Every finding on record at Rockcastle Health & Rehabilitation Center

Based on interview, record review, and facility policy review, the facility failed to immediately report (within no more than two hours) allegations of abuse to the state survey agency (SSA) for three residents (R) (R)3, R64 and R72) of three sampled residents reviewed for abuse. The facility failed to inform the SSA of an allegation of sexual abuse in which one resident (R72) was alleged to have masturbated in front of another resident (R64) without R64's consent, which meets the definition at S483.5 of non-consensual sexual contact of any type with a resident. The facility also failed to report an allegation of verbal abuse, when R3 initially reported that a nurse yelled at him. The facility made the determination to not report allegations to the SSA based on the findings of their investigations, rather than immediately as required by regulation.The findings included: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, last revised on 09/15/2023, revealed, It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property. The policy also revealed, The organization's policy is that the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation unless he or she has a conflict of interest or is implicated in the alleged violation. The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. The policy defined Allegation of Abuse as, This means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred. The policy revealed, All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made. 1. Review of the Resident Face Sheet revealed the facility admitted R64 on 05/02/2024. Further review revealed the resident had a medical history that included diagnoses of depression and anxiety disorder. Per review the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2025, R64 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident had intact cognition. Review of the Resident Face Sheet revealed the facility admitted R72 on 02/29/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease without dyskinesia, cognitive communication deficit, schizophrenia, generalized anxiety disorder, and other Alzheimer's disease. Per a significant change in status MDS, with an ARD of 08/05/2025, R72 had a BIMS score of 2/15, which indicated the resident had severe cognitive impairment. During an interview with the Resident Council on 08/26/2025 at 2:02 PM, R64 stated he was tired of seeing his roommate (R72) naked in the room and that the roommate would play with himself. R64 stated he voiced his concerns to the Administrator, and the Administrator offered to move him to a different room. R64 stated he did not understand why he needed to move rooms when it was his roommate (R72) who was the problem, and he should not have to live with a roommate like that. During an interview on 08/26/2025 at 5:21 PM, R64 stated he moved into the current room with R72 a couple of weeks prior, and It's been a mess since [R72]'s been here. R64 stated he woke up two mornings prior, on 08/24/2025, and observed R72 naked at the foot of his (R64's) bed, masturbating near the shared closet in the room. R64 stated he informed the SSD of the concern that day and also informed a Certified Nursing Assistant (CNA) but was unable to state the specific CNA he told. R64 stated he was offended by R72's behavior, and it was embarrassing to witness. During a telephone interview on 08/28/2025 at 4:05 PM, the SSD stated R72 had behaviors specific to toileting and personal hygiene, such as removing all his clothing before going to the bathroom and washing his genitals in the room sink. The SSD stated that on 08/25/2025, R64 reported to her that on 08/24/2025, he witnessed R72 masturbating in the room, but then he stated the resident was not completely sure if R72 was masturbating or not. The SSD stated the behavior was not reported to her by any other staff members. The SSD stated the Interdisciplinary Team (IDT) met to discuss moving R72, but the SSD did not mention if an allegation of sexual abuse was reported. Review of SSA's (State Survey Agency's) records revealed no evidence that the allegation, which the facility was aware of on 08/25/2026, was reported to the State Agency. Review of the form used for reporting allegations to the SSA revealed that an Alleged violation is a situation or occurrence that is observed or reported by staff, resident.but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to.abuse. Per the reporting form, In response to allegations of abuse.the facility must: (1) Ensure that all alleged violations involving abuse.are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator of the facility and to other officials (including to the State Survey Agency).in accordance with State law through established procedures. During an interview on 08/26/2025 at 4:34 PM, the Administrator stated the facility had not reported any allegations of abuse to the SSA since before August 2024. The Administrator stated he was aware of R64's concerns related to R72's sexual behaviors. In response, the facility's Social Services Director (SSD) spoke to R64, who reported he did not feel like he was abused by R72's behavior, and he simply did not want to see R64 naked in the room anymore. During an additional interview on 08/29/2025 at 1:31 PM, the Administrator stated the allegation involving R72 and R64 was not reported to the SSA. He stated he did not feel the allegation met the definition of sexual abuse because he did not think R64 was masturbating in front of R72. The Administrator added he did not report the allegation based on R72's recollection of the event. 2. Review of a Resident Face Sheet revealed the facility admitted R3 on 09/24/2018. An annual MDS, with an ARD of 07/31/2025, revealed the facility assessed R3 with a BIMS' score of 15/15, which indicated the resident had intact cognition. An interview was held with R3 on 08/25/2025 at 11:30 AM. During the interview, the resident stated the past weekend, she called the front office to contact the nurse's station so the staff would answer her call light. R3 stated a nurse (identified as Registered Nurse (RN) 5) yelled at her and told her to Quit calling everyone to get me and quit aggravating others. On 08/25/2025 at 11:40 AM, the allegation of verbal abuse was reported to the Administrator. The Administrator was interviewed on 08/26/2025 at 11:00 AM and stated that he, the Director of Nursing (DON), and SSD spoke to R3 regarding the allegation that RN5 yelled at her. The Administrator stated R3 was not upset about the incident and stated the incident was not an allegation of abuse, so he did not report the incident that alleged RN5 yelled at R3 to the state agency. Review of SSA's records confirmed that the facility failed to report the allegation of verbal abuse within two hours after initially becoming made of it on 08/25/2025. During additional interview on 08/29/2025 at 1:30 PM, the Administrator presented an investigation for the allegation involving R3 and RN5. The summary of the investigation indicated the resident had an issue with the nurse after an incident on 08/22/2025 when the nurse allegedly told the resident to stop calling the front office and ring the call bell. The Administrator stated he had not reported the incident to the state agency because after he spoke with the resident and the nurse, he did not feel the resident's interviews supported verbal abuse, and he thought it was more of a customer service issue.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure 1 of 1 sampled resident reviewed for self-administration of medications was assessed to determine if this practice was clinically appropriate and safe related to self-administration of potassium chloride, Resident (R)35.The findings include: Review of the facility's policy titled, Medication Administration Self-Administration by Resident, dated 01/2023, revealed, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. The policy also revealed, If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. Review of the facility's policy titled, Resident Rights, revised on 01/21/2025, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Self-administer medication, if the interdisciplinary care planning team determines it is safe. Review of R35's Resident Face Sheet, located in the medical record, revealed the facility re-admitted the resident on 07/10/2025. The resident's diagnoses included pneumonia, chronic kidney disease, emphysema, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2025, revealed the facility assessed R35 as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This score indicated R35 cognition was intact. Review of R35's Care Plan revealed no information regarding the resident's ability to self-administer any of her medications. Review of R35's Physician Order Report for the timeframe from 07/29/2025 through 08/29/2025 revealed an order dated 07/10/2025 for potassium chloride extended release 20 milliequivalents (mEq) once a day. The order did not indicate the resident was approved to self-administer this medication. During a concurrent observation and interview on 08/26/2025 at 10:29 AM, a large, white pill was observed in a medication cup located on R35's bedside table. R35 identified the medication as potassium and stated the nurses left it on her bedside table for her to take at lunch time with her meal, per her request. R35 stated she thought she was approved to keep and administer some of her medications, but she was not sure about the potassium. R35 stated Licensed Practical Nurse (LPN)10 was the nurse that left the potassium with her today (08/26/2025). During an interview on 08/27/2025 at 12:36 PM, LPN10 stated she was the nurse that left the potassium pill on R35's bedside table on Tuesday (08/26/2025). LPN10 stated she left it per the resident's request, because the resident stated she needed to wait until lunch to take the medication with food. LPN10 stated she was not familiar with or aware of the process for conducting an assessment before a medication could be left at the bedside. Review of R35's Observation Detail List Report for Self-Administration of Medications, dated 08/19/2025, revealed the facility assessed the resident for self-administration of two inhalers. However, the assessment did not address the resident's ability to self- administer potassium chloride. During an interview on 08/29/2025 at 5:23 PM, the Director of Nursing (DON) stated medications should not be left at the bedside without completing a self-administration assessment. During a follow-up interview on 08/29/2025 at 5:49 PM, the DON stated she expected staff to follow the facility's policy for assessing residents for self-administration of medications. During an interview on 08/29/2025 at 5:53 PM, the Administrator stated he expected staff to follow the facility's policy for self-administration of medications. He stated this included the completion of a self-administration assessment and ensuring there was an order for self- administration of medications in place.

Based on interview, record review, and facility policy review, the facility failed to provide written notification of a room change, including the reason for the change for 1 of 40 residents (Resident #3) sampled for room change, prior to relocating the resident to another room in the facility. The findings include: Review of the facility's policy titled, Room/Roommate Change Notification Policy, revised 01/31/2025, revealed a POLICY STATEMENT noting the facility would provide notice to the resident prior to changing the resident's room or roommate. Per policy review, the interdisciplinary team (IDT) was to participate in making all resident room relocation decisions. The policy specified, 2. Notice of intra-facility transfers will be made before the relocation except when: a. The safety of the resident or others in the facility is at risk; b. The health of the resident or others in the facility is at risk; or c. An immediate transfer is required by the resident's urgent medical needs. Further review revealed the intra-facility notice was to contain: a. Reasons for transfer. b. Effective date of the transfer. c. Location to which the resident is transferred. 4. The notice will be provided to: a. The resident and/or the resident's representative; and b. Documented in the electronic medical record. 1). Review of R3's Resident Face Sheet revealed the facility admitted the resident on 09/24/2018, and most recently readmitted the resident on 03/15/2024. Per review of the Resident Face Sheet, R3's diagnoses included: hemiparesis and hemiplegia following a cerebral infarction (stroke) affecting the left non-dominant side; type two diabetes mellitus; anxiety disorder; major depressive disorder, and post-traumatic stress disorder (PTSD). Review of a census sheet revealed Resident #3 was relocated to a new room on 08/19/2025. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/31/2025, revealed the facility assessed R35 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS Assessment revealed the facility assessed R3 to have exhibited no behaviors during the seven-day assessment look-back period. Review of R3's comprehensive Care Plan revealed a problem area, initiated on 04/05/2024 and revised on 08/07/2025, that noted the resident demonstrated non-compliance with physician's orders and/or the plan of care. Per review, R3's non-compliance was evidenced by not adhering to the ordered diet and refusing to shower/bathe at times. Continued review revealed an approach (intervention) started on 04/05/2024, instructing the nursing department and the social services department (SSD) to encourage R3 to participate in decision-making. Additional review of R3's Care Plan revealed it also included a problem area, started on 01/31/2023 and revised on 08/07/2025, that noted the resident needed to participate in decisions regarding tasks of daily life. Per review of that care plan, the long-term goal noted R3 was to be fully informed in advance about her care and treatment and also informed of any changes in that care or treatment. Review of R3's Social Services (SS) Progress Notes for the timeframe of 07/01/2025 through 08/28/2025, revealed no documented evidence of R3's room change on 08/19/2025. Continued review revealed no documented evidence R3 was provided notification regarding the room change as required. Review of R3's Resident Progress Notes for the timeframe of 07/28/2025 through 08/25/2025, revealed no documented evidence of R3's room change on 08/19/2025. Additionally, review revealed no documented evidence R3 was provided notification regarding the room change as required. In interview on 08/27/2025 at 1:05 PM, R3 stated she had been put out of her room about a week or so prior. She stated that before her room was changed, she shared a room with R40. R3 stated R40 (her former roommate) bought her (R3) some of her (R40) drinks on own free will. She stated she had not asked R40 to buy her anything, but the Social Services Director (SSD) moved her to another room due to R40 buying her drinks. 2). Review of the Quarterly MDS Assessment, with an ARD of 07/30/2025, revealed the facility assessed R40 to have a BIMS score of 14 out of 15. This score indicated the resident had intact cognition. In interview on 08/27/2025 at 1:10 PM, R40 stated R3 had previously been her roommate but R3 had recently been moved to another room. During the interview R40 acknowledged buying drinks for R3. R40 stated she had done that because she had always been taught to share, and liked doing that. She stated R3 had never asked her (R40) to buy her (R3) anything. In interview on 08/28/2025 at 12:03 PM, Registered Nurse (RN) 5 stated she had been told by another nurse or a certified nursing assistant (CNA) that R3 had been moved to another room because the resident took drinks from R40. She further stated she had also been told R40 bought other things for R3. In a telephone interview on 08/28/2025 at 4:30 PM, the SSD stated she tried to document everything about residents' room changes; however, sometimes she forgot to document. She stated she usually called family members and spoke with the resident about any room changes. The SSD stated the facility's policy required her to document conversations about room changes in the resident's electronic medical record (EMR). She explained she had not been involved in R3's recent room change, and she did not know why the resident's room change occurred. The SSD further stated she was unaware she was to be giving residents written notices about any room changes. In interview on 08/29/2025 at 8:57 AM, Licensed Practical Nurse (LPN) 12 stated she was the unit manager on the unit where R3 and R40 resided. She stated previously R3 had expressed an interest in a room change due to R40 keeping her awake at night, but there was no documentation regarding that conversation. LPN 12 stated she was the one who asked R3 to change rooms, and the resident was given a choice. She explained R3's room change had nothing to do with R40 sharing drinks with R3. During the interview, LPN 12 reviewed the facility's census information and confirmed R3's room was changed on 08/19/2025. LPN 12 stated she was unaware of the facility's policy to provide a notice to the resident that included details such as when the move would occur, why the move was needed, and where the resident would be moved. She stated the SSD should have documented in the SS progress notes about R3's room change. The LPN stated the room change was discussed during the IDT meetings; however, she was not sure if the SSD was present for the IDT meetings in which that had been discussed as the facility did not maintain notes or attendance records of the meetings. In interview on 08/29/2025 at 2:25 PM, the Director of Nursing (DON) stated she was unsure why the room transfer for R3 had been initiated. The DON stated she remembered the transfer was discussed during a morning meeting, and she thought the transfer had to do with roommate incompatibility. She stated the SSD managed residents' room moves and was the one that completed documentation of the transfers in the residents' EMR prior to the transfer. The DON further stated the SSD was a part of the discussions about R3's room transfer, and the SSD should have completed the required documentation regarding the transfer. In interview on 08/29/2025 at 3:02 PM, the Administrator stated he remembered the IDT reviewing the room change for R3. However, he stated he was unable to recall the reason for the room change. The Administrator stated he expected there to be documentation in the resident's chart to support the room change.

Based on observation, interview, record review, and facility policy review, the facility failed to provide needed services to maintain good grooming for one (Resident (R9) of four sampled residents reviewed for activities of daily living (ADLs). The facility failed to ensure that R9, who was dependent on staff for assistance with personal hygiene, received the care needed to keep the resident's fingernails trimmed and clean. The findings included: A facility policy titled, Activities of Daily Living (ADLs), reviewed 01/31/2025, indicated, For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares. Review of a Resident Face Sheet revealed the facility admitted R9 on 12/27/2024. According to the Resident Face Sheet, R9 had a medical history that included diagnoses of type 2 diabetes mellitus, muscle weakness, osteoarthritis, and cancer. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2025, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had moderate difficulty hearing, moderately impaired vision with the use of corrective lenses, and did not reject care during the assessment's lookback period. Per the MDS, R9 required substantial to maximal assistance from staff for completion of personal hygiene tasks. R9's Care Plan, included a problem statement edited 07/24/2025, that indicated the resident had concerns with ADL functional/rehabilitation potential. Interventions directed staff to assist the resident with ADL care as needed (created 12/30/2024). During an observation on 08/25/2025 at 9:51 AM, R9's fingernails extended at least 1/4 inch beyond the tip of his fingers. During an observation on 08/26/2025 at 2:55 PM, R9 was lying in bed. The resident's nails remained long. Two visitors whom R9 identified as family members were in the room. Interview with the family members revealed the resident's nails could stand trimming and the edges of his fingernails were jagged. The family stated that sometimes they trimmed R9's nails but thought it was the responsibility of the facility to trim the resident's nails. The family added that this time, they were waiting to see if the facility trimmed the resident's nails. During an observation on 08/27/2025 at 1:30 PM, R9's fingernails were still uncut and extended past the tip of his fingers, about 1/4 to 1/2 inch. Certified Nursing Assistant (CNA) 4 was interviewed on 08/27/2025 at 4:32 PM. She stated the CNAs were responsible for clipping and cleaning fingernails on shower days and as needed. CNA4 added that, if the resident had a diagnosis of diabetes, then the CNA told the nurse, and fingernail care was the responsibility of the nurse. Registered Nurse (RN) 5 was interviewed on 08/28/2025 at 11:49 AM. RN5 stated that the CNAs were supposed to look at the residents' nails on shower days and, if needed, trim the nails, unless the resident had diabetes. Per the interview, if the resident had diabetes, the CNAs were to report the need for nail trimming to the nurse, who was then responsible for performing this care as needed. During an observation on 08/29/2025 at 12:55 PM, R9 was lying in bed eating lunch. The resident's nails remained long and needed to be cleaned and trimmed. During a concurrent interview, R9 commented that the staff had not cleaned or trimmed his nails yet.CNA7 was interviewed on 08/29/2025 at 12:58 PM. CNA7, who stated she was not the resident's assigned CNA, observed R9's fingernails and confirmed that they needed to be trimmed and cleaned.Interview on 08/29/2025 at 12:59 PM with CNA9 revealed she was assigned to care for R9. CNA9 stated fingernails were to be cleaned and clipped either during showers or when the nails were noted to be long and dirty. CNA9 stated she had not given R9 a bath since there had been a shower aide on duty. After checking the schedule, she noted that day was not the resident's shower day. CNA9 stated that while she had assisted the resident with incontinence care and oral care, she had not noticed the resident's fingernails, which she indicated needed to be cleaned and clipped.The Director of Nursing (DON) was interviewed on 08/29/2025 at 5:44 PM. The DON stated she expected the staff to keep resident's nails clean and trimmed as the resident allowed. The Administrator was interviewed on 08/29/2025 at 5:53 PM. The Administrator stated he expected residents to be kept neat and tidy as the resident allowed staff to assist.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure services were provided so as to prevent complications of a gastrostomy tube (GT) for one of two sampled residents ((R) 49) who were observed for medication administration through a GT. Staff failed to check placement prior to administering medication, via the GT, to the resident.Findings included: Review of a facility policy titled, Medication Administration Enteral Tubes, dated 01/2025, revealed staff should, Verify tube placement per facility protocol. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 ml [milliliters]. Review of a Resident Face Sheet revealed the facility admitted R49 on 08/14/2025. Further review revealed the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) following a stroke and gastroparesis (delayed stomach emptying). Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2025, revealed the facility assessed R49 to have a Brief Interview for Mental Status (BIMS) score of 5/15, which indicated the resident had severe cognitive impairment. The MDS revealed R49 was dependent on staff for eating and had complaints of difficulty or pain with swallowing. Per the MDS, R49 received 51% or more of her nutrition and 501 cc (cubic centimeters) or more of water daily through tube feeding. Review of R49's Care Plan, included a problem statement with a start date of 08/20/2025, that indicated the resident was underweight and had an enteral nutrition order (feeding by GT). Interventions directed staff to give meals as ordered. Record review revealed an Order History for R49 that included active physician orders from 07/29/2025 through 08/29/2025 that indicated the resident received no food or medication by mouth. Further review of the Order History revealed there was no order to check the GT placement prior to medication administration. An observation was made on 08/27/2025 at 8:16 AM of Registered Nurse (RN) 11 preparing medication to administer to R49. RN11 crushed the medication, mixed the medication with water to dissolve, and then flushed the resident's GT with 30 ml of water. RN11 next gave the ordered medication to the resident and then flushed her GT with 30 ml of water. RN11 did not check placement of the resident's GT prior to flushing the GT with water or administration of the medication. During an interview on 08/27/2025 at 8:17 AM, RN11 stated she had been taught before giving medication by GT to check placement by listening for air to make sure the GT was in the right spot. RN11 stated she had been nervous and forgot to check the placement of R49's GT. The Director of Nursing (DON) was interviewed on 08/27/2025 at 3:49 PM. The DON stated she would have to read and verify the facility's policy for checking GT placement prior to medication administration. She stated the best practice was to check placement of the GT before giving medication to ensure the medication was administered into the correct location. The Administrator was interviewed on 08/29/2025 at 5:59 PM. The Administrator stated he expected the nurse to follow the facility's policy and physician's orders before giving medication via GT.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a resident who needs respiratory care, is provided oxygen per the physician's directions for 1 of 1 sampled resident reviewed related to oxygen therapy, Resident (R)9.The findings include: Review of the facility policy titled, Medication Administration General Guidelines, dated 09/2018, revealed, Medications are administered in accordance with written orders of the prescriber. Review of R9's Resident Face Sheet revealed the facility admitted the resident on 12/27/2024 and re-admitted the resident on 05/23/2025 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, muscle weakness, osteoarthritis, and cancer. Review of R9's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 9 out of 15, revealing moderate cognitive impairment. Further review revealed the resident was assessed as dependent on staff for all mobility. Review of R9's Care Plan included a problem area with a revision date of 07/24/2025, stating the resident had the potential for complications related to emphysema/COPD. The Approach instructed staff to administer oxygen as ordered and observe oxygen precautions, initiated 06/10/2025. Review of R9's Medication Administration Record (MAR), dated 08/2025, revealed on 05/23/2025 the physician ordered oxygen therapy to be administered at two liters per minute (LPM) via nasal cannula (NC) as needed. The entry gave a space for the assigned nurse to sign each shift noting the oxygen had been given during the designated shift. The entry had been signed each shift from 08/25/2025 through the day shift on 08/29/2025. Observation on 08/25/2025 at 9:54 AM, revealed R9 was lying in bed receiving oxygen at 1.5 LPM via nasal cannula. Observation on 08/28/2025 at 11:30 AM, revealed R9 was lying in bed receiving oxygen per NC. The oxygen concentrator was set on 3 LPM. During interview with Registered Nurse (RN)5, on 08/28/2025 at 11:49 AM, she stated staff was to follow Physician's orders related to LPM of oxygen to be administered to a resident. She further stated it was possible the LPM set on the concentrator was changed by R9. During interview with Licensed Practical Nurse (LPN)8, on 08/29/2025 at 1:03 PM, she stated the nurses were to set the oxygen concentrator on the LPM as ordered by the Provider. LPN8 further stated the resident's oxygen concentrator was checked each shift to ensure it was set on the correct amount of oxygen to be delivered. LPN8 stated R9 was unable to adjust the oxygen concentrator independently. During further interview with LPN8, on 08/29/2025 at 1:03 PM, she stated R9 had current physician's orders to receive 2 LPM of oxygen through the NC. LPN8 then observed R9's oxygen concentrator and stated the LPM was set at 2.5 LPM. LPN8 stated she had been sure the resident's oxygen concentrator was set at 2 LPM today, until she bent down to check the oxygen concentrator. During interview on 08/29/2025 at 5:54 PM, the Director of Nursing (DON) stated it was her expectation for oxygen to be delivered at the rate ordered by the physician. The DON was questioned about the potential negative effects of a resident receiving too much oxygen; however, she declined to answer. The DON agreed the oxygen rate of administration should be validated before signing the MAR. During interview on 08/29/2025 at 5:56 PM, with the Administrator, he stated it was his expectation oxygen be delivered as ordered and as per the facility policy. He stated he expected nurses to verify the rate of oxygen administration prior to signing the MAR, noting the rate was correct.

Based on interview, record review, and facility policy review, the facility failed to provide behavioral health services for one (Resident (R) 72) of six residents sampled for behavioral monitoring. The facility failed to monitor/document multiple behaviors displayed by R72. Staff were not consistently informed of and/or aware of significant behaviors which had the potential to affect others. The failure to monitor, be aware of, and/or take prompt actions to address all R72's behaviors affected at least three of his roommates (R64, R5, and R4).Findings included: A facility policy titled, Behavioral Health, last revised 09/15/2023, revealed, It is the organization's intent to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The policy also revealed, Stakeholders will be alert to the effectiveness of interventions and the care plan will be reviewed and revised as necessary. A Resident Face Sheet revealed the facility admitted R72 on 02/29/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease with fluctuations and without dyskinesia, cognitive communication deficit, schizophrenia, generalized anxiety disorder, and other Alzheimer's disease. A Progress Note, dated 10/22/2024 at 8:53 AM, revealed the interdisciplinary team (IDT) met to review R72's recorded behavior of self-directed sexual acts in a public area. The note revealed R72 was observed engaging in self-directed sexual acts in the hall of the facility, outside of his room door, and staff redirected the resident to his room for privacy. Per the note, R72's understanding of the need for privacy was limited due to cognitive impairment, but the plan was for the Social Services Director (SSD) to follow up with the resident to review privacy. The note stated the care plan was updated to include this behavior, and a nurse practitioner (NP) and psychiatric provider were provided with a report of the new behavior. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2025, revealed R72 had a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had fluctuating behaviors of disorganized thinking and inattention. Per the MDS, R72 had physical and other behavioral symptoms 1-3 days during the assessment period. The MDS documented that the behaviors put R72 at significant risk for physical illness or injury, significantly interfered with the resident's care, significantly interfered with the resident's participation in activities or social interactions, put others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. R72's Care Plan, included a problem statement edited on 08/22/2025, that indicated the resident demonstrated behaviors including yelling/screaming, combativeness at staff during care provisions, engaged in ritual behaviors including undressing to toilet and completing hygiene at the sink, and urinating in inappropriate places, such as the floor. Interventions directed staff to provide a quieted environment and reapproach the resident later if agitation was present, assist the resident away from other residents as needed, observe for triggers of inappropriate behaviors and alter the environment as needed, encourage participation in activities as appropriate, and observe for unmet needs such as for toileting, rest, food, fluids, and companionship. The Care Plan also included a problem statement, edited 08/19/2025, that indicated the resident exhibited inappropriate social and sexual behaviors. Interventions directed staff to allow the resident extended time to perform repetitive ritual tasks for completion to decrease the risk of socially inappropriate behaviors, provide diversional activities as needed, provide education on personal hygiene as needed, provide privacy for the resident as needed/or requested, and remind the resident to pull the curtain, and shut the door, as needed. R72's Physician Order Report for the timeframe from 07/28/2025 through 08/28/2025, contained an order, dated 03/10/2024, for monitoring of target behaviors by marking the frequency and intensity of the behaviors at the end of each shift. Target behaviors which were to be monitored/documented each shift included agitation, anxiousness, restlessness, hallucinations/delusions, sadness, tearfulness, and self-isolation. The Physician Order Report revealed no orders related to monitoring the additional identified behaviors of inappropriate social and sexual behavior, ritual behaviors including undressing to toilet and completing hygiene at the sink, or urinating in inappropriate places, such as the floor. R72's Treatment Administration History, for the timeframe from 08/01/2025 through 08/28/2025, revealed no documentation related to monitoring behaviors of ritual behaviors including undressing to toilet and completing hygiene at the sink; urinating in inappropriate places, such as the floor; or inappropriate social and sexual behaviors. Review of R72's Progress Note, entries for the timeframe from 02/29/2024 to 08/20/2025 revealed no further documentation related to R72's sexual behaviors or ritualistic behavior of removing clothing. On 08/20/2025 at 4:05 PM, a Progress Note documented that R72 was observed to have impulses to complete ritual behaviors. The note revealed the resident was observed to take off his clothing when toileting and stand at the sink area to clean his genitals several times with water and paper towels prior to dressing again. Per the note, R72 was observed to complete the ritual each time he toileted. During an interview with the Resident Council on 08/26/2025 at 2:02 PM, R64 stated he was tired of seeing his roommate (R72) naked in the room and that R72 would play with himself. R64 stated he voiced his concerns to the Administrator, who offered to move him to a different room. R64 stated he did not understand why he needed to move rooms when his roommate, R72, was the problem, and he should not have to live with a roommate like that. Review of a quarterly MDS, with an ARD of 08/07/2025, revealed R64 had a BIMS score of 15/15, which indicated the resident had intact cognition. During an additional interview on 08/26/2025 at 5:21 PM, R64 stated he moved into his current room with R72 a couple of weeks prior, and It's been a mess since [R72]'s been here. R64 stated he woke up two mornings prior, on 08/24/2025, and observed R72 naked at the foot of R64's bed, masturbating near the shared closet in their room, which was in front of R64's bed. R64 stated he informed the SSD of the concern that day and also told a Certified Nursing Assistant (CNA), whom he could not identify, of R72's behavior. R64 stated R72 was naked in the room the previous night, 08/25/2025, and he again notified a CNA, who then assisted the resident with getting dressed. R64 added that when he informed the SSD of R72's behavior of removing his clothing on 08/22/2025, the SSD started making excuses for [R72]. R64 stated he was offended by R72's behavior, and it was embarrassing to witness. During an interview on 08/27/2025 at 10:53 AM, R5 stated that when he was R72's former roommate, the resident would walk around the room naked, just about every other day. R5 added that R72 would come out of the bathroom naked or come out wearing no pants. A quarterly MDS, with an ARD of 08/01/2025, revealed R5 had a BIMS score of 9/15, which indicated the resident had moderate cognitive impairment. During an interview on 08/27/2025 at 2:07 PM, R4 he was R72's roommate for about two days. R4 also stated R72 would walk around the room naked and urinated in the sink and on the floor all the time. R4 stated he felt offended by R72's behavior, adding I don't like stuff like that. A quarterly MDS, with an ARD of 05/27/2025, revealed R4 had a BIMS score of 14/15, which indicated the resident had intact cognition. During an interview on 08/26/2025 at 4:34 PM, the Administrator confirmed he was aware of R64's concerns related to R72's sexual behaviors. The Administrator added that R72 had ritualistic behaviors and tendencies, such as removing his clothing, and was seen by psychiatric services on a regular basis. During this interview, the Administrator stated that in response to R64's concerns, R72 was supposed to be moved into a different room on 08/25/2025, and he was not sure why the resident was not moved as planned. During an additional interview on 08/28/2025 at 8:39 AM, the Administrator stated R72 had behaviors described as ritualistic, mostly relating to cleanliness and personal hygiene, such as performing personal hygiene at the sink with paper towels. The Administrator added that when he spoke to R64, the resident's main concern was related to R72's personal hygiene habits and the resident's tendency to remove his clothing. The Administrator also stated R64 explained to him that he witnessed R72 grabbing his genitals, and R64 told the Administrator that, [R72] was masturbating in his presence. The Administrator said that when he asked R64 why he thought R72 was masturbating, R64 replied, Why else would you have your hand down there? Further interview with the Administrator revealed he had no documentation of this conversation with R64. During an interview on 08/28/2025 at 9:13 AM, the Advanced Practitioner Registered Nurse (APRN) stated that when facility staff reported resident behaviors to her, it depended on the extent of those behaviors to determine the course of action they would take to address them. The APRN stated residents were referred to psychiatric services, and medications would be monitored and adjusted as needed. The APRN stated she was familiar with R72, and she was not aware of the resident displaying any sexual behaviors or being naked in public places. The APRN described R72 as very fixated on cleanliness and would stand at the sink in the room to perform cleaning rituals, such as repeated handwashing. The APRN stated she was aware R72 had several room changes and believed it was due to the roommates not being able to tolerate R72's behaviors. The APRN related that interventions were in place to offer the resident assistance with dressing himself, but she was not sure what other interventions were in place related to the resident's behaviors. During an interview on 08/28/2025 at 9:25 AM, Licensed Practical Nurse (LPN) 15 stated any reports of resident behavior toward another resident or involving another resident were to be reported to the SSD, and resident behaviors were to be documented every shift. LPN15 noted she was familiar with R72 and had observed the resident in the hallway with no shirt on a time or two. LPN15 indicated that to her knowledge, no residents had reported sexual behaviors involving R72. During a telephone interview on 08/28/2025 at 3:08 PM, the Psychiatric-Mental Health Nurse Practitioner (PMHNP) revealed she was informed by the facility on 08/26/2025 (the day of surveyor intervention), that R72 was displaying inappropriate sexual behaviors, but she had never witnessed the behaviors herself. The PMHNP stated R72 had ritualistic behaviors, such as taking off all his clothing to go to the bathroom, using a certain amount of paper towels when performing personal hygiene, or washing his hands a certain number of times, and if he was not allowed to do that, he got frustrated. The PMHNP stated she would expect facility staff to report and document any resident behaviors. During a telephone interview on 08/28/2025 at 4:05 PM, the SSD stated she participated in the facility's behavior management program, and resident behaviors were reviewed as part of the IDT behavioral meetings. The SSD was familiar with R72, saying the resident displayed impulsive and ritualistic behaviors daily. The SSD stated R72 had behaviors specific to toileting and personal hygiene, such as removing all his clothing before going to the bathroom and washing his genitals in the room sink. The SSD confirmed that on 08/25/2025, R64 reported to her that the previous day (08/24/2025). the resident witnessed R64 masturbating in the room but added that the resident was not completely sure if R72 was masturbating or not. The SSD stated the behavior was not reported to her by any other staff members. The SSD also stated she was not aware that any other residents had concerns related to R72 being naked in their room. During an interview on 08/29/2025 at 8:01 AM, CNA22 stated she was familiar with R72 and that his former roommates had reported R72's had a behavior of washing his genitals in the room sink; however, she did not witness this behavior. Further interview with CNA22 revealed she was assigned to the resident on 08/25/2025. CNA22 stated she received a report from R64, explaining that R72 was undressing in the room in front of him, and R64 wanted R72 out of the room. CNA22 stated the incident was reported to LPN8. During an interview on 08/29/2025 at 2:58 PM, LPN8 stated she worked on R72's unit on 08/25/2025, and no behaviors were reported to her. LPN8 stated R72 had ritualistic behaviors related to personal hygiene and would sometimes remove his clothing to perform personal hygiene at the sink in the room; however, she was not aware of any resident complaints related to R72's behaviors. During an interview on 08/29/2025 at 4:46 PM, LPN6 stated residents would normally have orders in their electronic chart to monitor behaviors. LPN6 also stated she would expect nursing staff to document any increase in the resident's behaviors, or any new behaviors displayed. LPN6 stated she was familiar with R72, and related she was not aware of any behavior related to the resident removing his clothing. LPN6 indicated that to her knowledge, no residents reported sexual behavior involving R72 or behavior related to the resident removing his clothing, as she stated staff had not reported any of these behaviors to her. During an interview on 08/29/2025 at 5:22 PM, the facility's Medical Director stated he was familiar with R72, adding that the resident liked to get naked, much to the chagrin of his roommates. Per the Medical Director, there had been mention of some masturbatory behaviors; however, nothing was documented to his knowledge. The Medical Director stated that ideally, R72 would have a private single room, and he would expect facility staff to redirect the resident if he was displaying behaviors. The MD also stated he would expect facility staff to document any masturbatory behaviors. During an interview on 08/29/2025 at 6:02 PM, the Director of Nursing (DON) stated resident behaviors should be monitored in accordance with the facility policy. The DON then stated the facility did not have a policy related to monitoring of resident behaviors. The DON stated she would expect nursing staff to document resident behaviors and any escalation in those behaviors as needed. The DON described the purpose of monitoring was to know what changed in the behavior, what new behaviors were present, and what behaviors were worsening. The DON stated that with that data, they could make sure the resident's physician was aware, and care plan interventions could be addressed by the IDT. During an additional interview on 08/29/2025 at 6:06 PM, the Administrator stated resident behaviors would be evaluated in the IDT meeting, and facility staff could chart and communicate any increase in resident behaviors. The Administrator stated that on 08/28/2025, an additional privacy curtain was installed around the sink in R72's room in case he decided to remove his clothing at the sink. Further interview with the Administrator revealed he could not state why this intervention was not put into place prior to 08/28/2025 (after surveyor intervention).

Based on interview, record review, and facility document review, the facility failed to assist with/provide medically related social services for one (Resident (R) 23) of one sampled resident reviewed for appointments and referrals. The facility failed to ensure follow-up appointments and referrals were made and/or kept as needed for R23. Findings included: Review of a Central Supply Staff job description revealed the duties included, Assist with Nursing Department activities to include administrative support; assist residents, families, and visitors, and running errands to include travel to supply sources, as well as other special projects and duties, as assigned. Review of a Resident Face Sheet revealed the facility admitted R23 on 09/10/2024. According to the Resident Face Sheet. the resident had a medical history that included diagnoses of difficulty in walking, unsteadiness on feet, and muscle weakness. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2025, revealed the facility assessed R23 to have a Brief Interview for Mental Status (BIMS) score of 15/15. This score indicated the resident had intact cognition Review of R23's Care Plan revealed a problem statement, edited 08/20/2025, that indicated that the resident, relative, or representative expressed their wish for the resident to remain in the facility for long term care. Interventions directed staff to provide services according to the plan of care in an effort to enhance optimum wellbeing and prevent hospitalizations. a. Review of R23's Progress Notes, dated 03/12/2025, revealed new orders were received to schedule an orthopedic referral. Additional review of Progress Notes, dated 04/08/2025, revealed the resident returned from an orthopedic appointment and had a follow-up appointment scheduled for May. b. Review of R23's Progress Notes, dated 04/23/2025, revealed the resident went out to a nephrology appointment and returned with referrals for cardiology and hematology. Additional Progress Notes, dated 07/12/2025, also noted the resident had an order for a hematology referral. Review of the resident's record revealed no evidence that the resident was seen by a physician for the follow up appointment or that the referrals were acted upon. During an interview on 08/25/2025 at 11:08 AM, R23 stated that they were told that until they were released by orthopedic, they would not receive therapy services at the facility. R23 stated there was an insurance issue, and the facility was supposed to reschedule the orthopedic appointment but that was months ago. During an interview on 08/28/2025 at 12:51 PM, the Central Supply/Transporter (CS) stated she thought R23 went back to the orthopedic appointment in 05/2025; however, she was not sure if the resident was seen by the doctor. She stated that she knew there was an insurance issue, and she failed to follow up with the resident to see if they had new insurance or try to find a doctor that would accept the resident's insurance. The CS confirmed that she had not followed up and rescheduled the orthopedic appointment for the resident. Further interview with the CS revealed she did not know about the referrals for hematology or cardiology. She stated normally she would have the resident's face sheet and referrals in a binder when she sent in the request for appointments, but she had no documentation for R23 to be referred to orthopedic, cardiology, or hematology in the binder. The CS stated that once appointments were made, they were then placed in the appointment binder at the nurses' stations. The CS stated she had no documented evidence to prove she had attempted to make R23's appointments. During an interview on 08/29/2025 at 12:18 PM, Registered Nurse (RN) 5 stated that if a resident needed to be referred for an appointment, they filled out a paper and put it in the binder. She stated the CS was then notified, and the nurses made a note in the resident's chart. During an interview on 08/29/2025 at 12:51 PM, Licensed Practical Nurse (LPN) 12 stated that appointments were placed in the appointment book. She stated the CS then gathered the information. During an interview on 08/29/2025 at 5:43 PM, the Director of Nursing (DON) stated she expected her staff to make appointments immediately once referred and if there were any issues to let her know. She stated that she expected the CS to follow up if there was an issue to ensure the residents were going to their appointments. She also expected that, if needed, the CS would try to find another doctor that accepted the resident's insurance. Further interview with the DON revealed that the facility did not have a policy on making appointments. During an interview on 08/29/2025 at 5:53 PM, the Administrator stated he expected the staff to schedule appointments in a timely manner. He stated he also expected staff to document the appointments.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5% (percent). There were 4 errors in 32 opportunities, for a medication error rate of 12.5%. This affected 4 out of 5 residents observed for medication pass, Residents (R)68, R69, R87, and R95. The findings include: Review of the facility policy titled, Medication Administration General Guidelines, dated 09/2018, revealed, 1. Medications are administered in accordance with written orders of the prescriber. 5b. Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. 1. Review of R69's Resident Face Sheet, located in the medical record, revealed the facility re-admitted the resident on 04/08/2025 with diagnoses including Alzheimer's disease. Review of R69's Medication Administration Record (MAR) for the timeframe from 08/01/2025 to 08/26/2025, revealed a physician's order was included for delayed release/enteric coated aspirin, 81 milligrams (mg), 1 tablet to be given once a day. Observation on 08/26/2025 beginning at 8:23 AM, revealed Licensed Practical Nurse (LPN)18 was preparing medication for R69. LPN18 crushed all the resident's medications, including the enteric coated aspirin, and committed to giving the crushed aspirin by placing all the crushed medications into a cup together. LPN18 stated the enteric coated aspirin did not have a warning label stating not to crush, and she had no access to a list of medications that should not be crushed. After crushing all the medications together, LPN18 reviewed the card for the enteric coated aspirin and commented, It says not to crush. At this point, LPN18 threw all the medications away and then started over. She stated R69 was able to take medications whole but would only take a few at a time. This was medication error #1. 2. Review of R95's Resident Face Sheet, located in the medical record, revealed the facility readmitted the resident on 08/13/2025 with diagnoses including type 2 diabetes mellitus. An instruction pamphlet for the Novolog FlexPen, revised 02/2023, revealed an air shot should be given before each injection. The pamphlet revealed this was to avoid injecting air into the resident and to ensure proper dosing. Instructions for completing the air shot included, Turn the dose selector to 2 units. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A dose of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. Observation on 08/26/2025 beginning at 10:53 AM, revealed LPN10 completed a fingerstick blood sugar test on R95 with results of 293 milligrams per deciliter (mg/dL). The nurse then removed a Novolog FlexPen with 100 units/ml and turned the dial on the Flexpen to 12 units. LPN10 attached the needle to the end of the pen and administered the insulin to R95's upper right arm. The insulin pen was not primed before administration of the insulin. This was medication error #2. During interview with LPN10 on 08/26/2025 at 11:03 AM, she stated she had not been taught to prime the insulin pen before administering insulin. LPN10 stated she had completed nursing school recently and had not been taught to prime the pen during that time either. LPN10 stated she was unaware the insulin pen needed to be primed before administering the insulin. During interview with the Director of Nursing (DON) on 08/27/2025 at 3:54 PM, she stated she taught nurses to prime insulin pens before administering insulin to ensure the resident received the ordered dose of insulin. The Administrator was interviewed on 08/29/2025 at 6:03 PM, and stated he expected nursing staff to follow manufacturer's guidelines for the insulin pen. 3. Review of R68's Resident Face Sheet, located in the medical record, revealed the facility admitted the resident on 08/12/2025 with diagnoses including chronic obstructive pulmonary disease and hypertension. Review of R68's MAR, with active orders for 08/2025, revealed an order for diltiazem extended-release capsules, 240 milligrams (mg), administer two capsules once a day. An observation was made on 08/27/2025 beginning at 7:49 AM, of LPN17 preparing medication to be administered to R68. LPN17 placed one capsule of diltiazem into the medication cup and then picked up another medication card and placed that medication into the cup. After the nurse had committed to giving the diltiazem, she was asked what dosage the resident was to receive. LPN68 read the label again and acknowledged R68 should receive two tablets of the diltiazem. This was medication error #3. Interview was conducted with LPN17 on 08/27/2025 at 7:58 AM. She stated she should have double checked the dosage of diltiazem that R68 was ordered to receive. 4. Review of R87's Face Sheet, located in the medical record, revealed the facility re-admitted the resident on 11/09/2023 with diagnoses including chronic obstructive pulmonary disease and an adjustment disorder with mixed anxiety and depressed mood. Review of R87's Medication Administration Record (MAR) with physician's orders active for 08/2025, revealed an order for buspirone (a medication to treat anxiety) 5 milligrams (mgs), give 10 mgs three times a day orally (started 06/13/2025). An observation was made on 08/27/2025 beginning at 8:30 AM of Registered Nurse (RN)11 preparing medications for R87. RN11 removed a medication card from the medication cart that read buspirone 5 mg and placed one tablet into the medication cup and placed the card back into the medication drawer, therefore committed to giving the resident one tablet (5 mg) of the buspirone. After the medication card was returned to the medication cart, RN11 was stopped, and a request was made that she read the medication label again. After reading the label, the nurse placed another tablet of the buspirone into the medication cup and stated she would have reviewed the medications again and would have caught her error. This was medication error #4. Interview was conducted with the Director of Nursing (DON) on 08/27/2025 at 1:39 PM, and on 08/27/2025 at 3:44 PM. The DON stated medication pass observations were not completed yearly on each nurse and were only completed when there was a need. She stated when preparing medications, she expected the nurses to follow the five rights of medication administration, which included giving the right dosage of medication. The DON further stated she expected the nurse to check the MAR against the medication label. The Administrator was interviewed on 08/29/2025 at 6:03 PM and stated he expected nurses to administer medication based on facility policy and best practice. The Administrator further stated he also expected the nurses to follow the pharmacy recommendations.

Based on observation, interview, facility document review, and facility policy review, the facility failed to accommodate food preference for one (Resident (R) 97) of five sampled residents reviewed for food preferences. The facility repeatedly served R97 food which did not honor the resident's identified preferences.The findings included: Review of the facility's policy titled, Resident Food Preferences, last revised on 01/31/2025, revealed, Nutritional assessments will include an evaluation of individual food preferences. The policy also noted that, 4. The resident's clinical record will have documented preferences. Review of a Face Sheet revealed the facility admitted R97 on 05/18/2024. According to the Face Sheet, the resident had a medical history that included a diagnosis of moderate protein-calorie malnutrition. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2025, revealed the facility assessed R97 to have a Brief Interview for Mental Status (BIMS) score of 14/15. This score indicated the resident was cognitively intact. Review of the Monthly Grievance Log for 06/2025 revealed an entry, dated 06/05/2025. Further review revealed R97 had a grievance concern related to food preferences. Review of the Complaint/Grievance Report, dated 06/05/2025, revealed R97 verbally communicated to the facility's Social Services Director (SSD) concerns related to receiving food she did not prefer. The investigation was then assigned to the Dietary Manager (DM) on 06/05/2025. The report noted the findings of the investigation included that, when speaking with the resident, they addressed concerns with food items not liked. The report stated the expected results of actions taken included the resident was to receive items she preferred. Further review of the Monthly Grievance Log for 06/2025 revealed the resolution to R97's grievance included updating the resident's food preferences. Further review revealed the resident was notified of the resolution on 06/09/2025. Review of R97's Physician Order Report, for the timeframe from 07/28/2025 through 08/28/2025, revealed a diet order, dated 06/03/2025. The order was for a regular diet with special instructions to send fortified foods with all meals. Review of R97's current Food Preference Assessment, revealed R97 had food dislikes, which included Oatmeal Cereal. This dislike was added on 12/11/2024. During an interview on 08/25/2025 at 11:34 AM, R97 stated she was served oatmeal for breakfast on a regular basis; however, the resident stated, she could not eat oatmeal because it made her sick. R97 stated she told someone in the cafeteria about it, but could not recall the date when the facility was notified or the name of the person she notified. During observation on 08/26/2025 at 7:43 AM, R97 was in her room during breakfast. R97's meal included a bowl of oatmeal, as well as a plate of scrambled eggs with cheese, biscuit with jelly, and a bowl of dry cereal. R97 stated she did not want the oatmeal on her tray. During an interview on 08/28/2025 at 8:14 AM, R97 stated she again received a bowl of oatmeal on her breakfast meal tray that morning. During a telephone interview on 08/28/2025 at 3:57 PM, the SSD stated any facility staff could file a grievance for a resident, but some residents would request to speak with her specifically regarding their concerns. Further interview revealed that complaints about food preferences would then be assigned to the dietary department. The SSD stated she remembered speaking to R97, who voiced concerns related to receiving food items she did not like. The SSD related that the grievance about food preferences was assigned to the dietary department, and R97's food preferences were updated. The SSD stated she was not aware of any further concerns related to R97's food preferences. During an interview on 08/29/2025 at 10:36 AM, the DM stated residents had a choice of food they could receive on their meal trays, and the choices were documented on the resident's meal preferences sheet. The DM added that R97 received fortified oats in the morning because the resident ate them when she was first admitted to the facility. The DM stated she was not aware R97 did not like oatmeal, and the resident received fortified oats because she had an order for fortified foods. Further interview with the DM revealed that fortified oats were not the only option the facility had to offer, and R97 could receive other fortified items, including milk, grits, or cream of wheat, instead of oatmeal. During an interview on 08/29/2025 at 3:19 PM, Certified Nursing Assistant (CNA) 19 stated that if a meal tray was served to a resident and the resident had a concern with the meal, staff were to offer the resident an alternative meal choice and let the dietary staff know so the resident's meal preferences could be updated. CNA19 confirmed R97 was served oatmeal during breakfast, and she would let the kitchen know the resident did not like oatmeal, adding that she could not remember the last time the resident voiced this concern to her. During an interview on 08/29/2025 at 6:18 PM, the Director of Nursing (DON) stated if a resident expressed concern about food preferences, she would expect the staff to offer the resident an alternative option and communicate the concern to the dietary staff if the resident continually received an item they did not want. During an interview on 08/29/2025 at 6:21 PM, the Administrator stated he would expect a grievance form to be filled out if a resident communicated a concern related to food, which would then go to the DM. The Administrator also stated if a resident received food items they did not like, he would expect the resident's food preferences to be updated.

Based on observation, interview, record review and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices to protect them from accidents and injury for 2 of twenty sampled residents (R) ( R29 and R41). 1. On 06/25/2024, R41 stated he had fractured his right leg two times since residing at the facility, once in 2020, and again in 2022. Per R41, the first time occurred when he was being transported in his wheelchair to be weighed without the right foot pedal being on the wheelchair. He stated his leg got tired and dropped and was pulled under the wheelchair. The first incident resulted in R41 sustaining a fracture to his right distal femur. The second incident happened during a transfer from his bed to the wheelchair when he was going to a physician's appointment. He stated the two (2) Certified Nurse Aides (CNA) assisting him did not use a gait belt and rushed him during the transfer. He stated as he transferred, the wheelchair brakes were not on and he was only sitting on the edge of the seat and the wheelchair kept going backwards. The resident stated his leg twisted during the incident. The second incident resulted in a right tibial fracture. 2. On 04/05/2023, R29 was transferred from the bed to a shower chair and back to bed after the shower without using a mechanical lift as per the resident's care plan. On 04/10/2023, staff were getting R29 ready for a shower and noticed both of the resident's upper arms had yellow/purple bruising and bruising. A portable X-ray report noted R29 had bilateral (left and right) humeral (upper arm bone) neck fractures. The resident was transferred to the hospital, where the bilateral humeral neck fractures were confirmed. Refer to F656 The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 06/29/2024 at 9:31 AM, alleging removal of the Immediate Jeopardy (IJ) on 04/18/2023, prior to the State Survey Agency's (SSA's) survey and investigation. The SSA validated the facility's IJ Removal Plan, on 06/29/2024 at 4:00 PM, and determined the deficient practice was corrected as alleged on 04/18/2023, prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Resident Rights, revised 09/15/2023, revealed all residents had the right to be treated with respect and dignity. Continued review revealed the facility was to promote and protect the rights of the residents. Further review revealed resident rights included providing all residents with a manner and environment that promoted maintenance or enhancement of quality of life. Review of the facility's, Certified Nursing Assistant (CNA) Job Description, revised December 2011, revealed the CNA was to perform direct care duties under the supervision of licensed nursing personnel and assist with promoting a compassionate physical and psychological environment for the residents. Continued review of the CNA's performance standards in the following areas, such as Essential Duties and Responsibilities, included the CNA to ambulate and transfer residents, utilizing appropriate assistive devices and body mechanics. 1(a). Review of R41's admission record revealed the facility admitted the resident on 12/18/2017, with diagnoses of acquired absence of left leg above knee, diabetes mellitus with diabetic neuropathy, muscle weakness, and limitation of activities due to disability. Review of R41's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/26/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. Continued review of R41's MDS Assessment revealed the resident's functional status for locomotion on the unit revealed the facility assessed that activity to have not occurred. Per the MDS Assessment review the facility assessed R41's (ADL) support as family and/or non-facility staff provided care 100% of the time over the entire 7-day period. Further review revealed the facility assessed R41's locomotion off the unit for self-performance as the activity occurred once or twice with one-person physical assist (with self-sufficiency once in wheelchair). Review of R41's Care Plan, dated 08/31/2020, revealed the facility added an intervention to place the right foot petal on the wheelchair prior to transportation needs for right leg. Review of R41's Care Plan revealed the facility added a problem for ADL functional status on 02/01/2023, for transfers for the resident to have extensive assist X2 (times two) staff with use of a sliding board. Continued review revealed after the first incident in 2020, the facility added the right foot pedal to the wheelchair at all times intervention. Review of the facility's Event Report dated 08/29/2020, noted by Registered Nurse (RN 5) revealed an incident occurred at 2:45 PM (on that date) involving R41. The resident sustained an injury to the right knee while being transported. Continued review revealed the leg was extended during transportation under the wheelchair. The Certified Nursing Assistant (CNA) had stated the resident was being wheeled down the hall, and resident had been asked to keep the leg up and to let the CNA know if his leg became tired. Further review of the Event Report revealed the CNA said the resident did not say anything but suddenly let the leg fall causing the leg to jerk back under the wheelchair, overextending the right leg. Further review revealed the Physician was contacted and an order was obtained for an x-ray and to add the right leg pedal to the wheelchair. Review of R41's Progress Note dated 08/29/2020 at 4:04 PM, documented by RN 5, revealed awaiting mobile x-ray of right knee. Further review revealed the resident had been given pain medication with effective relief for right leg pain. Review of the mobile x-ray report of R41's right leg dated 08/29/2020 at 7:59 PM, revealed no acute fracture or dislocation seen. However, a small joint effusion and diffuse osteopenia were noted. Review of the Progress Note dated 09/01/2020 at 2:55 PM, revealed R41 had complaints of right knee pain. Continued review revealed the physician was notified and an order for Tramadol (medication for moderate to severe pain) every six hours and an order for a Computed Tomography (CT) scan. Review of the CT imaging report dated 09/08/2020, revealed R41 had an insufficiency fracture of the distal right femur, and recommendations for an x-ray to confirm the results. Continued record review revealed a progress note dated 09/08/2020, documenting R41 was sent to the Emergency Department (ER) for the x-ray to be performed. Review of the hospital x-ray report dated 09/08/2020, revealed R41 had a fracture of the distal right femur meta-diaphysis (shaft portion of the long bone) above the prosthesis with impaction, a 2-centimeter gap between the fracture fragments and medial subluxation (partial dislocation) of the proximal femur. Review of the hospital nursing progress note dated 09/08/2020, revealed the resident was placed in a right knee immobilizer and new medications were prescribed. During interview with R41 on 06/25/2024 at 11:25 AM, the State Survey Agency (SSA) Surveyor asked about the resident's right leg fracture and he stated, Which time? They broke my leg twice. R41 stated the first time the CNA, (whose name started with A), came to get him from the day room on the East Wing to weigh him. He stated his wheelchair would not go through the door to the area where the scale was located due to the anti-tippers (device to keep a wheelchair from tipping over backwards) on his wheelchair. R41 said the CNA proceeded to take him over to the [NAME] Wing to weigh him there. In continued interview, R41 stated after being weighed when the CNA was taking him back to his room his leg became tired and before he could tell the CNA, his leg dropped. He stated when his leg dropped it resulted in the leg being pulled under the wheelchair. During an interview on 06/27/2024 at 4:04 PM, LPN 4 stated CNA3 had informed her that while pushing R41 in the wheelchair, the resident's leg dropped and went backwards under the wheelchair. LPN4 stated she contacted LPN 3, who was the Unit Coordinator at that time, and the resident's representative (RP). LPN4 further stated she could not recall if CNA3 was placed on leave after the incident. During interview with the Director of Nursing (DON) on 06/27/2024 at 4:10 PM, she stated CNA3 was the staff person transporting R#41 during the first incident. The DON stated RN5, who had written the progress note, passed away. She stated no investigation or report was made to the State Survey Agency (SSA) or any other entity due to the fact the facility knew how the incidents involving R41 happened and it had not been a reportable incident. However, later in another interview on 06/29/2024 at 2:50 PM, the DON stated the facility had completed an investigation, but that information was to be in the IJ Removal Plan to be provided to the SSA. Review of CNA3's employee file revealed the facility hired the CNA on 10/11/2019, and had performed a background check and completed an Adult Caregiver Misconduct Registry review with no issues. Further review revealed no documented evidence of education provided or of any reprimands. A telephonic (phone) interview was attempted to contact CNA3 on 06/22/2024 at 9:42 AM. However, she was unsuccessful as the person who answered stated the SSA Surveyor had the wrong number. 1(b). Review of the facility's policy titled, Gait Belts, dated 03/2011 revealed staff providing direct care to residents might use a gait belt during ambulation, transfer, or movement of residents. Further review of the policy revealed all CNA's, licensed nurses and therapists received education related to gait belt use during their schooling related to their licensure or certification. In continued interview on 06/25/2024 at 11:25 AM, R41 stated the second time his leg was broken two male CNAs were transferring him from his bed to the wheelchair as he was going out to a physician's appointment. The resident said with the assistance of two persons he could use a slide board to transfer. R41 stated the two male CNAs who were assisting him were rushing him to transfer that day and did not use a gait belt. He stated during the transfer the one CNA was behind the wheelchair, with the other in front of him and his wheelchair wheels were not locked. Per R41, as he was transferred he was only sitting on the edge of the seat, and the CNA behind him put his arms around R41's chest to try to pull him back, but the wheelchair kept moving. He stated the CNA in front of him was trying to hold him (R41) by his wrists to get him back onto the wheelchair, and his leg twisted somehow during the incident. Review of R41's Progress Note, dated 04/22/2022 2:42 PM, documented by LPN 8 revealed the resident returned from an appointment with complaints of discomfort to the right knee. Continued review revealed R41 stated he pivoted wrong this am when getting into w/c. MD notified, awaiting orders. Review of the physician's order, dated 04/22/2022, revealed at order to send R41 to the hospital for evaluation of discomfort to the right knee. Review of the Hospital Discharge Summary, dated 04/23/2022 revealed R41 arrived at the ED on 04/22/2022 at 10:22 PM, and was discharged back to the facility on [DATE] at 12:35 AM. Per review of the Summary, the mechanism of trauma was noted as a fall or jump, and under the comment section, Patient arrived from facility via Emergency Medical System (EMS) with chief complaint of no pulse in right foot and blue toes on right foot per facility nurse. Continued review revealed patient (R41) stated his right foot has had purple appearance with petechiae on right great toe like this for about 1 week. Further review revealed patient stated he was going to an appointment this morning from the nursing home, and the aides who had been assisting him transferred him to the wheelchair too quickly and he went backwards. Review of the hospital x-ray report dated 04/22/2022, revealed a fracture of R41's anterior right tibial (bone in the lower leg) tubercle measuring 2 1/2 by 0.7 centimeters. Additional review of the Hospital Discharge Summary dated 04/23/2022, revealed the final diagnosis for R41 was a displaced fracture of the right tibial tuberosity. Review of the Interdisciplinary Team (IDT) note dated 04/23/2022 at 3:11 PM, revealed the IDT met to review R41's plan of care. Per review of the IDT note, R41 was transferred to the wheelchair yesterday via two person assist with a gait belt and transfer board to go out to an appointment. Continued review revealed when R41 returned from the appointment, he stated his knee was hurting and he thought something was wrong. Review revealed R41 stated when the two CNA's transferred him yesterday, his leg caught on the floor and twisted. Per review of the IDT note, R41 had no initial complaints of pain; however, the knee was noted to be swollen and the resident later complained of pain in the knee. Review revealed R41 was sent to the Emergency Department ( ED) for evaluation, and treatment, and was diagnosed with right tibial fracture. The review of the IDT note revealed Physical Therapy (PT)/Occupational Therapy (OT) were to evaluate and treat. Additional review revealed care plan interventions were added for a pain assessment every four hours, and new pain medications. Review of the facility's Event Report dated 04/23/2022 at 3:09 PM, completed by prior DON, revealed an incident occurred on 04/22/2022 at 10:06 AM, in which R41 sustained a right tibia fracture during transfer when preparing to go to an appointment. Continued review revealed R41 was sent to the hospital for evaluation. Review of CNA1's witness statement located in the facility's investigation documentation, dated 05/03/2022, revealed the CNA noted, We were transferring the resident very gently and slowly because he likes to move slowly with transfers. Then just out of nowhere during the transfer he just dropped his weight. We didn't do anything to him, he just dropped down like he was trying too purposely. Review of CNA2's witness statement, dated 05/05/2022 revealed, During a transfer of a man, I was helping CNA 1 [sic]. We were just transferring the guy and in the middle of it he kind of jerks and sits down in the air. We kept ahold of him though. He just out of nowhere tried to sit down, but we were doing good and had a good transfer. . Review of the employee file for CNA1 revealed his date of hire was 09/14/2021 as a CNA. Further review revealed the facility performed a background check and a check of the Adult Caregiver Misconduct Registry with no issues. Review of the employee file for CNA2 revealed he was hired as a Hospitality Aide on 12/01/2020, and on 03/07/2022, he became a Personal Care Assistant (PCA). Further review revealed the facility performed a background check and a check of the Adult Caregiver Misconduct Registry with no issues. Review of the facility's Personal Care Aide (PCA) job description, undated, revealed the PCA could assist with transfers from bed to chair or wheelchair with use of a gait belt, for one person standby assist/transfer. Further review revealed for anything beyond a one-person transfer, the PCA might only assist and must be directed by a certified/licensed staff member. During an telephonic (phone) interview on 06/27/2024 at 9:20 AM, with CNA 1 he stated that he did recall transferring R41 from the bed to wheelchair using a slide board. CNA 1 stated, I gave my report to them during their investigation He stated he had not used a gait belt during the transfer because I didn't have to, it wasn't called for. CNA 1 further stated he was not aware R41's leg was injured initially, and then stated, I need to hang up now and ended the call. A phone attempt was made to contact CNA 2 on 06/27/2024 at 9:29 AM. However, it was unsuccessful as the number provided by the facility was a wrong number. No other number was provided by the facility. During an interview on 06/27/2024 at 10:30 AM with the Director of Rehabilitation (DOR), she stated she was not at the facility during the first incident in 2020, but did recall the 04/22/2022 incident. She stated R41 was a slide board transfer with minimal assistance from 01/22/2022 through 04/22/2022. The DOR stated after the incident on 04/22/2022, and returning from the hospital stay R41 had been a (mechanical) lift transfer for a short time. She stated when Physician's Orders were received for R41 to be weight bearing on the right leg, Physical Therapy (PT) saw the resident from 05/31/2022 through 09/15/2022. According to the DOR training/education was provided to all staff in 05/2022 that consisted of transfer training. The DOR further stated gait belts were usually not specified on the resident's care plan, but gait belts were a standard of care when transferring residents. 45113 3. Review of the facility's policy titled, Mechanical Lifts, dated 06/01/2015, and revised on 12/07/2023, revealed the policy was regarding safely transferring residents with mobility limitations using a mechanical lift to prevent falls and injuries from transfers. Continued policy review revealed provisions for general guidelines and procedural steps, including staff being alert for any resident requiring or needing a mechanical lift device upon admission and throughout the resident's stay for transfer needs. Further review of the policy revealed each certified nurse aide, licensed nurse, or licensed therapist utilizing a mechanical lift was to receive training on the proper use of the mechanicals as part of their schooling, during which they received certification or licensure. Review of the facility's guidelines and procedures revealed the mandatory training module titled, Day 1: New Hire Orientation: All Aides Competency-Full Body Lift Bed to Wheelchair undated, revealed Guideline #1, which instructed all aides to check the care plan and make sure to transfer a resident in accordance with the care plan. Review of R29's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 02/29/2016, with diagnoses to include dementia, adult failure to thrive, multiple sclerosis (MS), age-related physical debility and osteoporosis without current pathological fracture. Review of R29's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/14/2023, revealed the facility assessed the resident as being unable to interview and as rarely or never understood. Continued review of the MDS Assessment revealed the facility also assessed R29 as totally dependent on two staff for transfers. Review of R29's Comprehensive Care Plan (CCP) dated 12/21/2022, revealed the facility developed a focus on Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential Profile Care Guide for the resident. Continued review revealed for transfers the interventions included the resident requiring total dependent care from two staff assistants, using a mechanical lift, staff to use the green lift sling. Review of the Mechanical Lift Evaluation dated 12/21/2022, revealed the facility assessed R29 for the correct sling size to use: the green lift sling with mechanical lift, referenced in the care plan for staff awareness. Review of the Nurse Aide Care Plan found in R29's EMR under the Reports tab for the resident's ADL status on the Plan of Care (POC), specific to transfers revealed the resident required total care with two (2) staff assist, a mechanical lift with the use of a green lift sling for transfers. Further review revealed that intervention was noted and tagged to the Kardex (Nurse Aide Care Plan) from R29's comprehensive care plan intervention initiated on 12/21/2022. Review of the facility's Stop and Watch documentation revealed a change in R29's skin color or condition, dated 04/07/2023 at 9:54 PM, completed by Registered Nurse (RN) 3. Further review revealed the resident's skin color was lighter on the left arm/hand and very weak. Review of R29's Progress Note, dated 04/07/2023 at 11:37 PM, completed by RN3, revealed CNA 7 reported the resident's left arm was weaker. Continued review revealed RN 3 observed R29 and noted it appeared the resident was not using the left arm. In addition, review of the Note revealed RN3 notified the physician and received an order for Occupational Therapy (OT) to evaluate and treat R29. Review of R29's Progress Note, dated 04/10/2023 at noon (late entry), revealed the nurse (RN4) was told by staff that R29 was in pain. Continued review revealed x-rays were ordered for R29's shoulders, and the results were pending. Further review revealed the nurse gave R29 650 mg of acetaminophen for pain with some relief noted. Review of the facility's Initial-Self-Reported Incident Form, dated 04/10/2023 at 7:38 AM, completed by the former Administrator, revealed on that date stakeholder (CNA7) observed at approximately 6:00 AM-7:00 AM, during R29's bathing, bruising of unknown origin to the resident's bilateral upper extremities (BUE) and left clavicle. Continued review of the Form revealed nurses completed a full skin assessment and a pain assessment and identified no further issues. Review further revealed immediate notification was made to the physician, resident's responsible party (RP), State Agencies and an investigation was initiated. Review of RN3's Witness Statement dated 04/10/2023, located in the facility's investigation documentation, revealed the Nurse Aide (CNA7) called the RN to the shower room on 04/10/2023 at approximately 5:00 AM. RN3 noted she observed R29 in the shower chair and observed discoloration to the resident's bilateral upper arms. Continued review revealed RN3 documented on 04/10/2023 at 5:08 AM, she notified the Assistant Director of Nursing (ADON) of her observation of R29, and the ADON stated she was on her way to the facility to assess the resident. Per review of RN3's Witness Statement, at approximately 6:49 AM, she received a physician's order for bilateral shoulder x-rays related to her observation and assessment of R29's shoulders which were swollen. Further review revealed RN3 also noted she left a message with R29's RP to call the facility. Additional review revealed after R29's shower, CNA7 and CNA9 transferred the resident back to bed using a mechanical lift, as ordered, and a head-to-toe assessment was completed by the ADON and an investigation initiated. Review of CNA7's Witness Statement, dated 04/10/2023, located in the facility's investigation revealed she cared for R29 on Friday, 04/07/2023, Saturday, 04/08/2023, and Sunday, 04/09/2023. Continued review revealed on Friday night (04/07/2023), CNS7 noticed R29's left arm and hand were significantly weaker; therefore, she filled out a Stop and Watch with the nurse. Per review of the witness statement, CNA7 noted she did not notice any skin discoloration, bruising, or swelling, nor had the resident exhibited any signs of pain. Per review of the Witness Statement, she cared for R29 on Saturday (04/08/2023), and did not notice anything out of the resident's baseline. Further review of the Witness Statement, revealed on Monday morning, (prior to the end of her shift) when she took R29 to the shower room to bathe the resident she observed bruises on both R29's arms above the bends of her armpits. In addition, she stated she also noticed R29's shoulders were swollen, and the resident cried out in pain, so she immediately notified the nurse. Review of CNA4's Witness Statement, dated 04/12/2023, located in the facility's investigation revealed the CNA reported having been asked to assist CNA8 in transferring R29 for the shower task to be completed. Continued review of the Witness Statement revealed CNA4 reported assisting R29 to sit on the side of the bed and then completed a manual (without the use of the mechanical lift) transfer. Further review revealed following R29's shower, CNA4 noted he and CNA8 utilized the (mechanical) lift to assist in getting the resident back to bed. Review of CNA8's Witness Statement dated 04/14/2023, revealed she had been assigned to shower R29 on 04/05/2023, which she performed closer to the end of her shift. Continued review of the Witness Statement revealed CNA4 came to assist her with R29's transfer from the bed and CNA4 sat the resident up on the side of the bed and performed a manual transfer, without using the mechanical lift. Further review revealed CNA8 reported she showered R29, and when she was finished, CNA4 helped the resident back to bed, doing another manual transfer. Review of the facility's Final Report-Incident Summary dated 04/15/2023, revealed on 04/10/2023, between 5:30 AM and 6:00 AM, CNA (7) was getting R29 ready for a shower and noticed both upper arms had yellow/purple bruising and bruising around the clavicle. Continued review revealed a portable x-ray revealed left and right humeral neck fractures, and R29 was sent to the hospital, where they confirmed bilateral humeral neck fractures. Further review revealed R29 was sent back to the facility with a sling and to continue on the pain medications. Additional review revealed the Administrator reported the injury of unknown origin to all State Agencies and parties timely. Review of the facility's Final Report-Fracture Investigation dated 04/15/2023 revealed that on 04/05/2023, CNA8 requested help to get R29 up with the lift, and a CNA (CNA 4) assisted CNA 8. Per review, although the lift was in the room, CNA 4 manually lifted R29 from the bed to the shower chair and returned the resident to the bed after the shower the same way. Contiuned review revealed the outcome of the facility's fracture investigation revealed the fractures occurred from the actions performed by CNA4. Additionally, R29 was not gotten up any other time until 04/10/2023 when staff observed the bilateral bruising to upper arms and clavicle. Review of the facility's Final Report-Conclusion, dated 04/15/2023, revealed the facility determined R29's fractures were caused when she was moved manually and not with the mechanical lift as required. Per review, during CNA 4's interview, he acknowledged he moved R29 manually and had not used the mechanical lift. Continued review revealed CNA4 was suspended initially, but terminated after that based on his personal decision to move R29 manually and not follow the resident's care plan. In addition, however, the facility acknowledged staff (CNA4) did not follow the care plan related to transfers caused R29's fractures. Review of R29's facility portable Radiology Report, dated 04/10/2023 at 6:32 PM, completed on the resident's left and right shoulder revealed Recent Left and Right Humeral Neck Fracture. Further review of R29's Progress Note dated 04/10/2023 at 7:36 PM, completed by Licensed Practical Nurse #5 (LPN5), revealed the x-ray results of the left and right shoulders were called to the Advanced Practice Registered Nurse Practitioner (APRN) by the dayshift nurse at approximately 7:00 PM. Further review revealed the results reported to the APRN showed recent left and right humeral neck fractures. Additional review revealed an order was received to send R29 to the emergency room (ER) for evaluation and treatment and the ADON and RP were notified. Review of R29's Medical Decision Making/Emergency Department Course (MDM/ED) documentation dated 04/10/2023 at 8:24 PM, revealed the ER Physician assessed the resident and found scattered bruising to the proximal (point closer to the point of attachment) medial (center of the body) aspect of the bilateral upper arms which appeared yellowish/purple. Continued review revealed the ER Physician noted a similar yellow/purple bruise was noted on R29's left clavicle/lateral neck region. Review of the MDM/ED course also revealed the ER Physician considered neglect or abuse within the facility as a reason for R29's fractures, as the resident was bedbound. Further review revealed the ED nursing staff filed an Adult Protective Service (APS) report related to R29's bilateral humeral fractures with no reported trauma/injury. Review of the hospital Radiology Impression results for R29 revealed x-ray imaging of the resident's bilateral shoulders revealed a comminuted (broken in two or more areas) left humeral head/neck fracture and comminuted mildly displaced right humeral head/neck fracture, with no shoulder dislocation. Review of R29's Emergency Department Departure dated 04/10/2023 at 8:30 PM, revealed the resident was discharged back to the nursing home facility with instructions to continue taking the prescription of Norco (narcotic pain medication) 7.5/325 mg (milligram) as prescribed by the provider; wear the bilateral slings for comfort and supportive care. Review of the Physician Progress Note, dated 04/11/2023, for R29 revealed the resident was seen for a follow-up assessment after an ER visit and resident's condition reported by the nurse and Interdisciplinary Team (IDT). Per review, the Physician assessment revealed R29 was reported to have increased weakness starting on Friday (04/07/2023), and a stop and watch was put into place by the nurse, and an OT evaluation was ordered. Continued review revealed on Monday (04/10/2023), the nurse notified the physician before the physician arrived at the facility and reported R29 had swelling to the bilateral upper extremities (BUE), bruising, and appeared to be in pain. Review of the Note revealed an x-ray was ordered at that time and completed later that evening with the physician notified of the results showing a right humeral neck fracture. The physician documented orders were given to send R29 to the ER for further evaluation, and the resident returned from the ER evaluation with orders for a sling to the bilateral arms with a neck strap in place when the resident was sitting up related to bilateral humeral neck fractures. Further review revealed no surgical intervention was recommended. During a phone interview with RN3 on 06/29/2024 at 10:20 AM, she stated R29 was nonverbal and required complete total care related to her debility, chronic diagnoses and comorbidities; therefore, the resident required a mechanical lift with all transfers. RN3 stated all staff, including CNA6, agency staff, and newly hired staff, were all educated and aware of R29's requirement for a mechanical lift with transfers. She stated staff, especially nursing staff including CNAs, knew to reference the care plan for a resident's ADL plan of care, including their transfer interventions. RN3 emphasized the importance of referencing the care plan because it was the resident's overall assessment of what they required, and stated more importantly, it provided staff direction to ensure the resident's safety and not cause harm. In continued interview on 06/29/2024 at 10:20 AM, RN3 stated she had worked the weekend shift starting on Friday evening (04/07/2023) through Monday morning (04/10/2023). She stated on that Friday night, at approximately 9:30 PM, CNA7 informed her that R29's left arm/hand appeared significantly weaker. RN3 stated after completing her assessment of R29, she filled out a Stop and Watch form. RN3 stated she did not notice any bruising, or swelling, and the resident was not exhibiting any signs of pain and/or discomfort. She stated she recalled obtaining an order for the OT evaluation. RN3 stated that early on Monday morning (04/10/2023) at approximately 6:00 AM, while the CNAs were performing their morning showers, they requested she go look at some areas of bruising/discolorations they had found on R29's arms and clavicle area. She said she immediately assessed R29

Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs for two of 20 sampled residents (R), (R29 and R242 ) 1. R29's Comprehensive Care Plan, revised 12/21/2022, revealed an intervention to utilize a mechanical lift with two (2) staff members for transfers. However, on 04/05/2023, Certified Nursing Assistant (CNA) 4 and CNA 8, transferred R29 from the bed to the wheelchair without using the mechanical lift as per the care plan, and on 04/10/2023, staff observed both the resident's upper arms had yellow/purple bruising and bruising around the clavicle. A portable x-ray was ordered and performed, and noted R29 had bilateral (left and right) humeral (upper arm bone) neck fractures. R29 was transferred to the hospital, where bilateral humeral neck fractures were diagnosed . 2. Review of R242's Comprehensive Care Plan, dated 06/19/2024, revealed the facility failed to develop a respiratory care plan for R242, which included interventions for the resident's oxygen usage. Refer to F689 The findings include: Review of the facility's policy titled, Comprehensive Care Plans revised 02/09/2024, revealed the facility was to develop and implement a comprehensive, person-centered care plan for each resident. Continued review revealed the comprehensive, person-centered care plan was to include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs based on the comprehensive assessment of a thorough evaluation which included the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) Assessment. Per review of the policy, identified problem areas were to be incorporated into the care plan, and assessments of residents were to be ongoing. Further review revealed the care plan interventions were to be derived from thoroughly analyzing the information gathered in the comprehensive assessment. 1. Review of R29's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 02/29/2016, with diagnoses of adult failure to thrive, multiple sclerosis (MS), age-related physical debility, osteoporosis without current pathological fracture and dementia. Review of the Quarterly Minimum Data Set (MDS) Assessment with the Assessment Reference Date (ARD) of 04/14/2023, revealed the facility assessed R29 as being rarely or never understood and was unable to be interviewed. Further review revealed the facility also assessed R29 as totally dependent and to require maximal assistance of two (2) for transfers. Review of the Comprehensive Care Plan (CCP), dated 12/21/2022, for R29 revealed the facility developed a focus for Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential Profile Care Guide with an intervention to use a mechanical lift, with the green lift sling for the resident's transfers. Review of R29's Nurse Aide Care Plan located in the electronic medical record (EMR) under the Reports tab revealed the resident's ADL status Plan of Care (POC) specific to transfers noting the resident required total care of two (2) staff with use of a mechanical lift and the green lift sling. Review of the Nurse Aide Kardex (a quick reference for nursing staff) revealed the intervention for the mechanical lift and green lift sling were noted and tagged to it from R29's care plan intervention initiated on 12/21/2022. Review of the facility's Initial-Self-Reported Incident Form, dated 04/10/2023 at 7:38 AM, completed by the former Administrator, revealed a CNA observed R29 to have bruising of unknown origin on 04/10/2023. Continued review revealed the bruising of unknown origin was to R29's bilateral upper extremities (BUE) and left clavicle. Review of CNA7's Witness Statement, dated 04/10/2023, located in the facility's investigation revealed she cared for R29 on 04/07/2023, 04/08/2023, and 04/09/2023. Continued review revealed on Friday night (04/07/2023), CNA7 noticed R29's left arm/hand was significantly weaker. Per review, CNA7 cared for R29 on Saturday and again on Sunday night. Further review revealed when she took R29 to the shower room on Monday morning (prior to the end of her shift) she noticed bruises on both the resident's arms above the bends of her armpits. Addition review revealed CNA7 also noticed R29's shoulders were swollen and the resident cried out in pain, so she immediately notified the nurse. Review of CNA4's Witness Statement, dated 04/12/2023, located in the facility's investigation revealed the CNA was asked to assist CNA8 in transferring R29 for the resident's shower. Continued review revealed CNA4 reported assisting R29 to sit up on the side of the bed and then completed a manual transfer (of the resident). Review further revealed after R29's shower, CNA4 and CNA utilized the (mechanical) lift to assist the resident back to bed. Review of CNA8's Witness Statement dated 04/14/2023, located in the facility's investigation revealed CNA4 came to assist her with the transfer. CNA8 indicated CNA4 sat R29 up on the side of the bed and then performed a manual transfer, without using the mechanical lift (as per the resident's care plan). CNA8 further stated she showered R29, and when she was finished, CNA4 helped R29 back to bed, performing another manual transfer of the resident. Review of R29's Progress Note, dated 04/10/2023 at 12:00 PM (late entry), revealed x-rays were ordered of R29's shoulders, and (the facility was) awaiting results. Review of the facility's portable Radiology Report, dated 04/10/2023 at 6:32 PM, of R29's left and right shoulder revealed a Left and Right Humeral Neck Fracture. Review of R29's Progress Note dated 04/10/2023 at 7:36 PM, completed by Licensed Practical Nurse (LPN) 5, revealed R29's (portable) x-ray results showing left and right humeral neck fractures were called to the Advanced Practice Registered Nurse (APRN) at approximately 7:00 PM. Further review of the Note revealed LPN5 received an order to send R29 to the emergency room (ER) for evaluation and treatment. Review of R29's hospital documentation revealed Radiology Impression results for x-ray imaging of the resident's bilateral shoulders which showed a comminuted (fragmented) left humeral head/neck fracture and comminuted mildly displaced right humeral head/neck fracture, with no shoulder dislocation. Continued review of R29's hospital documentation revealed Emergency Department Departure documentation dated 04/10/2023 at 8:30 PM, which noted the resident was discharged back to the facility with instructions to continue the prescription of pain medication as prescribed by the provider, and to wear the bilateral slings for comfort. Review of the facility's Final Report-Fracture Investigation documentation dated 04/15/2023 revealed on 04/05/2023, CNA8 requested help to get R29 up with the mechanical lift, and CNA4 assisted. However, even though there was a lift in R29's room, CNA4 performed a manual lift of the resident from the bed to the shower chair. Continued review revealed CNA4 also performed a manual lift of R29 upon return to the resident's room to assist her back to bed. Further review revealed the outcome of the facility's fracture investigation revealed R29's fractures occurred from CNA4's actions (of performing a manual lift). Review of the facility's Final Report-Conclusion, documentation dated 04/15/2023, revealed the facility determined R29's fractures were caused when she was moved manually and not with the mechanical lift (as per her care plan). Per review, during CNA4's interview, he acknowledged he moved R29 manually and had not used a lift (as per the resident's care plan). Additional review revealed CNA4 was suspended initially but terminated based on his personal decision to move R29 manually and not follow the resident's care plan. Review further revealed the facility acknowledged staff (CNA 4) had not followed the resident's care plan related to transfers which caused R29's fractures. During a telephonic (phone) interview with Registered Nurse (RN) 3 on 06/29/2024 at 10:20 AM, she stated R29 was nonverbal, and required complete and total care related to her debility and comorbidities. She stated R29 was care planned for and required the use of a mechanical lift with all transfers. She stated all staff, including CNA4, newly hired and agency staff, had been educated and were aware of R29's care plan requirement for the use of a mechanical lift for transfers. RN3 stated staff, especially nurses and CNAs, knew to reference residents' care plans for their ADL plan of care, which included the transfer interventions. She stated the care plan was important because it was the resident's overall assessment of the care they required, more importantly, it provided staff direction on how to ensure a resident's safety and not cause harm. During an interview with Restorative Nurse/LPN 4 on 06/29/2024 at 11:00 AM, she stated the facility's current Leadership/Management was very involved with resident care and safety to ensure staff followed residents' care plans. LPN 4 stated staff were to be routinely monitored, continuously re-educated, and the importance of care plan interventions were reinforced. She said it was a must for all staff to reference and abide by residents' care plans to ensure the residents were safe and cared for appropriately. LPN4 further stated CNA4 knew R29 was a total mechanical lift and knew the resident was care planned for the lift. She also stated CNA4 had been trained/educated and knew better. In interview on 06/29/2024 at 11:28 AM, LPN 6 stated R29 required use of a mechanical lift for transfers as she was total care with all ADLs and was care planned for the lift. LPN 6 stated nursing assessments were performed to ensure residents' care plans were accurate and updated related to their needs and transfer requirements. She said management ensured staff were trained and educated to follow the residents' care plan interventions, and indicated harm could occur easily and quickly if the care plan was not followed. In interview on 06/29/2024 at 11:46 AM, Unit Manager (UM)/LPN7 stated R29 required total assistance with all ADLs and care plan interventions guided staff on how to provide proper care for the resident and ensure her safety. She stated staff,, including CNA4 were trained upon hire, re-educated, and provided constant communication of any new and/or updated care plan interventions for residents. UM/LPN7 stated that all new employees were educated with emphasis on residents' care plans, and therefore, she felt CNA4 had been trained/educated and was fully aware that R29 required a mechanical lift for all transfers (as per the care plan). During an interview with a former SDC on 06/29/2024 at 9:05 AM, she stated she had been very involved with the investigation process of the incident involving R29, regarding CNA4 not using a mechanical lift with the transfer of the resident, as care planned. She stated CNA4 knew the facility's process and was very aware that referencing the resident's care plan was a must to ensure resident safety. In interview on 06/29/2024 at 1:50 PM, the Director of Nursing (DON) stated she had actively been involved in the facility's investigation of the incident involving R29. She stated the facility's root cause analysis (RCA) determined R29's fractures were due to CNA4's failure to use the mechanical lift as R29 had been care planned. The DON stated CNA4's actions went against facility policy and procedure and was not tolerated so, CNA4 was terminated. In interview on 06/29/2024 at 2:35 PM, the current Administrator stated resident safety, transfers, ensuring the care plan was followed, and accidents/hazards were discussed at every meeting, to include the morning meeting. The Administrator stated not following the residents' care plans was not an exception and was not tolerated. In interview on 06/30/2024 at 9:55 AM, the Medical Director stated he was actively involved with the facility and was made aware of the incident involving R29. The Medical Director stated he was informed the CNA had not followed the resident's care plan. He further stated he expected staff to provide for the safety and well-being of the facility residents and follow their care plans. 49360 2. Review of R242's face sheet revealed the facility admitted the resident on 06/18/2024, with diagnoses of type 2 diabetes mellitus, hypoglycemia, hypothyroidism, and hypertension. Review of R242's Admission History and Physical, dated 06/20/2024, revealed the resident had an additional diagnosis of chronic obstructive pulmonary disease (COPD). Review of R242's Physician Orders dated June 19, 2024, revealed R242 was to be on oxygen therapy at 2 liters per minute (LPM) continuously via nasal cannula. Review of R242's Admission Minimum Data Set (MDS) Assessment with an ARD of 06/25/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Continued review of the Admission MDS Assessment revealed oxygen was not listed under Section O for special treatments, procedures, and programs. Review of R242's Comprehensive Care Plan, dated 06/19/2024, revealed the facility had not developed a respiratory care plan for R242, nor had the resident's oxygen usage and oxygen ancillary orders been placed on the care plan. Observation of R242 on 06/25/2024 at 2:40 PM, on 06/26/2024 at 9:42 AM, on 06/27/2024 at 3:16 PM, and on 06/28/2024 at 2:48 PM, revealed the resident wearing the ordered oxygen via nasal cannula, and her oxygen concentrator was set on 2 liters. In interview with R242 on 06/25/2024 at 2:40 PM, she stated she had been on oxygen therapy for about three years now and had been on home oxygen as well. In interview with the Director of Nursing (DON) on 06/27/2024 at 2:47 PM, she stated she expected residents' oxygen orders to be placed on their care plans. The DON stated any physician order should be noted on the care plans. She stated she was not aware of any residents who had continuous oxygen therapy who did not have a care plan for it. The DON stated new admissions were discussed in the next clinical meeting and the clinical team reviewed admission orders, which included oxygen therapy orders. In interview with the Administrator on 06/28/2024 at 10:43 AM, he stated he attended the daily morning meetings, but did not develop or implement care plans for residents. The Administrator stated he expected all oxygen orders to be placed on the resident's care plan and any changes should be updated on the care plans.

Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. The findings include: Review of the facility's policy titled, Safe Environment Policy, effective 01/13/2021, revealed the facility was to ensure plant operations were provided daily to maintain a safe, comfortable, and clean environment for its residents. Observation during the initial tour of the facility on 06/25/2024 at 9:11 AM, revealed the flooring at the entrance to the East Wing had a yellow/black strip adhered to the floor, which had become loose and was pulled up with cracks around it. Observation during the initial tour of the facility on 06/25/2024 at 9:46 AM, revealed the flooring at the entrance to the [NAME] Wing had a yellow/black strip adhered to the floor, which also had become loose and was pulled up with cracks around it. Observation of room [ROOM NUMBER] on 06/25/2024 at 11:03 AM, revealed the sink in the room had rubber bands around the hot water knob to turn the knob off. Continued observation revealed water was observed running down into the sink. In interview with Resident #45 (R45) on 06/25/2024 at 11:03 AM, he stated he had to use the rubber bands in order to turn off the hot water in his sink. R45 stated the rubber bands did not work as you can see the water is still running into the sink. In continued interview with R45, he stated the maintenance man had been in his room quite a few times but had not been able to fix the problem. R45 further stated having to use the rubber bands did not feel homelike to him. In interview with the Maintenance Assistant (MA) person on 06/25/2024 at 2:36 PM, he stated the fall hazard tape (the yellow/black strip on the floor at the entrance to the East and [NAME] Wings) had been placed on the flooring due to there being no threshold put down when the flooring was placed in the facility. The MA person stated with no threshold being placed, the flooring would rise up which created a fall hazard, therefore, the fall hazard tape was placed as a safety precaution. He stated he walked over the tape about twenty times a day and he had not noticed the tape had become loose and pulled up. The MA further stated the current condition of the fall hazard tape created a fall hazard, for any resident, staff, or visitor, which could result in falls with injuries. In interview with the Director of Nursing (DON) on 06/27/2024 at 2:47 PM, she stated she expected all residents to have a safe, clean, comfortable, and homelike environment. The DON stated R45 would, at times, run staff out of the room when they went into his room to look at the sink. She acknowledged any refusal should be documented in R45's chart; however, there was no documentation about him refusing to let maintenance staff work on the sink. The DON stated she expected any maintenance work orders to be completed, and any issues to be discussed in the daily morning meeting with all the department heads. She stated the fall hazard tape (on the floor at the entrance to the east and west wings), which had become loose, was a fall risk to anyone walking over it. The DON further stated the risk of someone falling (over the fall hazard tape) could be an injury, such as a broken bone. In interview with the Administrator on 06/28/2024 at 10:43 AM, he stated he made rounds daily and looked at the building during those rounds. The Administrator stated the resident's room should be homelike and everything in the room should be in good condition. He stated he was not aware of any work orders regarding the flooring (with the loose fall hazard tape); however, he was aware of the rubber band situation in room [ROOM NUMBER]. The Administrator stated R45 would not let the maintenance men work on the sink and he had ran them out of his room on multiple occasions. He stated he expected any maintenance issues to be fixed as soon as possible and he expected staff to notify the appropriate department whenever there was an issue in the facility. The Administrator stated the flooring at the entrances to both the East and [NAME] wings was a potential fall hazard, and the MA was working on getting the flooring fixed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one of two residents (Resident 242). The findings include: Review of the facility's policy titled, Oxygen Administration Policy, revised 05/30/2024, revealed oxygen therapy was to be administered as ordered by a physician. Review of the facility's policy titled, Comprehensive Care Plans, revised 02/09/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan (CCP) for each resident. Per review the care plan was to include measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs as identified on the comprehensive assessment. Review of the facility's policy titled, Policies and Practices-Infection Control, revised October 2018, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Continued review of the policy revealed the objectives of the facility's infection control policies and practices were to provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of R242's Face Sheet revealed the facility admitted the resident on 06/18/2024, with diagnoses of type 2 diabetes mellitus. Review of the Admission History and Physical, dated 06/20/2024, revealed an additional diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/25/2024, revealed the facility assessed R242 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. Further review of the Admission MDS Assessment revealed under Section O for special treatments, procedures, and programs oxygen was not listed. Review of R242's Physician's Order, dated June 19, 2024, revealed an order for oxygen therapy at two (2) liters per minute (LPM) continuously via nasal cannula. Review of R242's Comprehensive Care Plan (CCP) dated 06/19/2024, revealed the facility failed to develop and implement a respiratory care plan for the resident's oxygen usage which included the oxygen ancillary orders. Observation of R242 on 06/25/2024 at 2:40 PM; on 06/26/2024 at 9:30 AM; on 06/27/2024 at 11:42 AM; and on 06/28/2024 at 2:48 PM, revealed the resident wearing oxygen via a nasal cannula at 2 LPM. Observation of R242's oxygen concentrator revealed the filter was covered in dust. In interview on 06/25/2024 at 2:40 PM, R242 stated the (oxygen concentrator) filter had not been cleaned since she was admitted to the facility on [DATE]. In interview with Licensed Practical Nurse #5 (LPN5) on 06/28/2024 at 2:56 PM, she stated the oxygen company was responsible to change the filters on the oxygen machines. LPN5 stated, to her knowledge, the nurses did not touch oxygen filters on the oxygen concentrators. She stated if they found a dirty one (dirty filter) they notified the oxygen company. LPN5 further stated the risk for not having a clean filter on an oxygen machine was it could cause the residents to have more respiratory distress and could spread germs. During an interview with Registered Nurse #1 (RN1) on 06/28/2024 at 3:14 PM, she stated the oxygen company was responsible to come in and to check the filters on the oxygen equipment. RN1 stated if she found a dirty filter, she notified the Director of Nursing (DON), or the Unit Manager (UM) and they would in turn notify the oxygen company. She further stated if the filter was dirty, it could cause the machine to not run properly, which could cause the resident to not get all the oxygen needed, and could cause more respiratory issues for the resident. In interview with the DON on 06/27/2024 at 2:47 PM, she stated she expected oxygen filters to be clean and without dust. The DON stated the oxygen tubing change and cleaning of the oxygen filter was completed on night shift weekly and as needed. She stated filters could be cleaned anytime a nurse saw a dirty filter. The DON further stated the filter's job was to keep debris out of a resident's lung field, so a dusty filter posed no risk to the resident. In interview with the Administrator on 06/28/2024 at 10:43 AM, he stated he expected all oxygen filters to be clean, which included having no dust on it. The Administrator stated he expected all nurses to be observant and to clean the filters as needed whenever there was a dirty filter observed during routine rounds.

Based on observation, interview, facility policy review and medical record review it was determined the facility failed to develop a Comprehensive Plan of Care for one (1) of three (3) sampled residents (Resident #1) related to monitoring of the resident's pacemaker. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 07/19/2018, revealed each residents Comprehensive Care Plan is designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. The Comprehensive Care Plan will be person-centered and will include how the facility will assist the resident to meet their needs. Review of the medical record for Resident #1 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Resident Assessment and Care Screening Quarterly review, Section C, Cognitive Patterns, dated 03/12/2021 revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14) revealing the resident was cognitively intact. Interview with Resident #1, on 03/25/21 at 9:31 AM, revealed he/she has had her pacemaker since 2017. Resident #1 stated before the Covid-19 virus and visitation restrictions, her daughter would come in and check her pacemaker every three (3) months. Resident #1 stated recently her daughter called the facility and asked if the pacemaker had been checked. Review of the physician orders revealed the resident had an order dated 02/1/2021, for pacemaker check every month and to be transmitted to the(NAME)Heart Institute once a day on the twelfth (12th) of the month. Review of the Comprehensive Care Plan for Resident #1 revealed the resident had a pacemaker related to cardiac [MEDICAL CONDITION] with a start date of 02/12/2021, with an approach to monitor function of pacemaker per policy and per order/manufacturer guidelines with a start date of 02/12/2021. Further review of the care plan revealed care of the resident's pacemaker was not addressed on the care plan until 02/12/2021. Interview with the MDS Nurse, on 03/25/2021 at 3:16 PM, revealed she was not aware Resident #1 had a pacemaker and did not include it on the Comprehensive Care Plan for Resident #1 until she was made aware by the Director of Nursing (DON) on 02/12/2021. The MDS Nurse revealed she is responsible for ensuring the Comprehensive Care Plan is developed for the resident to meet their needs. The MDS Nurse revealed it was just a mistake because she was not aware of the pacemaker; however, the MDS Nurse stated she reviewed the Comprehensive Care Plan for two (2) more residents with pacemakers in the facility and it had been included on those residents Comprehensive Care Plans. Interview with the DON on 03/25/2021 at 3:30 PM, revealed Resident #1's pacemaker should have been included in the residents Comprehensive Care Plan. The DON further revealed an audit of the residents Comprehensive Care Plans have been done for the residents that have pacemakers. The DON also revealed facility staff were not aware of the pacemaker for Resident #1 and it had been overlooked.

Based on interview, medical record review and facility policy review, it was determined the facility failed to provide care and monitoring for an indwelling pacemaker (a small device placed under the skin in your chest to help control your heartbeat) for one (1) of three (3) sampled residents (Resident #1). The facility failed to identify/assess that Resident #1 had a pacemaker and failed to ensure the pacemaker was monitored remotely for functioning. The findings include: Interview with the facility administrator on 3/25/21 at 5:45 PM revealed the facility did not have a policy for care of a pacemaker; however, the administrator stated the facility had guidelines steps titled, Pacemaker Check. The guideline steps included directions to assist the resident to attach the pacemaker analysis machine to the phone according to the manufacturer's directions, dial the number, run the test and record the results in the medical record. In addition, the Administrator stated the facility was responsible to monitor resident pacemakers. Review of the medical record for Resident #1 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Minimum Data Set (MDS) Resident Assessment and Care Screening Quarterly review, Section C, Cognitive Patterns, dated 03/12/2021 revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14) revealing the resident was cognitively intact. Review of the Comprehensive Care Plan for Resident #1 revealed the facility had not addressed the need to monitor the resident's pacemaker until after the resident's family called the facility about the resident's pacemaker monitoring. Further review of the care plan revealed resident had a pacemaker related to cardiac [MEDICAL CONDITION] with a start date of 02/12/2021, with an approach to monitor function of pacemaker per policy and per order/manufacturer guidelines with a start date of 02/12/2021. Interview with Resident #1, on 03/25/21 at 9:31 AM, revealed he/she has had her pacemaker since 2017. Resident #1 stated before the Covid-19 virus and visitation restrictions, her daughter would come in and check her pacemaker every three (3) months. Resident #1 revealed the box (analysis machine) was kept in her room and he/she was not sure if the facility staff knew it was kept there or not. Resident #1 revealed the(NAME)Heart Institute phoned her daughter to ask about her pacemaker not being checked as scheduled. Resident #1 revealed her daughter called the facility and asked if the pacemaker had been checked. The resident stated the nurses came in and talked to him/her, found the box in my closet and checked my pace maker that day (could not remember the exact date). Per the resident, the nurse took my box and was going to put it in her office to keep. The resident revealed she had not had any problems with her heart during this time. Resident #1 also revealed she had never mentioned to anyone at the facility about having her pacemaker checked. Interview with Resident #1's daughter, on 03/25/21 at 1:26 PM, revealed she received a call from the(NAME)Heart Institute approximately one (1) month ago concerning her mother's pacemaker check. According to the daughter, the resident's pacemaker was last checked on 08/12/2020 when the resident was seen at the heart institute. The Resident's daughter stated she called and spoke to someone at the facility about the pacemaker not being checked. Per the daughter, the Director of Nursing (DON) called her back and said they had found the box in the resident's closet. The DON told the daughter they had checked the resident's pacemaker. According to the daughter, the DON said she was going to keep the box in another container in her office and would be checking the resident's pacemaker monthly. The daughter stated the DON also told her they had spoken to the(NAME)Heart Institute staff and the transmittal had went through. The resident's daughter revealed her sister had always checked it when it was due until the Covid-19 visitation restriction. The resident's daughter further revealed she had not told any staff at the facility about her mother needing the pacemaker checked. Interview with Licensed Practical Nurse (LPN) #1, on 03/25/2021 at 2:43 PM, revealed she had cared for Resident #1 in the past and Resident had never mentioned her pacemaker. LPN #1 revealed the device to check the pacemaker is now kept in a container in the DON's office. LPN #1 also revealed Resident #1's family had always checked the pacemaker before the Covid-19 virus. Interview with LPN #2, on 03/25/2021 at 3:08 PM, revealed she received a call from Resident #1's daughter approximately a month ago concerning Resident #1's pacemaker check. LPN #2 revealed she went directly to the DON and asked about the pacemaker being checked. LPN #2 stated the DON immediately returned a call to Resident #1's daughter and asked for more information concerning the pacemaker. The daughter told the DON her sister had always done it before and the box was kept in Resident #1's room. LPN #2 revealed she and the DON went directly to the residents room and found the box in Resident #1's closet and the transmission for the pacemaker was completed. Per the LPN, the DON followed up with a phone call to The(NAME)Heart Institute to ensure the transmittal was received. Interview with the DON, on 03/25/2021 at 3:30 PM, revealed nurses were responsible to check resident pacemakers. The DON revealed the facility received a call on 02/12/2021 from Resident #1's daughter concerning the pacemaker check and she returned the call. The DON revealed Resident #1's daughter informed her that Resident #1 had a pacemaker and it was to be checked every 3 months with a box to transmit by telephone. The DON revealed she was unaware that Resident #1 had a pacemaker. Per the DON, she and LPN #2 went to Resident #1's room and found the box and immediately transmitted the pacemaker information. The DON further revealed she followed up after the transmission with a phone call to The(NAME)Heart Institute for further instructions of when the transmissions should be done. The DON stated she called Resident #1's medical doctor and obtained an order for [REDACTED].#1's room and placed it in a container and stored it in her office. The DON further revealed the facility should have care planned and received an order for [REDACTED]. Interview with the Administrator, on 03/25/2021 at 3:50 PM, revealed the facility had not been providing care for the pacemaker, and the facility was responsible for providing the care required for the pacemaker. The Administrator further revealed upon learning of Resident #1's pacemaker on 02/12/2021, the facility reviewed every resident's medical record for any resident that had a pacemaker device. The Administrator stated as of 03/25/2021 three (3) residents in the facility had pacemakers, but only Resident #1's pacemaker was not being monitored by the facility. The Administrator revealed physician orders [REDACTED].#1 have now been added to the treatment administration record and Comprehensive Care Plan.

Based on observation, interview, review of the facility's policy, and review of the Plan of Correction (POC) for the COVID-19 focused infection control survey, dated 10/27/2020, it was determined the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) Program that developed and implemented effective plans of action to correct quality deficiencies. During a focused infection control survey with an exit date of 10/27/2020, the facility was cited at CFR 483.80 Infection Control (F-880). The facility submitted a plan of correction which included staff training on the use of Personal Protective Equipment (PPE) for COVID with a correction date of 11/24/2020. However, observation on 11/30/2020 revealed Housekeeper (HK) #2 and State Registered Nurse Aide (SRNA) #1 wearing face masks positioned below the nose. Refer to F880. The findings include: Review of the facility's policy, Quality Assurance and Improvement Program, dated 02/06/19, revealed the facility would maintain a Quality Assurance and Improvement Program through the specified procedures which align to guidance provided by Generally Accepted Government Audit Standards (GAGAS), the Institute of Internal Auditors (IIA) and the International Professional Practices Framework (IPPF). The policy states internal audit would include quality monitoring of the work of the auditors at each of the phase of the audit. On an annual basis, the Internal Audit Department would conduct a self assessment of the structure and operations of the Internal Audit Department, which would include, adequacy of the monitoring procedures for the audits completed, qualifications of the department leadership, the auditors understanding of the organizations quality control policies and procedures and implementation thereof. In addition, the Internal Audit Department would monitor the quality of work performed, whether Corrective Action Plans where needed, were implemented and effective at addressing the noted deficiencies. 1. Observation during the initial tour on 11/30/2020 at 9:20 AM, revealed HK #2 was observed in the hallway on the green unit getting a broom from the HK cart with his face mask positioned below his nose, leaving his nose exposed. The Administrator was with the surveyor at the time of the observation. Interview with HK #2, on 11/30/2020 at 9:30 AM, revealed he had been trained and understood how to wear a face mask. HK #2 stated his mask should have covered his nose. 2. Observation during initial tour on the yellow unit on 11/30/2020 at 10:35 AM, revealed SRNA #1 was observed in the hallway, to be wearing a face mask that was not covering her nose. Interview with SRNA #1, on 11/30/2020 at 10:35 AM, revealed she had been trained how to properly don a face mask and was required to wear her face mask while at work. The SRNA stated her mask kept falling down. Review of the facility's plan of correction for the statement of deficiencies dated 10/27/2020, revealed staff had received training on a You Tube Video titled,Keeping COVID-19 Out and Use of Personal Protective Equipment. The training also included education of staff on the facility policy on Novel Coronavirus to include the proper utilization of PPE. Review of the inservice rosters revealed both HK #2 and SRNA #1 had attended the inservices on 11/16/2020. Review of audit sheets beginning 11/16/2020, revealed ten (10) employees had been audited daily on random shifts to ensure staff were utilizing appropriate personal protective equipment. The audits revealed no concerns were identified. Interview conducted with the Director of Nursing (DON), on 11/30/2020 at 2:00 PM, revealed all staff were required to wear a face mask at all times when in the building to help prevent the spread of the Coronavirus. She stated all staff were trained on proper wearing of PPE, donning and doffing of PPE, the facility policy on Novel Coronavirus. According to the DON, she made rounds to monitor to ensure staff were following the policy and she was providing on-the-spot education if needed. The DON stated she had not identified any concerns during rounds or audits with staff not appropriately donning face masks. Interview conducted with the Administrator, on 11/30/2020 at 2:05 PM, revealed the Administrator was aware of the CMS Guidance, had revised the facility policy, and implemented the guidance on 04/03/2020. According to the Administrator, all staff were required to wear a face mask when inside the building in accordance with the facility policy to help prevent the spread of the Coronavirus. In addition, the Administrator stated all staff had been reeducated as part of the plan of correction for the statement of deficiencies dated 10/27/2020. The Administrator stated the completion date or the date the deficiency was to be corrected was 11/24/2020. The Administrator stated she had not observed HK #2 wearing his mask below his nose on 11/30/2020, but should have. The Administrator stated both HK #2 and SRNA #1 had been educated as part of the facility's plan of correction. The Administrator stated she made rounds daily and monitored to ensure staff were wearing personal protective equipment properly and had not identified any concerns. The Administrator stated she was responsible for the Quality Assurance Committee and the committee was meeting weekly at this time and all audits were being reviewed during the weekly meetings. The Administrator stated no concerns had been identified with the audits.

Based on observation, interview, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to properly prevent the possible spread of COVID-19. On 11/30/2020, two facility staff (Housekeeper (HK) #2 and State Registered Nursing Assistant (SRNA) #1) were observed wearing a face mask, which did not cover the nose and was not worn in accordance with facility policy, nor the CMS and CDC Guidance. The findings include: A review of COVID-19 Long-Term Care Facility Guidance from CMS dated 04/02/2020 and review of the facility's policy, Novel Coronavirus (COVID-19) with a revision date of 08/31/2020, revealed all staff should wear a face mask while they were in the facility. According to CDC guidance for Using PPE, updated on 06/09/2020, when applying a face mask, the nose piece (if the mask has one), should be fitted to the nose with both hands and should be extended under (the) chin. The guidance stated both the mouth and nose should be protected. The guidance also stated that face masks should not be pulled below the chin. 1. Observation during the initial tour on 11/30/2020 at 9:20 AM, revealed HK #2 was observed on the hallway of the green unit, getting a broom from the HK cart, with his face mask below his nose, leaving his nose exposed. Three (3) residents were observed in the sitting area at the end of the hall. Interview with HK #2, on 11/30/2020 at 9:30 AM, revealed he had been trained on 11/16/2020, regarding how to wear his face mask and should have covered his nose with the mask. The HK stated he could spread COVID-19 to a resident by not wearing his mask appropriately. 2. Observation during initial tour on the yellow unit, on 11/30/2020 at 10:35 AM, revealed SRNA #1 was observed in the hallway wearing a face mask that was not covering her nose. Two (2) residents were observed in the sitting area at the end of the hall. Interview with SRNA #1, on 11/30/2020 at 10:35 AM, revealed she had been trained on 11/16/2020, regarding how to properly don a face mask and was required to wear her face mask while at work. The SRNA stated her mask kept falling down below her nose. The SRNA stated she could possibly infect a resident by not wearing her mask appropriately. An interview with the Director of Nursing (DON), on 11/30/2020 at 2:00 PM, revealed all staff were required to wear a face mask at all times when in the building to help prevent the spread of the Coronavirus. She stated all staff were trained on how to properly wear face masks on 11/16/2020. According to the DON, she made rounds to monitor to ensure staff were following the policy and she was providing on-the-spot education if needed. The DON stated she had not identified any concerns with staff not appropriately donning face masks. The DON stated the risk of staff not wearing their masks appropriately was the spread of COVID-19. An interview with the Administrator, on 11/30/2020 at 2:05 PM, revealed the Administrator was aware of the CMS Guidance, had revised the facility policy, and implemented the guidance on 04/03/2020. According to the Administrator, all staff were required to wear a face mask when inside the building in accordance with the facility policy to help prevent the spread of the Coronavirus. In addition, the Administrator stated all staff had been reeducated 11/16/2020 through 11/18/2020 as part of the plan of correction for this tag on the statement of deficiencies dated 10/27/2020. Per the Administrator, the facility had alleged the deficiency would be corrected and had listed the completion date as 11/24/2020.

Based on observation, interview, review of the facility policy and Centers for Disease Control (CDC) Guidelines, it was determined the facility failed to ensure an effective infection control program was maintained to prevent the possible spread of COVID-19. Observation, on 10/27/2020, during a tour of the facility, revealed three (3) staff who failed to either put on appropriate personal protective equipment (PPE) or failed to remove PPE before exiting a resident room. The findings include: Review of the facility policy, Novel Coronavirus (COVID 19), revised 08/31/2020, revealed the facility should, if possible, place all new admissions and readmissions in droplet precautions for fourteen (14) days. Review of the facility policy, Categories of Transmission -Based Precautions, revised October 2018, revealed for droplet precautions masks should always be worn and gloves, gown and goggles should be worn if any risk spraying respiratory secretions. Review of the CDC (Center for Disease Control) guideline, Healthcare Workers Using Personal Protective Equipment (PPE), dated 08/19/2020, revealed the healthcare worker was to remove gloves then gown prior to exiting a patient's room. Observation, on 10/27/2020 while touring the facility's yellow zone (defined area for new or readmissions as well as residents returning from the dedicated COVID unit) at 9:00 AM, revealed Housekeeper #1 entered a resident room with signage on door. The signage stated to check with the nurse's station prior to entering the room. Further observation revealed the housekeeper entered the resident's room while wearing a mask and goggles. Housekeeper #1 was not wearing a gown or gloves. Continued observation, at 9:17 AM, revealed State Registered Nurse Aide (SRNA) #2 exited a resident's room, in droplet precautions, still donned in an isolation gown. The surveyor observed the SRNA remove the gown in the hall and dispose of the gown in a biohazard bag in the hall. Observation, on 10/27/2020 at 9:41 AM, revealed Housekeeper #2, came out of a resident's room, who was in droplet precautions, with an isolation gown still on and then returned into the room while mopping the floor. Further observation revealed the housekeeper then exited the room, with the isolation gown still on and then removed the gown and disposed of it into the biohazard bag on the housekeeping cart. Housekeeper #2 was observed to be wearing a black mask and goggles. Interview with Housekeeper #1, on 10/27/2020 at 9:00 AM, revealed staff had to wear goggles and mask to enter any resident's room, even if the room had a sign that noted to report to nurse prior to entering. She further stated the rooms that had a box of personal protective equipment (PPE) outside of them meant the staff had to put on a gown and gloves. Interview with SRNA #1, on 10/27/2020, at 9:12 AM, revealed all the doors with signs on them meant the residents were in precautions and staff were required to have on goggles, mask, gown and gloves prior to entering. She further stated the area was referred to as the yellow zone and the residents had just returned from the facility's COVID unit and would be in precautions for another ten (10) days. The SRNA then revealed the boxes of PPE in the hall were for all the rooms not just certain rooms. Interview with Housekeeper #2, on 10/27/2020 at 9:44 AM, revealed the signs on the resident's room doors meant before entering you had to have on mask, goggles, gown and gloves. He stated when staff left the room, they had to take off the gown and place it in a red (biohazard) bag. He stated he had been instructed to exit a room this way. Interview with Licensed Practical Nurse (LPN) #1, on 10/27/2020 at 10:30 AM, revealed that all residents residing in the yellow zone were on droplet precautions. She stated the precautions required putting on a mask, goggles, gown and gloves prior to entering the room. She stated before staff exited the room the gown and gloves were removed and placed in biohazard bag in hall. Per the LPN, the gown and gloves were not to be worn out into the hall. The LPN then revealed there had been a lot of training regarding infection control practices and PPE. Interview with LPN #2, Unit Manager, on 10/27/2020 at 10:45 AM, revealed the yellow zone included residents who had tested positive for COVID and had concluded their fourteen (14) days of isolation and were not symptomatic. She reiterated the PPE requirements of mask, goggles, gown and gloves were required prior to entering the rooms and upon exiting the room the gown and gloves would be removed in the room and placed in biohazard bag in the hall. She then stated she did monitor the staff daily for appropriate PPE usage and infection control practices and had not observed any concerns today. Interview with the Infection Preventionist, on 10/27/2020 at 11:00 AM, revealed the yellow zone were residents who had been COVID positive and recovered, new admits or readmits and those residents who been out of the facility for other reasons. She stated all these residents were placed into droplet precautions and required PPE of mask, goggles, gown and gloves to enter the rooms and provide care. She further stated upon exiting the room the staff were to remove the gown and gloves and put into a plastic bag and then place the plastic bag into biohazard bag in the hall. Further interview revealed education was an ongoing process and the most recent education on PPE usage was around the middle of October. The Director of Nursing and Administrator were present during this interview, and confirmed the procedure detailed by the Infection Preventionist was the procedure followed at the facility.

Based on interview, record review, and a review of the facility abuse/neglect policy, it was determined the facility failed to ensure that three (3) allegations of abuse/neglect for one (1) of three (3) sampled residents (Resident #1) were reported to facility Administration and the required state agencies. On 03/27/2020, 05/07/2020, and 06/22/2020, Resident #1's family member reported concerns regarding the resident's care to the facility (left in urine, an untreated cough, and/or not shaved/long fingernails). The facility failed to report the allegations to facility Administration and to state agencies. The findings include: A review of the facility's Abuse, Neglect and Misappropriation of Property policy, revised 05/08/2019, revealed all alleged violations of neglect were required to be reported immediately to the Facility Administrator and appropriate state agencies in accordance with federal law. Further review of the policy revealed the Facility Administrator was the abuse coordinator and would direct the reporting of allegations and findings to required agencies. A review of the medical record for Resident #1 revealed the facility admitted the resident on 04/12/2019 with [DIAGNOSES REDACTED]. A review of Resident #1's Brief Interview for Mental Status (BIMS) score of 15, dated 11/04/2019, indicated the resident had no cognition impairments. Further review revealed on 06/27/2020 the resident's BIMS score was 11, indicating the resident had impaired cognition but was able to be interviewed. An interview with Resident #1's family member on 06/23/2020 at 3:34 PM revealed the resident called the family member when facility staff were not caring for the resident appropriately (due to COVID-19, the family member was not permitted to visit inside the facility). She stated Resident #1 called in March and May 2020 because he/she was lying in urine and could not get staff to assist him/her. The family member also stated the resident had a cough in May and she requested that the resident go to the hospital. Further interview revealed that in May 2020, Licensed Practical Nurse (LPN) #1 threatened Resident #1 during incontinence care and stated she would not give the resident coffee. Further interview with Resident #1's family member revealed she visited the facility on 06/22/2020 and talked with the resident through the facility glass door. She stated the resident had not been assisted with grooming, he/she had not been shaven, hair was dirty, and fingernails were long. She stated a staff member (last name unknown) was going into the facility while she was visiting and she told the staff member that she was tired of the facility neglecting to care for Resident #1. 1. Review of Resident #1's nurse's notes revealed on 03/27/2020 at approximately 3:30 AM, Resident #1's family member called Licensed Practical Nurse (LPN) #1 because the resident was lying in urine. According to the nurse's note, staff went to the resident's room and changed the resident. An interview conducted with Resident #1 on 06/24/2020 at 10:16 AM and on 06/25/2020 at 12:05 PM, revealed staff would not check on the resident at night and would let the resident lie in urine. The resident could not recall specific dates that this occurred, but stated he/she contacted his/her family member when the incidents occurred. An interview with LPN #1 on 06/25/2020 at 9:20 AM confirmed that Resident #1's family member called her (could not recall the exact date) and stated that the resident was lying in urine. She stated she and SRNA #3 checked on the resident and provided care. LPN #1 stated the resident did not normally have incontinence episodes, but often spilled urine from his/her urinal. LPN #1 stated she documented the family member's call/concern in the nursing notes, but did not report the allegation to the Administrator because she did not consider that it was an allegation of neglect. 2. Further review of Resident #1's nurse's notes revealed on 05/07/2020 at 3:47 AM, Resident #1's family member contacted LPN #1 because the resident had called the family member and told her that he/she was coughing and staff were not doing anything. According to the note, the family member was upset and was going to notify Social Services. Continued interview with Resident #1's family member on 06/23/2020 at 3:34 PM revealed she was upset after the call on 05/07/2020 because LPN #1 hung up on her when she told the nurse that someone needed to check on the resident. The family member stated that Resident #1 also told her afterward that when LPN #1 was assisting him/her with incontinence care, the LPN threatened the resident and told him/her that she would not give the resident coffee because she had to clean the resident. The family member stated she reported the allegation to the social worker the next morning and the social worker and Administrator told her that LPN #1 would no longer provide care for Resident #1. Continued interview with Resident #1 on 06/24/2020 at 10:16 AM and on 06/25/2020 at 12:05 PM, revealed the resident had called Family Member #1 and told her that LPN #1 would not let the resident have coffee at night. He/she stated he/she sometimes woke up early in the morning and wanted coffee. He/she stated the other nurse would get coffee for the resident; however, LPN #1 would not get coffee for the resident. The resident stated he/she felt like the LPN tried to bully the resident, but the resident was not afraid of the LPN. Continued interview with LPN #1 on 06/25/2020 at 9:20 AM revealed the LPN had received calls from Resident #1's family member regarding allegations made by Resident #1. The LPN could not recall the dates, but stated she documented the calls in the nurse's notes. According to the LPN, on 05/07/2020 the family member called because the resident called and told her that staff were not taking care of him/her and that he/she wanted to go to the hospital. LPN #1 stated she assessed the resident and gave the resident some cough medication, but did not feel that the resident needed to go to the hospital. The LPN stated she did tell the resident that he/she could not have coffee. She stated she did not give any resident coffee at night because they (residents) are supposed to be sleeping. According to LPN #1, she notified the West Wing Unit Manager that the family member was upset because she thought the LPN hung up on her, but did not consider the resident/family member's concerns as an allegation of neglect and did not report the allegations to the Administrator. Interview with the West Wing Unit Manager on 06/25/2020 at 11:04 AM confirmed that LPN #1 notified her that she had a disagreement with Resident #1's family member on the phone. The Unit Manager stated she was not sure what was discussed between them, but was not aware any allegations of neglect were made. Interview with the Social Worker on 06/25/2020 at 11:30 AM revealed she talked to Resident #1's family member on 05/07/2020 and she was upset that LPN #1 hung up on her and asked that the LPN not care for Resident #1 anymore. The Social Worker stated she was not aware of an allegation that LPN #1 denied the resident coffee or that the resident had not received care for a cough. An interview with the Administrator on 06/29/2020 at 10:03 AM revealed the social worker reported that Resident #1 and LPN #1 had a conflict and she arranged it so that the LPN did not provide care for the resident any longer. The Administrator stated she was not notified nor aware that any allegations of neglect/abuse had been made regarding Resident #1. 3. An interview with State Registered Nurse Aide (SRNA) #1 on 06/25/2020 at 7:58 AM revealed she was at the facility for a COVID-19 Lab test (exact date unknown). The SRNA stated FM #1 was visiting Resident #1 outside the facility door and the family member informed her that she was tired of the facility neglecting the resident. The family member reported the facility was not shaving and grooming the resident. According to the SRNA, she immediately informed the West Wing Unit Manager of the allegation made by the resident's family member. Interview with the West Wing Unit Manager on 06/25/2020 at 11:04 AM revealed she was aware that Resident #1's family member visited the resident that week and recalled the family member saying the resident did not look clean. The Unit Manager stated she explained to the family member that the resident refused showers and shaving, but did not consider it an allegation of neglect. Further interview revealed the Unit Manager denied that SRNA #1 reported that the family member alleged the resident was being neglected. An interview with the Administrator on 06/29/2020 at 10:03 AM revealed she had not been informed of any allegations of neglect/abuse related to Resident #1. The Administrator stated the allegations should have been reported to her immediately.

Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change of condition and need to alter treatment for one (1) of four (4) sampled residents (Resident #1). Interviews with staff revealed on 07/19/19, after breakfast, staff observed discoloration and swelling to Resident #1's right arm, and that the resident was guarding his/her right arm and crying with pain with movement. Continued interviews with staff revealed Resident #1 continued to have discoloration and swelling to his/her right arm and the resident was guarding his/her right arm and showing signs of pain with movement (screaming, crying, and moaning) during the night shift and into the day shift on 07/19-20/19. However, the facility failed to notify Resident #1's physician of the changes in the resident until 07/20/19 at approximately 2:30 PM, at which time an order was received for an x-ray of the resident's right arm. On 07/21/19 at 11:58 AM, the facility was notified that the resident had a linear [MEDICAL CONDITION] (elbow) of the right arm with minimal displacement and significant swelling of the right upper arm and right elbow. The facility's failure to notify the physician of a resident's change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/19 and was determined to exist on 07/19/19 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697). The facility was notified of the Immediate Jeopardy on 07/25/19. An acceptable Allegation of Compliance was received on 08/06/19, which alleged removal of the Immediate Jeopardy on 08/03/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 08/03/19, prior to exit on 08/13/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Change of Condition policy, with a revision date of 07/10/18, revealed the facility would evaluate and document changes in a resident's health, mental, or psychosocial status in an efficient and effective manner to relay evaluation information to the resident's physician and to document actions to include, but not limited to, the following: a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment. The policy stated a licensed nurse would evaluate any change in condition through direct observation, physical examination, and vital signs at the onset of the change. Further review revealed staff would notify the resident's representative, consistent with his or her authority, of a change and follow-through completed by the facility. Review of Resident #1's medical record revealed the facility admitted the resident on 02/02/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. The facility assessed the resident to require extensive assistance of two (2) staff members with bed mobility, transfers, toileting, and hygiene. Review of Resident #1's Weekly Skin Integrity Evaluation dated 07/19/19 at 3:03 PM revealed Registered Nurse (RN) #4 documented that the resident had bruising/discoloration to his/her right upper arm area. Interview with SRNA #9 on 07/29/19 at 7:37 PM revealed after breakfast on 07/19/19, she noticed that Resident #1's right arm was red, looked like blood was pooling, and swollen. SRNA #9 stated Resident #1 would not let her touch his/her right arm, and was babying the arm and saying it was sick. She stated she reported the resident's condition immediately to RN #4, who looked at the resident's arm, without touching it, and stated it was fine. SRNA #9 stated that throughout the shift on 07/19/19, the resident had pain with movement during care. Continued interview with SRNA #9 revealed at the end of her shift, she reported to SRNA #13, the oncoming staff member, that the resident's right arm was red, swollen, and that the resident was guarding his/her arm during care. Further review of Resident #1's medical record revealed no documented evidence that the resident's physician was notified that the resident's arm was red, swollen, or that the resident had pain. Interview with RN #4 on 07/29/19 at 7:54 PM revealed she was Resident #1's nurse during day shift on 07/19/19 and 07/20/19. RN #4 stated that SRNA #9 reported on 07/19/19 that the resident had discoloration to his/her right arm; however, she stated she assessed the resident's arm (which included range of motion) and the resident did not express or show any signs of pain, other than the resident's normal yelling. RN #4 further stated she also completed Resident #1's weekly skin assessment on 07/19/19, and identified that the resident had bruising/discoloration to his/her right upper arm. However, RN #4 stated she did not feel that she should have notified the resident's physician of the changes in the resident's arm because Resident #1's arm didn't look bad and the resident was not experiencing pain. Interview with SRNA #13 on 07/30/19 at 10:15 AM and 3:26 PM revealed that she was the aide assigned to provide care for Resident #1 on the evening/night shift of 07/19/19. She stated that during report on 07/19/19, SRNA #9 told her that Resident #1's right arm was bruised, red, and swollen, and they went to the resident's room and observed the resident's arm. SRNA #13 stated she reported the resident's condition to RN #3 and observed RN #3 and Kentucky Medication Aide (KMA) #1 going into the resident's room. Continued interview with SRNA #13 revealed that she did not observe RN #3 assess Resident #1; however, she stated she heard RN #3 state that the resident's right arm was red and swollen. In addition, interview with SRNA #11 on 07/29/19 at 8:34 PM revealed he and SRNA #12 gave Resident #1 a bed bath on the evening/night shift of 07/19/19. He stated he observed discoloration, redness, bruising, and [MEDICAL CONDITION] to the resident's right upper arm, elbow, and forearm. He also stated the resident had pain with movement (whimpering and crying). SRNA #11 stated that he and SRNA #12 went to RN #3 and reported their observation. Interview with SRNA #12 on 07/29/19 at 8:48 PM revealed she assisted SRNA #11 on 07/19/19 with Resident #1's bed bath. She stated Resident #1 had dark blue/purple bruising with red edges to the right arm extending approximately one (1) inch above the resident's right elbow, inside the resident's arm, and toward the resident's forearm. She stated the resident did not want to move his/her arm and cried with movement. She stated after she and SRNA #11 reported the changes to RN #3, the RN looked at the resident's arm. Interview with Kentucky Medication Aide #1 on 07/30/19 at 3:37 PM revealed she and RN #3 observed Resident #1's right arm on the evening of 07/19/19, and it was warm to touch, red, and swollen. She stated that RN #3 stated staff should be careful with the resident's arm until they could get an x-ray the next day (07/20/19). Continued review of Resident #1's medical record revealed no documented evidence that the resident's physician was notified that the resident's arm was red, swollen, or that the resident had pain at any time on the night shift of 07/19-20/19. An interview with RN #3 on 07/29/19 at 7:18 PM and 07/30/19 at 3:14 PM revealed the RN denied that she observed or that anyone reported that Resident #1 had bruising, [MEDICAL CONDITION], or pain to the right arm; subsequently, she did not notify Resident #1's physician of any changes in the resident. According to RN #3, she did not enter Resident #1's room on 07/19/19 and assess the resident's right arm. Interview with SRNA #5 on 07/29/19 at 2:25 PM revealed she was Resident #1's aide on day shift on 07/20/19. She stated she was providing care to Resident #1 along with another aide (she could not remember the aide) and Resident #1 was saying ouch when they provided care. She stated the resident's right arm was swollen and had redness. Continued interview with SRNA #5 revealed she reported her observations to RN #4, who assessed the resident's arm immediately. Review of a Nursing assessment dated [DATE] at 3:00 PM completed by RN #4 revealed while SRNA #5 was providing care to Resident #1, she observed bruising with redness, [MEDICAL CONDITION] to the resident's right arm extending from the elbow down the forearm. Continued review revealed an x-ray was ordered and obtained and the facility was awaiting the results. Review of a physician's orders [REDACTED]. Continued interview with RN #4 on 07/29/19 at 7:54 PM revealed on 07/20/19, she assessed Resident #1's arm after SRNA #5 reported the resident's arm was bruised and swollen. RN #4 stated the resident's arm looked worse so she notified the resident's physician, who ordered an x-ray and [MEDICATION NAME]. Review of Resident #1's x-ray report dated 07/20/19 revealed the resident had no fractures. However, review of an addendum report received on 07/21/19 revealed the resident had a linear fracture involving the olecranon (elbow) with minimal displacement and significant swelling of the right upper arm and right elbow. Interview with the Unit Manager (UM) on 07/30/19 at 3:56 PM revealed she was not aware there had been any changes in Resident #1 until Monday, 07/22/19, when the resident's skin assessments, nursing notes, physician orders, etc. were reviewed during the morning meeting. She stated she did not recall a skin assessment from 07/19/19 indicating Resident #1 had a bruise/discoloration to his/her right upper arm. The UM stated that if staff observed a change in the resident's condition, the resident's physician and family should have been notified. In addition, the Unit Manager stated that if the resident experienced a change in condition during night shift, she expected staff to notify the resident's physician no matter what the time. She stated there was no reason to wait and expect an oncoming nurse to report the change if the nurse observed it on her shift. Interview with the Director of Nursing (DON) on 07/30/19 at 5:02 PM revealed she was not aware that staff had observed discoloration, [MEDICAL CONDITION], or pain to Resident #1's arm on 07/19/19. She stated the resident's physician should have been notified immediately on 07/19/19, when it was initially observed. Interview with the Administrator on 07/31/19 at 9:37 PM revealed she was out of town on 07/20/19, but staff notified her that the resident had redness to his/her right elbow and that an x-ray came back negative. She stated the DON then notified her on 07/21/19 that they had received an addendum to the report that stated the resident had a fracture. She stated she was not aware that staff had observed bruising/discoloration, [MEDICAL CONDITION], or pain on 07/19/19. The Administrator stated if there was a concern on 07/19/19, the resident's physician should have been notified. Interview with Resident #1's Physician/the Medical Director on 07/30/19 at 1:52 PM revealed the facility did not notify him of any discoloration or [MEDICAL CONDITION] to Resident #1's right arm until 07/20/19 and he ordered x-rays and [MEDICATION NAME] pain medication. He stated that if staff observed changes on 07/19/19, he should have been notified. The physician stated that he always had his phone and he expected to be notified of any change in a resident's condition, including bruising and [MEDICAL CONDITION]. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 08/03/19: 1. Resident #1 was transferred to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. The resident had the orthopedic consultation on 07/24/19 and orders were to continue with a sling as needed, range of motion as tolerated, and to return in two (2) weeks for a follow-up appointment. 2. A complete head-to-toe skin assessment was completed on 07/21/19 for Resident #1 with no other abnormalities noted by the charge nurse. 3. Resident #1's care plan and SRNA care plan were updated to reflect the resident's current needs on 07/21/19 by the MDS Coordinator. 4. All residents with a BIMS score of eight (8) or above were interviewed and asked the following questions: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? Interviews were completed by the Social Services Director on the East Unit on 07/22/19 and on the West Unit on 08/01/19. No concerns were identified. 5. The Charge Nurse/Unit Manager conducted a skin assessment for all residents currently residing on the East Unit on 07/22/19 and on 08/01/19 for all residents on the West Unit with a BIMS score of seven or less to assure there were no concerns with new onset of bruising, skin tears, pressure ulcers, rashes, irregularities of the skin, or other injuries of unknown origin that were not previously reported. No concerns were identified. 6. Starting on 08/01/19, all staff that were not on medical leave were interviewed and asked the following questions: Have you reported any injuries that were not addressed; do you have any knowledge of any abuse that has not been reported; and are you aware of any resident that has untreated pain? All staff answered no to the questions with the exception of one staff member who referenced the current allegation regarding Resident #1 and reporting bruising to a Charge Nurse on 07/19/19. Certified letters were mailed to any staff who were not interviewed prior to 08/02/19 stating that they must contact the facility for questioning prior to working their next scheduled shift. 7. All residents currently residing on the East Unit were assessed for any signs and symptoms of pain, utilizing the Wong Baker Scale or Dementia Pain Scale on 07/22/19 by the Staff Development Coordinator (SDC), Assistant Director of Nursing (ADON), Director of Nursing (DON), and/or Charge Nurse to ensure that residents' pain levels were being treated appropriately. Two (2) elders (residents) complained that they have had long standing pain, but that they manage the pain appropriately on follow-up. All residents currently residing on the West Unit were assessed for any signs and symptoms of pain, on 08/01/19 and no concerns were noted with the pain assessments. 8. On 07/23/19 and 07/24/19, the DON, Unit Manager, ADON, and/or the SDC reviewed x-rays for the past 30 days to assure all residents' x-rays were followed up on appropriately and the resident's physician and family had been contacted. The physician had been notified of abnormal x-rays in a timely manner and no concerns were identified. 9. Beginning on 07/23/19, Monday through Friday, during the Morning Clinical Meeting, the IDT will review telephone orders, SBARs, 24-hour reports, lab and x ray results, and medical records of residents to ensure timely notification to the physician; changes in residents' pain addressed timely; x-rays completed, results obtained, and reported to physician timely; and care plans updated. 10. Daily, beginning 07/23/19, Monday through Friday a stand-down meeting will occur in the afternoon at approximately 3:00 PM where the DON, ADON, SDC, SSD, and/or MDS Coordinator will report on the status of residents for the day and follow up to ensure the following is completed as needed: physician notification; documentation in the medical record; completion of SBARs, Stop and Watch, pain, and/or x ray reports; and care plan updates. The Administrator or designee will attend this meeting to provide oversight and consultation. 11. On 08/01/19 and 08/02/19, the Corporate Consultant educated all facility managers to include the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Maintenance Director, Dietary Director, Rehabilitation Manager, Restorative Nurse, Medical Records Director, and MDS Nurses on the facility's policy and procedure for abuse and reporting, which includes investigative guidelines. A posttest was given after the education was completed with a score of 100%. Anyone who did not score 100% on the posttest was reeducated until a score of 100% was reached. 12. Department Head Managers to include DON, Unit Manager, and SDC were educated by the Corporate Consultant on 07/22/19 on assessing for pain, the pain policy, pain management, 24-hour report, incident and accident policy, lab policy tracking log, documentation in the medical record, updating care plans, following care plans (including SRNA care plans), utilization of the Stop and Watch tool, and the abuse and resident rights policies. Education also included pain assessments; pain policy; assessing for pain; assessing for new, worsening, and different pain; use of the Wong Baker Pain form; 24-hour report policy; updating care plans; notification to MD for any change in condition; completing the SBAR for change in resident condition; follow-up documentation for change in condition; and lab tracking form. 13. The DON, SDC, and/or ADON educated licensed nurses beginning on 07/22/19 regarding physician notification as it occurs throughout the shift, changes in resident condition, pain management, assessing for pain, and documentation to include completing SBARs for change of condition with MD and family notification. Education will continue until current licensed nursing staff are educated. Staff not working as of 07/30/19 will receive education prior to returning to work. Licensed nursing staff on leave will be educated prior to returning to work. Staff members will not return to work until education has been provided. All licensed nurses were educated by 08/02/19. 14. Beginning on 07/22/19 licensed nurses and nurse aides were educated by the DON, SDC, Unit Manager, and/or ADON on pain management, incident and accident policy, following care plans/nurse aide care plans, utilization of the Stop and Watch tool, abuse policy and resident rights policies, and reporting of changes of condition. All education was completed for licensed nurses and nurse aides currently employed with the facility by 08/02/19. 15. Beginning on 08/01/19 and 08/02/19 all non-nursing staff including dietary, housekeeping, and therapy staff were educated on utilization of the Stop and Watch tool and the abuse policy. Any staff member that was not educated prior to 08/02/19, was mailed a certified letter that they must receive the training prior to working again. 16. On 07/22/19 through 07/23/19, the DON audited charts on the East Unit for the past 30 days and on 08/02/19, the Corporate Consultant audited medical records for residents on the West Unit to ensure any documented pain or change in condition had been addressed to include physician notification and care plan revision. Any identified concerns were addressed at that time. 17. Beginning 07/23/19, daily for two (2) weeks, a member of Nursing Administration (including but not limited to the DON, ADON, SDC, MDS Coordinators, and the Restorative Nurse Manager) will visit five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. These audits will be decreased to Monday-Friday starting the week of 08/06/19, and will continue for two (2) weeks. Any issues identified will be addressed by completing a SBAR and physician notification. Results of the audits will be discussed in the Quality Assurance Performance Improvement (QAPI) meeting. 18. Beginning 07/23/19, the Nursing Administration Team will audit ten resident records daily until immediacy is lifted to ensure physician notification and to ensure changes in condition are being addressed by completion of a SBAR, updated care plan, and documentation. Any issues identified will be addressed at the time of discovery. Results of audits will be discussed in QAPI meeting. 19. On 07/23/19, the DON, ADON, Unit Manager, SDC, and MDS Nurse audited care plans for residents with fractures to ensure the care plan was updated and accurate. There are four (4) residents in the facility with fractures. Resident #1's care plan has been updated to reflect the current needs of the resident with current interventions added regarding his/her fracture and potential for pain related to the fracture. 20. On 07/22/19 and 07/23/19, the DON, SDC, and Corporate Consultant reviewed all event manager documentation for the last 30 days for all residents residing on the East Unit, and on 08/02/19 for all residents on the West Unit regarding issues or concerns related to injuries of unknown origin including bruising, skin tears, fractures, skin irregularities, and/or [MEDICAL CONDITION] that had not been previously reported. No concerns were identified. 21. Starting 08/02/19, any issue reported to State Agencies will be reviewed in its entirety by the Corporate Consultant and/or the Regional Vice President to assure that an accurate and thorough investigation has been completed. This will include a review of all resident interviews, resident skin assessments, staff interviews, and/or family interviews, and any other information that may be pertinent to the investigation, to include but not limited to lab/x-ray results, hospital records, physician documentation, and physician interviews. 22. Starting 08/03/19, members of the IDT (including but not limited to, the Administrator, DON, ADON, Unit Manager, Medical Records Director, Dietary Director, Social Services Director, Corporate Consultant, Central Supply Staff, Chaplain, Maintenance Director, Business Office Director, Activities Director, and/or MDS Nurses) will interview five (5) residents with a BIMS score of eight or above to assess for any new concerns regarding care. The following questions will be asked: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? The interviews will occur daily for four (4) weeks, and then decrease to five (5) times per week for one month starting on 09/04/19. 23. Starting 08/03/19, the IDT will conduct five (5) resident skin assessments to assess for any injury of unknown origin or new onset of skin issues including bruising, skin tears, rashes, pressure ulcers, [MEDICAL CONDITION], and/or unknown skin irregularities for residents with a BIMS score of seven (7) or less. Skin assessments will occur daily for four (4) weeks and then decrease to five (5) times a week for one month starting on 09/04/19. 24. Starting 08/03/19, the IDT is interviewing five (5) staff members to determine any new concerns regarding care with the following: Have you reported an injury that was not addressed; do you have any knowledge of any abuse that has not been addressed; and are you aware of any resident that has untreated pain? Interviews will occur daily for four (4) weeks, and then decrease to five (5) times a week for one month starting on 09/04/19. 25. Beginning 07/21/19, the VP of Operations, Corporate Consultant, and Director of Clinical Programs Administrative will provide oversight of the facility daily in person or by phone until removal of immediacy; then weekly for four (4) weeks, and then monthly to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the SBARs/Nurse's Notes for change in condition and care plans occurs daily by the Administrator along with attending the Morning Clinical Meeting and daily stand-down meeting where SBARs and pain assessments are reviewed. 26. A QAPI meeting was held on 07/22/19 with the Medical Director (by phone), Administrator, DON, QA Nurse, SDC, and Unit Managers reviewing the occurrence of Resident #1's fracture and the steps that have been put in place. 27. A QAPI meeting was held on 07/31/19 with the Medical Director and IDT to discuss the above items regarding corrective action for identified issues. 28. Beginning 07/21/19, a QAPI meeting will be held weekly for four (4) weeks until immediacy is removed, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator is providing oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Beginning 07/22/19, Corporate Administrative oversight of the QAPI meeting will be completed by the Corporate Consultant, Director of Clinical Programs, the Regional Vice President of Operations, or member of regional staff daily by telephone or in person until removal of immediacy, then every other week for four (4) weeks, and then monthly. Audits reviewed will include, but not limited to, morning clinical meetings, pain, change in condition, x-rays, and SBARs. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed effective 08/03/19 as alleged by the facility: 1. Review of Resident #1's medical record revealed the facility transferred the resident to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. Further review revealed the resident saw the Orthopedist on 07/24/19 and orders were received to continue utilizing a sling as needed and to provide range of motion as tolerated. 2. Review of Resident #1's medical record revealed a nurse conducted a head-to-toe skin assessment of the resident on 07/21/19 and no other abnormalities were identified. 3. Review of Resident #1's care plan and SRNA care plan revealed they were revised on 07/21/19 regarding the resident's fracture. 4. Review of facility documentation and interview with the Social Services Director on 08/13/19 at 11:09 AM revealed she interviewed all residents with a BIMS score of eight (8) or above regarding any mistreatment or unrelieved pain. No concerns were identified. 5. Review of resident skin assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM, revealed by 08/01/19 a skin assessment had been conducted for all residents with a BIMS score of seven (7) or less. No concerns with injuries of unknown origin were identified. 6. Review of staff interviews and interviews with the Corporate Consultant on 08/13/19 at 12:12 PM and with the DON on 08/13/19 at 1:49 PM revealed Administrative staff interviewed all staff regarding any injuries of unknown origin/abuse or untreated resident pain and no new concerns were identified. Interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, LPN #2 on 08/12/19 at 6:30 PM, SRNA #7 on 08/12/19 at 6:53 PM, SRNA #3 on 08/12/19 at 6:23 PM, SRNA #21 on 08/12/19 at 6:16 PM, SRNA #22 on 08/12/19 at 6:08 PM, and SRNA #23 on 08/12/19 at 5:59 PM revealed Administrative Staff interviewed them regarding their knowledge of any resident mistreatment/pain and all stated they were not aware of any concerns. 7. Review of pain assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM revealed all residents had been reassessed for pain. The staff stated that all residents with pain were being treated appropriately. 8. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM revealed they reviewed all x-ray reports for the past 30 days to assure all residents' x-rays were followed up on appropriately and that the resident's physician and family had been contacted. They stated no concerns were identified and all abnormal x-ray results were followed up on in a timely manner. 9. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed they were meeting daily Monday through Friday to review resident records to ensure any change in resident condition was addressed, x-rays addressed, and care plans revised as needed. 10. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed every afternoon, Monday through Friday, they held a stand-down meeting to report on the status of residents and to follow up to ensure documentation/follow-up was completed for any resident who had a change in condition. Interview with the Administrator on 08/13/19 at 2:21 PM revealed she attended this meeting to provide oversight and consultation. 11. Review of in-service records and post-tests and interview with the Corporate Consultant on 08/13/19 at 12:12 PM revealed on 08/01/19 and 08/02/19, she educated all facility managers regarding the facility's policy and procedure for abuse, which included investigative guidelines. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, the Maintenance Director on 08/13/19 at 12:52 PM, and the MDS Coordinator on 08/13/19 at 11:30 AM, revealed the Corporate Consultant educated them regarding the facility's abuse policy, including conducting an investigation. 12. Review of in-service records and interview with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM, revealed the Corporate Consultant educated them regarding the facility's pain management policy, the 24-hour report, incident and accident policy, lab policy tracking log, abuse policy, resident rights policy, physician notification, and documentation (updating care plans, following care plans, Stop and Watch tool, SBAR). 13. Review of in-service records and interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, and LPN #2 on 08/12/19 at 6:30 PM revealed they had been educated regarding physician notification, changes in resident condition, pain management, assessing for pain, and documentation. 14. Review of in-service records and interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, LPN #2 on 08/12/19 at 6:30 PM, SRNA #16 on 08/12/19 at 7:14 PM, SRNA #7 on 08/12/19 at 6:53 PM, SRNA #3 on 08/12/19 at 6:23 PM, SRNA #21 on 08/12/19 at 6:16 PM, SRNA #22 on 08/12/19 at 6:08 PM, and SRNA #23 on 08/12/19 at 5:59 PM revealed they were educated regarding the facility's pain management policy/procedure, incident and accident policy, abuse policy, resident rights policy, following care plans/nurse aide ca

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure an injury of unknown source was thoroughly investigated for one (1) of four (4) sampled residents (Resident #1). On 07/21/19, Resident #1 was diagnosed with [REDACTED]. The facility completed an investigation of the injury, but failed to interview staff who cared for the resident to attempt to determine the cause of the fracture. The facility determined that the injury possibly occurred as a result of the resident hitting his/her elbow on a wall because a nurse stated the resident had hit the wall; however, interview with the nurse revealed it was a long time ago. In addition, the resident's physician, who was not interviewed during the facility's investigation regarding the injury, stated the injury could not have been caused as a result of the resident hitting the wall. The facility's failure to thoroughly investigate injuries of unknown origin has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/19 and was determined to exist on 07/19/19 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697). The facility was notified of the Immediate Jeopardy on 07/25/19. An acceptable Allegation of Compliance was received on 08/06/19, which alleged removal of the Immediate Jeopardy on 08/03/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 08/03/19, prior to exit on 08/13/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, with a revision date of (MONTH) 2019, revealed it was the intention to prevent the occurrence of injuries of unknown origin, and to assure that all injuries of unknown origin were investigated. The policy stated that the facility's Administrator or designee would direct a reasonable investigation of each alleged violation. According to the policy, the definition of an injury of unknown source was an injury not observed by any person, and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, location of the injury, the number of injuries, or the incidence of injuries over time. Further review of the policy revealed the investigation would include interviews of persons who may have knowledge of the alleged incident and review of pertinent parts of the resident's record to determine the resident's past history and condition. The policy also stated that the facility's Administrator would investigate all injuries of unknown source and that the facility's Administrator retained the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident. Review of Resident #1's medical record revealed the facility admitted the resident on 02/02/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired and not interviewable. Review of Resident #1's Weekly Skin Integrity Evaluation completed by Registered Nurse (RN) #4 and dated 07/19/19 at 3:03 PM revealed the resident had bruising/discoloration to his/her right upper arm area. Review of a physician's orders [REDACTED]. Review of the radiology report dated 07/20/19 revealed the x-ray was negative (no fractures). However, review of an addendum radiology report received on 07/21/19 revealed the resident had a linear fracture involving the olecranon (elbow) with minimal displacement, and significant swelling of the right upper arm and right elbow. Review of a facility investigation initiated on 07/21/19 and finalized on 07/25/19, revealed that on 07/20/19 Resident #1 was noted to have bruising with redness to his/her right arm extending from the resident's elbow down to his/her forearm. According to the investigation, the resident was not exhibiting any signs or symptoms of pain. Further review revealed the facility identified that the initial x-ray report was negative for a fracture; however, an addendum to the report revealed the resident had an elbow fracture. Continued review revealed the facility unsubstantiated abuse based on information that was received during their investigation and felt that the fracture occurred from the resident hitting his/her elbow against the wall. However, review of the investigation revealed there was no evidence that the facility interviewed direct care staff that provided care to Resident #1 on the days prior to the resident's fracture related to the care Resident #1 received or any observations or incidents that could have possibly caused the injury. Continued review of the investigation revealed the facility interviewed staff, regarding resident complaints or observations of poor activities of daily living (ADL) care, and whether they were aware of any abuse allegations that had not been reported. There was no documented evidence that the facility interviewed staff regarding what caused the injury of unknown origin to Resident #1. Further, review of the interviews revealed six (6) of the facility's interviews had staff names and dates; however, none of the facility's interview questions were answered. In addition, eight (8) of the staff members that the facility interviewed did not provide care to Resident #1 on the days prior to his/her injury, including five (5) staff members that did not provide resident care, the Chaplain, Social Services Director, Medical Records Staff, Staff Development Coordinator, and a MDS nurse. Interview with SRNA #6 on 07/31/19 at 8:00 PM, SRNA #14 on 07/31/19 at 8:40 PM, SRNA #9 on 07/29/19 at 7:37 PM, SRNA #13 on 07/31/19 at 8:44 PM, SRNA #11 on 07/31/19 at 7:58 PM, SRNA #12 on 07/29/19 at 8:48 PM, RN #3 on 07/31/19 at 7:14 PM, and SRNA #1 on 07/31/19 at 6:17 PM, revealed they provided care for Resident #1 at some point from 07/18/19 through 07/20/19. However, they stated the facility had not interviewed them regarding their knowledge of how Resident #1 sustained a right elbow fracture. SRNA #9 stated she was not aware that the resident had a fracture. According to SRNA #14, she provided care for the resident alone, without the assistance of another staff member, during the night shift on 07/18-19/19. There was no documented evidence that the facility identified that the resident's care plan was not followed. Further review of the facility's five (5) day final investigation report revealed RN #4 had reported that she had observed Resident #1 become agitated during a medication pass and that the resident was observed to bump his/her arm against the wall. According to the facility's investigation, they determined this behavior was the cause of the resident's right elbow fracture. However, interview with RN #4 on 07/29/19 at 7:54 PM revealed she had observed the resident hit his/her arm/elbow in the past, but it was a long time ago. RN #4 stated she had not seen the resident hit his/her arm on the days prior to the injury. Interview with the Director of Nursing (DON) on 07/30/19 at 5:02 PM revealed RN #4 notified her on 07/20/19 that Resident #1 had redness and [MEDICAL CONDITION] to his/her right arm. She stated she assessed the resident's arm and it was red and swollen like [MEDICAL CONDITION]. Further interview with the DON revealed on 07/21/19 when the facility received a report that the resident had a fracture, she initiated an investigation. She stated the facility conducted resident skin assessments. She stated she interviewed staff that were working on 07/21/19, and they did not know what happened to the resident's arm. However, the DON stated she did not do a lot of other staff interviews because RN #4 worked with Resident #1 on 07/19/19 and stated the resident's arm was not injured that day. She stated she did not interview staff on other shifts, or staff that worked with the resident prior to 07/20/19; therefore, she did not determine that the resident's arm was injured on 07/19/19 or how the injury occurred. Furthermore, she stated she felt that they had performed a thorough investigation because once they realized Resident #1's right arm was fractured, they transferred the resident to the emergency room where the fracture was confirmed, and an orthopedic evaluation was recommended. Interview with the Administrator on 07/31/19 at 9:37 PM revealed she was out of town on 07/20/19 and did not return until 07/24/19. She stated she was notified of Resident #1's fracture on 07/21/19 when the addendum radiology report was sent to the facility. She stated she instructed the DON to begin skin assessments on residents with a BIMS score of seven (7) and lower and to begin interviewing residents with a BIMS score of eight (8) and above. The Administrator stated the DON conducted the investigation, So I can't tell you what she did as far as staff interviews. She stated she did not ask staff questions related to Resident #1 because she understood that they had already been conducted. According to the Administrator, the resident's injury was reviewed during the facility's Quality Assurance (QA) meeting on 07/30/19. She stated they were not sure because the injury was not witnessed, but they believed the injury was due to the resident bumping his/her arm on the wall. Interview with Resident #1's Physician/Facility Medical Director on 07/30/19 at 1:52 PM revealed the facility did not notify him that Resident #1 had discoloration and [MEDICAL CONDITION] to his/her right arm until 07/20/19 and he ordered an x-ray. Further interview revealed that staff notified him on 07/21/19 that the resident had a right olecranon fracture. He stated that the type of fracture Resident #1 sustained was typically an exertional fracture, and would not have been caused from the resident hitting/bumping his/her arm against the wall. He stated the facility did not discuss the resident's fracture with him during their investigation. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 08/03/19: 1. Resident #1 was transferred to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. The resident had the orthopedic consultation on 07/24/19 and orders were to continue with a sling as needed, range of motion as tolerated, and to return in two (2) weeks for a follow-up appointment. 2. A complete head-to-toe skin assessment was completed on 07/21/19 for Resident #1 with no other abnormalities noted by the charge nurse. 3. Resident #1's care plan and SRNA care plan were updated to reflect the resident's current needs on 07/21/19 by the MDS Coordinator. 4. All residents with a BIMS score of eight (8) or above were interviewed and asked the following questions: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? Interviews were completed by the Social Services Director on the East Unit on 07/22/19 and on the West Unit on 08/01/19. No concerns were identified. 5. The Charge Nurse/Unit Manager conducted a skin assessment for all residents currently residing on the East Unit on 07/22/19 and on 08/01/19 for all residents on the West Unit with a BIMS score of seven or less to assure there were no concerns with new onset of bruising, skin tears, pressure ulcers, rashes, irregularities of the skin, or other injuries of unknown origin that were not previously reported. No concerns were identified. 6. Starting on 08/01/19, all staff that were not on medical leave were interviewed and asked the following questions: Have you reported any injuries that were not addressed; do you have any knowledge of any abuse that has not been reported; and are you aware of any resident that has untreated pain? All staff answered no to the questions with the exception of one staff member who referenced the current allegation regarding Resident #1 and reporting bruising to a Charge Nurse on 07/19/19. Certified letters were mailed to any staff who were not interviewed prior to 08/02/19 stating that they must contact the facility for questioning prior to working their next scheduled shift. 7. All residents currently residing on the East Unit were assessed for any signs and symptoms of pain, utilizing the Wong Baker Scale or Dementia Pain Scale on 07/22/19 by the Staff Development Coordinator (SDC), Assistant Director of Nursing (ADON), Director of Nursing (DON), and/or Charge Nurse to ensure that residents' pain levels were being treated appropriately. Two (2) elders (residents) complained that they have had long standing pain, but that they manage the pain appropriately on follow-up. All residents currently residing on the West Unit were assessed for any signs and symptoms of pain, on 08/01/19 and no concerns were noted with the pain assessments. 8. On 07/23/19 and 07/24/19, the DON, Unit Manager, ADON, and/or the SDC reviewed x-rays for the past 30 days to assure all residents' x-rays were followed up on appropriately and the resident's physician and family had been contacted. The physician had been notified of abnormal x-rays in a timely manner and no concerns were identified. 9. Beginning on 07/23/19, Monday through Friday, during the Morning Clinical Meeting, the IDT will review telephone orders, SBARs, 24-hour reports, lab and x ray results, and medical records of residents to ensure timely notification to the physician; changes in residents' pain addressed timely; x-rays completed, results obtained, and reported to physician timely; and care plans updated. 10. Daily, beginning 07/23/19, Monday through Friday a stand-down meeting will occur in the afternoon at approximately 3:00 PM where the DON, ADON, SDC, SSD, and/or MDS Coordinator will report on the status of residents for the day and follow up to ensure the following is completed as needed: physician notification; documentation in the medical record; completion of SBARs, Stop and Watch, pain, and/or x ray reports; and care plan updates. The Administrator or designee will attend this meeting to provide oversight and consultation. 11. On 08/01/19 and 08/02/19, the Corporate Consultant educated all facility managers to include the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Maintenance Director, Dietary Director, Rehabilitation Manager, Restorative Nurse, Medical Records Director, and MDS Nurses on the facility's policy and procedure for abuse and reporting, which includes investigative guidelines. A posttest was given after the education was completed with a score of 100%. Anyone who did not score 100% on the posttest was reeducated until a score of 100% was reached. 12. Department Head Managers to include DON, Unit Manager, and SDC were educated by the Corporate Consultant on 07/22/19 on assessing for pain, the pain policy, pain management, 24-hour report, incident and accident policy, lab policy tracking log, documentation in the medical record, updating care plans, following care plans (including SRNA care plans), utilization of the Stop and Watch tool, and the abuse and resident rights policies. Education also included pain assessments; pain policy; assessing for pain; assessing for new, worsening, and different pain; use of the Wong Baker Pain form; 24-hour report policy; updating care plans; notification to MD for any change in condition; completing the SBAR for change in resident condition; follow-up documentation for change in condition; and lab tracking form. 13. The DON, SDC, and/or ADON educated licensed nurses beginning on 07/22/19 regarding physician notification as it occurs throughout the shift, changes in resident condition, pain management, assessing for pain, and documentation to include completing SBARs for change of condition with MD and family notification. Education will continue until current licensed nursing staff are educated. Staff not working as of 07/30/19 will receive education prior to returning to work. Licensed nursing staff on leave will be educated prior to returning to work. Staff members will not return to work until education has been provided. All licensed nurses were educated by 08/02/19. 14. Beginning on 07/22/19 licensed nurses and nurse aides were educated by the DON, SDC, Unit Manager, and/or ADON on pain management, incident and accident policy, following care plans/nurse aide care plans, utilization of the Stop and Watch tool, abuse policy and resident rights policies, and reporting of changes of condition. All education was completed for licensed nurses and nurse aides currently employed with the facility by 08/02/19. 15. Beginning on 08/01/19 and 08/02/19 all non-nursing staff including dietary, housekeeping, and therapy staff were educated on utilization of the Stop and Watch tool and the abuse policy. Any staff member that was not educated prior to 08/02/19, was mailed a certified letter that they must receive the training prior to working again. 16. On 07/22/19 through 07/23/19, the DON audited charts on the East Unit for the past 30 days and on 08/02/19, the Corporate Consultant audited medical records for residents on the West Unit to ensure any documented pain or change in condition had been addressed to include physician notification and care plan revision. Any identified concerns were addressed at that time. 17. Beginning 07/23/19, daily for two (2) weeks, a member of Nursing Administration (including but not limited to the DON, ADON, SDC, MDS Coordinators, and the Restorative Nurse Manager) will visit five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. These audits will be decreased to Monday-Friday starting the week of 08/06/19, and will continue for two (2) weeks. Any issues identified will be addressed by completing a SBAR and physician notification. Results of the audits will be discussed in the Quality Assurance Performance Improvement (QAPI) meeting. 18. Beginning 07/23/19, the Nursing Administration Team will audit ten resident records daily until immediacy is lifted to ensure physician notification and to ensure changes in condition are being addressed by completion of a SBAR, updated care plan, and documentation. Any issues identified will be addressed at the time of discovery. Results of audits will be discussed in QAPI meeting. 19. On 07/23/19, the DON, ADON, Unit Manager, SDC, and MDS Nurse audited care plans for residents with fractures to ensure the care plan was updated and accurate. There are four (4) residents in the facility with fractures. Resident #1's care plan has been updated to reflect the current needs of the resident with current interventions added regarding his/her fracture and potential for pain related to the fracture. 20. On 07/22/19 and 07/23/19, the DON, SDC, and Corporate Consultant reviewed all event manager documentation for the last 30 days for all residents residing on the East Unit, and on 08/02/19 for all residents on the West Unit regarding issues or concerns related to injuries of unknown origin including bruising, skin tears, fractures, skin irregularities, and/or [MEDICAL CONDITION] that had not been previously reported. No concerns were identified. 21. Starting 08/02/19, any issue reported to State Agencies will be reviewed in its entirety by the Corporate Consultant and/or the Regional Vice President to assure that an accurate and thorough investigation has been completed. This will include a review of all resident interviews, resident skin assessments, staff interviews, and/or family interviews, and any other information that may be pertinent to the investigation, to include but not limited to lab/x-ray results, hospital records, physician documentation, and physician interviews. 22. Starting 08/03/19, members of the IDT (including but not limited to, the Administrator, DON, ADON, Unit Manager, Medical Records Director, Dietary Director, Social Services Director, Corporate Consultant, Central Supply Staff, Chaplain, Maintenance Director, Business Office Director, Activities Director, and/or MDS Nurses) will interview five (5) residents with a BIMS score of eight or above to assess for any new concerns regarding care. The following questions will be asked: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? The interviews will occur daily for four (4) weeks, and then decrease to five (5) times per week for one month starting on 09/04/19. 23. Starting 08/03/19, the IDT will conduct five (5) resident skin assessments to assess for any injury of unknown origin or new onset of skin issues including bruising, skin tears, rashes, pressure ulcers, [MEDICAL CONDITION], and/or unknown skin irregularities for residents with a BIMS score of seven (7) or less. Skin assessments will occur daily for four (4) weeks and then decrease to five (5) times a week for one month starting on 09/04/19. 24. Starting 08/03/19, the IDT is interviewing five (5) staff members to determine any new concerns regarding care with the following: Have you reported an injury that was not addressed; do you have any knowledge of any abuse that has not been addressed; and are you aware of any resident that has untreated pain? Interviews will occur daily for four (4) weeks, and then decrease to five (5) times a week for one month starting on 09/04/19. 25. Beginning 07/21/19, the VP of Operations, Corporate Consultant, and Director of Clinical Programs Administrative will provide oversight of the facility daily in person or by phone until removal of immediacy; then weekly for four (4) weeks, and then monthly to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the SBARs/Nurse's Notes for change in condition and care plans occurs daily by the Administrator along with attending the Morning Clinical Meeting and daily stand-down meeting where SBARs and pain assessments are reviewed. 26. A QAPI meeting was held on 07/22/19 with the Medical Director (by phone), Administrator, DON, QA Nurse, SDC, and Unit Managers reviewing the occurrence of Resident #1's fracture and the steps that have been put in place. 27. A QAPI meeting was held on 07/31/19 with the Medical Director and IDT to discuss the above items regarding corrective action for identified issues. 28. Beginning 07/21/19, a QAPI meeting will be held weekly for four (4) weeks until immediacy is removed, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator is providing oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Beginning 07/22/19, Corporate Administrative oversight of the QAPI meeting will be completed by the Corporate Consultant, Director of Clinical Programs, the Regional Vice President of Operations, or member of regional staff daily by telephone or in person until removal of immediacy, then every other week for four (4) weeks, and then monthly. Audits reviewed will include, but not limited to, morning clinical meetings, pain, change in condition, x-rays, and SBARs. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed effective 08/03/19 as alleged by the facility: 1. Review of Resident #1's medical record revealed the facility transferred the resident to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. Further review revealed the resident saw the Orthopedist on 07/24/19 and orders were received to continue utilizing a sling as needed and to provide range of motion as tolerated. 2. Review of Resident #1's medical record revealed a nurse conducted a head-to-toe skin assessment of the resident on 07/21/19 and no other abnormalities were identified. 3. Review of Resident #1's care plan and SRNA care plan revealed they were revised on 07/21/19 regarding the resident's fracture. 4. Review of facility documentation and interview with the Social Services Director on 08/13/19 at 11:09 AM revealed she interviewed all residents with a BIMS score of eight (8) or above regarding any mistreatment or unrelieved pain. No concerns were identified. 5. Review of resident skin assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM, revealed by 08/01/19 a skin assessment had been conducted for all residents with a BIMS score of seven (7) or less. No concerns with injuries of unknown origin were identified. 6. Review of staff interviews and interviews with the Corporate Consultant on 08/13/19 at 12:12 PM and with the DON on 08/13/19 at 1:49 PM revealed Administrative staff interviewed all staff regarding any injuries of unknown origin/abuse or untreated resident pain and no new concerns were identified. Interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, LPN #2 on 08/12/19 at 6:30 PM, SRNA #7 on 08/12/19 at 6:53 PM, SRNA #3 on 08/12/19 at 6:23 PM, SRNA #21 on 08/12/19 at 6:16 PM, SRNA #22 on 08/12/19 at 6:08 PM, and SRNA #23 on 08/12/19 at 5:59 PM revealed Administrative Staff interviewed them regarding their knowledge of any resident mistreatment/pain and all stated they were not aware of any concerns. 7. Review of pain assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM revealed all residents had been reassessed for pain. The staff stated that all residents with pain were being treated appropriately. 8. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM revealed they reviewed all x-ray reports for the past 30 days to assure all residents' x-rays were followed up on appropriately and that the resident's physician and family had been contacted. They stated no concerns were identified and all abnormal x-ray results were followed up on in a timely manner. 9. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed they were meeting daily Monday through Friday to review resident records to ensure any change in resident condition was addressed, x-rays addressed, and care plans revised as needed. 10. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed every afternoon, Monday through Friday, they held a stand-down meeting to report on the status of residents and to follow up to ensure documentation/follow-up was completed for any resident who had a change in condition. Interview with the Administrator on 08/13/19 at 2:21 PM revealed she attended this meeting to provide oversight and consultation. 11. Review of in-service records and post-tests and interview with the Corporate Consultant on 08/13/19 at 12:12 PM revealed on 08/01/19 and 08/02/19, she educated all facility managers regarding the facility's policy and procedure for abuse, which included investigative guidelines. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, the Maintenance Director on 08/13/19 at 12:52 PM, and the MDS Coordinator on 08/13/19 at 11:30 AM, revealed the Corporate Consultant educated them regarding the facility's abuse policy, including conducting an investigation. 12. Review of in-service records and interview with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM, revealed the Corporate Consultant educated them regarding the facility's pain management policy, the 24-hour report, incident and accident policy, lab policy tracking log, abuse policy, resident rights policy, physician notification, and documentation (updating care plans, following care plans, Stop and Watch tool, SBAR). 13. Review of in-service records and interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, and LPN #2 on 08/12/19 at 6:30 PM revealed they had been educated regarding physician notification, changes in resident condition, pain management, assessing for pain, and documentation. 14. Review of in-service records and interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, LPN #2 on 08/12/19 at 6:30 PM, SRNA #16 on 08/12/19 at 7:14 PM, SRNA #7 on 08/12/19 at 6:53 PM, SRNA #3 on 08/12/19 at 6:23 PM, SRNA #21 on 08/12/19 at 6:16 PM, SRNA #22 on 08/12/19 at 6:08 PM, and SRNA #23 on 08/12/19 at 5:59 PM revealed they were educated regarding the facility's pain management policy/procedure, incident and accident policy, abuse policy, resident rights policy, following care plans/nurse aide care plans, utilization of the Stop and Watch tool, and reporting of changes of condition. 15. Review of in-service records and interviews with Housekeeper #1 on 08/13/19 at 12:46 PM, Dietary Aide #1 on 08/13/19 at 11:54 AM, Occupational Therapist #1 on 08/13/19 at 12:03 PM, and the Maintenance Director on 08/13/19 at 12:52 PM revealed they were educated on the utilization of the stop and watch tool and the abuse policy. 16. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM and the DON on 08/13/19 at 1:49 PM revealed they audited resident medical records to ensure the physician was aware and a care plan was in place for any resident who had pain or who had experienced a change in condition. 17. Interview with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed they had been assessing five (5) residents daily to ensure the residents had no untreated pain and no concerns had been identified. Review of Residents #5 and #6's medical records revealed no concerns with untreated/unaddressed pain. 18. Interview with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed they were monitoring ten residents' medical records daily to ensure any change in

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to implement a comprehensive person-centered care plan for two (2) of four (4) sampled residents (Resident #1 and Resident #2). Resident #1 had a care plan that required two (2) staff members to assist the resident with activities of daily living. However, an interview with staff revealed they cared for Resident #1 on 07/18/19 without the assistance of another staff member. Further review of Resident #1's care plan revealed staff were required to report changes in the resident's skin or pain location, type, frequency, and intensity to the resident's physician. Interviews with staff revealed Resident #1 began experiencing right arm pain with bruising and swelling after breakfast on 07/19/19; however, the facility failed to ensure the resident's physician was notified as required by the resident's care plan until 07/20/19 at 3:00 PM, approximately thirty (30) hours later. The resident's physician ordered an x-ray of the resident's arm and on 07/21/19, the facility received a report that the resident's elbow was fractured. The facility's failure to ensure resident care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/19 and was determined to exist on 07/19/19 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697). The facility was notified of the Immediate Jeopardy on 07/25/19. An acceptable Allegation of Compliance was received on 08/06/19, which alleged removal of the Immediate Jeopardy on 08/03/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 08/03/19, prior to exit on 08/13/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697) while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, Resident #2 was care planned to require supervision with walking. However, the resident was permitted to sign out of the facility and walk approximately 350 feet across the road to a retail store unaccompanied and unsupervised by staff. The findings include: Review of the facility's Comprehensive Care Plans Policy, revised 07/19/18, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident with participation from the resident, resident's family, or resident representative. The policy stated the comprehensive care plan was based on a thorough assessment of the resident that included the Resident Assessment Instrument (RAI). Further review revealed the comprehensive care plan was designed to identify the professional services that were responsible for each element of care; aid in preventing or reducing declines in the resident's functional status and/or functional levels; and reflect currently recognized standards of practice for problem areas and conditions. Continued review of the policy revealed the Minimum Data Set (MDS) assessment would be used to assess the resident's clinical condition, cognitive and functional status, and use of services. The care plan interventions would be implemented after consideration of the resident's problem areas and their causes. Interventions would reflect the action, treatment, or procedure to meet the objectives toward achieving the resident's goals. Further review of the policy revealed that care plans were ongoing and revised as information about the resident and the resident's condition changed. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 02/02/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired and not interviewable. The facility also determined that the resident required extensive assistance of two (2) staff members for bed mobility, transfers, toileting, and hygiene. Review of Resident #1's comprehensive care plan for Activities of Daily Living (ADL) care dated 10/15/18, revealed the facility developed an intervention that required two (2) staff members to provide total assistance with bed mobility. However, interview with State Registered Nurse Aide (SRNA) #14 on 07/30/19 at 10:53 AM revealed she was Resident #1's aide on the night shift of 07/18/19, and provided incontinence care and bed mobility for the resident without the assistance of another staff member. According to SRNA #14, Resident #1 only required the assistance of two (2) staff members with bathing, and was not aware the resident required two (2) staff members to provide incontinence care and assist with bed mobility. She stated she provided the care without the assistance of another staff member even though the resident pushed against the staff member when providing care. Continued review of Resident #1's Comprehensive Care Plan dated 10/15/18 revealed nursing staff were required to observe for pain and medicate as needed (PRN) per the resident's physician's orders [REDACTED]. Continued review of Resident #1's Comprehensive Care Plan for Pain dated 10/15/18, revealed the resident had chronic pain as evidenced by crying, moaning, and complaints of generalized pain. Further review revealed the facility developed interventions for the resident that included observing for and reporting signs and symptoms of pain and worsening pain to the nurse; and reporting changes in pain location, type, frequency, and intensity to the resident's physician. Interview with SRNA #9 on 07/29/19 at 7:37 PM revealed that after breakfast on 07/19/19, she noticed that Resident #1's right arm was red and swollen and the resident was babying the arm. Resident #1 stated that his/her arm was sick and would not let SRNA #9 touch his/her arm. She stated she reported the resident's condition immediately to Registered Nurse (RN) #4; however, there was no documented evidence that the resident's physician was notified of the resident's condition as required by the resident's plan of care. Interview with SRNA #13 on 07/30/19 at 10:15 AM, SRNA #11 on 07/29/19 at 8:34 PM, and SRNA #12 on 07/29/19 at 8:48 PM revealed they provided care for the resident during the night shift on 07/19-20/19 and stated they also reported to a nurse (RN #3) that the resident had bruising, swelling, and pain to the right arm. Again, there was no documented evidence that the resident's physician was notified of the resident's bruising/swelling or pain as required by the resident's plan of care. Interview with SRNA #5 on 07/29/19 at 2:25 PM revealed she provided care for Resident #1 during the day shift on 07/20/19. She stated she reported to RN #4 that the resident's right arm was red and swollen and the resident had pain throughout the day. She stated RN #4 assessed the resident; however, she could not recall what time the assessment occurred. Continued review of Resident #1's medical record revealed no documented evidence that Resident #1's physician was notified of the resident's right arm pain, swelling, and discoloration until 07/20/19 at 3:00 PM, approximately thirty (30) hours after the changes to the resident's arm were initially discovered. Review of a Nursing assessment dated [DATE] at 3:00 PM revealed RN #4 documented that Resident #1 had bruising with red edges to the resident's right arm extending from his/her elbow down his/her forearm. Continued review revealed an x-ray was ordered and the results were pending. Interview with RN #3 on 07/29/19 at 7:18 PM and 07/30/19 at 3:14 PM revealed she provided care for Resident #1 during the night of 07/19-20/19, and did not recall anyone reporting that Resident #1 had bruising to his/her arm or pain. According to RN #3, she did not assess Resident #1's arm or notify the resident's physician of any changes in the resident's condition. Interview with RN #4 on 07/29/19 at 7:54 PM revealed that she was Resident #1's nurse for day shift of 07/19/19 and 07/20/19. She stated SRNA #9 reported to her on 07/19/19 that Resident #1 had bruising and [MEDICAL CONDITION] to his/her right arm and was yelling. She stated the resident always yelled, and she did not feel there was anything abnormal. RN #4 stated she completed the resident's weekly skin assessment on 07/19/19 and identified that the resident had right upper arm bruising/discoloration. However, RN #4 stated the resident's arm looked bad and did not believe the resident's pain had changed/was new; therefore, she did not notify Resident #1's physician. Continued interview revealed on 07/20/19, SRNA #5 reported to her that Resident #1 had redness and swelling to his/her right arm and that he/she was experiencing pain. She stated she assessed the resident's arm and it looked worse than it did previously on 07/19/19, and she contacted Resident #1's Physician and received orders for x-rays of the resident's right arm and [MEDICATION NAME] (a narcotic pain medication) as needed (PRN) for pain. She stated the x-ray was obtained on 07/20/19 and she received a radiology report stating the x-ray was negative for a fracture. However, review of an addendum to the x-ray report received on 07/21/19 revealed the resident had a fractured right elbow. Interview with the Director of Nursing (DON) on 07/30/19 at 5:02 PM revealed RN #4 did not notify her of the changes to Resident #1's arm until 07/20/19. She stated the physician was also notified on 07/20/19 and orders were received for x-rays and [MEDICATION NAME] for pain. The DON stated it was the nurse's responsibility to follow up on any staff reports of a change in a resident's condition and to follow the resident's plan of care. She further stated the SRNA care plan and the comprehensive care plan detailed the amount of assistance that residents required for care and that she expected staff to provide the amount of assistance that a resident was assessed to require. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 06/23/15 with [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS assessment revealed the facility assessed the resident to require supervision of one (1) staff member for locomotion off the unit. Review of Resident #2's Comprehensive Care Plan for (MONTH) 2019 revealed the resident required supervision when walking related to [MEDICAL CONDITIONS], Anxiety, and Tremors. Review of a Release of Responsibility for Leave of Absence form for Resident #2 revealed the resident routinely signed out of the facility and went to a retail store located across from the facility on a busy road and approximately 350 feet from the facility, unaccompanied and unsupervised by facility staff. Interview with Resident #2's Power of Attorney (POA) on 08/01/19 at 11:29 AM revealed she did not want Resident #2 to leave the facility unsupervised, and had made her wishes known to the facility on several occasions. However, according to the POA, the facility continued to allow Resident #2 to leave the facility unattended and unsupervised. Continued interview with Resident #2's POA revealed that to her knowledge the facility had failed to provide the resident supervision while ambulating outside of the facility, as required by the resident's plan of care. Interview with the DON on 08/01/19 at 6:26 PM revealed Resident #2 was permitted to sign out of the facility and walk across the road to the store. She stated it was the resident's right to do so if the resident was alert, oriented, and physically capable of walking across the street. However, the DON stated the resident did not want staff to accompany him/her to the store, and that is why the facility failed to follow the resident's plan of care and supervise the resident while ambulating outside the facility. Interview with Resident #2 on 07/31/19 at 3:46 PM, revealed he/she did sign out and walk across the road from the facility to the store. The resident stated he/she did not care if staff accompanied him/her to the store, but knew they did not have the time to do that. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 08/03/19: 1. Resident #1 was transferred to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. The resident had the orthopedic consultation on 07/24/19 and orders were to continue with a sling as needed, range of motion as tolerated, and to return in two (2) weeks for a follow-up appointment. 2. A complete head-to-toe skin assessment was completed on 07/21/19 for Resident #1 with no other abnormalities noted by the charge nurse. 3. Resident #1's care plan and SRNA care plan were updated to reflect the resident's current needs on 07/21/19 by the MDS Coordinator. 4. All residents with a BIMS score of eight (8) or above were interviewed and asked the following questions: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? Interviews were completed by the Social Services Director on the East Unit on 07/22/19 and on the West Unit on 08/01/19. No concerns were identified. 5. The Charge Nurse/Unit Manager conducted a skin assessment for all residents currently residing on the East Unit on 07/22/19 and on 08/01/19 for all residents on the West Unit with a BIMS score of seven or less to assure there were no concerns with new onset of bruising, skin tears, pressure ulcers, rashes, irregularities of the skin, or other injuries of unknown origin that were not previously reported. No concerns were identified. 6. Starting on 08/01/19, all staff that were not on medical leave were interviewed and asked the following questions: Have you reported any injuries that were not addressed; do you have any knowledge of any abuse that has not been reported; and are you aware of any resident that has untreated pain? All staff answered no to the questions with the exception of one staff member who referenced the current allegation regarding Resident #1 and reporting bruising to a Charge Nurse on 07/19/19. Certified letters were mailed to any staff who were not interviewed prior to 08/02/19 stating that they must contact the facility for questioning prior to working their next scheduled shift. 7. All residents currently residing on the East Unit were assessed for any signs and symptoms of pain, utilizing the Wong Baker Scale or Dementia Pain Scale on 07/22/19 by the Staff Development Coordinator (SDC), Assistant Director of Nursing (ADON), Director of Nursing (DON), and/or Charge Nurse to ensure that residents' pain levels were being treated appropriately. Two (2) elders (residents) complained that they have had long standing pain, but that they manage the pain appropriately on follow-up. All residents currently residing on the West Unit were assessed for any signs and symptoms of pain, on 08/01/19 and no concerns were noted with the pain assessments. 8. On 07/23/19 and 07/24/19, the DON, Unit Manager, ADON, and/or the SDC reviewed x-rays for the past 30 days to assure all residents' x-rays were followed up on appropriately and the resident's physician and family had been contacted. The physician had been notified of abnormal x-rays in a timely manner and no concerns were identified. 9. Beginning on 07/23/19, Monday through Friday, during the Morning Clinical Meeting, the IDT will review telephone orders, SBARs, 24-hour reports, lab and x ray results, and medical records of residents to ensure timely notification to the physician; changes in residents' pain addressed timely; x-rays completed, results obtained, and reported to physician timely; and care plans updated. 10. Daily, beginning 07/23/19, Monday through Friday a stand-down meeting will occur in the afternoon at approximately 3:00 PM where the DON, ADON, SDC, SSD, and/or MDS Coordinator will report on the status of residents for the day and follow up to ensure the following is completed as needed: physician notification; documentation in the medical record; completion of SBARs, Stop and Watch, pain, and/or x ray reports; and care plan updates. The Administrator or designee will attend this meeting to provide oversight and consultation. 11. On 08/01/19 and 08/02/19, the Corporate Consultant educated all facility managers to include the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Maintenance Director, Dietary Director, Rehabilitation Manager, Restorative Nurse, Medical Records Director, and MDS Nurses on the facility's policy and procedure for abuse and reporting, which includes investigative guidelines. A posttest was given after the education was completed with a score of 100%. Anyone who did not score 100% on the posttest was reeducated until a score of 100% was reached. 12. Department Head Managers to include DON, Unit Manager, and SDC were educated by the Corporate Consultant on 07/22/19 on assessing for pain, the pain policy, pain management, 24-hour report, incident and accident policy, lab policy tracking log, documentation in the medical record, updating care plans, following care plans (including SRNA care plans), utilization of the Stop and Watch tool, and the abuse and resident rights policies. Education also included pain assessments; pain policy; assessing for pain; assessing for new, worsening, and different pain; use of the Wong Baker Pain form; 24-hour report policy; updating care plans; notification to MD for any change in condition; completing the SBAR for change in resident condition; follow-up documentation for change in condition; and lab tracking form. 13. The DON, SDC, and/or ADON educated licensed nurses beginning on 07/22/19 regarding physician notification as it occurs throughout the shift, changes in resident condition, pain management, assessing for pain, and documentation to include completing SBARs for change of condition with MD and family notification. Education will continue until current licensed nursing staff are educated. Staff not working as of 07/30/19 will receive education prior to returning to work. Licensed nursing staff on leave will be educated prior to returning to work. Staff members will not return to work until education has been provided. All licensed nurses were educated by 08/02/19. 14. Beginning on 07/22/19 licensed nurses and nurse aides were educated by the DON, SDC, Unit Manager, and/or ADON on pain management, incident and accident policy, following care plans/nurse aide care plans, utilization of the Stop and Watch tool, abuse policy and resident rights policies, and reporting of changes of condition. All education was completed for licensed nurses and nurse aides currently employed with the facility by 08/02/19. 15. Beginning on 08/01/19 and 08/02/19 all non-nursing staff including dietary, housekeeping, and therapy staff were educated on utilization of the Stop and Watch tool and the abuse policy. Any staff member that was not educated prior to 08/02/19, was mailed a certified letter that they must receive the training prior to working again. 16. On 07/22/19 through 07/23/19, the DON audited charts on the East Unit for the past 30 days and on 08/02/19, the Corporate Consultant audited medical records for residents on the West Unit to ensure any documented pain or change in condition had been addressed to include physician notification and care plan revision. Any identified concerns were addressed at that time. 17. Beginning 07/23/19, daily for two (2) weeks, a member of Nursing Administration (including but not limited to the DON, ADON, SDC, MDS Coordinators, and the Restorative Nurse Manager) will visit five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. These audits will be decreased to Monday-Friday starting the week of 08/06/19, and will continue for two (2) weeks. Any issues identified will be addressed by completing a SBAR and physician notification. Results of the audits will be discussed in the Quality Assurance Performance Improvement (QAPI) meeting. 18. Beginning 07/23/19, the Nursing Administration Team will audit ten resident records daily until immediacy is lifted to ensure physician notification and to ensure changes in condition are being addressed by completion of a SBAR, updated care plan, and documentation. Any issues identified will be addressed at the time of discovery. Results of audits will be discussed in QAPI meeting. 19. On 07/23/19, the DON, ADON, Unit Manager, SDC, and MDS Nurse audited care plans for residents with fractures to ensure the care plan was updated and accurate. There are four (4) residents in the facility with fractures. Resident #1's care plan has been updated to reflect the current needs of the resident with current interventions added regarding his/her fracture and potential for pain related to the fracture. 20. On 07/22/19 and 07/23/19, the DON, SDC, and Corporate Consultant reviewed all event manager documentation for the last 30 days for all residents residing on the East Unit, and on 08/02/19 for all residents on the West Unit regarding issues or concerns related to injuries of unknown origin including bruising, skin tears, fractures, skin irregularities, and/or [MEDICAL CONDITION] that had not been previously reported. No concerns were identified. 21. Starting 08/02/19, any issue reported to State Agencies will be reviewed in its entirety by the Corporate Consultant and/or the Regional Vice President to assure that an accurate and thorough investigation has been completed. This will include a review of all resident interviews, resident skin assessments, staff interviews, and/or family interviews, and any other information that may be pertinent to the investigation, to include but not limited to lab/x-ray results, hospital records, physician documentation, and physician interviews. 22. Starting 08/03/19, members of the IDT (including but not limited to, the Administrator, DON, ADON, Unit Manager, Medical Records Director, Dietary Director, Social Services Director, Corporate Consultant, Central Supply Staff, Chaplain, Maintenance Director, Business Office Director, Activities Director, and/or MDS Nurses) will interview five (5) residents with a BIMS score of eight or above to assess for any new concerns regarding care. The following questions will be asked: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? The interviews will occur daily for four (4) weeks, and then decrease to five (5) times per week for one month starting on 09/04/19. 23. Starting 08/03/19, the IDT will conduct five (5) resident skin assessments to assess for any injury of unknown origin or new onset of skin issues including bruising, skin tears, rashes, pressure ulcers, [MEDICAL CONDITION], and/or unknown skin irregularities for residents with a BIMS score of seven (7) or less. Skin assessments will occur daily for four (4) weeks and then decrease to five (5) times a week for one month starting on 09/04/19. 24. Starting 08/03/19, the IDT is interviewing five (5) staff members to determine any new concerns regarding care with the following: Have you reported an injury that was not addressed; do you have any knowledge of any abuse that has not been addressed; and are you aware of any resident that has untreated pain? Interviews will occur daily for four (4) weeks, and then decrease to five (5) times a week for one month starting on 09/04/19. 25. Beginning 07/21/19, the VP of Operations, Corporate Consultant, and Director of Clinical Programs Administrative will provide oversight of the facility daily in person or by phone until removal of immediacy; then weekly for four (4) weeks, and then monthly to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the SBARs/Nurse's Notes for change in condition and care plans occurs daily by the Administrator along with attending the Morning Clinical Meeting and daily stand-down meeting where SBARs and pain assessments are reviewed. 26. A QAPI meeting was held on 07/22/19 with the Medical Director (by phone), Administrator, DON, QA Nurse, SDC, and Unit Managers reviewing the occurrence of Resident #1's fracture and the steps that have been put in place. 27. A QAPI meeting was held on 07/31/19 with the Medical Director and IDT to discuss the above items regarding corrective action for identified issues. 28. Beginning 07/21/19, a QAPI meeting will be held weekly for four (4) weeks until immediacy is removed, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator is providing oversight to ensure an effective plan is in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Beginning 07/22/19, Corporate Administrative oversight of the QAPI meeting will be completed by the Corporate Consultant, Director of Clinical Programs, the Regional Vice President of Operations, or member of regional staff daily by telephone or in person until removal of immediacy, then every other week for four (4) weeks, and then monthly. Audits reviewed will include, but not limited to, morning clinical meetings, pain, change in condition, x-rays, and SBARs. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed effective 08/03/19 as alleged by the facility: 1. Review of Resident #1's medical record revealed the facility transferred the resident to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. Further review revealed the resident saw the Orthopedist on 07/24/19 and orders were received to continue utilizing a sling as needed and to provide range of motion as tolerated. 2. Review of Resident #1's medical record revealed a nurse conducted a head-to-toe skin assessment of the resident on 07/21/19 and no other abnormalities were identified. 3. Review of Resident #1's care plan and SRNA care plan revealed they were revised on 07/21/19 regarding the resident's fracture. 4. Review of facility documentation and interview with the Social Services Director on 08/13/19 at 11:09 AM revealed she interviewed all residents with a BIMS score of eight (8) or above regarding any mistreatment or unrelieved pain. No concerns were identified. 5. Review of resident skin assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM, revealed by 08/01/19 a skin assessment had been conducted for all residents with a BIMS score of seven (7) or less. No concerns with injuries of unknown origin were identified. 6. Review of staff interviews and interviews with the Corporate Consultant on 08/13/19 at 12:12 PM and with the DON on 08/13/19 at 1:49 PM revealed Administrative staff interviewed all staff regarding any injuries of unknown origin/abuse or untreated resident pain and no new concerns were identified. Interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, LPN #2 on 08/12/19 at 6:30 PM, SRNA #7 on 08/12/19 at 6:53 PM, SRNA #3 on 08/12/19 at 6:23 PM, SRNA #21 on 08/12/19 at 6:16 PM, SRNA #22 on 08/12/19 at 6:08 PM, and SRNA #23 on 08/12/19 at 5:59 PM revealed Administrative Staff interviewed them regarding their knowledge of any resident mistreatment/pain and all stated they were not aware of any concerns. 7. Review of pain assessments and interviews with Unit Manager #1 on 08/13/19 at 12:31 PM and Unit Manager #2 on 08/13/19 at 10:22 AM revealed all residents had been reassessed for pain. The staff stated that all residents with pain were being treated appropriately. 8. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM revealed they reviewed all x-ray reports for the past 30 days to assure all residents' x-rays were followed up on appropriately and that the resident's physician and family had been contacted. They stated no concerns were identified and all abnormal x-ray results were followed up on in a timely manner. 9. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed they were meeting daily Monday through Friday to review resident records to ensure any change in resident condition was addressed, x-rays addressed, and care plans revised as needed. 10. Interview with the Corporate Consultant on 08/13/19 at 12:12 PM, Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, and the MDS Coordinator on 08/13/19 at 11:30 AM revealed every afternoon, Monday through Friday, they held a stand-down meeting to report on the status of residents and to follow up to ensure documentation/follow-up was completed for any resident who had a change in condition. Interview with the Administrator on 08/13/19 at 2:21 PM revealed she attended this meeting to provide oversight and consultation. 11. Review of in-service records and post-tests and interview with the Corporate Consultant on 08/13/19 at 12:12 PM revealed on 08/01/19 and 08/02/19, she educated all facility managers regarding the facility's policy and procedure for abuse, which included investigative guidelines. Interviews with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, the SDC on 08/13/19 at 11:09 AM, the Maintenance Director on 08/13/19 at 12:52 PM, and the MDS Coordinator on 08/13/19 at 11:30 AM, revealed the Corporate Consultant educated them regarding the facility's abuse policy, including conducting an investigation. 12. Review of in-service records and interview with Unit Manager #1 on 08/13/19 at 12:31 PM, Unit Manager #2 on 08/13/19 at 10:22 AM, the DON on 08/13/19 at 1:49 PM, and the SDC on 08/13/19 at 11:09 AM, revealed the Corporate Consultant educated them regarding the facility's pain management policy, the 24-hour report, incident and accident policy, lab policy tracking log, abuse policy, resident rights policy, physician notification, and documentation (updating care plans, following care plans, Stop and Watch tool, SBAR). 13. Review of in-service records and interviews with RN #3 on 08/12/19 at 7:09 PM, LPN #3 on 08/12/19 at 7:00 PM, RN #4 on 08/12/19 at 6:38 PM, and

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure that pain management was provided consistent with physician orders [REDACTED].#1). On 07/19/19, Resident #1 was noted to have bruising/discoloration to his/her right upper arm. Staff interviews revealed the resident also began showing signs of pain (guarding his/her arm, crying, and moaning with movement) on 07/19/19. However, review of the resident's medical record revealed [REDACTED]. The resident's physician ordered an x-ray of the resident's right arm and ordered [MEDICATION NAME] (a narcotic pain reliever) every six (6) hours as needed for pain on 07/20/19. The x-ray results on 07/21/19 revealed Resident #1 had a fractured elbow; however, the facility failed to assess/treat the resident's pain with the physician ordered [MEDICATION NAME] (narcotic pain medication) from 07/20/19-07/22/19, even though staff stated the resident had pain. The facility's failure to assess and treat resident's pain has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/19 and was determined to exist on 07/19/19 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697). The facility was notified of the Immediate Jeopardy on 07/25/19. An acceptable Allegation of Compliance was received on 08/06/19, which alleged removal of the Immediate Jeopardy on 08/03/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 08/03/19, prior to exit on 08/13/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F697) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Pain Management, revised 09/05/18, revealed each resident identified with pain would have ongoing assessments and monitoring. The policy stated that the facility was committed to preventing and managing pain to the extent possible; recognizing when the resident experienced pain and circumstances when pain could be anticipated; evaluating the existence of pain; and the management or prevention of pain consistent with professional standards of care. The policy stated staff were expected to complete a pain evaluation on each shift and document in the EzMAR (Medication Administration Record) computer system. In addition, the effectiveness of routine pain medication would be monitored through the use of the pain assessment completed every shift. Further review of the policy revealed staff were required to assess when there was a potential for pain, noting the onset, presence, duration, and characteristics of pain. Observations of Resident #1 on 07/29/19 at 11:42 AM and 12:36 PM revealed the resident in bed with his/her right arm in a sling. Review of Resident #1's medical record revealed the facility admitted the resident on 02/02/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. The facility assessed the resident to require extensive assistance of two (2) staff members with bed mobility, transfers, toileting, and hygiene. Continued review of Resident #1's MDS revealed the resident received scheduled pain medication, but did not have any pain at the time of the assessment. Review of Resident #1's Comprehensive Care Plan for Pain dated 10/15/18, revealed the resident had chronic pain as evidenced by crying, moaning, and complaints of pain related to generalized pain. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. According to the documentation, the resident did not have any pain from 07/01/19 through 07/20/19. Review of a Weekly Skin Integrity Evaluation dated 07/19/19 at 3:03 PM revealed Registered Nurse (RN) #4 documented that the resident had bruising/discoloration to his/her right upper arm area. However, review of Resident #1's Medication Administration Record [REDACTED]. Interview with SRNA #9 on 07/29/19 at 7:37 PM revealed she was assigned to care for Resident #1' during day shift on 07/19/19 and after breakfast, the resident would not let her touch his/her arm due to pain. She stated that she noticed that Resident #1's right arm was red, looked like blood was pooling, and was swollen. She stated the resident was babying his/her arm, crying, and was saying that his/her arm was sick. SRNA #9 stated she reported this to RN #4 immediately and RN #4 looked at the resident's arm, without touching it, and stated it was fine. SRNA #9 stated that throughout the shift on 07/19/19, Resident #1 had pain with movement during care. She stated she did not report the resident's pain, discoloration, and swelling to his/her arm to any other staff during her shift, but reported Resident #1's pain and discoloration to the right arm to the oncoming shift on 07/19/19, SRNA #13. Interview with RN #4 on 07/29/19 at 7:54 PM revealed she was Resident #1's nurse during day shift on 07/19/19. She stated that SRNA #9 did report on 07/19/19 that the resident had discoloration to his/her right arm (she could not recall what time). According to RN #4, even though SRNA #9 stated that RN #4 did not assess the resident's arm, RN #4 stated she assessed the resident's right arm (which included range of motion), and the resident did not express or show any signs of pain. However, then she stated that the resident always yelled when he/she was touched and she did not observe anything abnormal with the resident. In addition, RN #4 stated Resident #1 did have discoloration to his/her right arm, but she did not feel that it looked bad. Therefore, she did not notify Resident #1's physician. Interview with SRNA #13 on 07/30/19 at 10:15 AM and 3:26 PM revealed that she cared for Resident #1 during the evening/night shift of 07/19/19. She stated that during shift report on 07/19/19, SRNA #9 reported that Resident #1's right arm was bruised, red, and swollen up toward his/her shoulder and down toward the resident's forearm. She stated that SRNA #9 took her to Resident #1's room and showed her the resident's arm. SRNA #13 stated the resident had pain with movement during care and she stated she reported what she observed to RN #3 immediately. SRNA #13 stated that RN #3 along with KMA #1 came into Resident #1's room while she was providing care to Resident #1's roommate. Continued interview with SRNA #13 revealed that she did not observe RN #3 assess Resident #1 because she was providing care to Resident #1's roommate; however, she stated she heard RN #3 say that the resident's right arm was red and swollen. SRNA #13 stated she tried not to move the resident's arm that night when she provided care to prevent the resident from having increased pain. Interview with SRNA #11 on 07/29/19 at 8:34 PM revealed he and SRNA #12 gave Resident #1 a bed bath on the evening/night shift of 07/19/19. He stated when preparing to give Resident #1 a bed bath, he observed discoloration, redness, bruising, and [MEDICAL CONDITION] to the resident's right upper arm, elbow, and forearm. He stated the resident also had pain with movement (whimpering and crying). SRNA #11 stated that he and SRNA #12 went to RN #3 and reported their concerns prior to completing the resident's bath. He stated RN #3 looked at the resident's arm and stated that she would report it to the oncoming day shift nurse so that an x-ray could be obtained. He stated he was not aware what happened with the resident after he completed the resident's bath. Interview with SRNA #12 on 07/29/19 at 8:48 PM revealed she assisted SRNA #11 on 07/19/19 with Resident #1's bed bath. She stated she observed dark blue/purple bruising with red edges to Resident #1's right arm extending approximately one (1) inch above the resident's right elbow, inside the resident's arm, extending down toward the resident's forearm. She stated the resident did not want to move his/her arm and cried with movement. She stated she and SRNA #11 reported Resident #1's condition to RN #3 and stated that RN #3 looked at the resident's arm. SRNA #12 stated she was not aware what happened after that because she left for the evening after Resident #1's bath. Interview with Kentucky Medication Aide (KMA) #1 on 07/30/19 at 3:37 PM revealed during the night shift of 07/19/19, she observed Resident #1's right arm and stated that it was warm to touch, red, and swollen. She stated RN #3 was with her during the observation and told her that staff should be careful with the resident's arm until they could get an x-ray the next day (07/20/19). She further stated that she could not remember if the resident was experiencing pain when she observed the resident's arm. However, continued review of Resident #1's MAR for 07/19/19 revealed no documented evidence that RN #3 assessed Resident #1's pain during the evening/night shift as required. In addition, the resident's medical record contained no documented evidence that RN #3 assessed the resident's arm or assessed the resident's pain. Interview with RN #3 on 07/29/19 at 7:18 PM and 07/30/19 at 3:14 PM revealed she was Resident #1's nurse on the evening/night shift of 07/19/19. However, RN #3 denied that staff reported any changes with Resident #1's condition during shift report or during the shift, including bruising or [MEDICAL CONDITION] to the right arm. RN #3 also denied that the resident had pain and stated she did not assess the resident's right arm. Interview with SRNA #5 on 07/29/19 at 2:25 PM revealed she provided care for Resident #1 during the day shift on 07/20/19. She stated she and another aide (could not remember the aide's name) were providing care to Resident #1 and the resident was saying ouch when they provided care and the resident's arm was swollen and red. Continued interview with SRNA #5 revealed she reported the change to RN #4, who assessed the resident's arm immediately. She stated she could not recall what time she reported her concerns to RN #4. Review of a Nursing assessment dated [DATE] at 3:00 PM revealed RN #4 documented that SRNA #5 reported the resident had bruising with red edges to the resident's right arm extending from his/her elbow down his/her forearm. Even though SRNA #5 stated the resident had pain, RN #4's note stated the resident had no pain. Continued review revealed an x-ray was ordered and the results were pending. Review of Resident #1's Physician order [REDACTED]. Continued interview with RN #4 on 07/29/19 at 7:54 PM revealed that on 07/20/19, she cared for Resident #1 during day shift. She stated SRNA #5 reported that Resident #1 had bruising and [MEDICAL CONDITION] to his/her right arm. She stated she assessed the resident's arm and observed that the resident's arm looked worse than the day before. She further stated the resident did not have any signs of pain when she assessed his/her right arm on 07/20/19; however, she obtained an order on 07/20/19 for [MEDICATION NAME] pain medication in case the resident experienced pain. Review of Resident #1's radiology report dated 07/20/19 revealed the resident had an x-ray of the right upper arm, elbow, and forearm. According to the report, no negative findings (fractures) were identified. However, a review of an addendum radiology report received on 07/21/19 revealed the resident had a linear fracture involving the olecranon (elbow) with minimal displacement and significant swelling of the right upper arm and right elbow. Continued review of Resident #1's MAR indicated [REDACTED]. Interview with LPN #6 on 07/31/19 at 8:49 PM revealed she was Resident #1's nurse on 07/21/19 during day shift when the addendum x-ray was received for Resident #1 that stated the resident had an acute right olecranon fracture. She stated she assessed Resident #1's right arm and could tell that the resident was having pain with movement because he/she groaned, grimaced, and tried to prevent the LPN from moving his/her arm. She stated, however, that she did not give the resident [MEDICATION NAME] pain medication because the resident only had pain with movement. She stated if the resident's arm was not moved, he/she did not experience pain. Continued review of Resident #1's medical record revealed nursing health status notes dated 07/21/19 at 8:54 PM, which revealed RN #3 documented that Resident #1 returned to the facility from the hospital at 7:30 PM and was noted to have a fracture of his/her right arm, but denied pain and was not grimacing. Further review of Resident #1's medical record revealed RN #3 documented on 07/22/19 at 1:09 AM, 3:11 AM, and 6:21 AM that the resident was sleeping with no signs of pain observed. However, interview with SRNA #11 on 07/31/19 at 7:58 PM revealed Resident #1 had pain to the right arm when he provided care for the resident during the night shift on 07/21-22/19. He stated the resident would hold his/her arm and moan. He stated he specifically asked the resident if he/she was in pain and the resident stated yes. Continued interview with SRNA #11 revealed he tried to be careful with the resident when he was providing ADL care. He stated he reported the resident's pain to the resident's nurse; however, he could not remember the nurse's name. He further stated that he did not know if the nurse assessed the resident or gave him/her anything for pain after he reported it to her. Interview with RN #3 on 07/31/19 at 7:14 PM revealed she was Resident #1's nurse during the night shift of 07/21/19. She stated once she knew that Resident #1's arm was fractured, she assessed the resident for pain numerous times during her shift; however, RN #3 stated that the resident did not voice any pain or show signs of pain. According to RN #3, staff did not report that the resident was experiencing pain with movement during the night of 07/21/19. Review of nursing health status notes dated 07/22/19 at 10:05 AM revealed LPN #2 documented that Resident #1 was resting well in bed with no distress noted and no signs of pain or discomfort. The note stated that the scheduled Tylenol administered that morning was effective. Continued review revealed at 3:30 PM on 07/22/19, LPN #2 documented that Resident #1 was resting comfortably in bed with no signs of pain or discomfort voiced. In addition, review of Resident #1's MAR indicated [REDACTED]. However, interview with SRNA #4 on 07/31/19 at 7:48 PM revealed she was Resident #1's aide during day shift on 07/22/19 and she stated the resident had major pain when staff provided care. She stated the resident would scream if staff even touched the top of his/her arm. She stated she reported the resident's pain to the resident's nurse: however, she was not sure if his/her nurse assessed the resident or gave him/her pain medication. Interview with LPN #2 on 07/31/19 at 7:05 PM revealed she was Resident #1's nurse for day shift on 07/22/19. She stated she assessed the resident's pain every four (4) hours during her shift, and the resident did not express any signs of pain. She further stated that no staff reported that the resident was experiencing pain with movement. Even though LPN #2 stated she assessed the resident, she stated if staff had reported the resident was experiencing pain, she would have assessed the resident and administered the resident's pain medication. Interview with Resident #1's physician/the facility Medical Director on 07/30/19 at 1:52 PM revealed facility staff should have notified him on 07/19/19 when the resident initially began experiencing pain and he would have prescribed narcotic pain medication to treat the resident's pain. He further stated that staff should have assessed and administered the [MEDICATION NAME] to Resident #1 once it was ordered if the resident was experiencing pain. Interview with the Unit Manager (UM) on 07/30/19 at 3:56 PM revealed Resident #1's cognition fluctuated from day to day and the resident could not always communicate that he/she had pain; therefore, staff had to assess the resident's nonverbal cues (moaning, guarding, crying). Interview with the Director of Nursing (DON) on 07/30/19 at 5:02 PM revealed that she was notified on 07/20/19 of discoloration and [MEDICAL CONDITION] to Resident #1's right arm and the resident did not moan or appear to be in pain with movement at that time. The DON stated Resident #1 flinched during the assessment, but that was not abnormal for the resident. According to the DON, staff should have assessed Resident #1 for pain at a minimum of every shift. She stated if the resident was experiencing pain, staff should have assessed the resident's pain and administered [MEDICATION NAME] to the resident to treat his/her pain. She further stated that if Resident #1 was assessed to have moderate pain on 07/21/19, whether or not the resident experienced pain with movement only, the resident should have been treated. Interview with the Administrator on 07/31/19 at 9:37 PM revealed staff should have assessed Resident #1 for pain every shift and if the resident was experiencing new or worsened pain, staff were expected to treat the resident's pain. Further interview with the Administrator revealed she was shocked that nursing staff assessed Resident #1 to have moderate pain with movement on 07/21/19 and failed to administer prescribed [MEDICATION NAME] to treat the resident's pain. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 08/03/19: 1. Resident #1 was transferred to the hospital on [DATE] where the fracture was confirmed and orders were received for an orthopedic consultation. The resident had the orthopedic consultation on 07/24/19 and orders were to continue with a sling as needed, range of motion as tolerated, and to return in two (2) weeks for a follow-up appointment. 2. A complete head-to-toe skin assessment was completed on 07/21/19 for Resident #1 with no other abnormalities noted by the charge nurse. 3. Resident #1's care plan and SRNA care plan were updated to reflect the resident's current needs on 07/21/19 by the MDS Coordinator. 4. All residents with a BIMS score of eight (8) or above were interviewed and asked the following questions: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? Interviews were completed by the Social Services Director on the East Unit on 07/22/19 and on the West Unit on 08/01/19. No concerns were identified. 5. The Charge Nurse/Unit Manager conducted a skin assessment for all residents currently residing on the East Unit on 07/22/19 and on 08/01/19 for all residents on the West Unit with a BIMS score of seven or less to assure there were no concerns with new onset of bruising, skin tears, pressure ulcers, rashes, irregularities of the skin, or other injuries of unknown origin that were not previously reported. No concerns were identified. 6. Starting on 08/01/19, all staff that were not on medical leave were interviewed and asked the following questions: Have you reported any injuries that were not addressed; do you have any knowledge of any abuse that has not been reported; and are you aware of any resident that has untreated pain? All staff answered no to the questions with the exception of one staff member who referenced the current allegation regarding Resident #1 and reporting bruising to a Charge Nurse on 07/19/19. Certified letters were mailed to any staff who were not interviewed prior to 08/02/19 stating that they must contact the facility for questioning prior to working their next scheduled shift. 7. All residents currently residing on the East Unit were assessed for any signs and symptoms of pain, utilizing the Wong Baker Scale or Dementia Pain Scale on 07/22/19 by the Staff Development Coordinator (SDC), Assistant Director of Nursing (ADON), Director of Nursing (DON), and/or Charge Nurse to ensure that residents' pain levels were being treated appropriately. Two (2) elders (residents) complained that they have had long standing pain, but that they manage the pain appropriately on follow-up. All residents currently residing on the West Unit were assessed for any signs and symptoms of pain, on 08/01/19 and no concerns were noted with the pain assessments. 8. On 07/23/19 and 07/24/19, the DON, Unit Manager, ADON, and/or the SDC reviewed x-rays for the past 30 days to assure all residents' x-rays were followed up on appropriately and the resident's physician and family had been contacted. The physician had been notified of abnormal x-rays in a timely manner and no concerns were identified. 9. Beginning on 07/23/19, Monday through Friday, during the Morning Clinical Meeting, the IDT will review telephone orders, SBARs, 24-hour reports, lab and x ray results, and medical records of residents to ensure timely notification to the physician; changes in residents' pain addressed timely; x-rays completed, results obtained, and reported to physician timely; and care plans updated. 10. Daily, beginning 07/23/19, Monday through Friday a stand-down meeting will occur in the afternoon at approximately 3:00 PM where the DON, ADON, SDC, SSD, and/or MDS Coordinator will report on the status of residents for the day and follow up to ensure the following is completed as needed: physician notification; documentation in the medical record; completion of SBARs, Stop and Watch, pain, and/or x ray reports; and care plan updates. The Administrator or designee will attend this meeting to provide oversight and consultation. 11. On 08/01/19 and 08/02/19, the Corporate Consultant educated all facility managers to include the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Maintenance Director, Dietary Director, Rehabilitation Manager, Restorative Nurse, Medical Records Director, and MDS Nurses on the facility's policy and procedure for abuse and reporting, which includes investigative guidelines. A posttest was given after the education was completed with a score of 100%. Anyone who did not score 100% on the posttest was reeducated until a score of 100% was reached. 12. Department Head Managers to include DON, Unit Manager, and SDC were educated by the Corporate Consultant on 07/22/19 on assessing for pain, the pain policy, pain management, 24-hour report, incident and accident policy, lab policy tracking log, documentation in the medical record, updating care plans, following care plans (including SRNA care plans), utilization of the Stop and Watch tool, and the abuse and resident rights policies. Education also included pain assessments; pain policy; assessing for pain; assessing for new, worsening, and different pain; use of the Wong Baker Pain form; 24-hour report policy; updating care plans; notification to MD for any change in condition; completing the SBAR for change in resident condition; follow-up documentation for change in condition; and lab tracking form. 13. The DON, SDC, and/or ADON educated licensed nurses beginning on 07/22/19 regarding physician notification as it occurs throughout the shift, changes in resident condition, pain management, assessing for pain, and documentation to include completing SBARs for change of condition with MD and family notification. Education will continue until current licensed nursing staff are educated. Staff not working as of 07/30/19 will receive education prior to returning to work. Licensed nursing staff on leave will be educated prior to returning to work. Staff members will not return to work until education has been provided. All licensed nurses were educated by 08/02/19. 14. Beginning on 07/22/19 licensed nurses and nurse aides were educated by the DON, SDC, Unit Manager, and/or ADON on pain management, incident and accident policy, following care plans/nurse aide care plans, utilization of the Stop and Watch tool, abuse policy and resident rights policies, and reporting of changes of condition. All education was completed for licensed nurses and nurse aides currently employed with the facility by 08/02/19. 15. Beginning on 08/01/19 and 08/02/19 all non-nursing staff including dietary, housekeeping, and therapy staff were educated on utilization of the Stop and Watch tool and the abuse policy. Any staff member that was not educated prior to 08/02/19, was mailed a certified letter that they must receive the training prior to working again. 16. On 07/22/19 through 07/23/19, the DON audited charts on the East Unit for the past 30 days and on 08/02/19, the Corporate Consultant audited medical records for residents on the West Unit to ensure any documented pain or change in condition had been addressed to include physician notification and care plan revision. Any identified concerns were addressed at that time. 17. Beginning 07/23/19, daily for two (2) weeks, a member of Nursing Administration (including but not limited to the DON, ADON, SDC, MDS Coordinators, and the Restorative Nurse Manager) will visit five (5) residents to assess/evaluate them for new, worsening, or different pain and change in condition. These assessments are performed on different shifts. These audits will be decreased to Monday-Friday starting the week of 08/06/19, and will continue for two (2) weeks. Any issues identified will be addressed by completing a SBAR and physician notification. Results of the audits will be discussed in the Quality Assurance Performance Improvement (QAPI) meeting. 18. Beginning 07/23/19, the Nursing Administration Team will audit ten resident records daily until immediacy is lifted to ensure physician notification and to ensure changes in condition are being addressed by completion of a SBAR, updated care plan, and documentation. Any issues identified will be addressed at the time of discovery. Results of audits will be discussed in QAPI meeting. 19. On 07/23/19, the DON, ADON, Unit Manager, SDC, and MDS Nurse audited care plans for residents with fractures to ensure the care plan was updated and accurate. There are four (4) residents in the facility with fractures. Resident #1's care plan has been updated to reflect the current needs of the resident with current interventions added regarding his/her fracture and potential for pain related to the fracture. 20. On 07/22/19 and 07/23/19, the DON, SDC, and Corporate Consultant reviewed all event manager documentation for the last 30 days for all residents residing on the East Unit, and on 08/02/19 for all residents on the West Unit regarding issues or concerns related to injuries of unknown origin including bruising, skin tears, fractures, skin irregularities, and/or [MEDICAL CONDITION] that had not been previously reported. No concerns were identified. 21. Starting 08/02/19, any issue reported to State Agencies will be reviewed in its entirety by the Corporate Consultant and/or the Regional Vice President to assure that an accurate and thorough investigation has been completed. This will include a review of all resident interviews, resident skin assessments, staff interviews, and/or family interviews, and any other information that may be pertinent to the investigation, to include but not limited to lab/x-ray results, hospital records, physician documentation, and physician interviews. 22. Starting 08/03/19, members of the IDT (including but not limited to, the Administrator, DON, ADON, Unit Manager, Medical Records Director, Dietary Director, Social Services Director, Corporate Consultant, Central Supply Staff, Chaplain, Maintenance Director, Business Office Director, Activities Director, and/or MDS Nurses) will interview five (5) residents with a BIMS score of eight or above to assess for any new concerns regarding care. The following questions will be asked: Has anyone mistreated you; do you have any unrelieved pain; and do you feel safe? The interviews will occur daily for four (4) weeks, and then decrease to five (5) times per week for one month starting on 09/04/19. 23. Starting 08/03/19, the IDT will conduct five (5) resident skin assessments to assess for any injury of unknown origin or new onset of skin issues including bruising, skin tears, rashes, pressure ulcers, [MEDICAL CONDITION], and/or unknown skin irregularities for residents with a BIMS score of seven (7) or less. Skin assessments will occur daily for four (4) weeks and then decrease to five (5) times a week for one month starting on 09/04/19. 24. Starting 08/03/19, the IDT is interviewing five (5) staff members to determine any new concerns regarding care with the following: Have you reported an injury that was not addressed; do you have any knowledge of any abuse that has not been addressed; and are you aware of any resident that has untreated pain? Interviews will occur daily for four (4) weeks, and then decrease to five (5) times a week for one month starting on 09/04/19. 25. Beginning 07/21/19, the VP of Operations, Corporate Consultant, and Director of Clinical Programs Administrative will provide oversight of the facility daily in person or by phone until removal of immediacy; then weekly for four (4) weeks, and then monthly to ensure the above audits are completed and any concerns are addressed. Oversight includes assisting with audits, reviewing charts, reviewing audits, and providing oversight and consultation. Review of the SBARs/Nurse's Notes for change in condition and care plans occurs daily by the Administrator along with attending the Morning Clinical Meeting and daily stand-down meeting where SBARs and pain assessments are reviewed. 26. A QAPI meeting was held on 07/22/19 with the Medical Director (by phone), Administrator, DON, QA Nurse, SDC, and Unit Managers reviewing the occurrence of Resident #1's fracture and the steps that have been put in place. 27. A QAPI meeting was held on 07/31/19 with the Medical Director and IDT to discuss the above items regarding corrective action for identified issues. 28. Beginning 07/21/19, a QAPI meeting will be held weekly for four (4) weeks until immediacy is removed, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QAPI Committee will determine at what frequency any ongoing audits will need to continue. The Administrator is providing oversight to ensure an effective plan is in place to

Based on observation, interview, record review, and policy review, it was determined the facility failed to implement the comprehensive plan of care for one (1) of six (6) sampled residents (Resident #1). The facility developed a plan of care for Resident #1's wandering behavior with interventions of surveillance of resident every 15- 30 minutes .Observe behavior episodes to determine causative factors-time of day, location, person(s) involved. The facility failed to implement the plan of care and observe the resident every 15-30 minutes, and failed to consistently document Resident #1's behavioral symptoms. Resident #1 left the facility without staff knowledge via the dining room exit door on 09/03/18 at approximately 10:48 PM. An off-duty staff member found the resident at approximately 11:22 PM, thirty-four (34) minutes later, lying in a shallow ditch across the street from the facility. Staff were not aware the resident was outside unassisted until the off-duty staff member called the facility to report the incident. The resident was assessed to have abrasions to the knee and arm. The facility's failure to ensure supervision was implemented in accordance with the resident's care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/20/18, and determined to exist on 09/03/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 09/20/18. An acceptable Allegation of Compliance was received on 09/27/18, which alleged removal of the Immediate Jeopardy on 09/26/18. The State Survey Agency determined the Immediate Jeopardy was removed on 09/26/18, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Care Plans - Comprehensive, reviewed on 09/21/16, revealed, The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument .Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying sources(s) of the problem areas(s), rather than addressing only symptoms or triggers. Review of the facility's policy titled, Safety and Supervision of Resident, reviewed on 06/01/15, revealed staff were required to make routine resident checks to help maintain resident safety and well-being. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy further stated the interdisciplinary care team was required to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. According to the policy, the care team would target interventions to reduce the potential for accidents and implement interventions to reduce accident risks and hazards to include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; and ensuring that interventions are implemented and documenting interventions. Review of Resident #1's medical record revealed the facility admitted the resident on 06/26/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated severe cognitive impairment. The MDS also revealed that the resident displayed wandering behavior symptoms on a daily basis. Review of the resident's Admission Nursing assessment dated [DATE], reflected that the resident was at risk for elopement. Review of Resident #1's Comprehensive Plan of Care dated 08/02/18, revealed the facility identified the resident was at risk and had an active behavior problem of wandering (moves with no rational purpose, seemingly oblivious to needs or safety). The goal for the resident was, Will be protected from elopement and/or unsafe wandering. Further review of the care plan revealed the facility developed interventions that included, Surveillance of resident every 15-30 minutes .Observe behavior episodes to determine causative factors-time of day, location, person(s) involved. Observation of Resident #1 on 09/18/18 at 10:05 AM revealed the resident was in his/her room with Hospitality Aide #2. The resident stated he/she had lived at the facility for approximately three (3) years. Resident #1 stated that staff watch me close. Review of Resident #1's Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed staff documented that Resident #1 had behaviors for approximately a two (2) week period at the end of (MONTH) (YEAR) (08/16/18 through 08/29/18). However, further review of the MAR and the nurse's notes revealed the behaviors documented on the MAR did not correspond with the documentation made in the nursing notes, making it difficult to determine what behavior the resident was exhibiting. Review of Resident #1's Nurse's Notes from 08/03/18 through 09/01/18 revealed staff documented thirty-three (33) times that the resident exhibited behaviors. Review of the Nurse's Notes dated 08/21/18 at 12:02 PM, revealed the resident had attempted to get up unassisted on twelve (12) occasions that day. There was no evidence that staff documented the causative factors-time of day, location, or person(s) involved when the resident exhibited a maladaptive behavior as required by the resident's care plan. Further review of Nurse's Notes revealed on 08/24/18 at 4:24 AM, Resident (#1) had several negative behaviors during the shift tonight. (Resident #1) has been up and down most of the night. Several times (Resident #1) has been out of bed ambulating without assistance. (Resident #1) was going into other resident rooms and then would become angry and curse staff when they would inform (him/her) that (he/she) was in someone else's room .During the first med pass, nurse was in the med room switching the med carts and resident was noted to be ambulating up the hall to the nurse's station naked . There was no documented evidence that staff noted the specific time when each of the behaviors occurred, or the person(s) involved as required by the resident's care plan. Review of a Behavior check Monitoring Log revealed fifteen (15) minute checks had been conducted for Resident #1 in twenty-four (24) hour increments on 07/23/18 from 7:00 AM to 6:45 AM on 07/24/18; and on 08/26/18 from 7:00 AM to 6:45 AM on 08/27/18. However, there was no documented evidence that staff were observing the resident every 15 to 30 minutes daily to prevent elopement and/or unsafe wandering as required by the resident's 08/02/18 care plan. Review of a facility investigation revealed on 09/03/18, Resident #1 exited the facility without staff knowledge through an exterior door located in the dining room. A few minutes later a night shift State Registered Nurse Aide (SRNA) responded to the door alarm, but did not notice the resident inside the courtyard. According to the investigation, the facility was not aware Resident #1 was outside unassisted until the facility received a phone call alerting staff that the resident was found outside in front of the facility. Interview with the Director of Nursing (DON) on 09/18/18 at 3:50 PM and with the Administrator on 09/19/18 at 11:40 AM revealed video surveillance footage of the dining room area revealed Resident #1 exited the dining room to the outside at approximately 10:48 PM. The facility was notified at approximately 11:22 PM that the resident was found outside, and the resident was returned inside the facility at 11:33 PM. Interview with State Registered Nurse Aide (SRNA) #5 on 09/18/18 at 12:15 PM revealed she was working on the evening of 09/03/18. According to SRNA #5, SRNA #1 was assigned to Resident #1; however, SRNA #5 stated Resident #1 was not receiving increased supervision prior to the incident. SRNA #5 stated prior to receiving the call that the resident was outside, she had not seen Resident #1 since 7:00 PM to 8:00 PM on 09/03/18. Interview with SRNA #1 on 09/18/18 at 2:10 PM revealed she and SRNA #5 were caring for Resident #1 on 09/03/18. SRNA #1 said they assisted Resident #1 to bed at approximately 9:00 PM, and was not aware the resident was outside unsupervised until someone called the facility at approximately 11:30 PM on 09/03/18. According to the interview, SRNA #1 was not aware that Resident #1's care plan required staff to supervise the resident every 15 to 30 minutes. Interview with Registered Nurse (RN) #1 on 09/18/18 at 2:15 PM revealed she was caring for Resident #1 on 09/03/18. RN #1 stated she last saw Resident #1 on 09/03/18, at approximately 8:00 PM to 8:30 PM, when she administered medications to the resident. The RN stated she did not see the resident again until SRNA #1 told her that Resident #1 was outside. RN #1 stated she was not aware that Resident #1 required increased supervision. Interview with the Director of Nursing (DON) on 09/19/18 at 11:20 AM, and on 10/02/18 at 10:50 AM revealed there had recently been several administrative staff changes and the facility had identified a concern with documentation of resident behavior. The DON also stated the staff member who revised the resident's care plan on 08/02/18 no longer worked for the facility. The DON stated staff were not aware of the intervention to monitor the resident every 15-30 minutes and had no evidence that the intervention was implemented. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 09/26/18: 1. Resident #1 was returned to the facility on [DATE] by staff at approximately 11:33 PM. The Charge Nurse immediately performed an assessment, to include a head-to-toe skin assessment, and found a scrape to the resident's left elbow and knee. The resident voiced no pain or concerns. Vital signs were obtained and were within normal limits. Resident #1 was assisted to bed and fell asleep. The facility staff notified the physician at 2:10 AM on 09/04/18 with new orders received. The resident's Power of Attorney was notified at 4:00 AM on 09/04/18. The Director of Nursing (DON) and Regional Vice President (RVP) were notified at 1:15 AM on 09/04/18. Per the new physician orders, Resident #1 was transferred to a Behavioral Health Unit on 09/05/18, after a Mental Inquest Warrant was obtained. 2. The facility assessed Resident #1 as an elopement risk on 06/26/18 and added the resident to the elopement binder. An elopement care plan was developed. Resident #1 was reassessed for elopement on 09/04/18. Resident #1's care plan and State Registered Nurse Aide (SRNA) care plan were reviewed and updated on 09/04/18 by the DON to reflect 1:1 supervision. 3. On 09/05/18, the Administrator reviewed all doors to ensure the doors had been checked for locking, alarms, mag-lock and delayed egress for the last 30 days. No concerns were identified. 4. All doors in the facility were checked by Maintenance staff and the Administrator on 09/04/18 to ensure the doors were locked and secure and that delayed egress was functioning properly. All doors were noted to be functioning properly. On the initial tour, the door egress key for the dining room door as well as the key located in the east exit door beside the nurses' station were removed. The only stakeholders that will have access to these keys moving forward will be the Charge Nurses, the Plant Operations Staff, and the Facility Administrator. On 09/04/18, the Regional Maintenance Director also completed a 100% audit of all exit doors to ensure all doors were locked, secure, and the delayed egress was functioning. No concerns were noted. 5. The DON immediately reeducated Employee #5 following the incident on 09/04/18 related to what actions to take when a door alarm sounds, and the facility's policy and procedure on elopement. The education also included immediately reporting to the charge nurse when a door alarm sounds, and thoroughly checking the surrounding area where the alarm was sounding. 6. All residents (100%) were reassessed for elopement potential by the DON, Unit Manager (UM), and the Assistant Director of Nursing (ADON) on 09/04/18 following the occurrence. Three (3) residents were identified to be at risk for elopement during the reassessment. The residents' care plans and SRNA care plans were updated to include risk of elopement. Their pictures were taken and added to the elopement binders, per facility policy. 7. All care plans were reviewed and updated by the DON, UM, and ADON with any changes found on the elopement assessment. Elopement binders were reviewed and updated for accuracy by the DON on 09/04/18 to reflect current elopement assessments; and on 09/05/18 to include personalized interventions for each resident identified as being at risk for elopement. 8. On 09/05/18, behavioral management care plans were updated on the eighteen (18) residents assessed to be at risk for elopement, to include interventions for wandering or exit-seeking behaviors. 9. Interviews with staff, residents with Brief Interview for Mental Status (BIMS) scores of 8 and above, and families interviewed as to their knowledge of any prior elopements were initiated on 09/04/18 and completed on 09/04/18 by the Chaplain, UMs, Administrator, and Social Services, with no concerns that could be validated. 10. On 09/04/18 and 09/05/18, a Signature Care Consultant (SCC) conducted a 30-day look back of residents' Electronic Medical Records (EMRs) of all events and 24-hour reports for exit-seeking behaviors. No concerns were identified. 11. The DON, ADON, and SCC completed a 30-day look back of Nurses' Notes for exit-seeking behaviors and/or elopements. No concerns were identified. This was initiated on 09/04/18 and completed 09/05/18. 12. The Administrator, DON, Unit Managers, ADON, Social Services, Admissions Director, Dietary Manager, Minimum Data Set (MDS) Coordinators, Plant Operations, Quality of Life Director, and the Chaplain were educated on 09/04/18 by the SCC on the policies below. This training was performed face to face in order to facilitate discussion and questions. Department Administrative Managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures, and 100% score obtained. If the manager did not score 100% on the post-test, the manager was immediately re-educated and the post-test re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. Detailed and specific training included the following policies/procedures/processes: A. Elopement Policy and Procedure to include a review of the policy and procedure, Elopement/Wandering Assessment, Exit-seeking behaviors, Elopement/wandering Care plan, and Elopement binders. B. Missing Resident Policy and Procedure to include a review of the policy and procedure, process for a missing resident, Code Green, and resident safety. C. Door codes/alarms process to include the purpose of door codes/alarms and the process for responding to alarms to include the following: 1) Respond to Alarm 2) Walk Outside Perimeter 3) Report Active Door Alarm to Charge Nurse 4) Initiate Resident Headcount D. Accident/Incident policy and procedure that included a review of the policy/procedures, resident safety, supervision, and care planning. E. Safety and Supervision policy and procedure to include Increased/Decreased Level of Supervision, implementation of interventions, and Interdisciplinary Team (IDT) Communication. F. Care Plan Policy and Procedure including Elopement/wandering care plan interventions and creating, reviewing, implementing, and following the Care Plan. G. Behavior Management policy and procedure including exit-seeking behaviors, care plan interventions, monitoring, and documentation. H. QAPI (Quality Assurance/Performance Improvement) policy and procedure that includes the following: Process, Identification, Implementation, and Monitoring. 13. Once the Administrator, DON, and Department Managers were re-educated, they began to re-educate the entire staff on the above policies and procedures. The education was initiated on 09/04/18 and was completed for staff on the current working schedule by 09/06/18. On 09/05/18 through 09/06/18, the DON, ADON, or UM educated staff regarding the elopement books and the care plan information located within. Staff was educated to redirect wandering or exit-seeking residents back to their assigned unit and or room and to consult the resident's behavioral management care plan for a list of personalized interventions. This education is ongoing and all employees will be educated prior to working on the floor. Education will be ongoing after 09/06/18 to ensure all employees not educated by 09/05/18, will be educated prior to working the floor. 14. On 09/25/18, the facility held weekly an AD Hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the need for additional education of nursing staff on the Behavioral Management Policy, focusing on documenting elopement/exit-seeking behaviors on the EZMAR (electronic medical record) system. Additional education was started on 09/25/18 and will continue until all facility nurses on staff are educated. Any nurse not educated as of 09/26/18, will be educated prior to the start of their next scheduled shift to ensure education is completed before returning to work. In addition, on 09/25/18 the ADON and UM were re-educated on EZMAR monitoring as part of the daily clinical white board policy to ensure documentation of elopement and or exit-seeking behavior is being done appropriately. Pre and post-tests were administered related to elopement policy and procedures following the education provided. A 100% score was required to be obtained on the post-test before being permitted to continue to provide care in the facility. Staff scheduled after 09/06/18 were reeducated prior to working their next shift with a post-test score requirement of 100%. All post-tests were reviewed for compliance by SCC. Active employees, anyone on vacation, FMLA (Family and Medical Leave Act), or other leave will receive education prior to returning to work and a post-test score of 100%. Education regarding the elopement policy and procedure, to include identification and prevention of exit-seeking behaviors, will be included in the orientation process for all newly hired staff members effective 09/05/18 with a pre and post-test. No newly hired employee will be allowed to work until elopement education is provided. Employee will be immediately re-educated and post-test re-administered. 15. All doors will be checked for proper function each shift for two weeks by a member of the nursing staff, department managers, or plant operations staff beginning 09/04/18. Any concerns will be immediately reported to the Administrator and Plant Ops Director. No concerns were identified during the audits and beginning 09/18/18 the audits were decreased to daily. Maintenance staff will checks doors daily and the department head weekend manager will check them on the weekends. 16. An elopement drill was completed on 09/05/18, by the DON, and will be conducted daily on random shifts, for one week and weekly for four (4) weeks by the Administrator, DON, or Department Head Managers. Then they will be conducted quarterly thereafter. Elopement drills being conducted will ensure that stakeholders are following the Missing Resident Policy and Procedure, specifically, actions to take when a door alarm sounds that include: responding to active door alarms, walking outside the perimeter of the alarming door to ensure no resident is observed outside unattended, reporting to the charge nurse, and initiating a headcount. 17. Following the incident on 09/03/18, all administrative staff received an updated list of all residents that have been assessed to be at risk for elopement. A member of the Administrative staff, including but not limited to: the Chaplain, Medical Records, Central Supply, Housekeeping Director, Dietary Director, Business Office Manager, Assistant Business Office Manager, Quality of Life Director, Assistant Quality of Life Director, or the Office Assistant has been in the building on all shifts. The Administrative staff have been present to ensure the following are completed: post elopement tests; elopement drills; door alarm functionality; facility rounds on West and East units every two hours to ensure care plan interventions are being implemented on residents who had been assessed for risk of elopement. Night Shift Managers were also educated on the updated behavioral management care plans for the residents assessed to be at risk for elopement. A member of the management staff was put on a rotating schedule to work 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM beginning 09/05/18. This managerial oversight will continue for 30 days. 18. The DON, ADON, or UM will monitor all residents, as well as new admissions for evidence of new or worsening exit-seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday-Friday for three (3) months to determine if there are any new exit-seeking behaviors. New Admissions will be assessed for elopement risk and any resident identified as being at risk will be updated in the facility's elopement books. The DON and/or the Administrator has been on-site on Saturdays and/or Sundays since the incident occurred to provide oversight and to ensure the daily reviews have been completed, as outlined in the A[NAME]. The following will be reviewed daily Monday-Friday by the DON, ADON, or Unit Manager to ensure no resident is at risk that has not been identified by the facility: a. Events in event manager b. Clinical Summary 24 hour report c. Review new and readmissions for elopement assessments and updated care plans and elopement book as needed. d. Nurses Notes e. New or worsening exit-seeking and/or wandering behavior tracking f. Care plan interventions for any identified new or worsening exit-seeking and/or wandering behavior. g. EZMAR monitoring starting on 09/25/18 19. Beginning 09/05/18, the following elopement testing will be completed and the employee must make a 100%, if not they must be re-educated and re-tested until 100% obtained. Five (5) employees per shift (10 per day) for two (2) weeks; three (3) employees per shift for 1 week (6 per day), two (2) employees per shift for 1 week (4 per day), 1 employee per shift for 1 week (total 2/day), 1 employee per week for four (4) weeks (1 per week), and 1 employee every other week for four (4) weeks (one every other week). 20. A nurse from the regional team or corporate office and/or the VP of Operations has been available on-site Monday through Friday since 09/04/18. Regional resources have been available by phone during the weekend as needed. The Administrator and Director of Nursing have been on-site on weekends (Saturday and Sundays) since 09/03/18 to ensure continued compliance with audits established by the Quality Assurance Performance Improvement (QAPI) Committee. The nurses from the regional team or from the home office are assisting the facility's Director of Nursing, Assistant Director of Nursing, and Unit Manager with audits recommended from the QAPI Committee. Additionally, the regional nurses are reviewing facility implementation of care plans updated on 09/05/18 to ensure delivery of care being given matches that of the care plan. This review is being conducted daily Monday-Friday. The Director of Nursing is monitoring on weekends, and includes all residents that have been identified as being at risk for elopement. Oversight is being conducted in the form of reviewing the administrative audit tools daily, since the event occurred, to ensure completion of audits. These audits include the night shift manager calendar, elopement tests, elopement drills, reviewing elopement assessments on new admissions, reviewing nurses' notes, event manager, twenty-four hour reports to look for evidence of new or worsening wandering/exit-seeking behavior, and to ensure elopement books and care plans were updated when identified. Also ensuring care plan interventions were being implemented on residents who had been assessed for risk of elopement. Reviewing facility established audits to ensure compliance with a set forth plan created by the facility's QAPI Committee. A nurse from the regional team or home office has attended the facility's weekly AD Hoc QA meetings. 21. The Administrator will review daily to ensure all areas of correction, education, ongoing post-tests, drills, and audits are completed as outlined in the A[NAME]. The Administrator will be notified immediately of any concerns identified with ongoing monitoring/corrective measures taken as a result of the elopement that occurred in the facility. The Administrator will then discuss all concerns with the RVP of operations immediately. 22. A QAPI meeting was conducted following the incident on 09/04/18, regarding immediate action taken, as well as the facility's plan to ensure compliance was discussed in its entirety. A QAPI meeting was conducted on 09/10/18, 09/17/18, and 09/25/18 to discuss audits, post-test, ongoing monitoring and current plan, and discussion for any needed revisions to the plan. Recommendations were made during the 09/25/18 QAPI meeting for improvements in the ongoing exit-seeking monitoring. A QAPI meeting with the following attendees: Administrator, DON, ADON, UM, Social Services, MDS, Plant Ops, Dietary Manager, and Medical Director will occur weekly for four (4) weeks. Results of all the above audits and post-tests will be reviewed and reported to the committee members to assist in ensuring compliance with the facility's ongoing plan. Any concerns noted will have recommendations for increased monitoring and/or education. The SCC and RVP will be in attendance during these four (4) weeks to validate compliance with this plan. ****The State Agency determined Immediate Jeopardy was removed on 09/26/18 based on the following: 1. Interview with Registered Nurse (RN) #1 on 09/18/18 at 2:15 PM, and the Director of Nursing (DON) on 09/18/18 at 3:50 PM, and record review revealed the facility was notified at approximately 11:22 PM that Resident #1 was outside and the resident was returned inside the facility at 11:33 PM. The resident was assessed to have abrasions to the elbow and knee. The notifications of the physician, DON, and family were confirmed via record review. Further review of the record revealed the resident was transferred to a behavioral health unit on 09/05/18. 2. Record review and interview with the DON on 09/18/18 at 3:50 PM and on 10/01/18 at 10:50 AM, revealed Resident #1 was assessed on 06/26/18, 09/04/18, and 09/12/18 to be at risk for elopement. Interview revealed the resident was added to the elopement binder located at each nurses' station. On 09/18/18 at 11:05 AM, the elopement binders with pictures of residents at risk for elopement were observed at each nurses' station. Review of Resident #1's care plan revealed the facility updated the care plan with an intervention for 1:1 supervision. Observation of Resident #1 on 09/18/18 at 10:05 AM, 11:32 AM, and 1:57 PM, and on 09/19/18 at 11:05 AM, 12:46 PM, and 2:21 PM revealed staff were supervising the resident 1:1. 3. Record review and interview with RN #1 on 10/01/18 at 4:35 PM and LPN #3 on 10/01/18 at 4:40 PM, revealed a head count of all residents was performed on 09/04/18 after Resident #1 was returned to the facility. All residents were present in the facility. 4. Record review and interview with the Administrator on 10/02/18 at 11:34 AM revealed all doors were checked on 09/04/18 to ensure the doors were secure and functioning properly. The Administrator stated the Corporate Regional Maintenance Director also completed a 100% audit of all exit doors to ensure the doors were secure and functioning. Two (2) keys were found in the alarm reset boxes located on two (2) exit doors. One of the doors was the dining room exit door. The keys to reset these door alarms were removed and interview with the Administrator and other staff (SRNA #12 on 10/01/18 at 4:10 PM, SRNA #7 on 10/01/18 at 3:55 PM, LPN #4 on 10/01/18 at 3:35 PM, SRNA #13 on 10/01/18 at 4:02 PM, LPN #2 on 10/01/18 at 3:15 PM, and LPN #5 on 10/01/18 at 3:00 PM) confirmed these keys were not to be left in the boxes. All staff stated the nurse now has the keys to reset the alarms. Observation on 09/18/18 at 10:00 AM revealed no keys were observed in the reset boxes on the exit doors. 5. Interview with the DON on 10/02/18 at 10:50 AM and record review revealed the DON educated and conducted a counseling session with SRNA #5 on 09/04/18. The education included following the Elopement policy/procedure and what to do if a door alarm sounded. Interview with SRNA #5 on 10/02/18 at 9:40 AM revealed she received training after the incident with Resident #1 related to what to do if a door alarm sounded. SRNA #5 stated she also received training on plans of correction and missing persons. 6. Record review and interview with the DON on 10/02/18 at 10:50 AM, the Assistant Director of Nursing (ADON) on 10/01/18 at 5:25 PM, and the Unit Manager (UM) on 10/01/18 at 5:15 PM revealed all residents were reassessed on 09/04/18 and 09/05/18 for elopement risk. Record review of Resident #1, Resident #2, and Resident #3's medical records revealed an Elopement Risk Evaluation had been completed on each resident and added to the elopement binders on 09/04/18. The DON also stated staff were educated on binder updates and the updates to the residents' plan of care. 7. Interview with the DON on 10/02/18 at 10:50 AM, the Assistant Director of Nursing (ADON) on 10/01/18 at 5:25 PM, and the Unit Manager (UM) on 10/01/18 at 5:15 PM, revealed all resident care plans were reviewed and revised as needed on 09/04/18. The DON stated the facility reviewed and updated the plan of care for all residents with wandering/exit-seeking behaviors by 09/05/18. Review of Resident #1, Resident #2, and Resident #3's care plan revealed all were updated on 09/05/18 related to the resident's risk for elopement. 8. Record review and interview with the DON on 10/02/18 at 10:50 AM, the Assistant Director of Nursing (ADON) on 10/01/18 at 5:25 PM, and the Unit Manager (UM) on 10/01/18 at 5:15 PM revealed the behavior management care plans were updated on 09/05/18 for all residents at risk for elopement. 9. Review of interviews conducted by the facility and interview with the Administrator on 10/02/18 at 11:34 AM, SRNA #10 on 10/01/18 at 4:18 PM, SRNA #12 on 10/01/18 at 4:10 PM, LPN #4 on 10/01/18 at 3:35 PM, LPN #5 on 10/01/18 at 3:00 PM, SRNA #13 on 10/01/18 at 4:02 PM, and LPN #2 on 10/01/18 at 3:15 PM revealed staff, residents, and families were interviewed related to their knowledge of any prior elopements. None were identified. 10. Record review and interview with the Signature Care Consultant (SCC) on 10/02/18 at 11:58 AM, revealed she conducted a 30-day look back of 24-hour reports and events documented in the Electronic Medical Records (EMRs) for exit-seeking behaviors that had occurred in the facility. Documentation and interview revealed this review was conducted on 09/04/18 and 09/05/18 with no concerns identified

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of six (6) sampled residents (Resident #1). On 09/03/18, at approximately 10:48 PM, staff heard the dining room exit door alarm sounding, responded to the alarm, but failed to look outside the facility to ensure a resident had not exited the building. The staff member who turned off the alarm was unaware that Resident #1 (assessed to be at risk for elopement) was outside the facility. An off-duty staff member was walking down the street, heard the resident yell, and found Resident #1 lying in a shallow ditch across the street from the facility. The off-duty staff member assisted the resident across the street and at approximately 11:22 PM, thirty-four (34) minutes after the door alarm sounded, called the facility to notify them that Resident #1 was outside. Facility staff assisted the resident back inside the facility and assessed the resident to have small abrasions to the elbow and knee. In addition, the facility failed to ensure supervision was provided to prevent falls for Resident #1. The facility failed to determine the root cause of the resident's falls and implement interventions based on the risk factors. Further, the facility developed an intervention to supervise Resident #1 every fifteen (15) minutes; however, the facility failed to implement this intervention and Resident #1 sustained thirty (30) falls with no significant injury from 06/26/18 through 09/13/18. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/20/18, and determined to exist on 09/03/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 09/20/18. An acceptable Allegation of Compliance was received on 09/27/18, which alleged removal of the Immediate Jeopardy on 09/26/18. The State Survey Agency determined the Immediate Jeopardy was removed on 09/26/18, prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Elopement/Wandering, reviewed on 05/30/18, revealed, An elopement/wandering assessment will be completed upon admission, located in the nursing admission information packet, and quarterly thereafter .Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services, kept at nurse's station and receptionist desk. Updates will be done quarterly. If a resident is identified as missing, refer to the missing resident procedure. Review of the Missing Resident policy, reviewed 05/30/18, revealed, Notify the charge nurse and nursing staff when a resident is suspected of being missing. Notify the supervisor, Director of Nursing, Administrator, RVP, and SCC .Identify the missing resident to stakeholders and a staff member will immediately check all exit doors. Have available copies of the resident's photograph for those unfamiliar with the identified resident. An exhaustive search of the facility will be conducted to include the following: .Assign two or more personnel to check the area immediately outside the facility including the parking lot and the grounds surrounding the facility. Personnel should go around the facility in opposite directions. When they meet, they should return inside for reassignment. Further review of the policies revealed the policies did not address the staff's responsibility when an exit door alarm sounded. Interview with the Administrator on 09/20/18 at 2:45 PM and the Director of Nursing (DON) on 09/18/18 at 3:50 PM, revealed when an exit door alarm sounded, staff were required to respond to the alarm, check the door, and look for the resident who activated the alarm, including searching outside the facility. Review of Resident #1's medical record revealed the facility admitted the resident on 06/26/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated severe cognitive impairment. The resident was also assessed to display wandering behavior symptoms on a daily basis. Continued review of the MDS assessment revealed the resident required assistance of two (2) staff members for ambulation. The assessment also revealed Resident #1 was Not steady, only able to stabilize with staff assistance during walking, moving from a standing to sitting position, and during surface-to-surface transfers (transfer between bed and chair or wheelchair). The MDS assessment also revealed the resident utilized a wheelchair. Review of an Admission Nursing assessment dated [DATE] for Resident #1 revealed the facility assessed the resident to be at risk for elopement. Resident #1 was observed on 09/18/18 at 10:05 AM in his/her room with Hospitality Aide #2. The resident stated he/she had been in the facility approximately three (3) years and staff watch me close. When asked about the incident, the resident stated, When I left, I left. I didn't know where I was going. Further observations of Resident #1 on 09/18/18 at 11:32 AM and 1:57 PM, and on 09/19/18 at 11:05 AM, 12:46 PM, and 2:21 PM revealed the resident was in his/her bed or up in a wheelchair in his/her room. A facility staff member was with the resident during each observation either inside the resident's room or sitting just outside the doorway to the resident's room. Review of a facility investigation revealed on 09/03/18, Resident #1 exited the facility through the exterior door located in the dining room without staff knowledge. According to the investigation, the exit door alarm sounded and a few minutes after the alarm sounded a night shift State Registered Nurse Aide (SRNA) responded to the door alarm, but did not notice the resident inside the courtyard. According to the investigation, the facility received a phone call alerting staff that the resident was on the sidewalk in front of the facility. The investigation revealed facility staff responded and escorted the resident back inside. The Charge Nurse conducted a head to toe assessment of the resident and abrasions were noted to the resident's elbow and knee. The investigation further revealed the resident was wearing pajama pants and a long sleeve shirt when he/she was found. The temperature outside was 71-73 degrees Fahrenheit. Review of the incident/event documentation dated 09/03/18 at 10:45 PM, revealed the resident was also wearing nonskid socks. Interview with the DON on 09/18/18 at 3:50 PM and the Administrator on 09/19/18 at 11:40 AM revealed the facility had video footage of the dining room area where Resident #1 exited the facility on 09/03/18. The staff stated that based on the video footage, the resident exited the dining area to the outside at approximately 10:48 PM. The SRNA responded to the door alarm and turned off the alarm at 10:50 PM. The staff stated the facility was notified at approximately 11:22 PM on 09/03/18 that Resident #1 was outside. According to the video footage, the resident returned to the facility at 11:33 PM. Observation of the exit doors and interview with the Administrator and Plant Operation Director on 09/18/18 at 10:00 AM, revealed the exit door in the dining room was equipped with a bar across the door that released (unlocked) the door when pressed and held for fifteen (15) seconds. The Plant Operation Director demonstrated by opening the dining room door and the alarm sounded loudly when opened. The alarm was reset by inserting a key into a box located on the upper portion of the doorframe. According to the Administrator and Plant Operation Director, the key to reset the dining room door alarm was left in the box prior to this incident. Observation of the area outside the dining room exit door revealed there was a sidewalk that led to a smoking area, and continued to a sidewalk that ran alongside Main Street. The distance from the dining room exit door to Main Street was less than 100 feet. Interview with SRNA #5 on 09/18/18 at 12:15 PM revealed she was working on the evening of 09/03/18. She stated another SRNA (SRNA #1) was assigned to care for Resident #1. SRNA #5 stated she was providing care in another resident's room at approximately 10:00 PM on 09/03/18, and heard a door alarm sounding. The SRNA stated she initially did not know which alarm was sounding, but searched and discovered the door in the back of the dining room was alarming. SRNA #5 stated she saw an empty wheelchair sitting outside the door, but she did not see anything else because it was dark outside. Further interview revealed she turned off the door alarm, but failed to look outside to ensure a resident had not exited the building. The SRNA stated she had been trained to look outside the building if an exit door alarm sounded, but she failed to do so on 09/03/18. SRNA #5 stated staff were also required to do a head count of residents to ensure no resident was missing, but she failed to do the count also. The SRNA stated, I can't tell you why I didn't do it. According to the SRNA, prior to the resident leaving the facility without staff knowledge, she had last seen Resident #1 at approximately 7:00 PM to 8:00 PM. Interview with SRNA #1 on 09/18/18 at 2:10 PM, revealed she and SRNA #5 were assigned to care for Resident #1 on 09/03/18. SRNA #1 stated they assisted Resident #1 to bed at approximately 9:00 PM on 09/03/18, and did not see the resident again until she went outside after someone called and said Resident #1 was outside. SRNA #1 said she went outside with other staff and assisted the resident back inside. Continued interview revealed SRNA #1 said she did not hear the alarm sounding in the dining room. Per the SRNA, staff have been trained to look and do a resident head count if there was not a resident by the alarming door. Interview with Registered Nurse (RN) #1 on 09/18/18 at 2:15 PM revealed she was caring for Resident #1 on 09/03/18. Per the RN, she gave Resident #1's medications at approximately 8:00 PM to 8:30 PM on 09/03/18, and the resident went to bed. The RN stated she did not see the resident again until SRNA #1 told her the resident was outside the facility without staff assistance. RN #1 stated when she went outside, Resident #1 was sitting on the grass between the office entrance and the sidewalk. SRNA #1, SRNA #5, and another woman was with the resident when she arrived. The RN stated she assessed the resident and found an abrasion on his/her knee. RN #1 stated she was not aware an exit door alarm had sounded, nor had anyone reported to her that an alarm had sounded. The RN stated she asked the resident what he/she was doing outside, and the resident stated, I don't know. Interview with SRNA #4 on 09/18/18 at 5:45 PM revealed she worked at the facility on day shift. SRNA #4 stated she was off duty and was walking her dog on 09/03/18 at approximately 10:40 PM to 11:00 PM, when she heard someone yell for help. SRNA #4 stated she found Resident #1 across the street from the facility lying in a shallow ditch. The SRNA stated another citizen had also stopped and was helping the resident to stand when she got to them. SRNA #4 said she recognized Resident #1 and assisted the resident across the street and sat with the resident while she called the facility to notify them the resident was outside unassisted by staff. Further interview revealed facility staff came outside in just a couple of minutes and helped the resident inside the facility. Interview with the DON on 09/18/18 at 3:50 PM and on 09/20/18 at 10:48 AM revealed staff did not see Resident #1 leave the facility. The DON stated she had watched the video footage of the dining room and observed the resident exit the facility via an exit door in the dining room. The DON stated SRNA #5 entered the dining room approximately three (3) minutes after the resident exited, and turned the key to reset the alarm. She stated that from the video footage, she could not tell if the SRNA looked outside of the facility through the window in the door, but was able to determine that SRNA #5 did not go outside to search for a resident. During further interview, the DON stated she found out the next day that SRNA #4, who was off duty, had found the resident across the street. She said she thought the resident was across the side street, not the main street in front of the facility. The DON stated SRNA #5 did not respond appropriately to the exit door alarm. Interview with the Administrator on 09/20/18 at 2:45 PM revealed the facility's investigation concluded that the cause of Resident #1's elopement was due to the SRNA's failure to search for Resident #1 after the alarm sounded. 2. Review of the facility's policy titled Falls, reviewed 06/01/15, revealed the facility would provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. The policy also stated that all residents would have a comprehensive fall risk assessment completed upon admission/readmission, quarterly, annually, and with any significant change of condition. In addition, the policy stated appropriate care plan interventions would be implemented and evaluated based on the resident's assessment. Further, the policy stated that if a resident sustained [REDACTED]. Observation of Resident #1 on 09/18/18 at 10:05 AM, 11:32 AM, and 1:57 PM and on 09/19/18 at 11:05 AM, 12:46 PM, and 2:21 PM, revealed during each observation, the resident was in his/her room and a facility staff member was present in the room or just outside the doorway of the room. Review of Resident #1's medical record revealed the facility admitted the resident on 06/26/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated severe cognitive impairment. Resident #1 was assessed to need extensive assistance of two (2) staff members for transfers and limited assistance of two (2) staff members for walking in the room. Resident #1 was also assessed to have had two (2) or more non-injury falls since the previous assessment completed on 07/03/18. Review of Resident #1's admission nursing assessment dated [DATE] revealed the facility determined the resident was at a high risk for falls. Review of fall investigations for Resident #1 completed by the facility from 06/26/18 through 07/21/18, revealed the resident sustained [REDACTED]. Further review of the fall investigations revealed on 07/22/18 at 6:25 PM, Resident #1 was attempting to open an exit door that was equipped with a delayed egress (door will not open until a release bar is pushed and held for 15 seconds) and fell out the door onto the pavement. Review of Resident #1's care plan revealed the facility identified the resident was at risk for falls and on 07/22/18, placed the resident on 1:1 supervision with a staff person supervising the resident at all times. On 07/23/18, the facility decreased the supervision to every fifteen (15) minutes. According to the care plan, there was no documented evidence that 15-minute checks were discontinued; however, the only documentation that the resident was supervised every 15 minutes was on 07/23/18 and on 08/26/18. Review of a Behavior Check Monitoring Log revealed staff supervised Resident #1 every 15 minutes on 07/23/18 and 08/26/18 from 7:00 AM through 6:45 AM. Review of the fall investigations for Resident #1 revealed on 08/07/18 at 9:00 AM, Resident #1 sustained a fall while up unassisted in his/her bedroom, while a CNA was making the resident's bed. Continued review revealed Resident #1 sustained eight (8) additional falls from 08/10/18 through 09/13/18 while getting up or attempting to get up unassisted. In addition, review of the Nurse's Notes dated 08/24/18, 08/25/18, 08/29/18, and 09/02/18, revealed Resident #1 continued to get up unassisted numerous times. However, there was no evidence found to indicate the facility recognized that the resident was not being provided the increased supervision that should have been implemented on 07/23/18. Interview with SRNA #7 on 09/19/18 at 12:32 PM, SRNA #6 on 09/20/18 at 10:25 AM, and Licensed Practical Nurse (LPN) #2 on 09/20/18 at 10:37 AM, revealed they had all cared for Resident #1 since the resident's admission to the facility. The staff stated Resident #1 could be very impulsive and in their opinion, the only way to prevent Resident #1 from falling was to supervise the resident 1:1 continually. Interview with the Director of Nursing (DON) on 09/18/18 at 3:50 PM, on 09/20/18 at 10:48 AM, and on 10/02/18 at 10:50 AM revealed she had been employed at the facility as the DON for approximately six (6) weeks. The DON stated she had not conducted the investigation related to Resident #1's fall on 07/22/18, but she had reviewed the investigation. The DON stated it appeared the resident was placed on 1:1 supervision due to the resident's exit-seeking behavior and the fall. She said it was unclear when or if the 15-minute checks for the resident were discontinued. Continued interview with the DON revealed she completed fall investigations for Resident #1 when the resident fell on [DATE], 08/10/18, 08/13/18, 08/16/18, 08/21/18, 08/28/18, 09/03/18, and two falls on 09/13/18. Although the DON stated that new interventions or actions had been implemented after each of the resident's falls, the DON stated the facility had not identified that the increased supervision initiated on 07/23/18 was not being implemented, and that there was no evidence the supervision had been discontinued. In addition, the DON stated she had determined that the resident had sustained more falls during the morning when getting out of bed or going back to bed, but the facility had not developed care plan interventions to address the timeframe of the resident's falls. The DON stated Resident #1 had impulsive behaviors, was cognitively impaired, and had impaired safety awareness, which all contributed to the resident's root cause for falling. The DON stated the facility did not get to the root cause of Resident #'1's falls, and staff had difficulty with getting to the root cause of residents' falls when doing the fall investigations. According to the DON, increased supervision was probably the only way to prevent Resident #1 from falling. ****The facility alleged the following was implemented to remove Immediate Jeopardy on 09/26/18: 1. Resident #1 was returned to the facility on [DATE] by staff at approximately 11:33 PM. The Charge Nurse immediately performed an assessment, to include a head-to-toe skin assessment, and found a scrape to the resident's left elbow and knee. The resident voiced no pain or concerns. Vital signs were obtained and were within normal limits. Resident #1 was assisted to bed and fell asleep. The facility staff notified the physician at 2:10 AM on 09/04/18 with new orders received. The resident's Power of Attorney was notified at 4:00 AM on 09/04/18. The Director of Nursing (DON) and Regional Vice President (RVP) were notified at 1:15 AM on 09/04/18. Per the new physician orders, Resident #1 was transferred to a Behavioral Health Unit on 09/05/18, after a Mental Inquest Warrant was obtained. 2. The facility assessed Resident #1 as an elopement risk on 06/26/18 and added the resident to the elopement binder. An elopement care plan was developed. Resident #1 was reassessed for elopement on 09/04/18. Resident #1's care plan and State Registered Nurse Aide (SRNA) care plan were reviewed and updated on 09/04/18 by the DON to reflect 1:1 supervision. 3. On 09/05/18, the Administrator reviewed all doors to ensure the doors had been checked for locking, alarms, mag-lock and delayed egress for the last 30 days. No concerns were identified. 4. All doors in the facility were checked by Maintenance staff and the Administrator on 09/04/18 to ensure the doors were locked and secure and that delayed egress was functioning properly. All doors were noted to be functioning properly. On the initial tour, the door egress key for the dining room door as well as the key located in the east exit door beside the nurses' station were removed. The only stakeholders that will have access to these keys moving forward will be the Charge Nurses, the Plant Operations Staff, and the Facility Administrator. On 09/04/18, the Regional Maintenance Director also completed a 100% audit of all exit doors to ensure all doors were locked, secure, and the delayed egress was functioning. No concerns were noted. 5. The DON immediately reeducated Employee #5 following the incident on 09/04/18 related to what actions to take when a door alarm sounds, and the facility's policy and procedure on elopement. The education also included immediately reporting to the charge nurse when a door alarm sounds, and thoroughly checking the surrounding area where the alarm was sounding. 6. All residents (100%) were reassessed for elopement potential by the DON, Unit Manager (UM), and the Assistant Director of Nursing (ADON) on 09/04/18 following the occurrence. Three (3) residents were identified to be at risk for elopement during the reassessment. The residents' care plans and SRNA care plans were updated to include risk of elopement. Their pictures were taken and added to the elopement binders, per facility policy. 7. All care plans were reviewed and updated by the DON, UM, and ADON with any changes found on the elopement assessment. Elopement binders were reviewed and updated for accuracy by the DON on 09/04/18 to reflect current elopement assessments; and on 09/05/18 to include personalized interventions for each resident identified as being at risk for elopement. 8. On 09/05/18, behavioral management care plans were updated on the eighteen (18) residents assessed to be at risk for elopement, to include interventions for wandering or exit-seeking behaviors. 9. Interviews with staff, residents with Brief Interview for Mental Status (BIMS) scores of 8 and above, and families interviewed as to their knowledge of any prior elopements were initiated on 09/04/18 and completed on 09/04/18 by the Chaplain, UMs, Administrator, and Social Services, with no concerns that could be validated. 10. On 09/04/18 and 09/05/18, a Signature Care Consultant (SCC) conducted a 30-day look back of residents' Electronic Medical Records (EMRs) of all events and 24-hour reports for exit-seeking behaviors. No concerns were identified. 11. The DON, ADON, and SCC completed a 30-day look back of Nurses' Notes for exit-seeking behaviors and/or elopements. No concerns were identified. This was initiated on 09/04/18 and completed 09/05/18. 12. The Administrator, DON, Unit Managers, ADON, Social Services, Admissions Director, Dietary Manager, Minimum Data Set (MDS) Coordinators, Plant Operations, Quality of Life Director, and the Chaplain were educated on 09/04/18 by the SCC on the policies below. This training was performed face to face in order to facilitate discussion and questions. Department Administrative Managers could not return to work until the education was provided, post-test administered related to elopement policy and procedures, and 100% score obtained. If the manager did not score 100% on the post-test, the manager was immediately re-educated and the post-test re-administered. This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Signature Care Consultant. Detailed and specific training included the following policies/procedures/processes: A. Elopement Policy and Procedure to include a review of the policy and procedure, Elopement/Wandering Assessment, Exit-seeking behaviors, Elopement/wandering Care plan, and Elopement binders. B. Missing Resident Policy and Procedure to include a review of the policy and procedure, process for a missing resident, Code Green, and resident safety. C. Door codes/alarms process to include the purpose of door codes/alarms and the process for responding to alarms to include the following: 1) Respond to Alarm 2) Walk Outside Perimeter 3) Report Active Door Alarm to Charge Nurse 4) Initiate Resident Headcount D. Accident/Incident policy and procedure that included a review of the policy/procedures, resident safety, supervision, and care planning. E. Safety and Supervision policy and procedure to include Increased/Decreased Level of Supervision, implementation of interventions, and Interdisciplinary Team (IDT) Communication. F. Care Plan Policy and Procedure including Elopement/wandering care plan interventions and creating, reviewing, implementing, and following the Care Plan. G. Behavior Management policy and procedure including exit-seeking behaviors, care plan interventions, monitoring, and documentation. H. QAPI (Quality Assurance/Performance Improvement) policy and procedure that includes the following: Process, Identification, Implementation, and Monitoring. 13. Once the Administrator, DON, and Department Managers were re-educated, they began to re-educate the entire staff on the above policies and procedures. The education was initiated on 09/04/18 and was completed for staff on the current working schedule by 09/06/18. On 09/05/18 through 09/06/18, the DON, ADON, or UM educated staff regarding the elopement books and the care plan information located within. Staff was educated to redirect wandering or exit-seeking residents back to their assigned unit and or room and to consult the resident's behavioral management care plan for a list of personalized interventions. This education is ongoing and all employees will be educated prior to working on the floor. Education will be ongoing after 09/06/18 to ensure all employees not educated by 09/05/18, will be educated prior to working the floor. 14. On 09/25/18, the facility held weekly an AD Hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the need for additional education of nursing staff on the Behavioral Management Policy, focusing on documenting elopement/exit-seeking behaviors on the EZMAR (electronic medical record) system. Additional education was started on 09/25/18 and will continue until all facility nurses on staff are educated. Any nurse not educated as of 09/26/18, will be educated prior to the start of their next scheduled shift to ensure education is completed before returning to work. In addition, on 09/25/18 the ADON and UM were re-educated on EZMAR monitoring as part of the daily clinical white board policy to ensure documentation of elopement and or exit-seeking behavior is being done appropriately. Pre and post-tests were administered related to elopement policy and procedures following the education provided. A 100% score was required to be obtained on the post-test before being permitted to continue to provide care in the facility. Staff scheduled after 09/06/18 were reeducated prior to working their next shift with a post-test score requirement of 100%. All post-tests were reviewed for compliance by SCC. Active employees, anyone on vacation, FMLA (Family and Medical Leave Act), or other leave will receive education prior to returning to work and a post-test score of 100%. Education regarding the elopement policy and procedure, to include identification and prevention of exit-seeking behaviors, will be included in the orientation process for all newly hired staff members effective 09/05/18 with a pre and post-test. No newly hired employee will be allowed to work until elopement education is provided. Employee will be immediately re-educated and post-test re-administered. 15. All doors will be checked for proper function each shift for two weeks by a member of the nursing staff, department managers, or plant operations staff beginning 09/04/18. Any concerns will be immediately reported to the Administrator and Plant Ops Director. No concerns were identified during the audits and beginning 09/18/18 the audits were decreased to daily. Maintenance staff will checks doors daily and the department head weekend manager will check them on the weekends. 16. An elopement drill was completed on 09/05/18, by the DON, and will be conducted daily on random shifts, for one week and weekly for four (4) weeks by the Administrator, DON, or Department Head Managers. Then they will be conducted quarterly thereafter. Elopement drills being conducted will ensure that stakeholders are following the Missing Resident Policy and Procedure, specifically, actions to take when a door alarm sounds that include: responding to active door alarms, walking outside the perimeter of the alarming door to ensure no resident is observed outside unattended, reporting to the charge nurse, and initiating a headcount. 17. Following the incident on 09/03/18, all administrative staff received an updated list of all residents that have been assessed to be at risk for elopement. A member of the Administrative staff, including but not limited to: the Chaplain, Medical Records, Central Supply, Housekeeping Director, Dietary Director, Business Office Manager, Assistant Business Office Manager, Quality of Life Director, Assistant Quality of Life Director, or the Office Assistant has been in the building on all shifts. The Administrative staff have been present to ensure the following are completed: post elopement tests; elopement drills; door alarm functionality; facility rounds on West and East units every two hours to ensure care plan interventions are being implemented on residents who had been assessed for risk of elopement. Night Shift Managers were also educated on the updated behavioral management care plans for the residents assessed to be at risk for elopement. A member of the management staff was put on a rotating schedule to work 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM beginning 09/05/18. This managerial oversight will continue for 30 days. 18. The DON, ADON, or UM will monitor all residents, as well as new admissions for evidence of new or worsening exit-seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday-Friday for three (3) months to determine if there are any new exit-seeking behaviors. New Admissions will be assessed for elopement risk and any resident identified as being at risk will be updated in the facility's elopement books. The DON and/or the Administrator has been on-site on Saturdays and/or Sundays since the incident occurred to provide oversight and to ensure the daily reviews have been completed, as outlined in the A[NAME]. The following will be reviewed daily Monday-Friday by the DON, ADON, or Unit Manager to ensure no resident is at risk that has not been identified by the facility: a. Events in event manager b. Clinical Summ

Based on interview, record review, and review of the facility's investigation and policy entitled "Federal Resident/Patient Rights," it was determined the facility failed to ensure one (1) of four (4) sampled residents had the right to refuse treatment (Resident #1). On 05/26/14, Medication Aide (MA) #1 administered a rectal suppository to Resident #1 even though the resident informed the MA that he/she did not want the suppository. Despite Resident #1's verbal refusal of the treatment, MA #1 proceeded to insert the rectal suppository against the resident's will. Resident #1 voiced feeling "violated" after the incident. The facility's failure to have an effective system in place to ensure each resident's right to refuse treatment was honored was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/26/14 at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226), and 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance was received on 06/25/14 which alleged removal of the Immediate Jeopardy on 06/25/14. A partial extended survey was conducted on 06/26-27/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.10 Resident Rights (F155) 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and 226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, "Federal Resident/Patient Rights," revised November 2013, revealed "every facility resident had a right to a dignified existence" and "self-determination." The policy stated, "...in accordance with the Omnibus Budget Act, a facility must protect and promote the rights of each resident..." including the "right to refuse treatment." Review of Resident #1's medical record revealed the facility admitted the resident on 03/28/08, with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan dated 11/14/13 revealed staff should have Resident #1 sign refusal forms "as appropriate." Review of Resident #1's Minimum Data Set (MDS) assessment completed on 04/18/14, revealed the facility assessed Resident #1 to be cognitively intact, "to have the ability to express ideas and wants clearly with no deficits in understanding or being understood," and to have no limitations in the upper extremities. Resident #1 also served as his/her own responsible party. Review of an investigation report dated 05/30/14 revealed on 05/26/14, Resident #1 refused a scheduled suppository. Further review revealed Medication Aide (MA) #1 proceeded to insert the suppository despite the resident's refusal. Interview with Resident #1 on 06/12/14 at 9:50 AM, revealed MA #1 entered the resident's room on 05/26/14, at approximately 10:10 PM and informed the resident that she was going to administer the resident's routinely scheduled rectal suppository. However, Resident #1 stated to MA #1 that he/she did not want the suppository. Resident #1 stated that MA #1 proceeded to tell him/her that the physician had ordered it and wanted the resident to have the suppository. Resident #1 explained, during the interview, that he/she was a paraplegic and was already positioned on the right side when MA #1 entered the room. Resident #1 stated that, although she had verbally refused the suppository, MA #1 proceeded to push his/her leg in an upward motion, and at that time Resident #1 stated he/she placed his/her hand over the rectal area but MA #1 pushed his/her hand out of the way and inserted the suppository against Resident #1's will. Resident #1 described feeling "violated" after the incident. Interview with the Administrator on 06/12/14 at 4:51 PM and review of the facility's investigation dated 05/30/14, revealed the facility investigated the incident and terminated the employment of MA #1 due to Resident #1's "perception of the incident." However, he did not feel the events occurred as stated by Resident #1 because MA #1 denied that Resident #1 refused the suppository and he did not "believe" that MA #1 would have the strength to move Resident #1's hand out of the way to successfully insert the suppository against the resident's will. Unsuccessful attempts were made to interview Medication Aide #1. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/25/14. The facility implemented the following actions to remove the Immediate Jeopardy: All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with Brief Interview for Mental Status (BIMS) scores of 8 or greater were interviewed by the Admissions Director, Dietary Director, Plant Operations Director, Minimum Data Set (MDS) Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, Staff Development Coordinator (SDC), or Chaplain for any abuse/neglect concerns on 06/13/14. Eleven concerns with ten residents were identified through interviews conducted on 06/13/14, two of which involved Resident #1 and Resident #2 (with Resident #2 having two reported incidents). The eleven concerns consist of four allegations of physical abuse, three allegations of neglect, one allegation of verbal abuse, two allegations of misappropriation of resident property and one allegation of mental abuse; all of which were reported to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman between 06/13/14 and 06/17/14. Residents with BIMS scores of 7 or less were physically assessed by the Assistant Directors of Nursing (ADON), Admissions Director, or Staff Development Coordinator for any signs and symptoms of abuse/neglect on 06/13/14. No concerns were identified. All Power of Attorneys of residents with a BIMS score of 7 or less were attempted to be contacted in regards to any abuse/neglect concerns on 06/14/14, and on resident rights and advanced directives on 06/15/14 by the Social Services Director, Chaplain, DON, ADON, Administrator, SDC or Admissions Director. The facility will continue to attempt contact daily until remaining Power of Attorneys (POAs) have been reached. No concerns have been identified from any POA at this time. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Administrator, Director of Nursing and Regional Nurse Consultant, and the Chief Nurse Executive on 06/13/14 for any indications of abuse/neglect concerns. All residents with a BIMS score of 8 or greater received education on Residents Rights and were given a copy of the Resident Rights on 06/15/14 by the Business Office Manager or Chaplain. The facility Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director, were re-educated on 06/13/14 by the Regional Nurse Consultant on the abuse policy and procedure, to include but not limited to: training, prevention, identification, protection and reporting/response, completing a thorough investigation which includes obtaining witness statements from any stakeholder, resident or any person witnessing the event, statements from any other staff that have worked with the alleged perpetrator (employee), conversations with the residents' POAs, head to toe assessments of residents under the care of the employee that were unable to tell us if an event has occurred (BIMS score of 7 or less) and interviews with residents that can tell us if they feel safe, abused or mistreated or violated by alleged victim. The education also included that in the report of any allegation or suspicion of abuse or violation of a resident's right, safety of the resident is to be ensured and then immediately reported to the Charge Nurse. If the perpetrator is an employee, they will be immediately removed from the resident care area to ensure safety of all other residents. The alleged perpetrator would be moved to a non-patient care area and suspended, the Charge Nurse will report to the Abuse Coordinator/Administrator/DON in which the alleged allegation is reported to OIG, APS, and Ombudsman. An investigation is then initiated. As well, the grievance process is not for reporting or handling allegations of abuse. This training was performed face to face in order to facilitate discussion and question and include examples of items that would be considered as reportable: reports of staff being physically or verbally mean or rough, injuries of unknown origin, withholding belongings, resident to resident altercations to include verbal or physical, and taking belongings or exploitation. Department Administrative Managers could not return to work until abuse education was provided, pre and post-test administered and 100% score obtained on post-test. If the manager did not score 100% on post-test, then the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director were re-educated on the abuse policy, which included training, prevention, identification, investigation, protection and reporting/response. They were then assigned to re-educate the staff on the abuse policy and procedure which included, but not limited to, ensuring resident safety when witnessing abuse or if an allegation is made, then reporting immediately to a Charge Nurse, removal of the perpetrator from the resident care area, alleged perpetrator is suspended, then reported to Abuse Coordinator/Administrator/ DON, in which the alleged allegation is reported to OIG, APS, and Ombudsman which started on 06/13/14. No employee will be allowed to work until abuse education is provided, pre and post-test administered and 100% score obtained on post-test, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Education regarding the abuse policy and procedure, to include the components of training, prevention, identification, investigation, protection and reporting/response with identification/reporting and process will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until abuse education and resident right education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. The Administrator, DON, ADONs, Dietary Director, Business Office Manager, Chaplain and Admissions Director, were re-educated on 06/15/14 by the Chief Nurse Executive on Resident Rights and Advanced Directives. This training was performed face to face in order to facilitate discussion and question and include examples of resident rights, the types of Advanced Directives, and examples of resident refusals. A pre and post-test were administered and 100% score obtained on post-test. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Department administrative managers will not be allowed to return to work until the Residents' Rights and Advanced Directive Education is provided pre and post-test administered and 100% score obtained on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director and Human Resources Director were re-educated on Residents' Rights and Advanced Directives, they were then assigned to re-educate the staff on the Residents Rights and Advanced Directives beginning on 06/15/14 to include examples of Resident Rights, the types of Advanced Directives and examples of resident refusals. All staff working on 06/15/14 received the education and all other staff is receiving the education prior to clocking in for their next scheduled shift. All new staff will obtain education on Residents' Rights during Orientation. Staff questionnaire regarding abuse and resident rights and Advanced Directives is being administered by Administrator, DON, ADONs, MDS coordinators, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director to five staff members on each shift and different staff members until the immediacy of the Jeopardy is removed. All results of questionnaires, tests, skin assessments are reviewed daily by the Administrator, DON, Nurse Consultant, Vice President of Operations, Chief Operations Officer, or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown origin are reported immediately to the Abuse Coordinator, Administrator, Director of Nursing, Regional Nurse Coordinator, Regional Vice President of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nurse Executive. Results of the staff questionnaire will be reported to the Quality Assurance committee weekly to determine the further need of continued education or revision of plan. Human Resources performed an audit of all personnel files for any abuse concerns on 06/13/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, termination forms, abuse registry checks, background checks, and licensure. Results of audit were given to the Administrator, on 06/14/14, to review for any abuse/neglect concerns that needed reported. None was identified. Information on Caring for the Caregiver, which addresses the signs of stress and burnout, shows the caregiver ways to cope and reduce stress and useful ways that friends can offer help to the caregiver were posted by the time clock on 06/14/14 by the administrator. A nurse from the regional team or corporate office has been onsite since 06/13/14 and will remain in the facility daily until the Jeopardy has been lifted. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse or Director of Clinical Programs will be in daily contact with the Regional Nurse Consultant and will review allegations. All grievances and Resident Questionnaires since 02/01/13, were reviewed by the Administrator, DON, Chief Nurse Executive, Human Resources Director, Admissions Director or Regional Nurse Consultants by 06/16/14 to determine if any items documented were a reportable event. The Facility Administrator, Social Services Director or Director of Nursing reported 58 allegations of abuse, neglect or misappropriation to the Office of Inspector General, APS and Ombudsmen and appropriate authorities as required state law by 06/16/14. The Administrator, Social Services Director or the Director of Nursing will review daily, the grievances and incident/accident reports, until the immediacy of the Jeopardy is lifted, starting 06/13/14, to determine if there are reportable allegations that have not been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. The Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. A Resident Council meeting was held on 06/13/14, conducted by the Chaplain and Staff Development Coordinator, to discuss any abuse/neglect concerns, the facility's Abuse Policy and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director, one per shift, will be on site each shift to perform walking rounds in which 20 residents (ten with BIMS scores of 8 or greater and ten with BIMS scores of 7 or less) will be visited by the Department Head and interviewed regarding staff treatment. Those residents that can be interviewed and for those residents who are not able to be interviewed, the Department Heads will visit the resident, skin checks will be completed by the nurse, as well as speaking to nurse and the CNA regarding any noted changes in resident behaviors. The Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director will interview ten staff members daily, five from day shift and five from night shift, regarding the types of abuse, who is the abuse coordinator, when suspected abuse is reported, residents rights and advanced directives which began on 06/14/14 and will continue until Immediate Jeopardy is lifted. Results of resident and staff questionnaires will be reported to the Administrator, DON, Regional Nurse Consultant, or VP of Operations daily, and if the Administrator is not in the facility, the Department Director conducting the questionnaires will telephone the Administrator or VP of Operations the results of the resident and staff questionnaires. This began on 06/14/14 and will continue until the Jeopardy is lifted. A binder is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift. This binder contains a resident roster in which the interview date and shift is noted next to the resident's name to ensure that residents with BIMS scores of 8 or greater will be interviewed and residents with BIMS scores of 7 or less will be visited, with skin checks completed, beginning on 06/14/14 and will continue until the Jeopardy is lifted. The MDS Coordinators have the responsibility for updating the binder weekly to identify residents with BIMS scores of 8 or greater and residents with BIMS scores of 7 or less. If abuse, mistreatment, neglect, misappropriation or violation of resident rights is alleged during the interviews and/or visits are reported by a staff member, the Department Head will ensure the resident is safe, report to a Charge Nurse in which the Charge Nurse will remove the alleged perpetrator to a non-patient care area and notify the Administrator, Director of Nursing, and/or Social Services Direct/Abuse Coordinator. The alleged perpetrator will be suspended and an investigation will begin immediately. The Administrator, Director of Nursing, Social Services, or a member of the regional staff will review all resident and staff questionnaires daily for any allegations of abuse, neglect, misappropriation to include violation of resident rights or advanced directives. Investigations of grievances/concerns will be initiated upon receipt, starting on 06/14/14. Nursing Administration (DON, ADON, Staff Development Coordinator, MDS staff, Medical Records Director, or Social Service Director) will review documentation in the Nursing Notes and Social Service Notes in order to assess for any documented evidence of an allegation of abuse, neglect, misappropriation, or violation of resident rights daily on ten different residents each day. This began on 06/14/14. No concerns have been identified. Any concerns identified, resident safety will first be ensured, and then the Charge Nurse will be notified. The Abuse Policy will be followed in which the alleged perpetrator will be removed from a resident care area (if on duty) suspended pending investigation and the Administrator, DON, or Social Service Director will be notified. All resident Social Service Notes and Nursing Notes that were in the chart (3 months) were reviewed on 06/13/14 by the DON, ADONs, Staff Development Coordinator, MDS staff, Medical Records Director, Admissions Director, or a Social Service Director and Administrator from a "sister" facility, or regional/home office nurses for any documentation regarding abuse or violation of resident rights. No new incidents were identified. Ten charts are reviewed by a member of Nursing Administration or Regional or Home Office Nurse daily to validate that no other abuse allegations or violations of resident rights have been documented but not reported. This will continue until the Immediate Jeopardy is removed. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse allegations daily to ensure that the resident is protected, the alleged perpetrator is removed from the resident care area, reports to the Office of the Inspector General, APS and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log starting on 06/14/14 that will include documentation of the following: validate protection of residents, perpetrator is removed from resident care area, reports to the Office of the Inspector General, APS, and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Chief Operation Officer, VP of Operations, Chief Nurse Executive or Regional Nurse Consultant will review the abuse log daily until removal of the Immediate Jeopardy, beginning on 06/14/14, to validate protection of the resident, that the perpetrator is removed from the resident care area, that reports to the Office of the Inspector General, APS, Ombudsman and appropriate authorities required by State law, are filed timely, and a thorough investigation has been completed. All Incident Reports from January 2014 to June 2014 were reviewed by the Director of Nursing, ADON, Regional Nurse Consultant or Chief Nursing Executive to identify any abuse or neglect or violation of a residents rights on 06/14/14. None was identified. Beginning on 06/13/14, the care plan conference for each resident will include any abuse/neglect concerns that the resident or families have, or any concerns with violation of resident rights or advanced directives. Resident safety will be validated and then the allegation will be reported to the Charge Nurse. The abuse policy will then be followed. The DON, ADON, or Staff Development Coordinator will observe the care delivery, for any suspected abuse/neglect concerns on five residents daily, beginning on 06/14/14, until removal of the immediacy and then weekly (Monday through Friday). Results of the care delivery audits will be reported to the Quality Assurance Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the Quality Assurance Committee will determine at what frequency the audits will need to continue. Concerns identified will be corrected immediately and reported to administrator to ensure investigation of suspected neglect was investigated/completed and reporting guidelines are met. A Quality Assurance meeting will be held weekly for four weeks beginning 06/13/14, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation the Quality Assurance Committee will determine at what frequency ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special Projects Administrator, the Regional Vice President of Operations, Signature Care Consultant, Chief Nursing Officer, member of regional staff or Chief Operating Officer, daily until removal of the immediacy beginning 06/13/14, then weekly for four weeks, then monthly. **The surveyor validated the Immediate Jeopardy was removed as follows: Review of the "Random Follow up Questionnaires for Residents," dated 06/13/14 and interviews on 06/27/14, at 1:51 PM with the MDS Coordinator and at 11:25 AM with the Staff Development Coordinator revealed the residents had been interviewed. Review of documentation revealed the allegations were faxed to the Office of Inspector General between the dates of 06/13/14 and 06/17/14. Review of "C.N.A Skin Care Alert" forms dated 06/13/14, and interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator and at 11:30 AM with the Assistant Director of Nursing, revealed the assessments had been completed. Interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator, at 11:30 AM with the Assistant Director of Nursing, at 11:00 AM with the Administrator, and at 1:56 PM with the Social Worker revealed staff had contacted the residents' Power of Attorneys regarding abuse/neglect concerns and resident rights. The staff stated they were continuing to contact all Power of Attorneys not yet reached. Additionally, interview on 06/27/14 at 11:15 AM with Resident G's Power of Attorney revealed he had been contacted by the facility and voiced no concerns. Interviews on 06/27/14 at 11:00 AM with the Administrator, and at 11:45 AM with the Director of Nursing, revealed all Abuse/Neglect audits, assessments, interviews, and questionnaires had been reviewed on 06/13/14. Review of acknowledgement sheets signed by residents and interviews on 06/27/14 at 10:10 AM with Resident #3, at 10:15 AM with Resident D, at 10:23 AM with Resident E, and at 10:30 AM with Resident F revealed the education had been provided to residents. Review of "Random Follow-Up Questionnaires for Staff," dated 06/13/14 with designations of pre-test and post-test revealed the Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Staff Development Coordinator, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director had all taken the test and scored 100%. Review of "Random Follow-Up Questionnaire for Staff," forms and interviews on 06/27/14, at 10:30 AM with Housekeeper #1, at 11:18 AM with Licensed Practical Nurse #1, and at 11:38 AM with CNA #3 revealed the staff had taken the test and scored 100%. Review of "Resident Rights" questionnaires designated with pre-test and post-test dated 06/15/14, revealed the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Director, Business Office Manager, Chaplain, and Admissions Director had all taken the test and scored 100%. Review of "Resident Rights" questionnaire and interviews on 06/27/14, at 10:30 AM with Housekeeper #1, at 11:18 AM with Licensed Practical Nurse #1, and at 11:38 AM with CNA #3 revealed the staff had taken the test and scored 100%. Interview on 06/27/14 at 11:25 AM the Staff Development Coordinator revealed orientation training and education material includes Resident Rights training. Review of "Random Follow-Up Questionnaire for Staff" forms and interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator, at 11:30 AM with the Assistant Director of Nursing, at 11:00 AM with the Administrator, and at 1:56 PM with the Social Worker, revealed the questionnaires regarding abuse, resident rights, and advanced directives had been administered to five staff members on each shift. Interview with the Administrator on 06/27/14, at 11:20 AM revealed the questionnaires had been reviewed and no concerns were identified. Review of Quality Assurance Meetings conducted on 06/13/14 and 06/20/14 revealed the results of the questionnaire had been reported in the meetings. Review of a signed statement dated 06/13/14, by the Human Resources Director revealed all Human Resource files had been audited for Coaching and Counseling forms, Suspension Forms, Termination Forms, Abuse Registry Checks, Background Checks, and Licensure requirements. Observation of the employee time clock on 06/27/14 at 11:58 AM revealed "caring for the caregiver" educational material was present. Review of a signed facility log dated 06/13/14 through 06/27/14, revealed a corporate staff person had been designated and served as Administrative Oversight in the facility on each of the days. Interviews on 06/27/14 at 11:00 AM with the Administrator and at 11:45 AM with the Director of Nursing revealed all Grievances and Resident Questionnaires since 02/01/13 had been reviewed. The identified concerns had been reported to the Office of Inspector General. Interviews on 06/27/14 at 11:00 AM with the Administrator, at 1:56 PM with the Social Worker, and at 11:45 AM with the Director of Nursing revealed all grievances and incident/accident reports had been reviewed daily since 06/13/14. Review of the "Resident Council Meeting Minutes," dated 06/13/14, and interviews with Resident #3 on 06/27/14 at 10:10 AM and Resident D at 10:15 AM, revealed they had attended the meeting and discussed any abuse/neglect concerns. Interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator, at 11:30 AM with the Assistant Director of Nursing, at 11:00 AM with the Administrator, and at 1:56 PM with the Social Worker revealed Department Heads had been assigned each shift to perform walking rounds and visit 20 residents. Staff interviews were also being conducted to identify any changes in resident behavior. Review of "Random Follow-Up Questionnaire for Staff" forms and interviews on 06/27/14, at 11:00 AM with the Administrator, at 1:56 PM with the Social Worker, and at 11:30 AM with the Assistant Director of Nursing revealed the interviews were being conducted with ten staff members daily. Review on 06/27/14, of the questionnaire binder revealed it contained a resident roster with the date and shift that each resident had been interviewed. Interview on 06/27/14 at 1:51 PM with the Minimum Data Set Coordinator revealed she was responsible to ensure the binder was kept updated with each resident's current BIMS score. Interviews on 06/27/14 at 11:00 AM with the Administrator, at 1:56 PM with the Social Worker, and at 11:45 AM with the Director of Nursing revealed all resident and staff questionnaires had been reviewed daily for any allegations of abuse, neglect, and misappropriation of property. The questionnaires were also reviewed for violation of resident rights or advanced directives. Review of signed statements by staff and interviews on 06/27/14 at 1:56 PM with the Social Worker, and at 11:45 AM with the Director of Nursing revealed Nursing Notes and Social Service Notes had been reviewed daily for evidence of any allegations of abuse, neglect, misappropriation of property, or violation of resident rights. Review of a signed statement by the Administrator and Social Services Director of a "sister" facility dated 06/13/14, revealed all Nursing and Social Services Notes had been reviewed. Interviews on 06/27/14 at 11:00 AM with the Administrator, at 1:56 PM with the Social Worker, and at 11:45 AM with the Director of Nursing revealed all abuse allegations were reviewed daily and discussed to ensure the abuse policy was followed. Interviews on 06/27/14 at 11:00 AM with the Administrator, and observation of the abuse investigation log revealed the log had been maintained since 06/14/14, and included documentation that resident rights were protected, the alleged perpetrator was removed from resident care, and the required reporting was completed. Review of the Abuse Investigation Log on 06/27/14, revealed documentation that the

Based on interview, record review, and review of the facility's Resident/Visitor/Grievance/Complaint Forms and policy entitled "Abuse, Neglect and Misappropriation Policy," it was determined the facility failed to have an effective system to ensure two (2) of four (4) sampled residents remained free from abuse (Residents #1 and #2). Interview with Residents #1 and #2 on 06/12/14, revealed both residents had reported allegations of abuse by Medication Aide (MA) #1 to the facility. Additionally, Resident #2 reported an allegation of abuse that involved Certified Nurse Aide (CNA) #1 to the facility. However, the facility failed to implement measures to protect residents from further potential abuse. Review of the facility's investigation, dated 05/30/14, revealed on 05/26/14 Resident #1 refused a scheduled suppository, but MA #1 proceeded to insert the rectal suppository despite the resident's refusal. Although the facility terminated the employment of MA #1, the facility unsubstantiated the abuse allegation based on MA #1's statement that Resident #1 had not refused the suppository. In addition, upon questioning Resident #2 (the roommate of Resident #1) about care and services provided by MA #1, Resident #2 reported that MA #1 had been "rough" with him/her on a previous occasion. Also, on 06/02/14, Resident #2 contacted his/her family member by telephone and requested assistance because CNA #1 had refused to assist the resident to the toilet and instructed Resident #2 to "pee in the bed." The resident's family member contacted the facility on 06/02/14 and CNA #1 subsequently assisted Resident #2 to the toilet. However, when CNA #1 assisted Resident #2 to the toilet, CNA #1 stated to Resident #2, "You better not call (family member) on me again." Resident #1 (Resident #2's roommate) confirmed in interview on 06/12/14 that he/she had witnessed CNA #1 refuse to take Resident #2 to the toilet and tell Resident #2 to "pee in the bed." Resident #2 and Resident #1 both stated the Administrator and Director of Nursing (DON) came to their room and spoke with Resident #2 about the incident on the morning after it occurred. However, the Administrator and DON denied knowledge of the incident until reported by Resident #2 to the Activity Assistant in a Resident Council Meeting on 06/04/14, at which time the DON and Administrator spoke with Resident #2 regarding the allegation. Review of a statement dated 06/04/14 by the DON, and a statement dated 06/13/14 by the Administrator, revealed CNA #1 had been questioned about the incident by the DON and informed the DON that she had been caring for another resident and could not assist Resident #2 to the toilet at the time of the incident. Documentation revealed the CNA received education on time management. However, the facility took no action to initiate an investigation, protect residents from further potential abuse, or report the allegation as required. The facility's failure to have an effective system in place to ensure residents remained free from abuse was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/26/14 at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226), and 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance was received on 06/25/14 which alleged removal of the Immediate Jeopardy on 06/25/14. A partial extended survey was conducted on 06/26-27/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.10 Resident Rights (F155) 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and 226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's "Abuse, Neglect and Misappropriation" policy, effective April 2013, revealed "...verbal, sexual, physical, and mental abuse" was prohibited. Additionally, the policy stated "...retribution against residents who file reports of abuse is prohibited." 1. Review of the medical record revealed the facility admitted Resident #1 on 03/28/08, with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment completed on 04/18/14, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 and was cognitively intact. Review of a facility investigation dated 05/30/14, revealed Resident #1 had reported to CNA #2 on 05/26/14 that, even though he/she had refused his/her scheduled rectal suppository, MA #1 had administered the suppository in spite of the resident's refusal. Further review of the facility's investigation dated 05/30/14, revealed CNA #2 immediately reported the allegation to the Charge Nurse and MA #1 was suspended from employment at the facility on 05/26/14, and ultimately terminated from employment at the facility on 05/30/14. However, according to the investigation the facility did not substantiate Resident #1's allegation of abuse. Interview with Resident #1 on 06/12/14, at 9:50 AM revealed that at approximately 10:00 PM on 05/26/14, MA #1 informed Resident #1 that she was going to administer the resident's routinely scheduled rectal suppository. According to Resident #1, he/she (the resident is a paraplegic) was positioned on the right side when MA #1 entered the room. Resident #1 stated he/she informed MA #1 that he/she did not want the suppository. However, despite telling the MA not to administer the suppository, the MA proceeded to push the resident's leg in an upward motion while stating the physician wanted the resident to have the suppository as ordered. Resident #1 stated at that time he/she positioned his/her hand over the rectal area in an attempt to block MA #1 from inserting the suppository. MA #1 pushed Resident #1's hand out of the way and inserted the suppository against Resident #1's will. Resident #1 voiced feeling "violated" after the incident. Resident #1 stated he/she placed the call light on when MA #1 exited the room, and reported the incident to CNA #2, who answered the call light. Interview with CNA #2 on 06/12/14 at 2:40 PM, revealed she answered Resident #1's call light on 05/26/14, and Resident #1 reported to her that MA #1 had administered a suppository to the resident despite the resident's refusal. CNA #2 stated she reported the incident to Licensed Practical Nurse (LPN) #1. Interview with Licensed Practical Nurse (LPN) #1 on 06/12/14 at 2:10 PM revealed she went directly to speak with Resident #1 on 05/26/14 after CNA #2 reported Resident #1's allegation to her. LPN #1 stated Resident #1 repeated the same version of events to her that the resident had reported to CNA #2. Interview with the Administrator on 06/12/14, at 4:51 PM, revealed the facility's investigation had unsubstantiated that MA #1 had abused Resident #1 because MA #1 denied that Resident #1 had refused the suppository. However, the Administrator stated the facility had been "watching" MA #1 "close" prior to the incident reported by Resident #1 on 05/26/14 due to MA #1 having "many performance issues" and resident reports that MA #1 was "hateful." The Administrator could not recall specific residents who had made reports related to MA #1 or specific dates and times of the reports. The Administrator also stated that the facility had not initiated or conducted special supervision or monitoring of MA #1's job performance or to ensure resident safety. In addition, an interview was conducted with Resident #2 on 06/12/14 at 10:00 AM regarding the care and services provided to the resident by Medication Aide (MA) #1. Resident #2 immediately stated that MA #1 had been rough in the past when providing care to the resident and had caused him/her to cry. Resident #2 stated that MA #1 was "hateful" and believed MA #1's actions had been intentional when she was rough with him/her. Resident #2 stated he/she was unable to recall the exact date of the incident but stated he/she had reported it to facility staff the morning after it had occurred. Interview on 06/12/14 at 10:10 AM with Resident #1 revealed he/she had witnessed MA #1 "grab" Resident #2's legs, causing the resident to cry. A review of a "Resident/Visitor/Grievance/ Complaint Form" dated 05/16/13, revealed Resident #2 reported to the Admissions Director on 05/16/13, that MA #1 had been "rough" while assisting the resident to bed on 05/15/13. The review revealed the facility questioned other residents regarding care provided to them by MA #1 and obtained no complaints. Therefore, the report revealed the facility determined the incident was resolved by educating MA #1 to be "more gentle" when assisting with transfers. Interview with the Administrator on 06/12/14 at 4:51 PM revealed the facility failed to investigate the incident as an allegation of abuse. 2. Review of a "Resident/Visitor/Grievance/ Complaint Form" dated 06/05/14, revealed Resident #2 had reported to staff during a Resident Council meeting held on 06/04/14, that he/she asked CNA #1 for assistance to the bathroom on 06/03/14 and the CNA had told the resident to void in his/her brief. Documentation on the form revealed CNA #1 had worked from 7:00 PM on 06/02/14 until 7:00 AM on 06/03/14. The Resident/Visitor/Grievance/Complaint Form also indicated the Administrator and DON were notified of the complaint. Interview with Resident #2 on 06/12/14, at 10:00 AM revealed he/she (exact date unknown) rang the call light for assistance to the toilet but stated CNA #1 answered the call light and instructed the resident "to pee in the bed." Resident #2 stated he/she did not want to void in the bed and informed his/her family member by telephone of the CNA's refusal to assist him/her to the toilet and that the CNA had told him/her to "pee in the bed." Resident #2 voiced being very upset over the incident stating, "I shouldn't have to pee on myself." Resident #2 stated CNA #1 returned later to assist him/her to the toilet, and while in the bathroom CNA #1 stated to Resident #2, "You better not call (family member) on me again." Resident #2 stated she felt threatened and afraid of CNA #1 at that time. Resident #2 stated the Administrator and DON came to her room and talked to her about the incident the next morning. Resident #1 (Resident #2's roommate) confirmed in interview conducted on 06/14/14 at 10:10 AM that CNA #1 had answered Resident #2's call light (exact date unknown) and instructed the resident to void in the bed and that she would clean it up later. Resident #1 also stated CNA #1 returned to assist Resident #2 to the bathroom on the same night. Resident #1 denied hearing CNA #1 threaten Resident #2, but stated although CNA #1 routinely left the door to the bathroom open when she assisted one of the residents to the bathroom, CNA #1 closed the bathroom door when she assisted Resident #2 to the bathroom. Resident #1 stated that immediately upon CNA #1 exiting the room after assisting Resident #2 from the toilet and back to bed, Resident #2 said, "She told me I better not call (family member) on her again." Interview on 06/12/14 at 4:40 PM with CNA #1 revealed when Resident #1 rang the light for assistance to toilet on 06/02/14, she was busy and could not assist the resident at the time and had told the resident she would clean him/her up if the resident voided in bed. CNA #1 stated that although the facility was fully staffed at the time, she did not attempt to ask for the assistance of other staff to assist Resident #2 to the toilet. CNA #1 denied she told Resident #1 not to contact his/her family member again. Interview on 06/12/14 at 2:15 PM with Resident #2's family member confirmed that Resident #2 had called her on 06/02/14 at approximately 8:45 PM and was very upset, stating that he/she needed to go to the bathroom and the staff would not take him/her, and that staff had told the resident to "pee in the bed." The family member stated Resident #2 told her, "I need help; I can't pee in the bed." The resident's family member stated she assured Resident #2 she would help him/her, and contacted the facility requesting staff to assist Resident #2 to the bathroom. The family member stated she spoke with Resident #2 a few days after the incident (exact date unknown) and Resident #2 informed her that CNA #1 had assisted him/her to the bathroom after he/she had telephoned the family member and that the CNA had told the resident not to call "me" anymore. The DON acknowledged in interview conducted on 06/12/14 at 4:20 PM that she had been informed of Resident #2's complaint on 06/04/14 after Resident #2 reported the incident in a Resident Council meeting. The DON stated she contacted CNA #1 on the telephone and questioned her regarding the complaint. The DON stated CNA #1 explained to her that Resident #2's call light was on, but she told Resident #1 that she had to "prioritize" and could not assist him/her to the toilet at that time. According to the DON, CNA #1 reported to her that Resident #2 had stated that she could not wait and would "pee" on himself/herself. According to the DON, CNA #1 acknowledged she failed to take Resident #1 to the bathroom. The DON stated she viewed the report made by Resident #2 as a "grievance," and educated CNA #1 on "answering call lights in the order they ring" and proper time management. Interview with the Administrator on 06/13/14, at 1:30 PM and review of statements signed by the DON on 06/04/14 and the Administrator on 06/13/14, revealed the Activity Assistant had informed the DON that "there was a problem" with CNA #1 not taking Resident #2 to the bathroom. The DON then "immediately notified" the Administrator "about the report." Review of the statements revealed on 06/04/14 the Administrator and DON talked to Resident #2 about "a problem" when CNA #1 had not assisted the resident to the bathroom and had told the resident to void in the bed. However, the Administrator stated after the DON spoke with CNA #1, he did not view the incident as abuse/neglect to Resident #2 and took no further action. The Administrator acknowledged he had not interviewed Resident #2's roommate or contacted Resident #2's family member in an effort to confirm Resident #2's report of the incident. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/25/14. The facility implemented the following actions to remove the Immediate Jeopardy: All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with Brief Interview for Mental Status (BIMS) scores of 8 or greater were interviewed by the Admissions Director, Dietary Director, Plant Operations Director, Minimum Data Set (MDS) Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, Staff Development Coordinator (SDC), or Chaplain for any abuse/neglect concerns on 06/13/14. Eleven concerns with ten residents were identified through interviews conducted on 06/13/14, two of which involved Resident #1 and Resident #2 (with Resident #2 having two reported incidents). The eleven concerns consist of four allegations of physical abuse, three allegations of neglect, one allegation of verbal abuse, two allegations of misappropriation of resident property and one allegation of mental abuse; all of which were reported to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman between 06/13/14 and 06/17/14. Residents with BIMS scores of 7 or less were physically assessed by the Assistant Directors of Nursing (ADON), Admissions Director, or Staff Development Coordinator for any signs and symptoms of abuse/neglect on 06/13/14. No concerns were identified. All Power of Attorneys of residents with a BIMS score of 7 or less were attempted to be contacted in regards to any abuse/neglect concerns on 06/14/14, and on resident rights and advanced directives on 06/15/14 by the Social Services Director, Chaplain, DON, ADON, Administrator, SDC or Admissions Director. The facility will continue to attempt contact daily until remaining Power of Attorneys (POAs) have been reached. No concerns have been identified from any POA at this time. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Administrator, Director of Nursing and Regional Nurse Consultant, and the Chief Nurse Executive on 06/13/14 for any indications of abuse/neglect concerns. All residents with a BIMS score of 8 or greater received education on Residents Rights and were given a copy of the Resident Rights on 06/15/14 by the Business Office Manager or Chaplain. The facility Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director, were re-educated on 06/13/14 by the Regional Nurse Consultant on the abuse policy and procedure, to include but not limited to: training, prevention, identification, protection and reporting/response, completing a thorough investigation which includes obtaining witness statements from any stakeholder, resident or any person witnessing the event, statements from any other staff that have worked with the alleged perpetrator (employee), conversations with the residents' POAs, head to toe assessments of residents under the care of the employee that were unable to tell us if an event has occurred (BIMS score of 7 or less) and interviews with residents that can tell us if they feel safe, abused or mistreated or violated by alleged victim. The education also included that in the report of any allegation or suspicion of abuse or violation of a resident's right, safety of the resident is to be ensured and then immediately reported to the Charge Nurse. If the perpetrator is an employee, they will be immediately removed from the resident care area to ensure safety of all other residents. The alleged perpetrator would be moved to a non-patient care area and suspended, the Charge Nurse will report to the Abuse Coordinator/Administrator/DON in which the alleged allegation is reported to OIG, APS, and Ombudsman. An investigation is then initiated. As well, the grievance process is not for reporting or handling allegations of abuse. This training was performed face to face in order to facilitate discussion and question and include examples of items that would be considered as reportable: reports of staff being physically or verbally mean or rough, injuries of unknown origin, withholding belongings, resident to resident altercations to include verbal or physical, and taking belongings or exploitation. Department Administrative Managers could not return to work until abuse education was provided, pre and post-test administered and 100% score obtained on post-test. If the manager did not score 100% on post-test, then the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director were re-educated on the abuse policy, which included training, prevention, identification, investigation, protection and reporting/response. They were then assigned to re-educate the staff on the abuse policy and procedure which included, but not limited to, ensuring resident safety when witnessing abuse or if an allegation is made, then reporting immediately to a Charge Nurse, removal of the perpetrator from the resident care area, alleged perpetrator is suspended, then reported to Abuse Coordinator/Administrator/ DON, in which the alleged allegation is reported to OIG, APS, and Ombudsman which started on 06/13/14. No employee will be allowed to work until abuse education is provided, pre and post-test administered and 100% score obtained on post-test, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Education regarding the abuse policy and procedure, to include the components of training, prevention, identification, investigation, protection and reporting/response with identification/reporting and process will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until abuse education and resident right education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. The Administrator, DON, ADONs, Dietary Director, Business Office Manager, Chaplain and Admissions Director, were re-educated on 06/15/14 by the Chief Nurse Executive on Resident Rights and Advanced Directives. This training was performed face to face in order to facilitate discussion and question and include examples of resident rights, the types of Advanced Directives, and examples of resident refusals. A pre and post-test were administered and 100% score obtained on post-test. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Department administrative managers will not be allowed to return to work until the Residents' Rights and Advanced Directive Education is provided pre and post-test administered and 100% score obtained on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director and Human Resources Director were re-educated on Residents' Rights and Advanced Directives, they were then assigned to re-educate the staff on the Residents Rights and Advanced Directives beginning on 06/15/14 to include examples of Resident Rights, the types of Advanced Directives and examples of resident refusals. All staff working on 06/15/14 received the education and all other staff is receiving the education prior to clocking in for their next scheduled shift. All new staff will obtain education on Residents' Rights during Orientation. Staff questionnaire regarding abuse and resident rights and Advanced Directives is being administered by Administrator, DON, ADONs, MDS coordinators, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director to five staff members on each shift and different staff members until the immediacy of the Jeopardy is removed. All results of questionnaires, tests, skin assessments are reviewed daily by the Administrator, DON, Nurse Consultant, Vice President of Operations, Chief Operations Officer, or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown origin are reported immediately to the Abuse Coordinator, Administrator, Director of Nursing, Regional Nurse Coordinator, Regional Vice President of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nurse Executive. Results of the staff questionnaire will be reported to the Quality Assurance committee weekly to determine the further need of continued education or revision of plan. Human Resources performed an audit of all personnel files for any abuse concerns on 06/13/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, termination forms, abuse registry checks, background checks, and licensure. Results of audit were given to the Administrator, on 06/14/14, to review for any abuse/neglect concerns that needed reported. None was identified. Information on Caring for the Caregiver, which addresses the signs of stress and burnout, shows the caregiver ways to cope and reduce stress and useful ways that friends can offer help to the caregiver were posted by the time clock on 06/14/14 by the administrator. A nurse from the regional team or corporate office has been onsite since 06/13/14 and will remain in the facility daily until the Jeopardy has been lifted. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse or Director of Clinical Programs will be in daily contact with the Regional Nurse Consultant and will review allegations. All grievances and Resident Questionnaires since 02/01/13, were reviewed by the Administrator, DON, Chief Nurse Executive, Human Resources Director, Admissions Director or Regional Nurse Consultants by 06/16/14 to determine if any items documented were a reportable event. The Facility Administrator, Social Services Director or Director of Nursing reported 58 allegations of abuse, neglect or misappropriation to the Office of Inspector General, APS and Ombudsmen and appropriate authorities as required state law by 06/16/14. The Administrator, Social Services Director or the Director of Nursing will review daily, the grievances and incident/accident reports, until the immediacy of the Jeopardy is lifted, starting 06/13/14, to determine if there are reportable allegations that have not been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. The Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. A Resident Council meeting was held on 06/13/14, conducted by the Chaplain and Staff Development Coordinator, to discuss any abuse/neglect concerns, the facility's Abuse Policy and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director, one per shift, will be on site each shift to perform walking rounds in which 20 residents (ten with BIMS scores of 8 or greater and ten with BIMS scores of 7 or less) will be visited by the Department Head and interviewed regarding staff treatment. Those residents that can be interviewed and for those residents who are not able to be interviewed, the Department Heads will visit the resident, skin checks will be completed by the nurse, as well as speaking to nurse and the CNA regarding any noted changes in resident behaviors. The Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director will interview ten staff members daily, five from day shift and five from night shift, regarding the types of abuse, who is the abuse coordinator, when suspected abuse is reported, residents rights and advanced directives which began on 06/14/14 and will continue until Immediate Jeopardy is lifted. Results of resident and staff questionnaires will be reported to the Administrator, DON, Regional Nurse Consultant, or VP of Operations daily, and if the Administrator is not in the facility, the Department Director conducting the questionnaires will telephone the Administrator or VP of Operations the results of the resident and staff questionnaires. This began on 06/14/14 and will continue until the Jeopardy is lifted. A binder is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift. This binder contains a resident roster in which the interview date and shift is noted next to the resident's name to ensure that residents with BIMS scores of 8 or greater will be interviewed and residents with BIMS scores of 7 or less will be visited, with skin checks completed, beginning on 06/14/14 and will continue until the Jeopardy is lifted. The MDS Coordinators have the responsibility for updating the binder weekly to identify residents with BIMS scores of 8 or greater and residents with BIMS scores of 7 or less. If abuse, mistreatment, neglect, misappropriation or violation of resident rights is alleged during the interviews and/or visits are reported by a staff member, the Department Head will ensure the resident is safe, report to a Charge Nurse in which the Charge Nurse will remove the alleged perpetrator to a non-patient care area and notify the Administrator, Director of Nursing, and/or Social Services Direct/Abuse Coordinator. The alleged perpetrator will be suspended and an investigation will begin immediately. The Administrator, Director of Nursing, Social Services, or a member of the regional staff will review all resident and staff questionnaires daily for any allegations of abuse, neglect, misappropriation to include violation of resident rights or advanced directives. Investigations of grievances/concerns will be initiated upon receipt, starting on 06/14/14. Nursing Administration (DON, ADON, Staff Development Coordinator, MDS staff, Medical Records Director, or Social Service Director) will review documentation in the Nursing Notes and Social Service Notes in order to assess for any documented evidence of an allegation of abuse, neglect, misappropriation, or violation of resident rights daily on ten different residents each day. This began on 06/14/14. No concerns have been identified. Any concerns identified, resident safety will first be ensured, and then the Charge Nurse will be notified. The Abuse Policy will be followed in which the alleged perpetrator will be removed from a resident care area (if on duty) suspended pending investigation and the Administrator, DON, or Social Service Director will be notified. All resident Social Service Notes and Nursing Notes that were in the chart (3 months) were reviewed on 06/13/14 by the DON, ADONs, Staff Development Coordinator, MDS staff, Medical Records Director, Admissions Director, or a Social Service Director and Administrator from a "sister" facility, or regional/home office nurses for any documentation regarding abuse or violation of resident rights. No new incidents were identified. Ten charts are reviewed by a member of Nursing Administration or Regional or Home Office Nurse daily to validate that no other abuse allegations or violations of resident rights have been documented but not reported. This will continue until the Immediate Jeopardy is removed. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse allegations daily to ensure that the resident is protected, the alleged perpetrator is removed from the resident care area, reports to the Office of the Inspector General, APS and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log starting on 06/14/14 that will include documentation of the following: validate protection of residents, perpetrator is removed from resident care area, reports to the Office of the Inspector General, APS, and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Chief Operation Officer, VP of Operations, Chief Nurse Executive or Regional Nurse Consultant will review the abuse log daily until removal of the Immediate Jeopardy, beginning on 06/14/14, to validate protection of the resident, that the perpetrator is removed from the resident care area, that reports to the Office of the Inspector General, APS, Ombudsman and appropriate authorities required by State law, are filed timely, and a thorough investigation has been completed. All Incident Reports from J

Based on interview, record review, review of Resident/Visitor/Grievance/Complaint Forms, and the facility's policy entitled, "Abuse, Neglect and Misappropriation," it was determined the facility failed to ensure allegations of resident abuse were immediately reported to the State Survey Agency and other officials in accordance with State law for two (2) of four (4) sampled residents (Residents #2 and #4). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation. Interview on 06/12/14 at 10:00 AM, with Resident #2 revealed the resident had reported two (2) potential allegations of abuse to facility staff. Resident #2 stated that Certified Nurse Aide (CNA) #1 had refused to assist him/her to the bathroom and had instructed Resident #2 to "pee in the bed" (exact date unknown). Additionally, Resident #2 stated that Medication Aide (MA) #1 (exact date unknown) had been hateful and intentionally rough when she had assisted the resident to bed and, as a result, the resident became upset and cried. Record review confirmed that both allegations made by Resident #2 had been reported to the Administrator and documented on the facility's Resident/Visitor/ Grievance/Complaint Forms. In addition, review of a Resident/Visitor/ Grievance/Complaint Form dated 05/19/14, revealed Resident #4's family member had contacted the facility on 05/19/14 and had made a request for the facility not to assign CNA #1 to provide direct care to Resident #4 because CNA #1 had been "disrespectful/hateful" to the resident. As a result of the complaint reported by Resident #4's family member, the facility documented CNA #1 had been moved to another unit of the facility to provide direct care to other residents as a resolution to the complaint. Record reviews and interviews revealed that although the facility had been made aware of the three complaints that alleged staff had treated a resident roughly, had failed to assist a resident to the bathroom and instructed the resident to "pee in the bed," and of speaking to a resident in a "disrespectful and hateful" manner, the facility failed to conduct an investigation of the allegations, failed to ensure residents were protected from further potential abuse, and failed to report the allegations to the appropriate State agencies. The facility's failure to immediately report all allegations of abuse/neglect, failure to protect residents during the course of an investigation of abuse/neglect, and failure to investigate allegations of abuse/neglect caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/26/14 at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226), and 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance was received on 06/25/14 which alleged removal of the Immediate Jeopardy on 06/25/14. A partial extended survey was conducted on 06/26-27/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.10 Resident Rights (F155) 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and 226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, "Abuse, Neglect and Misappropriation," effective April 2013, revealed, "...all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines." In addition, the policy revealed, "The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation." The policy stated, "The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate," and "The Administrator and/or DON will notify state agencies according to their reporting guidelines." In addition, according to the policy, "All allegations of abuse will be investigated and reported to the appropriate agencies," and "The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances." 1. Review of Resident #2's medical record revealed the facility admitted the resident on 04/01/09, with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set Assessment ((MDS) dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and required extensive assistance with mobility and transfers. Review of a Resident/Visitor/Grievance/ Complaint Form dated 06/05/14, revealed Resident #2 reported to staff on 06/04/14, that CNA #1 had refused to take him/her to the toilet and instructed the resident to void in the bed. Further review of the form revealed the allegation was reported to the Administrator and DON. Interview with Resident #2 on 06/12/14 at 10:00 AM, revealed the resident rang the call light recently (exact date unknown) for assistance to the toilet but CNA #1 answered the call light and instructed the resident "to pee in the bed" and that "she would clean it up later." Resident #2 stated he/she became upset that CNA #2 had instructed him/her to void in the bed. Resident #2 stated he/she contacted his/her family member by telephone and informed the family member that staff would not assist him/her to the toilet. After contacting his/her family member, Resident #2 stated CNA #1 returned to his/her room and provided the resident assistance to the toilet; however, at that time Resident #2 stated CNA #1 told him/her, "You better not call (family member) on me again." Interview with Resident #2's roommate, Resident #1, on 06/14/14 at 10:10 AM, revealed he/she was present and heard CNA #1 instruct Resident #2 to void in the bed. Review of the facility's schedule for the week of 06/01-07/14 revealed CNA #1 had only provided care to Resident #2 one night during the period from 7:00 PM until 7:00 AM on the evening of 06/02/14 and the morning of 06/03/14. Interview on 06/12/14 at 2:15 PM with Resident #2's family member revealed Resident #2 had called her on 06/02/14 at approximately 8:45 PM and informed her that he/she needed help and that staff would not assist the resident to the toilet and had instructed the resident to "pee in the bed." The family member stated she called the facility and spoke with staff (name unknown) who assured her that Resident #2 would be assisted to the toilet. Continued interview with the family member revealed she spoke with Resident #2 a few days after the incident and the resident informed her that when CNA #1 returned to assist the resident to the bathroom, the CNA told the resident, "You better not call (family member) on me again." The family member stated no one from the facility had been in contact with her regarding the incident even though the family member had called the facility and requested someone provide Resident #2 assistance to the bathroom on 06/02/14. Resident #2's family member also stated on 06/12/14 that the facility had contacted her in regards to an unrelated issue and stated at that time she informed the facility of her concerns related to staff failing to assist Resident #2 to the toilet, and then "threatening" the resident because he/she had contacted the family member for assistance. Review of CNA #1's employee file revealed the facility had conducted a "Coaching and Counseling Session" with the CNA on 11/22/13 due to reports the CNA had left residents wet and had failed to provide proper care of residents. The nurse who conducted the counseling session was no longer employed at the facility. Interview with the Administrator on 06/13/14, at 1:30 PM and review of statements signed by the Director of Nursing (DON) on 06/04/14 and the Administrator on 06/13/14, revealed on 06/04/14, the Administrator and the DON talked to Resident #2 and the resident stated that CNA #1 had not assisted him/her to the toilet and told him/her to void in the bed. However, the Administrator stated when CNA #1 was questioned regarding the incident she stated she was "busy" at the time and could not take Resident #2 to the toilet. According to the Administrator, he and the DON had not considered the allegation as abuse and/or neglect. The Administrator acknowledged he was aware of the counseling session which was provided to CNA #1 on 11/22/13 for leaving residents wet, failing to properly care for residents, and of the report made by a family member of Resident #4 that alleged CNA #1 had been "disrespectful and hateful" to the resident on 05/19/14. The Administrator acknowledged the facility had not investigated the allegation further, had not taken measures to ensure residents were protected from further potential abuse, and had not reported the resident's complaint to State agencies. In addition, interview with Resident #2 on 06/12/14, at 10:00 AM and review of a Resident/Visitor/Grievance /Complaint Form dated 05/16/13, revealed Resident #2 had previously reported to the Admissions Director that MA #1 had been "rough" when she had assisted the resident to bed on 05/15/13. Resident #1 stated as a result of the MA's actions, he/she became upset and cried. Interview conducted on 06/12/14 at 10:10 AM with Resident #2's roommate, Resident #1, revealed he/she had witnessed MA #1 "grab" Resident #2's lower extremities and that Resident #2 became "upset" and had cried during the incident. However, Resident #2's roommate stated the facility had not questioned him/her about the reported incident. Interview with the Admissions Director on 06/13/14 at 9:30 AM, revealed on 05/16/13, Resident #2 reported to her that MA #1 had been "rough" with him/her when MA #1 assisted Resident #2 to bed on 05/15/13. After discussing the incident with Resident #2, the Admissions Director stated she documented the resident's allegation on a Resident/Visitor/Grievance/ Complaint Form and informed the facility's Social Worker (SW), who is the facility's Abuse Prevention Coordinator, of the allegation. Interview with the facility's SW on 06/13/14, at 9:50 AM, revealed she spoke with Resident #2 on 05/16/13 regarding the incident. According to the SW, Resident #2 described MA #1's actions as "hoisted (Resident #2) into bed with more force than was necessary" and that MA #1's actions were "overzealous." Therefore, the SW stated she did not view Resident #1's report as an allegation of abuse. The facility provided documentation that 25 residents had been asked on 05/16/13 if their needs were being met, if they were "afraid" of any staff who worked in the facility, or if any staff had been rough with them in the "last seventy-two (72) hours," and provided a "Weekly Skin Round" form for review to show staff performed a routine skin assessment for Resident #2 on 05/17/13, (two days after the alleged abuse had occurred). However, no further investigation was conducted, including interviewing Resident #1 (the roommate of Resident #2) about witnessing the incident that had occurred between Resident #2 and MA #1 on 05/15/13. In addition, the facility "failed to remove the perpetrator from resident care areas," failed to "obtain staff members witness statements," failed to "immediately suspend the employee pending the outcome of the investigation," and failed to "notify state agencies according to their reporting guidelines." Interview with the Administrator on 06/12/14 at 4:51 PM revealed he reviewed and signed the Resident/Visitor/Grievance/Complaint Form on 05/16/13. Although the Administrator stated that MA #1 was already "being watched closely" due to job performance issues and resident reports that MA #1 was "hateful," he failed to recognize the report made by Resident #2 as abuse and stated the facility did not conduct an investigation of the resident's complaint and the incident was not reported to State authorities. 2. The facility admitted Resident #4 on 03/01/09 with [DIAGNOSES REDACTED]. Review of Resident #4's Behavioral assessment dated [DATE], revealed the facility had assessed the resident to be excessively demanding with care needs and that the resident exhibited attention-seeking behaviors. Based on a review of the Minimum Data Set Assessment (MDS) completed on 06/05/14, Resident #4 was moderately cognitively impaired and displayed behavioral symptoms. Review of a Complaint/Grievance Report dated 05/19/14, revealed Resident #4's family member contacted the facility and requested that CNA #1 no longer provide care to Resident #4 because the staff member had been "disrespectful/ hateful" to the resident. The report indicated the Assistant Director of Nursing (ADON) reported the family member's concern to the Administrator, the Director of Nursing (DON), and the facility's Social Worker (who also functions as the facility's Abuse Prevention Coordinator) on 05/19/14. Additionally, the report revealed the ADON had been assigned responsibility for the investigation. Continued review of the Complaint/Grievance Report revealed the ADON spoke with Resident #4 and the resident informed the ADON he/she was not afraid of anyone in the facility and reported "just that (CNA #1) was rude." The facility's plan to resolve the resident's complaint was to assign "two (2) to go in (Resident #4's) room at night," and that CNA #1 would be reassigned to provide direct resident care on another unit in the facility, and educated on the "tone" of her voice. Interview with the ADON on 06/16/14 at 3:20 PM, revealed she had not considered the request made by Resident #4's family member that CNA #1 not provide care to Resident #4 as an allegation of possible abuse and therefore required no further investigation. The ADON stated that after she had spoken to Resident #4, she discussed the incident with the DON and the facility's Social Worker and the decision was made to move CNA #1 to another unit to provide resident care. However, the ADON could not recall why that decision was made. Interview with the DON on 06/16/14, at 3:55 PM revealed CNA #1 was moved to another unit to "make (Resident #4's family member) feel better." Although the facility's policy revealed " ...all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines," the DON acknowledged the facility did not conduct an investigation related to the report that CNA #1 was "disrespectful and hateful" to Resident #4, and did not report the allegation to officials in accordance with State law. Interview with the Administrator on 06/16/14 at 2:30 PM, revealed he had been made aware of the request made by Resident #4's family member on 05/19/14 for CNA #1 not to provide care to Resident #4 because the CNA had been disrespectful and rude. However, the Administrator stated he did not consider the request an allegation of abuse and had not conducted an investigation of the report and stated CNA #1 had been allowed to continue to provide direct care to other residents in the facility. According to the Administrator, because the facility had not considered the family member/resident's report as an allegation of abuse, the facility had not reported the incident to the State agencies. Interview revealed the Administrator failed to ensure "The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances...All allegations of abuse will be investigated and reported to the appropriate agencies...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines" as indicated in facility policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/25/14. The facility implemented the following actions to remove the Immediate Jeopardy: All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with Brief Interview for Mental Status (BIMS) scores of 8 or greater were interviewed by the Admissions Director, Dietary Director, Plant Operations Director, Minimum Data Set (MDS) Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, Staff Development Coordinator (SDC), or Chaplain for any abuse/neglect concerns on 06/13/14. Eleven concerns with ten residents were identified through interviews conducted on 06/13/14, two of which involved Resident #1 and Resident #2 (with Resident #2 having two reported incidents). The eleven concerns consist of four allegations of physical abuse, three allegations of neglect, one allegation of verbal abuse, two allegations of misappropriation of resident property and one allegation of mental abuse; all of which were reported to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman between 06/13/14 and 06/17/14. Residents with BIMS scores of 7 or less were physically assessed by the Assistant Directors of Nursing (ADON), Admissions Director, or Staff Development Coordinator for any signs and symptoms of abuse/neglect on 06/13/14. No concerns were identified. All Power of Attorneys of residents with a BIMS score of 7 or less were attempted to be contacted in regards to any abuse/neglect concerns on 06/14/14, and on resident rights and advanced directives on 06/15/14 by the Social Services Director, Chaplain, DON, ADON, Administrator, SDC or Admissions Director. The facility will continue to attempt contact daily until remaining Power of Attorneys (POAs) have been reached. No concerns have been identified from any POA at this time. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Administrator, Director of Nursing and Regional Nurse Consultant, and the Chief Nurse Executive on 06/13/14 for any indications of abuse/neglect concerns. All residents with a BIMS score of 8 or greater received education on Residents Rights and were given a copy of the Resident Rights on 06/15/14 by the Business Office Manager or Chaplain. The facility Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director, were re-educated on 06/13/14 by the Regional Nurse Consultant on the abuse policy and procedure, to include but not limited to: training, prevention, identification, protection and reporting/response, completing a thorough investigation which includes obtaining witness statements from any stakeholder, resident or any person witnessing the event, statements from any other staff that have worked with the alleged perpetrator (employee), conversations with the residents' POAs, head to toe assessments of residents under the care of the employee that were unable to tell us if an event has occurred (BIMS score of 7 or less) and interviews with residents that can tell us if they feel safe, abused or mistreated or violated by alleged victim. The education also included that in the report of any allegation or suspicion of abuse or violation of a resident's right, safety of the resident is to be ensured and then immediately reported to the Charge Nurse. If the perpetrator is an employee, they will be immediately removed from the resident care area to ensure safety of all other residents. The alleged perpetrator would be moved to a non-patient care area and suspended, the Charge Nurse will report to the Abuse Coordinator/Administrator/DON in which the alleged allegation is reported to OIG, APS, and Ombudsman. An investigation is then initiated. As well, the grievance process is not for reporting or handling allegations of abuse. This training was performed face to face in order to facilitate discussion and question and include examples of items that would be considered as reportable: reports of staff being physically or verbally mean or rough, injuries of unknown origin, withholding belongings, resident to resident altercations to include verbal or physical, and taking belongings or exploitation. Department Administrative Managers could not return to work until abuse education was provided, pre and post-test administered and 100% score obtained on post-test. If the manager did not score 100% on post-test, then the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director were re-educated on the abuse policy, which included training, prevention, identification, investigation, protection and reporting/response. They were then assigned to re-educate the staff on the abuse policy and procedure which included, but not limited to, ensuring resident safety when witnessing abuse or if an allegation is made, then reporting immediately to a Charge Nurse, removal of the perpetrator from the resident care area, alleged perpetrator is suspended, then reported to Abuse Coordinator/Administrator/ DON, in which the alleged allegation is reported to OIG, APS, and Ombudsman which started on 06/13/14. No employee will be allowed to work until abuse education is provided, pre and post-test administered and 100% score obtained on post-test, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Education regarding the abuse policy and procedure, to include the components of training, prevention, identification, investigation, protection and reporting/response with identification/reporting and process will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until abuse education and resident right education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. The Administrator, DON, ADONs, Dietary Director, Business Office Manager, Chaplain and Admissions Director, were re-educated on 06/15/14 by the Chief Nurse Executive on Resident Rights and Advanced Directives. This training was performed face to face in order to facilitate discussion and question and include examples of resident rights, the types of Advanced Directives, and examples of resident refusals. A pre and post-test were administered and 100% score obtained on post-test. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Department administrative managers will not be allowed to return to work until the Residents' Rights and Advanced Directive Education is provided pre and post-test administered and 100% score obtained on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director and Human Resources Director were re-educated on Residents' Rights and Advanced Directives, they were then assigned to re-educate the staff on the Residents Rights and Advanced Directives beginning on 06/15/14 to include examples of Resident Rights, the types of Advanced Directives and examples of resident refusals. All staff working on 06/15/14 received the education and all other staff is receiving the education prior to clocking in for their next scheduled shift. All new staff will obtain education on Residents' Rights during Orientation. Staff questionnaire regarding abuse and resident rights and Advanced Directives is being administered by Administrator, DON, ADONs, MDS coordinators, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director to five staff members on each shift and different staff members until the immediacy of the Jeopardy is removed. All results of questionnaires, tests, skin assessments are reviewed daily by the Administrator, DON, Nurse Consultant, Vice President of Operations, Chief Operations Officer, or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown origin are reported immediately to the Abuse Coordinator, Administrator, Director of Nursing, Regional Nurse Coordinator, Regional Vice President of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nurse Executive. Results of the staff questionnaire will be reported to the Quality Assurance committee weekly to determine the further need of continued education or revision of plan. Human Resources performed an audit of all personnel files for any abuse concerns on 06/13/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, termination forms, abuse registry checks, background checks, and licensure. Results of audit were given to the Administrator, on 06/14/14, to review for any abuse/neglect concerns that needed reported. None was identified. Information on Caring for the Caregiver, which addresses the signs of stress and burnout, shows the caregiver ways to cope and reduce stress and useful ways that friends can offer help to the caregiver were posted by the time clock on 06/14/14 by the administrator. A nurse from the regional team or corporate office has been onsite since 06/13/14 and will remain in the facility daily until the Jeopardy has been lifted. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse or Director of Clinical Programs will be in daily contact with the Regional Nurse Consultant and will review allegations. All grievances and Resident Questionnaires since 02/01/13, were reviewed by the Administrator, DON, Chief Nurse Executive, Human Resources Director, Admissions Director or Regional Nurse Consultants by 06/16/14 to determine if any items documented were a reportable event. The Facility Administrator, Social Services Director or Director of Nursing reported 58 allegations of abuse, neglect or misappropriation to the Office of Inspector General, APS and Ombudsmen and appropriate authorities as required state law by 06/16/14. The Administrator, Social Services Director or the Director of Nursing will review daily, the grievances and incident/accident reports, until the immediacy of the Jeopardy is lifted, starting 06/13/14, to determine if there are reportable allegations that have not been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. The Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. A Resident Council meeting was held on 06/13/14, conducted by the Chaplain and Staff Development Coordinator, to discuss any abuse/neglect concerns, the facility's Abuse Policy and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director, one per shift, will be on site each shift to perform walking rounds in which 20 residents (ten with BIMS scores of 8 or greater and ten with BIMS scores of 7 or less) will be visited by the Department Head and interviewed regarding staff treatment. Those residents that can be interviewed and for those residents who are not able to be interviewed, the Department Heads will visit the resident, skin checks will be completed by the nurse, as well as speaking to nurse and the CNA regarding any noted changes in resident behaviors. The Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director will interview ten staff members daily, five from day shift and five from night shift, regarding the types of abuse, who is the abuse coordinator, when suspected abuse is reported, residents rights and advanced directives which began on 06/14/14 and will continue until Immediate Jeopardy is lifted. Results of resident and staff questionnaires will be reported to the Administrator, DON, Regional Nurse Consultant, or VP of Operations daily, and if the Administrator is not in the facility, the Department Director conducting the questionnaires will telephone the Administrator or VP of Operations the results of the resident and staff questionnaires. This began on 06/14/14 and will continue until the Jeopardy is lifted. A binder is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift. This binder contains a resident roster in which the interview date and shift is noted next to the resident's name to ensure that residents with BIMS scores of 8 or greater will be interviewed and residents with BIMS scores of 7 or less will be visited, with skin checks completed, beginning on 06/14/14 and will continue until the Jeopardy is lifted. The MDS Coordinators have the responsibility for updating the binder weekly to identify residents with BIMS scores of 8 or greater and residents with BIMS scores of 7 or less. If abuse, mistreatment, neglect, misappropriation or violation of resident rights is alleged during the interviews and/or visits are reported by a staff member, the Department Head will ensure the resident is safe, report to a Charge Nurse in which the Charge Nurse will remove the alleged perpetrator to a non-patient care area and notify the Administrator, Director of Nursing, and/or Social Services Direct/Abuse Coordinator. The alleged perpetrator will be suspended and an investigation will begin immediately. The Administrator, Director of Nursing, Social Services, or a member of the regional staff will review all resident and staff questionnaires daily for any allegations of abuse, neglect, misappropriation to include violation of resident rights or advanced directives. Investigations of grievances/concerns will be initiated upon receipt, starting on 06/14/14. Nursing Administration (DON, ADON, Staff Development Coordinator, MDS staff, Medical Records Director, or Social Service Director) will review documentation in the Nursing Notes and Social Service Notes in order to assess for any documented evidence of an allegation of abuse, neglect, misappropriation, or violation of resident rights daily on ten different residents each day. This began on 06/14/14. No concerns have been identified. Any concerns identified, resident safety will first

Based on interview, record review, and review of Resident/Visitor/Grievance/Complaint Forms and the facility's policy entitled, "Abuse, Neglect and Misappropriation," it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for two (2) of four (4) sampled residents (Residents #2 and #4). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation in accordance with facility policy which stated, "The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation," and "All allegations of abuse will be investigated and reported to the appropriate agencies." Resident #2 revealed in interview conducted on 06/12/14 at 10:00 AM that he/she had reported two potential allegations of abuse to facility staff. According to Resident #2, Certified Nurse Aide (CNA) #1 had refused to assist him/her to the bathroom and had instructed Resident #2 to "pee in the bed" (exact date unknown). In addition, Resident #2 stated that Medication Aide (MA) #1 had been hateful and intentionally rough when she had assisted the resident to bed and, as a result, the resident became upset and cried. The resident was unable to recall the date of the incident. Record review confirmed that both allegations made by Resident #2 had been reported to the Administrator and documented on the facility's Resident/Visitor/Grievance/Complaint Forms. Review of a Resident/Visitor/Grievance/ Complaint Form dated 05/19/14 revealed on 05/19/14 (time not documented) Resident #4's family member contacted the facility and asked staff not to assign CNA #1 to provide direct care to Resident #4. The family member reported CNA #1 had been "disrespectful and hateful" to the resident. As a result of the complaint reported by Resident #4's family member, the facility documented that CNA #1 had been moved to another unit of the facility to provide direct care to other residents as a resolution to the complaint. Record reviews and interviews revealed that the facility had been made aware that staff had treated a resident roughly, had instructed the resident to "pee in the bed" when the resident requested assistance to the bathroom, and had spoken to a resident in a "disrespectful and hateful" manner. However, the facility failed to implement its policies that stated, "All allegations of abuse will be investigated...," that staff was to "...immediately remove the suspected perpetrator from resident care areas...," and that "...all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law..." The facility's failure to immediately report all allegations of abuse/neglect, failure to protect residents during the course of an investigation of abuse/neglect, and failure to investigate allegations of abuse/neglect caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/26/14 at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226), and 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance was received on 06/25/14 which alleged removal of the Immediate Jeopardy on 06/25/14. A partial extended survey was conducted on 06/26-27/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.10 Resident Rights (F155) 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and 226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: According to the facility's policy, "Abuse, Neglect and Misappropriation," effective April 2013, "The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances...All allegations of abuse will be investigated and reported to the appropriate agencies...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines." In addition, the policy revealed, "The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate," and "The Administrator and/or DON will notify state agencies according to their reporting guidelines." 1. The facility admitted Resident #2 on 04/01/09 with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #2 was cognitively intact, had a Brief Interview for Mental Status (BIMS) score of 13, and required extensive assistance with mobility and transfers. Review of a Resident/Visitor/Grievance/ Complaint Form dated 06/05/14 revealed Resident #2 reported to staff on 06/04/14, that CNA #1 had refused to take him/her to the toilet and instructed the resident to void in the bed. Further review of the form revealed the allegation was reported to the Administrator and DON. Resident #2 stated in interview on 06/12/14 at 10:00 AM that he/she rang the call light (exact date unknown) for assistance to the toilet, CNA #1 answered the call light, and instructed the resident "to pee in the bed" and "she would clean it up later." Resident #2 stated he/she became upset and contacted his/her family member. According to Resident #2, his/her family member contacted the facility and CNA #1 returned to his/her room and assisted the resident to the bathroom; however, Resident #2 stated at that time CNA #1 told him/her, "You better not call (family member) on me again." Resident #1 (Resident #2's roommate) stated in an interview conducted on 06/14/14 at 10:10 AM that he/she had overheard CNA #1 instruct Resident #2 to void in the bed. In addition, Resident #2's family member confirmed in interview conducted on 06/12/14 at 2:15 PM that Resident #2 had called her on 06/02/14 at approximately 8:45 PM, informed her that he/she needed help and that staff had instructed the resident to "pee in the bed," and the family called the facility and spoke with staff (name unknown). Resident #2's family member also stated on 06/12/14, the facility had contacted her in regards to an unrelated issue and stated, at that time, she informed the facility of her concerns related to staff failing to assist Resident #2 to the toilet, and then "threatening" the resident because he/she had contacted the family member for assistance. Interview with the Administrator on 06/13/14, at 1:30 PM and review of a statement signed by the Director of Nursing (DON) on 06/04/14 and the Administrator on 06/13/14, revealed on 06/04/14, the Administrator and the DON spoke to Resident #2 about the incident. However, the Administrator stated when CNA #1 was questioned regarding the incident she stated she was "busy" at the time and could not take Resident #2 to the toilet. According to the Administrator, he and the DON had not considered the allegation as abuse and/or neglect. The Administrator acknowledged the facility had not investigated the allegation further, had not taken measures to ensure residents were protected from further potential abuse, and had not reported the resident's complaint to State agencies. Additionally, review of a Resident/Visitor/ Grievance/Complaint Form dated 05/16/13, revealed Resident #2 had reported that Medication Aide (MA) #1 had been "rough" when she assisted the resident to bed. Documentation revealed the resident reported the incident to the Admissions Director (on 05/16/13) and, based on documentation, the incident reportedly occurred on 05/15/13. Interview with Resident #2 on 06/12/14 at 10:00 AM, with Resident #1 (Resident #2's roommate) on 06/12/14 at 10:10 AM, with the Admissions Director on 06/13/14 at 9:30 AM, and with the facility's Social Worker (SW) on 06/13/14 at 9:50 AM, revealed Resident #2 reported that MA #1 had been "rough" and/or "overzealous" when she had assisted the resident to bed. Resident #1 stated as a result of the MA's actions, he/she became upset and cried. Review of documentation provided by the facility revealed, after the report was received on 05/16/13, the facility questioned 25 residents to determine if their needs were met, if they were "afraid" of any staff who worked in the facility, or if any staff had been rough with them in the "last seventy-two (72) hours." Review of a "Weekly Skin Round" form revealed staff performed a routine skin assessment for Resident #2 on 05/17/13 (two days after the alleged abuse had occurred); however, no further investigation was conducted to include interviews with Resident #1 (the roommate of Resident #2) about witnessing the incident that occurred between Resident #2 and MA #1 on 05/15/13. In addition, the facility failed to "remove the perpetrator from resident care areas," failed to "obtain staff members witness statements," failed to "immediately suspend the employee pending the outcome of the investigation," and failed to "notify state agencies according to their reporting guidelines." Interview with the Administrator on 06/12/14 at 4:51 PM revealed he reviewed and signed the Resident/Visitor/Grievance/Complaint Form on 05/16/13. Although the Administrator stated that MA #1 was already "being watched closely" due to job performance issues and resident reports that MA #1 was "hateful," he failed to identify the report made by Resident #2 as an allegation of abuse and stated the facility did not conduct an investigation of the resident's complaint and that the facility had not reported the incident to State authorities. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 03/01/09 with [DIAGNOSES REDACTED]. Review of Resident #4's Behavioral assessment dated [DATE], revealed the facility had assessed the resident to be excessively demanding with care needs and that the resident exhibited attention-seeking behaviors. Review of the MDS completed on 06/05/14 revealed the facility assessed Resident #4 to be moderately cognitively impaired, and to display behavioral symptoms. Review of Resident #4's Comprehensive Care Plan, updated 06/10/14, revealed the facility noted Resident #4 continued to display physically and verbally abusive behavior toward staff, socially inappropriate behavior, and was resistive to care. Review of a Complaint/Grievance Report dated 05/19/14, revealed that on 05/19/14 Resident #4's family member contacted the facility and requested that CNA #1 no longer provide care to Resident #4 due to the staff member being "disrespectful/hateful" to the resident (date not indicated). The report indicated the Assistant Director of Nursing (ADON) reported the family member's concern to the Administrator, the DON, and the facility's Social Worker (who also functions as the facility's Abuse Prevention Coordinator) on 05/19/14. Additionally, the report revealed the ADON had been assigned responsibility for the investigation. Continued review of the Complaint/Grievance Report revealed the ADON spoke with Resident #4 and the resident informed the ADON he/she was not afraid of anyone in the facility and reported "just that (CNA #1) was rude." The facility's plan to resolve the resident's complaint was to assign "two (2) to go in (Resident #4's) room at night," and that CNA #1 would be reassigned to provide direct resident care on another unit in the facility, and educated on the "tone" of her voice. The ADON stated in interview conducted on 06/16/14 at 3:20 PM that she had not considered the request made by Resident #4's family member an allegation of possible abuse and therefore, no additional investigation was conducted. The ADON stated that after she had spoken to Resident #4, she discussed the incident with the DON and the facility's Social Worker and the decision was made to move CNA #1 to another unit to provide resident care. However, the ADON could not recall why that decision was made. Interview with the DON on 06/16/14, at 3:55 PM revealed CNA #1 was moved to another unit to "make (Resident #4's family member) feel better." Although the facility's policy revealed "...All allegations of abuse will be investigated and reported to the appropriate agencies," the DON stated the facility did not conduct an investigation related to Resident #4's family member's statement that CNA #1 had been "disrespectful and hateful" to Resident #4 and did not report the allegation to State authorities. Interview with the Administrator on 06/16/14 at 2:30 PM, revealed he had been made aware of the request made by Resident #4's family member on 05/19/14 for CNA #1 not to provide care to Resident #4 because the CNA had been disrespectful and rude. However, the Administrator stated he did not consider the request an allegation of abuse and an investigation had not been conducted, and CNA #1 continued to provide direct care to other residents in the facility. In addition, the Administrator stated because the facility had not considered the family member/resident's report as an allegation of abuse, the facility had not reported the incident to the State agencies. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/25/14. The facility implemented the following actions to remove the Immediate Jeopardy: All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with Brief Interview for Mental Status (BIMS) scores of 8 or greater were interviewed by the Admissions Director, Dietary Director, Plant Operations Director, Minimum Data Set (MDS) Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, Staff Development Coordinator (SDC), or Chaplain for any abuse/neglect concerns on 06/13/14. Eleven concerns with ten residents were identified through interviews conducted on 06/13/14, two of which involved Resident #1 and Resident #2 (with Resident #2 having two reported incidents). The eleven concerns consist of four allegations of physical abuse, three allegations of neglect, one allegation of verbal abuse, two allegations of misappropriation of resident property and one allegation of mental abuse; all of which were reported to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman between 06/13/14 and 06/17/14. Residents with BIMS scores of 7 or less were physically assessed by the Assistant Directors of Nursing (ADON), Admissions Director, or Staff Development Coordinator for any signs and symptoms of abuse/neglect on 06/13/14. No concerns were identified. All Power of Attorneys of residents with a BIMS score of 7 or less were attempted to be contacted in regards to any abuse/neglect concerns on 06/14/14, and on resident rights and advanced directives on 06/15/14 by the Social Services Director, Chaplain, DON, ADON, Administrator, SDC or Admissions Director. The facility will continue to attempt contact daily until remaining Power of Attorneys (POAs) have been reached. No concerns have been identified from any POA at this time. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Administrator, Director of Nursing and Regional Nurse Consultant, and the Chief Nurse Executive on 06/13/14 for any indications of abuse/neglect concerns. All residents with a BIMS score of 8 or greater received education on Residents Rights and were given a copy of the Resident Rights on 06/15/14 by the Business Office Manager or Chaplain. The facility Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director, were re-educated on 06/13/14 by the Regional Nurse Consultant on the abuse policy and procedure, to include but not limited to: training, prevention, identification, protection and reporting/response, completing a thorough investigation which includes obtaining witness statements from any stakeholder, resident or any person witnessing the event, statements from any other staff that have worked with the alleged perpetrator (employee), conversations with the residents' POAs, head to toe assessments of residents under the care of the employee that were unable to tell us if an event has occurred (BIMS score of 7 or less) and interviews with residents that can tell us if they feel safe, abused or mistreated or violated by alleged victim. The education also included that in the report of any allegation or suspicion of abuse or violation of a resident's right, safety of the resident is to be ensured and then immediately reported to the Charge Nurse. If the perpetrator is an employee, they will be immediately removed from the resident care area to ensure safety of all other residents. The alleged perpetrator would be moved to a non-patient care area and suspended, the Charge Nurse will report to the Abuse Coordinator/Administrator/DON in which the alleged allegation is reported to OIG, APS, and Ombudsman. An investigation is then initiated. As well, the grievance process is not for reporting or handling allegations of abuse. This training was performed face to face in order to facilitate discussion and question and include examples of items that would be considered as reportable: reports of staff being physically or verbally mean or rough, injuries of unknown origin, withholding belongings, resident to resident altercations to include verbal or physical, and taking belongings or exploitation. Department Administrative Managers could not return to work until abuse education was provided, pre and post-test administered and 100% score obtained on post-test. If the manager did not score 100% on post-test, then the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director were re-educated on the abuse policy, which included training, prevention, identification, investigation, protection and reporting/response. They were then assigned to re-educate the staff on the abuse policy and procedure which included, but not limited to, ensuring resident safety when witnessing abuse or if an allegation is made, then reporting immediately to a Charge Nurse, removal of the perpetrator from the resident care area, alleged perpetrator is suspended, then reported to Abuse Coordinator/Administrator/ DON, in which the alleged allegation is reported to OIG, APS, and Ombudsman which started on 06/13/14. No employee will be allowed to work until abuse education is provided, pre and post-test administered and 100% score obtained on post-test, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Education regarding the abuse policy and procedure, to include the components of training, prevention, identification, investigation, protection and reporting/response with identification/reporting and process will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until abuse education and resident right education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. The Administrator, DON, ADONs, Dietary Director, Business Office Manager, Chaplain and Admissions Director, were re-educated on 06/15/14 by the Chief Nurse Executive on Resident Rights and Advanced Directives. This training was performed face to face in order to facilitate discussion and question and include examples of resident rights, the types of Advanced Directives, and examples of resident refusals. A pre and post-test were administered and 100% score obtained on post-test. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Department administrative managers will not be allowed to return to work until the Residents' Rights and Advanced Directive Education is provided pre and post-test administered and 100% score obtained on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director and Human Resources Director were re-educated on Residents' Rights and Advanced Directives, they were then assigned to re-educate the staff on the Residents Rights and Advanced Directives beginning on 06/15/14 to include examples of Resident Rights, the types of Advanced Directives and examples of resident refusals. All staff working on 06/15/14 received the education and all other staff is receiving the education prior to clocking in for their next scheduled shift. All new staff will obtain education on Residents' Rights during Orientation. Staff questionnaire regarding abuse and resident rights and Advanced Directives is being administered by Administrator, DON, ADONs, MDS coordinators, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director to five staff members on each shift and different staff members until the immediacy of the Jeopardy is removed. All results of questionnaires, tests, skin assessments are reviewed daily by the Administrator, DON, Nurse Consultant, Vice President of Operations, Chief Operations Officer, or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown origin are reported immediately to the Abuse Coordinator, Administrator, Director of Nursing, Regional Nurse Coordinator, Regional Vice President of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nurse Executive. Results of the staff questionnaire will be reported to the Quality Assurance committee weekly to determine the further need of continued education or revision of plan. Human Resources performed an audit of all personnel files for any abuse concerns on 06/13/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, termination forms, abuse registry checks, background checks, and licensure. Results of audit were given to the Administrator, on 06/14/14, to review for any abuse/neglect concerns that needed reported. None was identified. Information on Caring for the Caregiver, which addresses the signs of stress and burnout, shows the caregiver ways to cope and reduce stress and useful ways that friends can offer help to the caregiver were posted by the time clock on 06/14/14 by the administrator. A nurse from the regional team or corporate office has been onsite since 06/13/14 and will remain in the facility daily until the Jeopardy has been lifted. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse or Director of Clinical Programs will be in daily contact with the Regional Nurse Consultant and will review allegations. All grievances and Resident Questionnaires since 02/01/13, were reviewed by the Administrator, DON, Chief Nurse Executive, Human Resources Director, Admissions Director or Regional Nurse Consultants by 06/16/14 to determine if any items documented were a reportable event. The Facility Administrator, Social Services Director or Director of Nursing reported 58 allegations of abuse, neglect or misappropriation to the Office of Inspector General, APS and Ombudsmen and appropriate authorities as required state law by 06/16/14. The Administrator, Social Services Director or the Director of Nursing will review daily, the grievances and incident/accident reports, until the immediacy of the Jeopardy is lifted, starting 06/13/14, to determine if there are reportable allegations that have not been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. The Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. A Resident Council meeting was held on 06/13/14, conducted by the Chaplain and Staff Development Coordinator, to discuss any abuse/neglect concerns, the facility's Abuse Policy and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director, one per shift, will be on site each shift to perform walking rounds in which 20 residents (ten with BIMS scores of 8 or greater and ten with BIMS scores of 7 or less) will be visited by the Department Head and interviewed regarding staff treatment. Those residents that can be interviewed and for those residents who are not able to be interviewed, the Department Heads will visit the resident, skin checks will be completed by the nurse, as well as speaking to nurse and the CNA regarding any noted changes in resident behaviors. The Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director will interview ten staff members daily, five from day shift and five from night shift, regarding the types of abuse, who is the abuse coordinator, when suspected abuse is reported, residents rights and advanced directives which began on 06/14/14 and will continue until Immediate Jeopardy is lifted. Results of resident and staff questionnaires will be reported to the Administrator, DON, Regional Nurse Consultant, or VP of Operations daily, and if the Administrator is not in the facility, the Department Director conducting the questionnaires will telephone the Administrator or VP of Operations the results of the resident and staff questionnaires. This began on 06/14/14 and will continue until the Jeopardy is lifted. A binder is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift. This binder contains a resident roster in which the interview date and shift is noted next to the resident's name to ensure that residents with BIMS scores of 8 or greater will be interviewed and residents with BIMS scores of 7 or less will be visited, with skin checks completed, beginning on 06/14/14 and will continue until the Jeopardy is lifted. The MDS Coordinators have the responsibility for updating the binder weekly to identify residents with BIMS scores of 8 or greater and residents with BIMS scores of 7 or less. If abuse, mistreatment, neglect, misappropriation or violation of resident rights is alleged during the interviews and/or visits are reported by a staff member, the Department Head will ensure the resident is safe, report to a Charge Nurse in which the Charge Nurse will remove the alleged perpetrator to a non-patient care area and notify the Administrator, Director of Nursing, and/or Social Services Direct/Abuse Coordinator. The alleged perpetrator will be suspended and an investigation will begin immediately. The Administrator, Director of Nursing, Social Services, or a member of the regional staff will review all resident and staff questionnaires daily for any allegations of abuse, neglect, misappropriation to include violation of resident rights or advanced directives. Investigations of grievances/concerns will be initiated upon receipt, starting on 06/14/14. Nursing Administration (DON, ADON, Staff Development Coordinator, MDS staff, Medical Records Director, or Social Service Director) will review documentation in the Nursing Notes and Social Service Notes in order to assess for any documented evidence of an allegation of abuse, neglect, misappropriation, or violation of resident rights daily on ten different residents each day. This began on 06/14/14. No concerns have been identified. Any concerns identified, resident safety will first be ensured, and then the Charge Nurse will be notified. The Abuse Policy will be followed in which the alleged perpetrator will be removed from a resident care area (if on duty) suspended pending investigation and the Administrator, DON, or Social Service Director will be notified. All resident Social Service Notes and Nursing Notes that were in the chart (3 months) were reviewed on 06/13/14 by the DON, ADONs, Staff Development Coordinator, MDS staff, Medical Records Director, Admissions Director, or a Social Service Director and Administrator from a "sister" facility, or regional/home office nurses for any documentation regarding abuse or violation of resident rights. No new incidents were identified. Ten charts are reviewed by a member of Nursing Administration or Regional or Home Office Nurse daily to validate that no other abuse allegations or violations of resident rights have been documented but not reported. This will continue until the Immediate Jeopardy is removed. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse allegations daily to ensure that the resident is protected, the alleged perpetrator is removed from the resident care area, reports to the Office of the Inspector General, APS and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log starting on 06/14/14 that will include documentation of the following: validate protection of residents, perpetrator is removed from resident care area, reports to the Office of the Inspector General, APS, and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Chief Operation Officer, VP of Operations, Chief Nurse Executive or Regional Nurse Consultant will review the abuse log daily until removal of the Immediate Jeopardy, beginning on 06/14/14, to validate protection of the resident, that the perpetrator is removed from the resident care area, that reports to the Office of the Inspector General, APS, Ombudsman and appropriate authorities required by State law, are filed timely, and a thorough investigation has been completed. All Incident Reports from January 2014 to June 2014 were reviewed by the Director of Nursing, ADON, Regional Nurse Consultant or Chief Nursing Executive to identify any abuse or neglect or violation of a residents rights on 06/14/14. None was identified. Beginning on 06/13/14, the care plan conference for each resident will include any abuse/neglect concerns that the resident or families have, or any concerns with violation of resident rights or advanced

Based on interview, record review, and review of policy/procedures it was determined the Administrator failed to ensure the facility's resources, including policies related to abuse and neglect, were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for three (3) of four (4) sampled residents (Residents #1, #2, and #4). It was reported to the Administrator on 05/26/14 that Medication Aide (MA) #1 had administered a suppository despite the resident's verbal refusal and the resident's physical gesture of refusal by placing a hand over the rectal area. Although the facility terminated MA #1's employment, the Administrator unsubstantiated that abuse had occurred, and stated he did not "believe" the events had occurred as described by Resident #1 because MA #1 denied that Resident #2 refused the suppository. It was reported to the Administrator on 06/04/14, that CNA #1 had refused to assist Resident #2 to the toilet on 06/02/14 and instructed the resident to "pee in the bed." However, the Administrator failed to ensure the resident's allegations were investigated or that witness interviews and evidence that was available to the facility had been obtained and/or considered in an effort to determine if abuse had occurred. In addition, on 05/19/14, Resident #4's family member contacted the facility and requested that CNA #1 not provide direct care to Resident #4 because the CNA had been "disrespectful and hateful." Although the Administrator was made aware of the request on 05/19/14, the facility failed to initiate an investigation of the allegation to determine if abuse had occurred or to protect residents in the facility from potential abuse during an investigation, and on 05/19/14, moved CNA #1 to another unit in the facility to provide direct resident care. The Administrator's failure to ensure facility policies/procedures related to recognizing, investigating, and reporting abuse were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy was determined to exist on 05/26/14 at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and F226), and 42 CFR 483.75 Administration (F490). An acceptable Allegation of Compliance was received on 06/25/14 which alleged removal of the Immediate Jeopardy on 06/25/14. A partial extended survey was conducted on 06/26-27/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.10 Resident Rights (F155) 42 CFR 483.13 Resident Behavior and Facility Practices (F223, F225, and 226) and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the "Job Description" for the Administrator, updated December 2011, revealed the Administrator would "lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies..." The "Essential Duties and Responsibilities" of the Administrator included "maintain a working knowledge of and confirm compliance with all governmental regulations." Review of the facility's policy, "Abuse, Neglect and Misappropriation," effective April 2013, revealed, "The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances." In addition, according to the policy, "...all allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines." Further review revealed, "The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation." The policy revealed, "The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate. The Administrator and/or DON will notify state agencies according to their reporting guidelines. "All allegations of abuse will be investigated and reported to the appropriate agencies." 1. Review of a facility's investigation dated 05/30/14, revealed on 05/26/14, Resident #1 refused a rectal suppository that had been prescribed by the physician; however, according to the report, MA #1 proceeded to push the resident's leg in an upward motion while stating the physician wanted the resident to have the suppository as ordered. Resident #1 stated at that time he/she positioned his/her hand over the rectal area in an attempt to block MA #1 from inserting the suppository. Although the Administrator acknowledged in interview conducted on 06/13/14 at 1:30 PM that he had knowledge that MA #1 had a previous history of being "rough" with Resident #2 and of reports that MA #1 was "hateful" to residents, the Administrator unsubstantiated the allegation of abuse because MA #1 denied that Resident #1 refused the suppository. 2. Continued interview with Resident #2 revealed on a recent occasion, he/she rang the call light for assistance to the toilet and was told by CNA #1 that she could not assist him/her to the bathroom, and to "pee in the bed." Resident #2 stated he/she did not want to void in the bed, and called his/her family member to inform her that staff would not assist him/her to the toilet, and that staff had told him/her to "pee in the bed." Resident #2 stated the incident upset him/her and stated, "I shouldn't have to pee on myself." Resident #2 stated after he/she had reported the incident to the family member, CNA #1 returned to his/her room to assist him/her to the bathroom. According to Resident #2, while in the bathroom, CNA #1 told the resident, "You better not call (family member) on me again." Resident #2 stated she felt threatened and afraid of CNA #1 at that time. Resident #2 stated he/she reported the comment made by CNA #1 to facility staff and was interviewed by the Administrator and DON. However, according to the Administrator in interview on 06/13/14 at 1:30 PM, he did not consider the report an allegation of abuse/neglect and did not conduct an investigation of the incident to determine if abuse occurred. Due to the facility's failure to investigate the resident's allegation, the facility did not follow its policy, and failed to "...remove the perpetrator from resident care areas," failed to "...obtain staff members witness statements," failed to "...immediately suspend the employee pending the outcome of the investigation," and failed to "...notify state agencies according to their reporting guidelines," as required by policy. 3. Review of a Complaint/Grievance Report dated 05/19/14, revealed Resident #4's family member contacted the facility and requested that CNA #1 no longer provide care to Resident #4 due to the staff member being "disrespectful and hateful." The concern was reported to the Administrator and the Social Worker (SW), who also functions as the facility's Abuse Prevention Coordinator. The facility resolved the complaint/grievance by instructing staff that "two (staff) were to go in (Resident #4's) room at night," and that CNA #1 would be moved to another unit in the facility and educated on "tone" of voice. Interview with the Director of Nursing (DON) on 06/16/14, at 3:55 PM revealed CNA #1 was moved to another unit to "make (Resident #4's family member) feel better." Interview with the Administrator on 06/13/14, at 1:30 PM revealed the Unit Manager made him aware of Resident #4's family member's request to not allow CNA #1 to provide care to Resident #4, but he did not consider the request to be an allegation of possible abuse and therefore had not conducted an investigation of the incident. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/25/14. The facility implemented the following actions to remove the Immediate Jeopardy: All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with Brief Interview for Mental Status (BIMS) scores of 8 or greater were interviewed by the Admissions Director, Dietary Director, Plant Operations Director, Minimum Data Set (MDS) Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, Staff Development Coordinator (SDC), or Chaplain for any abuse/neglect concerns on 06/13/14. Eleven concerns with ten residents were identified through interviews conducted on 06/13/14, two of which involved Resident #1 and Resident #2 (with Resident #2 having two reported incidents). The eleven concerns consist of four allegations of physical abuse, three allegations of neglect, one allegation of verbal abuse, two allegations of misappropriation of resident property and one allegation of mental abuse; all of which were reported to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman between 06/13/14 and 06/17/14. Residents with BIMS scores of 7 or less were physically assessed by the Assistant Directors of Nursing (ADON), Admissions Director, or Staff Development Coordinator for any signs and symptoms of abuse/neglect on 06/13/14. No concerns were identified. All Power of Attorneys of residents with a BIMS score of 7 or less were attempted to be contacted in regards to any abuse/neglect concerns on 06/14/14, and on resident rights and advanced directives on 06/15/14 by the Social Services Director, Chaplain, DON, ADON, Administrator, SDC or Admissions Director. The facility will continue to attempt contact daily until remaining Power of Attorneys (POAs) have been reached. No concerns have been identified from any POA at this time. Abuse/neglect audits, assessments, interviews, and questionnaires were reviewed by the Administrator, Director of Nursing and Regional Nurse Consultant, and the Chief Nurse Executive on 06/13/14 for any indications of abuse/neglect concerns. All residents with a BIMS score of 8 or greater received education on Residents Rights and were given a copy of the Resident Rights on 06/15/14 by the Business Office Manager or Chaplain. The facility Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director, were re-educated on 06/13/14 by the Regional Nurse Consultant on the abuse policy and procedure, to include but not limited to: training, prevention, identification, protection and reporting/response, completing a thorough investigation which includes obtaining witness statements from any stakeholder, resident or any person witnessing the event, statements from any other staff that have worked with the alleged perpetrator (employee), conversations with the residents' POAs, head to toe assessments of residents under the care of the employee that were unable to tell us if an event has occurred (BIMS score of 7 or less) and interviews with residents that can tell us if they feel safe, abused or mistreated or violated by alleged victim. The education also included that in the report of any allegation or suspicion of abuse or violation of a resident's right, safety of the resident is to be ensured and then immediately reported to the Charge Nurse. If the perpetrator is an employee, they will be immediately removed from the resident care area to ensure safety of all other residents. The alleged perpetrator would be moved to a non-patient care area and suspended, the Charge Nurse will report to the Abuse Coordinator/Administrator/DON in which the alleged allegation is reported to OIG, APS, and Ombudsman. An investigation is then initiated. As well, the grievance process is not for reporting or handling allegations of abuse. This training was performed face to face in order to facilitate discussion and question and include examples of items that would be considered as reportable: reports of staff being physically or verbally mean or rough, injuries of unknown origin, withholding belongings, resident to resident altercations to include verbal or physical, and taking belongings or exploitation. Department Administrative Managers could not return to work until abuse education was provided, pre and post-test administered and 100% score obtained on post-test. If the manager did not score 100% on post-test, then the manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director were re-educated on the abuse policy, which included training, prevention, identification, investigation, protection and reporting/response. They were then assigned to re-educate the staff on the abuse policy and procedure which included, but not limited to, ensuring resident safety when witnessing abuse or if an allegation is made, then reporting immediately to a Charge Nurse, removal of the perpetrator from the resident care area, alleged perpetrator is suspended, then reported to Abuse Coordinator/Administrator/ DON, in which the alleged allegation is reported to OIG, APS, and Ombudsman which started on 06/13/14. No employee will be allowed to work until abuse education is provided, pre and post-test administered and 100% score obtained on post-test, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. Education regarding the abuse policy and procedure, to include the components of training, prevention, identification, investigation, protection and reporting/response with identification/reporting and process will be included in the orientation process for all newly hired staff members. No newly hired employee will be allowed to work until abuse education and resident right education is provided, post-test administered and 100% score obtained, if employee did not score 100% on post-test, then employee will be immediately re-educated and post-test re-administered. This process will continue until employee obtains a 100% score on post-test. The Administrator, DON, ADONs, Dietary Director, Business Office Manager, Chaplain and Admissions Director, were re-educated on 06/15/14 by the Chief Nurse Executive on Resident Rights and Advanced Directives. This training was performed face to face in order to facilitate discussion and question and include examples of resident rights, the types of Advanced Directives, and examples of resident refusals. A pre and post-test were administered and 100% score obtained on post-test. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. This process continued until all managers obtained a 100% score on post-test. Department administrative managers will not be allowed to return to work until the Residents' Rights and Advanced Directive Education is provided pre and post-test administered and 100% score obtained on post-test. Once the Administrator, DON, ADON, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director and Human Resources Director were re-educated on Residents' Rights and Advanced Directives, they were then assigned to re-educate the staff on the Residents Rights and Advanced Directives beginning on 06/15/14 to include examples of Resident Rights, the types of Advanced Directives and examples of resident refusals. All staff working on 06/15/14 received the education and all other staff is receiving the education prior to clocking in for their next scheduled shift. All new staff will obtain education on Residents' Rights during Orientation. Staff questionnaire regarding abuse and resident rights and Advanced Directives is being administered by Administrator, DON, ADONs, MDS coordinators, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director to five staff members on each shift and different staff members until the immediacy of the Jeopardy is removed. All results of questionnaires, tests, skin assessments are reviewed daily by the Administrator, DON, Nurse Consultant, Vice President of Operations, Chief Operations Officer, or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown origin are reported immediately to the Abuse Coordinator, Administrator, Director of Nursing, Regional Nurse Coordinator, Regional Vice President of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nurse Executive. Results of the staff questionnaire will be reported to the Quality Assurance committee weekly to determine the further need of continued education or revision of plan. Human Resources performed an audit of all personnel files for any abuse concerns on 06/13/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, termination forms, abuse registry checks, background checks, and licensure. Results of audit were given to the Administrator, on 06/14/14, to review for any abuse/neglect concerns that needed reported. None was identified. Information on Caring for the Caregiver, which addresses the signs of stress and burnout, shows the caregiver ways to cope and reduce stress and useful ways that friends can offer help to the caregiver were posted by the time clock on 06/14/14 by the administrator. A nurse from the regional team or corporate office has been onsite since 06/13/14 and will remain in the facility daily until the Jeopardy has been lifted. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse or Director of Clinical Programs will be in daily contact with the Regional Nurse Consultant and will review allegations. All grievances and Resident Questionnaires since 02/01/13, were reviewed by the Administrator, DON, Chief Nurse Executive, Human Resources Director, Admissions Director or Regional Nurse Consultants by 06/16/14 to determine if any items documented were a reportable event. The Facility Administrator, Social Services Director or Director of Nursing reported 58 allegations of abuse, neglect or misappropriation to the Office of Inspector General, APS and Ombudsmen and appropriate authorities as required state law by 06/16/14. The Administrator, Social Services Director or the Director of Nursing will review daily, the grievances and incident/accident reports, until the immediacy of the Jeopardy is lifted, starting 06/13/14, to determine if there are reportable allegations that have not been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. The Social Services Director or the Director of Nursing will report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. A Resident Council meeting was held on 06/13/14, conducted by the Chaplain and Staff Development Coordinator, to discuss any abuse/neglect concerns, the facility's Abuse Policy and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director, one per shift, will be on site each shift to perform walking rounds in which 20 residents (ten with BIMS scores of 8 or greater and ten with BIMS scores of 7 or less) will be visited by the Department Head and interviewed regarding staff treatment. Those residents that can be interviewed and for those residents who are not able to be interviewed, the Department Heads will visit the resident, skin checks will be completed by the nurse, as well as speaking to nurse and the CNA regarding any noted changes in resident behaviors. The Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Activities Director, Chaplain, Admissions Director, Medical Records Director or Human Resources Director will interview ten staff members daily, five from day shift and five from night shift, regarding the types of abuse, who is the abuse coordinator, when suspected abuse is reported, residents rights and advanced directives which began on 06/14/14 and will continue until Immediate Jeopardy is lifted. Results of resident and staff questionnaires will be reported to the Administrator, DON, Regional Nurse Consultant, or VP of Operations daily, and if the Administrator is not in the facility, the Department Director conducting the questionnaires will telephone the Administrator or VP of Operations the results of the resident and staff questionnaires. This began on 06/14/14 and will continue until the Jeopardy is lifted. A binder is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift. This binder contains a resident roster in which the interview date and shift is noted next to the resident's name to ensure that residents with BIMS scores of 8 or greater will be interviewed and residents with BIMS scores of 7 or less will be visited, with skin checks completed, beginning on 06/14/14 and will continue until the Jeopardy is lifted. The MDS Coordinators have the responsibility for updating the binder weekly to identify residents with BIMS scores of 8 or greater and residents with BIMS scores of 7 or less. If abuse, mistreatment, neglect, misappropriation or violation of resident rights is alleged during the interviews and/or visits are reported by a staff member, the Department Head will ensure the resident is safe, report to a Charge Nurse in which the Charge Nurse will remove the alleged perpetrator to a non-patient care area and notify the Administrator, Director of Nursing, and/or Social Services Direct/Abuse Coordinator. The alleged perpetrator will be suspended and an investigation will begin immediately. The Administrator, Director of Nursing, Social Services, or a member of the regional staff will review all resident and staff questionnaires daily for any allegations of abuse, neglect, misappropriation to include violation of resident rights or advanced directives. Investigations of grievances/concerns will be initiated upon receipt, starting on 06/14/14. Nursing Administration (DON, ADON, Staff Development Coordinator, MDS staff, Medical Records Director, or Social Service Director) will review documentation in the Nursing Notes and Social Service Notes in order to assess for any documented evidence of an allegation of abuse, neglect, misappropriation, or violation of resident rights daily on ten different residents each day. This began on 06/14/14. No concerns have been identified. Any concerns identified, resident safety will first be ensured, and then the Charge Nurse will be notified. The Abuse Policy will be followed in which the alleged perpetrator will be removed from a resident care area (if on duty) suspended pending investigation and the Administrator, DON, or Social Service Director will be notified. All resident Social Service Notes and Nursing Notes that were in the chart (3 months) were reviewed on 06/13/14 by the DON, ADONs, Staff Development Coordinator, MDS staff, Medical Records Director, Admissions Director, or a Social Service Director and Administrator from a "sister" facility, or regional/home office nurses for any documentation regarding abuse or violation of resident rights. No new incidents were identified. Ten charts are reviewed by a member of Nursing Administration or Regional or Home Office Nurse daily to validate that no other abuse allegations or violations of resident rights have been documented but not reported. This will continue until the Immediate Jeopardy is removed. The Administrator, Director of Nursing, and Social Services Director will review and discuss all abuse allegations daily to ensure that the resident is protected, the alleged perpetrator is removed from the resident care area, reports to the Office of the Inspector General, APS and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator will maintain an abuse investigation log starting on 06/14/14 that will include documentation of the following: validate protection of residents, perpetrator is removed from resident care area, reports to the Office of the Inspector General, APS, and Ombudsman are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Chief Operation Officer, VP of Operations, Chief Nurse Executive or Regional Nurse Consultant will review the abuse log daily until removal of the Immediate Jeopardy, beginning on 06/14/14, to validate protection of the resident, that the perpetrator is removed from the resident care area, that reports to the Office of the Inspector General, APS, Ombudsman and appropriate authorities required by State law, are filed timely, and a thorough investigation has been completed. All Incident Reports from January 2014 to June 2014 were reviewed by the Director of Nursing, ADON, Regional Nurse Consultant or Chief Nursing Executive to identify any abuse or neglect or violation of a residents rights on 06/14/14. None was identified. Beginning on 06/13/14, the care plan conference for each resident will include any abuse/neglect concerns that the resident or families have, or any concerns with violation of resident rights or advanced directives. Resident safety will be validated and then the allegation will be reported to the Charge Nurse. The abuse policy will then be followed. The DON, ADON, or Staff Development Coordinator will observe the care delivery, for any suspected abuse/neglect concerns on five residents daily, beginning on 06/14/14, until removal of the immediacy and then weekly (Monday through Friday). Results of the care delivery audits will be reported to the Quality Assurance Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the Quality Assurance Committee will determine at what frequency the audits will need to continue. Concerns identified will be corrected immediately and reported to administrator to ensure investigation of suspected neglect was investigated/completed and reporting guidelines are met. A Quality Assurance meeting will be held weekly for four weeks beginning 06/13/14, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation the Quality Assurance Committee will determine at what frequency ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident wellbeing as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Special Projects Administrator, the Regional Vice President of Operations, Signature Care Consultant, Chief Nursing Officer, member of regional staff or Chief Operating Officer, daily until removal of the immediacy beginning 06/13/14, then weekly for four weeks, then monthly. **The surveyor validated the Immediate Jeopardy was removed as follows: Review of the "Random Follow up Questionnaires for Residents," dated 06/13/14 and interviews on 06/27/14, at 1:51 PM with the MDS Coordinator and at 11:25 AM with the Staff Development Coordinator revealed the residents had been interviewed. Review of documentation revealed the allegations were faxed to the Office of Inspector General between the dates of 06/13/14 and 06/17/14. Review of "C.N.A Skin Care Alert" forms dated 06/13/14, and interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator and at 11:30 AM with the Assistant Director of Nursing, revealed the assessments had been completed. Interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator, at 11:30 AM with the Assistant Director of Nursing, at 11:00 AM with the Administrator, and at 1:56 PM with the Social Worker revealed staff had contacted the residents' Power of Attorneys regarding abuse/neglect concerns and resident rights. The staff stated they were continuing to contact all Power of Attorneys not yet reached. Additionally, interview on 06/27/14 at 11:15 AM with Resident G's Power of Attorney revealed he had been contacted by the facility and voiced no concerns. Interviews on 06/27/14 at 11:00 AM with the Administrator, and at 11:45 AM with the Director of Nursing, revealed all Abuse/Neglect audits, assessments, interviews, and questionnaires had been reviewed on 06/13/14. Review of acknowledgement sheets signed by residents and interviews on 06/27/14 at 10:10 AM with Resident #3, at 10:15 AM with Resident D, at 10:23 AM with Resident E, and at 10:30 AM with Resident F revealed the education had been provided to residents. Review of "Random Follow-Up Questionnaires for Staff," dated 06/13/14 with designations of pre-test and post-test revealed the Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Coordinator, Staff Development Coordinator, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records Director, and Human Resources Director had all taken the test and scored 100%. Review of "Random Follow-Up Questionnaire for Staff," forms and interviews on 06/27/14, at 10:30 AM with Housekeeper #1, at 11:18 AM with Licensed Practical Nurse #1, and at 11:38 AM with CNA #3 revealed the staff had taken the test and scored 100%. Review of "Resident Rights" questionnaires designated with pre-test and post-test dated 06/15/14, revealed the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Director, Business Office Manager, Chaplain, and Admissions Director had all taken the test and scored 100%. Review of "Resident Rights" questionnaire and interviews on 06/27/14, at 10:30 AM with Housekeeper #1, at 11:18 AM with Licensed Practical Nurse #1, and at 11:38 AM with CNA #3 revealed the staff had taken the test and scored 100%. Interview on 06/27/14 at 11:25 AM the Staff Development Coordinator revealed orientation training and education material includes Resident Rights training. Review of "Random Follow-Up Questionnaire for Staff" forms and interviews on 06/27/14 at 11:25 AM with the Staff Development Coordinator, at 11:30 AM with the Assistant Director of Nursing, at 11:00 AM with the Administrator, and at 1:56 PM with the Social Worker, revealed the questionnaires regarding abuse, resident rights, and advanced directives had been administered to five staff members on each shift. Interview with the Administrator on 06/27/14, at 11:20 AM revealed the questionnaires had been reviewed and no concerns were identified. Review of Quality Assurance Meetings conducted on 06/13/14 and 06/20/14 revealed the results of the questionnaire had been reported in the meetings. Review of a signed statement dated 06/13/14, by the Human Resources Director revealed all Human Resource files had been audited for Coaching and Counseling forms, Suspension Forms, Termination Forms, Abuse Registry Checks, Background Checks, and Licensure requirements. Observation of the employee time clock on 06/27/14 at 11:58 AM revealed "caring for the caregiver" educational material was present. Review