back. An immediate intervention was put in place to ensure tag alarms were in place when shift is changed. Further review of the investigation revealed a 72-hour bowel and bladder pattern to be initiated on 11/25/19. Review of the Comprehensive Care Plan for Self-Care Deficit related to weakness following fracture to left leg, requires assist with ADL's, initiated 10/29/19 revealed an intervention was placed on 12/03/19 by the MDS Nurse for scheduled toileting upon rising, after meals, at bedtime and at 3:00 AM. However, the intervention should have been initiated on 11/28/19 when the 72 hour bowel and bladder pattern should have been completed. Interviews on 12/04/19 with Registered Nurse (RN) #3 at 9:55 AM and RN #1 at 11:00 AM, revealed the MDS Nurse is responsible for ensuring interventions are on care plans. Interview with MDS Nurse on 12/04/19 at 10:00 AM and 3:00 PM revealed she was responsible for ensuring revisions were completed to the care plan timely. The MDS Nurse stated she would revise Resident #1's care plan as the resident being non-complaint or refusing related to pulling tag alarm off. The MDS Nurse further revealed she did not look at the bowel and bladder training until later and it would be a fall intervention and should have been placed on the care plan sooner. Interview with the Director of Nursing (DON) on 12/04/19 at approximately 3:15 PM revealed Resident #1 should be care planned for pulling off the tag alarms. The DON stated she expected the toileting schedule to have been in place prior to 12/03/19. Interview with the Assistant Administrator on 12/05/19 at 11:10 AM revealed Quality Assurance had been reviewing the fall process and this had been ongoing for several weeks. She stated the purpose was to ensure interventions were being done timely.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision and assistance devices to prevent accidents. Staff were aware Resident #1 would remove his/her alarm and attempt to go to the bathroom without assistance; however, the facility failed to address the resident removing the alarm and failed to address Resident #1's attempts to use restroom without assistance timely. The findings include: Review of facility policy titled, Environmental Accident Prevention, last revised 03/17/10 revealed the environment and personal safety of each resident is to be ensured through a program of continuous reporting, monitoring, and educating. Procedure: the resident is assessed to ensure adequate supervision to prevent accidents and promote safety and well-being. Review of facility policy titled, Fall Management Program, last revised 08/21/13, revealed it is the policy of this facility to safeguard the residents while promoting the highest possible level of independence and quality of life. This will be accomplished though a thorough assessment of all residents to establish their risk for falls, care planning and implementing appropriate interventions to minimize falls and injuries related to falls and tracking and trending patterns. Residents assessed to be at risk for falling will have appropriate interventions in place and the individual care plan will have a plan of care for their risks for falls, with comprehensive and CNA care plans reflecting risks and interventions for falls. Both will be updated timely removing or adding interventions as necessary. Record review revealed the facility admitted Resident #1 on 10/29/19 with diagnoses, which included fracture of Unspecified Part of Neck of Left Femur, Symbolic Dysfunction, Dementia without Behaviors, Unsteadiness on feet, Need for Assistance with Personal Care, [CONDITION(S)]-Right Ankle/Joints of Right Foot, Cervical Disc Degeneration C4-C7, and Spondylolisthesis-Cervical Region. Review of Admission Minimum Data Set (MDS) assessment, dated 11/05/19 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment, revealed the facility assessed the resident required extensive assistance of one-two (1-2) person, and had a history of falls. Review of facility fall investigation revealed on 11/01/19 at 12:15 AM, Resident #1 was found sitting on the floor to right of bed on bottom leaning to left side with left arm propping resident up. Resident #1 stated, I was just getting up to go to the bathroom to pee when I slipped into the floor on accident. No injury noted. The facility determined a tag alarm was to be placed to bed and wheelchair. Review of the Comprehensive Care Plan for at risk for falls/injury related to history of falls, impaired balance last revised 11/13/19 revealed an intervention for a tag alarm placed on bed and wheelchair Observation on 12/03/19 at 12:55 PM revealed Resident #1 was observed walking from room to hallway with no alarm sounding and no staff assistance. Interview with Resident #1's roommate on 12/03/19 at 12:55 PM revealed Resident #1 has an alarm but gets out of bed. He/she stated he/she has to put on the call light for assistance because Resident #1 pulls off the alarm. Interview with Certified Nursing Assistant (CNA) #1 on 12/03/19 at 12:57 revealed Resident #1 pulled off his/her alarm all the time. Interview with Licensed Practical Nurse (LPN #2) on 12/04/19 at 1:13 PM revealed she had been informed on 11/23/19 that Resident #1 would remove tag alarm. Interview with the Unit Manager (UM) #1 on 12/03/19 at 4:00 PM revealed Resident #1 takes off tag alarm. Review of Resident #1's Comprehensive Care Plan for at risk for falls/injury related to history of falls, impaired balance, last revised on 11/13/19 revealed an intervention for tag alarm placed on bed and wheelchair with no interventions to address the resident's removing the alarm. Review of facility Fall Investigation dated 11/23/19 at 6:50 AM revealed Resident #1 was found sitting on floor in the door on buttocks with tag alarm unattached/not sounding and no call light on in room. Resident #1 stated he/she had been to the bathroom and lost balance on the way back. An immediate intervention was put in place to ensure tag alarms were in place when shift is changed and a to initiate a 72-hour bowel and bladder pattern on 11/25/19. Review of the Comprehensive Care Plan for Self-Care Deficit related to weakness following fracture to left leg, requires assist with ADL's, initiated 10/29/19 revealed an intervention for scheduled toileting upon rising, after meals, at bedtime and at 3:00 AM was not put in place until 12/03/19 (five {5} days after the bowel and bladder pattern should have been completed. Interviews on 12/04/19 with Registered Nurse (RN) #3 at 9:55 AM and RN#1 at 11:00 AM revealed the MDS Nurse is responsible for ensuring interventions are on care plans. Interview with MDS Nurse on 12/04/19 at 10:00 AM and 3:00 PM revealed she was responsible for ensuring revisions were completed to the care plan timely. The MDS Nurse stated she would revise Resident #1's care plan as the resident being non-complaint or refusing related to pulling tag alarm off. The MDS Nurse further revealed she did not look at the bowel and bladder training until later and it would be a fall intervention and should have been placed on the care plan sooner. Interview with the Director of Nursing (DON) on 12/04/19 at approximately 3:15 PM revealed alarms do not prevent falls but alert the staff. She stated staff have been educated to ensure that alarms are in place and bowel and bladder assessments are completed quarterly and on admission by MDS. The DON revealed she did not think alarms were good interventions if a resident has learned to pull them off, and at that point, another intervention should be tried. The DON further stated she thought it was related to Resident #1's behaviors and another intervention should be tried. She revealed she had met with staff on 11/22/19 related to staff not documenting behaviors of the resident. Interview with the Assistant Administrator on 12/05/19 at 11:10 AM revealed Quality Assurance had been reviewing the fall process and this had been ongoing for several weeks. She stated the purpose was to ensure interventions were being done timely. She revealed the IDT team would reconvene in the afternoon to ensure that notification had been made, and interventions had been put in place; and, the staff had been doing weekly rounds to ensure effectiveness. .

Based on interview, record review, review of restorative log, and review of facility policy, it was determined the facility failed to ensure thirteen (13) of twenty-four (24) sampled residents' Comprehensive Care Plans were implemented related to restorative services (Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #92) . Interviews with Registered Nurse (RN) #1 and RN #2 revealed there were fifty-six (56) residents on the facility's restorative program roster. Review of the Care Plans and (MONTH) and (MONTH) (YEAR) Restorative Service logs for Resident #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #92 and remaining forty-three (43) residents' who were also on the Restorative Program revealed the residents did not receive restorative services two (2) to five times a week from 10/28/18-11/17/18 (three (3) weeks) . The findings include: Review of the facility policy titled Comprehensive Care Plan, last revised 02/10/15, revealed residents receive care and treatment based on an assessment of their needs, the severity of their [DIAGNOSES REDACTED]. The data obtained from the assessment is used to determine and prioritize the resident's comprehensive care plan. The nurse overseeing the resident's care will complete and implement the initial care plan. The interdisciplinary team (IDT) and or Minimum Data Set (MDS) Coordinator will review and finalize the care plan for continued provision of care. The plan is based upon: Assessment by licensed nursing, current orders including therapy, history and physical, Physician and consultant notes, condition of the resident, documented individualized care, and other relevant documentation that relates to the care of the resident. The development, implementation, and maintenance of a resident's care plan is an interdisciplinary process. 1. Record review revealed the facility admitted Resident #2 on 09/03/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/13/18, revealed the facility assessed Resident #2's cognition as intact which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Actual Contractures and/or Limited Range of Motion , dated 06/13/17 revealed interventions for Passive Range of Motion (PROM) to bilateral upper extremities (BUE), two (2) sets of fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes. However, review of the Restorative Service Log for (MONTH) and November, (YEAR), revealed Resident #2 received restorative services four days a week for three (3) weeks from (MONTH) 28, (YEAR) through (MONTH) 17, (YEAR) instead of daily (seven {7} days a week) as care planned. 2. Record review revealed the facility admitted Resident #14 on 08/07/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 08/14/18, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 06/05/17 and 07/09/18 revealed interventions for Active ROM to BUE one (1) set of 75 repetitions daily with one (1) pound weight; at least six (6) out of seven (7) days; and splint/brace to bilateral lower extremities (BLE) to be donned after stretching of BLE, leave brace on for eight (8) hours of duration daily. However, review of the Restorative Service Logs for (MONTH) and November, (YEAR), revealed the resident received restorative services two (2) days the week of 10/28/18 and four (4) days the week of 11/04/18, instead of six (6) days a week and daily as care planned. 3. Record review revealed the facility admitted Resident #31 on 11/15/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/06/18, revealed the facility assessed Resident #31's cognition as severely impaired as he/she rarely or never understood and was unable to complete a BIMS assessment. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 02/19/18, revealed interventions for passive ROM to BLE, two (2) sets of twenty (20) repetitions daily. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed Resident #31 received services four (4) or five (5) days days for three (3) weeks from (MONTH) 28, (YEAR) to (MONTH) 17, (YEAR) instead of daily as care planned. 4. Record review revealed the facility admitted Resident #44 on 02/05/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 09/20/18, revealed the facility assessed Resident #44's cognition as severely impaired with a BIMS score of three (3) which indicated the Resident was not interviewable. Review of the Comprehensive Care Plan for self care deficits, dated 12/12/17 revealed interventions to cue/prompt/assist self feeding equal to or greater than fifteen (15) minutes for meals six (6) out of seven (7) days per week; at least six (6) out of seven (7) days. Review of a Care Plan for At Risk for Contractures and/or Limited Range of Motion, with interventions for passive ROM to BUE twenty (20) repetitions for one (1) set, once daily, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days a week. However, review of the Restorative Service Logs for (MONTH) and November, (YEAR), revealed Resident #44 received restorative services four (4) days the week of 10/28/18 and five (5) days the following two (2) weeks instead of six (6) days a week as care planned. 5. Record review revealed the facility admitted Resident #62 on 04/03/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment,, dated 10/11/18, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for self care deficits with bed mobility, dated 08/24/18 revealed interventions to cue/prompt/assist resident for bed mobility, at least six (6) out of seven (7) days. Review of a Care Plan for At Risk for Contractures and/or Limited Range of Motion, dated 10/16/17 revealed interventions for active ROM to BUE and bilateral lower extremities (BLE) twenty (20) repetitions for one (1) set equal to or greater than fifteen (15) minutes once daily, six (6) out of seven (7) days a week. However, review of the Restorative Service Logs for (MONTH) and November, (YEAR), revealed Resident #44 received restorative services three (3) days a week from 10/28/18 to 11/10/18 (two weeks) and four (4) days the following week instead of six (6) days a week as care planned. 6. Record review revealed the facility admitted Resident #54 on 02/24/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/03/18, revealed the facility assessed Resident #54's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 11/05/18 revealed interventions for active ROM to BLE two (2) sets of ten (10) repetitions all planes as tolerated by the resident daily equal to or greater than fifteen (15) minutes for at least six (6) out of seven (7) days. However, review of the Restorative Service Log for November, (YEAR) revealed the resident received restorative services four days the first week and five (5) days the second week of (MONTH) instead of six (6) days as care planned. 7. Record review revealed the facility admitted Resident #55 on 09/05/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/12/18, revealed the facility assessed Resident #55's cognition as severely impaired with a BIMS score of eight (8) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for impaired physical mobility, initiated 11/05/18, revealed an intervention to ambulate (200 feet) with assistance of one (1) with rolling walker daily. However, review of the Restorative Services Log for November, (YEAR), revealed the resident received restorative services four days the first and second weeks after restorative therapy was initiated instead of daily as care planned. 8. Record review revealed the facility admitted Resident #32 on 12/01/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for self care deficits in dressing/grooming , last revised on 02/19/18 revealed an intervention to cue/prompt/assist resident to brush hair and teeth daily. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, revealed an intervention for active ROM to BUE with two (2) pound weight, one (1) set of twenty (2) repetitions daily. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed the resident received restorative services three (3) days the week of 10/28/18, four (4) days the week of 11/04/18, and six (6) days the week of 11/11/18; instead of daily as care planned. 9. Record review revealed the facility admitted Resident #35 on 05/19/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 09/26/18, revealed an intervention to provide active ROM to BLE, knee flexion/extension and ankle mobility two (2) sets of fifteen (15) repetitions daily. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed the resident received restorative services two (2) days the week of 10/28/18, four (4) days the week of 11/04/18, and six (6) days the week of 11/11/18; instead of daily as care planned. 10. Record review revealed the facility admitted Resident #20 on 05/19/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/24/18, revealed the facility assessed Resident #20's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised on 02/22/17, revealed an interventions for active ROM to RUE twenty (20) repetitions, one (1) set equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; passive ROM to left upper extremity (LUE) one (1) set of twenty (20) repetitions daily equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; and splint/brace to LUE six (6) hours daily. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed Resident #20 received restorative services four (4) days the weeks of 10/28/18 and 11/04/18; and five (5) days the week of 11/11/18; instead of six (6) days as care planned . 11. Record review revealed the facility admitted Resident #81 on 01/25/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/23/18, revealed the facility assessed Resident #81's cognition as severely impaired as the resident was rarely or never understood and the BIMS assessment was not completed. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, last revised 11/21/18, revealed an intervention for passive ROM to BUE twenty (20) repetitions equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week. However, further review of the logs revealed the resident received restorative services two (2) days the week of 10/28/18; three (3) days the week of 11/04/18; and four (4) days the week of 11/11/18; instead of six (6) days a week as care planned. 12. Record review revealed the facility admitted Resident #88 on 02/23/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/25/18, revealed the facility assessed Resident #88's cognition as severely impaired as he/she was unable to complete the BIMS assessment due to being rarely or never understood, therefore, the resident was not interviewable. Review of the Comprehensive Care Plan for self care deficit of dressing/grooming and inability to convey food into mouth, last revised 06/07/17, revealed interventions to cue/prompt/assist resident to brush hair and teeth and dress upper and lower extremities daily, equal to or greater than fifteen (15) minutes, six (6) out of seven (7) days per week. Further review revealed to provide verbal cues with meals allowing resident to do as much for self as possible with an acceptable amount of time then assist, encourage resident to stay at table, check mouth frequently for pocketing foot equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed Resident #88 received restorative nursing services four (4) days the week of 10/28/18 and five (5) days the week of 11/04/18, instead of six (6) days a week as care planned. 13. Record review revealed the facility admitted Resident #92 on 05/08/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/26/18, revealed the facility assessed Resident #92's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for At Risk for Contractures and/or Limited Range of Motion, , initiated on 06/18/18, revealed an interventions for a splint/brace to left upper hand six (6) hours daily, remove every two (2) hours to check for circulation, skin condition and to reposition, six (6) out of seven (7) days per week; and passive ROM to LUE, gentle ROM fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. However, review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed the resident received restorative nursing services three (3) days the week of 10/28/18 and 11/04/18; and four (4) days the week of 11/11/18 instead of six (6) days as care planned. In addition, review of the Comprehensive Care Plans and Restorative Service Logs for the other forty-two (42) residents in the restorative program revealed the Restorative Services were not provided two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, RA #4 at 1:18 PM, and RA #1 at 8:00 AM revealed RA #2, RA #3, and RA #4 are not able to follow the care plan for restorative services everyday because they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. RA #1 stated she works for the therapy department so cannot be pulled to the floor so she provides restorative services when the other aides get pulled. She stated she primarily provides walking services, applies splints and completes assessments, and attempts to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interview with the MDS Coordinator, Restorative Supervisor, RN #1, on 11/21/18 at 8:10 AM revealed she and RN #2 are responsible for the Restorative Program. She stated due to the restorative staff being pulled frequently, the restorative care had not been provided consistently. RN #1 revealed she expected the care plans to be followed as written. Interview with the Director of Nursing (DON) on 11/28/18 at 11:36 AM revealed she is not responsible for the Restorative Program or the Restorative care plans what-so-ever. She stated the MDS Coordinators, RN #1 and RN #2, are responsible for that program and she expected the care plans to be followed as written.

Based on interview, record review, review of restorative logs, and review of facility policy, it was determined the facility failed to ensure three (3) of three (3) residents in the restorative nursing program for Activities of Daily Living (ADL's) of twenty-four (24) sampled residents received the care and services to ensure that a resident's abilities in Activities of Daily Living (ADL's) are maintained or improved (Residents #32, #55, and #88). Review of the Restorative Services logs for (MONTH) and (MONTH) (YEAR), for Residents #32, Resident #88, Resident #55 and the remaining twenty-eight (28) residents who were also in the facility Restorative Program for ADL's, revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). The findings include: Interview with the Administrator on 11/21/18 at 10:46 AM revealed the facility does not have a Restorative policy, but refers to the Resident Assessment Instrument (RAI) Manual for provision of care. He further stated physician's orders [REDACTED]. 1. Record review revealed the facility admitted Resident #32 on 12/01/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Restorative Nursing Care Referral dated 01/23/18, revealed Resident #32 was to receive hygiene and grooming tasks. Review of the Comprehensive Care Plan, last revised on 02/19/18 revealed Resident #32 had self care deficits in dressing/grooming related to decreased independence with grooming with an intervention to cue/prompt/assist resident to brush hair and teeth daily. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed staff were to cue/prompt/assist resident to brush hair and teeth daily. However, further review revealed the resident received restorative services three (3) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18; and six (6) of seven (7) days the week of 11/11/18. 2. Record review revealed the facility admitted Resident #88 on 02/23/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/25/18, revealed the facility assessed Resident #88's cognition as severely impaired as he/she was unable to complete the BIMS assessment due to being rarely or never understood, therefore, the resident was not interviewable. Further review of the MDS revealed the resident required limited assistance of one (1) staff with eating and dressing; and, extensive assistance with two (2) staff for grooming. Review of the Comprehensive Care Plan, last revised 06/07/17, revealed Resident #88 had a self care deficit of dressing/grooming and inability to convey food into mouth related to impaired cognition and decreased independence with eating. Further review revealed interventions to cue/prompt/assist resident to brush hair and teeth. Dress upper and lower extremities daily, equal to or greater than fifteen (15) minutes, six (6) out of seven (7) days per week; provide verbal cues with meals allowing resident to do as much for self as possible with an acceptable amount of time then assist, encourage resident to stay at table, check mouth frequently for pocketing foot equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. Review of the Restorative Nursing Care Referral, dated 07/27/17, revealed Resident #88 was to receive verbal cuing and redirection as needed during meals to encourage independent self feeding. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed staff were to cue/prompt/assist resident to brush hair and teeth and with dressing daily, six (6) out of seven (7) days per week; and provide verbal cues with meals six (6) out of seven (7) days per week. However, further review revealed the resident received restorative nursing services four (4) of six (6) days the week of 10/28/18 and five (5) of six (6) days the week of 11/04/18. 3. Record review revealed the facility admitted Resident #55 on 09/05/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/12/18, revealed the facility assessed Resident #55's cognition as severely impaired with a BIMS score of eight (8) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required limited assistance to extensive assistance with ADL's. Review of the Restorative Nursing Care Referral dated 10/12/18 revealed Resident #55 was to receive ambulation assistant up to 200 feet to maintain current functional mobility five (5) times per week, daily. Review of the Comprehensive Care Plan, initiated 11/05/18, revealed Resident #55 had impaired physical mobility related to decreased ambulation with an interventions to ambulate 200 feet with assistance of one (1) with rolling walker daily. Review of the Restorative Services Logs for (MONTH) (YEAR), revealed Resident #55 was to ambulate 200 feet daily. However, further review revealed restorative services began on 11/05/18, over three (3) weeks after the referral date and the resident received restorative services four (4) of seven (7) days the first and second weeks after restorative therapy was initiated. In addition, review of the Restorative Service Logs for the remaining twenty-eight (28) sampled residents' in the restorative program for eating, ambulation and transfers revealed staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, and RA #4 at 1:18 PM, they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. They stated they are pulled from restorative on average one (1) to two (2) times per week and weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. They stated when they are pulled to the floor the remaining RA's are unable to complete the Restorative care. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week. RA #1 stated she provides restorative services when other aides get pulled. She revealed stated she primarily provides walking services, applies splints and completes assessments, but will attempt to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interviews on 11/21/18 with RN #1, Restorative Supervisor at 8:10 AM and RN #2, Restorative Supervisor at 9:25 AM revealed restorative aides are often pulled to fill certified nurse Aide (CNA) spots when there are call-ins or residents have doctor's appointments. They stated they expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. RN #2 stated RA #1 was out on surgical leave for a few weeks the end of (MONTH) and returned in early November, (YEAR). RN#1 stated they monitor the restorative logs to ensure services were being provided, but they had not reviewed the logs recently. Interview with Therapy Director on 11/21/18 at 9:45 AM revealed there is a potential for decline when residents are only receiving restorative therapy four (4) to five (5) times per week. Interview with the Administrator on 11/21/18 at 10:17 AM revealed prior to survey date, nothing had been implemented to identify and assess residents for potential declines in ADL's. He stated the facility's process is if a CNA sees a decline in resident function, it should be reported to the charge nurse and the charge nurse reports it to the therapy department, and notifies the physician for orders to evaluate and treat the resident. The Administrator revealed he knew there were holes in the provision of care, but was not aware how many because he had not reviewed the logs either. He further stated there was no plan or back up system in place to assure restorative services were provided prior to this annual survey.

Based on interview, record review, review of restorative logs, and review of facility policy, it was determined the facility failed to ensure eleven (11) of eleven (11) residents receiving restorative services for range of motion (ROM)/mobility of twenty-four (24) sampled residents, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility (Residents #2, #14, #31, #44, #62, #54, #32, #35, #20, #81, and #92). Review of the Restorative Services logs for (MONTH) and (MONTH) (YEAR), for Residents #2, #14, #31, #44, #62, #54, #32, #35, #20, #81, and #92 and the remaining thirty-nine (39) residents who were also in the facility Restorative Program for ROM/mobility, revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). The findings include: Interview with the Administrator on 11/21/18 at 10:46 AM revealed the facility does not have a Restorative policy, but refers to the Resident Assessment Instrument (RAI) Manual for provision of care. He further stated physician's orders [REDACTED]. 1. Record review revealed the facility admitted Resident #2 on 09/03/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2's cognition as intact which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in range of motion (ROM) in bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 12/21/16, revealed Resident #2 was to receive restorative care six (6) times per week with bilateral elbow orthotics donned for three (3) to four (4) hours daily and range of motion (ROM) to bilateral upper extremities (BUE), especially shoulders for assisted active range of motion (AAROM) all planes two (2) sets of fifteen (15). Review of the Comprehensive Care Plan, dated 06/13/17 revealed Resident #1 was At Risk for Actual Contractures and/or Limited Range of Motion related to Decreased Range of Motion with interventions which included Passive Range of Motion (PROM) to BUE two (2) sets of fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes. Review of the Restorative Service Log for (MONTH) and November, (YEAR), revealed Resident #2 was to receive passive ROM to BUE two (2) sets of fifteen (15) repetitions daily, equal to or greater than fifteen (15) minutes. However, further review of the logs revealed the resident received restorative services four (4) of seven (7) days each week for three (3) weeks from (MONTH) 28, (YEAR) through (MONTH) 17, (YEAR). 2. Record review revealed the facility admitted Resident #14 on 08/07/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 08/14/18, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to one side of upper extremities and bilateral lower extremities. Review of the Restorative Nursing Care Referrals, dated 06/23/16 and 07/04/18 revealed Resident #14 was to receive bilateral lower extremity (BLE) brace application after stretching of BLE. Leave brace on for one (1) hour and begin to increase in hour increments week by week until achieving six (6) to eight (8) hours duration, five (5) times per week. The resident was to also receive BLE exercises to increase flexibility and strength five (5) times per week. Review of the Comprehensive Care Plans, dated 06/05/17 and 07/09/18 revealed Resident #14 was At Risk for Contractures and/or Limited Range of Motion Related to Decreased Mobility and Requiring Splint/Brace Application. Further review revealed Interventions for Active ROM to BUE one (1) set of 75 repetitions daily with one (1) pound weight; Minimum requirements state that the resident have at least two (2) restorative services provided for a minimum of fifteen (15) minutes, at least six (6) out of seven (7) days; and splint/brace to BLE to be donned after stretching of BLE, leave brace on for eight (8) hours of duration daily. Review of the Restorative Service Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #14 was to receive active ROM to BUE one (1) set of seventy-five (75) repetitions daily; passive ROM to BLE two (2) sets for thirty (30) repetitions daily; and splint/brace to BLE to be donned after stretching daily. However, further review of the logs revealed the resident received restorative services only two (2) of seven (7) days the week of 10/28/18 and four (4) of seven (7) days the week of 11/04/18. 3. Record review revealed the facility admitted Resident #31 on 11/15/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/06/18, revealed the facility assessed Resident #31's cognition as severely impaired as he/she rarely or never understood and was unable to complete a BIMS assessment. Further review of the MDS revealed the resident had functional limitations in ROM in bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 01/31/18, revealed Resident #31 was to receive BLE ROM/stretches, heel slides, hip abduction and adduction ten (10) to fifteen (15) repetitions five (5) times per week. Review of the Comprehensive Care Plan, dated 02/19/18, revealed Resident #31 was at risk for contractures and/or limited ROM related to decreased mobility with interventions for passive ROM to BLE, two (2) sets of twenty (20) repetitions daily. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #31 was to received restorative services for passive ROM to BLE two (2) sets of twenty (20) daily. However, further review of the logs revealed the resident received services four (4) to five (5) days per week from (MONTH) 28, (YEAR) to (MONTH) 17, (YEAR). 4. Record review revealed the facility admitted Resident #44 on 02/05/18 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 09/20/18, revealed the facility assessed Resident #44's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had no functional limitations in ROM. Review of the Comprehensive Care Plans, dated 12/12/17 revealed Resident #44 was at risk for actual contracture and/or limited ROM related to decreased ROM and impaired cognition with interventions of passive ROM to BUE twenty (20) repetitions for one (1) set, once daily, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days a week. Review of the Restorative Service Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #44 was to receive Passive ROM to BUE six (6) out of seven (7) days a week. However, further review of the logs revealed the resident received restorative services four (4) of six (6) days the week of 10/28/18 and five (5) of six (6) days each week the following two (2) weeks. 5. Record review revealed the facility admitted Resident #62 on 04/03/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, assessment, dated 10/11/18, revealed the facility assessed Resident #62's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required extensive assistance with two (2) staff for bed mobility and the resident had no functional limitations in ROM Review of the Restorative Nursing Care Referral, dated 08/23/18, revealed Resident #62 was to receive active assisted ROM/passive ROM to BUE with gentle stretch to elbows and all joints; and active assisted ROM to all joints of BLE. No recommendations were made as to the frequently of care. Review of the Comprehensive Care Plans dated 08/24/18 and 10/16/17 revealed Resident #44 had self care deficits with bed mobility related to decreased mobility and decreased strength. Further review revealed interventions to cue/prompt/assist resident for bed mobility, roll side to side in bed, equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days; Minimum requirements state the resident have at lease two (2) restorative services, provided a minimum of fifteen (15) minutes per twenty-four (24) hours, at least six (6) out of seven (7) days. Additionally, further review revealed Resident #44 was at risk for actual contracture and/or limited ROM related to decreased ROM and impaired cognition with an interventions for active ROM to BUE and BLE twenty (20) repetitions for one (1) set equal to or greater than fifteen (15) minutes once daily, six (6) out of seven (7) days a week. Review of the Restorative Service Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #44 was to receive active ROM to BUE and BLE six (6) out of seven (7) days a week and cue/prompt/assist resident with bed mobility six (6) out of seven (7) days. However, further review of the logs revealed the resident received restorative services only three (3) of six (6) days each week from 10/28/18 to 11/10/18 and four (4) of six (6) days the following week. 6. Record review revealed the facility admitted Resident #54 on 02/24/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/03/18, revealed the facility assessed Resident #54's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS revealed had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral dated 10/26/18 revealed Resident #54 was to receive complete Active ROM to BLE two (2) sets of ten (10) repetitions in all planes as tolerated. Review of the Comprehensive Care Plan, last revised 11/05/18 revealed Resident #54 was at risk for actual contracture and/or limited ROM related to decreased ROM with an intervention for active ROM to BLE two (2) set of ten (10) repetitions all planes as tolerated by the resident daily equal to or greater than fifteen (15) minutes for at least six (6) out of seven (7) days. Review of the Restorative Service Log for (MONTH) (YEAR) revealed Resident #54 was to receive active ROM to BLE daily equal to or greater than fifteen (15) minutes for at least six (6) of seven (7) days. However, further review of the log revealed restorative services did not begin until 11/05/18, ten (10) days after the referral date and the resident received restorative services four (4) of six (6) days the first week and five (5) of six (6) days the second week of November. 7. Record review revealed the facility admitted Resident #32 on 12/01/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/07/18, revealed the facility assessed Resident #32's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral lower extremities. Review of the Restorative Nursing Care Referral dated 01/23/18, revealed Resident #32 was to receive BUE exercise with two (2) pound weight in all planes. Review of the Comprehensive Care Plan, last revised on 02/19/18 revealed Resident #32 was at risk for actual contracture and/or limited range of motion related to decreased mobility with an intervention for active ROM to BUE with two (2) pound weight, one (1) set of twenty (2) repetitions. Review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed Resident #32 was to receive active ROM to BUE with two (2) pounds weight daily; however, further review of the logs revealed the resident received restorative services three (3) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18; and six (6) of seven (7) days the week of 11/11/18 8. Record review revealed the facility admitted Resident #35 on 05/19/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive to total care with all ADL's, was non-ambulatory and had no functional limitations in ROM. Review of the Restorative Nursing Care Referral dated 09/24/18 revealed Resident #35 was to received active ROM to BLE, hip flexion, knee flexion/extension and ankle mobility, five (5) times per week. Review of the Comprehensive Care Plan, revised on 09/26/18, revealed Resident #35 was at risk for actual contracture and/or limited ROM related to acute illness, decreased ROM, decreased cognition with an interventions for active ROM to BLE, knee flexion/extension and ankle mobility two (2) sets of fifteen (15) repetitions daily. Review of the Restorative Services Logs for (MONTH) and November, (YEAR), revealed Resident #35 was to receive active ROM to BLE hip, knee flexion/extension and ankle mobility daily. However, further review of the logs revealed the resident received restorative services two (2) of seven (7) days the week of 10/28/18; four (4) of seven (7) days the week of 11/04/18, and six (6) of seven (7) days the week of 11/11/18. 9. Record review revealed the facility admitted Resident #20 on 05/19/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/24/18, revealed the facility assessed Resident #20's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had functional limitation in ROM to one (1) side upper extremity. Review of the Restorative Nursing Care Referral dated 02/10/17, revealed Resident #20 was to receive gentle stretch to left hand; active assisted ROM to BUE all joints and bilateral hands; blue hand orthotic with finger separating six (6) hours daily. Review of the Comprehensive Care Plan, last revised on 02/22/17, revealed Resident #20 was at risk for actual contracture and/or limited ROM related to [DIAGNOSES REDACTED], and decreased ROM. Further review revealed interventions for active ROM to RUE twenty (20) repetitions, one (1) set equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; passive ROM to left upper extremity (LUE) one (1) set of twenty (20) repetitions daily equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week; splint/brace to LUE six (6) hours daily observe for redness, discolorations, increased temperature in extremities and expression or complains of pain during program procedures. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #20 was to receive active ROM to RUE daily six (6) of seven (7) days per week; passive ROM to LUE daily six (6) of seven (7) days per week; and splint/brace to LUE six (6) hours daily. However, further review of the logs revealed the resident received restorative services four (4) of six (6) days the weeks of 10/28/18 and 11/04/18; and five (5) of six (6) days the week of 11/11/18. 10. Record review revealed the facility admitted Resident #81 on 01/25/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/23/18, revealed the facility assessed Resident #81's cognition as severely impaired as the resident was rarely or never understood and the BIMS assessment was not completed. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 02/05/18, revealed resident #81 was to receive passive ROM to BUE in all planes; apply blue resting hand splints to both hands for four (4) hours. Review of the Comprehensive Care Plan, revised on 11/21/18, revealed Resident #81 was at risk for actual contracture and/or limited ROM related to decreased ROM, impaired cognition with an intervention for passive ROM to BUE twenty (20) repetitions equal to or greater than fifteen (15) minutes once daily six (6) out of seven (7) days per week. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed Resident #81 was to receive passive ROM to BUE six (6) of seven (7) days per week; and resting hand orthotics to BUE four (4) hours per day six (6) of seven (7) days per week. However, further review of the logs revealed the resident received restorative services two (2) of six (6) days the week on 10/28/18; three (3) of six (6) days the week of 11/04/18; and four (4) of six (6) days the week of 11/11/18. 11. Record review revealed the facility admitted Resident #92 on 05/08/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/26/18, revealed the facility assessed Resident #92's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the resident had functional limitations in ROM to bilateral upper and lower extremities. Review of the Restorative Nursing Care Referral, dated 06/04/18, revealed Resident #92 was to receive gentle ROM with LUE; place blue resting hand splint for six (6) hours daily. Review of the Comprehensive Care Plan, initiated on 06/18/18, revealed Resident #92 was at risk for contracture and/or limited ROM requiring splint/brace application related to decreased ROM, contracture to left hand. Further review revealed interventions for splint/brace to left upper hand six (6) hours daily, remove every two (2) hours to check for circulation, skin condition and to reposition, six (6) out of seven (7) days per week; and, passive ROM to LUE, gentle ROM fifteen (15) repetitions daily equal to or greater than fifteen (15) minutes six (6) out of seven (7) days per week. Review of the Restorative Services Logs for (MONTH) and (MONTH) (YEAR), revealed the resident was to receive passive ROM to LUE six (6) of seven (7) days per week; and splint;/brace to left upper hand six (6) hours daily six (6) of seven (7) days per week. However, further review of the logs revealed the resident received restorative nursing services three (3) of six (6) days the week of 10/28/18 and 11/04/18; and, four (4) of six (6) days the week of 11/11/18. In addition, review of the Restorative Logs for the remaining thirty-nine (39) residents who were also in the restorative program for ROM/mobility revealed the staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interview with Restorative Aide (RA) #2 on 11/21/18 at 8:41 AM revealed restorative aides are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. RA #2 stated she was pulled from restorative an average of one (1) to two (2) times per week. She further revealed the weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. RA #2 stated when she was pulled to work the floor, she could not always get the restorative program done. Interview with RA #3 on 11/21/18 at 8:48 AM revealed restorative aides are pulled to the floor to work as nursing assistants or to go out with residents for doctor's appointments quite often. She stated she was pulled to work the floor most weekends. RA #3 stated there is a restorative aide in the therapy department that does not get pulled (RA #1). RA #3 stated RA #1 does what she can to provide restorative services when the other RA's are pulled. Interview with RA #4 on 11/21/18 at 1:18 PM revealed some weeks she gets to provide restorative two (2) to three (3) times. RA #4 stated she often gets pulled from restorative to work the floor or go with residents to doctor's appointments. She stated most times one (1) restorative aide and the restorative aide from the therapy department are the only two (2) scheduled to provide restorative services. RA #4 stated there had been times when she was pulled to work the floor, and she was unable to provide restorative services. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week. RA #1 further stated she provided restorative services when other aides get pulled but she primarily provides walking services, applies splints, and completes assessments. She revealed she attempted to provide programs to other residents when the RA's were pulled but cannot get all the work done when it is just her providing restorative services. Interview with RN #1, Restorative Supervisor, on 11/21/18 at 8:10 AM revealed restorative aides are often pulled to fill certified nurse aide (CNA) spots when there are call-ins or residents have doctor's appointments. She stated when RA's are pulled to the floor as CNA's, she expected restorative services to be provided when daily care was provided. RN #1 stated I'm sure there has been a time when restorative care was not provided as it should be. RN #1 further stated RA #1 does not ever get pulled to the floor and is available to provide the needed services RN #1 revealed she reviewed the logs to assure services were being provided, but had not reviewed the logs recently. Interview with RN #2, Restorative Supervisor, on 11/21/18 at 9:25 AM revealed RA #1 was out on surgical leave for a few weeks the end of (MONTH) and returned in early November, (YEAR). She stated RA's are pulled often to work the floor, at least a couple times per week and she expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. She further stated she expected restorative services to be provided the way it is supposed to be and according to the care plan. Interview with the Assistant Director of Nursing (ADON) on 11/21/18 at 9:08 AM revealed restorative aides are pulled to the floor when there are staffing issues. The ADON stated when restorative aides are pulled to the floor, it is her expectation that the restorative program is completed while providing activities of daily living care. Interview with Therapy Director on 11/21/18 at 9:45 AM revealed there is a potential for decline based on the residents only receiving restorative therapy four (4) to five (5) times per week. Interview with the Administrator on 11/21/18 at 10:17 AM revealed prior to survey date, nothing had been implemented to assess residents for potential declines. He stated the facility's process is if a CNA sees a decline in resident function, it should be reported to the charge nurse and the charge nurse reports it to the therapy department and notifies the physician for orders to evaluate and treat the resident. The Administrator revealed he knew there were holes in the provision of care, but was not aware how many because he had not reviewed the logs either. The Administrator further stated there was no plan or back up system in place to assure restorative services were provided prior to this annual survey.

Based on interview, record review and facility policy review it was determined the facility failed to ensure there was sufficient nursing staff to provide restorative nursing services for thirteen (13) of thirteen (13) residents in the restorative program of twenty-four (24) sampled residents (Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91). Interview with Registered Nurse (RN) #1 and RN #2 revealed fifty-six (56) residents were on the facility's restorative program roster. Review of the Restorative Services logs for (MONTH) and November, (YEAR), for Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91 and the remaining forty (43) residents in the restorative program revealed the staff failed to provide restorative services for ADL's, ROM/mobility/bracing two (2) to five (5) days a week from 10/28/18-11/17/18 (three (3) weeks) because the Restorative staff were pulled to the floor. The findings include: Review of signed statement from the facility Administrator, dated 11/28/18, revealed the facility does not have a specific staffing policy and the facility follows the state guidelines for staffing. Review of the Restorative Logs for (MONTH) and (MONTH) (YEAR) revealed Residents #2, #14, #20, #31, #32, #35, #44, #54, #55, #62, #81, #88, and #91 and the remaining forty-three (43) residents who were in the Restorative Program for ADL's and ROM/mobility/splinting, revealed facility staff failed to provide restorative services two (2) to five (5) days out of six (6) to seven (7) days a week from 10/28/18-11/17/18 (three (3) weeks). Interviews on 11/21/18 with Restorative Aide (RA) #2 at 8:41 AM, RA #3 at 8:48 AM, and RA #4 at 1:18 PM, revealed they are pulled from restorative services frequently to work the floor as nursing assistants or to go out to doctor's appointments with a resident. They stated they are pulled from restorative an average of one (1) to two (2) times per week and weekends were the worse for getting pulled out of restorative services, because of a lot of call ins. They stated when they are pulled to the floor the remaining RA's are unable to complete the Restorative care. Interview with RA #1 on 11/21/18 at 8:00 AM revealed she is a restorative aide but is employed through the therapy department, so she cannot get pulled to work the floor as a nurse assistant. She stated she works five (5) days a week and provides restorative services when other aides get pulled. She revealed she primarily provides walking services, applies splints and completes assessments, but will attempt to provide programs to other residents when the RA's are pulled but cannot get all the work done when it is just her providing restorative services. Interviews on 11/21/18 with RN #1, Restorative Supervisor at 8:10 AM and RN #2, Restorative Supervisor at 9:25 AM revealed restorative aides are often pulled to fill certified nurse Aide (CNA) spots when there are call-ins or residents have doctor's appointments. They stated they expected the RA's to provide restorative care to their assigned residents when they are pulled to the floor. RN #2 stated RA #1 was out on surgical leave for a few weeks the end of (MONTH) and returned in early November, (YEAR). RN#1 stated they monitor the restorative logs to ensure services were being provided, but they had not reviewed the logs recently. Interview with the Assistant Director of Nursing (ADON) on 11/21/18 at 9:08 AM revealed restorative aides are pulled to the floor when there are staffing issues. The ADON stated when restorative aides are pulled to the floor, it is her expectation that the restorative program is completed while providing activities of daily living care.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Kitchen observations on 11/19/18, revealed foods were not labeled, dated or sealed completely in the walk-in refrigerator or walk-in freezer and the kitchen's manual can opener was visibly dirty. Review of the Census and Condition, dated 11/19/18, revealed one-hundred-four (104) of one-hundred-five (105) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled, Refrigerated Food Storage, not dated, revealed all refrigerated products shall be labeled indicating product name, date product was received and date product was opened. Observation of the walk-in refrigeration on 11/19/18 at 11:34 AM, revealed a Ziploc bag of white, sliced cheese, a bag of shredded cheese and bag of parmesan cheese on a shelf with no labeling or dating present on these items to know when they were opened or when the use by date was. 2. Review of facility policy Frozen Food Storage, not dated, revealed all refrigerated products shall be labeled indicating product name, date product was received and date product was opened. It further states food shall be covered completely in its original box or in a production pan to prevent air exposure. Observation of the walk-in freezer on 11/19/18 at 11:40 AM, revealed a open bag of diced carrots open to the air and an open bag of beef patties open to the air. 3. Review of facility policy Equipment Cleaning, not dated, revealed the can opener is to be cleaned and sanitized after each use or at the end of each shift. Observation of the kitchen on 11/19/18 at 11:44 AM, revealed the kitchen's manual can opener had a build up of black crusted material on the cutting edge. Interview with Dietary Manager on 11/19/18 at 11:50 AM, revealed she expected all foods stored in the refrigerators and freezers to be labeled, dated and sealed completely. She stated she expected the manual can opener to be cleaned after each use which would prevent any buildup on the cutting edge.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to follow the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #7). Resident #7 was care planned for wanderguard bracelet intact at all times and to check Wanderguard bracelet daily for placement, functioning, and replace device as needed. However, the facility failed to have a system in place to ensure the wanderguard device was removed from a resident within 90 days from the activate by date and/or not applied more than 90 after the activate by date. Resident #7 exited the building, on 06/23/18, without staff's knowledge and was found walking across the front lawn of the facility as a staff member arriving at work. The facility's failure to implement the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 06/29/18 and determined to exist on 06/23/18. The facility was notified of the Immediate Jeopardy on 06/29/18. An acceptable Allegation of Compliance (AoC) was received on 07/09/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 07/06/18. 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. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, last revised 02/10/15, revealed Residents receive care and treatment based on an assessment of their needs, the severity of their [DIAGNOSES REDACTED]. The data obtained from the assessment is used to determine and prioritize the resident's Comprehensive Plan of Care. Review of the facility's policy titled, Wandering Residents, not dated, revealed it is the facility's policy to identify residents who walk or wheel about unrestricted and are a threat to leave the facility unattended due to their confusion while utilizing the least restrictive means available to ensure their safety. Facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. Wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. The residents' name, picture, and physical description is placed in the wander book located at the nurses' stations. All staff is responsible for knowing whose name is on the list and be able to recognize the resident and be able to intervene as necessary. Every new employee will be informed of wandering residents upon orientation. A monitoring device (Wanderguard) will be placed on the resident according to manufacturer's directions. Exit monitoring system will be kept operational twenty-four (24) hours a day. Review of the alarm system's User Instructions, not dated, revealed the device the facility uses is a 90-day device that has a four to six-month shelf life from the date of manufacture and there is a date on the back of the device, Activate by Date, that indicates the last date the device can be activated to provide approximately ninety (90) days of useful life and that the date should be recorded in the resident's records. Review of the Stanley Healthcare Solutions Long Life vs. 90-Day Signaling Devices webpage, not dated, states By recording activation dates on the resident's med sheet, you'll know exactly how much life is left on the device. Record review revealed the facility admitted Resident #7 on 02/10/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/06/18, revealed the facility was unable to complete Brief Interview for Mental Status (BIMS) Score and staff assessed Resident #7's cognitive skills as severely impaired. Further review of the MDS revealed the facility assessed Resident #7 with behaviors to include wandering four to six days a week and to use a wander/elopement alarm daily. Review of Resident #7's Risk for Injury Due Too Wandering Care Plan, dated 12/16/16, revealed interventions for wanderguard bracelet intact at all times and to check Wanderguard bracelet daily for placement, functioning, and replace device as needed. However, review of Resident #7's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no evidence the facility documented what the Wanderguard bracelet's Activate By Date was so they would know when the bracelet's 90 days were used. Review of a Nurse's Note, dated 06/23/18 at 3:45 PM, Registered Nurse (RN) #1, on 06/27/18 at 9:41 AM, and Certified Nurse Aide (CNA) #2, on 06/27/18 at 9:07 AM revealed Resident #1 was found outside walking across the front lawn when CNA #2 returned from break in her car. RN #1 walked Resident #1 to the door and the door did not lock down. A new wanderguard was placed on the resident. Observations of Wanderguard bracelets with the Director of Nursing (DON), on 06/28/18 at 3:30 PM, revealed the monitor bracelet on Resident #7 had an Activate by Date of 02/14/18 (45 days past the recommended 90 days). Interview with A Stanley Healthcare Technician, on 06/29/18 at 4:19 PM, revealed when using the 90-day Signaling Device the Activate by Date is the last day it can be activated and guarantee a 90-day lifespan. Interview with LPN #1, on 07/01/18 at 8:58 PM, revealed he replaced the monitoring device on Resident #7 after Registered Nurse (RN) #1 reported the device failed when she walked the resident to the front door. He denied checking the device for an Activate by Date prior to placing the monitor. He stated he was not aware there was an activate by date on the devices when he got a sealed device from supply in the filing cabinet. Interview with Director of Nursing (DON), on 06/28/18 at 3:30 PM, revealed the monitoring bracelets should be dated when applied so they could verify the devices were only used 90 days and then replaced. She stated it was the staff's responsibility to check the activate by date before application to ensure the device will have 90 days of life when activated. Interview with the Administrator, on 07/26/18 at 3:10 PM, revealed he was not aware of the activate by date being on the devices and that staff did not start getting trained on the reason for the date or checking the date until 06/25/18. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 06/23/18, Resident #7 was assessed with [REDACTED]. 2. On 06/25/18, Resident #7's Care plan was updated by the Activities Director and revised with person centered revisions. 3. On 07/04/18, an audit of all residents' care plans was completed by the Interdisciplinary Team (IDT). Wandering behaviors and interventions were revised and updated with more specific person centered interventions for each of the residents identified as wanderers. 4. On 06/25/18, all exit doors in the facility were checked by Vanguard Alarm Services to ensure proper functioning of the alarming system to include locking of the doors and that the Wanderguard system was working to manufacturer's specifications. The system was found to be functioning properly. 5. On 06/28/18, all Wanderguard bracelets in use on wandering residents were checked for the Activate by Date, placement, and function per manufacturer's instructions by the DON. One device was identified as out of date, replaced, dated, and tested for function by the DON. 6. On 06/28/18, the Wander Risk Policy was reviewed, revised, and implemented. Revisions implemented included that the Nursing Department would be responsible for Wander Risk Assessments on admission, Minimum Data Set (MDS) Quarterly, Annual, and any Significant Change assessment. 7. On 06/28/18, the WanderGuard System Management Policy was initiated with interventions to include determining the source of a sounding alarm in a timely manner. 8. On 07/2/18 through 07/05/18, in-service training was provided by the Corporate Public Relations Specialist related to the Wander Risk Protocol and Wanderguard System Management policies. Staff not present will be in-serviced prior to working their next shift. 9. On 06/23/18, the Maintenance Director changed all the door codes in the building so only staff could open the doors for access and exit from the building. 10. On 06/23/18, the Corporate Quality Assurance Nurse/Administrator initiated in-service training on Wander Risk Program/Protocol, Dr. Walker, Care Plan revisions, Security Codes, and Alarm Surveillance. 11. On 06/27/18, the facility initiated twenty-four hour (24) staffing of the main entrance/exit where the elopement occurred and will continue until construction of a new entrance/exit door is completed. 12. On 06/23/18, Wander Risk Assessments were completed for all residents to ensure all residents at risk for wandering were identified. The Wander Risk Assessments were performed by the SSD, DON, ADON, and the night shift Nursing Supervisor. 13. On 06/23/18, a complete head count was completed to ensure all residents were accounted for and in the building. 14. On 06/25/18, the Wanderer Book (an informational book kept at the nurse's stations, front office, and in the Dietary Department, with information on each resident identified as a wander risk) was updated with current pictures, verified all current wanderers in the book, and updated resident characteristics. On 06/27/18, the Wanderer Book was updated again related to a new admission identified by the Wandering/Elopement Risk assessment. 15. On 06/29/18, at 12:00 PM the Quality Assurance/Performance Improvement (QAPI) Performance Improvement Project (PIP) team (Team members included the Medical Director, Consulting Administrator, DON, ADON, East and West Charge Nurses, MDS Coordinator, Maintenance Director, SSD, and Activities Director) met to examine the root cause and offer interventions for wandering and elopement prevention. Their recommendation for installing the alarming doors between the foyer and the lobby was presented to the Board of Directors and approved. 16. QAPI team members will monitor door check logs of entry/exit daily and present results of the daily audit to the Corporate Quality Assurance Nurse/Administrator (CQANA). 17. On 06/28/18, in-service training was initiated by the Maintenance Director with the CMTs on the Wanderguard Departure Alert System/Wanderguard bracelet. The in-service included proper procedure for checking the Wanderguard bracelet and the exit door receivers, documenting the test results, and reporting any device malfunction to the Charge Nurse. The Maintenance Director also in-serviced the Administrative Nurses so any CMT's not present for the training could receive the training prior to start of their next shift. 18. On 06/26/18, the QAPI team started reviewing results of the elopement drills. The drills will be done at least weekly for one month then once a month for six months, and quarterly thereafter. The drills will be on alternating shifts, on weekdays, weekends, and holidays. The QAPI team will meet weekly for the first month and monthly thereafter to review, discuss, evaluate effectiveness of changes and make changes if indicated. All results of elopement drill audits will be presented to the CQANA either in person or by phone by a member of the QAPI team. 19. On 06/28/18, in-service training on Wanderguard User instructions for the Wanderguard Departure Alert System was initiated by the MDS Coordinator and the Night shift Nursing Supervisor. Training consisted of ensuring the device was activated by the Activate by Date and the date activated was documented in the Residents Medication Administration Record (MAR)/Treatment Administration Record (TAR). Certified Medical Technician (CMT) training consisted of documenting proper function and placement on each shift in the MAR and ensuring Licensed Nurses are notified of the day the device is activated and report any malfunctions to the Charge Nurse immediately. Licensed Nurses will then be responsible to document the date each device is activated on the TAR so it will trigger for the device to be changed ninety (90) days from activation. Licensed Nurses were also in-serviced to obtain an order for [REDACTED]. 20. A member of the QAPI team will review each wanderer's MAR/TAR daily to ensure proper documentation of the Wanderguard Bracelet function and placement and the QAPI team with meet daily for one month then and monthly thereafter at Quality Assurance Meetings to discuss findings, evaluate effectiveness and make changes if indicated. 21. On 07/03/18, the licensed members of the QAPI team initiated a daily review of ten (10) residents' care plans updating and ensuring those residents' care plans were current based on the resident's needs and goals. A member of the QAPI team will ensure the audits are done every day for the first month and monthly thereafter and results of audits will be reviewed by the QAPI team daily for the first month and monthly thereafter. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with RN #1, on 06/27/18 at 9:41 AM, revealed she completed an assessment following notification of Resident #1 entering the building after suspected elopement. Review of RN #1's Nursing Note dated, 06/23/18 at 3:45 PM, revealed she performed an assessment and obtained Resident #1's vital signs without any pain or distress identified. One to one supervision verified by reviewing the facility's supervision forms with staff initials and location codes every fifteen (15) minutes dated from 06/23/18 at 3:15 PM through 07/11/18 at 12:45 PM and observation at 12:50 PM on 07/11/18 when Resident #7 was noted in sitting area near the west side nursing station and observed current supervision form being filled out by staff providing supervision. Interviews with CNA #9, CNA #15, CNA #16, LPN #2, LPN #4, LPN #5, Restorative Aide (RA) #1, and RN #2, on 07/10/18 at 9:45 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:29 PM respectively, revealed they had either sat with Resident #7 one to one, or observed someone with Resident #1 or both. 2. Review of Resident #1's Wandering Care Plan revealed the care plan was revised on 06/23/18 to include one to one supervision until further notice. 3. Interview with the Activities Director, on 06/27/18 at 2:59 PM, revealed she updated Resident #7's care plan on 06/25/18. Review of the Wandering Care Plan, revised 06/27/18, revealed updates created by the Activities Director included offering resident baby doll to comfort, provide snacks to resident, participation in out of facility trips, and accompany resident outside to bird feeder. Interview with the Social Services Director, DON, and ADON, on 07/11/18 at 1:30 PM verified the IDT team updated care plans to reflect more person centered interventions, they were revised dates on 07/04/18. Review of ten (10) of ten (10) wandering residents' Wandering Care plans revealed revisions made to the care plan on 07/04/18. 4. Interview with the Maintenance Director, on 06/27/18 at 1:54 PM, revealed Vanguard Alarm services made a service call on 06/25/18 to verify proper functioning of the Wanderguard alarm system. Review of the Vanguard Alarm Services service ticket, dated 06/25/18, revealed all doors were tested , alarmed and sounded. 5. Interview with the DON, on 07/11/18 at 1:55 PM, revealed she performed the audit of Wanderguard bracelets in use and identified one bracelet, on Resident #7, that had an activate by date of 02/14/18; it was replaced with a new device with an activate by date of 11/19/18. Observations of ten of ten wandering residents, on 07/10/18, verified the placement, date device placed, and Activate by date of each device. No concerns were identified. 6. Review of the Wander Risk Protocol revealed the policy was revised on 06/28/18 to put nursing responsibility for performing the Wander Risk Assessment on admission, MDS Quarterly, Annual, and with any Significant Change Assessments required. Interviews with LPN #2, LPN #3, and LPN #4, on 07/10/18 at 9:55 AM, 10:04 AM, and 10:22 AM respectively, revealed they have always done the assessments on admission but now they were responsible to perform the assessments required for MDS reporting. 7. Review of the Wanderguard System Management policy revealed the policy was initiated on 06/28/18 to include At the sound of the Wanderguard alarm staff members are required to immediately seek the source causing the alarm. 8. Review of In-service Training Record, sign-in attendance record, and signed post test forms revealed staff training began on 07/02/18 and continued through until all staff had been in-serviced and post test completed prior to returning to work. Interviews with CMT #1, CMT #4, CNA #9, CNA #15, CNA #16, LPN #2, LPN #3, LPN #4, LPN #5, and Restorative Aide (RA) #1, on 07/10/18 at 9:10 AM, 9:15 AM, 9:55 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:45 PM respectively, and Administrative Assistant #1, on 07/11/18 at 3:20 PM revealed they had an in-service on the policy and took a test to make sure they retained the information. Staff interviewed stated when they respond to a Wanderguard alarm they are to search inside and outside the building until they verify who, or what caused the alarm and a headcount is performed to ensure all residents are present on the property. 9. Interviews with CMT #1, CMT #4, CNA #9, CNA #15, CNA #16, LPN #2, LPN #3, LPN #4, LPN #5, Restorative Aide (RA) #1, on 07/10/18 at 9:10 AM, 9:15 AM, 9:55 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:45 PM respectively, and Administrative Assistant #1, on 07/11/18 at 3:20 PM revealed the Maintenance Director changed the door codes to the facility and the staff were trained not to give out the door code to anyone but facility staff and then given the new code to the door so they could open the door for themselves or visitors. 10. Interview with the Corporate Quality Assurance Nurse/Administrator, on 07/11/18 at 2:45 PM, revealed she initiated the training on 06/23/18 about the changes in the security codes and not giving the codes to anyone not working in the building, the Wander Risk Program/Protocol, Dr. Walker Protocol, and revised care plans. She stated the training continued until all employees received the training prior to working their next shift. Review of the sign-in attendance records for those in-services revealed all staff have been trained with the exception of one who has not returned to work since the incident. 11. Review of the front entrance monitoring log and observation of Administrative Assistant #1, on 07/11/18 at 3:20 PM, revealed the entrance continues to be monitored and she continues to document on the Front Entrance Monitoring Log. Interview with the Administrator, on 07/11/18 at 3:16 PM, revealed the front door has been installed and is functioning, but 24 hour monitoring has continued in an effort to monitor the effectiveness and function of the system after being moved. 12. Interview with the Social Services Director, DON, and ADON, on 07/11/18 at 1:30 PM revealed they performed Wander Risk Assessments on all residents in the building on 06/23/18. Review of Wandering/Elopement Risk Assessments performed on 06/23/18 revealed all residents in building had an assessment performed. 13. Interview with the ADON and DON, on 07/11/18 at 1:30 PM, revealed the DON initiated a complete head count of all residents upon arrival to the facility on [DATE] and by the time the ADON arrived it had been completed and verified all residents were present. Review of the Daily Census logs signed by the DON, on 06/23/18, revealed she checked off and signed each census page as the residents were verified present in the building. 14. Interview with the SSD, on 07/11/18 at 5:41 PM verified she was the one who coordinated all the updates to the book to ensure the Wandering book was up to date and has continued to update the Wanderer book as Wandering/Elopement Risk Assessments have identified new residents at risk. Observation of the Wanderer book, on 07/11/18 at 5:41 PM, revealed all residents currently identified as wanderers have complete information in the books. 15. Observation of construction, on 07/09/18, revealed the doors were installed, Wanderguard system was tested by Vanguard Alarm Systems staff, keypad was moved for employee access, and staff were observed unlocking the doors and directing visitors to sign in/out of the building. Interview with the Administrator, on 07/11/18 at 3:16 PM, revealed the front door had been installed and was functioning, but 24-hour monitoring has continued and is reviewed daily by a QAPI team member in an effort to monitor the effectiveness and function of the system after being moved. Review of the front entrance monitoring log and observation of Administrative Assistant #1, on 07/11/18 at 3:20 PM, revealed the entrance continues to be monitored and she was observed to document on the Front Entrance Monitoring Log. 16. Interview with the CQANA and Administrator, on 07/12/18 at 9:17 AM, revealed the results of the audits performed on the door check logs are presented and discussed with the CQANA daily either in person or by phone. 17. Interview with the Maintenance Director, on 06/27/18 at 1:54 PM, revealed he did the initial training with the CMT's and the Administrative Nurses on proper testing of the Wanderguard system on both shifts, documentation of test results, and reporting of any malfunctions to the Charge Nurse immediately. Interview with the DON, on 07/11/18 at 1:55 PM, revealed she performed several of the in-service training's of staff not present for the initial training prior to staff working their next shift. Review of the In-service training record revealed a signed attendance record of all CMT's and one LPN (#5) who works as a CMT, Interviews with CMT #1, CMT #4, and LPN #5, on 07/10/18 at 9:10 AM, 9:15 AM, and 2:45 PM respectively, revealed they had an in-service on how to verify the Activate by Date when placing a Wanderguard bracelet, documenting the date of activation on the device, notification of the nurse to place and order for device to be changed in ninety days from date of activation in the TAR, how to properly test the Wanderguard system, and reporting of any malfunctions to nursing supervisor immediately. 18. Interview with CQANA, on 07/12/18 at 9:50 AM, revealed the elopement drills started on 06/25/18 and the results of the elopement drills were reviewed by the QAPI team and presented to the CQANA starting on 06/26/18. CQANA stated there have been three drills so far with two on day shift and one on night shift. No concerns were reported with any of the drills per the CQANA. Review of the in-service training/attendance record for the Dr. Walker/Elopement drill revealed signatures of all staff present for the drills on 06/25/18, 07/05/18, and 07/09/18. Interview with the CQANA and Administrator, on 07/12/18 at 9:17 AM, revealed the results of the audit tool, drills, and training are presented and discussed with the CQANA daily. Daily Monitoring Calendar presented by CQANA revealed every day since 06/26/18 through 07/11/18 have been initialed as she is given results of the monitoring provided for the day. 19. Interview with the MDS Coordinator, on 07/11/18 at 4:45 PM, revealed she and the Night Shift Nursing supervisor provided the training on how to use the Wanderguard devices and document in the MAR/TAR according to manufacturers recommendations to ensure the devices were activated by the date recommended and changed every 90 days as recommended. Review of the In-service training record, dated 06/28/18, revealed training was initiated with CMT's and Licensed Nursing staff on the proper use of the Wanderguard Departure Alert System. Review of the MAR/TAR for ten of ten wandering residents revealed the Wanderguard Bracelets have been checked on both shifts daily and the TAR shows the date the current bracelet is due to be changed. Review of the MAR's revealed the CMT's have completed their checks of the Wanderguard bracelets every shift on all wandering residents and review of the Wander Control checklist documentation revealed CMT's or Maintenance Director have verified checks on doors every day of the week. 20. Interview with the ADON, DON, SSD, Administrator, and CQANA, on 07/12/18 at 11:20 AM, revealed members of the QAPI team review the MAR/TAR daily to ensure documentation of function/placement of Wanderguard is completed and it is reviewed daily in the QAPI team meeting. 21. Review of the ten daily Care Plan Audits revealed the QAPI members are auditing the care plans of ten residents every day to ensure they are current based on resident status, new orders, interventions, goals, and needs. Interviews with DON, ADON, SSD, and Administrator, on 07/12/18 at 1:27 PM revealed team members perform these audits daily and then the QAPI team reviews the results daily and report all information to the CQANA daily. Interview with the CQANA, on 07/12/18 at 9:17 AM, revealed the results of all reviews are presented and discussed with her daily.

Based on observation, interview, record review, review of the facility's investigation, facility policy review, and review of the monitoring systems User Instructions, it was determined the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #7). On 06/23/18, Resident #7 exited the building without staff's knowledge and was found crossing the front lawn of the facility by staff. Certified Nursing Assistant (CNA) #1 responded to the alarm triggered by Resident #7, but when she did not see the resident in the immediate area, she reset the alarm and did not exit the building to ensure no resident had exited the building. The facility failed to ensure staff responding to the monitoring alarms verified the source that triggered the alarm prior to resetting the alarm. In addition, the facility failed to follow the User Instructions related to application and tracking of the monitoring device (wanderguard) to ensure the highest probability of proper functioning. The facility failed to document the date the device was activated to ensure the device was only used ninety (90) days prior to replacement; and, failed to ensure devices were activated prior to their, activate by date, to ensure the device would last approximately ninety (90) days after activation; per manufacturer's instructions. The facility's failure to ensure adequate supervision was provided to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 06/29/18 and determined to exist on 06/23/18. The facility was notified of the Immediate Jeopardy on 06/29/18. An acceptable Allegation of Compliance (AoC) was received on 07/09/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 07/06/18. 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. The findings include: Review of the facility's policy titled, Wandering Residents, not dated, revealed it is the facility's policy to identify residents who walk or wheel about unrestricted and are a threat to leave the facility unattended due to their confusion while utilizing the least restrictive means available to ensure their safety. The facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. Wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. The residents' name, picture, and physical description is placed in the wander book located at the nurses' stations. All staff is responsible for knowing whose name is on the list and be able to recognize the resident and be able to intervene as necessary. Every new employee will be informed of wandering residents upon orientation. A monitoring device (Wanderguard) will be placed on the resident according to manufacturer's directions. Exit monitoring system will be kept operational twenty-four (24) hours a day. Interview with the Administrator, on 07/12/18 at 4:26 PM, revealed employees have always been trained to respond to all alarms and identify the source of the alarm and if unable to find the source of the alarm inside the building to search outside. Review of the alarm system's User Instructions, not dated, revealed the device the facility uses is a 90-day device that has a four (4) to six (6)-month shelf life from the date of manufacture. There is a date on the back of the device, Activate By Date, that indicates the last date the device can be activated to provide approximately ninety (90) days of useful life. This date should be recorded in the resident's records. Review of the Stanley Healthcare Solutions Long Life vs. 90-Day Signaling Devices webpage, not dated, states By recording activation dates on the resident's med sheet, you'll know exactly how much life is left on the device. In addition, interview with a Stanley Healthcare Technician, on 06/29/18 at 4:19 PM, revealed when using the 90-day Signaling Device, the Activate by Date is the last day it can be activated to guarantee a 90-day lifespan. He stated the manual recommends daily testing of the device and once activated they are only recommended for 90 days of service. He stated the tester can only validate functioning of the battery and there is no way to determine battery strength. Record review revealed the facility admitted Resident #7 on 02/10/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/06/18, revealed the facility was unable to complete a Brief Interview for Mental Status (BIMS). Staff assessed Resident #7's cognitive skills as severely impaired. Further review of the MDS revealed the facility assessed Resident #7 to have behaviors which included wandering four (4) to six (6) days a week. Review of Resident #7's Risk for Injury- Due Too Wandering Comprehensive Care Plan, dated 12/16/16, revealed a goal for the resident to remain free of injury related too wandering. Interventions included to allow resident to wander freely within the facility, but remove from area if resident is annoying peers; monitor and record mood and behaviors every shift on the Behavior Observation Program (BOP) sheets; Wanderguard bracelet intact at all times; check Wanderguard bracelet daily for placement and functioning; and, replace device as needed. Review of the Wandering/Elopement Risk Data Set, dated 10/03/17, revealed Resident #7 was at risk of elopement due to his/her ability to ambulate independently and resident does attempt to follow family members, staff, or visitors out of the facility. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record revealed staff had checked placement and functioning of the resident's wanderguard bracelet on 06/23/18 on the 6 AM to 6 PM shift. Review of a Nurse's Note written by Registered Nurse (RN) #1, dated 06/23/18 at 3:45 PM, revealed she was summoned to the back door by housekeeping staff because Resident #7 was being escorted into the building by Certified Nurse Aide (CNA) #2. Further review of the Note revealed a skin assessment was performed with no concerns and the resident was noted to be in a pleasant mood, with no signs or symptoms of pain or distress noted. Vital signs recorded: Blood Pressure (B/P) 152/85, Pulse (P.) 70, Respirations (R.) 18, Temperature (T) 97.3 and Oxygen saturation 94%. The Note stated RN #1 walked the resident to the front door and the alarm did not sound. When the Wanderguard and door sensors were tested with the test box both functioned and worked properly. Interview with RN #1, on 06/27/18 at 9:41 AM, revealed she was called by housekeepers to the backdoor and saw CNA #2 bring Resident #7 into the back door and got report from her. RN #1 stated she assessed the resident and did not find him/her in any distress. She stated she took the resident to the front door to see if the monitoring system was working and it did not alarm. RN #1 stated LPN #1 tested the monitoring device and the receivers at the door and they both worked with the tester, so they took Resident #7 to the door again and the alarm activated. RN #1 stated she placed Resident #7 on 1:1 observation, notified the resident's daughter and physician on call while LPN #1 notified the Director of Nursing (DON) Review of the Kentucky Mesonet Site revealed the average temperature on 06/23/18 was 74.2 degrees Fahrenheit (F). Interview with the Activities Director, on 07/12/18 at 3:48 PM, revealed the resident had on light pink pants, long sleeve shirt, sun glasses, and white bunny slippers. Interview with CNA #2, on 06/27/18 at 9:07 AM, revealed she was returning from a break and observed Resident #7 crossing the front lawn of the facility. She stated she called the resident, asking the resident to go with her. Further interview revealed the resident rode with her to the employee parking lot, then she walked the resident into the facility and reported to Registered Nurse (RN) #1. Review of a Nurse's Note by Licensed Practical Nurse (LPN) #1, dated 06/23/18 at 6:57 PM, revealed he observed RN #1 take Resident #7 to the front door to test the Wanderguard and the alarm did not sound. He checked the Wanderguard and the receiver at the door and both worked with the device checker. Further review of the Note revealed the Restorative Aide escorted the resident to the front door and the alarm sounded. LPN #1 changed the wanderguard and it worked with the device tester and when Resident #7 was taken closer to the receiver at door the alarm sounded. Interview with Resident #7's Daughter, on 06/26/18 at 2:11 PM, revealed she visits almost daily. She stated the resident always enjoyed being out in the yard and working in the garden. The daughter stated she often takes the resident out through the front door and they go into the central courtyard. The Resident's daughter stated her and Resident #7 often enjoyed visiting the courtyard when they were at the facility visiting her father before Resident #7 was admitted to the facility. Interview with CNA #10, on 06/27/18 at 9:57 AM, revealed she had been working on the hallway with Resident #7 and had seen him/her about ten (10) minutes before finding out that he/she had gotten out of building. She stated she had gone to the front door to let visitors out and saw Resident #7 in his/her room as she came back down the hallway headed to take a break. CNA #10 stated she had not ever seen Resident #7 attempting to exit through the front door, but the resident often would hang out in the lobby area and go into the central courtyard to look at the flowers. Interview with CNA #1, on 06/29/18 at 12:06 PM, revealed she responded to an alarm at the main entrance on 06/23/15, a few minutes before Resident #7 was discovered outside the building and reset the alarm when she did not find a source of the alarm. CNA #1 stated she searched the immediate area around the front doors and looked out the doors, but she did not see a source that may have set off the alarm and thought it was a false alarm. The CNA stated she did not go outside to look for a resident. Review of the facility's initial investigation by the Director of Nursing (DON), revision date 06/24/18, revealed the facility's investigation determined Resident #7 most likely exited the building through the main entrance following a group of visitors leaving the facility. She stated the resident was out of the building approximately five (5) minutes. The investigation further revealed Resident #7 was found on the facility's property by a staff member; and, upon returning to the building was assessed by RN #1 with no injury or distress determined. The DON, Assistant Director of Nursing (ADON), Social Service Director (SSD), and Maintenance Director initiated an investigation shortly after notification and determined the root cause to the resident exiting the building was multiple recent activities out of the building with staff and family as well as the resident's enjoyment of being outside feeding the birds and tending to plants. Review of the facility's investigation, revised 06/25/18, revealed Resident #7 exited the building on 06/23/18, following visitors out the main entrance. Interview with the Activities Director, on 06/27/18 at 2:59 PM, revealed she reviewed some pictures taken by the security camera and identified a group of visitors near the exit at 3:06 PM on 06/23/18. She stated through further review of the security camera photos Resident #7 was approaching the employee entrance in the back of the building with CNA #2 at 3:12 PM. Review of the pictures, on 07/12/18 at 4:21 PM, revealed they were very blurry, but you could identify what looked like Resident #7's pants and bunny slippers at the front exit with a group of visitors. Resident #7 and CNA #2 could only be identified by the color of their clothing. The Activities Director stated after seeing the clothing Resident #7 was wearing she was able to identify the resident in the group by a picture that showed his/her outfit from the waist down. Interview with the Maintenance Director, on 06/27/18 at 1:54 PM, revealed he came to the facility to check the function of all the doors that were equipped with pass codes and Wanderguard alarms. He stated he did not find any malfunction with the monitoring system, but it was determined the resident exited with visitor so he changed the passcode to the doors so only staff would have the passcode to enter or exit the building using the code. He also provided a receipt dated 06/25/18, that verified all doors with the wandering device on them had been tested , with no failures. He stated the doors alarmed and sounded as they should. Observations of monitor bracelets with the DON, on 06/28/18 at 3:30 PM, revealed the monitor bracelet on Resident #7 had an application date of 06/23/18, written on the monitor. However, the Activate by Date stamped on the back was noted to be 02/14/18. The DON observed the date stamped on the monitor and stated that the monitor should not have been placed on the resident. She ensured that a new device was placed on the resident; this device had an activate by date stamp of 11/19/18. No other devices in use or available for use were dated beyond their effective Activate by Date. Interview with LPN #1, on 07/01/18 at 8:58 PM, revealed he replaced the monitoring device on Resident #7, dated the monitoring device, and tested the device for proper function. He denied checking the device for an Activate by Date prior to placing the monitor. Interview with Certified Medication Technician (CMT) #1, on 06/27/18 at 5:08 PM, revealed she had checked the monitor bracelet function with a Wanderguard signaling device tester and placement on 06/23/18. She stated the Medication Administration Record (MAR) only had a place to mark that placement and function has been checked on each shift. CMT #1 stated she normally checked Resident #7 between 8:00 AM and 8:30 AM. The CMT stated she changed Resident #7's wanderguard bracelet about three (3) weeks prior, but she presented no documentation to show when the bracelet was changed or what the Activate by date was on the Monitor bracelet at the time of application. The CMT stated she did not document the activate by date or date the monitor placed on the resident. She stated she only replaced them when they failed. Interview with CMT #2, on 06/28/18 at 4:07 PM, revealed she has always checked the activate by date, but there was no place to document it on the MAR. She stated they had just started placing a date on the Monitor Bracelet when it was placed since the incident, but she had not prior to 06/23/18. Interview with CMT #3, on 06/28/18 at 3:30 PM, revealed she checked placement and function of the monitoring device after 6:00 PM on her shift. She stated she has never had a device to apply that had a date beyond the activate by date. CMT #3 stated the facility just started dating the devices when they placed them on a resident. Interview with the DON, on 06/27/18 at 10:54 AM, revealed she was notified by LPN #1 about Resident #7 eloping from the facility. She stated she called the Social Services Director (SSD), Assistant Director of Nursing (ADON), Director of Marketing, and Director of Maintenance to assist with the investigation. The DON stated they initiated the investigation by checking all monitoring devices and doors for proper function; initiated wander risk assessments on all residents; started interviewing staff to determine how the resident eloped from the building without being detected; had the Maintenance Director reset the pass code to the key pad at the entrance to the facility; and, staffed the door so only a staff member could open the entrance/exit door to the building. The DON stated staff training was initiated on security codes to the doors, responding to door alarms, and the protocol for responding to a suspected resident elopement. Interview with the Administrator, on 07/02/18 at 11:53 AM, revealed he expected the staff to check all door alarms with the expectation the alarm was triggered by a monitoring device. He stated he expected the staff to check the immediate area for the source of the alarm and if not in the building to exit the building to verify a resident did not exit the facility. He further stated if source was not found staff should come back in the building to notify nursing staff so they can verify the location of all residents in the wandering book and perform a head count of all residents if needed. He revealed the administrative staff responded to the facility immediately to investigate the elopement and put actions in place to prevent the elopement of any resident with visitors by changing the code to the doors and posting staff member at the exit at all times to monitor the entry and exit of all visitors and residents. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 06/23/18, Resident #7 was assessed with [REDACTED]. 2. On 06/25/18, Resident #7's Care plan was updated by the Activities Director and revised with person centered revisions. 3. On 07/04/18, an audit of all residents' care plans was completed by the Interdisciplinary Team (IDT). Wandering behaviors and interventions were revised and updated with more specific person centered interventions for each of the residents identified as wanderers. 4. On 06/25/18, all exit doors in the facility were checked by Vanguard Alarm Services to ensure proper functioning of the alarming system to include locking of the doors and that the Wanderguard system was working to manufacturer's specifications. The system was found to be functioning properly. 5. On 06/28/18, all Wanderguard bracelets in use on wandering residents were checked for the Activate by Date, placement, and function per manufacturer's instructions by the DON. One device was identified as out of date, replaced, dated, and tested for function by the DON. 6. On 06/28/18, the Wander Risk Policy was reviewed, revised, and implemented. Revisions implemented included that the Nursing Department would be responsible for Wander Risk Assessments on admission, Minimum Data Set (MDS) Quarterly, Annual, and any Significant Change assessment. 7. On 06/28/18, the WanderGuard System Management Policy was initiated with interventions to include determining the source of a sounding alarm in a timely manner. 8. On 07/2/18 through 07/05/18, in-service training was provided by the Corporate Public Relations Specialist related to the Wander Risk Protocol and Wanderguard System Management policies. Staff not present will be in-serviced prior to working their next shift. 9. On 06/23/18, the Maintenance Director changed all the door codes in the building so only staff could open the doors for access and exit from the building. 10. On 06/23/18, the Corporate Quality Assurance Nurse/Administrator initiated in-service training on Wander Risk Program/Protocol, Dr. Walker, Care Plan revisions, Security Codes, and Alarm Surveillance. 11. On 06/27/18, the facility initiated twenty-four hour (24) staffing of the main entrance/exit where the elopement occurred and will continue until construction of a new entrance/exit door is completed. 12. On 06/23/18, Wander Risk Assessments were completed for all residents to ensure all residents at risk for wandering were identified. The Wander Risk Assessments were performed by the SSD, DON, ADON, and the night shift Nursing Supervisor. 13. On 06/23/18, a complete head count was completed to ensure all residents were accounted for and in the building. 14. On 06/25/18, the Wanderer Book (an informational book kept at the nurse's stations, front office, and in the Dietary Department, with information on each resident identified as a wander risk) was updated with current pictures, verified all current wanderers in the book, and updated resident characteristics. On 06/27/18, the Wanderer Book was updated again related to a new admission identified by the Wandering/Elopement Risk assessment. 15. On 06/29/18, at 12:00 PM the Quality Assurance/Performance Improvement (QAPI) Performance Improvement Project (PIP) team (Team members included the Medical Director, Consulting Administrator, DON, ADON, East and West Charge Nurses, MDS Coordinator, Maintenance Director, SSD, and Activities Director) met to examine the root cause and offer interventions for wandering and elopement prevention. Their recommendation for installing the alarming doors between the foyer and the lobby was presented to the Board of Directors and approved. 16. QAPI team members will monitor door check logs of entry/exit daily and present results of the daily audit to the Corporate Quality Assurance Nurse/Administrator (CQANA). 17. On 06/28/18, in-service training was initiated by the Maintenance Director with the CMTs on the Wanderguard Departure Alert System/Wanderguard bracelet. The in-service included proper procedure for checking the Wanderguard bracelet and the exit door receivers, documenting the test results, and reporting any device malfunction to the Charge Nurse. The Maintenance Director also in-serviced the Administrative Nurses so any CMT's not present for the training could receive the training prior to start of their next shift. 18. On 06/26/18, the QAPI team started reviewing results of the elopement drills. The drills will be done at least weekly for one month then once a month for six months, and quarterly thereafter. The drills will be on alternating shifts, on weekdays, weekends, and holidays. The QAPI team will meet weekly for the first month and monthly thereafter to review, discuss, evaluate effectiveness of changes and make changes if indicated. All results of elopement drill audits will be presented to the CQANA either in person or by phone by a member of the QAPI team. 19. On 06/28/18, in-service training on Wanderguard User instructions for the Wanderguard Departure Alert System was initiated by the MDS Coordinator and the Night shift Nursing Supervisor. Training consisted of ensuring the device was activated by the Activate by Date and the date activated was documented in the Residents Medication Administration Record (MAR)/Treatment Administration Record (TAR). Certified Medical Technician (CMT) training consisted of documenting proper function and placement on each shift in the MAR and ensuring Licensed Nurses are notified of the day the device is activated and report any malfunctions to the Charge Nurse immediately. Licensed Nurses will then be responsible to document the date each device is activated on the TAR so it will trigger for the device to be changed ninety (90) days from activation. Licensed Nurses were also in-serviced to obtain an order for [REDACTED]. 20. A member of the QAPI team will review each wanderer's MAR/TAR daily to ensure proper documentation of the Wanderguard Bracelet function and placement and the QAPI team with meet daily for one month then and monthly thereafter at Quality Assurance Meetings to discuss findings, evaluate effectiveness and make changes if indicated. 21. On 07/03/18, the licensed members of the QAPI team initiated a daily review of ten (10) residents' care plans updating and ensuring those residents' care plans were current based on the resident's needs and goals. A member of the QAPI team will ensure the audits are done every day for the first month and monthly thereafter and results of audits will be reviewed by the QAPI team daily for the first month and monthly thereafter. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with RN #1, on 06/27/18 at 9:41 AM, revealed she completed an assessment following notification of Resident #1 entering the building after suspected elopement. Review of RN #1's Nursing Note dated, 06/23/18 at 3:45 PM, revealed she performed an assessment and obtained Resident #1's vital signs without any pain or distress identified. One to one supervision verified by reviewing the facility's supervision forms with staff initials and location codes every fifteen (15) minutes dated from 06/23/18 at 3:15 PM through 07/11/18 at 12:45 PM and observation at 12:50 PM on 07/11/18 when Resident #7 was noted in sitting area near the west side nursing station and observed current supervision form being filled out by staff providing supervision. Interviews with CNA #9, CNA #15, CNA #16, LPN #2, LPN #4, LPN #5, Restorative Aide (RA) #1, and RN #2, on 07/10/18 at 9:45 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:29 PM respectively, revealed they had either sat with Resident #7 one to one, or observed someone with Resident #1 or both. 2. Review of Resident #1's Wandering Care Plan revealed the care plan was revised on 06/23/18 to include one to one supervision until further notice. 3. Interview with the Activities Director, on 06/27/18 at 2:59 PM, revealed she updated Resident #7's care plan on 06/25/18. Review of the Wandering Care Plan, revised 06/27/18, revealed updates created by the Activities Director included offering resident baby doll to comfort, provide snacks to resident, participation in out of facility trips, and accompany resident outside to bird feeder. Interview with the Social Services Director, DON, and ADON, on 07/11/18 at 1:30 PM verified the IDT team updated care plans to reflect more person centered interventions, they were revised dates on 07/04/18. Review of ten (10) of ten (10) wandering residents' Wandering Care plans revealed revisions made to the care plan on 07/04/18. 4. Interview with the Maintenance Director, on 06/27/18 at 1:54 PM, revealed Vanguard Alarm services made a service call on 06/25/18 to verify proper functioning of the Wanderguard alarm system. Review of the Vanguard Alarm Services service ticket, dated 06/25/18, revealed all doors were tested , alarmed and sounded. 5. Interview with the DON, on 07/11/18 at 1:55 PM, revealed she performed the audit of Wanderguard bracelets in use and identified one bracelet, on Resident #7, that had an activate by date of 02/14/18; it was replaced with a new device with an activate by date of 11/19/18. Observations of ten of ten wandering residents, on 07/10/18, verified the placement, date device placed, and Activate by date of each device. No concerns were identified. 6. Review of the Wander Risk Protocol revealed the policy was revised on 06/28/18 to put nursing responsibility for performing the Wander Risk Assessment on admission, MDS Quarterly, Annual, and with any Significant Change Assessments required. Interviews with LPN #2, LPN #3, and LPN #4, on 07/10/18 at 9:55 AM, 10:04 AM, and 10:22 AM respectively, revealed they have always done the assessments on admission but now they were responsible to perform the assessments required for MDS reporting. 7. Review of the Wanderguard System Management policy revealed the policy was initiated on 06/28/18 to include At the sound of the Wanderguard alarm staff members are required to immediately seek the source causing the alarm. 8. Review of In-service Training Record, sign-in attendance record, and signed post test forms revealed staff training began on 07/02/18 and continued through until all staff had been in-serviced and post test completed prior to returning to work. Interviews with CMT #1, CMT #4, CNA #9, CNA #15, CNA #16, LPN #2, LPN #3, LPN #4, LPN #5, and Restorative Aide (RA) #1, on 07/10/18 at 9:10 AM, 9:15 AM, 9:55 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:45 PM respectively, and Administrative Assistant #1, on 07/11/18 at 3:20 PM revealed they had an in-service on the policy and took a test to make sure they retained the information. Staff interviewed stated when they respond to a Wanderguard alarm they are to search inside and outside the building until they verify who, or what caused the alarm and a headcount is performed to ensure all residents are present on the property. 9. Interviews with CMT #1, CMT #4, CNA #9, CNA #15, CNA #16, LPN #2, LPN #3, LPN #4, LPN #5, Restorative Aide (RA) #1, on 07/10/18 at 9:10 AM, 9:15 AM, 9:55 AM, 10:04 AM, 10:22 AM, 10:32 AM, 10:41 AM, 12:50 PM, 1:23 PM, 2:45 PM respectively, and Administrative Assistant #1, on 07/11/18 at 3:20 PM revealed the Maintenance Director changed the door codes to the facility and the staff were trained not to give out the door code to anyone but facility staff and then given the new code to the door so they could open the door for themselves or visitors. 10. Interview with the Corporate Quality Assurance Nurse/Administrator, on 07/11/18 at 2:45 PM, revealed she initiated the training on 06/23/18 about the changes in the security codes and not giving the codes to anyone not working in the building, the Wander Risk Program/Protocol, Dr. Walker Protocol, and revised care plans. She stated the training continued until all employees received the training prior to working their next shift. Review of the sign-in attendance records for those in-services revealed all staff have been trained with the exception of one who has not returned to work since the incident. 11. Review of the front entrance monitoring log and observation of Administrative Assistant #1, on 07/11/18 at 3:20 PM, revealed the entrance continues to be monitored and she continues to document on the Front Entrance Monitoring Log. Interview with the Administrator, on 07/11/18 at 3:16 PM, revealed the front door has been installed and is functioning, but 24 hour monitoring has continued in an effort to monitor the effectiveness and function of the system after being moved. 12. Interview with the Social Services Director, DON, and ADON, on 07/11/18 at 1:30 PM revealed they performed Wander Risk Assessments on all residents in the building on 06/23/18. Review of Wandering/Elopement Risk Assessments performed on 06/23/18 revealed all residents in building had an assessment performed. 13. Interview with the ADON and DON, on 07/11/18 at 1:30 PM, revealed the DON initiated a complete head count of all residents upon arrival to the facility on [DATE] and by the time the ADON arrived it had been completed and verified all residents were present. Review of the Daily Census logs signed by the DON, on 06/23/18, revealed she checked off and signed each census page as the residents were verified present in the building. 14. Interview with the SSD, on 07/11/18 at 5:41 PM verified she was the one who coordinated all the updates to the book to ensure the Wandering book was up to date and has continued to update the Wanderer book as Wandering/Elopement Risk Assessments have identified new residents at risk. Observation of the Wanderer book, on 07/11/18 at 5:41 PM, revealed all residents currently identified as wanderers have complete information in the books. 15. Observation of construction, on 07/09/18, revealed the doors were installed, Wanderguard system was tested by Vanguard Alarm Systems staff, keypad was moved for employee access, and staff were observed unlocking the doors and directing visitors to sign in/out of the building. Interview with the Administrator, on 07/11/18 at 3:16 PM, revealed the front door had been installed and was functioning, but 24-hour monitoring has continued and is reviewed daily by a QAPI team member in an effort to monitor the (TRUNCATED)

Based on interview, record review, the facility's investigation review, and facility policy review, it was determined the facility failed to protect one (1) of four (4) sampled residents (Resident #1) from abuse. On 03/07/18 at approximately 8:00 PM, Certified Nursing Assistant (CNA) #1 witnessed Licensed Practical Nurse (LPN) #1 slap Resident #1 across the lips with her open palm, then twist and pinch the upper arm of Resident #1. While pinching and twisting the resident's arm, LPN #1 stated to Resident #1,How does it feel to get pinched. However, CNA #1, who witnessed this incident, did not immediately report the abuse. CNA #1 left the facility at 12:06 AM on 03/08/18; and she and CNA #2 discussed the incident. However, neither CNA #1 or CNA #2 reported the incident of abuse. LPN #1 was not removed from resident care and continued to work providing care to residents until the end of her shift at 6:55 AM on 03/08/18 (approximately eleven {11} hours later). The alleged abuse incident was not reported to management until approximately 8:00 AM on 03/08/18 (approximately twelve{12} hours later) by CNA #1. The facility's failure to ensure residents are free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/14/18 and determined to exist on 03/07/18. The facility was notified of the Immediate Jeopardy on 03/14/18. An acceptable Allegation of Compliance (AoC) was received on 03/21/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/18/18. 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. The findings include: Review of the facility's policy related to Resident Abuse, Neglect, and Exploitation, last revised 07/08/17, revealed physical abuse included hitting, slapping, punching, kicking, and controlling behavior through corporal punishment All suspected or alleged incidents of abuse, neglect or exploitation must be reported immediately to the employee's supervisor. Allegations or suspicions will be thoroughly investigated by the Abuse/Neglect Coordinator, Administrator and/or their designee. Employees witnessing an incident of resident abuse must report the incident immediately. The employee(s) witnessing the abuse may be considered an accessory to the abuse if they do not report the incident. Notifications must be made to the appropriate reporting agencies within two (2) hours, including local law enforcement. Record review revealed the facility admitted Resident #1 on 05/10/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/29/17, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9) indicating the resident was interviewable. Further review of the MDS revealed the resident required extensive to total assistance with activities of daily living (ADLs). Review of the facility's investigation, dated 03/08/18, revealed CNA #1's witness statement of the incident. The CNA stated she assisted Resident #1 with a bath and the resident called her and LPN #1 the N word. LPN #1 slapped Resident #1 hard on the lips with the palm of her hand and stated, Don't ever call me the N word again. Then Resident #1 pinched CNA #1 and LPN #1 grabbed the resident's right arm (fatty loose skin) twisting and pinching the skin and asked the resident, How does it feel to get pinched? Interview with Resident #1, on 03/13/18 at 4:02 PM, revealed he/she was slapped in the mouth and his/her breast was pinched by the black girl. During the interview with Resident #1 on 03/14/18 at 4:30 PM, the resident stated, Is the girl gone, is the black girl fired. Resident #1 stated that he/she wanted to know so LPN #1 would not hurt him/her again; then the resident started to cry. In addition, review of Resident #1's skin assessment, dated 03/08/18 at 11:45 AM, revealed bruising to the left and right back upper portion of the arm above the elbow. Interview with CNA #1 on 03/13/18 at 1:27 PM, and on 03/15/18 at 11:40 AM, revealed while she was bathing Resident #1 on 03/07/18, Licensed Practical Nurse (LPN ) #1 came in the room about 8:00 PM-8:30 PM and said she had to do a finger stick and place a butt patch on the resident. CNA #1 stated the resident was half way turned over and he/she (Resident #1) called LPN #1 the N word. The CNA stated LPN #1 smacked Resident #1 in the mouth with her open palm and told the resident not to say that, it was not nice. CNA #1 stated the resident started pinching her (CNA #1), and LPN #1 grabbed the back of Resident #1's upper arm (the fatty loose skin on the right arm) and twisted and pinched it. The CNA stated Resident #1 kept telling LPN #1 he/she was going to report her. LPN #1 finished placing the butt patch on and left the room. CNA #1 stated she completed dressing the resident and took everything to the laundry. She stated at the end of her shift she left the facility with CNA #2 and told CNA #2 of the incident because she knew she was supposed to report what she saw immediately per facility policy but she was scared because of her history of abuse. Further interview with CNA #1 revealed CNA #2 told her to text the Director of Nursing (DON). CNA #1 stated she text the DON about 12:30 AM-1:00 AM on 03/08/18 telling the DON to call her in the morning when she woke up. CNA #1 stated the DON called her the next morning at approximately 7:30 AM and she went to the facility and talked to the Administrator, DON and the Abuse Coordinator. CNA #1 stated Resident #1's face looked shocked when LPN #1 slapped him/her, and the resident was screaming-but the resident's scream sounds like a person talking. Interview with CNA #2, on 03/14/18 at 12:50 PM, revealed she had a conversation with CNA #1 upon leaving the facility in the early morning of 03/08/18 around 1:00 AM in which CNA #1 reported to her that she thought she needed to report an abuse case. CNA #2 stated CNA #1 told her that LPN #1 had come in to do a treatment on Resident #1, the resident called LPN #1 the N word and LPN #1 slapped the resident in the mouth, telling the resident not to call her a N word. CNA #2 further revealed that CNA #1 stated Resident #1 was pinching her (CNA #1's) arm and LPN #1 grabbed Resident #1's arm tight above the right elbow and started pinching him/her and asked the resident How does that feel. CNA #2 stated she and CNA #1 had clocked out and were leaving the building at the time of the conversation because their shift ended at midnight. She stated LPN #1 was still working the floor with residents when they left the facility, and CNA #1 had not reported the incident immediately per facility policy. She stated she should have reported the incident herself. Interview with LPN #1 on 03/14/18 at 3:09 PM revealed Resident #1 was slinging his/her arms and pinching CNA #1 like always. LPN #1 stated she reached across the bed, kind of towards the face of the resident but did not slap the resident. She revealed she left to obtain a patch for the resident and when she returned to Resident #1's room, Resident #1 was pinching CNA #1. She stated she placed the patch on the resident and went back outside the room. Additionally, LPN #1 stated that the bruising on the resident's arm and the mark on the skin assessment were from the finger sticks. She stated nothing was reported and the resident never did say that he/she did not want LPN #1's care. LPN #1 stated if CNA #1 and CNA #2 thought that she had done it they should have reported it, as supervisors were there all night. Interview with the Assistant DON, on 03/13/18 at 4:07 PM, and on 03/14/18 at 5:28 PM revealed Resident #1 told her that LPN #1 had slapped him/her on the mouth. She stated she expected abuse and neglect to be reported immediately. She stated she expected staff to protect the resident and make sure the resident was safe by removing the person (alleged abuser) out of the room, and reporting to the supervisor on duty immediately. Interview (Post Survey) with the DON, on 04/05/18 at 1:58 PM, revealed the CNAs had been inserviced on the abuse policy upon hire and they knew when to report and who to report, and to do it immediately. The DON stated she told CNA #1 she should have stayed in the room and yelled as loud as she could. She revealed there was an RN Supervisor and the CNA should have hollered for her and reported it immediately to protect the residents. She stated CNA #1's main focus should have been to protect the residents. Interview with the Administrator on 03/23/18 at 1:59 PM, revealed the staff should have immediately reported the abuse and the nurse should have been removed from resident care immediately to protect the residents. He stated he had been notified of the allegation of abuse involving Resident #1 on 03/08/18 at approximately 8:15 AM. He stated he expected staff to report abuse immediately per the facility policy to assure the safety of residents. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 (the alleged perpetrator of the physical abuse) was suspended pending further investigation by the Administrator on 03/08/18. The Administrator terminated LPN #1 on 03/12/18. 2. The ADON reported LPN #1 to the Kentucky Board of Nursing on 03/13/18. 3. CNA #1 was reprimanded and suspended on 03/8/18 for failure to report timely, and on 03/16/18 after further consideration by the Administrator and consulting with a Long-Term Care Consultant it was decided by the Administrator to terminate CNA #1 on 03/17/18. 4. CNA #2 was terminated on 03/17/18. 5. On 03/08/18, Resident #1 had a full body assessment completed by the Director of Nursing (DON) and ADON with yellow bruising on the upper right arm noted. In addition, Resident #1 was placed on 72-hour alert charting to follow and monitor for affects from the allegation of physical abuse. 6. Beginning on 03/08/18 until 04/06/18, the Center's Social Worker, Administrator or Charge Nurse will complete an interview with Resident #1 daily to check for any signs of abuse, fearfulness and to assure that the resident feels safe at the Center. 7. Full body assessments were completed on each resident on 03/15/18 through 03/16/18 to identify any signs or symptoms of physical abuse. There were no signs or symptoms of physical abuse on any resident. The full body assessments were completed by the DON, ADON, Corporate Admissions Director (LPN), Charge Nurse (LPN), Unit Manager East Wing (LPN), MDS Coordinator (LPN), and MDS Director (RN). 8. On 03/15/18, resident interviews were completed utilizing an established questionnaire for the Center; Review Questions to Solicit Resident Concerns. The questionnaire was completed for each resident to identify any resident that may have an allegation of abuse. Responsible parties were asked the review questions when a resident had a cognitive deficit; and the residents without a cognitive deficit were permitted to answer the pertinent questions. The Review Questions to Solicit Resident Concerns were completed by the Social Services Director (SSD), Activities Director, Corporate Resident Services Coordinator (CRSC), and the Dietary Manager. Department Managers which included LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records. There were no concerns identified from the questions. 9. On 03/15/18, the Corporate Admissions Director in-serviced the Administrator, DON, ADON, Social Services Director (SSD), MDS Coordinator, MDS Director, Housekeeping/Laundry, Maintenance Director, Therapy Program Director, Human Resources Assistant, Medical Records, Dietary Manager, Human Resources, and Corporate Resident Services Coordinator on Abuse Prevention, the timeliness of reporting an allegation, and how to complete a thorough investigation. 10. On 03/15/18 through 03/17/18, abuse education was provided by the Administrator, Social Worker and Corporate Admissions Director to all departments and all employees of the Center. Any employees that were unavailable or unreachable by telephone on these education dates will not be able to return to work until they have received the abuse education and have been post-tested with each employee passing the post-test. Any newly hired employee will receive the abuse education and complete post-testing with a passing score before working in the Center. The abuse education includes the abuse prohibition policies of the facility, the types of abuse, the importance and urgency of reporting allegations of abuse immediately and assuring that the resident is removed from any abuse or potential abuse situation. Each employee completed an abuse prevention post-test and passed the post test as a result of the abuse education that was provided on 03/15/18 through 03/17/18. At the time of the abuse education, each employee is required to read, understand, and sign the Acknowledgement of Responsibilities for Prevention and Reporting of Resident Abuse that is part of the Abuse Prohibition Policies of the Center. 11. Beginning 03/17/18, Department Managers will rotate weekends to identify any resident that may be a victim of abuse. The monitoring by the Department Managers will include both shifts which include 6a-6p and 6p-6a each day of the week and weekends---completed daily for a three (3) month minimum. The Department Managers includes the Administrator, DON, ADON, SSD, MDS Coordinator, MDS Director, Dietary Manager, Housekeeping Coordinator, Activities Director, and Medical Records. These managers will use a standard tool developed by an owner of the Center on 03/16/18. This Administrative Rounds Checklist is a tool designed to interview employees for the purpose of soliciting any concerns related to allegations of resident abuse. The Administrative Rounds Checklist will be completed on a total of ten (10) employees daily which will include both shifts of 6a-6p and 6p-6a and also weekends. The Administrator will monitor on the weekend by discussing with the Department Manager working each specified weekend. In the absence of the Administrator the Director of Nursing will monitor the week-end rotations by the department heads. 12. On 03/16/18, the DON and the Administrator are attending and/or calling in and listening to shift rotation which is 6a-6p and also 6p-6a This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. On 03/16/18, the DON and the Administrator are participating in the 24-hour shift report to monitor for any changes in resident behavior and other incidents that may be a potential for abuse. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. In the absence of the Administrator and Director of Nursing, the Assistant Director of Nursing and/or Night Shift Nursing House Supervisor will fill in. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. 13. On 03/16/18, the Administrator initiated a Performance Improvement Team (PIT) to monitor abuse prohibition policies, investigation of abuse allegations and reporting of abuse allegations. The PIT members include the Administrator, DON, ADON, Social Worker, MDS Coordinator, MDS Director, and Night Shift Nursing House Supervisor. The PIT meets daily and completes the monitoring process by reviewing the current allegations of abuse, incident reports, and the root cause analysis. The PIT will monitor this on a daily basis during the week, and the PIT monitors the Director of Nursing and Administrator rotations for shift transitions initiated on 03/16/18. The PIT team will bring the information being monitored to the monthly QAPI meeting, which will include the SSD, Administrator, ADON, DON, Medical Director, Activities Director, Maintenance Director, Housekeeping/Laundry, Medical Records, MDS Coordinator, MDS Director, and Dietary Manager. 14. The Medical Director was notified of the Immediate Jeopardy by the Corporate Admissions Director on 03/16/18, a QAPI meeting was held which included the Medical Director, MDS Coordinator, MDS Director, Activities Director, Administrator, SSD, DON, ADON, and Medical Records. They discussed the Immediate Jeopardy and the plans the facility was taking to assure an allegation of compliance. 15. Starting on 03/19/18, the Department Managers which include LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records will complete Review Questions to Solicit Resident Concerns for every resident or family member/guardian once a week for three (3) months to assure sustainment of compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview on 03/22/18 at 1:37 PM with Administrator revealed he did not fill out a suspension form when he suspended LPN #1 but will supply time card; and will supply the time cards for CNA #1 and CNA #2. Review of a facility's Termination Notice, dated 03/12/18, revealed LPN #1 was terminated for Misconduct with circumstances of termination: Failure to follow abuse policies. 2. Interview on 03/14/18 at 5:28 PM and on 03/22/18 at 2:08 PM with the ADON revealed she reported LPN #1 to the Kentucky Board of Nursing (KBN) on 03/13/18. 3. Review of the facility's Progressive Disciplinary Form dated 03/08/18, revealed CNA #1 was terminated on 03/16/18 related to the failure to follow facility policy. 4. Review of the facility's Payroll Termination Notice dated 03/17/18, revealed CNA #2 was terminated due to not following facility policy. 5. Review of the 03/08/18 weekly skin assessment for Resident #1, dated 03/03/18 at 11:45 AM, provided by ADON revealed bruising to the left and right upper arm/quadrant/extremity. Review of Progress Notes dated 03/08/18 at 8:30 AM through 03/12/18 at 11:26 PM, revealed Resident #1 was assessed for affects from the alleged physical abuse with no concerns identified. 6. Review of Resident #1 interviews dated 03/08/18 through 03/21/18, completed by the SSD and Administrator revealed no concerns. Interview on 03/22/18 at 1:56 PM with Administrator revealed Resident #1 had voiced no concerns, seemed fine, and seemed as if nothing really happened. 7. Review of the full body assessments of all residents completed by the DON, ADON, MDS Coordinator, MDS Director, Charge Nurse, and Unit Managers, dated 03/15/18 through 03/16/18 revealed no concerns. 8. Review of the Review Questions to Solicit Resident Concerns interviews, dated 03/16/18 through 03/21/18 completed on all interviewable, non-interviewable residents and by the SSD, Activities Director, Dietary Manager, and Unit Manager (UM) revealed no concerns identified. Interviews on 03/23/18 with Unsampled Resident A at 1:43 PM, Unsampled Resident B at 1:45 PM, Unsampled Resident C's family member at 1:48 PM, Unsampled Resident D at 1:55 PM, Resident 31 at 1:55 PM and Resident #3 at 1:52 PM, revealed staff had asked them questions related abuse with no concerns. 9. Review of the Facility Inservice Training Record dated 03/15/18, revealed Abuse Prevention, Timely Reporting, and How to Complete Thorough Investigation was provided by Corporate Admissions and Marketing Director to Administrative staff and Department Managers. Interview on 03/23/18 at 11:08 AM with Corporate Admissions and Marketing Director revealed she had provided training on 03/15/18 through 03/16/18 to the Administrative staff to include all department managers and administrative staff. Interviews on 03/23/18 with the Administrator at 9:45 AM, the Dietary Manage at at 10:01 AM, Activities Director at 11:30 AM, DON at 11:42 AM, ADON at 12:05 PM , and MDS Coordinator at 12:35 PM revealed abuse and neglect training had been provided to them. 10. Review of the binder for Abuse/Neglect Inservices revealed the Abuse, Neglect and Exploitation Policy, and a listing of employees dated 03/15/18 that had completed the inservice training. In addition, there were Resident Abuse, Neglect, and Exploitation forms signed by employees and a listing of staff that had completed the abuse post test. Interviews on 03/22/18 with Housekeeper #1 at 2:35 PM, LPN #5 at 4:27 PM, Administrative Assistant at 4:41 PM, CNA #10 at 4:49 PM, Physical Therapy Assistant #1 at 4:58 PM, Laundry #1 at 5:08 PM, CMT #2 at 5:19 PM; and, on 03/23/18 with House Supervisor #1 at 9:00 AM, MDS Director at 10:20 AM, LPN #4 at 10:49 AM, CNA #9 at 11:17 AM, Activities Director at 11:30 AM, Maintenance Assistant at 12:02 PM, MDS Coordinator at 12:32 PM, and Dietary Assistant at 12:42 PM, revealed they received abuse/neglect training; which included going over the policy, taking a pre/post test, and signing an acknowledgement form. The staff stated they were to report abuse immediately to the charge nurse and if the charge nurse was not available to go above them and call the DON or Administrator. The staff revealed they should make sure the residents were safe, by removing the resident if possible or to stay with them until help could be obtained. The staff also stated the following types of abuse are to be reported: verbal, physical, sexual, mental, emotional, misappropriation of funds, and involuntary seclusion. Additionally, the staff revealed the Administrator and the Unit Supervisor went around and asked about concerns with the residents and if any concerns were voiced by the residents to the staff. 11. Review of March/April/May calendar revealed the schedule for administrative staff/Department Manager rotation for weekend shifts. Review of Administrative Rounds Checklist completed daily by the Administrator, DON, ADON, SSD, MDS Director, MDS Coordinator, dated 03/17/18-03/21/18, revealed no concerns with daily monitoring done Interview with the Administrator on 03/23/18 at 4:12 PM revealed the schedule was placed on the calendar and that is how staff are made aware of when they are scheduled to work the weekend. Interview with CNA #10 on 03/22/18 at 4:49 PM, CNA #11 on 03/23/18 at 12:52 AM, CMT #2 on 03/22/18 at 5:19 PM, and CNA #9 on 03/23/18 at 11:17 AM revealed they had been asked questions by Administrative Staff related to resident concerns while working their shift. Interview with the SSD, on 03/23/18 at 12:50 PM, revealed she was involved in the application of the Administrative Rounds Checklist. 12. Review of 03/17/18 through 03/22/18 documentation by the Administrator and DON revealed they were in attendance/or listening during shift rotations. Interviews on 03/23/18 with House Supervisor #1 at 9:00 AM, the DON at 11:42 AM, the ADON at 12:05 PM and the Administrator at 9:45 AM revealed shift report and 24 hour report were completed by the Administrator and DON, and in the absence of Administrator or the DON the ADON would fill in. Interview with the Administrator on 03/22/18 at 4:15 PM revealed he and the DON divide the halls to call in or physically participate in shift report and 24 hour report. He stated if the ADON needs to fill in for one of them it would be placed on the schedule. 13. Review of the Performance Improvement Team (PIT) meeting notes revealed daily meetings were being held by the DON, Administrator, ADON, SSD, MDS Director, and MDS Coordinator. Interview with the Administrator on 03/22/18 at 3:34 PM revealed allegations of abuse, incident reports, and the root cause analysis were reviewed daily in the morning meeting. 14. Review of Quality Assurance and Performance Improvement (QAPI) Meeting Notes revealed QAPI met on 03/16/18 to discuss the Immediate Jeopardy and developed their plan of action to remove the IJ. Interview with the Medical Director on 03/23/18 at 10:29 AM revealed he had been notified of the incident and of the different measures to prevent occurrences from happening in the future. He stated he had recommended 1:1 with residents daily so the residents can make staff aware of daily concerns, and the possibility of a call number to be put in place for the residents who do not feel comfortable with staff members. The Medical Director stated that interventions were not limited to these. Additionally, the Medical Director stated he was notified of the Immediate Jeopardy less than 24 hours after staff was notified. 15. Review of Questions to Solicit Resident Concerns forms, dated 03/16/18 through 03/21/18, revealed they were completed for every resident or family member/guardian by the Social Services Director (SSD), Activities Director (AD), Dietary Manager (DM), and Unit Manager (UM). No concerns were identified.

Based on interview, record review, review of initial report of allegation, review of facility final investigation, and review of the facility's Polices Related to Resident Abuse, Neglect and Exploitation policy, it was determined the facility failed to implement written policies and procedures to prevent and protect residents from abuse; failed to include the specifics of the investigation component in the policy and procedure, and, failed to conduct a thorough investigation of the alleged abuse for one (1) of four (4) sampled residents (Resident #1). On 03/07/18 at approximately 8:00 PM, Certified Nurse Aide (CNA) #1 witnessed Licensed Practical Nurse (LPN) #1 slap Resident #1 across the lips with an open palm, and twist and pinch the resident's upper arm, while stating How does it feel to get pinched. CNA #1 left the facility at 12:06 AM on 03/08/18, and discussed the incident with CNA #2 However, the incident of abuse was not reported immediately, per facility policy. CNA #1 did not report the incident until 03/08/18 at 8:00 AM, approximately twelve (12) hours later. LPN #1 continued to work with residents at the facility until 6:55 AM on 03/08/18. In addition, the facility failed to conduct a thorough investigation related to determining the extent of the alleged abuse when they failed to assess non-interviewable residents that LPN #1 provided care too for physical/mental sign/symptoms of abuse. The facility's failure to ensure the facility's abuse policy was implemented has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 03/15/18, and it was determined to exist on 03/07/18. The facility was notified of Immediate Jeopardy on 03/15/18. An acceptable Allegation of Compliance (AoC) was received on 03/21/18. The State Agency validated the AoC and determined Immediate Jeopardy was removed on 03/18/18. 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 monitors effectiveness of implemented changes. The findings Include: Review of the facility's policy titled, Polices Related to Resident Abuse, Neglect and Exploitation, last revised 07/08/17 revealed it is essential for all staff, volunteers, and visitors to be responsible for the health, safety, and welfare of all individuals receiving support. The organization shall ensure that the rights of individuals are protected and enforced as outlined in state and federal regulations. The facility's employees are prohibited to exploit, neglect, or abuse residents served. Definitions under F223 and F224 are as follows: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse is defined as the use of oral, written, or gestured language that will fully include disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse includes hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, photographing or videotaping against the resident's will. Further review of the above policy revealed, All suspected or alleged incidents of abuse, neglect or exploitation must be reported immediately to the employee's supervisor. Allegations or suspicions will be thoroughly investigated by the Abuse/Neglect Coordinator, Administrator and/or their designee. If an employee is involved, he/she may be restricted from further contact with individuals during the investigation process and the employee statement will be obtained and will be sent off duty, without pay, pending investigation and final determination. The charge nurse shall also notify the following persons: DON, Social Service Director, Administrator (who will report to appropriate agencies as indicated), Family or legal representative, if applicable. If the investigation is substantiated by DCBS (Department of Community Based Services) the employee shall be terminated effective on the date the incident occurred. Additionally, the employee's name will be forwarded to a registry and the employee will be barred for working in any health care facility. Employees witnessing an incident of resident abuse MUST report the incident immediately. The employee(s) witnessing the abuse may be considered an accessory to the abuse if they do not report the incident. As such, they will be subject to disciplinary action in the form of warnings, or discharge from employment and if appropriate, legal action. A statement from a resident or visitor regarding an abuse claim will be considered as strongly as that from an employee and will be given the same considerations. The Administrator or designee shall take prompt action to protect the individual, including suspension of the suspected staff member pending outcome of the investigation. Notifications must be made to the appropriate reporting agencies within 2 hours including local law enforcement. Further review of the above policy revealed the policy did not address the specifics of the investigation component to include how the facility would determine the extent of the alleged abuse during the facility investigation. Record review revealed the facility admitted Resident #1 on 05/10/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/29/17, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9). Review of CNA #1's witness statement, Resident #1's Progress Note dated 03/08/18 at 8:30 AM; and interview with CNA #1, on 03/13/18 at 1:27 PM and 03/15/18 at 11:40 AM, revealed CNA #1 witnessed LPN #1 slap Resident #1 hard on the lips with an open palm and grab the resident's right arm (fatty loose skin) twisting and pinching the skin. CNA #1 stated she told CNA #2 of the incident when they were leaving the facility on 03/08/18 at 12:06 AM. However, neither of them reported the alleged abuse immediately, as required per facility policy. CNA #1 notified Administration the next morning (03/08/18) at approximately 8:00 AM (approximately twelve (12) hours after the incident). She stated she knew she was supposed to report the abuse immediately per facility policy but she did not report it immediately because she was scared. In addition, review of LPN #1's time sheet, dated 02/25/18 through 03/10/18, revealed LPN #1 was not removed from resident care at the time of the incident but continued to provide care to residents in the facility until 03/08/18 at 6:55 AM (approximately twelve (12) hours after the alleged abuse occurred). Interview with CNA #2 on 03/14/18 at 12:50 PM revealed CNA #1 told her on 03/08/18 around 1:00 AM that LPN #1 had slapped Resident #1 in the mouth and grabbed Resident #1 above the right elbow and started pinching him/her. CNA #2 stated she and CNA #1 were clocking out and leaving the building when they had the conversation and LPN #1 was still working. She stated she should have reported the alleged abuse herself but did not report it because it was hearsay. She stated she told CNA #1 to call or text the DON. Review of the facility's Initial Report of the allegation revealed the facility reported the allegation of abuse by fax to the State Agency on 03/08/18 at 12:06 PM and at 1:33 PM approximately four (4) hours after notification instead of within two (2) hours, per policy. Review of the facility's final investigation, dated 03/12/18, revealed the facility determined CNA #1 and CNA #2 failed to report alleged abuse immediately per the facility policy and procedure; and, failed to remove LPN #1 from providing care to residents immediately. However, further review revealed there was no documented evidence the facility determined the extent of the alleged abuse. Interviewable residents that LPN #1 provided care for were interviewed to determined if any complaints of abuse/or symptoms of abuse; however, there was no evidence the non-interviewable residents that LPN #1 provided care for were assessed for physical/mental signs/symptoms of abuse. Interview on 03/13/18 at 4:07 PM, on 03/14/18 at 4:07 PM; and, on 03/23/18 at 12:05 PM with the Assistant Director of Nursing (ADON) revealed she expected staff to report allegations of abuse immediately and for the alleged perpetrator to have been removed from resident care per facility policy. Interview with the Abuse Coordinator/Social Service Director (AC/SSD) on 03/13/18 at 10:40 AM and 12:55 PM and on 03/23/18 at 12:50 PM and 1:16 PM revealed CNA #1, and CNA #2, did not report the abuse allegation immediately as per facility policy. She stated interviews with interviewable residents on the East Side were completed. However, the facility had not taken any action related to non-interviewable residents yet to look for visible signs--such as no visible bruising, discomfort, and expressions (if they look as if scared or disturbed) -anything out of the normal. She stated there were about 40-50 residents on the hall that LPN #1 had worked. Interview with Director of Nursing (DON) on 03/23/18 at 11:42 AM revealed CNA #1, and CNA #2 did not follow the facility's abuse policy by not reporting the abuse immediately. The DON stated she expected to be notified of allegations of abuse immediately and for the alleged abuser to be removed immediately from the floor per facility policy. Further interview (Post Survey) with the DON, on 04/05/18 at 1:58 PM, revealed the CNAs had been inserviced on the abuse policy upon hire and they knew when to report and who to report, and to do it immediately. The DON stated she told CNA #1 she should have stayed in the room and yelled as loud as she could. She stated there was an RN Supervisor and the CNA should have hollered for her and reported it immediately. Interview with the Administrator, on 03/12/18 at 5:27 PM, on 03/14/18 at 10:00 AM, 10:22 AM and 3:05 PM, and on 03/23/18 at 1:59 PM revealed the staff should have immediately reported the abuse per facility policy. He stated the nurse was able to continue to work with residents until the next day due to the staff's delay in reporting the abuse. He stated the time was off on the faxed initial report and the confirmation of 12:06 PM was not correct as he had looked at his watch after the initial report for Resident #1 and it was 11:30 AM (three and one-half hours). However, the Administrator stated the facility had two (2) hours once notified per facility policy to report to State Agencies. He also stated LPN #1 was not reported to the Board of Nursing until 03/14/18 at 3:05 PM. Further interview (Post Survey) with the Administrator on 04/05/18 at 2:55 PM, revealed the Administration was notified of the allegation on 03/08/18 at approximately 8:15 AM to 8:30 AM by CNA #1. He stated he went to a meeting and when he returned at approximately 11:30 AM the allegation had already been sent to the State agency. He revealed all staff were aware an abuse allegation must be reported within two (2) hours and he could not explain why it had not been done. The Administrator stated the DON had asked him about the Abuse policy and he printed it out and noted it did not have the investigation component in the policy. The Administrator further stated all residents that LPN #1 cared for should have been assessed for emotional or physical harm; however, the facility did not conduct the assessments until after the Immediate Jeopardy was identified. Interview on 03/23/18 at 10:29 AM with Medical Director revealed he expected allegations of abuse to be reported immediately per facility policy. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 (the alleged perpetrator of the physical abuse) was suspended pending further investigation by the Administrator on 03/08/18. The Administrator terminated LPN #1 on 03/12/18. 2. The ADON reported LPN #1 to the Kentucky Board of Nursing on 03/13/18. 3. CNA #1 was reprimanded and suspended on 03/8/18 for failure to report timely, and on 03/16/18 after further consideration by the Administrator and consulting with a Long-Term Care Consultant it was decided by the Administrator to terminate CNA #1 on 03/17/18. 4. CNA #2 was terminated on 03/17/18. 5. On 03/08/18, Resident #1 had a full body assessment completed by the Director of Nursing (DON) and ADON with yellow bruising on the upper right arm noted. In addition, Resident #1 was placed on 72-hour alert charting to follow and monitor for affects from the allegation of physical abuse. 6. Beginning on 03/08/18 until 04/06/18, the Center's Social Worker, Administrator or Charge Nurse will complete an interview with Resident #1 daily to check for any signs of abuse, fearfulness and to assure that the resident feels safe at the Center. 7. Full body assessments were completed on each resident on 03/15/18 through 03/16/18 to identify any signs or symptoms of physical abuse. There were no signs or symptoms of physical abuse on any resident. The full body assessments were completed by the DON, ADON, Corporate Admissions Director (LPN), Charge Nurse (LPN), Unit Manager East Wing (LPN), MDS Coordinator (LPN), and MDS Director (RN). 8. On 03/15/18, resident interviews were completed utilizing an established questionnaire for the Center; Review Questions to Solicit Resident Concerns. The questionnaire was completed for each resident to identify any resident that may have an allegation of abuse. Responsible parties were asked the review questions when a resident had a cognitive deficit; and the residents without a cognitive deficit were permitted to answer the pertinent questions. The Review Questions to Solicit Resident Concerns were completed by the Social Services Director (SSD), Activities Director, Corporate Resident Services Coordinator (CRSC), and the Dietary Manager. Department Managers which included LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records. There were no concerns identified from the questions. 9. On 03/15/18, the Corporate Admissions Director in-serviced the Administrator, DON, ADON, Social Services Director (SSD), MDS Coordinator, MDS Director, Housekeeping/Laundry, Maintenance Director, Therapy Program Director, Human Resources Assistant, Medical Records, Dietary Manager, Human Resources, and Corporate Resident Services Coordinator on Abuse Prevention, the timeliness of reporting an allegation, and how to complete a thorough investigation. 10. On 03/15/18 through 03/17/18, abuse education was provided by the Administrator, Social Worker and Corporate Admissions Director to all departments and all employees of the Center. Any employees that were unavailable or unreachable by telephone on these education dates will not be able to return to work until they have received the abuse education and have been post-tested with each employee passing the post-test. Any newly hired employee will receive the abuse education and complete post-testing with a passing score before working in the Center. The abuse education includes the abuse prohibition policies of the facility, the types of abuse, the importance and urgency of reporting allegations of abuse immediately and assuring that the resident is removed from any abuse or potential abuse situation. Each employee completed an abuse prevention post-test and passed the post test as a result of the abuse education that was provided on 03/15/18 through 03/17/18. At the time of the abuse education, each employee is required to read, understand, and sign the Acknowledgement of Responsibilities for Prevention and Reporting of Resident Abuse that is part of the Abuse Prohibition Policies of the Center. 11. Beginning 03/17/18, Department Managers will rotate weekends to identify any resident that may be a victim of abuse. The monitoring by the Department Managers will include both shifts which include 6a-6p and 6p-6a each day of the week and weekends---completed daily for a three (3) month minimum. The Department Managers includes the Administrator, DON, ADON, SSD, MDS Coordinator, MDS Director, Dietary Manager, Housekeeping Coordinator, Activities Director, and Medical Records. These managers will use a standard tool developed by an owner of the Center on 03/16/18. This Administrative Rounds Checklist is a tool designed to interview employees for the purpose of soliciting any concerns related to allegations of resident abuse. The Administrative Rounds Checklist will be completed on a total of ten (10) employees daily which will include both shifts of 6a-6p and 6p-6a and also weekends. The Administrator will monitor on the weekend by discussing with the Department Manager working each specified weekend. In the absence of the Administrator the Director of Nursing will monitor the week-end rotations by the department heads. 12. On 03/16/18, the DON and the Administrator are attending and/or calling in and listening to shift rotation which is 6a-6p and also 6p-6a This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. On 03/16/18, the DON and the Administrator are participating in the 24-hour shift report to monitor for any changes in resident behavior and other incidents that may be a potential for abuse. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. In the absence of the Administrator and Director of Nursing, the Assistant Director of Nursing and/or Night Shift Nursing House Supervisor will fill in. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. 13. On 03/16/18, the Administrator initiated a Performance Improvement Team (PIT) to monitor abuse prohibition policies, investigation of abuse allegations and reporting of abuse allegations. The PIT members include the Administrator, DON, ADON, Social Worker, MDS Coordinator, MDS Director, and Night Shift Nursing House Supervisor. The PIT meets daily and completes the monitoring process by reviewing the current allegations of abuse, incident reports, and the root cause analysis. The PIT will monitor this on a daily basis during the week, and the PIT monitors the Director of Nursing and Administrator rotations for shift transitions initiated on 03/16/18. The PIT team will bring the information being monitored to the monthly QAPI meeting, which will include the SSD, Administrator, ADON, DON, Medical Director, Activities Director, Maintenance Director, Housekeeping/Laundry, Medical Records, MDS Coordinator, MDS Director, and Dietary Manager. 14. The Medical Director was notified of the Immediate Jeopardy by the Corporate Admissions Director on 03/16/18, a QAPI meeting was held which included the Medical Director, MDS Coordinator, MDS Director, Activities Director, Administrator, SSD, DON, ADON, and Medical Records. They discussed the Immediate Jeopardy and the plans the facility was taking to assure an allegation of compliance. 15. Starting on 03/19/18, the Department Managers which include LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records will complete Review Questions to Solicit Resident Concerns for every resident or family member/guardian once a week for three (3) months to assure sustainment of compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview on 03/22/18 at 1:37 PM with Administrator revealed he did not fill out a suspension form when he suspended LPN #1 but will supply time card; and will supply the time cards for CNA #1 and CNA #2. Review of a facility's Termination Notice, dated 03/12/18, revealed LPN #1 was terminated for Misconduct with circumstances of termination: Failure to follow abuse policies. 2. Interview on 03/14/18 at 5:28 PM and on 03/22/18 at 2:08 PM with the ADON revealed she reported LPN #1 to the Kentucky Board of Nursing (KBN) on 03/13/18. 3. Review of the facility's Progressive Disciplinary Form dated 03/08/18, revealed CNA #1 was terminated on 03/16/18 related to the failure to follow facility policy. 4. Review of the facility's Payroll Termination Notice dated 03/17/18, revealed CNA #2 was terminated due to not following facility policy. 5. Review of the 03/08/18 weekly skin assessment for Resident #1, dated 03/03/18 at 11:45 AM, provided by ADON revealed bruising to the left and right upper arm/quadrant/extremity. Review of Progress Notes dated 03/08/18 at 8:30 AM through 03/12/18 at 11:26 PM, revealed Resident #1 was assessed for affects from the alleged physical abuse with no concerns identified. 6. Review of Resident #1 interviews dated 03/08/18 through 03/21/18, completed by the SSD and Administrator revealed no concerns. Interview on 03/22/18 at 1:56 PM with Administrator revealed Resident #1 had voiced no concerns, seemed fine, and seemed as if nothing really happened. 7. Review of the full body assessments of all residents completed by the DON, ADON, MDS Coordinator, MDS Director, Charge Nurse, and Unit Managers, dated 03/15/18 through 03/16/18 revealed no concerns. 8. Review of the Review Questions to Solicit Resident Concerns interviews, dated 03/16/18 through 03/21/18 completed on all interviewable, non-interviewable residents and by the SSD, Activities Director, Dietary Manager, and Unit Manager (UM) revealed no concerns identified. Interviews on 03/23/18 with Unsampled Resident A at 1:43 PM, Unsampled Resident B at 1:45 PM, Unsampled Resident C's family member at 1:48 PM, Unsampled Resident D at 1:55 PM, Resident 31 at 1:55 PM and Resident #3 at 1:52 PM, revealed staff had asked them questions related abuse with no concerns. 9. Review of the Facility Inservice Training Record dated 03/15/18, revealed Abuse Prevention, Timely Reporting, and How to Complete Thorough Investigation was provided by Corporate Admissions and Marketing Director to Administrative staff and Department Managers. Interview on 03/23/18 at 11:08 AM with Corporate Admissions and Marketing Director revealed she had provided training on 03/15/18 through 03/16/18 to the Administrative staff to include all department managers and administrative staff. Interviews on 03/23/18 with the Administrator at 9:45 AM, the Dietary Manage at at 10:01 AM, Activities Director at 11:30 AM, DON at 11:42 AM, ADON at 12:05 PM , and MDS Coordinator at 12:35 PM revealed abuse and neglect training had been provided to them. 10. Review of the binder for Abuse/Neglect Inservices revealed the Abuse, Neglect and Exploitation Policy, and a listing of employees dated 03/15/18 that had completed the inservice training. In addition, there were Resident Abuse, Neglect, and Exploitation forms signed by employees and a listing of staff that had completed the abuse post test. Interviews on 03/22/18 with Housekeeper #1 at 2:35 PM, LPN #5 at 4:27 PM, Administrative Assistant at 4:41 PM, CNA #10 at 4:49 PM, Physical Therapy Assistant #1 at 4:58 PM, Laundry #1 at 5:08 PM, CMT #2 at 5:19 PM; and, on 03/23/18 with House Supervisor #1 at 9:00 AM, MDS Director at 10:20 AM, LPN #4 at 10:49 AM, CNA #9 at 11:17 AM, Activities Director at 11:30 AM, Maintenance Assistant at 12:02 PM, MDS Coordinator at 12:32 PM, and Dietary Assistant at 12:42 PM, revealed they received abuse/neglect training; which included going over the policy, taking a pre/post test, and signing an acknowledgement form. The staff stated they were to report abuse immediately to the charge nurse and if the charge nurse was not available to go above them and call the DON or Administrator. The staff revealed they should make sure the residents were safe, by removing the resident if possible or to stay with them until help could be obtained. The staff also stated the following types of abuse are to be reported: verbal, physical, sexual, mental, emotional, misappropriation of funds, and involuntary seclusion. Additionally, the staff revealed the Administrator and the Unit Supervisor went around and asked about concerns with the residents and if any concerns were voiced by the residents to the staff. 11. Review of March/April/May calendar revealed the schedule for administrative staff/Department Manager rotation for weekend shifts. Review of Administrative Rounds Checklist completed daily by the Administrator, DON, ADON, SSD, MDS Director, MDS Coordinator, dated 03/17/18-03/21/18, revealed no concerns with daily monitoring done Interview with the Administrator on 03/23/18 at 4:12 PM revealed the schedule was placed on the calendar and that is how staff are made aware of when they are scheduled to work the weekend. Interview with CNA #10 on 03/22/18 at 4:49 PM, CNA #11 on 03/23/18 at 12:52 AM, CMT #2 on 03/22/18 at 5:19 PM, and CNA #9 on 03/23/18 at 11:17 AM revealed they had been asked questions by Administrative Staff related to resident concerns while working their shift. Interview with the SSD, on 03/23/18 at 12:50 PM, revealed she was involved in the application of the Administrative Rounds Checklist. 12. Review of 03/17/18 through 03/22/18 documentation by the Administrator and DON revealed they were in attendance/or listening during shift rotations. Interviews on 03/23/18 with House Supervisor #1 at 9:00 AM, the DON at 11:42 AM, the ADON at 12:05 PM and the Administrator at 9:45 AM revealed shift report and 24 hour report were completed by the Administrator and DON, and in the absence of Administrator or the DON the ADON would fill in. Interview with the Administrator on 03/22/18 at 4:15 PM revealed he and the DON divide the halls to call in or physically participate in shift report and 24 hour report. He stated if the ADON needs to fill in for one of them it would be placed on the schedule. 13. Review of the Performance Improvement Team (PIT) meeting notes revealed daily meetings were being held by the DON, Administrator, ADON, SSD, MDS Director, and MDS Coordinator. Interview with the Administrator on 03/22/18 at 3:34 PM revealed allegations of abuse, incident reports, and the root cause analysis were reviewed daily in the morning meeting. 14. Review of Quality Assurance and Performance Improvement (QAPI) Meeting Notes revealed QAPI met on 03/16/18 to discuss the Immediate Jeopardy and developed their plan of action to remove the IJ. Interview with the Medical Director on 03/23/18 at 10:29 AM revealed he had been notified of the incident and of the different measures to prevent occurrences from happening in the future. He stated he had recommended 1:1 with residents daily so the residents can make staff aware of daily concerns, and the possibility of a call number to be put in place for the residents who do not feel comfortable with staff members. The Medical Director stated that interventions were not limited to these. Additionally, the Medical Director stated he was notified of the Immediate Jeopardy less than 24 hours after staff was notified. 15. Review of Questions to Solicit Resident Concerns forms, dated 03/16/18 through 03/21/18, revealed they were completed for every resident or family member/guardian by the Social Services Director (SSD), Activities Director (AD), Dietary Manager (DM), and Unit Manager (UM). No concerns were identified.

Based on interview, record review, facility initial report of allegation, and facility policy review, it was determined the facility failed to ensure an allegation of abuse was reported immediately for one (1) of four (4) sampled residents (Residents #1) On 03/07/18 at approximately 8:00 PM, Certified Nurse Aide (CNA) #1 witnessed Resident #1 being slapped and pinched by Licensed Practical Nurse (LPN) #1 and then discussed the incident with CNA #2. However, the CNAs failed to report the abuse allegation to Administration until 03/08/18 at approximately 8:00 AM (approximately twelve {12} hours later). In addition, Administration failed to report the allegation to the appropriate State agencies until approximately 12:06 PM on 03/08/18 (four {4} hours later). The facility's failure to report an allegation of abuse immediately has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/14/18 and determined to exist on 03/07/18. The facility was notified of the Immediate Jeopardy on 03/14/18. An acceptable Allegation of Compliance (AoC) was received on 03/21/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/18/18. 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. The findings include: Review of the facility's policy titled, Polices Related to Resident Abuse, Neglect and Exploitation, last revised 07/08/17, revealed all suspected or alleged incidents of abuse, neglect or exploitation must be reported immediately to the employee's supervisor. The employee(s) witnessing the abuse may be considered an accessory to the abuse if they do not report the incident. Notifications must be made to the appropriate reporting agencies within two (2) hours, including local law enforcement. Record review revealed the facility admitted Resident #1 on 05/10/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/29/17, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9) indicating the resident was interviewable. Review of CNA #1's witness statement and interview with CNA #1, on 03/13/18 at 1:27 PM and 03/15/18 at 11:40 AM, revealed CNA #1 observed and heard Resident #1 call her and LPN #1 the N word. Further review revealed LPN #1 slapped Resident #1 hard on the lips with an open palm and stated, Don't ever call me the N word again. Resident #1 then pinched CNA #1 and LPN #1 grabbed the resident's right arm (fatty loose skin) twisting and pinching the skin and asked the resident, How does it feel to get pinched?. CNA #1 stated she told CNA #2 of the incident when they were leaving the facility on 03/08/18 at 12:06 AM. However, she did not notify Administration until approximately 8:00 AM on the morning of 03/08/18 approximately twelve (12) hours after the incident. She stated she knew she was supposed the report the abuse immediately but she was scare due to having a history of being abused herself. Review of the facility's Initial Report of the allegation revealed the report was faxed to the State Agency on 03/08/18 at 12:06 PM; and, at 1:33 PM on 03/08/18, approximately four (4) hours after the facility's administrative staff was made aware of the allegation. Interview with CNA #2 on 03/14/18 at 12:50 PM revealed CNA #1 told her on 03/08/18 around 1:00 AM that LPN #1 had slapped Resident #1 in the mouth and grabbed Resident #1 above the right elbow and started pinching him/her. CNA #2 stated she and CNA #1 were clocking out and leaving the building when they had the conversation and LPN #1 was still working. CNA #2 revealed she was aware she was supposed to report the allegation immediately but she felt it was hearsay and she told CNA #1 text the DON. Interview with the Abuse Coordinator/Social Service Director (AC/SSD) on 03/13/18 at 12:55 PM and 03/23/18 at 12:50 PM and 1:16 PM revealed CNA #1 and CNA #2, did not follow the facility's abuse policy when they failed to immediately report the allegation. The AC/SSD stated the facility had two (2) hours to report abuse allegations to State Agencies once they become aware of them. She stated the time was off on the initial report of the abuse allegation for Resident #1. Interview with the Director of Nursing (DON) on 03/23/18 at 11:42 AM revealed CNA #1, and CNA #2 did not follow the facility's abuse policy by not reporting the allegation of abuse immediately. The DON stated she expected staff to report allegations of abuse immediately, and no staff member should leave the facility with knowledge of an allegation of abuse without reporting. Additionally, the DON stated the facility has two (2) hours to report abuse allegations to the State Agencies. Further interview (Post Survey) with the DON, on 04/05/18 at 1:58 PM, revealed the CNAs had been inserviced on the abuse policy upon hire and they knew when to report and who to report, and to do it immediately. The DON stated she told CNA #1 she should have stayed in the room and yelled as loud as she could. She stated there was an RN Supervisor and the CNA should have hollered for her and reported it immediately. The DON revealed the facility has two (2) hours to report abuse allegations to the State Agencies per facility policy. Interview with the Administrator on 03/23/18 at 1:59 PM revealed the time (12:06 PM) was off on the faxed initial report and was not correct as he had looked at his watch after the initial report for Resident #1 had been sent and it was 11:30 AM (three and one-half hours). The Administrator stated the facility has two (2) hours after they have knowledge of an allegation to report to State Agencies. Further interview (Post Survey) with the Administrator on 04/05/18 at 2:55 PM, revealed he went to a meeting and when he returned at approximately 11:30 AM the initial report had already been sent to the State agency. He stated all staff were aware an abuse allegation must be reported within two (2) hours and he could not explain why it had not been done. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 (the alleged perpetrator of the physical abuse) was suspended pending further investigation by the Administrator on 03/08/18. The Administrator terminated LPN #1 on 03/12/18. 2. The ADON reported LPN #1 to the Kentucky Board of Nursing on 03/13/18. 3. CNA #1 was reprimanded and suspended on 03/8/18 for failure to report timely, and on 03/16/18 after further consideration by the Administrator and consulting with a Long-Term Care Consultant it was decided by the Administrator to terminate CNA #1 on 03/17/18. 4. CNA #2 was terminated on 03/17/18. 5. On 03/08/18, Resident #1 had a full body assessment completed by the Director of Nursing (DON) and ADON with yellow bruising on the upper right arm noted. In addition, Resident #1 was placed on 72-hour alert charting to follow and monitor for affects from the allegation of physical abuse. 6. Beginning on 03/08/18 until 04/06/18, the Center's Social Worker, Administrator or Charge Nurse will complete an interview with Resident #1 daily to check for any signs of abuse, fearfulness and to assure that the resident feels safe at the Center. 7. Full body assessments were completed on each resident on 03/15/18 through 03/16/18 to identify any signs or symptoms of physical abuse. There were no signs or symptoms of physical abuse on any resident. The full body assessments were completed by the DON, ADON, Corporate Admissions Director (LPN), Charge Nurse (LPN), Unit Manager East Wing (LPN), MDS Coordinator (LPN), and MDS Director (RN). 8. On 03/15/18, resident interviews were completed utilizing an established questionnaire for the Center; Review Questions to Solicit Resident Concerns. The questionnaire was completed for each resident to identify any resident that may have an allegation of abuse. Responsible parties were asked the review questions when a resident had a cognitive deficit; and the residents without a cognitive deficit were permitted to answer the pertinent questions. The Review Questions to Solicit Resident Concerns were completed by the Social Services Director (SSD), Activities Director, Corporate Resident Services Coordinator (CRSC), and the Dietary Manager. Department Managers which included LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records. There were no concerns identified from the questions. 9. On 03/15/18, the Corporate Admissions Director in-serviced the Administrator, DON, ADON, Social Services Director (SSD), MDS Coordinator, MDS Director, Housekeeping/Laundry, Maintenance Director, Therapy Program Director, Human Resources Assistant, Medical Records, Dietary Manager, Human Resources, and Corporate Resident Services Coordinator on Abuse Prevention, the timeliness of reporting an allegation, and how to complete a thorough investigation. 10. On 03/15/18 through 03/17/18, abuse education was provided by the Administrator, Social Worker and Corporate Admissions Director to all departments and all employees of the Center. Any employees that were unavailable or unreachable by telephone on these education dates will not be able to return to work until they have received the abuse education and have been post-tested with each employee passing the post-test. Any newly hired employee will receive the abuse education and complete post-testing with a passing score before working in the Center. The abuse education includes the abuse prohibition policies of the facility, the types of abuse, the importance and urgency of reporting allegations of abuse immediately and assuring that the resident is removed from any abuse or potential abuse situation. Each employee completed an abuse prevention post-test and passed the post test as a result of the abuse education that was provided on 03/15/18 through 03/17/18. At the time of the abuse education, each employee is required to read, understand, and sign the Acknowledgement of Responsibilities for Prevention and Reporting of Resident Abuse that is part of the Abuse Prohibition Policies of the Center. 11. Beginning 03/17/18, Department Managers will rotate weekends to identify any resident that may be a victim of abuse. The monitoring by the Department Managers will include both shifts which include 6a-6p and 6p-6a each day of the week and weekends---completed daily for a three (3) month minimum. The Department Managers includes the Administrator, DON, ADON, SSD, MDS Coordinator, MDS Director, Dietary Manager, Housekeeping Coordinator, Activities Director, and Medical Records. These managers will use a standard tool developed by an owner of the Center on 03/16/18. This Administrative Rounds Checklist is a tool designed to interview employees for the purpose of soliciting any concerns related to allegations of resident abuse. The Administrative Rounds Checklist will be completed on a total of ten (10) employees daily which will include both shifts of 6a-6p and 6p-6a and also weekends. The Administrator will monitor on the weekend by discussing with the Department Manager working each specified weekend. In the absence of the Administrator the Director of Nursing will monitor the week-end rotations by the department heads. 12. On 03/16/18, the DON and the Administrator are attending and/or calling in and listening to shift rotation which is 6a-6p and also 6p-6a This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. On 03/16/18, the DON and the Administrator are participating in the 24-hour shift report to monitor for any changes in resident behavior and other incidents that may be a potential for abuse. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. In the absence of the Administrator and Director of Nursing, the Assistant Director of Nursing and/or Night Shift Nursing House Supervisor will fill in. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. 13. On 03/16/18, the Administrator initiated a Performance Improvement Team (PIT) to monitor abuse prohibition policies, investigation of abuse allegations and reporting of abuse allegations. The PIT members include the Administrator, DON, ADON, Social Worker, MDS Coordinator, MDS Director, and Night Shift Nursing House Supervisor. The PIT meets daily and completes the monitoring process by reviewing the current allegations of abuse, incident reports, and the root cause analysis. The PIT will monitor this on a daily basis during the week, and the PIT monitors the Director of Nursing and Administrator rotations for shift transitions initiated on 03/16/18. The PIT team will bring the information being monitored to the monthly QAPI meeting, which will include the SSD, Administrator, ADON, DON, Medical Director, Activities Director, Maintenance Director, Housekeeping/Laundry, Medical Records, MDS Coordinator, MDS Director, and Dietary Manager. 14. The Medical Director was notified of the Immediate Jeopardy by the Corporate Admissions Director on 03/16/18, a QAPI meeting was held which included the Medical Director, MDS Coordinator, MDS Director, Activities Director, Administrator, SSD, DON, ADON, and Medical Records. They discussed the Immediate Jeopardy and the plans the facility was taking to assure an allegation of compliance. 15. Starting on 03/19/18, the Department Managers which include LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records will complete Review Questions to Solicit Resident Concerns for every resident or family member/guardian once a week for three (3) months to assure sustainment of compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview on 03/22/18 at 1:37 PM with Administrator revealed he did not fill out a suspension form when he suspended LPN #1 but will supply time card; and will supply the time cards for CNA #1 and CNA #2. Review of a facility's Termination Notice, dated 03/12/18, revealed LPN #1 was terminated for Misconduct with circumstances of termination: Failure to follow abuse policies. 2. Interview on 03/14/18 at 5:28 PM and on 03/22/18 at 2:08 PM with the ADON revealed she reported LPN #1 to the Kentucky Board of Nursing (KBN) on 03/13/18. 3. Review of the facility's Progressive Disciplinary Form dated 03/08/18, revealed CNA #1 was terminated on 03/16/18 related to the failure to follow facility policy. 4. Review of the facility's Payroll Termination Notice dated 03/17/18, revealed CNA #2 was terminated due to not following facility policy. 5. Review of the 03/08/18 weekly skin assessment for Resident #1, dated 03/03/18 at 11:45 AM, provided by ADON revealed bruising to the left and right upper arm/quadrant/extremity. Review of Progress Notes dated 03/08/18 at 8:30 AM through 03/12/18 at 11:26 PM, revealed Resident #1 was assessed for affects from the alleged physical abuse with no concerns identified. 6. Review of Resident #1 interviews dated 03/08/18 through 03/21/18, completed by the SSD and Administrator revealed no concerns. Interview on 03/22/18 at 1:56 PM with Administrator revealed Resident #1 had voiced no concerns, seemed fine, and seemed as if nothing really happened. 7. Review of the full body assessments of all residents completed by the DON, ADON, MDS Coordinator, MDS Director, Charge Nurse, and Unit Managers, dated 03/15/18 through 03/16/18 revealed no concerns. 8. Review of the Review Questions to Solicit Resident Concerns interviews, dated 03/16/18 through 03/21/18 completed on all interviewable, non-interviewable residents and by the SSD, Activities Director, Dietary Manager, and Unit Manager (UM) revealed no concerns identified. Interviews on 03/23/18 with Unsampled Resident A at 1:43 PM, Unsampled Resident B at 1:45 PM, Unsampled Resident C's family member at 1:48 PM, Unsampled Resident D at 1:55 PM, Resident 31 at 1:55 PM and Resident #3 at 1:52 PM, revealed staff had asked them questions related abuse with no concerns. 9. Review of the Facility Inservice Training Record dated 03/15/18, revealed Abuse Prevention, Timely Reporting, and How to Complete Thorough Investigation was provided by Corporate Admissions and Marketing Director to Administrative staff and Department Managers. Interview on 03/23/18 at 11:08 AM with Corporate Admissions and Marketing Director revealed she had provided training on 03/15/18 through 03/16/18 to the Administrative staff to include all department managers and administrative staff. Interviews on 03/23/18 with the Administrator at 9:45 AM, the Dietary Manage at at 10:01 AM, Activities Director at 11:30 AM, DON at 11:42 AM, ADON at 12:05 PM , and MDS Coordinator at 12:35 PM revealed abuse and neglect training had been provided to them. 10. Review of the binder for Abuse/Neglect Inservices revealed the Abuse, Neglect and Exploitation Policy, and a listing of employees dated 03/15/18 that had completed the inservice training. In addition, there were Resident Abuse, Neglect, and Exploitation forms signed by employees and a listing of staff that had completed the abuse post test. Interviews on 03/22/18 with Housekeeper #1 at 2:35 PM, LPN #5 at 4:27 PM, Administrative Assistant at 4:41 PM, CNA #10 at 4:49 PM, Physical Therapy Assistant #1 at 4:58 PM, Laundry #1 at 5:08 PM, CMT #2 at 5:19 PM; and, on 03/23/18 with House Supervisor #1 at 9:00 AM, MDS Director at 10:20 AM, LPN #4 at 10:49 AM, CNA #9 at 11:17 AM, Activities Director at 11:30 AM, Maintenance Assistant at 12:02 PM, MDS Coordinator at 12:32 PM, and Dietary Assistant at 12:42 PM, revealed they received abuse/neglect training; which included going over the policy, taking a pre/post test, and signing an acknowledgement form. The staff stated they were to report abuse immediately to the charge nurse and if the charge nurse was not available to go above them and call the DON or Administrator. The staff revealed they should make sure the residents were safe, by removing the resident if possible or to stay with them until help could be obtained. The staff also stated the following types of abuse are to be reported: verbal, physical, sexual, mental, emotional, misappropriation of funds, and involuntary seclusion. Additionally, the staff revealed the Administrator and the Unit Supervisor went around and asked about concerns with the residents and if any concerns were voiced by the residents to the staff. 11. Review of March/April/May calendar revealed the schedule for administrative staff/Department Manager rotation for weekend shifts. Review of Administrative Rounds Checklist completed daily by the Administrator, DON, ADON, SSD, MDS Director, MDS Coordinator, dated 03/17/18-03/21/18, revealed no concerns with daily monitoring done Interview with the Administrator on 03/23/18 at 4:12 PM revealed the schedule was placed on the calendar and that is how staff are made aware of when they are scheduled to work the weekend. Interview with CNA #10 on 03/22/18 at 4:49 PM, CNA #11 on 03/23/18 at 12:52 AM, CMT #2 on 03/22/18 at 5:19 PM, and CNA #9 on 03/23/18 at 11:17 AM revealed they had been asked questions by Administrative Staff related to resident concerns while working their shift. Interview with the SSD, on 03/23/18 at 12:50 PM, revealed she was involved in the application of the Administrative Rounds Checklist. 12. Review of 03/17/18 through 03/22/18 documentation by the Administrator and DON revealed they were in attendance/or listening during shift rotations. Interviews on 03/23/18 with House Supervisor #1 at 9:00 AM, the DON at 11:42 AM, the ADON at 12:05 PM and the Administrator at 9:45 AM revealed shift report and 24 hour report were completed by the Administrator and DON, and in the absence of Administrator or the DON the ADON would fill in. Interview with the Administrator on 03/22/18 at 4:15 PM revealed he and the DON divide the halls to call in or physically participate in shift report and 24 hour report. He stated if the ADON needs to fill in for one of them it would be placed on the schedule. 13. Review of the Performance Improvement Team (PIT) meeting notes revealed daily meetings were being held by the DON, Administrator, ADON, SSD, MDS Director, and MDS Coordinator. Interview with the Administrator on 03/22/18 at 3:34 PM revealed allegations of abuse, incident reports, and the root cause analysis were reviewed daily in the morning meeting. 14. Review of Quality Assurance and Performance Improvement (QAPI) Meeting Notes revealed QAPI met on 03/16/18 to discuss the Immediate Jeopardy and developed their plan of action to remove the IJ. Interview with the Medical Director on 03/23/18 at 10:29 AM revealed he had been notified of the incident and of the different measures to prevent occurrences from happening in the future. He stated he had recommended 1:1 with residents daily so the residents can make staff aware of daily concerns, and the possibility of a call number to be put in place for the residents who do not feel comfortable with staff members. The Medical Director stated that interventions were not limited to these. Additionally, the Medical Director stated he was notified of the Immediate Jeopardy less than 24 hours after staff was notified. 15. Review of Questions to Solicit Resident Concerns forms, dated 03/16/18 through 03/21/18, revealed they were completed for every resident or family member/guardian by the Social Services Director (SSD), Activities Director (AD), Dietary Manager (DM), and Unit Manager (UM). No concerns were identified.

Based on observation, interview, record review, review of the facility's initial report of allegation; final report of allegation; and, the facility's policy review it was determined the facility failed to prevent the possibility of further abuse by not removing alleged perpetrator from resident care immediately, and failed to have evidence a thorough investigation was completed to determine the extent of the abuse for one of four (4) sampled residents (Resident #1). On 03/07/18 at approximately 8:00 PM, Certified Nurse Aide (CNA) #1 witnessed Resident #1 being slapped and pinched by Licensed Practical Nurse (LPN). However, the allegation was not reported until the next morning on 03/08/18 at approximately 8:00 AM (twelve {12} hours later) which enabled LPN #1 to continue to provide care to Resident #1 and other residents in the facility until 03/08/18 at 6:55 AM (eleven {11} hours) after the incident occurred. In addition, the facility's Abuse policy did not include the specifics of the investigation component and the facility failed to assess non-interviewable residents who LPN #1 provided care too for any physical/mental signs/symptoms of abuse to determine the extent of the abuse in the facility. The facility's failure to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/14/18 and determined to exist on 03/07/18. The facility was notified of the Immediate Jeopardy on 03/14/18. An acceptable Allegation of Compliance (AoC) was received on 03/21/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/18/18. 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. The findings include: Review of the facility's policy titled, Polices Related to Resident Abuse, Neglect and Exploitation, last revised 07/08/17, revealed allegations or suspicions of Abuse/neglect will be thoroughly investigated by the Abuse/Neglect Coordinator, Administrator and/or their designee. Further review of the policy revealed an employee is involved, he/she may be restricted from further contact with individuals during the investigation process and the employee's statement will be obtained and the employee will be sent off duty, without pay, pending investigation and final determination. If the investigation is substantiated by DCBS (Department of Community Based Services) the employee shall be terminated effective on the date the incident occurred. Additionally, the employee's name will be forwarded to a registry and the employee will be barred from working in any health care facility. However, further review revealed the policy did not address the specific actions the facility would take to investigate an allegation. The policy did not address how the facility would determine the extent of the abuse. Record review revealed the facility admitted Resident #1 on 05/10/07 with [DIAGNOSES REDACTED]. Review of the facility's investigation, conducted on 03/13/18 and 03/14/18, and interview with CNA #1, on 03/13/18 at 1:27 PM and 03/15/18 at 11:40 AM revealed CNA #1 was assisting Resident #1 with a bath on 03/08/18 at approximately 8:00 PM when she witnessed LPN #1 slap Resident #1 hard on the lips with an open palm. The LPN stated, Don't ever call me the N word again and grabbed the resident's right arm (fatty loose skin) twisting and pinching the skin and asking the resident, How does it feel to get pinched? CNA #1 stated she discussed the incident with CNA #2 as they were leaving the facility around midnight. She stated she text the Director of Nursing around 12:30 AM-1:00 AM on 03/08/18 and asked her to call as soon as possible but the DON did not call until 03/08/18 around 7:30 AM. She stated the DON told her to come to the facility. CNA #1 went to the facility at approximately 8:00 AM and informed them of the allegation. Review of the initial report for the abuse allegation revealed the allegation was reported by CNA #1 on 03/08/18 at approximately 8:00 AM (approximately twelve (12) hours after the incident). Further review revealed the report was faxed to the State Agency on 03/08/18 at 12:09 PM on 03/08/18, and again at 1:33 PM on 03/08/18 (approximately four hours later). Review of LPN #1's time sheet, dated 02/25/18 through 03/10/18, revealed LPN #1 reported to work on 03/07/18 at 5:54 PM and clocked out at 03/08/18 at 6:55 AM. LPN #1 continued to provide care to residents for approximately twelve (12) hours after the alleged abuse occurred. Review of the facility's final investigation, dated 03/12/18 revealed the facility interview interviewable residents to determine if there were any other incidents of abuse; however, there was no documented evidence, the facility's investigation included assessing non-interviewable residents for any mental/physical signs/symptoms of abuse to determine the extent of the abuse. Interview with the Abuse Coordinator/Social Service Director (AC/SSD) on 03/13/18 at 10:40 AM and 12:55 PM and on 03/23/18 at 12:50 PM and 1:16 PM revealed CNA #1, and CNA #2, did not report the abuse allegation immediately. The AC/SSD stated the facility had two (2) hours to report abuse allegations to State agencies once they become aware of them. She stated the time was off on the initial report of the abuse allegation. In addition, she stated interviews with interviewable residents on the East Side were completed; however, the facility had not taken any action related to non-interviewable residents yet. She stated there were about 40-50 residents on the hall that LPN #1 had worked. Interview with Director of Nursing (DON) on 03/23/18 at 11:42 AM revealed CNA #1, and CNA #2 did not follow the facility's abuse policy by not reporting it. The DON stated she expected the resident to be made safe from immediate danger/harm; the abuser removed immediately from the floor; and no staff member should leave the facility with knowledge of an allegation of abuse. She stated to investigate the allegation the facility conducts interviews with interviewable residents, and usually conducts skin assessments on non-interviewable residents to determine if other residents abused. She stated the non-interviewable residents should have been assessed and she could not provide an explanation as to why it was not done. Interview with the Administrator, on 03/12/18 at 5:27 PM, on 03/14/18 at 10:00 AM, 10:22 AM and 3:05 PM, and on 03/23/18 at 1:59 PM revealed the abuse should not have occurred. He stated when a staff member witnesses the abuse, the staff should immediately report to assure the safety of the residents. The Administrator stated the staff did not report the abuse until the next day and the nurse was allowed to work. He stated the final report of the investigation for Resident #1's abuse allegation had been sent on 03/12/18. Further interview (Post Survey) with the Administrator on 04/05/18 at 2:55 PM, revealed the Administrator stated he printed the Abuse policy out and noted it did not have the investigation component in the policy. The Administrator stated all residents that LPN #1 cared for to be assessed for emotional or physical harm; however, the facility did not conduct the assessments until after the Immediate Jeopardy was identified. He was unable to provide an explanation as to why this was not done. The Administration revealed Administration was notified of the allegation on 03/08/18 at approximately 8:15 AM to 8:30 AM by CNA #1. He stated he went to a meeting and when he returned at approximately 11:30 AM the allegation had already been sent to the State agency. He revealed all staff were aware an abuse allegation must be reported within two (2) hours and he could not explain why it had not been done. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 (the alleged perpetrator of the physical abuse) was suspended pending further investigation by the Administrator on 03/08/18. The Administrator terminated LPN #1 on 03/12/18. 2. The ADON reported LPN #1 to the Kentucky Board of Nursing on 03/13/18. 3. CNA #1 was reprimanded and suspended on 03/8/18 for failure to report timely, and on 03/16/18 after further consideration by the Administrator and consulting with a Long-Term Care Consultant it was decided by the Administrator to terminate CNA #1 on 03/17/18. 4. CNA #2 was terminated on 03/17/18. 5. On 03/08/18, Resident #1 had a full body assessment completed by the Director of Nursing (DON) and ADON with yellow bruising on the upper right arm noted. In addition, Resident #1 was placed on 72-hour alert charting to follow and monitor for affects from the allegation of physical abuse. 6. Beginning on 03/08/18 until 04/06/18, the Center's Social Worker, Administrator or Charge Nurse will complete an interview with Resident #1 daily to check for any signs of abuse, fearfulness and to assure that the resident feels safe at the Center. 7. Full body assessments were completed on each resident on 03/15/18 through 03/16/18 to identify any signs or symptoms of physical abuse. There were no signs or symptoms of physical abuse on any resident. The full body assessments were completed by the DON, ADON, Corporate Admissions Director (LPN), Charge Nurse (LPN), Unit Manager East Wing (LPN), MDS Coordinator (LPN), and MDS Director (RN). 8. On 03/15/18, resident interviews were completed utilizing an established questionnaire for the Center; Review Questions to Solicit Resident Concerns. The questionnaire was completed for each resident to identify any resident that may have an allegation of abuse. Responsible parties were asked the review questions when a resident had a cognitive deficit; and the residents without a cognitive deficit were permitted to answer the pertinent questions. The Review Questions to Solicit Resident Concerns were completed by the Social Services Director (SSD), Activities Director, Corporate Resident Services Coordinator (CRSC), and the Dietary Manager. Department Managers which included LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records. There were no concerns identified from the questions. 9. On 03/15/18, the Corporate Admissions Director in-serviced the Administrator, DON, ADON, Social Services Director (SSD), MDS Coordinator, MDS Director, Housekeeping/Laundry, Maintenance Director, Therapy Program Director, Human Resources Assistant, Medical Records, Dietary Manager, Human Resources, and Corporate Resident Services Coordinator on Abuse Prevention, the timeliness of reporting an allegation, and how to complete a thorough investigation. 10. On 03/15/18 through 03/17/18, abuse education was provided by the Administrator, Social Worker and Corporate Admissions Director to all departments and all employees of the Center. Any employees that were unavailable or unreachable by telephone on these education dates will not be able to return to work until they have received the abuse education and have been post-tested with each employee passing the post-test. Any newly hired employee will receive the abuse education and complete post-testing with a passing score before working in the Center. The abuse education includes the abuse prohibition policies of the facility, the types of abuse, the importance and urgency of reporting allegations of abuse immediately and assuring that the resident is removed from any abuse or potential abuse situation. Each employee completed an abuse prevention post-test and passed the post test as a result of the abuse education that was provided on 03/15/18 through 03/17/18. At the time of the abuse education, each employee is required to read, understand, and sign the Acknowledgement of Responsibilities for Prevention and Reporting of Resident Abuse that is part of the Abuse Prohibition Policies of the Center. 11. Beginning 03/17/18, Department Managers will rotate weekends to identify any resident that may be a victim of abuse. The monitoring by the Department Managers will include both shifts which include 6a-6p and 6p-6a each day of the week and weekends---completed daily for a three (3) month minimum. The Department Managers includes the Administrator, DON, ADON, SSD, MDS Coordinator, MDS Director, Dietary Manager, Housekeeping Coordinator, Activities Director, and Medical Records. These managers will use a standard tool developed by an owner of the Center on 03/16/18. This Administrative Rounds Checklist is a tool designed to interview employees for the purpose of soliciting any concerns related to allegations of resident abuse. The Administrative Rounds Checklist will be completed on a total of ten (10) employees daily which will include both shifts of 6a-6p and 6p-6a and also weekends. The Administrator will monitor on the weekend by discussing with the Department Manager working each specified weekend. In the absence of the Administrator the Director of Nursing will monitor the week-end rotations by the department heads. 12. On 03/16/18, the DON and the Administrator are attending and/or calling in and listening to shift rotation which is 6a-6p and also 6p-6a This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. On 03/16/18, the DON and the Administrator are participating in the 24-hour shift report to monitor for any changes in resident behavior and other incidents that may be a potential for abuse. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. In the absence of the Administrator and Director of Nursing, the Assistant Director of Nursing and/or Night Shift Nursing House Supervisor will fill in. This will be completed daily for a minimum of three (3) months to assure sustainment of compliance. 13. On 03/16/18, the Administrator initiated a Performance Improvement Team (PIT) to monitor abuse prohibition policies, investigation of abuse allegations and reporting of abuse allegations. The PIT members include the Administrator, DON, ADON, Social Worker, MDS Coordinator, MDS Director, and Night Shift Nursing House Supervisor. The PIT meets daily and completes the monitoring process by reviewing the current allegations of abuse, incident reports, and the root cause analysis. The PIT will monitor this on a daily basis during the week, and the PIT monitors the Director of Nursing and Administrator rotations for shift transitions initiated on 03/16/18. The PIT team will bring the information being monitored to the monthly QAPI meeting, which will include the SSD, Administrator, ADON, DON, Medical Director, Activities Director, Maintenance Director, Housekeeping/Laundry, Medical Records, MDS Coordinator, MDS Director, and Dietary Manager. 14. The Medical Director was notified of the Immediate Jeopardy by the Corporate Admissions Director on 03/16/18, a QAPI meeting was held which included the Medical Director, MDS Coordinator, MDS Director, Activities Director, Administrator, SSD, DON, ADON, and Medical Records. They discussed the Immediate Jeopardy and the plans the facility was taking to assure an allegation of compliance. 15. Starting on 03/19/18, the Department Managers which include LPN Unit Manager West, LPN Unit Manager East, Housekeeping/Laundry, Social Services, Administrator, MDS Coordinator, MDS Director, Night Shift Nursing House Supervisor, Dietary Manager, Administrative Assistant, Activities Director, and Medical Records will complete Review Questions to Solicit Resident Concerns for every resident or family member/guardian once a week for three (3) months to assure sustainment of compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview on 03/22/18 at 1:37 PM with Administrator revealed he did not fill out a suspension form when he suspended LPN #1 but will supply time card; and will supply the time cards for CNA #1 and CNA #2. Review of a facility's Termination Notice, dated 03/12/18, revealed LPN #1 was terminated for Misconduct with circumstances of termination: Failure to follow abuse policies. 2. Interview on 03/14/18 at 5:28 PM and on 03/22/18 at 2:08 PM with the ADON revealed she reported LPN #1 to the Kentucky Board of Nursing (KBN) on 03/13/18. 3. Review of the facility's Progressive Disciplinary Form dated 03/08/18, revealed CNA #1 was terminated on 03/16/18 related to the failure to follow facility policy. 4. Review of the facility's Payroll Termination Notice dated 03/17/18, revealed CNA #2 was terminated due to not following facility policy. 5. Review of the 03/08/18 weekly skin assessment for Resident #1, dated 03/03/18 at 11:45 AM, provided by ADON revealed bruising to the left and right upper arm/quadrant/extremity. Review of Progress Notes dated 03/08/18 at 8:30 AM through 03/12/18 at 11:26 PM, revealed Resident #1 was assessed for affects from the alleged physical abuse with no concerns identified. 6. Review of Resident #1 interviews dated 03/08/18 through 03/21/18, completed by the SSD and Administrator revealed no concerns. Interview on 03/22/18 at 1:56 PM with Administrator revealed Resident #1 had voiced no concerns, seemed fine, and seemed as if nothing really happened. 7. Review of the full body assessments of all residents completed by the DON, ADON, MDS Coordinator, MDS Director, Charge Nurse, and Unit Managers, dated 03/15/18 through 03/16/18 revealed no concerns. 8. Review of the Review Questions to Solicit Resident Concerns interviews, dated 03/16/18 through 03/21/18 completed on all interviewable, non-interviewable residents and by the SSD, Activities Director, Dietary Manager, and Unit Manager (UM) revealed no concerns identified. Interviews on 03/23/18 with Unsampled Resident A at 1:43 PM, Unsampled Resident B at 1:45 PM, Unsampled Resident C's family member at 1:48 PM, Unsampled Resident D at 1:55 PM, Resident 31 at 1:55 PM and Resident #3 at 1:52 PM, revealed staff had asked them questions related abuse with no concerns. 9. Review of the Facility Inservice Training Record dated 03/15/18, revealed Abuse Prevention, Timely Reporting, and How to Complete Thorough Investigation was provided by Corporate Admissions and Marketing Director to Administrative staff and Department Managers. Interview on 03/23/18 at 11:08 AM with Corporate Admissions and Marketing Director revealed she had provided training on 03/15/18 through 03/16/18 to the Administrative staff to include all department managers and administrative staff. Interviews on 03/23/18 with the Administrator at 9:45 AM, the Dietary Manage at at 10:01 AM, Activities Director at 11:30 AM, DON at 11:42 AM, ADON at 12:05 PM , and MDS Coordinator at 12:35 PM revealed abuse and neglect training had been provided to them. 10. Review of the binder for Abuse/Neglect Inservices revealed the Abuse, Neglect and Exploitation Policy, and a listing of employees dated 03/15/18 that had completed the inservice training. In addition, there were Resident Abuse, Neglect, and Exploitation forms signed by employees and a listing of staff that had completed the abuse post test. Interviews on 03/22/18 with Housekeeper #1 at 2:35 PM, LPN #5 at 4:27 PM, Administrative Assistant at 4:41 PM, CNA #10 at 4:49 PM, Physical Therapy Assistant #1 at 4:58 PM, Laundry #1 at 5:08 PM, CMT #2 at 5:19 PM; and, on 03/23/18 with House Supervisor #1 at 9:00 AM, MDS Director at 10:20 AM, LPN #4 at 10:49 AM, CNA #9 at 11:17 AM, Activities Director at 11:30 AM, Maintenance Assistant at 12:02 PM, MDS Coordinator at 12:32 PM, and Dietary Assistant at 12:42 PM, revealed they received abuse/neglect training; which included going over the policy, taking a pre/post test, and signing an acknowledgement form. The staff stated they were to report abuse immediately to the charge nurse and if the charge nurse was not available to go above them and call the DON or Administrator. The staff revealed they should make sure the residents were safe, by removing the resident if possible or to stay with them until help could be obtained. The staff also stated the following types of abuse are to be reported: verbal, physical, sexual, mental, emotional, misappropriation of funds, and involuntary seclusion. Additionally, the staff revealed the Administrator and the Unit Supervisor went around and asked about concerns with the residents and if any concerns were voiced by the residents to the staff. 11. Review of March/April/May calendar revealed the schedule for administrative staff/Department Manager rotation for weekend shifts. Review of Administrative Rounds Checklist completed daily by the Administrator, DON, ADON, SSD, MDS Director, MDS Coordinator, dated 03/17/18-03/21/18, revealed no concerns with daily monitoring done Interview with the Administrator on 03/23/18 at 4:12 PM revealed the schedule was placed on the calendar and that is how staff are made aware of when they are scheduled to work the weekend. Interview with CNA #10 on 03/22/18 at 4:49 PM, CNA #11 on 03/23/18 at 12:52 AM, CMT #2 on 03/22/18 at 5:19 PM, and CNA #9 on 03/23/18 at 11:17 AM revealed they had been asked questions by Administrative Staff related to resident concerns while working their shift. Interview with the SSD, on 03/23/18 at 12:50 PM, revealed she was involved in the application of the Administrative Rounds Checklist. 12. Review of 03/17/18 through 03/22/18 documentation by the Administrator and DON revealed they were in attendance/or listening during shift rotations. Interviews on 03/23/18 with House Supervisor #1 at 9:00 AM, the DON at 11:42 AM, the ADON at 12:05 PM and the Administrator at 9:45 AM revealed shift report and 24 hour report were completed by the Administrator and DON, and in the absence of Administrator or the DON the ADON would fill in. Interview with the Administrator on 03/22/18 at 4:15 PM revealed he and the DON divide the halls to call in or physically participate in shift report and 24 hour report. He stated if the ADON needs to fill in for one of them it would be placed on the schedule. 13. Review of the Performance Improvement Team (PIT) meeting notes revealed daily meetings were being held by the DON, Administrator, ADON, SSD, MDS Director, and MDS Coordinator. Interview with the Administrator on 03/22/18 at 3:34 PM revealed allegations of abuse, incident reports, and the root cause analysis were reviewed daily in the morning meeting. 14. Review of Quality Assurance and Performance Improvement (QAPI) Meeting Notes revealed QAPI met on 03/16/18 to discuss the Immediate Jeopardy and developed their plan of action to remove the IJ. Interview with the Medical Director on 03/23/18 at 10:29 AM revealed he had been notified of the incident and of the different measures to prevent occurrences from happening in the future. He stated he had recommended 1:1 with residents daily so the residents can make staff aware of daily concerns, and the possibility of a call number to be put in place for the residents who do not feel comfortable with staff members. The Medical Director stated that interventions were not limited to these. Additionally, the Medical Director stated he was notified of the Immediate Jeopardy less than 24 hours after staff was notified. 15. Review of Questions to Solicit Resident Concerns forms, dated 03/16/18 through 03/21/18, revealed they were completed for every resident or family member/guardian by the Social Services Director (SSD), Activities Director (AD), Dietary Manager (DM), and Unit Manager (UM). No concerns were identified.

Based on interview, record review, review of the facility's policy/procedure and review of the facility's Incident/Investigative Report, it was determined the facility failed to ensure all alleged violations were reported in accordance with State and Federal regulations; failed to provide evidence that an alleged violation was thoroughly investigated ; and failed to prevent further potential abuse for one resident (#5), in the selected sample of 19 residents. The facility failed to follow their Investigation and Abuse policy/procedure. Resident #5 reported an allegation of verbal abuse to Certified Medication Technician (CMT) #2, witnessed by CMT #3 (refer to F241) on 04/28/12. While the CMTs notified the Administrative nurse, the facility continued to allow the alleged perpetrator, Nurse Aide State Registered (NASR) #5, to give direct care to other residents to include bathing the victim, prior to removing the perpetrator for over an hour after the allegation was made. On 05/15/12, eighteen (18) days after the incident, Resident #5 was observed crying while describing the incident stating it embarrassed him/her and made him/her feel bad. The facility's investigation was not thorough as all witnesses, staff nor the victim were interviewed. Additionally, the facility failed to report the allegation to the State Agency. Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established.A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long-Term Care. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as cognitively intact. A review of the facility's Incident/Investigation Report, dated 04/28/12, revealed an allegation was made by Resident #5 to Certified Medication Tech (CMT) #2. CMT #2 reported the allegation to Licensed Practical Nurse (LPN) #8. Allegedly, Nurse Aide State Registered (NASR) #5 stated that the way the resident drank water reminded her of her "dog." According to the investigation, the comment was made on 04/27/12, during a meal. The investigation included a statement by NASR #5, dated 04/28/12, indicating, that on 04/27/12, she was feeding Resident #5 in the dining room. There were other residents and family members present at the table. She was talking to the resident about her "puppy" and she made a comment that the resident nodded his/her head like her "puppy." NASR #5 indicated in the statement, she did not mean to hurt the resident's feelings. There were no other written statements included in the investigation. The Administrator's Report (included in the investigation), dated 04/28/12, revealed NASR #5 was suspended after the report was made to LPN #8. It further revealed Resident #5 was "extremely sensitive" about the progression of his/her ALS and the resident was noted to cry at various times about his/her loss of function. The Administrator interviewed three other residents in the facility with no complaints, and indicated that Resident #5 was very sensitive about ALS and his/her health, but there was no crying noted during the Administrator's interview with the resident. That concluded the investigation. There was no evidence the facility substantiated/unsubstantiated the incident. An interview with Resident #5, on 05/15/12 at 4:15 PM and 05/16/12 at 2:10 PM, revealed he/she was fed by staff due to a recent decline related to the disease process of ALS. The resident revealed it was going to get worse and he/she was discouraged with the loss of independence. The resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. An observation during the resident interview, on 05/15/12 at 4:15 PM, revealed Resident #5 was visibly upset and crying while discussing the comment made by NASR #5, on 04/27/12. An interview with CMT #2, on 05/16/12 at 9:32 AM, revealed Resident #5 reported that NASR #5 made the comment about the resident drinking water like her "dog." He reported the comment to LPN #8. After reporting, LPN #8 made a phone call in her office, so he went to lunch with CMT #3. He did not know when NASR #5 was removed from resident care. An interview with CMT #3, on 05/16/12 at 10:35 AM, revealed she was a witness to the resident's allegation reported to CMT #2. She revealed CMT #2 left the resident's room to report the allegation to LPN #8. CMT #3 left the resident's room shortly after, and went to LPN #8's office. She went to lunch with CMT #2 after the report was made. She revealed NASR #5 had been preparing to give the resident a shower, but she "assumed" it was not given by her, as this was an allegation of verbal abuse. She did not know when NASR #5 was removed from care. A review of the Timecard Report for CMT #2 and CMT #3, dated 04/28/12, revealed both employees clocked out for lunch at 10:31 AM. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she gave Resident #5 a shower and provided incontinent care for another resident, on 04/28/12, prior to her suspension. A review of the Timecard Report for NASR #5, on 04/28/12, revealed she did not clock out until 11:48 AM, at least one hour and fifteen minutes after the allegation was reported to LPN #8. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed she was the Administrative Licensed Nurse in the facility, on 04/28/12. The allegation of verbal abuse was reported to her by CMT #2. She revealed when she went to find NASR #5, she was giving a resident a shower. She stated that everyone on the floor was "busy", so she reported to the charge nurse to send NASR #5 to her office when she was finished with the resident's shower. She did not know which resident was in the shower room with NASR #5. She admitted she should have removed NASR #5 from resident care immediately, per the facility policy. LPN #8 revealed she did not conduct a thorough investigation. She did not document a statement from Resident #5. She also revealed she should have obtained statements from CMT #2 and CMT #3. She did not verify who was sitting at the table when the comment was made to the resident, and did not try to contact any of them. She stated it was "very busy" that morning. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed LPN #8 contacted her at home, on 04/28/12, to report the allegation. She revealed LPN #8 was instructed to gather statements from anyone around the area, any resident that could have heard the comment, and any residents cared for by NASR #5. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. She expected LPN #8 to suspend NASR #5 immediately. She stated she did not speak to Resident #5 about the allegation. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was the facility's abuse coordinator; however, she was not aware of the allegation made by Resident #5. An interview with the Administrator, on 05/14/12 at 4:00 PM and 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation; however, it was discussed in the Quality Assurance (QA) committee meeting, on 04/28/12, with no concerns. She revealed the Social Services Director was responsible for ensuring a thorough investigation, with assistance from the DON and Administrator. She revealed the allegation was not reported to the State Agency, as it did not qualify as verbal abuse. NASR #5 was terminated due to the "questionable" incident. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QA committee meeting, on 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report the allegation because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported to the State Agency; however, he did not feel this was verbal abuse.

Based on interview, record review, review of the facility's policy/procedure and review of the facility's Incident/Investigative Report, it was determined the facility failed to ensure all alleged violations were reported in accordance with State and Federal regulations; failed to provide evidence that an alleged violation was thoroughly investigated ; and failed to prevent further potential abuse for one resident (#5), in the selected sample of 19 residents. The facility failed to follow their Investigation and Abuse policy/procedure. Resident #5 reported an allegation of verbal abuse to Certified Medication Technician (CMT) #2, witnessed by CMT #3 (refer to F241) on 04/28/12. While the CMTs notified the Administrative nurse, the facility continued to allow the alleged perpetrator, Nurse Aide State Registered (NASR) #5, to give direct care to other residents to include bathing the victim, prior to removing the perpetrator for over an hour after the allegation was made. On 05/15/12, eighteen (18) days after the incident, Resident #5 was observed crying while describing the incident stating it embarrassed him/her and made him/her feel bad. The facility's investigation was not thorough as all witnesses, staff nor the victim were interviewed. Additionally, the facility failed to report the allegation to the State Agency. Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established.A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long-Term Care. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as cognitively intact. A review of the facility's Incident/Investigation Report, dated 04/28/12, revealed an allegation was made by Resident #5 to Certified Medication Tech (CMT) #2. CMT #2 reported the allegation to Licensed Practical Nurse (LPN) #8. Allegedly, Nurse Aide State Registered (NASR) #5 stated that the way the resident drank water reminded her of her "dog." According to the investigation, the comment was made on 04/27/12, during a meal. The investigation included a statement by NASR #5, dated 04/28/12, indicating, that on 04/27/12, she was feeding Resident #5 in the dining room. There were other residents and family members present at the table. She was talking to the resident about her "puppy" and she made a comment that the resident nodded his/her head like her "puppy." NASR #5 indicated in the statement, she did not mean to hurt the resident's feelings. There were no other written statements included in the investigation. The Administrator's Report (included in the investigation), dated 04/28/12, revealed NASR #5 was suspended after the report was made to LPN #8. It further revealed Resident #5 was "extremely sensitive" about the progression of his/her ALS and the resident was noted to cry at various times about his/her loss of function. The Administrator interviewed three other residents in the facility with no complaints, and indicated that Resident #5 was very sensitive about ALS and his/her health, but there was no crying noted during the Administrator's interview with the resident. That concluded the investigation. There was no evidence the facility substantiated/unsubstantiated the incident. An interview with Resident #5, on 05/15/12 at 4:15 PM and 05/16/12 at 2:10 PM, revealed he/she was fed by staff due to a recent decline related to the disease process of ALS. The resident revealed it was going to get worse and he/she was discouraged with the loss of independence. The resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. An observation during the resident interview, on 05/15/12 at 4:15 PM, revealed Resident #5 was visibly upset and crying while discussing the comment made by NASR #5, on 04/27/12. An interview with CMT #2, on 05/16/12 at 9:32 AM, revealed Resident #5 reported that NASR #5 made the comment about the resident drinking water like her "dog." He reported the comment to LPN #8. After reporting, LPN #8 made a phone call in her office, so he went to lunch with CMT #3. He did not know when NASR #5 was removed from resident care. An interview with CMT #3, on 05/16/12 at 10:35 AM, revealed she was a witness to the resident's allegation reported to CMT #2. She revealed CMT #2 left the resident's room to report the allegation to LPN #8. CMT #3 left the resident's room shortly after, and went to LPN #8's office. She went to lunch with CMT #2 after the report was made. She revealed NASR #5 had been preparing to give the resident a shower, but she "assumed" it was not given by her, as this was an allegation of verbal abuse. She did not know when NASR #5 was removed from care. A review of the Timecard Report for CMT #2 and CMT #3, dated 04/28/12, revealed both employees clocked out for lunch at 10:31 AM. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she gave Resident #5 a shower and provided incontinent care for another resident, on 04/28/12, prior to her suspension. A review of the Timecard Report for NASR #5, on 04/28/12, revealed she did not clock out until 11:48 AM, at least one hour and fifteen minutes after the allegation was reported to LPN #8. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed she was the Administrative Licensed Nurse in the facility, on 04/28/12. The allegation of verbal abuse was reported to her by CMT #2. She revealed when she went to find NASR #5, she was giving a resident a shower. She stated that everyone on the floor was "busy", so she reported to the charge nurse to send NASR #5 to her office when she was finished with the resident's shower. She did not know which resident was in the shower room with NASR #5. She admitted she should have removed NASR #5 from resident care immediately, per the facility policy. LPN #8 revealed she did not conduct a thorough investigation. She did not document a statement from Resident #5. She also revealed she should have obtained statements from CMT #2 and CMT #3. She did not verify who was sitting at the table when the comment was made to the resident, and did not try to contact any of them. She stated it was "very busy" that morning. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed LPN #8 contacted her at home, on 04/28/12, to report the allegation. She revealed LPN #8 was instructed to gather statements from anyone around the area, any resident that could have heard the comment, and any residents cared for by NASR #5. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. She expected LPN #8 to suspend NASR #5 immediately. She stated she did not speak to Resident #5 about the allegation. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was the facility's abuse coordinator; however, she was not aware of the allegation made by Resident #5. An interview with the Administrator, on 05/14/12 at 4:00 PM and 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation; however, it was discussed in the Quality Assurance (QA) committee meeting, on 04/28/12, with no concerns. She revealed the Social Services Director was responsible for ensuring a thorough investigation, with assistance from the DON and Administrator. She revealed the allegation was not reported to the State Agency, as it did not qualify as verbal abuse. NASR #5 was terminated due to the "questionable" incident. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QA committee meeting, on 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report the allegation because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported to the State Agency; however, he did not feel this was verbal abuse.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to implement written policies and procedures that prohibit abuse of residents for one resident (#5), in the selected sample of 19 residents. The facility failed to implement the Investigation and Abuse policy/procedure as evidenced by the failure to protect Resident #5 after an allegation of verbal abuse. Resident #5 reported an allegation of verbal abuse to Certified Medication Technician (CMT) #2, witnessed by CMT #3 (refer to F241) on 04/28/12. While the CMTs notified the Administrative nurse, the facility continued to allow the alleged perpetrator, Nurse Aide State Registered (NASR) #5, to give direct care to other residents to include bathing the victim, prior to removing the perpetrator for over an hour after the allegation was made. On 05/15/12, eighteen (18) days after the incident, Resident #5 was observed crying while describing the incident stating it embarrassed him/her and made him/her feel bad. The facility's investigation was not thorough as all witnesses, staff nor the victim were interviewed. Findings include: A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as cognitively intact. An interview with Resident #5, on 05/15/12 at 4:15 PM and 05/16/12 at 2:10 PM, revealed he/she had to be fed by the staff due to a recent decline related to the disease process of ALS. The resident revealed it was going to get worse and he/she was discouraged with the loss of independence. The resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. An observation during the resident interview, on 05/15/12 at 4:15 PM, revealed Resident #5 was visibly upset and crying while discussing the comment made by NASR #5, on 04/27/12. An interview with CMT #2, on 05/16/12 at 9:32 AM, revealed Resident #5 was in his/her room, on 04/28/12, visibly upset and crying. He revealed the resident expressed a complaint about having to get a shower so late in the morning. During conversation with Resident #5 while providing care, the resident stated "they probably would not listen because apparently he/she looked like a dog." He revealed upon discussion with the resident, it was reported that NASR #5 made the comment about the resident drinking water like her "dog." He reported the comment to Licensed Practical Nurse (LPN) #8 and left for lunch. An interview with CMT #3, on 05/16/12 at 10:35 AM, revealed she was a witness to the resident's allegation reported to CMT #2. She stated that NASR #5 was in the room, but left to get towels for the resident's shower. She revealed the resident stated that he/she did not like NASR #5 because of the comment made, on 04/27/12. She revealed CMT #2 left the room to report the allegation to LPN #8. After the report was made, she left for lunch with CMT #2. She revealed NASR #5 was preparing to give the resident a shower, but she "assumed" it was not given by her. She did not know when NASR #5 was removed from resident care. An interview with NASR #6, on 05/17/12 at 11:45 PM, revealed NASR #5 gave Resident #5 a shower, on 04/28/12, prior to her suspension. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she gave Resident #5 a shower and provided incontinent care for another resident, on 04/28/12, prior to her suspension. A review of the Timecard Report for CMT #2 and CMT #3, dated 04/28/12, revealed both employees clocked out for lunch at 10:31 AM. A review of the Timecard Report for NASR #5, on 04/28/12, revealed she did not clock out until 11:48 AM, at least one hour and fifteen minutes after the allegation was reported to LPN #8. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed the allegation was reported to her, by CMT #2 (right before he left for lunch). She revealed she went to find NASR #5; however, she was giving a resident a shower. She stated that everyone on the floor was "busy", so she reported to the charge nurse to send NASR #5 to her office when she was finished with the shower. She did not know which resident was in the shower room with NASR #5. She admitted she should have removed NASR #5 from resident care immediately, per the facility's policy. An interview with LPN #3, on 05/16/12 at 10:05 AM, revealed she was the charge nurse, on 04/28/12, and was aware of the allegation made against NASR #5. She stated that LPN #8 asked her to send NASR #5 to her office after completing care for a resident in the shower room. She admitted she was making "rounds" and providing care for other residents; therefore, she was not monitoring the shower room to ensure NASR #5 went to see LPN #8. She revealed NASR #5 should have been sent home immediately, but LPN #8 was in charge as the Administrative Licensed Nurse on duty. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed she was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. She expected LPN #8 to suspend NASR #5 immediately, removing her from care of any residents. An interview with the Administrator, on 05/17/12 at 4:05 PM, revealed she was not aware NASR #5 provided care to Resident #5, prior to her suspension. She expected LPN #8 to find another caregiver to take over for NASR #5.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to promote care for residents in a manner that enhanced each resident's dignity and respect for one resident (#5), in the selected sample of 19 residents. The facility failed to follow the Dignity/Respect policy. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 allegedly made a comment that the resident was drinking his/her water similar to her "dog." Resident #5 reported the comment to the staff, on 04/28/12; however, NASR #5 was allowed to continue providing care for Resident #5. An interview with Resident #5, on 05/15/12 at 4:15 PM, revealed the resident did not want NASR #5 providing his/her care. The resident revealed the comment was embarrassing and made him/her "feel bad." Resident #5 was visibly upset and crying during the interview with the surveyor, 18 days after the incident. Findings include: A review of the facility's Dignity/Respect policy, revised 10/04/11, revealed appropriate measures would be taken to assure the residents were treated in a courteous and dignified manner. The staff would promote independence and dignity in dining. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as cognitively intact and able to eat independently with tray setup. A review of the Activities of Daily Living (ADL) Tracking record, dated March 2012 and April 2012, revealed a decline in the resident's eating abilities, requiring extensive to total assistance for eating after 03/27/12. An interview with Resident #5, on 05/15/12 at 4:15 PM, and on 05/16/12 at 2:10 PM, revealed he/she required assistance to be fed due to a recent decline related to the disease process of ALS. The resident revealed things were going to get worse and he/she was discouraged with the loss of independence. The resident stated, on 04/27/12, NASR #5 was feeding him/her. NASR #5 made a comment that "I drank my water like her dog." The resident revealed the comment made by the NASR made him/her feel bad and was embarrassing, because there were other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident revealed he/she did not want NASR #5 to provide his/her care. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. An observation during a resident interview, on 05/15/12 at 4:15 PM, revealed Resident #5 was visibly upset and crying while discussing a comment made by NASR #5, on 04/27/12, 18 days after the incident. An interview with CMT #2, on 05/16/12 at 9:32 AM, revealed Resident #5 was in his/her room, on 04/28/12, visibly upset and crying. He revealed the resident expressed a complaint about having to get a shower so late in the morning. He revealed the resident wanted to get up at 9:00 AM, and it was almost 11:00 AM. CMT #2 told the resident he would report it to the charge nurse; however, the resident stated "they probably would not listen because apparently he/she looked like a dog." He revealed upon discussion with the resident, it was reported that NASR #5 made the comment about the resident drinking water like her "dog." He reported the comment to Licensed Practical Nurse (LPN) #8. An interview with CMT #3, on 05/16/12 at 10:35 AM, revealed she was a witness to the allegation reported to CMT #2. She revealed the resident was upset and crying when she went into the room. She stated that NASR #5 was in the room, but left to get towels for the resident's shower. She revealed the resident stated that he/she did not like NASR #5 because of the comment made, on 04/27/12. She revealed NASR #5 was preparing to give the resident a shower, but she "assumed" it was not given by her, as this was an allegation of verbal abuse. An interview with NASR #6, on 05/17/12 at 11:45 PM, revealed NASR #5 gave Resident #5 a shower, on 04/28/12. She revealed NASR #5 needed assistance with the resident after the shower, but she and another NASR took over while NASR #5 went to assist another resident. She revealed the resident began talking about the comment made by NASR #5 and appeared to be upset. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she was feeding Resident #5 in the dining room, on 04/27/12, and they were talking about her "puppy." She revealed the resident nodded his/her head to drink and the comment was made "that was how my puppy nods its head." NASR #5 admitted she gave the resident a shower, on 04/28/12, prior to her suspension. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, on 05/16/12 at 2:35 PM, and on 05/17/12 at 2:00 PM, revealed the allegation was reported to her, by CMT #2. She revealed she went to find NASR #5; however, she was giving a resident a shower. She stated that everyone on the floor was "busy", so she reported to the charge nurse to send NASR #5 to her office when she was finished with the resident's shower. She did not know which resident was in the shower room with NASR #5. LPN #8 revealed when questioning Resident #5 about the allegation, the resident was quiet and had "one tear" roll down his/her face. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed she did not speak to Resident #5 about the allegation. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was not aware of the allegation made by Resident #5. She revealed she spoke to the resident about his/her [DIAGNOSES REDACTED]. She revealed she did not recall the discussion about the allegation in the QA meeting, held on 04/30/12. An interview with the Administrator, on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened or ask the resident how the comment made him/her feel.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to promote care for residents in a manner that enhanced each resident's dignity and respect for one resident (#5), in the selected sample of 19 residents. The facility failed to follow the Dignity/Respect policy. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 allegedly made a comment that the resident was drinking his/her water similar to her "dog." Resident #5 reported the comment to the staff, on 04/28/12; however, NASR #5 was allowed to continue providing care for Resident #5. An interview with Resident #5, on 05/15/12 at 4:15 PM, revealed the resident did not want NASR #5 providing his/her care. The resident revealed the comment was embarrassing and made him/her "feel bad." Resident #5 was visibly upset and crying during the interview with the surveyor, 18 days after the incident. Findings include: A review of the facility's Dignity/Respect policy, revised 10/04/11, revealed appropriate measures would be taken to assure the residents were treated in a courteous and dignified manner. The staff would promote independence and dignity in dining. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident as cognitively intact and able to eat independently with tray setup. A review of the Activities of Daily Living (ADL) Tracking record, dated March 2012 and April 2012, revealed a decline in the resident's eating abilities, requiring extensive to total assistance for eating after 03/27/12. An interview with Resident #5, on 05/15/12 at 4:15 PM, and on 05/16/12 at 2:10 PM, revealed he/she was fed by the staff due to a recent decline related to the disease process of ALS. The resident revealed it was going to get worse and he/she was discouraged with the loss of independence. The resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. An observation during a resident interview, on 05/15/12 at 4:15 PM, revealed Resident #5 was visibly upset and crying while discussing a comment made by NASR #5, on 04/27/12, 18 days after the incident. An interview with CMT #2, on 05/16/12 at 9:32 AM, revealed Resident #5 was in his/her room, on 04/28/12, visibly upset and crying. He revealed the resident expressed a complaint about having to get a shower so late in the morning. He revealed the resident wanted to get up at 9:00 AM, and it was almost 11:00 AM. CMT #2 told the resident he would report it to the charge nurse; however, the resident stated "they probably would not listen because apparently he/she looked like a dog." He revealed upon discussion with the resident, it was reported that NASR #5 made the comment about the resident drinking water like her "dog." He reported the comment to Licensed Practical Nurse (LPN) #8. An interview with CMT #3, on 05/16/12 at 10:35 AM, revealed she was a witness to the allegation reported to CMT #2. She revealed the resident was upset and crying when she went into the room. She stated that NASR #5 was in the room, but left to get towels for the resident's shower. She revealed the resident stated that he/she did not like NASR #5 because of the comment made, on 04/27/12. She revealed NASR #5 was preparing to give the resident a shower, but she "assumed" it was not given by her, as this was an allegation of verbal abuse. An interview with NASR #6, on 05/17/12 at 11:45 PM, revealed NASR #5 gave Resident #5 a shower, on 04/28/12. She revealed NASR #5 needed assistance with the resident after the shower, but she and another NASR took over while NASR #5 went to assist another resident. She revealed the resident began talking about the comment made by NASR #5 and appeared to be upset. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she was feeding Resident #5 in the dining room, on 04/27/12, and they were talking about her "puppy." She revealed the resident nodded his/her head to drink and the comment was made "that was how my puppy nods its head." NASR #5 admitted she gave the resident a shower, on 04/28/12, prior to her suspension. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, on 05/16/12 at 2:35 PM, and on 05/17/12 at 2:00 PM, revealed the allegation was reported to her, by CMT #2. She revealed she went to find NASR #5; however, she was giving a resident a shower. She stated that everyone on the floor was "busy", so she reported to the charge nurse to send NASR #5 to her office when she was finished with the resident's shower. She did not know which resident was in the shower room with NASR #5. LPN #8 revealed when questioning Resident #5 about the allegation, the resident was quiet and had "one tear" roll down his/her face. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed she did not speak to Resident #5 about the allegation. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was not aware of the allegation made by Resident #5. She revealed she spoke to the resident about his/her [DIAGNOSES REDACTED]. She revealed she did not recall the discussion about the allegation in the QA meeting, held on 04/30/12. An interview with the Administrator, on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened or ask the resident how the comment made him/her feel.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure two residents (#1 and #8), in the selected sample of 19 residents, were provided care in accordance with the plan of care. Resident #1 was care planned to have two staff for transfers. On 03/29/12, Nurse Aide (NA) #1 assisted Resident #1 to transfer from the toilet to the wheelchair alone. The resident fell which resulted in a laceration to his/her left eyebrow and abrasions to the resident's bilateral knees. Resident #1 was transferred to the local hospital and diagnosed with [REDACTED]. (Refer to F323) Resident #8 was care planned to be turned and repositioned every hour; however, observations, on 05/17/12 from 8:40 AM through 11:00 AM, revealed the resident remained in the same position in bed without repositioning. Findings include: A review of the facility's policy and procedure, "Nurse Aide Care Plan," dated 02/10/10, revealed the purpose of the form was to document how each resident's daily care needs were provided by the nursing staff as outlined in the Comprehensive Care Plan in accordance with guidelines of RAI process and in keeping with the Commonwealth of Kentucky Department of Medicaid Services Documentation Guidelines. 1. A record review revealed the facility admitted Resident #1 on 09/04/09 with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, dated 01/11/12, for "Self Care Deficit related to required assistance with activities of daily living (ADLs) due to impaired cognition" revealed an intervention to "transfer with assistance of two and a gait belt." A review of the Fall Assessment Screening Tool (FAST), dated 02/20/12, revealed the resident was assessed as a high falls risk with a score of "95." A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility had assessed Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of "5." The resident was assessed as requiring extensive assistance of two staff for transfers and totally dependent on two staff for toileting. A review of the Nurse Aide Care Plan, dated May 2012, revealed the resident required the assistance of two staff for toileting and the assistance of two staff plus a gait belt for transfers. A phone interview with NA #1, on 05/17/12 at 9:52 AM, revealed she assisted the resident to the bathroom and transferred him/her from the toilet to the wheelchair alone. She assisted Resident #1 to stand up, and he/she started shuffling his/her feet. The resident tripped over the aide's foot as they were trying to move back to the wheelchair. Resident #1 fell to the floor and hit his/her head as he/she fell to the floor. Resident #1 sustained a cut above his/her eye. She was unaware the resident was care planned for the assistance of two staff for transfers. She revealed the aides arrived to the facility 15 minutes prior to their shift to do a walking round and get a report from the previous shift's aides. There was no time to review the resident's care plan, but they were suppose to review the care plans before the shift started. NA #1 revealed she had not reviewed Resident #1's care plan before she transferred the resident. A phone interview with Registered Nurse (RN) #5, on 05/17/12 at 2:22 PM, revealed the resident was sitting up in the wheelchair when she walked in. She questioned the aide how the injuries occurred and the aide reported she transferred the resident alone. The aide reported the resident tripped over her foot and they went down to the floor together. The chair tilted over and bumped the resident's head. Later during the day, RN #5 educated the aide about lifting the resident, the use of the gait belt, and review of the care plan book to know many staff it required to assist the resident. RN #5 revealed she explained to the aide if she was unsure about how a resident was to be transferred, then she should not transfer him/her alone. The aides should review the care plans daily prior to the start of the shift. She was unaware if the aide reviewed Resident #1's care plan prior to provision of care. An interview with the Director of Nursing (DON), on 05/17/12 at 1:23 PM revealed she was notified about Resident #1's fall approximately 10 minutes after it occurred. She questioned RN #5 about who was involved and what happened. She was informed by RN #5 that the aide had transferred the resident alone in the bathroom, and the resident's feet got tangled up with the staff's feet, which resulted in the resident's fall and hitting his/her head. RN #5 checked the care plan and stated the resident was care planned for the assistance of two staff with transfers. The incident was investigated and NA #1 was sent home that day. The likelihood of the resident's fall would be less if there had been the right amount of people for the transfer. The staff were expected to read the care plans of the residents daily prior to starting their assignment. NA #1 was later terminated because it was determined she transferred the resident with the assistance of one and did not follow the resident's care plan. 2. A record review revealed the facility admitted Resident #8 on 09/22/10 with [DIAGNOSES REDACTED]. Observations, on 05/17/12 at 8:40 AM, 9:30 AM, 10:30 AM and 11:00 AM, revealed Resident #8 was in bed on his/her back with the head of the bed slightly raised. The resident's position in the bed remained unchanged during the observations. A review of the resident's comprehensive care plan, "At Risk for Skin Integrity" revealed an intervention, dated 03/26/12, for the resident to be turned and repositioned hourly. A review of a quarterly MDS assessment, dated 05/09/12, revealed the facility assessed Resident #8 as non-ambulatory and required extensive assistance with all activities of daily living and was assessed as high risk for pressure sores and required two staff for turning and repositioning. A review of the Nurse Aide Care Plan, dated 05/12, revealed turning and repositioning was to be provided by two staff and the resident was to be turned and repositioned every hour. An interview with CNA #1, on 05/17/12 at 11:30 AM, revealed she was responsible for Resident #8's care and was aware the resident needed to be turned and repositioned every hour due to fragile skin. CNA #1 stated she did not turn and reposition Resident #8 every hour because she had a hard time getting someone to assist her. CNA #1 did not inform the nurse she needed assistance with repositioning the resident hourly. An interview with the DON, on 05/17/12 at 11:50 AM, revealed Resident #8 was to be turned hourly due to his/her fragile skin. The CNA was responsible to provide care according to the care plan and the nurse was ultimately responsible to ensure that it was completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents and failed to ensure the residents' environment remained as free from accident hazards as is possible for three residents (#1, #4, and #8), in the selected sample of 19 residents. Resident #1 was care planned to have two staff for transfers. On 03/29/12, Nurse Aide (NA) #1 assisted Resident #1 to transfer from the toilet to the wheelchair alone. The resident fell which resulted in a laceration to his/her left eyebrow and abrasions to the resident's bilateral knees. Resident #1 was transferred to the local hospital and diagnosed with [REDACTED]. Resident #4, who required constant oxygen (O2) therapy, was transported to a physician's appointment outside the facility without staff escort. The facility failed to ensure there was enough O2 to maintain the resident throughout the physician's appointment as well as the return trip back to the facility. Resident #8, who was prescribed a mechanical soft diet, was observed in bed on multiple occasions eating popcorn and peanuts. Findings include: 1. A review of the policy entitled "Fall Prevention Policy" revised 10/21/10 revealed they identify residents at risk for falls and implement a fall prevention approach to reduce the risk of falls and possible injury. The Fall Prevention Approach is incorporated with the facility's Quality Improvement and Safety Committees. Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. Direct Care Providers will be instructed regarding approaches and goals for the management of the resident falls risk. A record review revealed the facility admitted Resident #1 on 09/04/09 with [DIAGNOSES REDACTED]. A review of the comprehensive care plan, dated 01/11/12, for "Self Care Deficit related to requires assistance with activities of daily living (ADLs) due to impaired cognition," revealed an intervention which stated "transfer with assistance of two and a gait belt." A review of the Fall Assessment Screening Tool (FAST), dated 02/20/12, revealed the resident was assessed as high falls risk with a score of "95." A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of "5." The resident was assessed to require extensive assistance of two staff for transfers and totally dependent on two staff for toileting. A review of the nurse's notes, dated 03/29/12 at 7:15 AM, revealed documentation by Registered Nurse (RN) #5 which revealed an aide called for assistance and RN #5 entered the bathroom to find the resident sitting up in the wheelchair. NA #1 stated the resident fell and she assisted the resident onto the floor. The resident hit his/her head in the process and the resident had a laceration on his/her left brow and lateral eye, and abrasions to his/her bilateral knees. The resident complained of a headache and dizziness with no nodules noted on his/her head. He/she complained of blurred vision. Vitals signs were checked and an ice pack was applied to his/her left eye. Steri-strips were applied to his/her lateral left eye, a band-aid was applied to the left brow and bilateral knees. The physician was notified with orders received to send the resident to the hospital for an evaluation. The family was notified about the resident's condition and he/she was to be sent to the emergency room for an evaluation. A review of the history and physical, from an acute care hospital, dated 03/29/12, revealed the resident sustained [REDACTED]. Resident #1 was readmitted to the facility later on 03/30/12. A review of the Nurse Aide Care Plan, dated May 2012, revealed the resident required the assistance of two staff for toileting and the assistance of two staff plus a gait belt for transfers. An interview with NA #1, on 05/17/12 at 9:52 AM, revealed at the time of the incident she was not certified. She had assisted the resident to the bathroom and transferred him/her from the wheelchair to the toilet alone. The resident was on the toilet and she noticed the colostomy bag needed changing. The aide called for assistance. Nobody came and the resident was swaying like he/she was unbalanced on the toilet. Resident #1 was assisted to stand up, and he/she started shuffling his/her feet and he/she tripped over the aide's foot as they were trying to move back to the wheelchair. NA #1 moved in front of the resident to keep him/her from falling and they both fell to the floor. Resident #1 hit his/her head as he/she fell to the floor. The resident hit his/her head on the aide's shoulder as well as the wall, and the resident sustained [REDACTED]. They were on the floor and she called for assistance a second time for approximately 15 minutes. No other staff came to assist the resident or the staff. NA #1 wiggled out from under the resident and she saw the resident was bleeding from the above and beneath his/her eye. She continued to call out for assistance and picked the resident up from the floor and sat him/her in the wheelchair. The nurse finally came in the room and asked what happened. NA #1 explained and showed the nurse what happened. The nurse examined the resident and he/she was sent out to the emergency room for an evaluation later. NA #1 reported she did not know the resident was care planned for the assistance of two staff for transfers. She stated the aides arrived to the facility 15 minutes before shift to do a walking round and get report from the previous shift. There was no time to look at the resident's care plan, but they were suppose to look at the care plans before their shift started. She had not reviewed Resident #1's care plan prior to transferring the resident. An interview with RN #5, on 05/17/12 at 2:22 PM, revealed the resident was sitting up in the wheelchair when she arrived to the room. She checked the resident over and there was an injury above his/her brow, on the side of his/her eye and abrasions on his/her knees. She questioned the aide about the injuries, and the aide reported she transferred the resident alone. The aide stated the resident tripped over her foot and they went down to the floor together. The chair tilted over and bumped the resident's head. Later, during the day she educated the aide about lifting the resident, use of the gait belt, and reviewing the care plan book to know how many staff it took to assist the resident. An interview with the DON, on 05/17/12 at 1:23 PM, revealed RN #5 notified her by phone about Resident #1's fall approximately 10 minutes after it happened. She questioned RN #5 about who was involved and what happened. She was informed the aide transferred the resident alone in the bathroom and the resident's feet got tangled up with the staff's feet which resulted in the resident's fall and hitting his/her head. RN #5 checked the care plan and reported the resident was care planned for the assistance of two staff with transfers. The incident was investigated and NA #1 was sent home that day. The likelihood of the resident's fall would be less if there were the right amount of people for the transfer. The staff were expected to read the care plans of the residents daily prior to the start of their shift. The aide was later terminated because it was determined she transferred the resident with the assistance of one, and did not follow the resident's care plan. 2. On 05/17/12 at 1:00 PM, the Director of Nursing (DON) and the ADON provided a facility policy for Transporting Patients with Oxygen Out of the Facility. The DON revealed the policy was created, on 05/17/12, with direction from the facility's O2 therapy vendor representative. A record review revealed the facility admitted Resident #4 on 10/18/10, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]." A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 and the Resident Mood Interview (PHQ-9) score of 4. A review of the nurse's notes, dated 05/16/12 at 2:10 PM, revealed an O2 saturation level of 97% on 5 liters of O2 per nasal canula. An observation, on 05/16/12 at 10:50 AM, revealed Resident #4 was not in his/her room. Upon questioning RN #2, she stated Resident #4 was transported to a physician's appointment by the local public transportation system. It was reported to RN #2, that an observation and an attempted interview by the surveyor at 9:30 AM, revealed the resident demonstrated confusion and the inability to answer questions. RN #2 stated the resident was very hard of hearing and questions should be asked by writing it down on paper to get a better response. Interview with CNA #2, on 05/17/12 at 1:45 PM, revealed that prior to the resident's transfer to a physician's appointment on 05/16/12, she observed LPN #2 place an O2 tank in the pouch attached to the wheelchair, connect the oxygen delivery tubing, set the regulator to match the number on the bedside concentrator, and then left the room. CNA #2 stated the resident returned to the facility at the end of the lunch pass, and she did not see anyone check the O2 tank setting. An interview with LPN #2, on 05/17/12 at 2:35 PM, revealed, on 05/16/12, Resident #4 was prepared for a physician's office visit outside the facility by the CNA staff and she got a full O2 tank and secured it to the back of the wheelchair. LPN #2 stated she tested the O2 tank by turning on the tank to the continuous delivery setting of 5 liters, and then turned the regulator back to zero (0) as the CNAs had not transferred Resident #4 into the wheelchair. LPN #2 immediately left the room and was unsure who set the regulator at 5 liters when the resident was in the wheelchair and ready to leave the building. She stated the charge nurse was responsible for documentation in the nurse's notes when a resident left and returned to the facility. LPN #2 stated she was at the nurse's station when Resident #4 returned to the facility, at approximately 12:30 PM. She reported the process for providing an escort was dependent on the resident's ability to communicate and the level of confusion. She stated the facility depended on the physician's office staff to notify the facility if an O2 tank ran low, and the facility would send a new O2 tank to the physician's office via a facility CNA or the Social Services Assistant. A phone interview, on 05/16/12 at 3:00 PM, with staff at the physician's office revealed the office staff did not look at Resident #4's O2 tank regulator during the time the resident was in the physician's office. A phone interview with the public transportation scheduler, on 05/17/12 at 9:30 AM, revealed the transportation driver picked up Resident #4 at 10:00 AM and returned the resident to the facility at 12:30 PM. The transportation company policy for transportation of persons with O2 was the transportation driver was not allowed to handle, monitor, or adjust the O2 tank or delivery settings. An observation, on 05/16/12 at 12:40 PM, revealed Resident #4 was in the room sitting in a wheelchair with O2 delivered by nasal cannula from a portable tank attached to the back of his/her wheelchair. The Social Services Assistant was conducting a regularly scheduled BIMS and PHQ-9 assessment. The Social Services Assistant stated he never had such difficulty completing the assessment in the past and saw a decline in the resident's responses. A review of the assessment, completed on 05/16/12 at 1:05 PM, revealed a BIMS score of 13 and the PHQ-9 score was 12. Further observation revealed the resident's O2 tank regulator showed the reading of "Refill," meaning the O2 tank was empty. An interview with the Social Services Assistant, on 05/16/12 at 4:15 PM, revealed he completed a reassessment of the BIMS and PHQ-9 for Resident #4 after learning of the empty O2 tank during the earlier assessment. The second BIMS score was 15 and the PHQ-9 score was 17. A phone interview with the Respiratory Therapist employed by the facility's O2 therapy vendor, on 05/17/12 at 10:15 AM, revealed the tank used by Resident #4 for transport outside the facility was an "E" tank and contained 680 liters. The respiratory therapist stated the tank would last 1.5 hours and might last up to 2 hours. Interview with CNA #3, on 05/16/12 at 1:25 PM, revealed the process for preparing a resident for transport to an appointment outside the facility began with the CNA's responsibility of bathing and grooming the resident and transferring to the wheelchair. It was the charge nurse's responsibly to attach and adjust the O2 for the resident. An interview with LPN #3, on 05/17/12 at 2:05 PM, revealed the process for residents on O2 therapy who left the faciity on a trip were prepared by the CNA staff, and the licensed staff prepared the O2 by ensuring the O2 tank was full. If a resident had difficulty communicating, an escort was assigned to go with him/her. She stated, that on 05/16/12, O2 therapy preparation for Resident #4 was provided by the float nurse, LPN #2. LPN #3 stated she was not present when the O2 was hooked up. LPN #3 stated she expected a full O2 tank at the continuous delivery setting of 5 liters to last 2.5 hours to 3 hours related to the resident's breathing. She stated it was the responsibility of the licensed staff to document in the nurse's notes when a resident left and returned to the facility. An interview with the Assistant Director of Nursing (ADON), on 05/17/12 at 9:55 AM, revealed the facility had no policy and procedure for transporting a resident requiring O2 therapy to an outside appointment. The ADON stated the facility's process for a resident, requiring O2 therapy, who left the facility was for the charge nurse to provide a new O2 tank and secure it to the wheelchair. In the case of Resident #4, a facility staff person would escort the resident to the appointment related to the resident being hard of hearing. The facility routinely sent a facility escort for any resident who was confused or had difficulty with communication. Upon the resident's return to the facility, the charge nurse was to check the tank and ensure the tank still had O2 delivery. The ADON stated she expected an O2 tank to last two (2) to three (3) hours on the setting of 2.0 - 2.5 liters per minute. With Resident #4, the O2 delivery setting was 5 liters per minute and the ADON expected the tank to last one (1) hour to one and a half (1.5) hours. Interview with the Director of Nursing (DON) and the ADON, on 05/17/12 at 1:00 PM, was prompted by the provision of a facility policy for Transporting Patients with Oxygen Out of the Facility. The DON revealed the policy was created, on 05/17/12, with direction from the facility's O2 therapy vendor representative. The ADON stated the licensed nursing staff was responsible for documentation of a resident's departure and return to the facility, and the documentation would be in the nurse's notes and on the 24-hour shift report. The DON stated information related to O2 therapy during the resident's time out of the facility would also be documented. The DON stated Resident #4 was not ambulatory, not always able to make needs known, and was very hard of hearing. She stated Resident #4 went to an appointment outside the facility on 05/15/12 and was escorted by facility staff. The facility escort could be anyone in the building and typically it was a CNA. The DON stated if the O2 tank malfunctioned or the O2 supply got low, the escort notified the facility for direction. Review of the facility provided CNA job description did not cover provision or adjustment of O2 therapy. The DON stated she expected a full O2 tank with the continuous delivery setting of 5 liters to last 1 hour to 1.5 hours. Further interview with the DON, on 05/17/12 at 3:00 PM, revealed the charge nurse was responsible for ensuring the resident was safely and adequately prepared to leave the facility for an outside appointment. The charge nurse could receive assistance from the float nurse, but the charge nurse was responsible for the resident. The DON reported the facility provided O2 education, and the presenter covered the number of hours of coverage expected from a full O2 tank according to the delivery setting. 3. A review of the facility's sample menu for mechanical soft diet, no date, revealed appropriate snacks for mechanical soft diet to include graham crackers, vanilla wafers, ice cream, house supplement, applesauce, canned fruit, pimento cheese sandwich, meat salad and sugar cookies. A record review revealed the facility admitted Resident #8 on 09/22/10 with [DIAGNOSES REDACTED]. A review of a hospital admission History and Physical, dated 02/01/12, revealed the resident was admitted to the hospital with [REDACTED]. The resident was treated with antibiotics and placed on a pureed diet. A review of the comprehensive care plan, "At risk for weight loss, altered nutrition and dehydration" revealed interventions to include "Assist with feeding" and "Provide and serve diet as ordered," both were dated 02/15/12. A review of a physician's orders [REDACTED]." A review of the Nurse Aide Care Plan, dated 05/12, revealed the resident was to be totally fed by staff and was to have a mechanical soft diet with pureed meat. Observation, on 05/15/12 at 5:25 PM, revealed Resident #8 was in bed eating popcorn from a bag, with no staff present. Observation, on 05/16/12 at 8:30 AM, revealed the resident was asleep in bed and an opened bag of popcorn was on the overbed table. Observation, on 05/16/12 at 11:00 AM, revealed the resident in bed, no staff present, with a white bag that had peanuts in it. The resident was eating the peanuts and stated he/she did not know where the peanuts came from. An interview with the Registered Dietician (RD), on 05/16/12 at 4:10 PM, revealed Resident #8 was on a mechanically altered, pureed meat diet. The RD revealed appropriate snacks for mechanically soft diet with pureed meat included soft canned fruit, pudding or some other soft dessert, but peanuts or popcorn were not appropriate. On 05/16/12 at 5:45 PM, the DON verified the peanuts and popcorn on Resident #8's over bed table. The DON revealed peanuts and popcorn were not appropriate for any resident on a mechanical soft diet and thought family might have brought these items to the resident. The DON stated the CNA should have noticed the inappropriate snacks and removed them and alerted nursing. Additionally, she stated the peanuts and popcorn were an increased risk for potential choking and aspiration for Resident #8.

Based on interview, record review, review of the facility's policy/procedure, and review of the facility's Incident/Investigation Report, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one resident (#5), in the selected sample of 19 residents. The facility failed to follow the "Abuse, Neglect, and Exploitation" policy/procedure related to the protection of residents, investigation, and reporting of an allegation of abuse. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 made a comment that the resident was drinking his/her water similar to her "dog." Resident #5 reported the comment to the staff, on 04/28/12; however, the facility allowed NASR #5 to continue to provide care to Resident #5 and other residents for at least one hour and fifteen minutes, prior to suspension. An interview with Resident #5, on 05/15/12 at 4:15 PM, revealed the resident did not want NASR #5 providing his/her care. The resident revealed the comment was embarrassing and made him/her "feel bad." Resident #5 was visibly upset and crying during the interview, 18 days after the incident (refer to F241). Licensed Practical Nurse (LPN) #8 failed to conduct a thorough investigation of the allegation and remove NASR #5 from resident care immediately. The allegation was discussed in the morning Quality Assurance (QA) committee meeting, on 04/30/12; however, these issues were not identified as a problem. Additionally, the Administrator failed to report the allegation of abuse to the State Agency (refer to F225 and F226). Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established.A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long-Term Care. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. An interview with Resident #5, on 05/15/12 at 4:15 PM, and on 05/16/12 at 2:10 PM, revealed the resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. Interviews with CMT #2 and CMT #3, on 05/16/12 at 9:32 AM and 10:35 AM, respectively, confirmed the resident's allegation and that it was reported to LPN #8 as an allegation of verbal abuse. CMT #3 revealed the resident was upset and crying. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed the resident was quiet and had "one tear" roll down his/her face. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed the allegation was reported to her, by CMT #2. NASR #5 was giving a resident a shower. She confirmed she did not remove NASR #5 form direct care immediately. She admitted she should have removed NASR #5 from resident care immediately, per the policy. LPN #8 further revealed she did not conduct a thorough investigation. She did not document a statement from Resident #5. She also revealed she should have obtained statements from CMT #2 and CMT #3. She did not verify who was sitting at the table when the comment was made to the resident, and did not try and contact any of them. She also indicated that the investigation was turned over to the Administrator and reviewed in the QA committee meeting; therefore, they should have ensured the investigation was completed. A review of the Timecard Report for CMT #2 and CMT #3, dated 04/28/12, revealed both employees clocked out for lunch at 10:31 AM. A review of the facility's Incident/Investigation Report, dated 04/28/12, revealed a written statement by NASR #5; however, there were no other statements included in the investigation. A review of the Timecard Report for NASR #5, on 04/28/12, revealed she did not clock out until 11:48 AM, at least one hour and fifteen minutes after the allegation was reported to LPN #8. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she gave Resident #5 a shower and provided incontinent care for another resident on 04/28/12, prior to her suspension. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed LPN #8 contacted her at home, on 04/28/12, to report the allegation. She revealed LPN #8 was instructed to gather statements from anyone around the area, from any resident that could have heard the comment, and from residents cared for by NASR #5. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. She expected LPN #8 to suspend NASR #5 immediately. She did not speak to the resident about the allegation. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was the facility's abuse coordinator. She was not knowledgeable of the facility's policy/procedure related to abuse/neglect. She revealed if allegations of abuse/neglect were unsubstantiated, they were not reported to the State Agency. She was not aware of the allegation made by Resident #5; however, she attended the Quality Assurance (QA) committee meeting (where the investigation was discussed), on 04/30/12. An interview with the Administrator, on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation. She revealed Social Services was responsible for ensuring a thorough investigation, with assistance from the DON and Administrator. She further verified it was discussed in the QA committee meeting, on 04/30/12, with no concerns. She revealed the allegation was not reported to the State Agency, as it did not qualify as verbal abuse. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QA committee meeting, on 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report to the State Agency because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported; however, he did not feel this was verbal abuse. However, interview with CMT #3 revealed this was an allegation of abuse.

Based on interview, record review, review of the facility's policy/procedure and Plan of Correction, it was determined the facility's Quality Assessment and Assurance Program failed to follow their Plan of Correction related to the implementation of an appropriate plan of action related to an investigation involving care and services of one resident (#5), in the selected sample of 19 residents. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 allegedly made a comment that the resident was drinking his/her water similar to her "dog." The comment was reported by Resident #5 to Certified Medication Tech (CMT) #2 on Saturday, 04/28/12. CMT #2 reported the allegation to Licensed Practical Nurse (LPN) #8, who was the Administrative Licensed Nurse on duty. LPN #8 failed to remove NASR #5 immediately from resident care. NASR #5 was allowed to work at least one hour and fifteen minutes after the allegation was reported. LPN #8 failed to conduct a thorough investigation to determine the findings of the allegation. The facility's Incident Investigation Report contained one statement only, from the alleged perpetrator. The Administrator was made aware of the allegation, on 04/28/12; however, could not provide evidence that she notified the Registered Nurse (RN) Corporate Compliance Nurse immediately. The investigation was discussed in the Quality Assurance and Assessment (QAA) Committee meeting, on 04/30/12; however, there were no issues identified related to the investigation. The investigation was determined as unsubstantiated, on 04/30/12, and the allegation was not reported to the State Agency. NASR #5 was terminated on 05/07/12 due to misconduct. Refer to (F225, F226, F241, and F490) Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established. A review of the facility's Continuous Quality Improvement Program policy/procedure, revised 03/30/10, revealed monitoring and evaluation of resident care and services with a focus on continuous improvement were the fundamental activities of any quality improvement process. A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long- Term Care. A review of the facility's inservice sign-in sheet for "Investigation of Incident", dated 02/17/12, revealed LPN #8, the Administrator, and RN Corporate Compliance Nurse attended the inservice. A review of the facility's Plan of Correction, compliance date 03/11/12, revealed Licensed Administrative Staff would be appointed on a rotating basis to provide four hours of on-site supervision on weekends. The Licensed Administrative Staff would report any neglect investigation reports or issues involving care and services to the Administrator and DON. The Plan of Correction further revealed "In the event that an occurrence would be noted on the rotating weekend rounds, the Administrator would be notified immediately who would immediately notify the RN Corporate Compliance Nurse. An evidence based investigation would be conducted and all appropriate agencies, family, Medical Doctor (MD) notified." "Findings from the weekend rotations of Licensed Administrative Staff were reported to the Interdisciplinary Team (IDT)/QA Committee on Monday so that any investigations could be discussed and appropriate action could be taken. An interview with various members of the QAA Committee, on 05/17/12 at 8:00 PM, revealed no issues had been identified by the committee since 03/12/12. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, on 05/16/12 at 2:35 PM, and on 05/17/12 at 2:00 PM, revealed she was the Administrative Licensed Nurse in the facility, on 04/28/12. The allegation of verbal abuse was reported to her; however, she did remove NASR #5 from resident care immediately, per the facility's policy. LPN #8 revealed she did not conduct a thorough investigation of the allegation. She did not get statements from all staff/witnesses that were involved, per the facility's policy. An interview with the Administrator, on 05/14/12 at 4:00 PM, and on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She could not provide evidence that she notified the RN Corporate Compliance Nurse of the allegation, on 04/28/12. The Administrator admitted she did not question the resident directly about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation; however, it was discussed in the QAA committee meeting, on 04/28/12, with no concerns. The allegation was not reported to the State Agency, as it did not quality as verbal abuse. NASR #5 was terminated due to the "questionable" incident. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QAA committee meeting, on 04/30/12. He revealed the facility did not notify him prior to 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported to the State Agency; however, he did not feel this was verbal abuse. While the facility's investigation did not substantiate the allegation of verbal abuse, the QAA Committee did not identify, that their staff failed to follow their policy and procedure related immediate suspension after receiving an allegation of abuse, failed to immediately notify the Administrator which prevented the Administrator from immediately notifying the Corporate Consultant. Furthermore the IDT/QAA Committee review of the allegation failed to identify that the investigation was not thorough, due to this failure they did not ensure appropriate action was taken as detailed in the facility's plan of correction. Furthermore, the Corporate Consultant could not provide evidence that he had identified these failures and could not provide evidence that he had ensured necessary action was taken to prevent the recurrence in failing to follow regulation and policy.

Based on interview, record review, review of the facility's policy/procedure and Plan of Correction, it was determined the facility's Quality Assessment and Assurance Program failed to follow their Plan of Correction related to the implementation of an appropriate plan of action related to an investigation involving care and services of one resident (#5), in the selected sample of 19 residents. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 allegedly made a comment that the resident was drinking his/her water similar to her "dog." The comment was reported by Resident #5 to Certified Medication Tech (CMT) #2 on Saturday, 04/28/12. CMT #2 reported the allegation to Licensed Practical Nurse (LPN) #8, who was the Administrative Licensed Nurse on duty. LPN #8 failed to remove NASR #5 immediately from resident care. NASR #5 was allowed to work at least one hour and fifteen minutes after the allegation was reported. LPN #8 failed to conduct a thorough investigation to determine the findings of the allegation. The facility's Incident Investigation Report contained one statement only, from the alleged perpetrator. The Administrator was made aware of the allegation, on 04/28/12; however, could not provide evidence that she notified the Registered Nurse (RN) Corporate Compliance Nurse immediately. The investigation was discussed in the Quality Assurance and Assessment (QAA) Committee meeting, on 04/30/12; however, there were no issues identified related to the investigation. The investigation was determined as unsubstantiated, on 04/30/12, and the allegation was not reported to the State Agency. NASR #5 was terminated on 05/07/12 due to misconduct. Refer to (F225, F226, F241, and F490) Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established. A review of the facility's Continuous Quality Improvement Program policy/procedure, revised 03/30/10, revealed monitoring and evaluation of resident care and services with a focus on continuous improvement were the fundamental activities of any quality improvement process. A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long- Term Care. A review of the facility's inservice sign-in sheet for "Investigation of Incident", dated 02/17/12, revealed LPN #8, the Administrator, and RN Corporate Compliance Nurse attended the inservice. A review of the facility's Plan of Correction, compliance date 03/11/12, revealed Licensed Administrative Staff would be appointed on a rotating basis to provide four hours of on-site supervision on weekends. The Licensed Administrative Staff would report any neglect investigation reports or issues involving care and services to the Administrator and DON. The Plan of Correction further revealed "In the event that an occurrence would be noted on the rotating weekend rounds, the Administrator would be notified immediately who would immediately notify the RN Corporate Compliance Nurse. An evidence based investigation would be conducted and all appropriate agencies, family, Medical Doctor (MD) notified." "Findings from the weekend rotations of Licensed Administrative Staff were reported to the Interdisciplinary Team (IDT)/QA Committee on Monday so that any investigations could be discussed and appropriate action could be taken. An interview with various members of the QAA Committee, on 05/17/12 at 8:00 PM, revealed no issues had been identified by the committee since 03/12/12. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, on 05/16/12 at 2:35 PM, and on 05/17/12 at 2:00 PM, revealed she was the Administrative Licensed Nurse in the facility, on 04/28/12. The allegation of verbal abuse was reported to her; however, she did remove NASR #5 from resident care immediately, per the facility's policy. LPN #8 revealed she did not conduct a thorough investigation of the allegation. She did not get statements from all staff/witnesses that were involved, per the facility's policy. An interview with the Administrator, on 05/14/12 at 4:00 PM, and on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She could not provide evidence that she notified the RN Corporate Compliance Nurse of the allegation, on 04/28/12. The Administrator admitted she did not question the resident directly about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation; however, it was discussed in the QAA committee meeting, on 04/28/12, with no concerns. The allegation was not reported to the State Agency, as it did not quality as verbal abuse. NASR #5 was terminated due to the "questionable" incident. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QAA committee meeting, on 04/30/12. He revealed the facility did not notify him prior to 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported to the State Agency; however, he did not feel this was verbal abuse. While the facility's investigation did not substantiate the allegation of verbal abuse, the QAA Committee did not identify, that their staff failed to follow their policy and procedure related immediate suspension after receiving an allegation of abuse, failed to immediately notify the Administrator which prevented the Administrator from immediately notifying the Corporate Consultant. Furthermore the IDT/QAA Committee review of the allegation failed to identify that the investigation was not thorough, due to this failure they did not ensure appropriate action was taken as detailed in the facility's plan of correction. Furthermore, the Corporate Consultant could not provide evidence that he had identified these failures and could not provide evidence that he had ensured necessary action was taken to prevent the recurrence in failing to follow regulation and policy.

Based on interviews, record review, and facility policy/procedure, it was determined the facility failed to ensure each resident was free from neglect for one of three residents (Resident #1). The facility failed to ensure staff followed the "Abuse, Neglect, or Exploitation" and "Change in Resident Condition or Status" policy/procedure to protect the health and welfare of each resident. On [DATE] at 7:30 PM and 8:15 PM, the facility staff notified the facility's Charge Nurse that Resident #1 was observed having black "tarry" diarrhea, described to the charge nurse as an "active bleed." The Charge Nurse failed to conduct a thorough assessment of the resident to determine if the resident was having a change in condition that required immediate medical attention. Between 10:00 PM and 10:30 PM, facility staff notified the Charge Nurse of the resident's abnormal vital signs and continued bloody diarrhea. Facility staff described the resident's condition as bloody bowel "pouring" out of Resident #1, "it looked like he/she was hemorrhaging." and described the stool as "dark, mixed with blood and a foul odor." Three facility staff observed the charge nurse take a "smoke break" before notifying the physician of the resident's condition, at 10:45 PM more than three hours after facility staff initially notified the nurse of the resident's change in condition. Upon arrival to the hospital at 11:00 PM, the resident was admitted to the Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock requiring a blood transfusion. Resident #1 subsequently expired at the hospital on [DATE] at 9:53 PM. The failure to conduct a timely thorough assessment of Resident #1, notify the physician of a significant change in a resident's physical condition and the need to transfer a resident to a hospital has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The ongoing Immediate Jeopardy with substandard quality of care was determined to exist on [DATE]. Findings include: A review of the "Abuse, Neglect, or Exploitation" policy/procedure, revised [DATE], revealed it was essential for all staff, volunteers, and visitors to be responsible for the health, safety, and welfare of all individuals receiving support. Employees were prohibited to exploit, neglect, or abuse residents served. "Neglect" was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A review of the "Change in Resident Condition or Status" policy/procedure, revised [DATE], revealed the nurse supervisor or charge nurse would timely notify the resident's attending physician or on-call physician when there had been a significant change in the resident's physical condition or there was a need to transfer the resident to a hospital or treatment center. A record review revealed Resident #1 was admitted to the facility on [DATE] with no documented [DIAGNOSES REDACTED]. A phone interview with Certified Nurse Aide (CNA) #1, on [DATE] at 11:30 AM, revealed he completed incontinent care for Resident #1, on [DATE] at 7:30 PM. Black "tarry" diarrhea, "soupy" in consistency, was noted in the resident's brief. He revealed Registered Nurse (RN) #2 was notified immediately of the diarrhea, describing his observation to RN #2 as an "active bleed." He further revealed RN #2 did not assess the resident at that time. A phone interview with CNA #11, on [DATE] at 3:30 PM, revealed she helped CNA #1 with incontinent care for Resident #1 sometime between 7:30 PM and 8:00 PM. She stated she had "never witnessed anything like it", as it was a large amount of stool. She revealed CNA #1 stated that the resident "had a bleed." Record review revealed no documented evidence that the facility assessed the resident or notified the physician related to the resident's change in condition. CNA #1 revealed that he reported another episode of diarrhea to RN #2 at approximately 8:15 PM. RN #2 observed the resident, indicating there was blood in the resident's stool. CNA #1 stated that RN #2 left the resident's room and took a "smoke break" at that time. Record review revealed no documented evidence that the facility assessed the resident or notified the physician of the resident's change in condition. CNA #1 further revealed he made RN #2 aware again, sometime between 10:00 PM and 10:30 PM, of the resident's continued diarrhea and also that the resident had abnormal vital signs of blood pressure ,[DATE] (normal ,[DATE]), pulse in the 120s and blood oxygen saturation ,[DATE]% (normal 90% or above). Continued interview with CNA #11 revealed the resident was provided care later in the shift and observed stool coming out of the resident's brief "up to (his/her) belly." She stated she knew RN #2 had been made aware of the resident's condition as RN #2 had stated to her that she had been made aware of the resident's stool previously in the shift. RN #2 observed the resident at that time. A phone interview with CNA #9, on [DATE] at 10:45 AM, revealed he was asked to help CNA #1 with incontinent care, on [DATE] at approximately 10:30 PM. He revealed as he was walking into the resident's room, RN #2 was leaving the room and stated that she was going out to "smoke" before notifying the physician. CNA #11 and CNA #1 witnessed RN #2 leave the resident's room to "smoke." She revealed RN #2 stated that she would notify the physician after her "smoke break." Further interview with CNA #9 revealed when he entered Resident #1's room to assist in care he observed there was bloody bowel "pouring" out of Resident #1. He stated the resident had to be changed several times while he was in the room. He stated "it looked like he/she was hemorrhaging." He described the stool as "dark, mixed with blood and a foul odor." A phone interview with RN #1, on [DATE] at 4:25 PM, revealed she was on break when RN #2 came out to "smoke", but was unsure of an exact time. She revealed RN #2 began discussing one of her residents that was bleeding from the rectum. RN #1 asked RN #2 if it was an "active bleed", and RN #2 responded "yes." RN #1 revealed she told RN #2 to call the resident's physician. She revealed RN #2 put out her cigarette and went back into the facility. A review of the nurse's notes revealed there was no assessment of the resident made, by RN #2, prior to 10:00 PM, on [DATE]. The nurse's notes, dated [DATE] at 10:00 PM, revealed RN #2 documented Resident #1 having diarrhea stool, dark in color, with a foul smell. At 10:30 PM, documentation revealed the resident was having constant diarrhea stools, one right after the other. The on-call physician was notified, per the documentation, at 10:45 PM, and subsequently the resident was sent to the emergency room at 11:00 PM. A review of the Physician Report from the hospital, dated [DATE], revealed the resident was admitted to the Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock. Further review of the hospital's History and Physical revealed the resident presented with a low blood pressure of ,[DATE] and requiring a blood transfusion. A phone interview with RN #2, on [DATE] at 10:00 AM, revealed her documentation in the resident's record was accurate. An interview with the Primary Physician, on [DATE] at 9:00 AM, revealed he would have expected the nurse to notify him of the resident's "tarry" stool, at 7:30 PM on [DATE], as he would have recommended the resident be sent to the emergency room at that time. He revealed black "tarry" stool indicated a bleed, and it was important to "get to the bottom of the issue." He revealed a [MEDICAL CONDITION] was not something that could be managed at the nursing facility. Interview with the Director of Nursing (DON), on [DATE] at 1:15 PM, revealed she expected the nurse to notify the physician as soon as she was aware of the change in condition for Resident #1. She discussed the incident with RN #2, on [DATE], and RN #2 verified the resident's "tarry stool" was reported to her, on [DATE] at 7:30 PM. The DON revealed RN #2 admitted she did not assess the resident at that time. She revealed RN #2 was terminated, on [DATE], due to neglect of Resident #1. An interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:50 PM, revealed she was the witness of the conversation between the DON and RN #2, on [DATE]. She verified RN #2 acknowledged she was aware of the resident's "bloody diarrhea" on [DATE] at 7:30 PM. Interview with the DON, on [DATE] at 4:50 PM, revealed that despite the detailed actions listed in the Facility's Allegation of Compliance (AoC) to determine removal of Immediate Jeopardy, she revealed that the charge nurse compliance rounds, used to determine potential abuse and/or neglect or to identify significant change in condition of residents requiring immediate attention, were not being completed twice per shift as they were suppose to be done. In review of the documentation, she stated that the staff put the completed compliance round documents in her box but she had not verified that all required rounds had been completed or problems identified had been addressed. She further revealed that audits required to be completed on the weekend had not been completed. Furthermore she stated that no licensed administrative staff had been designated to review the 24 hour shift reports on the weekends to ensure significant change in condition, abuse and/or neglect concerns were addressed immediately per the facility's policy. She revealed that the facility has just initiated the weekend schedule to ensure that licensed administrative staff would begin this weekend monitoring and auditing. Interview with the RNA, on [DATE] at 11:40 PM, confirmed that the facility just initiated the weekend monitoring by licensed Administrative staff to begin the coming weekend. The DON further stated that while the facility was discussing the Unit Manager compliance audits in the morning meetings with the Interdisciplinary Team (IDT), they had not reviewed the charge nurse compliance rounds to discuss any potential concerns, problems or to identify necessary action required to be taken related to abuse, neglect or significant change. Interview with LPN #1, on [DATE] at 12:20 PM, confirmed that the facility had not been discussing compliance rounds in the IDT meetings. Due to the facility's failure to fully implement their AoC to remove Immediate Jeopardy, Immediate Jeopardy was determined ongoing.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the abbreviated survey, concluded on 02/22/12, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related to the failure to conduct a timely and thorough assessment and notify the physician of a change the the resident's physical condition and the need to transfer to the hospital. The findings include: Review of the Acceptable Allegation of Compliance (AOC,) dated 02/17/12, revealed the facility developed and implemented check sheets to be utilized for reviewing charge nurse compliance rounds, unit manager and administrative nurses neglect assessments, unit manager chart audits, CNA hourly observation check lists and residents at risk assessments. Inservices for all licensed staff members regarding the Abuse, Neglect and Exploitation Policy was initially conducted by the RN Corporate Compliance Nurse and the LPN Corporate Nurse Educator, with further education provided by the Administrator, Director of Nursing (DON) and the Assistant DON (ADON) or Compliance Nurse. Information was distributed to all licensed staff members and department heads regarding investigation, identification and reporting of abuse and neglect after being inserviced by the corporate compliance nurse and the nurse educator. All residents were assessed for a significant medical problem that was not addressed timely and a 100% audit was completed of all resident's medical records. An interview with the RN Corporate Compliance Nurse, on 03/19/12 at 4:44 PM, revealed the Quality Assurance Committee (QAC) had met and would continue to analyze and trend the check sheets and the information would be reported and monitored by the QAC on 03/12/12, to include the weekend monitoring of these audits. As of 03/09/12, the facility had not submitted an acceptable Plan of Correction (PoC.)

Based on interviews, record review, and facility policy/procedure, it was determined the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident #1). The facility failed to ensure licensed nursing staff thoroughly assessed residents' once informed by staff of a possible change in condition thus failing to follow the "Change in Resident Condition or Status" policy/procedure to protect the health and welfare of each resident. On [DATE] at 7:30 PM and 8:15 PM, the facility staff notified the facility's Charge Nurse that Resident #1 was observed having black "tarry" diarrhea, described to the charge nurse as an "active bleed." The Charge Nurse failed to conduct a thorough assessment of the resident to determine if the resident was having a change in condition that required immediate medical attention. Between 10:00 PM and 10:30 PM, facility staff notified the Charge Nurse of the resident's abnormal vital signs and continued bloody diarrhea. Facility staff described the resident's condition as bloody bowel "pouring" out of Resident #1, "it looked like he/she was hemorrhaging." and described the stool as "dark, mixed with blood and a foul odor." Three facility staff observed the charge nurse take a "smoke break" before notifying the physician of the resident's condition, at 10:45 PM more than three hours after facility staff initially notified the nurse of the resident's change in condition. The resident was transferred to the hospital at 11:00 PM, where he/she was admitted to the Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock requiring a blood transfusion. Resident #1 subsequently expired at the hospital on [DATE] at 9:53 PM. The failure to conduct a timely thorough assessment of Resident #1, notify the physician of a significant change in a resident's physical condition and the need to transfer a resident to a hospital has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The ongoing Immediate Jeopardy with substandard quality of care was determined to exist on [DATE]. Findings include: A review of the "Change in Resident Condition or Status" policy/procedure, revised [DATE], revealed the nurse supervisor or charge nurse would timely notify the resident's attending physician or on-call physician when there had been a significant change in the resident's physical condition or there was a need to transfer the resident to a hospital or treatment center. Review of Resident #1's medical record revealed the facility admitted this resident on [DATE] with multiple [DIAGNOSES REDACTED]. A phone interview with Certified Nurse Aide (CNA) #1, on [DATE] at 11:30 AM, revealed on [DATE] at 7:30 PM he completed incontinent care for Resident #1. He observed black "tarry" diarrhea, "soupy" in consistency, in the resident's brief. He stated that he notified Registered Nurse (RN) #2 immediately of the diarrhea, describing his observation to RN #2 as an "active bleed." He further revealed RN #2 did not assess the resident at that time. A phone interview with CNA #11, on [DATE] at 3:30 PM, revealed she helped CNA #1 with incontinent care for Resident #1 sometime between 7:30 PM and 8:00 PM. She stated she had "never witnessed anything like it", as it was a large amount of stool. She stated that CNA #1 described that the resident "had a bleed." Record review revealed no documented evidence that the facility assessed the resident or notified the physician related to the resident's change in condition at approximately 7:30 PM. At approximately 8:15 PM, CNA #1 stated he reported another episode of diarrhea to RN #2. RN #2 observed the resident, indicating there was blood in the resident's stool. CNA #1 stated that RN #2 left the resident's room and took a "smoke break" at that time. Record review revealed no documented evidence that the facility assessed the resident or notified the physician of the resident's change in condition at approximately 8:15 PM. CNA #1 further revealed he made RN #2 aware again, sometime between 10:00 PM and 10:30 PM, of the resident's continued diarrhea and also that the resident had abnormal vital signs of blood pressure ,[DATE] (normal ,[DATE]), pulse in the 120s and blood oxygen saturation ,[DATE]% (normal 90% or above). CNA #11 revealed during interview that the resident was provided care later in the shift and observed stool coming out of the resident's brief "up to (his/her) belly." She stated she knew RN #2 had been made aware of the resident's condition as RN #2 had stated to her that she had been made aware of the resident's stool previously in the shift. RN #2 observed the resident at that time. Interview with CNA #9, on [DATE] at 10:45 AM via phone, revealed he was asked to help CNA #1 with incontinent care, on [DATE] at approximately 10:30 PM. He revealed as he was walking into the resident's room, RN #2 was leaving the room and stated that she was going out to "smoke" before notifying the physician. CNA #11 and CNA #1 witnessed RN #2 leave the resident's room to "smoke." She revealed RN #2 stated that she would notify the physician after her "smoke break." CNA #9 further revealed when he entered Resident #1's room to assist in care he observed there was bloody bowel "pouring" out of Resident #1. He stated the resident had to be changed several times while he was in the room. He stated "it looked like he/she was hemorrhaging." He described the stool as "dark, mixed with blood and a foul odor." A phone interview with RN #1, on [DATE] at 4:25 PM, revealed she was on break when RN #2 came out to "smoke", but was unsure of an exact time. She revealed RN #2 began discussing one of her residents that was bleeding from the rectum. RN #1 asked RN #2 if it was an "active bleed", and RN #2 responded "yes." RN #1 revealed she told RN #2 to call the resident's physician. She revealed RN #2 put out her cigarette and went back into the facility. A review of the nurse's notes revealed there was no assessment of the resident made, by RN #2, prior to 10:00 PM, on [DATE]. The nurse's notes, dated [DATE] at 10:00 PM, revealed RN #2 documented Resident #1 having diarrhea stool, dark in color, with a foul smell. At 10:30 PM, documentation revealed the resident was having constant diarrhea stools, one right after the other. The on-call physician was notified, per the documentation, at 10:45 PM, and subsequently the resident was sent to the emergency room at 11:00 PM. A review of the Physician Report from the hospital, dated [DATE], revealed the resident was admitted to the Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock. Further review of the hospital's History and Physical revealed the resident presented with a low blood pressure of ,[DATE] and requiring a blood transfusion. A phone interview with RN #2, on [DATE] at 10:00 AM, revealed her documentation in the resident's record was accurate. RN#2 stated that she did check the resident's rectum, stool, and pulse. She stated that the bowel sounds were sluggish, she just didn't chart all of it. She stated that it was only about forty-five minutes from the time she noticed stool until she called the physician. She stated she couldn't remember the exact times. She stated that she felt like she did all she could do. Primary Physician interview, on [DATE] at 9:00 AM, revealed he would expect the nurse to notify him of the resident's "tarry" stool, at 7:30 PM on [DATE], as he would have recommended the resident be sent to the emergency room at that time. He revealed black "tarry" stool indicates a bleed, and it is important to "get to the bottom of the issue." He revealed a [MEDICAL CONDITION] was not something that could be managed at the nursing facility. Interview with the Director of Nursing (DON), on [DATE] at 1:15 PM, revealed she expected the nurse to notify the physician as soon as she was aware of the change in condition for Resident #1. She discussed the incident with RN #2, on [DATE], and RN #2 verified the resident's "tarry stool" was reported to her, on [DATE] at 7:30 PM. The DON stated that RN #2 admitted she did not assess the resident at that time. She revealed RN #2 was terminated, on [DATE], due to neglect of Resident #1. An interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:50 PM, revealed she was the witness of the conversation between the DON and RN #2, on [DATE]. She verified RN #2 acknowledged she was aware of the resident's "bloody diarrhea" on [DATE] at 7:30 PM. Interview with the DON, on [DATE] at 4:50 PM, revealed that despite the detailed actions listed in the Facility's Allegation of Compliance (AoC) to determine removal of Immediate Jeopardy, she revealed that the charge nurse compliance rounds, used to determine potential abuse and/or neglect or to identify significant change in condition of residents requiring immediate attention, were not being completed twice per shift as they were suppose to be done. In review of the documentation, she stated that the staff put the completed compliance round documents in her box but she had not verified that all required rounds had been completed or problems identified had been addressed. She further revealed that audits required to be completed on the weekend had not been completed. Furthermore she stated that no licensed administrative staff had been designated to review the 24 hour shift reports on the weekends to ensure significant change in condition, abuse and/or neglect concerns were addressed immediately per the facility's policy. She revealed that the facility has just initiated the weekend schedule to ensure that licensed administrative staff would begin this weekend monitoring and auditing. Interview with the RNA, on [DATE] at 11:40 PM, confirmed that the facility just initiated the weekend monitoring by licensed Administrative staff to begin the coming weekend. The DON further stated that while the facility was discussing the Unit Manager compliance audits in the morning meetings with the Interdisciplinary Team (IDT), they had not reviewed the charge nurse compliance rounds to discuss any potential concerns, problems or to identify necessary action required to be taken related to abuse, neglect or significant change. Interview with LPN #1, on [DATE] at 12:20 PM, confirmed that the facility had not been discussing compliance rounds in the IDT meetings. Due to the facility's failure to fully implement their AoC to remove Immediate Jeopardy, Immediate Jeopardy was determined ongoing.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 02/22/12, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related to conducting a thorough assessment to determine a change of condition that required immediate medical attention. Findings include: Validation of the AOC revealed assessments were completed on each interviewable resident, on 02/16/12, by the licensed nurses to determine if any resident had experienced a significant medical problem that was not addressed timely, or if any resident witnessed a lack of treatment involving any other residents and none were identified. In addition, all residents were assessed by licensed staff for any signs of abuse or neglect with no evidence noted. 24 hour shift reports were reviewed for occurrences implicating timely assessments and/or neglect of care and services with no concerns identified. For week-end coverage, the Licensed Administrative Staff were appointed, on a rotating basis, to provide direct supervision of Charge Nurses and or Nursing Supervisors to monitor and report any neglect investigations to the DON and the Administrator and to ensure timely assessment and protection of the resident. Reports of all resident assessments regarding the assessment for abuse or neglect and any issues of compliance or significant changes in resident status or conditions were being forwarded to the QA Committee for review on 03/12/12. A review of the reports through 03/08/12 revealed no identified concerns. As of 03/09/12, the facility had not submitted an acceptable Plan of Correction (PoC.)

Based on interviews, record review, review of the facility's investigation, the facility's nursing schedule, and facility policy/procedure, it was determined the facility failed to implement written policies and procedures that prohibited neglect of residents for one of three residents (Resident #1). The facility failed to ensure staff followed the "Abuse, Neglect, or Exploitation" policy/procedure related to the identification, protection of residents, investigation, and reporting of an allegation of neglect. On [DATE] at 7:30 PM, 8:15 PM, and between 10:00 PM and 10:30 PM, facility staff notified the facility's Charge Nurse that Resident #1 was observed having black "tarry" diarrhea, described to the charge nurse as an "active bleed." The Charge Nurse failed to conduct a thorough assessment of the resident to determine if the resident was having a change in condition that required immediate medical attention. Between 10:00 PM and 10:30 PM, facility staff notified the Charge Nurse of the resident's abnormal vital signs and continued bloody diarrhea. Facility staff described the resident's condition as bloody bowel "pouring" out of Resident #1, "it looked like he/she was hemorrhaging." and described the stool as "dark, mixed with blood and a foul odor." Three facility staff observed the charge nurse take a "smoke break" before notifying the physician of the resident's condition. At approximately 10:35 PM, a facility staff member made an allegation of neglect that the charge nurse was not responding to the needs of Resident #1, who was actively bleeding (refer to F224). The house supervisor did not initiate or conduct an investigation, report the allegation of neglect, or initiate measures to protect the residents from further neglect, per the facility policy. At 10:45 PM, more than three hours after facility staff initially notified the charge nurse of the resident's change in condition, the charge nurse notified the physician. At 11:00 PM, the resident was admitted to the Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock requiring a blood transfusion where the resident subsequently died on [DATE] at 9:53 PM. The incident was reported by two facility staff members again on [DATE], nine days later at which time the facility's Administrator conducted an investigation. While the facility's investigation determined neglect occurred and terminated the charge nurse, the facility's investigation did not address the house supervisor's untimely reporting, failure to initiate the neglect investigation and failure to initiate protection of residents from further neglect as the Charge Nurse continued to work on [DATE] and [DATE] without supervision to ensure that residents' needs were being met. The failure to identify, protect residents, investigate, and report an allegation of neglect has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The ongoing Immediate Jeopardy with substandard quality of care was determined to exist on [DATE]. Findings include: A review of the "Abuse, Neglect, or Exploitation" policy/procedure, revised [DATE], revealed any incident of suspected abuse, neglect, or exploitation involving staff towards a resident should be immediately reported to the employee's immediate supervisor and the Administrator and/or designee, at which time an investigation would begin. In the case of alleged abuse involving an employee against a resident, that employee would be suspended immediately pending further investigation by the Administrator and/or designee. "Neglect" was defined in the policy as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A record review revealed Resident #1 was admitted to the facility on [DATE] with no documented [DIAGNOSES REDACTED]. Interview with Certified Nurse Aide (CNA) #1, on [DATE] at 11:30 AM via phone, revealed he completed incontinent care for Resident #1, on [DATE] at 7:30 PM. Black "tarry" diarrhea, "soupy" in consistency, was noted in the resident's brief. He revealed Registered Nurse (RN) #2 was notified immediately of the diarrhea, describing his observation to RN #2 as an "active bleed." He further revealed RN #2 did not assess the resident at that time. Interview with CNA #11, on [DATE] at 3:30 PM, revealed she assisted CNA #1 with incontinent care for Resident #1 between 7:30 PM and 8:00 PM, describing the situation as "never witnessed anything like it", as it was a large amount of stool. CNA #1 revealed that he reported another episode of diarrhea to RN #2 at approximately 8:15 PM. RN #2 observed the resident, indicating there was blood in the resident's stool. CNA #1 stated that RN #2 left the resident's room and took a "smoke break" at that time. CNA #1 stated that he made RN #2 aware again, between 10:00 PM and 10:30 PM, of the resident's continued diarrhea and also that the resident had abnormal vital signs of blood pressure ,[DATE] (normal ,[DATE]), pulse in the 120s and blood oxygen saturation ,[DATE]% (normal 90% or above). Continued interview with CNA #11 revealed the resident was provided care later in the shift and observed stool coming out of the resident's brief "up to (his/her) belly." She stated RN #2 had stated to her that she had been made aware of the resident's condition previously in the shift. RN #2 observed the resident at that time. Interview with CNA #9, via phone on [DATE] at 10:45 AM, revealed he entered Resident #1's room to assist CNA #1 with incontinent care, on [DATE] at approximately 10:30 PM, and as he walked into the room, RN #2 was leaving and stated that she was going out to "smoke" before notifying the physician. CNA #11 and CNA #1 witnessed RN #2 leave the resident's room to "smoke." She revealed RN #2 stated that she would notify the physician after her "smoke break." CNA #9 stated that upon entering Resident #1's room he observed there was bloody bowel "pouring" out of Resident #1. He stated the resident had to be changed several times while he was in the room. He stated "it looked like he/she was hemorrhaging." He described the stool as "dark, mixed with blood and a foul odor." A phone interview with CNA #7, on [DATE] at 3:15 PM, revealed she started her shift, on [DATE] at 10:00 PM. She revealed CNA #1 asked her to observe Resident #1, sometime after 10:00 PM. She revealed the resident's brief was covered with blood. She described it as "thin, old blood, black in color." She revealed CNA #1 told her he had been reporting to RN #2 for several hours, but RN #2 was not doing anything for the resident. She revealed she notified Licensed Practical Nurse (LPN) #1 who was the house supervisor, of her observation, at approximately 10:30 PM, detailing the resident's brief was filled with blood and RN #2 was not doing anything for the resident. She revealed LPN #1 said she would take care of the situation upon her return to the facility. An interview with LPN #1, on [DATE] at 1:20 PM, revealed she was the night shift house supervisor, on [DATE]. She verified the phone call she received from CNA #7, on [DATE] at approximately 10:35 PM. She revealed CNA #7 reported to her "a lot" of blood in the resident's brief. CNA #7 also reported that RN #2 was not doing anything for the resident. She informed CNA #7 she would be "right back" to the facility, as the resident needed to go to the emergency room . Upon her return to the facility, LPN #1 revealed she spoke with RN #2 who told her she had already notified the physician of the resident's bleeding, with orders received to send the resident to the emergency room . LPN #1 revealed she did not initiate or conduct an investigation related to the allegation of neglect. She revealed RN #2 said she had assessed the resident previously, and "everything was fine." She revealed no other staff was interviewed about the incident and she was not aware the resident's condition had been reported numerous times before being sent to the emergency room . A review of the facility's nursing schedule, dated [DATE] through [DATE], revealed RN #2 continued to work at the facility on [DATE] and [DATE] without supervision to ensure that residents' needs were being met. A review of the facility's investigation, dated [DATE], revealed CNA #1 and CNA #7 reported, on [DATE], the allegation of neglect (from [DATE]) to the Administrator. The investigation confirmed the allegation of neglect was substantiated; however, there was no documented evidence that the facility identified or addressed LPN #1's failure to initiate an investigation of a report of neglect, report the allegation to facility Administration timely, or take necessary action to prevent further neglect of residents within the facility, per the facility's policy. An interview with the Administrator, on [DATE] at 3:50 PM, revealed LPN #1 should have suspended RN #2, per the facility's policy. She revealed the allegation should have been reported to the Administrator, with an investigation to begin immediately. She acknowledged her investigation did not address these issues. On [DATE] at 4:50 PM, the Director of Nursing (DON) revealed that despite the detailed actions listed in the Facility's Allegation of Compliance (AoC) to determine removal of Immediate Jeopardy, the charge nurse compliance rounds, used to determine potential abuse and/or neglect or to identify significant change in condition of residents requiring immediate attention, were not being completed twice per shift as they were suppose to be done. Review of the charge nurse compliance rounds documentation validated that all shifts were not completing two compliance rounds. The DON stated that the staff put the completed compliance round documents in her box but she had not verified that all required rounds had been completed or problems identified had been addressed. She further revealed weekend audits had not been completed and stated that no licensed administrative staff had been designated to review the 24 hour shift reports on the weekends to ensure significant change in condition, abuse and/or neglect concerns were addressed immediately per the facility's policy. She revealed that the facility had just initiated the weekend schedule to ensure that licensed administrative staff would begin monitoring and auditing the coming weekend. Interview with the RNA, on [DATE] at 11:40 PM, confirmed that the facility just initiated the weekend monitoring by licensed Administrative staff to begin the coming weekend. The DON further stated that while the facility was discussing the Unit Manager compliance audits in the morning meetings with the Interdisciplinary Team (IDT), they had not reviewed the charge nurse compliance rounds to discuss any potential concerns, problems or to identify necessary action required to be taken related to abuse, neglect or significant change. Interview with LPN #1, on [DATE] at 12:20 PM, confirmed that the facility had not been discussing compliance rounds in the IDT meetings. Due to the facility's failure to fully implement their AoC to remove Immediate Jeopardy, Immediate Jeopardy was determined ongoing.

Based on interview and record review, it was determined that Immediate Jeopardy (IJ) identified during the abbreviated survey (02/22/12) had been removed related to the written policies and procedures that prohibited neglect of residents related to the identification, protection of residents, investigation, and reporting of an allegation of neglect. However, non-compliance continued to exist at the S/S of a "D" as the facility had not completed the Quality Assessment and Assurance (QAA) initiative related to staff monitoring, analysis of monitoring results of audits, and the development and implementation of the Plan of Correction (POC) as related to the prohibited neglect of residents. Findings include: A review of the acceptable Allegation of Compliance (AOC,) dated 02/17/12, and the inservicing records and signatures, dated 02/16/12, revealed the supervisory staff, licensed staff, department heads and all other staff members were inserviced on 02/16/12 by the RN Corporate Compliance Nurse about the policies related to Resident Abuse, Neglect and Exploitation, as well as the Federal regulations related to the policies. Charge Nurse Compliance Rounds were completed two times per shift and verified as reviewed daily in the Interdisplinary Team (IT) meetings and the RN Corporate Compliance Nurse monitoring forms to include the week-end coverage and auditing sheet review. The Administrator and /or DON would continue to monitor any reports the Nursing House Supervisors, as well as the Preceptor Certified Nurse Aide's (CNA) reports submitted to them regarding any staff members knowledge of occurrence pertaining to a resident's change of condition or status that has not been addressed in a timely manner. An interview with the RN Corporate Compliance Nurse and the Administrator, on 03/09/12 at 4:44 PM, revealed the information and data from these reports would be trended and reviewed in the morning meetings and in the QA meeting on 03/12/12, to identify opportunities for improvement and immediate action. As of 03/09/12, the facility had not submitted an acceptable Plan of Correction (PoC.)

Based on interviews, record review, and the facility policy/procedure, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of three residents (Resident #1). The facility failed to ensure staff followed the "Abuse, Neglect, or Exploitation" policy/procedure related to the identification, protection of residents, investigation, and reporting of an allegation of neglect. On [DATE], facility staff reported to the Charge Nurse that Resident #1 had black "tarry" diarrhea at 7:30 PM, at 8:15 PM, and again between 10:00 PM and 10:30 PM. It was reported to the charge nurse at this time as an "active bleed." The charge nurse neglected to notify the resident's physician until 10:45 PM, more than three hours after initial notification of a change in condition of Resident #1. At 11:00 PM, the resident was admitted to the Hospital's Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock requiring a blood transfusion, where the resident subsequently died on [DATE]. While the facility staff reported the allegation of neglect regarding Resident #1 to the house supervisor, at approximately 10:35 PM, the house supervisor failed to report, investigate the allegation of neglect, and initiate protection of residents to prevent further potential neglect. On [DATE], Certified Nurse Aides (CNAs) #1 and #7 reported the allegation of neglect to the Administrator, nine days later due to their concerns that no action had been taken since it was reported on [DATE]. While the facility's investigation determined neglect occurred and terminated the charge nurse, the facility's investigation did not address the house supervisor's untimely reporting, failure to initiate the neglect investigation and failure to initiate protection of residents from further neglect as the Charge Nurse continued to work on [DATE] and [DATE] without supervision to ensure that residents needs were being met. The Administrator's failure to administer the facility in a manner that enabled it to use its resources to ensure policy and procedures were implemented to ensure allegations of neglect were identified, investigated and reported timely, and residents were protected has caused, or is likely to cause, serious injury, harm, impairment, or death to Resident #1 and other residents in the facility. The ongoing Immediate Jeopardy with substandard quality of care at 42 CFR 483.13 Resident Behaviors and Facility Practices and 42 CFR 483.25 Quality of Care and was determined to exist on [DATE]. Findings include: A review of the "Abuse, Neglect, or Exploitation" policy/procedure, revised [DATE], revealed any incident of suspected abuse, neglect, or exploitation involving staff towards a resident should be immediately reported to the employee's immediate supervisor and the Administrator and/or designee, at which time an investigation would begin. In case of alleged abuse involving an employee against a resident, that employee would be suspended immediately pending further investigation by the Administrator and/or designee. On [DATE], CNA #1 reported to the Charge Nurse that Resident #1 had black "tarry" diarrhea at 7:30 PM, at 8:15 PM, and again between 10:00 PM and 10:30 PM. It was reported to the charge nurse at this time as an "active bleed." A phone interview with CNA #7, on [DATE] at 3:15 PM, revealed she started her shift, on [DATE] at 10:00 PM, sometime after 10:00 PM CNA #1 asked her to observe Resident #1. She revealed the resident's brief was covered with blood and described it as "thin, old blood, black in color." She revealed CNA #1 told her he had been reporting to Registered Nurse (RN) #2 for several hours, but RN #2 was not doing anything for the resident. She stated that she notified Licensed Practical Nurse (LPN) #1, by phone, at approximately 10:30 PM and told her that Resident #1's brief was filled with blood and RN #2 was not doing anything for the resident. She revealed LPN #1 said she would take care of the situation upon her return to the facility. At 10:45 PM, per record review, RN #2 notified the physician regarding Resident #1's change in condition, more than three hours after initial notification of a change in condition of Resident #1. At 11:00 PM, the resident was admitted to the Hospital's Intensive Care Unit with a massive [MEDICAL CONDITION] with Shock requiring a blood transfusion. (Refer to F224 and F226). An interview with LPN #1, on [DATE] at 1:20 PM, revealed she was the night shift house supervisor, on [DATE]. She received a phone call from CNA #7, on [DATE] at approximately 10:35 PM. She revealed CNA #7 reported Resident #1 had "a lot" of blood in his/her brief. CNA #7 also reported that RN #2 was not doing anything for the resident. Upon her return to the facility, she revealed RN #2 had already notified the physician of the resident's bleeding, with orders received to send the resident to the emergency room . LPN #1 revealed she did not do an investigation related to the allegation of neglect. She revealed no other staff were interviewed about the incident. There was no evidence that the facility took any action to address the allegation of neglect on [DATE]. A review of the facility's nursing schedule, dated [DATE] through [DATE], revealed RN #2 worked on [DATE] and [DATE], without supervision to ensure all residents' needs were met. A review of the facility's investigation, dated [DATE], revealed CNA #1 and CNA #7 reported, on [DATE], the allegation of neglect (from [DATE]) to the Administrator. The investigation confirmed the allegation of neglect was substantiated; however, did not address the untimely identification, investigation, and reporting of the allegation of neglect. An interview with the Administrator, on [DATE] at 3:50 PM, revealed LPN #1 did not follow the facility's policy. She revealed LPN #1 should have suspended RN #2. She revealed the allegation should have been reported to the Administrator, with an investigation to begin immediately. She acknowledged her investigation did not address these issues. This failure to address these issues, prevented the facility from taking corrective action to prevent and protect its resident from further potential abuse/neglect. On [DATE] at 4:50 PM, interview with the Director of Nursing (DON) revealed that despite the detailed actions listed in the Facility's Allegation of Compliance (AoC) to determine removal of Immediate Jeopardy, the charge nurse compliance rounds, used to determine potential abuse and/or neglect or to identify significant change in condition of residents requiring immediate attention, were not being completed twice per shift as they were suppose to be done. Documentation review of the charge nurse compliance rounds validated that not all shifts were completing two compliance rounds. The DON stated that the staff put the completed compliance round documents in her box but she had not verified that all required rounds had been completed or problems identified had been addressed. She stated the weekend audits had not been completed and that no licensed administrative staff had been designated to review the 24 hour shift reports on the weekends to ensure significant change in condition, abuse and/or neglect concerns were addressed immediately per the facility's policy. She revealed that the facility had just initiated the weekend schedule to ensure that licensed administrative staff would begin monitoring and auditing the coming weekend. Interview with the RNA, on [DATE] at 11:40 PM, confirmed that the facility just initiated the weekend monitoring by licensed Administrative staff to begin the coming weekend. The DON further stated that while the facility was discussing the Unit Manager compliance audits in the morning meetings with the Interdisciplinary Team (IDT), they had not reviewed the charge nurse compliance rounds to discuss any potential concerns, problems or to identify necessary action required to be taken related to abuse, neglect or significant change. Interview with LPN #1, on [DATE] at 12:20 PM, confirmed that the facility had not been discussing compliance rounds in the IDT meetings. Due to the facility's failure to fully implement their AoC to remove Immediate Jeopardy, Immediate Jeopardy was determined ongoing.

Based on interview, record review, and Allegation of Compliance (AoC) review, it was determined the Immediate Jeopardy (IJ) identified during the survey, concluded on 02/22/12, had been removed. However, non-compliance continued to exist as the facility's Quality Assessment and Assurance Committee (QAAC) had not fully implemented a plan of correction to prevent recurrence of the deficient practice related to the deficient practice of the failure to ensure the staff followed the "Abuse, Neglect, or Exploitation" policy/procedure related to the identification, protection of residents, investigation, and reporting of an allegation of neglect. Findings include: A review of the acceptable Allegation of Compliance (AOC,) dated 02/17/12, revealed the facility revised policies and educated staff on the revision of policies related to resident abuse and neglect and required written competencies for verification of comprehension. Further review revealed the Administrator was re-educated, by the RN Corporate Compliance Nurse, on 02/16/12, in regard to conducting and reporting of abuse or neglect investigations and the management of the facility. Record review revealed the RN Corporate Compliance Nurse visited the facility daily, through 03/09/12, to follow-up on Administrative practices and review results with the Administrator and to review any significant changes in any resident's condition or status. No concerns were identified. An interview with the RN Corporate Compliance Nurse, on 03/09/12 at 4:44 PM, revealed the results of all audits and monitors for compliance would be reviewed in the QA Committee Meeting on 03/12/12. As of 03/09/12, the facility had not submitted an acceptable Plan of Correction (PoC.)

Based on interview, record review, review of the facility's policy/procedure, and review of the facility's Incident/Investigation Report, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one resident (#5), in the selected sample of 19 residents. The facility failed to follow the "Abuse, Neglect, and Exploitation" policy/procedure related to the protection of residents, investigation, and reporting of an allegation of abuse. While feeding Resident #5 in the dining room, on 04/27/12, Nurse Aide State Registered (NASR) #5 made a comment that the resident was drinking his/her water similar to her "dog." Resident #5 reported the comment to the staff, on 04/28/12; however, the facility allowed NASR #5 to continue to provide care to Resident #5 and other residents for at least one hour and fifteen minutes, prior to suspension. An interview with Resident #5, on 05/15/12 at 4:15 PM, revealed the resident did not want NASR #5 providing his/her care. The resident revealed the comment was embarrassing and made him/her "feel bad." Resident #5 was visibly upset and crying during the interview, 18 days after the incident (refer to F241). Licensed Practical Nurse (LPN) #8 failed to conduct a thorough investigation of the allegation and remove NASR #5 from resident care immediately. The allegation was discussed in the morning Quality Assurance (QA) committee meeting, on 04/30/12; however, these issues were not identified as a problem. Additionally, the Administrator failed to report the allegation of abuse to the State Agency (refer to F225 and F226). Findings include: A review of the facility's Investigation policy/procedure, revised 02/25/10, revealed all incidents that occurred in the facility required thorough investigation and accurate documentation so the facility could evaluate the reason the incident occurred, take corrective measures to curtail the number of incidents, assure resident safety and report any incidents of abuse according to state and federal guidelines. The investigation required the review of the following: Data Collection-interview the alleged resident or victim; interview witnesses to include the assigned caregiver, caregivers in the immediate area, remote or potential witnesses; and interview the alleged suspect. Data Analysis-summarize the analysis of facts gathered that either established reasonable cause for the incident or establish the need for further investigation before a reasonable cause for the incident could be established.A review of the facility's Abuse, Neglect, and Exploitation policy/procedure, revised 02/07/12, revealed in case of alleged abuse involving an employee against a resident, that employee should be suspended immediately pending further investigation by the Administrator and/or designee. The Administrator and/or designee would conduct an investigation of the allegation and report the results of the investigation within five working days to the Division of Long-Term Care. A record review revealed the facility admitted Resident #5 on 11/07/11 with [DIAGNOSES REDACTED]. An interview with Resident #5, on 05/15/12 at 4:15 PM, and on 05/16/12 at 2:10 PM, revealed the resident stated that NASR #5 was feeding him/her on 04/27/12, and made a comment "I drank my water like her dog." The resident revealed the comment made him/her feel bad and was embarrassing, as other residents and guests were at the table. He/she revealed the comment was reported the next day, to Certified Medication Tech (CMT) #2, and the resident expressed he/she did not want NASR #5 providing care for him/her. After making the report, the resident revealed NASR #5 was allowed to give him/her a shower. Interviews with CMT #2 and CMT #3, on 05/16/12 at 9:32 AM and 10:35 AM, respectively, confirmed the resident's allegation and that it was reported to LPN #8 as an allegation of verbal abuse. CMT #3 revealed the resident was upset and crying. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed the resident was quiet and had "one tear" roll down his/her face. An interview with LPN #8, on 05/14/12 at 2:00 PM and 3:10 PM, 05/16/12 at 2:35 PM, and 05/17/12 at 2:00 PM, revealed the allegation was reported to her, by CMT #2. NASR #5 was giving a resident a shower. She confirmed she did not remove NASR #5 form direct care immediately. She admitted she should have removed NASR #5 from resident care immediately, per the policy. LPN #8 further revealed she did not conduct a thorough investigation. She did not document a statement from Resident #5. She also revealed she should have obtained statements from CMT #2 and CMT #3. She did not verify who was sitting at the table when the comment was made to the resident, and did not try and contact any of them. She also indicated that the investigation was turned over to the Administrator and reviewed in the QA committee meeting; therefore, they should have ensured the investigation was completed. A review of the Timecard Report for CMT #2 and CMT #3, dated 04/28/12, revealed both employees clocked out for lunch at 10:31 AM. A review of the facility's Incident/Investigation Report, dated 04/28/12, revealed a written statement by NASR #5; however, there were no other statements included in the investigation. A review of the Timecard Report for NASR #5, on 04/28/12, revealed she did not clock out until 11:48 AM, at least one hour and fifteen minutes after the allegation was reported to LPN #8. An interview with NASR #5, on 05/16/12 at 3:45 PM, revealed she gave Resident #5 a shower and provided incontinent care for another resident on 04/28/12, prior to her suspension. An interview with the Director of Nursing (DON), on 05/17/12 at 2:35 PM, revealed LPN #8 contacted her at home, on 04/28/12, to report the allegation. She revealed LPN #8 was instructed to gather statements from anyone around the area, from any resident that could have heard the comment, and from residents cared for by NASR #5. She was not aware NASR #5 continued to provide care for the resident after the allegation was reported to LPN #8. She expected LPN #8 to suspend NASR #5 immediately. She did not speak to the resident about the allegation. An interview with the Social Services Director, on 05/17/12 at 9:10 AM and 3:00 PM, revealed she was the facility's abuse coordinator. She was not knowledgeable of the facility's policy/procedure related to abuse/neglect. She revealed if allegations of abuse/neglect were unsubstantiated, they were not reported to the State Agency. She was not aware of the allegation made by Resident #5; however, she attended the Quality Assurance (QA) committee meeting (where the investigation was discussed), on 04/30/12. An interview with the Administrator, on 05/17/12 at 4:05 PM, revealed she was at the facility, on 04/28/12, after the allegation was reported. She stated that the resident was not upset about the comment; however, she admitted she did not question the resident about what happened. The Administrator revealed the investigation did not have enough information to determine the findings of the allegation. She revealed Social Services was responsible for ensuring a thorough investigation, with assistance from the DON and Administrator. She further verified it was discussed in the QA committee meeting, on 04/30/12, with no concerns. She revealed the allegation was not reported to the State Agency, as it did not qualify as verbal abuse. An interview with the Corporate Compliance Nurse, on 05/17/12 at 5:00 PM, revealed he did review the investigation in the QA committee meeting, on 04/30/12. The allegation was unsubstantiated due to the statement by NASR #5; however, he admitted it was not a thorough investigation to determine the findings of the allegation. He could not recall if he recommended a more thorough investigation after review, on 04/30/12. He revealed the facility did not report to the State Agency because the allegation was unsubstantiated. He stated that any allegation of abuse would be reported; however, he did not feel this was verbal abuse. However, interview with CMT #3 revealed this was an allegation of abuse.