Every finding on record at Sansbury Care Center

Based on interview, record review, and review of the facility's policies, the facility failed to ensure the resident's medical record included declination documentation indicating the resident or resident representative was provided education regarding the benefits and potential risks of the COVID-19 vaccine, or documentation the resident received the vaccine, for 3 of 5 residents sampled for immunizations, Resident (R) 2, R5, and R7.1. Review of R2's medical record revealed no documentation of COVID-19 vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccination.2. Review of R5's medical record revealed no signed documentation of COVID-19 vaccine consent or declination by the resident's representative, and no documentation of education provided on the benefits and potential risks of the vaccination.3. Review of R7's medical record revealed no documentation of COVID-19 vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccinations.The findings include:Review of the facility's policy titled, Vaccination of Residents, revised 10/2019, revealed all residents will be offered vaccines that aid in preventing infectious disease. According to the policy, prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination. Provision of such education shall be documented in the residents' medical record. The resident or the resident's legal representative may refuse vaccines for any reason and refusals are documented in the residents' medical record.Review of the facility's policy titled, Coronavirus Disease (Covid-19) Vaccination of Residents, revised 05/2023, revealed before the vaccine is ordered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. Refusal of the vaccination is appropriately documented in the resident's medical record.Review of the admission Face Sheet, found in R2's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 11/18/2022 with diagnoses to include type 2 diabetes mellitus, hypertensive heart disease, and chronic kidney disease.Review of R2's comprehensive Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/02/2026, revealed a Brief Interview for Mental Status [BIMS] score of 12 out of 15, which indicated the resident was moderately cognitively impaired.Review of R2's Immunization Report, with the current report ending on 07/28/2026, revealed the resident refused the 2025/2026 COVID-19 vaccine.Review of R2's EMR revealed no documentation of COVID-19 vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccination.Review of the admission Face Sheet, found in R5's EMR under the Profile tab, revealed the facility admitted the resident on 07/20/2023 with diagnoses to include neurocognitive disorder with Lewy body dementia, Parkinson's disease, and type 2 diabetes mellitus.Review of R5's quarterly MDS, with an ARD of 05/28/2026, revealed a BIMS score of 3 out of 15, which indicated the resident was severely cognitively impaired.Review of R5's Immunization Report, with the current report ending on 07/28/2026, revealed the resident representative refused the COVID-19 vaccination.Review of R5's EMR revealed no signed documentation of COVID-19 consent or declination by the resident's representative, and no documentation of education provided on the benefits and potential risks of the vaccinations.Review of the admission Face Sheet, found in R7's EMR under the Profile tab, revealed the facility admitted the resident on 01/05/2026 with diagnoses to include hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus.Review of R7's quarterly MDS, with an ARD of 07/02/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R7's Immunization Report, with the current report ending on 07/28/2026, revealed the resident refused the COVID-19 vaccination.Review of R7's EMR revealed no documentation of COVID-19 consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccination.During an interview with R2 on 07/30/2026 at 10:30 AM, she stated she declined the COVID-19 vaccination; however, the resident stated she did not remember signing any documentation related to the vaccination. Additionally, she did not remember being educated on the risks and benefits associated with the vaccination.During an interview with R7 on 07/30/2026 at 10:15 AM, she stated she refused the COVID-19 vaccine but did not remember being offered education or signing a declination form indicating her refusal of the vaccination. She stated she did not receive a vaccine information sheet providing education about the COVID-19 vaccination.During an interview with the Infection Preventionist (IP) on 07/29/2026 at 3:25 PM, she stated she was responsible for coordinating immunizations for the facility. The IP stated a local pharmacy administered the COVID-19 vaccine to residents at the facility and obtained its own immunization screening and consent forms for those vaccines. When asked by the State Survey Agency (SSA) Surveyor why appropriate documentation was not maintained, including consent and education, she stated she was not aware that a signed declination and education was required documentation in the medical record. The IP stated if a resident refused an immunization, the facility did not obtain a signed declination. Instead, the refusal and the resident's reason for declining were documented on the resident's Immunization Report.The IP further stated accurate immunization documentation was important for resident safety. She stated it ensured each resident received the appropriate vaccines and prevented missed or duplicate vaccinations. Furthermore, the IP stated COVID-19 vaccination was important for reducing infection risk and should be administered and documented in accordance with CDC guidelines.During an interview with the Director of Nursing (DON) on 07/30/2026 at 1:40 PM, she stated documentation of immunization administration, consent, or refusal demonstrated residents or authorized representatives received the opportunity to accept or decline recommended vaccines. The DON stated residents had the right to refuse immunizations, and documentation should reflect informed refusal. The DON stated residents with decision-making capacity could make their own vaccination decisions, while authorized representatives made decisions for residents lacking capacity. She stated the COVID-19 vaccination protected residents, staff, and the community by reducing the risk and severity of COVID-19 illness associated complications.During an interview with the Administrator on 07/30/2026 at 2:12 PM, she stated the facility identified opportunities to improve the immunization process after recognizing incomplete documentation of resident and responsible party declinations for the COVID-19 vaccine. The Administrator stated residents and responsible parties had the right to refuse immunizations; however, the facility should obtain signed declination forms or document refusals received by telephone when signatures could not be obtained. The Administrator stated documentation should reflect education, the offer of immunization, and the resident's or responsible party's decision. The Administrator acknowledged the immunization process required improvement and stated the COVID-19 vaccination was important to reduce the spread of the virus.

Based on interview, record review, and review of the facility's policy, the facility failed to reassess the effectiveness of the interventions and review and revise the resident's care plan to meet the resident's needs for 1 of 25 sampled residents, Resident (R) 7.The facility failed to revise R7's care plan with interventions to improve or stabilize the skin integrity/tissue breakdown and to provide treatments after a skin assessment revealed the resident had skin breakdown on her buttocks delaying appropriate treatment for two weeks.The findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 2022, revealed an individualized, comprehensive, person-centered care plan is required for each resident that addresses identified physical, psychosocial, and functional needs. The interdisciplinary team (IDT), in collaboration with the resident and/or representative, develops interventions based on the comprehensive assessment. Further review revealed the care plan must include measurable objectives and timeframes and identify services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being in accordance with recognized standards of practice. The IDT must review and revise the care plan following a significant change in condition, when desired outcomes are not achieved, upon readmission, and at least quarterly in conjunction with the required MDS [Minimum Data Set] assessment.Review of the admission Face Sheet, found in R7's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 01/05/2026 with diagnoses to include hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus.Review of R7's quarterly MDS, with an Assessment Reference Date (ARD) of 07/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of R7's Care Plan Report, dated 06/25/2026, found in R7's EMR under the Care Plan tab, revealed the resident was identified as a risk for pressure ulcers related to reduced mobility, secondary to hemiplegia and hemiparesis following cerebral infarction. Further review revealed the care plan was not updated after a skin breakdown was identified on R7's buttocks during the 07/02/2026 weekly skin assessment to include interventions that addressed the change in the skin condition and to provide treatment.During an interview with R7 on 07/29/2026 at 10:15 AM, she stated she had a red, raw area between her gluteal fold that periodically causes itching. She stated the area has been present for approximately one month. R7 stated staff initially treated it with a barrier cream. She further stated the area became worse and the itching was more intense. R7 stated nurses noted the issue and stated there was superficial skin shearing but continued to use the barrier cream. She stated the provider examined the area recently and subsequently prescribed an antifungal cram. She stated that since starting the antifungal cream, the area was healing.During an interview with the Infection Preventionist (IP/WCN) on 07/30/2026 at 1:20 PM, she stated the expected process required staff to notify the IP/WCN or physician immediately when identifying a new skin concern, especially when wound care services were not immediately available. The IP/WCN stated communication supported timely assessment and treatment before worsening occurred. Additionally, she stated with timely communication, the care plan can be revised to include the new skin focus to allow for appropriate care and prevent further skin breakdown.During an interview with the Director of Nursing (DON) on 07/30/2026 at 1:40 PM, she stated an individualized care plan identified each resident's needs, activities of daily living, risks, and changes in condition. The DON stated staff were expected to revise care plans following any significant change in condition to reflect the residents' current status. The DON stated residents with changes in skin integrity required care plan updates to address the condition until resolution. She stated care plans directed staff in providing resident-specific interventions and monitoring.Furthermore, the DON stated updating the care plan and timely communication of changes in skin integrity ensured prompt assessment, treatment, physician notification, and monitoring before worsening occurred. The DON stated delays could result in worsening skin breakdown, infection, and delayed treatment.During an interview with the Administrator on 07/30/2026 at 2:12 PM, she stated care plans directed resident care and reflected individualized needs, interventions, and changes in condition. The Administrator stated staff were expected to follow facility policies, implement care plans, and revise care plans timely following significant changes in a resident's condition. The Administrator stated timely care plan revisions ensured all staff had access to current resident information and interventions.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 25 sampled residents, Resident (R) 7.R7's weekly skin assessments, dated 07/02/2026 and 07/09/2026, documented skin breakdown over the coccyx; however, Registered Nurse (RN) 1 failed to follow facility procedure by not completing an incident report or notifying the appropriate clinical personnel of the resident's skin breakdown. As a result, timely evaluation and intervention were delayed until 07/16/2026, when Certified Nursing Assistant (CNA) 5 notified the Infection Preventionist /Wound Care Nurse (IP/WCN) that R7 had developed a red, pruritic rash involving the buttocks. The failure to promptly communicate the resident's change in skin condition delayed assessment, implementation of appropriate treatment, and follow-up care, placing the resident at risk for worsening skin breakdown.The findings include:Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 03/2014, revealed staff are to assess and document skin alteration in order for the provider to order the wound treatment and assist with interventions.Review of the facility's policy titled, Pressure Injuries Overview, revised 03/2022, revealed shearing occurs when layers of the skin rub against each other, or when the skin remains stationary and the underlying tissue moves and stretches or tears.Review of the admission Face Sheet, found in R7's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 01/05/2026 with diagnoses to include hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus.Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of R7's Care Plan Report, dated 06/25/2026, found in R7's EMR under the Care Plan tab, revealed the resident was identified as a risk for pressure ulcers related to reduced mobility, secondary to hemiplegia and hemiparesis following cerebral infarction. Further review revealed R7's care plan was updated on 07/19/2026 to address a red, scaly fungal rash of the buttocks, with a goal for resolution and treatment with Nystatin (anti-fungal) cream applied to the bilateral buttocks twice daily.Review of the Basic Skin Assessment, dated 07/02/2026, found in R7's EMR under the Progress Note tab, revealed a skin assessment documented a Red, coccyx area with some shearing of the top layer skin.Review of the Nursing Services Basic Skin Assessment v2, dated 07/02/2026, found in R7's EMR under the Assessment tab, revealed there was an area on the tail bone with some shearing of the top layer of skin. Review of the nursing recommendations for follow up section revealed staff did not document nursing recommendations or follow-up interventions.Review of the Basic Skin Assessment, dated 07/09/2026, found in R7's EMR under the Progress Note tab, revealed a skin assessment documented a Red, coccyx area with some shearing of the top layer skin.Review of the Nursing Services Basic Skin Assessment v2, dated 07/09/2026, found in R7's EMR under the Assessment tab, revealed there was an area on the tail bone with some shearing of the top layer of skin. Review of the nursing recommendations for follow up section revealed staff did not document nursing recommendations or follow-up interventions.Review of the Skin/Wound Note, dated 07/16/2026, found in R7's EMR under the Progress Note tab, revealed the Wound Advance Practice Registered Nurse (WAPRN) examined and assessed R7's bilateral buttocks and the findings revealed the area was reddened and scaly.Review of the Order Summary Report, dated 07/2026, found in R7's EMR under the Orders tab, revealed an order for Nystatin (antifungal) external cream, 100000 unit/gram, apply to buttocks twice a day (BID) for fungal infection.Review of the Wound Care Progress Note, dated 07/16/2026, found in R7's EMR under the Provider Notes tab, revealed R7 reported occasional pain to the buttocks, and the area was noted with redness. Further review revealed the provider ordered Nystatin external cream, frequent repositioning, and wound care follow-up in one to two weeks.Review of the Wound Care Progress Note, dated 07/24/2026, found in R7's EMR under the Provider Notes tab, revealed on skin inspection, the WAPRN stated the redness to R7's buttocks had significantly improved, the scaly area had resolved, and a healing satellite lesion was noted.During an interview with R7 on 07/30/2026 at 10:15 AM, she stated she had a red, raw area on her buttocks, which periodically caused itching. She stated the area had been present for approximately one month. R7 stated staff initially treated her with a barrier cream. She further stated the area became worse and the itching was more intense. R7 stated nurses noted the issue and stated there was superficial skin shearing but continued to use the barrier cream. She stated the provider examined the area recently and subsequently prescribed an antifungal cream. She further stated that since starting the antifungal cream, the area was healing and the itching was less intense.During an interview with Licensed Practical Nurse (LPN) 5 on 07/30/2026 at 10:00 AM, she stated the WAPRN prescribed an antifungal cream for R7's fungal infection on 07/16/2026. She stated the resident had skin breakdown between her gluteal fold. LPN5 stated the area was reddened with skin shearing. She further stated she was not aware of skin breakdown until a new treatment order was received. When asked by the State Survey Agency (SSA) Surveyor what the facility protocol was when skin breakdown was identified, LPN5 stated the assigned nurse completed an incident report, documented the event in the nursing progress note, and performed the appropriate skin assessment when indicated. LPN5 stated the incident is to be reported to the Director of Nursing (DON). She further stated if a CNA identified skin breakdown, they should immediately report it to the nurse for assessment and follow up.During a telephone interview with RN1 on 07/30/2026 at 8:40 AM, she stated she first observed redness with superficial skin shearing over R7's coccyx during the resident's weekly skin assessment on 07/02/2026. She described the affected area as red with peeling superficial skin extending from the coccyx into the bilateral gluteal cleft. RN1 stated staff applied a topical barrier cream because they did not believe the area was a pressure injury. During the weekly skin assessment on 07/09/2026, RN1 stated she again observed skin breakdown over the coccyx and documented her findings in the resident's EMR.Furthermore, RN1 stated she believed new skin concerns were communicated during nurse-to-nurse shift report and that the Unit Manager routinely reviewed weekly skin assessments. She acknowledged she did not notify the provider or Unit Manager of the resident's change in skin condition and did not complete an incident report because she was unaware those actions were required. RN1 stated she did not recall reporting the resident's skin breakdown to anyone other than during handoff. She further acknowledged that prompt communication of changes in skin integrity facilitates timely evaluation and treatment, helping to prevent worsening of the condition and promoting healing.During an interview with the IP/WCN on 07/29/2026 at 3:25 PM, she stated staff did not notify her of R7's new skin concern when first assessed on 07/02/2026 and the subsequent skin assessment on 07/09/2026. She stated nursing staff and CNAs routinely communicated new skin concerns through direct notification, messages, or conversations on the unit. She further stated awareness of the resident's skin concern occurred only after a CNA reported worsening redness. The IP/WCN stated further review of the medical record revealed there was no new order placed when the skin issue was first identified on 07/02/2026. She stated that a previously ordered topical cream used before admission for moisture-associated skin damage was in place. The IP/WCN stated the WAPRN later discontinued the previous treatment and initiated Nystatin after determining the area appeared fungal.Furthermore, the IP/WCN stated the expected process required staff to notify her or the provider immediately when identifying a new skin concern, especially when wound care services were not immediately available. She stated communication supported timely assessment and treatment before worsening occurred. The IP/WCN stated RN1 did not follow the expected process for the resident's skin changes identified on 07/02/2026 and 07/09/2026.During an interview with the DON on 07/30/2026 at 10:45 AM, she stated new skin findings identified during a weekly skin assessment required completion of an incident report to notify staff unless treatment had already been initiated for an existing condition. The DON stated staff left a message for the Unit Manager to review the skin concern and stated the provider would be contacted when warranted. The DON stated staff initially applied a zinc barrier cream to protect the affected area before wound care determined the condition appeared to be fungal rather than moisture-associated skin damage.During additional interview with the DON on 07/30/2026 at 1:40 PM, she stated timely communication of changes in skin integrity ensured prompt assessment, treatment, provider notification, and monitoring before worsening occurred. The DON stated delays in communication could result in worsening skin breakdown, infection, and delayed treatment. She stated the expected process required the nurse who identified a new change in skin integrity to complete an incident report. She further stated incident reports were submitted to the Restorative Nurse, who was responsible for completing the appropriate notification and follow-up. The DON stated nursing management reviewed incident reports daily to discuss interventions, verify appropriate approaches, and ensure provider notification occurred when indicated. She stated the IP/WCN became aware of new skin concerns through daily management meetings or direct staff communication. She further stated nurses could notify the provider directly and should not delay provider notification until the IP/WCN or WAPRN became available.Additionally, the DON stated RN1 did not follow the expected process for the resident's skin changes identified on 07/02/2026 and 07/09/2026. She stated prompt communication and adherence to facility policies and procedures were necessary to ensure residents received timely treatment and to prevent worsening of the condition.During an interview with the Administrator on 07/30/2026 at 2:12 PM, she stated nursing staff were expected to follow facility policy by notifying the appropriate individuals or the provider when identifying a change in skin integrity. The Administrator stated timely communication ensured residents received prompt assessment, treatment, and appropriate interventions. She stated staff were expected to seek guidance whenever they had questions regarding changes in a resident condition.

Based on interview, record review, Centers for Disease Control and Prevention (CDC) guidance, and review of the facility's policy, the facility failed to ensure residents' medical records contained documentation that the resident or the resident representative refused the pneumococcal vaccination in accordance with facility policy and regulatory requirements for 1 of 5 residents sampled for immunization, Resident (R) 7.Review of R7's medical record and immunization reports revealed there was no signed documentation of the resident's or the resident representative's declination for the pneumococcal vaccination.The findings include:Review of CDC guidance titled, ACIP Recommendations: Pneumococcal Vaccine, dated 01/08/2025, revealed pneumococcal vaccination is based on age and risk factors, with vaccination recommended for adults age [AGE] and older and those with certain high-risk conditions, utilizing a one-time dose or series depending on prior vaccination status.Review of the facility's policy titled, Pneumonia Vaccine, revised 10/2022, revealed the facility's policy is to offer and encourage pneumonia vaccination to all residents, when indicated, to prevent the spread of pneumonia. The policy revealed residents are assessed upon admission for pneumonia vaccination history. Further review of the policy revealed the immunization is documented in the individual's medical record. Furthermore, the policy stated residents or their representatives have the right to decline vaccination; if refused, information of the refusal, including the date of the refusal, is documented in the resident's medical record.Review of the admission Face Sheet, found in R7's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 01/05/2026 with diagnoses to include hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus.Review of R7's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of R7's Immunization Report, with the current report ending on 07/28/2026, revealed the resident refused the pneumococcal vaccination.Review of R7's EMR revealed no documentation of pneumococcal vaccine consent or declination, and no documentation of education provided on the benefits and potential risks of the vaccinations.During an interview with R7 on 07/29/2026 at 9:25 AM, she stated she refused the pneumonia vaccine. She stated, It [pneumococcal vaccination] made me sick. She stated further she did not remember being offered education or signing a declination form indicating her refusal of the vaccination. She stated she did not receive a vaccine information sheet providing education about the pneumococcal vaccination.During an interview with the Infection Preventionist (IP) on 07/29/2026 at 3:25 PM, she stated she was responsible for coordinating immunizations for the facility. The IP stated that a local pharmacy administered the pneumococcal vaccines to residents at the facility and obtained its own immunization screening and consent forms for those vaccines. When asked by the State Survey Agency (SSA) Surveyor why appropriate documentation was not maintained, including consent and education, she stated she was not aware that a signed declination and education was required documentation in the medical record. The IP stated if a resident refused an immunization, the facility did not obtain a signed declination. Instead, the refusal and the resident's reason for declining were documented in a progress note and, on the resident's Immunization Report.Additionally, the IP stated accurate immunization documentation was important for resident safety. She stated it ensured each resident received the appropriate vaccines and prevented missed or duplicate vaccinations. Furthermore, the IP stated pneumococcal vaccinations were important for reducing infection risk and should be administered and documented in accordance with CDC guidelines.During an interview with the Director of Nursing (DON) on 07/30/2026 at 1:40 PM, she stated documentation of immunization administration, consent, or refusal demonstrated residents or authorized representatives received the opportunity to accept or decline recommended vaccines. She stated this was important because residents had the right to refuse immunization and documentation should reflect informed refusal. The DON stated residents with decision-making capacity could make their own vaccination decisions, while authorized representatives made decisions for residents lacking capacity. The DON stated immunizations protected residents, staff, and the community by reducing the risk and severity of vaccine-preventable illnesses.During an interview with the Administrator on 07/30/2026 at 2:12 PM, she stated the facility identified opportunities to improve the immunization process after recognizing incomplete documentation of resident and responsible party declinations for recommended vaccines. The Administrator stated residents and responsible parties had the right to refuse immunizations; however, the facility should obtain signed declination forms or document refusals received by telephone when signatures could not be obtained. The Administrator stated documentation should reflect education, the offer of immunization, and the resident's or responsible party's decision. She acknowledged the immunization process required improvement, and stated immunizations were important to reduce the spread of vaccine-preventable illnesses.

Based on observation, interview, review of the Food and Drug Administration's document, and review of the facility's documents and policy, the facility failed to prepare and serve food in accordance with professional standards for food service safety with incomplete documentation of hot and cold food temperatures, use of a cleaning cloth not sanitized after each use, and preparation of sanitizer at the wrong strength. This deficient practice had the potential to affect 44 current residents. The findings include: Review of the facility's policy titled, Sanitizing Solution-Quaternary, dated 2013, revealed containers used for sanitizing work areas, and the cleaning cloth, were changed every shift or as needed. Solutions and cloths could be changed more frequently if the workload warranted, producing a cloudy dirty solution. The policy stated the solution for sanitizing the work surface consisted of 1-1/2 gallons of warm water and one quaternary sanitizing tablet to equal 200 parts per million (PPM). Review of the Food and Drug Administration 2013 Kentucky Food Code 902 [Kentucky Administrative Regulation] [NAME] 45:005 revealed how to manage the sanitizer buckets. It stated to change the sanitizing solution in buckets when it became weak, diluted or cloudy, or as needed to maintain the proper concentration. Further, it stated to change sanitizer buckets at least every two to four hours, or more frequently if necessary. Review of the facility's document June 2025 Sanitize Sheet revealed the first and second shifts taped the sanitizer test strip, which indicated the sanitizing solution was at the proper strength, onto the sheet of paper per day and according to shift. Continued review revealed not all dates were completed. The first shift had only 20 days of test strips out of 30 days taped to the sheet; and the second shift had 17 days of test strips out of 30 days of test strips taped to the sheet. The results of the sanitizer test strips were not recorded for the PPM contained in the sanitizer from 06/01/2025 to 06/30/2025. Observation on 06/30/2025 at 11:13 AM of the lunch tray line and food preparations for supper revealed the Cook, positioned near the steam table, wiped the food off from the surface in front of the steam table pan, using a cleaning cloth that was kept on the side table near the steam table and not in the sanitizer bucket after each use. Also, no sanitizer bucket was in view. Observation of the sanitizer bucket with the [NAME] on 07/01/2025 at 8:55 AM revealed she did not know which bucket was the sanitizer. The [NAME] tried both buckets, the green and the red bucket. The sanitizer strip did not show any sanitizer in either bucket. The green bucket had the appearance of water, and the red bucket had soap suds on top of the water. In an interview with the [NAME] on 07/01/2025 at 8:57 AM, she stated she put two pumps of sanitizer in the bucket from the pot and pan sink, and the other bucket contained the dish detergent and water. She stated the cleaning cloth should be kept in the sanitizer bucket between uses to decrease the potential for bacteria to be spread. She stated the test strips for the sanitizer must not be the correct strips. She stated the sanitizer was changed every four hours. Review of the weekly menu spread sheets, dated 02/23/2025 to 07/01/2025, with the Dietary Manager on 07/01/2025 at 8:48 AM, revealed food temperatures were not recorded consistently on the weekly menu spreadsheets. In an interview with the [NAME] on 06/30/2025 at 11:15 AM, she stated she had recorded the food temperatures on the menu in the notebook. In an interview with the Dietary Manager on 07/01/2025 at 8:50 AM and 07/02/2025 at 9:45 AM, she stated the food temperatures were recorded on the menu for the week. However, she stated not all food temperatures were recorded on the weekly menu spreadsheet. She stated the concern for not recording food temperatures would be the potential for cross contamination if the food temperature was not in the safe temperature range. She stated the red bucket contained the sanitizer, and the green bucket contained the detergent with water. She stated the sanitizer was changed every four hours. She stated there was a potential for cross contamination by not using the correct product for cleaning and sanitizing. In an interview with the Director of Nursing on 07/02/2025 at 9:53 AM, she stated food could cause illness if not at the proper temperature, and germs and illness could spread if the cleaning cloth was not kept in the sanitizer bucket. In an interview with the Administrator on 07/02/2025 at 10:14 AM, she stated if the food temperatures were not recorded, it could lead to food safety concerns. She stated she expected staff to follow policy and guidance from the Food and Drug Administration (FDA).

Based on observation, interview, record review, review of a medication package insert, and review of the facility's policy, the facility failed to remove expired medications from 2 of the 2 medication carts and 1 of the 2 medication refrigerators. The findings include: Review of the facility's policy titled, Medication Storage, revised November 2020, revealed discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed. 1. Observation on 08/07/2024 at 11:17 AM of the medication refrigerator in the second-floor medication room revealed a box of Fluzone High Dose influenza vaccine that had an expiration date of 06/2024. The box had contained 10 single-dose prefilled syringes, 0.7 milliliters each. There was one remaining syringe in the box. During interview with Certified Medication Technician (CMT) 3, at the time of the observation, she stated night shift nurses looked for expired medications in the cart. 2. a. Observation on 08/07/2024 at 10:42 AM of the medication cart on the second floor revealed a Proair 90 microgram (mcg) inhaler (albuterol, bronchodilator) that had an expiration date of 01/2024. The inhaler was for Resident (R) 9. There were no other Proair 90 mcg inhalers in the cart for R9. During interview with CMT3, at the time of the observation, she stated night shift nurses looked for expired medications in the cart. She also stated she did not notice the Proair inhaler had expired. b. Observation on 08/07/2024 at 10:44 AM of the medication cart on the second floor revealed an unopened Levemir (insulin) Flexpen in the top drawer for R19 which noted, refrigerate until opened. During interview with CMT3 at the time of the observation, she stated she did not know why it was in the drawer and not in the refrigerator. c. Observation on 08/07/2024 at 11:05 AM of the medication cart on the second floor revealed nystatin and triamcinolone cream (used to treat skin fungal infections) for R23 that had an expiration date of 01/2024. d. Observation on 08/07/2024 at 11:07 AM of the medication cart on the second floor revealed Biofreeze (used to relieve muscle and joint pain) for R3 that had an expiration date of 07/2024. During interview with CMT3 at the time of the observation, she stated the medications would not be effective, and the resident would not have pain relief if she used an expired medication. e. Observation on 08/07/2024 at 11:15 AM of the medication cart on the second floor revealed sugar free cough drops for R44 with an expiration date of of 12/2023. During interview with CMT3 at the time of the observation, she stated these expired cough drops might not be effective, and the resident would not get relief from her cough. 3. a. Observation on 08/07/2024 at 2:15 PM of the medication cart on the third floor revealed the Insulin lispro pen for R33 had an expiration date of 07/03/2024. During interview with CMT3 at the time of observation, she stated the insulin pens expired 30 days after opening. She stated the insulin might not be effective, and the resident could have a high blood glucose if R33 used this insulin. b. Observation on 08/07/2024 at 2:23 PM of the medication cart on the third floor revealed fluticasone nasal spray for R21, date opened 03/27/2024; refill 04/12/2024; and directions, one spray in both nostrils daily. Review of the manufacturer's guidelines (package insert), enclosed in the fluticasone box, revealed each bottle would provide 120 actuations (sprays). Also, it stated the bottle should be discarded after 120 sprays even though the bottle was not completely empty. The bottle should be discarded when the labeled number of actuations had been used. Review of R21's Medication Administration Record revealed R21 received 266 actuations from 03/28/2024 to 08/07/2024. During interview with the Director of Nursing on 08/07/2024 at 3:59 PM, she stated the third shift nurses removed expired and discontinued medications. She stated the night shift nurses either did not do their job or they did not see the expired medications. During interview with the Administrator on 08/07/2024 at 3:57 PM, she stated she expected all nurses to look for expired medications periodically. She stated it was in the night shift job description for staff to remove expired medications. She stated expired medications should not be used.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to have an effective system to ensure residents were free from abuse for one (1) of six (6) sampled residents (Residents #1). On 01/22/2020 at approximately 8:15 AM, State Registered Nurse Aide (SRNA) #3 and Licensed Practical Nurse (LPN) #1 were assisting Resident #1 to change clothes while the resident was in bed. Resident #1 realized the side rail was not up on the side of the bed in which the resident was to turn and asked LPN #1 to raise the side rail in order for him/her to be able to hold on to the side rail. However, LPN #1 refused and SRNA #3 witnessed LPN #1 place her hands on the resident's left hip and shoulder blade, and yank on the resident while trying to roll him/her. As Resident #1's daughter entered the room Resident #1 screamed, No Dammit it I'm not going to roll. LPN #1 did not see the resident's daughter and yelled at Resident #1, Don't cuss at me. LPN #1 then grabbed/jerked the resident's left hand/arm and placed it across the resident's body and leaned into him/her so the resident could not grab the side rail behind him/her and continued to attempt to roll the resident towards the right, but the resident was terrified of rolling out of the bed and resisted. LPN #1 then slammed the side rail up and yelled, NOW roll over. SRNA #3 identified abuse occurred, but did not report the allegation of abuse because she thought the resident's daughter had reported the incident. Resident #1's daughter did immediately report that she witnessed LPN #1 yelling and jerking on Resident #1 to the Director of Nursing (DON) on 01/22/2020, and then left to take the resident to an appointment. Resident #1's daughter then met with the DON and the Administrator on 01/22/2020 at approximately 1:00 PM, to further discuss what she had witnessed and was informed it was Bad customer service. The DON and Administrator did not identify abuse had occurred, and determined additional witness statements were not needed and an investigation was not initiated. Although LPN #1 clocked out on 01/22/2020 at 9:10 AM as instructed by administrative staff, LPN #1 was allowed to come back to work the next day and coaching was provided to the nurse related to a Customer Service issue, not abuse. On 01/27/2020, SRNA #3 approached the Social Services Director (SSD) and reported what she had witnessed on 01/22/2020. However, LPN #1 worked providing direct resident care as scheduled, from 01/23/2020 until 02/12/2020 after 5:30 PM; when the facility suspended LPN #1 related to the allegation of abuse. (Refer to F-607, F-609, and F-610) The facility's failure to have an effective system in place to ensure each resident remains free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020, and was determined to exist on 01/22/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020, alleging removal of the Immediate Jeopardy on 02/19/2020. The State Survey Agency determined the Immediate Jeopardy had been removed 02/19/2020, as alleged, prior to exit on 02/21/2020. The findings include: Review of the facility's Abuse Prevention Program Policy, dated December 2016, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Additionally, Administration would protect residents from abuse by implementing policies and procedures to aid in preventing abuse; identify and assess all possible incidents of abuse; investigate and report any allegation of abuse within timeframes as required by federal requirements; and protect residents during abuse investigation. Further review revealed Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of Resident #1's medical record revealed the facility admitted the resident on 10/24/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/16/2020, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition. Additional review of the MDS Assessment, revealed the facility assessed the resident under Section E, Behavior, as having no behavior present. Further, under Section G, Functional Status, the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, toileting, and dressing. Review of Resident #1's Comprehensive Care Plan, revised 01/23/2020, revealed a problem of alteration in Cognition related to recent decline in health secondary to [DIAGNOSES REDACTED]. The goal stated the resident would maintain cognitive status as evidence by no less than an eleven (11) on the next BIMS score and the resident would continue to make decisions related to Activities of Daily Living (ADLs). The interventions included: introduce self, and explain intentions before providing care, BIMS quarterly and PRN (as needed) and Speech Therapy (ST) referral. Review of the Comprehensive Care Plan, revised 01/23/2020, revealed the resident was at risk for injury related to impaired mobility, Left Side [MEDICAL CONDITION] and [MEDICAL CONDITION], Muscle Weakness, Poor Upper Body Posture and Coordination. The goal stated the resident and staff would demonstrate and identify safe techniques. The interventions included: one fourth (¼) side rails with lambs wool to bed for mobility; educate staff on proper use of Hoyer lift (mechanical lift); ensure limbs were in alignment and placement; and support and protect left side of body when performing activities/during movement; Observation on 02/11/2020 at 10:55 AM, revealed the resident was lying in semi- fowler's (reclined in an angle of 35-45 degrees) position in bed, under the covers from his/her waist down. The bedside table was over the bed. Additionally the bilateral 1/4 side rails were up at the head of the bed and were covered in lamb's wool. Further, the resident's left hand was in an [MEDICAL CONDITION] glove and his/her right hand/finger tips was on the right side rail. Observation of Resident #1, on 02/11/2020 at 12:00 PM, revealed the resident was in bed in semi-fowler's position with the bedside table over the bed. Additionally, the right side rail was down to allow the bedside table to be close enough for the resident to reach his/her meal tray. Further, the resident was feeding self with his/her left hand independently. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial Report, which was faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Resident #1's Physician was notified of the alleged incident on 02/13/2020 at 7:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 02/13/2020 at 7:30 PM. This alleged incident occurred twenty-two (22) days prior to the Initial Report and notifications. Review of the facility's Investigation Report, dated 02/13/2020, signed by the Administrator, revealed an incident of physical and verbal abuse related to Resident #1 allegedly occurred on 01/22/2020 before 9:00 AM and the incident was reported on 01/22/2020 after 9:00 AM to the Director of Nursing (DON) and the Administrator. Per the investigation, Resident #1's daughter reported to the DON, that LPN #1 had a mean tone with the resident while helping him/her get ready for an appointment and she would talk to the DON about it when she returned from the appointment with the resident. The DON had LPN #1 clock out of the facility at 9:10 AM, as a precaution and the nurse was informed she would be removed from Resident #1's direct care and would be scheduled off work for a few days. However, there was no documented evidence the DON informed LPN #1 she was scheduled off a few days or was removed from Resident #1's direct care as a precaution after 01/22/2020. Further review of the Investigation, revealed on 01/22/2020 from 1:15 PM until 1:38 PM, the DON and Administrator met with Resident #1's daughter. Per the Investigation, there was no allegation of abuse or mistreatment per the resident's daughter; only a concern that LPN #1 was loud and had a mean tone. Continued review of the Investigation, revealed Resident #1's daughter spoke about other staff complaining that LPN #1 was strict. Further, the Investigation revealed Resident #1's daughter verbalized agreement related to the facility addressing customer service skills with LPN #1 and related to this nurse no longer providing any direct care to Resident #1. On 01/22/2020, the DON completed a Skin Assessment for Resident #1 with no new impairments identified. Per the Investigation, no other employee/person/resident verbalized any issues with LPN #1 on 01/22/2020; however, there was no documented evidence other employees/persons/residents were interviewed related to the alleged abuse until 01/27/2020. Continued review of the Investigation, revealed on 01/27/2020, SRNA #3 and SRNA #6 approached the Social Services Director (SSD) inquiring why LPN #1 had not been fired and verbalized they had a concern with LPN #1. The SSD directed the SRNAs to report any issue they felt was abuse or threats. SRNA #3 and SRNA #6 immediately provided verbal and written Statements to the Administrator, which included concerns that LPN #1 had a loud tone of voice. Further, SRNA #6's Statement revealed Resident #1 referred to LPN #1 as a red headed [***] and SRNA #6 had reported LPN #1's tone and loudness before. The SSD then interviewed Resident #1 on 01/27/2020 and the resident stated one (1) staff member got smart with him/her and the resident felt the staff member did not like him/her. Further, the resident stated the staff member grabbed his/her arm, but did not hurt him/her and he/she wished the staff member would be kinder. Resident #1 described the staff member as having a lot of freckles and red hair, which was a description of LPN #1. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Five (5) day/Follow up/Final Report, which was faxed to OIG on 02/18/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Review of the facility's Investigation Report, dated 02/18/2020, signed by the Administrator, revealed the alleged perpetrator, LPN #1, was suspended on 02/12/2020, after Immediate Jeopardy and Substandard Quality of Care (SQC) was identified by the State Agency, and on 02/13/2020 at 5:27 PM, via telephone conference call, LPN #1's employment with the facility was terminated. Continued review revealed SRNA #3 was placed on suspension from the facility via a telephone conference call on 02/12/2020, pending further investigation and was to return to work on 02/19/2020 for education training regarding abuse. Per the Investigation Report, an interview with Resident #1 was conducted by the SSD on 02/18/2020 at 10:35 AM, and he/she denied abuse, mistreatment or any concerns with care at the facility. Resident #1's daughter was interviewed on 02/18/2020 at 10:18 AM and denied any further issues. Further review revealed the facility determined that the alleged allegation was substantiated. Review of Resident #1's daughter's Statement, dated 01/22/2020 at 1:15 PM, revealed the Statement was hand written on a Post It Note by the Administrator. Per the Statement, LPN #1 yelled at Resident #1 when he/she wanted to hold onto the bed rail and the resident stated, Dammit, I'm trying. Additionally, LPN #1 was not nice in her tone when she was talking to Resident #1 and SRNA #3. Further, staff told Resident #1's daughter that LPN #1 was mean and hateful to employees and she felt it was terrible how LPN #1 talked to the nurses. Interview with Resident #1's daughter, on 02/11/2020 at 12:00 PM, revealed she arrived at the facility on 01/22/2020 before 8:30 AM, to take Resident #1 to an appointment. She stated when she arrived the resident's door was open and when she walked in the room, she noticed LPN #1's back was to the door and SRNA #3 was standing on the other side of the bed, by the window facing the door. Per interview, she heard LPN #1 yelling in a harsh raised voice at Resident #1 to Roll over and was Jerking around on Resident #1's right arm. Continued interview revealed Resident #1 was yelling out, Dammit I'm trying and the nurse yelled back at the resident, Don't cuss me. Per interview, SRNA #3 saw her enter the room; however; LPN #1 did not see her in the room at first because her back was to the door. When LPN #1 turned and saw Resident #1's daughter, the nurse immediately changed her tone and attitude and started calling Resident #1 Honey. Continued interview revealed she did report her concern of LPN #1 yelling and jerking on Resident #1 to the DON the morning of 01/22/2020, before leaving for the appointment and told the DON she would talk to both the DON and the Administrator when she returned later that afternoon. Further, after the appointment around 1:00 PM, Resident #1's daughter met with the Administrator and the DON and discussed what she had witnessed. Resident #1's daughter stated she was told the facility had the nurse leave the building earlier that day and they would be providing counseling to LPN #1 as the incident sounded like Bad customer service. Per interview, the Administrator and DON told her LPN #1 did not realize how she came across and she had always been a caring nurse. Resident #1's daughter stated she did not get any further follow up from the facility related to an investigation of the incident and did not feel satisfied with the outcome. Resident #1's daughter stated there were residents at the facility who did not have families to visit and some residents could not tell staff what was happening. Review of Resident #1's Interview on 01/27/2020 at 2:45 PM, conducted by the SSD, revealed when the SDD asked if anyone harmed him/her, the resident responded that one (1) staff member got smart with him/her. Additionally, this staff member made the resident feel he/she had done something wrong and the staff member did not like the resident. Continued review revealed the staff member had grabbed the resident's right forearm; however, had not hurt him/her. Further, the resident stated he/she wished this staff member was kinder to him/her. Resident #1 described the staff member as having a lot of freckles and red hair. The description was that of LPN #1. Interview with Resident #1, on 02/11/2020 at 10:55 AM, revealed he/she had been at the facility for approximately four (4) months. When asked how everyone was treating him/her, the resident replied a few weeks ago a red haired older nurse (LPN #1) yelled at him/her and yanked his/her right arm. Continued interview revealed the resident did not recall the nurse's name, but knew SRNA #3 and his/her daughter also witnessed the incident in his/her room. Additionally, the resident felt that this nurse always picked and fussed at him/her and the incident upset the resident as he/she felt intimidated by the nurse. Per interview, since the incident the resident did not feel comfortable or safe if the nurse provided care for him/her. Resident #1 stated, the nurse had a Bad attitude and if she mistreated me once, she would do it again and she had no right to treat anyone the way she treated me. Continued interview revealed the resident's daughter reported the incident to the head nurse and the Social Worker had talked to him/her about the incident. Further interview revealed since the incident, the nurse still worked on the resident's hallway; however, was not allowed to provide care to him/her. Review of SRNA #3's Witness Statement, dated 01/27/2020, untimed, revealed Resident #1 had a doctor's appointment on the morning of 01/22/2020, and the resident wanted to change from his/her gown into clothes before going to the appointment. Per the Statement, LPN #1 came with SRNA #3 to help get the resident ready as the resident was in the wheelchair and had to be assisted back to bed. After assisting the resident into bed, Resident #1 rolled towards SRNA #3 (towards the window) because it was easier for the resident to roll towards his/her left. As the resident settled back in preparation to roll to the right he/she realized the bed rail was completely down and there was nothing to hold. Resident #1 asked LPN #1 to please put up the bed rail. LPN #1 told the resident No, and to hold on to her (LPN #1), then LPN #1 started pulling on the resident, trying to roll him/her towards the right. SRNA #3 told LPN #1 at that time that Resident #1 needed the bed rail for safety and comfort and LPN #1 rolled her eyes, kept talking, and ignored her. Resident #1 pushed against LPN #1 and tried not to roll towards LPN #1 and asked again for the bed rail to be put up. Further, LPN #1 was yelling and told Resident #1 the bed rail would be in her way, so she would not put it up and began pulling on the resident again. Continued review of the Statement, revealed Resident #1 was upset and said, No Dammit, and tried pushing against LPN #1 while reaching for the bed rail behind him/her. Then LPN #1 grabbed Resident #1's hand and tucked it in front of the resident so he/she could not gain leverage. However, LPN #1 could not roll the resident and grabbed the bed rail and slammed it into place, then yanked Resident #1 over. Per the Statement, SRNA #3 and LPN #1 noticed Resident #1's daughter was in the doorway and then LPN #1's demeanor flipped entirely and she was sweet, patient and caring. Resident #1's daughter asked SRNA #3 who she could speak with and SRNA #3 wrote down the names. Interview with SRNA #3, on 02/11/2020 at 3:00 PM, revealed on 01/22/2020 about 8:15 AM, Resident #1 requested to change his/her clothing before an appointment. Per interview, the other SRNAs were assisting with the morning meal and LPN #1 came to assist her with transferring Resident #1 from his/her wheelchair to the bed in order to dress the resident. SRNA #3 stated she was on the window side of the bed and LPN #1 was on door side, with her back to the door. Once she and LPN #1 transferred Resident #1 to bed, he/she rolled towards the window onto his/her left side, then to his/her back. When the resident went to roll onto the right side, towards LPN #1, the resident realized the side rail was not up and asked LPN #1 to raise the side rail. However, LPN #1 replied, No, you are fine, just hold on to me. Per interview, again Resident #1 requested the side rail to be raised and LPN #1 said it was in her way and she was not going to put up the side rail. At that time, SRNA #3 told LPN #1 the resident used the side rail to assist in turning, the side rail helped with mobility, and the resident would be more willing to turn if he/she could use the side rail because it made him/her feel safe. Additional interview with SRNA #3, revealed LPN #1 had her hands on the resident's left hip and shoulder blade and yanked on the resident trying to roll him/her. Further, Resident #1 screamed and said No Dammit it I'm not going to roll, and started grabbing for the side rail behind him/her with his/her left hand/arm. Resident #1's daughter entered the room when the resident yelled, Dammit I'm not rolling, but LPN #1 did not see the resident's daughter because her back was to the door. LPN #1 then yelled at Resident #1, Don't cuss at me. Per interview, Resident #1 was terrified he/she was going to fall out of the bed. Resident #1 was pushing back from LPN #1 and the edge of the bed. When LPN #1 was trying to roll the resident, he/she was resistive. SRNA #3 stated LPN #1 grabbed/jerked the resident's left hand/arm and placed it across the resident's body and leaned into him/her so the resident could not grab the side rail behind him/her and continued to attempt to roll the resident towards the right, but the resident pushed back. Then LPN #1 slammed the side rail up and yelled, NOW roll over. Per interview, LPN #1's hands were still touching the resident and she pulled the resident over to the his/her right side and the resident was upset. Further interview with SRNA #3, revealed she knew what she witnessed on 01/22/2020 was abuse by LPN #1; however, she did not report the incident immediately because LPN #1 was the charge nurse and she could not find the DON or Administrator after the incident. Additionally, she thought Resident #1's daughter had reported the incident on 01/22/2020 because she had asked SRNA #3 who she should report the incident to and she (SRNA#3) had provided her the Administrator and DON's names on a piece of paper. Per interview, she also saw LPN #1 leave the building shortly after the incident on 01/22/2020, and therefore thought administration told her to leave. Further interview revealed neither the DON nor the Administrator asked SRNA #3 to provide a written statement about the incident on 01/22/2020. Continued interview revealed SRNA #3 was scheduled off work for a few days following the 01/22/2020 incident, and when she returned to work the weekend she still did not see LPN #1 in the facility. However, she stated on Monday 01/27/2020, she noticed LPN #1 was back in the building, and that was when SRNA #3 approached the SSD and reported the witnessed abuse that occurred on 01/22/2020. SRNA #3 stated the SSD then asked her to write out a statement of what happened on 01/22/2020 between Resident #1 and LPN #1. Review of LPN #1's Witness Statement, dated 01/22/2020, untimed, revealed on 01/21/2020 at 8:05 AM, she was informed Resident #1 needed help getting his/her clothes changed before an appointment. Per the Statement, at 8:15 AM, LPN #1 and SRNA #3 transferred Resident #1 via Hoyer lift from the wheelchair to the bed. Resident #1 then rolled away from LPN #1, towards the window for SRNA #3 to put his/her pants on, then rolled on to his/her back. When LPN #1 asked the resident to roll towards her (towards the door), the resident stated, Dammit put up the rail, why is it not up? LPN #1 explained the rail was placed down when transferring the resident to bed with the Hoyer lift; and LPN #1 raised the rail up and asked the resident to roll towards her and to not cuss her. However, the resident stated again the rail was not up and LPN #1 explained the rail was up. At that time, the resident reached for the rail and LPN #1 and SRNA #3 rolled the resident towards LPN #1. Further, LPN #1 asked the resident to roll towards SRNA #3 so she could straighten the resident's clothing and he/she did with help. Then LPN #1 moved the Hoyer lift back over to the edge of the bed to assist the resident back into the wheelchair. Per the Statement, the Resident #1's daughter was in the room at that time, and LPN #1 asked her to step back some in order for staff to assist the resident into the wheelchair per the Hoyer lift. Continued review of the Statement, revealed LPN #1 asked the resident if he/she needed anything else once he/she was in the wheelchair and ready to go for the appointment and the resident stated, No. LPN #1 informed Resident #1's daughter there was a folder at the desk that they needed to take to the appointment and the bus was at the facility for them, but the daughter did not respond. Resident #1 left the floor with his/her daughter at 8:35 AM. Interview with the DON on 02/12/2020 at 4:50 PM, revealed LPN #1 provided her statement of the incident to the facility when reporting to work on 01/23/2020 at 6:55 AM. Interview with LPN #1, on 02/11/2020 at 4:12 PM, revealed she had worked at the facility for three (3) years as a Charge nurse and on 01/22/2020 she was the assigned nurse for Resident #1. She stated on that date at approximately 8:15 AM, she assisted SRNA #3 with getting Resident #1 changed before his/her appointment, but nothing unusual occurred while providing direct care to the resident. Per interview, Resident #1 participated in care when turning in bed, and was pleasant and voiced no concerns. Further, LPN #1 stated she did not jerk/yank on the resident's arms or body and did not yell at him/her; however, she did ask the resident not to cuss at her or SRNA #3 when the resident got upset and said, Dammit the rails not up. Per interview, LPN #1 engaged the right side rail when the resident asked her to do so, while the resident was assisted with turning and repositioning in bed. Per interview, Resident #1's daughter was present in the resident's room during this care and was upset because she thought Resident #1 was upset when the resident stated, Dammit the rails not up. Further interview with LPN #1, revealed after Resident #1 left the floor at 8:35 AM with his/her daughter for an appointment, the DON asked her what happened with Resident #1. Per interview, LPN #1 told the DON she had assisted SRNA #3 with transferring Resident #1 to bed from his/her wheelchair to change his/her clothing and then transferred the resident back to the wheelchair. Additionally, LPN #1 stated she told the DON the resident's daughter was in the room and voiced no concerns, but was upset that Resident #1 was upset. Continued interview revealed the DON instructed LPN #1 to clock out and leave the facility at that time pending further investigation of the incident related to Resident #1. Further, she wrote a Statement about the incident and brought the statement back to the facility on [DATE] when she came back to work, and gave it to the DON. Further, she was told by the DON and Administrator not to provide care for Resident #1 and at the end of the day on 01/23/2020, she was provided customer service training including a video, by the Staff Development/Educator Director. Interview with the SSD, on 02/12/2020 at 11:15 AM, revealed she spoke with Resident #1 and his/her daughter on 01/22/2020 around 8:30 AM in the hallway before the resident left the facility for the appointment. Per interview, her interaction with Resident #1 was positive, as the resident was excited to be out of his/her room and the daughter was friendly and did not mention any concerns at that time. Further interview revealed between 1:00 PM and 1:30 PM she noticed Resident #1's daughter come out of the Administrator's office. She stated she then entered the Administrators office and was informed by the Administrator and the DON that Resident #1's daughter had a customer service complaint and the daughter did not care for LPN #1's tone when providing care to Resident #1. The SSD stated she was responsible for interviewing residents and staff as directed by the Administrator related to allegations of abuse in the facility and asked the DON and Administrator if she needed to do anything. Per interview, both the DON and the Administrator told her that they would address the customer service complaint. Additional interview with the SSD, revealed on 01/27/2020 she was on the floor visiting residents around breakfast time and SRNA #6 and SRNA #3 were in the day room assisting residents with the meal. She stated SRNA #6 and SRNA #3 came up to her and voiced they thought LPN #1 had been fired from the facility because she had abused Resident #1 and the resident's daughter had complained to Administration about the incident; however, they realized LPN #1 had not been fired because she was in the facility working. Continued interview revealed SRNA #3 then informed her she had witnessed abuse by LPN #1 toward Resident #1 on 01/22/2020. Per interview, the SSD took SRNA #3 and SRNA #6 to her office one at a time to write their statements and then sent them to the DON's office to be interviewed related to their account of the alleged abuse. The SSD stated she identified this as an allegation of abuse and immediately reported what she had been told by SRNA #3 to the Administrator. Further, it was her expectation residents were free from abuse and it was important for Resident Rights and the facility's Abuse Policy and Procedure to be maintained to ensure quality of life, health, safety, psychosocial well-being, quality of care, dignity and respect for all residents. Interview with the DON, on 02/11/2020 at 4:50 PM, and on 02/12/2020 at 2:00 PM, and 6:00 PM, revealed Resident #1's daughter reported to her, on 01/22/2020 before 9:00 AM, that she was mad because LPN #1 was yelling, Don't cuss at me to Resident #1 during direct care earlier that morning and she did not care for the tone of voice LPN #1 used with Resident #1. Per interview, the DON asked Resident #1's daughter if LPN #1 was actually yelling at Resident #1 or if the nurse was just loud, and if what she observed would be considered abuse. The DON stated Resident #1's daughter responded that LPN #1 needed to soften her tone and be polite to Resident #1, and she wanted to talk to the DON and the Administrator more when she returned from Resident #1's appointment. Additional interview revealed the DON immediately went to the floor and asked LPN #1 what happened and LPN #1 told her nothing had happened with Resident #1, but the daughter was upset when she observed Resident #1 cussing and yelling at her and SRNA #3. The DON stated she told LPN #3 to write a statement of the incident related to Resident #1 and to leave the facility. Per interview, she did not suspect abuse based on the daughter's interview or LPN #1's verbal statement, but asked LPN #1 to leave the facility to keep the gossip down. Continued interview with the DON, revealed Resident #1 and his/her daughter returned to the facility on [DATE] around 1:00 PM, and she and the Administrator met with Resident #1's daughter in the Administrator's office. Per interview, Resident #1's daughter stated when she walked in Resident #1's room around 8:30 AM, LPN #1 and SRNA #3 were trying to change the resident's clothing and Resident #1 asked why the side rail was not up because he/she used it to help turn. However, per Resident #1's daughter, LPN #1 would not put up the rail and the resident was upset and said, Dammit, I'm trying while staff was attempting to turn and reposition the resident. The DON further stated Resident #1's daughter heard LPN #1 say, Don't cuss me, I'm just trying to help you. Additionally, Resident #1's daughter told the DON, when LPN #1 saw the daughter in the room, LPN #1 started being polite to Resident #1. The DON stated she told Resident #1's daughter she had spoken with LPN #1 and the nurse denied yelling at Resident #1. Further, Resident #1's daughter was fine with the Administrator and the DON's decision that an investigation was not necessary, because LPN #1's behavior towards Resident #1 would be considered bad customer service. Continued interview revealed the DON and the Administrator spoke to Resident #1's daughter about how LPN #1 had a loud voice and her tone was stern and people often took her wrong and Resident #1's daughter responded that LPN #1 was not nice to Resident #1. Additional interview with the DON, revealed she spoke with SRNA #3 about the incident with Resident #1 on 01/23/2020, the day after the alleged incident, and provided education immediately regarding not talking about other staff when providing direct care because SRNA #3 had talked to Resident #1 and his/her daughter about LPN #1. Per interview, during the conversation with SRNA #3 on 01/23/2020, SRNA #3 reported that LPN #1 was using a harsh tone with Resident #1 and yanking him/her while trying to get the resident to turn towards the LPN. When questioned if the DON thought using a harsh tone and being yanked was abuse, the DON revealed her conversation with SRNA #3 did not lead her to think that abuse occurred. However, there was no doc (TRUNCATED)

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure its abuse policies were implemented for one (1) of six (6) sampled residents (Residents #1). Resident #1's daughter and State Registered Nurses Assistant (SRNA) #3 alleged they witnessed Licensed Practical Nurse (LPN) #1 jerk on the resident and yell at the resident during direct care on 01/22/2020 at approximately 8:15 AM. Resident #1's daughter did immediately report what she had witnessed to the Director of Nursing (DON) and then later in the day at approximately 1:00 PM, met with the Administrator and DON to further discuss what she had witnessed. However, SRNA #3 did not immediately report the allegation of abuse as per Policy. After Resident #1's daughter reported the allegation, the facility failed to implement their Abuse Policy related to reporting the Abuse to State Agencies, and initiating an investigation. On 01/27/2020, five (5) days after the incident, SRNA #3 reported the incident to the Social Services Director (SSD) and submitted a written statement. In addition, Resident #1 was interveiwed on 01/27/2020, and did report LPN #1 got smart with him/her and grabbed his/her arm. However, there was no documented evidence the facility notified State Agencies of the allegation of abuse or conducted further investigation until 02/13/2020, at 7:30 PM, twenty-two (22) days after the alleged abuse, and after Surveyor intervention. In addition, LPN #1 was instructed to leave the building on 01/22/2020 and clocked out at 9:10 AM; however, she was allowed to resume work on 01/23/2020 and continued to work her schedule until 02/12/2020 after 5:30 PM, thus allowing for further potential abuse. Refer to F-600, F-609, and F-610) The facility's failure to implement its policies and procedures regarding reporting, and investigating allegations of abuse, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020, and was determined to exist on 01/22/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020, alleging removal of the Immediate Jeopardy on 02/19/2020. The State Survey Agency determined the Immediate Jeopardy had been removed 02/19/2020, as alleged, prior to exit on 02/21/2020. The findings include: Review of the facility's Abuse Prevention Program Policy, dated December 2016, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Additionally, administration would protect residents from abuse by implementing policies and procedures to aid in preventing abuse; identify and assess all possible incidents of abuse; investigate and report any allegation of abuse within timeframes as required by federal requirements; and protect residents during the abuse investigation. Review of the facility's Abuse Investigation and Reporting Policy, dated July 2017, revealed all reports of resident abuse, neglect and injuries of unknown source would be investigated to include reviewing the medical record to determine events leading up to the incident; interviewing the person reporting the incident; interviewing any witnesses to the incident; interviewing the resident; interviewing staff members (on all shifts) who had contact with the resident during the period of the alleged incident; interviewing other residents to whom the accused employee provided care or services; and reviewing all events leading up to the alleged incident. Further review of the Policy, revealed when conducting interviews during the investigation each interview would be conducted separately in a private location. Per policy, witness reports would be obtained in writing and be signed and dated. Upon conclusion of the investigation, the investigator would record the results of the investigation on approved documentation forms. Further review of the Policy, revealed any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, would be reported to the following agencies: The State licensing agency; local/state Ombudsman; Resident Representative; Adult Protective Services; Law enforcement officials; the resident's Attending Physician and the Medical Director. Further, all alleged violations would be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Any employee who had been accused of resident abuse, would be suspended pending the outcome of the investigation. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial Report, faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Review of the facility's Investigation Report, dated 02/13/2020, signed by the Administrator, revealed an incident of physical and verbal abuse involving Resident #1, allegedly occurred 01/22/2020 before 9:00 AM, and was reported on 01/22/2020 after 9:00 AM to both the DON and the Administrator by the resident's daughter. Per the Investigation, Resident #1's daughter reported on 01/22/2020, that while LPN #1 and SRNA #3 were proving care to Resident #1, LPN #1 spoke in a loud and mean tone to the resident. Continued review of the Investigation, revealed the DON spoke with LPN #1 on 01/22/2020 before 9:00 AM, and LPN #1 denied the allegation of verbal abuse, but was instructed to leave the building and clocked out at 9:10 AM. On 01/22/2020 from 1:15 PM until 1:38 PM, Resident #1's daughter further discussed her concerns to the DON and the Administrator related to LPN #1's loud and mean tone. According to the Investigation, LPN #1 resumed work at the facility on 01/23/2020. Continued review of the Investigation, revealed SRNA #3 did report to the Social Services Director (SSD) on 01/27/2020, that while LPN #1 and SRNA #3 were providing care to Resident #1, on 01/22/2020, LPN #1 had a loud tone of voice towards the resident. A Statement was obtained from SRNA #3 and she was interviewed by the SSD, DON and Administrator on 01/27/2020. In addition, Resident #1 was interviewed on 01/27/2020 at 2:45 PM and confirmed LPN #1 had grabbed his/her right forearm and got smart with him/her. The Physician; Adult Protective Services (APS) and the Ombudsman were notified of the allegation on 02/13/2020 at 7:30 PM. Review of the facility's Investigation Report, dated 02/18/2020, signed by the Administrator, revealed the alleged perpetrator, LPN #1, continued to work her schedule until 02/12/2020 after 5:30 PM, and then was suspended on 02/12/2020, after Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified by the State Agency. Additionally SRNA #3 was suspended for not reporting the allegation of abuse on 01/22/2020. Further review of the Investigation, revealed the facility investigation determined the allegation of abuse was substantiated. There was no documented evidence the facility policy was implemented related to reporting abuse to the State Agencies, and related to initiating/conducting a thorough investigation. Although the allegation was initially reported to the facility on [DATE], State Agencies were not notified of the allegation until 02/13/2020, when the facility conducted further investigation, which was twenty-two (22) days after the alleged abuse was witnessed. Also, there was no documented evidence the facility's policy was implemented related to protecting residents from abuse, as the alleged perpetrator, LPN #1, continued to work starting 01/23/2020 per her schedule until 02/12/2020, allowing the potential for further abuse. Interview with the Director of Nursing (DON), on 02/12/2020 at 2:00 PM, and 6:00 PM, revealed during the facility's investigation, it was identified SRNA #3, who witnessed the alleged abuse towards Resident #1 on 01/22/2020, should have reported the alleged abuse immediately. Per interview, the reported allegation of abuse, by Resident #1's daughter, on 01/22/2020 was not identified as abuse, and the allegation was not reported to the State Agencies within two (2) hours, as per facility Policy. Further interview revealed the facility's Policy was not implemented related to initiating an investigation, as the investigation was not initiated on 01/22/2020. Additional interview revealed the facility's Policy was not implemented related to protecting the residents and removing the alleged perpetrator, LPN #1, from resident care in order to prevent further potential abuse to Resident #1 or other residents. The DON stated LPN #1 was sent home on 01/22/2020 after Resident #1's daughter reported the allegation, but continued to work in the facility as scheduled starting 01/23/2020 until 02/12/2020, when she was suspended. Per interview, LPN #1 was terminated on 02/13/2020. Interview with the Administrator, on on 02/12/2020 at 11:48 AM, and 6:30 PM, revealed she acknowledged the facility's written Policy was not implemented related to reporting abuse, investigating abuse, and protecting residents from further potential abuse related to the allegation of abuse for Resident #1. Per interview, the alleged abuse witnessed on 01/22/2020 related to Resident #1 should have been reported to the State Agencies within two (2) hours, as per Policy. Additional interview revealed there should have been an investigation initiated immediately on 01/22/2020 after Resident #1's daughter reported the allegation in order to gain further information as per Policy. Further, LPN #1, the alleged perpetrator, should have been immediately removed from direct resident care and suspended on 01/22/2020 for the protection of the residents; however, the Administrator stated LPN #1 did work from 01/23/2020 until she was suspended on 02/12/2020, and then the nurse was terminated. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020 that alleged removal of the Immediate Jeopardy (IJ) on 02/19/2020. Review of the AoC revealed the facility implemented the following. 1. On 01/27/2020, a Skin Assessment was completed for Resident #1, by the Director of Nursing (DON) and on 02/13/2020, a Skin Assessment was completed for Resident #1 by Licensed Practical Nurse (LPN) #3. 2. On 01/27/2020 and 02/13/2020, an interview was conducted by the Social Services Director (SSD) with Resident #1 related to abuse and mistreatment. 3. On 02/12/2020, the facility suspended LPN #1 from the facility pending further investigation, via conference call, with the Administrator, Human Resources Director, and DON. On 02/13/2020, the facility terminated LPN #1's employment with the facility, at 5:27 PM via conference call, with the Administrator, Human Resources Director, and Director of Nursing. 4. On 02/12/2020, the facility suspended State Registered Nursing Assistant (SRNA) #3, from the facility pending further investigation, via conference call with the Administrator, Human Resources Director, and DON. 5. Beginning 02/12/2020, Daily Abuse Prevention Audits will be completed per shift, until IJ is abated, by the Administrator, DON, or the Staff Development/Education Director (SDED). The Administrator is responsible for oversight of completion of audits, which will be reviewed weekly in Standards of Care (SOC) Meetings and during the next Quality Assurance Performance Improvement (QAPI) meeting. 6. On 02/13/2020, interviews were conducted by the SSD with all residents assessed as interviewable based on the Brief Interview for Mental Status (BIMS) scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. On 02/13/2020, interviews were conducted by the SSD with family representatives/Power of Attorneys for residents assessed as having a BIMS score of seven (7) or less. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. 7. On 02/13/2020, Skin Assessments were performed by the DON, Registered Nurse (RN)#1, RN #2 and LPN #3 for all facility residents. 8. On 02/13/2020, the facility initiated an investigation, upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) on 02/12/2020 of an allegation involving Resident #1, who was referenced in the Immediate Jeopardy (IJ) notification document. On 02/13/2020 at 7:30 PM, the facility initial investigation was completed and submitted electronically, to the OIG, the Ombudsman and the Power of Attorney (POA), by the Administrator. 9. On 02/14/2020 at 5:30 PM, the Administrator spoke with the Ombudsman, via telephone, about the Initial Investigation Report and alleged incident. 10. On 02/13/2020 at 6:10 PM, a phone conference call was completed between the facility's Board of Trustees Member, Administrator and DON to discuss: A) Immediate findings of four (4) IJs cited on 02/12/2020. B) The Board of Trustees Member stated she expected the facility's polices related to Abuse Investigations, Abuse Prevention, Abuse Reporting and Protecting Residents from Abuse to be followed by the Administrator and DON. C) The Administrator and Director of Nursing verbalized understanding. 11. On 02/14/2020 at 1:00 PM, the Board of Trustee member conducted education to Management Staff, related to abuse education and prevention. The training included types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of the resident from abuse, and facility policies related to abuse. Management staff included the Administrator, DON, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, Minimum Data Set Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, SSD, Director of Maintenance and Housekeeping, Registered Dietician, and Therapy Department Director. 12. By 02/17/2020 at 8:00 PM, Management Staff will complete Centers for Medicaid/Medicare Services (CMS) Hand in Hand Module #5, Preventing and Responding to Abuse, online training, including signature form, post-test, and associated worksheet with the training. Management staff on leave through or on 02/17/2020, will complete the above tasks upon return to work before any other task can be performed. The Administrator, DON or the Staff Development/Educator Director (SDED) will ensure management staff complete the training as assigned. 13. By 02/18/2020 at 8:00 PM, a mandatory, facility wide in-service and training session, for a minimum of eighty-five (85) employees will be completed to include types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse; including post-test with a passing score of ninety percent (90%). The SDED will be responsible as the first reviewer to ensure each staff member receives a passing score on the post-test, with the Administrator and DON providing oversight and monitoring. In-servicing will be completed by all staff that are not in the facility, immediately upon next day of employment and prior to completing any other task. In-servicing will be directed by the SDED or other managers who received Board of Trustee's training on 02/14/2020. The Administrator and/or DON will ensure employees receive training immediately upon return to work prior to performing any other task. 14. All newly hired employees will continue to receive training on types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse, by the SSD or Life Enrichment Coordinator. 15. On 02/18/2020 at 1:00 PM, an informal QAPI meeting was held to focus on a review of Abuse Prevention Audits from the past two (2) weeks, and root cause of any issues. The Medical Director was notified of the meeting on 02/18/2020. Those in attendance included the Administrator, DON, SSD, Central Supply Manager, Finance Director, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, MDS Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, and SSD. 16. The Administrator will be responsible for monitoring and providing direct oversight/reviewing for the completion of all the trainings listed in the plan. The DON may assist the Administrator in this monitoring and oversight process, as needed. 17. The Administrator and the DON will be responsible for ensuring that each future case of suspected, potential, or actual abuse is investigated and handled by following all relevant policies. 18. The Administrator, DON, and Human Resources Director will be responsible for enforcing current employee policy related to immediate termination of employment for any employee that does not report any abuse allegation immediately per policy. The SSA validated the implementation of the facility's AoC as follows: 1. Record review revealed a Skin Assessment for Resident #1, dated 01/27/2020, was completed by the DON. Additional review revealed LPN #3 completed a Skin Assessment for Resident #1, dated 02/13/2020. Further review revealed no skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she completed Resident #1's Skin Assessment on 01/27/2020 and reviewed Resident #1's Skin Assessment completed on 02/13/2020 by LPN #3. She stated she compared the skin assessments completed with the most recent previous skin assessment, looking for any discrepancies that could be indicative of abuse. She further stated she did not find any significant discrepancies. 2. Review of documented Interviews, revealed the SSD interviewed Resdient #1 on 01/27/2020 and 02/13/2020 related to abuse, to ensure no abuse or mistreatment had occurred. Interview with the SSD, on 02/21/2020 at 2:34 PM revealed she interviewed Resident #1 on 01/27/2020 and 02/13/2020. Per interview, Resident #1 had concerns related to LPN #1 getting smart with him/her and grabbing his/her arm when interviewed on 01/27/2020; however, follow up interview on 02/13/2020, revealed no concerns related to mistreatment at the facility. 3. Review of LPN #1's employee file, revealed documentation of a conference call, dated 02/12/2020 at 5:54 PM, by the Administrator, Human Resources Director, and DON, which stated LPN #1 was placed on suspension from the facility pending further investigation, on 02/12/2020. Additional, review revealed a Human Resources Action Form, dated 02/13/2020 at 5:27 PM, documenting LPN #1 was discharged from the facility. The Form was signed by the Administrator and DON. Interview with Human Resources, on 02/21/2020 at 2:48 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and the DON to place LPN #1 on suspension from the facility. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she was present on the conference call on 02/12/2020, with the Administrator, and Human Resources to place LPN #1 on suspension from the facility. Further, she was present when the Administrator presented the Human Resources Action Form, to discharge LPN #1 from the facility, on 02/13/2020. Interview with the Administrator, on 02/21/2020 at 3:15 PM, revealed she was present on the conference call, on 02/12/2020 with the DON and Human Resources to place LPN #1 on suspension from the facility. Further, she signed the Human Resources Action Form, to discharge LPN #1 from the facility, on 02/13/2020. 4. Review of SRNA #3's employee file, revealed documentation of a conference call, dated 02/12/2020 at 5:56 PM, by the Administrator, Human Resources Director, and DON, which revealed SRNA #3 was placed on suspension from the facility on 02/12/2020, pending further investigation. Review of Time Card Punches for SRNA #3, revealed she returned to the facility on [DATE], and received sixteen (16) hours of mandatory training regarding abuse, on 02/19/2020 and 02/20/2020. Interview with Human Resources, on 02/21/2020 at 2:48 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and the DON to place SRNA #3 on suspension from the facility. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and Human Resources to place SRNA #3 on suspension from the facility. Interview with the Administrator, on 02/21/2020 at 3:15 PM, revealed she was present on the conference call on 02/12/2020, with the DON and Human Resources to place SRNA #3 on suspension from the facility. Further, she called SRNA #3 on 02/18/2020 and informed her to return to the facility on [DATE] for mandatory training regarding Abuse with the SDED, on 02/19/2020 and 02/20/2020. 5. Review of the Abuse Prevention Audits, revealed audits began every shift starting 02/14/2020 and were completed daily by the SDED, DON, and Administrator. These audits included interviewing one (1) random staff member on all shifts daily and on the spot education was provided as required. Questions included: A) Can you name three (3) to four (4) types of abuse and give examples? B) What is the number first thing you do if you suspect abuse? C) Who do you report abuse to and when? Review of the Standards of Care (SOC) Meeting sign in sheet, dated 02/13/2020, revealed the Administrator, DON, SSD, SDED, and MDS Coordinator were in attendance and reviewed Abuse Prevention Audits between 02/13/2020 and 02/20/2020. No concerns were identified related to Abuse. Review of the QAPI minutes, dated 02/18/2020, revealed the Abuse Prevention audits were reviewed for the last two (2) weeks. No concerns were identified related to Abuse. Additional review revealed the Administrator was responsible for oversight of the audits. Further review revealed the audits would continue every shift, each day until IJ was abated. Interview with the SDED, on 02/21/ at 2:34 PM; and DON on 02/21/2020 at 2:57 PM; revealed Abuse Prevention Audits were conducted every shift daily to any staff member in the facility. Additionally, Audits were reviewed weekly in the SOC meeting and in the monthly QAPI meetings. Further interview revealed there were no identified concerns. Interveiw with the Administrator, on 02/21/2020 at 3:15 PM, revealed she was responsible for oversight of completion of audits which were discussed in the weekly SOC meetings and in the monthly QAPI meetings. 6. Review of Abuse Interviews, dated 02/13/2020, revealed the Social Services Director interviewed all thirty-three (33) residents that were assessed as interviewable based on the Brief Interview for Mental Status (BIMS) scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. The Social Services Director, conducted interviews on 02/13/2020, with eighteen (18) family representatives/Power of Attorneys for residents who were assessed as having BIMS scores of seven (7) or less. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. Interview with the SSD, on 02/21/2020 at 2:34 PM, revealed resident interviews were completed on 02/13/2020 for all facility residents with a BIMS score of eight (8) or above and family representatives/Power of Attorneys or resident healthcare surrogates for residents with BIMS scores below eight (8). The Questions asked of residents included: (1) Do you feel safe in the facility?; (2) Has anyone in the facility hurt you, threatened you, or scolded you?; (3) Has anyone touched you without your consent, or made you do something you did not want to do?; (4) Has anyone ever failed to assist you, ignored your request for help or failed to provide care to you when you needed/asked for assistance? Review of resident responses to questions revealed no concerns were identified. 7. Review of the Weekly Skin Assessments, dated 02/13/2020, revealed forty-three (43) residents were assessed by the DON, RN #1, RN #2 and LPN #3. No suspicious injuries were noted that could be possibly indicative of abuse. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she conducted many of the skin assessments on 02/13/2020. She stated she compared the skin assessments she completed with the previous skin assessments, looking for any discrepancies that could be indicative of abuse. She further stated she did not find any significant discrepancies. 8. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial Report, which was faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Additionally, the Ombudsman and Resident #1's Power of Attorney (POA) were notified of the alleged incident on 02/13/2020 at 7:30 PM. Review of the Investigation Report dated 02/13/2020, signed by the Administrator, revealed the facility initiated an investigation. Interview with the Administrator, on 02/12/2020 11:48 AM, revealed the facility initiated an investigation on 02/13/2020 after the OIG State Agency made the facility aware of the Immediate Jeopardy on 02/12/2020, related to the abuse allegation involving Resident #1. Per interview, the Initial Report was faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, related to the alleged 01/22/2020 incident of physical and verbal abuse and an Investigation Report was completed on 02/13/2020 with a follow up Investigation Report on 02/18/2020. 9. Interview with the Administrator, on 02/21/2020 at 3:15 PM revealed she spoke with the Ombudsman, via phone, on 02/14/2020 at 5:30 PM about the Initial Report and incident involving Resident #1 and LPN #1. Per interview, the conversation lasted approximately thirty (30) minutes and the Ombudsman was pleased with what the facility had done. 10. Review of documented notes, dated 02/13/2020 at 6:10 PM, revealed the Administrator and the DON were on a conference call with a Board of Trustees Member. Topics covered included: A) Explanations of the four (4) IJ's cited on 02/12/2020 B) Expectation of the Board of Trustees Member for the Administrator and the DON to follow the Policies related to Abuse Investigations, Abuse Prevention, Abuse Reporting and Protecting Residents from Abuse. C) Verbalization by Administrator and DON that they understood topics covered. The conference call notes were signed by the DON and Administrator. 11. Review of the In-Service Signature Page for Abuse, dated 02/14/2020, signed as provided by a Board of Trustee Member, revealed all management attended in-servicing which included: A) Types of Abuse with definitions. B) Facility policy's related to: *Abuse Investigation and Implementation: Role of Administrator and Investigator *Abuse Prevention *Investigating injuries *Protection of Resident During Abuse Investigation *Signs and Symptoms of Abuse/neglect *Reporting suspected cased and/or incidents of rape *Resident to Resident altercations C) Review of Regulations: *F-600 Free from Abuse and Neglect *F-602 Free from Misappropriation/Exploitation *F-603 Free from Involuntary Seclusion *F-604 Right to be free from Physical Restraints *F-605 Right to be free from Chemical Restraints *F-606 Not Employ/Engage Staff with Adverse Actions *F-607 Develop/Implement Abuse/Neglect Etc. Policies *F-608 Reporting of Reasonable Suspicion of a Crime *F-609 Reporting of alleged Violation *F-610 Investigation/Prevention/Correct Alleged Violation D) Review of Abuse Neglect Elder Justice Act E) CMS Hand in Hand Training, Abuse Prevention Module #5 and Post Test. The In-service education was provided to the management team including the Administrator, Director of Nursing, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, MDS Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, Social Services Director, Director of Maintenance and Housekeeping, Registered Dietician, and Therapy Department Director. Interview with the MDS Coordinator, on 02/21/2020 at 2:14 PM; SDED, on 02/21/2020 at 2:21 PM; Human Resources, on 02/21/2020 at 2:48 PM; Director of Nursing, on 02/21/2020 at 2:57 PM; and Administrator, on 02/21/2020 at 3:15 PM, revealed they attended the In-service education provided by the Board of Trustee's Member, on 02/14/2020. Additionally, the In-service included a review of the facility's Abuse polices, Abuse regulations, Abuse Neglect Elder Justice Act, and Hand-in-Hand video education related to Abuse Prevention. 12. Review of the signature form, post-test, and associated worksheet with the training, revealed seventeen (17) facility Management Staff completed the Center for Medicaid/Medicare Services (CMS) Hand in Hand Module #5, Preventing and Responding to Abuse, online training, no later than 02/17/2020 at 8:00 PM. Additionally, one (1) Management staff, was on leave through 02/19/2020 and completed the above training upon return to work. This was verified by reviewing employees Timecards 02/15/2020 through 02/20/2020. Interview with the Administrator on 02/21/2020 at 3:15 PM, revealed she ensured training was completed as assigned to management staff no later than 02/17/2020 at 8:00 PM. Per interview, one (1) Management Staff employee was out of the facility during this time and completed the training upon return to work on 02/20/2020. 13. Review of mandatory, facility wide in-service and training session In-service Sign in Sheets, revealed ninety-two (92) employees completed the training between 02/14/2020 and 02/18/2020, to include: A) Types of abuse B) Recognizing and Reporting Abuse C) Facility policy's on Abuse prevention, Abuse investigation, Abuse reporting, Protection of the resident from abuse D) The Elder Justice Act and Acknowledgement E) Abuse and Resident Rights Review of employee post-tests between 02/14/2020 and 02/18/2020, confirmed all employees in serviced had completed a post-test with a score of one hundred percent (100%). Interview with Housekeeper #1, on 02/21/2020 at 1:46 PM; SRNA #5, on 02/21/2020 at 1:51 PM; SRNA #2, on 02/21/2020 at 1:57 PM; LPN #2, on 02/21/2020 at 2:01 PM; and LPN # 3, on 02/21/2020 at 2:09 PM, revealed they received in-service training between 02/14/2020 and 02/18/2020 and were able to name the seven (7) types of abuse, and were knowledgable of the facility policy's on abuse; the Elder Justice Act; and Resident Rights. Interviews further revealed staff were to report any witnessed abuse or allegations of abuse to their supervisor or higher in the chain of command if their supervisor was unavailable or did not respond immediately. Interview with the SDED, on 02/21/2020 at 2:21 PM, revealed she was responsible to in-service all staff on types of abuse; recognizing and reporting abuse; facility policy's on abuse prevention; abuse investigation; abuse reporting; protection of the resident from abuse; the Elder Justice Act; and Resident Rights. Per interview, she (TRUNCATED)

Based on interview, record review, review of the facility's Policies, and review of the Kentucky Revised Statues (KRS), it was determined the facility failed to ensure all alleged violations involving abuse or neglect, were reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility and to State Agencies for one (1) of six (6) sampled Residents (Resident #1). State Registered Nurse Assistant (SRNA) #3 alleged on 01/22/2020 at approximately 8:15 AM, she witnessed Licensed Practical Nurse (LPN) #1 jerk on Resident #1's left shoulder and hip, jerk on Resident #1's left hand/arm and place it across the resident's body and lean into the resident's body, and also yell at the resident while providing care. However, SRNA #3 did not report the allegation of abuse immediately after she witnessed the incident because she thought the resident's daughter, who also witnessed LPN #1 yelling and yanking on the resident, had reported the incident. Resident #1's daughter did immediately report what she had witnessed to the Director of Nursing (DON) and then met with the Administrator and DON later in the day at approximately 1:00 PM to further discuss what she had witnessed. However, the facility did not identify abuse occurred and did not report the allegation to State Agencies as per Policy. On 01/27/2020, five (5) days after the incident, SRNA #3 reported the incident to the Social Services Director (SSD) and submitted a written statement. However, the facility failed to notify State Agencies of the allegation of abuse until 02/13/2020, at 7:30 PM, twenty-two (22) days after the alleged abuse, and after Surveyor intervention. Although LPN #1 was instructed to leave on 01/22/2020 and clocked out at 9:10 AM, she was allowed to resume work on 01/23/2020 and continued to work her schedule until 02/12/2020 after 5:30 PM, when the facility suspended the nurse related to the allegation of abuse. (Refer to F-600, F-607 and F-610) The facility's failure to ensure all allegations of abuse were reported immediately to the Administrator and to State Agencies within two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020, and was determined to exist on 01/22/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020, alleging removal of the Immediate Jeopardy on 02/19/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 02/19/2020, as alleged prior to exit on 02/21/2020. The findings include: Review of the facility's Abuse Prevention Program Policy, December 2016, revealed the facility would not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. Additionally, administration will report any allegation of abuse within timeframes as required by federal requirements. Further, any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported to the Administrator immediately. Upon receiving reports of mistreatment, abuse, misappropriation of property, or neglect, the Administrator or Director will immediately report the incident to the following agencies: Division of Licensing or Regulation, Adult Protective Services, and other Agencies, as appropriate (police, sheriff). In the event the Administrator or the Director of Nursing is not available, the charge nurse will report the incident immediately. All alleged violations should be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Further review of the Policy, revealed employees accused of participating in the alleged abuse will be suspended until the outcome of the investigation have been reviewed by the Administrator. Review of KRS Chapter 209.020, revealed an oral or written report was to be made immediately to the State Agencies upon knowledge of suspected abuse, neglect, or exploitation of an adult. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial Report, which was faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Per the Report, the resident's daughter and the Physician were notified of the allegation on 02/13/2020 at 7:30 PM; and Adult Protective Services (APS) and the Ombudsman were notified of the allegation on 02/13/2020 at 7:30 PM. Therefore, State Agencies were not notified of the allegation of abuse by the facility until 02/13/2020, twenty-two (22) days after the alleged abuse was witnessed. Review of the facility's Investigation Report, dated 02/13/2020, signed by the Administrator, revealed an incident of physical and verbal abuse involving Resident #1 allegedly occurred 01/22/2020 before 9:00 AM, which was reported on 01/22/2020 after 9:00 AM to both the DON and the Administrator by the resident's daughter. Resident #1's daughter reported on 01/22/2020, LPN #1 had a mean tone towards Resident #1 that morning and then Resident #1's daughter left to go with the resident to an appointment. On 01/22/2020 from 1:15 PM until 1:38 PM, Resident #1's daughter further relayed her concerns to the DON and the Administrator related to LPN #1's loud and mean tone. Per the Report, SRNA #3 then reported to the Social Services Director (SSD) on 01/27/2020, that while LPN #1 and SRNA #3 were providing care to Resident #1, on 01/22/2020, LPN #1 had a loud tone of voice towards the resident. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Five (5) day/Follow up/Final Report, faxed to OIG on 02/18/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020. Review of the facility's Investigation Report, dated 02/18/2020, signed by the Administrator, revealed the alleged perpetrator, LPN #1, was suspended on 02/12/2020, after Immediate Jeopardy (IJ) and Substandard Quality of Care was identified by the State Agency. Additionally SRNA #3 was suspended for not reporting the allegation of abuse on 01/22/2020. Per the Investigation, Resident #1 was interviewed on 01/27/2020 at 2:45 PM and confirmed LPN #1 had grabbed his/her right forearm and got smart with him/her. Further review of the Investigation, revealed the facility investigation determined the allegation of abuse was substantiated. Interview with Resident #1's daughter, on 02/11/2020 at 12:00 PM, revealed on 01/22/2020 before 8:30 AM, Resident #1's door was open and when she walked in the room, she heard LPN #1 yelling in a harsh raised voice at Resident #1 to Roll over and was Jerking around on Resident #1's right arm. Further, Resident #1 was yelling out, Dammit I'm trying and the nurse yelled back at the resident, Don't cuss me. Per interview, LPN #1 did not see her in the room at first because the nurse's back was to the door and when LPN #1 turned and saw her (Resident #1's daughter), the nurse immediately changed her tone and attitude. Continued interview revealed she reported her concern of LPN #1 yelling and jerking on Resident #1 to the DON the morning of 01/22/2020, before leaving for the appointment and and on that same day at 1:00 PM, she met with the Administrator and the DON and discussed what she had witnessed. Resident #1's daughter stated she was told the incident sounded like Bad customer service. Interview with Resident #1, on 02/11/2020 at 10:55 AM, revealed a few weeks ago a red haired older nurse (LPN #1) yelled at him/her and yanked his/her right arm. Continued interview revealed the resident did not recall the nurse's name, but was aware SRNA #3 and his/her daughter also witnessed the incident in his/her room. Further, the resident felt that this nurse always picked and fussed at him/her and the incident upset the resident as he/she felt intimidated by the nurse. Per interview, the nurse had a Bad attitude and if she mistreated me once, she would do it again and she had no right to treat anyone the way she treated me. Additional interview revealed the resident's daughter reported the incident to the head nurse and the Social Worker. Interview with LPN #1, on 02/11/2020 at 4:12 PM, revealed she was the assigned nurse to Resident #1 on 01/22/2020. Per interview, on that date at approximately 8:15 AM, she assisted SRNA #3 with getting Resident #1 changed before his/her appointment. LPN #1 stated Resident #1 participated in care when turning in bed, and was pleasant and voiced no concerns. Further, LPN #1 jerking/yanking on the resident's arms and denied yelling at the resident. Per interview, she did ask the resident not to cuss at her or SRNA #3 when the resident got upset and said, Dammit the rails not up. LPN #1 stated she did raise the right side rail when the resident asked her to do so, during care while the resident was being assisted with turning and repositioning in bed. Per interview, Resident #1's daughter was present in the resident's room and was upset because she thought Resident #1 was upset when the resident stated, Dammit the rails not up. Additional interview revealed after Resident #1 left the floor at 8:35 AM with his/her daughter for an appointment, the DON asked her what happened with Resident #1. After giving her account of what happened that morning, the DON instructed her to clock out and leave the facility pending further investigation of the incident. Further, she returned to work on 01/23/2020 and was told by the DON and Administrator not to provide care for Resident #1 and was provided customer service training including a video, by the Staff Development/Educator Director. Interview with SRNA #3, on 02/11/2020 at 3:00 PM, revealed on the morning of 01/22/2020, at approximately 8:15 AM she (SRNA #3) and LPN #1 were assisting Resident #1 to change clothes while the resident was in bed. Resident #1 noticed the side rail was not up on the side of the bed in which the resident was to turn and asked LPN #1 to raise the side rail in order for him/her to be able to hold on to the side rail while being repositioned. However, SRNA #3 stated LPN #1 refused and SRNA #3 witnessed LPN #1 place her hands on the resident's left hip and shoulder blade, and yank on the resident while trying to roll him/her. Per interview, then Resident #1's daughter entered the room and heard Resident #1 scream, No Dammit it I'm not going to roll. SRNA #3 stated LPN #1 did not see the resident's daughter and yelled at Resident #1, Don't cuss at me. LPN #1 then grabbed/jerked the resident's left hand/arm and placed it across the resident's body and leaned into the resident in order to prevent him/her from grabbing the side rail behind him/her. Per interview, LPN #1 continued to attempt to roll the resident towards the right, but the resident was terrified of rolling out of the bed and resisted. SRNA #3 stated LPN #1 then slammed the side rail up and yelled, NOW roll over. Further interview with SRNA #3, revealed what she witnessed incident on 01/22/2020 was abuse as she had been provided education/training by the facility on abuse prior to the incident. She stated she knew abuse was to be reported immediately; however, she did not report the incident because she could not find the DON or Administrator after the incident. Further, she thought Resident #1's daughter had reported the incident because she had given the resident's daughter the Administrator and DON's name on a piece of paper after the incident per the daughter's request. Per interview, she also saw LPN #1 leave the building shortly after the incident and thought the nurse had been sent home related to the incident. Continued interview revealed SRNA #3 was scheduled off work for a few days following the 01/22/2020 incident, and noticed LPN #1 was working on 01/27/2020. Additional interview revealed on the morning of 01/27/2020, five (5) days after she witnessed the abuse, she (SRNA #3) reported that she had witnessed LPN #1 yelling and yanking at Resident #1 to the Social Service Director (SSD) and then gave a written and verbal statement to the Administrator, DON and SSD. Interview with the SSD, on 02/12/2020 at 11:15 AM revealed on 01/27/2020 around breakfast time, she was on the floor visiting residents, and SRNA #3 stated she had witnessed LPN #1 abuse Resident #1, on 01/22/2020. Per interview, the SSD immediately took SRNA #3 to the DON's office to write a statement and for an interview related to her account of the alleged abuse. Further, the allegation of abuse should have been reported when the incident was witnessed, on 01/22/2020, to ensure the safety of the residents. Interview with the DON, on 02/11/2020 at 4:50 PM, and on 02/12/2020 at 2:00 PM, and 6:00 PM, revealed on the morning of 01/22/2020 sometime before 9:00 AM, Resident #1's daughter reported LPN #1 was yelling, Don't cuss at me to Resident #1 during direct care earlier that morning. The DON stated Resident #1's daughter was leaving to escort Resident #1 to an appointment and said she would talk to the DON and the Administrator more about her concern when she returned from the appointment. Additional interview revealed the DON immediately asked LPN #1 what happened and LPN #1 responded that nothing had happened with Resident #1, but the daughter was upset when she observed Resident #1 cussing and yelling at her and SRNA #3. The DON stated she told LPN #3 to leave the facility, but she did not suspect abuse based on the daughter's interview or LPN #1's verbal statement. Continued interview revealed Resident #1 and his/her daughter returned to the facility on [DATE] around 1:00 PM, and both she and the Administrator met with the daughter. She stated Resident #1's daughter reported when she walked in Resident #1's room around 8:30 AM, LPN #1 and SRNA #3 were trying to change the resident's clothing and Resident #1 asked why the side rail was not up because he/she used it to help turn. Resident #1's daughter told the DON, LPN #1 would not put up the rail and the resident was upset and said, Dammit, I'm trying while staff was attempting to turn and reposition the resident. The DON stated Resident #1's daughter heard LPN #1 say, Don't cuss me, I'm just trying to help you. Further interview revealed she and the Administrator informed Resident #1's daughter that LPN #1's behavior towards Resident #1 would be considered bad customer service, as the DON and the Administrator did not identify abuse had occurred after speaking with Resident #1's daughter. Additional interview with the DON, revealed on 01/22/2020, the SSD informed her that SRNA #3 reported LPN #1 had abused Resident #1, on 01/22/2020. Per interview, she (DON) then had SRNA #3 write a statement regarding the alleged abuse. Additionally, the DON met with the SSD, the Administrator and SRNA #3 to review SRNA #3's Statement. The DON stated the allegation should have been reported immediately when witnessed on 01/22/ , and the alleged perpetrator should have been removed from resident care on 01/22/ and suspended, pending further investigation, to prevent further potential abuse to Resident #1 or other residents. However, she stated she and the Administrator did not identify abuse occurred after speaking with SRNA #3 and obtaining her Statement. The DON stated LPN #1 did return to work and continued to work her schedule on 01/23/2020 after the alleged abuse was witnessed and also worked as scheduled before she was suspended on 02/12/2020 after Surveyor intervention. Further interview verified the facility did learn of the allegation on 01/22/ before 9:00 AM, but failed to identify the allegation as an allegation of abuse and failed to report the allegation to the State Agencies timely. Interview with the Administrator, on 02/12/2020 at 11:48 AM, and 6:30 PM, revealed on 01/22/2020 some time after 9:00 AM, the DON informed her Resident #1's daughter's reported LPN #1 yelled at Resident #1 and wanted to speak with her (Administrator) and the DON later that day, after the resident's medical appointment. Per interview, LPN #1 was pulled off the floor on 01/22/2020 and clocked out at 9:10 AM. She stated when Resident #1's daughter returned to the facility at 1:15 PM, the DON and Administrator met with her to discuss any concerns. The Administrator stated Resident #1's daughter expressed she was upset because LPN #1 was loud and used a mean tone of voice towards Resident #1. Further, Resident #1's daughter was concerned because she did not like the way LPN #1 talked to other nurses and the SRNAs. Continued interview revealed the Administrator asked Resident #1's daughter if LPN #1 mistreated Resident #1 and she responded that LPN #1 stated, Don't cuss me using a harsh tone of voice with Resident #1 which upset the resident causing the resident to yell,I'm trying dammit. The Administrator stated she told Resident #1's daughter what she was hearing sounded like bad customer service and LPN #1 would be trained on customer services skills and not be allowed to care for Resident #1. The Administrator stated the facility did not identify this as an allegation of abuse and therefore did not report the allegation to State Agencies on 01/22/2020. Further interview with the Administrator, revealed on 01/27/2020 the DON, SSD and Administrator interviewed SRNA #3 after she reported to the SSD on that date, LPN #1 had abused Resident #1. The Administrator stated if SRNA #3 witnessed abuse by LPN #1 on 01/22/2020, SRNA #3 should have immediately reported the allegation. Per interview, it was her expectation staff immediately report any allegations of abuse to their immediate supervisor, management or the Administrator in order to protect the residents from further potential abuse. Additionally, she stated when SRNA #3 reported the alleged abuse on 01/27/2020, the SSD, DON and Administrator interviewed SRNA #3 related to her account of the incident that allegedly occurred on 01/22/2020. Per interview, the SSD was then directed to talk to Resident #1 about the incident. However, the Administrator stated after interviews were conducted with Resident #1 and SRNA #3 on 01/27/2020, the facility did not identify this as an allegation of abuse, and and did not report the allegation to State Agencies on 01/27/2020. Additional interview with the Administrator, revealed after Surveyor intervention, LPN #1, was suspended on 02/12/2020, and SRNA #3 was suspended for not reporting the allegation of abuse on 01/22/2020. The Administrator stated the facility allowed LPN #1 to work from 01/23/2020 until 02/12/2020, and the residents were not protected from further potential abuse during this timeframe related to the facility's failure to identify the allegation of abuse. Continued interview, revealed the regulations should be followed related to notification to State Agencies within two (2) hours of any allegation of abuse. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020 that alleged removal of the Immediate Jeopardy (IJ) on 02/19/2020. Review of the AoC revealed the facility implemented the following. 1. On 01/27/2020, a Skin Assessment was completed for Resident #1, by the Director of Nursing (DON) and on 02/13/2020, a Skin Assessment was completed for Resident #1 by Licensed Practical Nurse (LPN) #3. 2. On 01/27/2020 and 02/13/2020, an interview was conducted by the Social Services Director (SSD) with Resident #1 related to abuse and mistreatment. 3. On 02/12/2020, the facility suspended LPN #1 from the facility pending further investigation, via conference call, with the Administrator, Human Resources Director, and DON. On 02/13/2020, the facility terminated LPN #1's employment with the facility, at 5:27 PM via conference call, with the Administrator, Human Resources Director, and Director of Nursing. 4. On 02/12/2020, the facility suspended State Registered Nursing Assistant (SRNA) #3, from the facility pending further investigation, via conference call with the Administrator, Human Resources Director, and DON. 5. Beginning 02/12/2020, Daily Abuse Prevention Audits will be completed per shift, until IJ is abated, by the Administrator, DON, or the Staff Development/Education Director (SDED). The Administrator is responsible for oversight of completion of audits, which will be reviewed weekly in Standards of Care (SOC) Meetings and during the next Quality Assurance Performance Improvement (QAPI) meeting. 6. On 02/13/2020, interviews were conducted by the SSD with all residents assessed as interviewable based on the Brief Interview for Mental Status (BIMS) scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. On 02/13/2020, interviews were conducted by the SSD with family representatives/Power of Attorneys for residents assessed as having a BIMS score of seven (7) or less. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. 7. On 02/13/2020, Skin Assessments were performed by the DON, Registered Nurse (RN)#1, RN #2 and LPN #3 for all facility residents. 8. On 02/13/2020, the facility initiated an investigation, upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) on 02/12/2020 of an allegation involving Resident #1, who was referenced in the Immediate Jeopardy (IJ) notification document. On 02/13/2020 at 7:30 PM, the facility initial investigation was completed and submitted electronically, to the OIG, the Ombudsman and the Power of Attorney (POA), by the Administrator. 9. On 02/14/2020 at 5:30 PM, the Administrator spoke with the Ombudsman, via telephone, about the Initial Investigation Report and alleged incident. 10. On 02/13/2020 at 6:10 PM, a phone conference call was completed between the facility's Board of Trustees Member, Administrator and DON to discuss: A) Immediate findings of four (4) IJs cited on 02/12/2020. B) The Board of Trustees Member stated she expected the facility's polices related to Abuse Investigations, Abuse Prevention, Abuse Reporting and Protecting Residents from Abuse to be followed by the Administrator and DON. C) The Administrator and Director of Nursing verbalized understanding. 11. On 02/14/2020 at 1:00 PM, the Board of Trustee member conducted education to Management Staff, related to abuse education and prevention. The training included types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of the resident from abuse, and facility policies related to abuse. Management staff included the Administrator, DON, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, Minimum Data Set Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, SSD, Director of Maintenance and Housekeeping, Registered Dietician, and Therapy Department Director. 12. By 02/17/2020 at 8:00 PM, Management Staff will complete Centers for Medicaid/Medicare Services (CMS) Hand in Hand Module #5, Preventing and Responding to Abuse, online training, including signature form, post-test, and associated worksheet with the training. Management staff on leave through or on 02/17/2020, will complete the above tasks upon return to work before any other task can be performed. The Administrator, DON or the Staff Development/Educator Director (SDED) will ensure management staff complete the training as assigned. 13. By 02/18/2020 at 8:00 PM, a mandatory, facility wide in-service and training session, for a minimum of eighty-five (85) employees will be completed to include types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse; including post-test with a passing score of ninety percent (90%). The SDED will be responsible as the first reviewer to ensure each staff member receives a passing score on the post-test, with the Administrator and DON providing oversight and monitoring. In-servicing will be completed by all staff that are not in the facility, immediately upon next day of employment and prior to completing any other task. In-servicing will be directed by the SDED or other managers who received Board of Trustee's training on 02/14/2020. The Administrator and/or DON will ensure employees receive training immediately upon return to work prior to performing any other task. 14. All newly hired employees will continue to receive training on types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse, by the SSD or Life Enrichment Coordinator. 15. On 02/18/2020 at 1:00 PM, an informal QAPI meeting was held to focus on a review of Abuse Prevention Audits from the past two (2) weeks, and root cause of any issues. The Medical Director was notified of the meeting on 02/18/2020. Those in attendance included the Administrator, DON, SSD, Central Supply Manager, Finance Director, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, MDS Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, and SSD. 16. The Administrator will be responsible for monitoring and providing direct oversight/reviewing for the completion of all the trainings listed in the plan. The DON may assist the Administrator in this monitoring and oversight process, as needed. 17. The Administrator and the DON will be responsible for ensuring that each future case of suspected, potential, or actual abuse is investigated and handled by following all relevant policies. 18. The Administrator, DON, and Human Resources Director will be responsible for enforcing current employee policy related to immediate termination of employment for any employee that does not report any abuse allegation immediately per policy. The SSA validated the implementation of the facility's AoC as follows: 1. Record review revealed a Skin Assessment for Resident #1, dated 01/27/2020, was completed by the DON. Additional review revealed LPN #3 completed a Skin Assessment for Resident #1, dated 02/13/2020. Further review revealed no skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she completed Resident #1's Skin Assessment on 01/27/2020 and reviewed Resident #1's Skin Assessment completed on 02/13/2020 by LPN #3. She stated she compared the skin assessments completed with the most recent previous skin assessment, looking for any discrepancies that could be indicative of abuse. She further stated she did not find any significant discrepancies. 2. Review of documented Interviews, revealed the SSD interviewed Resdient #1 on 01/27/2020 and 02/13/2020 related to abuse, to ensure no abuse or mistreatment had occurred. Interview with the SSD, on 02/21/2020 at 2:34 PM revealed she interviewed Resident #1 on 01/27/2020 and 02/13/2020. Per interview, Resident #1 had concerns related to LPN #1 getting smart with him/her and grabbing his/her arm when interviewed on 01/27/2020; however, follow up interview on 02/13/2020, revealed no concerns related to mistreatment at the facility. 3. Review of LPN #1's employee file, revealed documentation of a conference call, dated 02/12/2020 at 5:54 PM, by the Administrator, Human Resources Director, and DON, which stated LPN #1 was placed on suspension from the facility pending further investigation, on 02/12/2020. Additional, review revealed a Human Resources Action Form, dated 02/13/2020 at 5:27 PM, documenting LPN #1 was discharged from the facility. The Form was signed by the Administrator and DON. Interview with Human Resources, on 02/21/2020 at 2:48 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and the DON to place LPN #1 on suspension from the facility. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she was present on the conference call on 02/12/2020, with the Administrator, and Human Resources to place LPN #1 on suspension from the facility. Further, she was present when the Administrator presented the Human Resources Action Form, to discharge LPN #1 from the facility, on 02/13/2020. Interview with the Administrator, on 02/21/2020 at 3:15 PM, revealed she was present on the conference call, on 02/12/2020 with the DON and Human Resources to place LPN #1 on suspension from the facility. Further, she signed the Human Resources Action Form, to discharge LPN #1 from the facility, on 02/13/2020. 4. Review of SRNA #3's employee file, revealed documentation of a conference call, dated 02/12/2020 at 5:56 PM, by the Administrator, Human Resources Director, and DON, which revealed SRNA #3 was placed on suspension from the facility on 02/12/2020, pending further investigation. Review of Time Card Punches for SRNA #3, revealed she returned to the facility on [DATE], and received sixteen (16) hours of mandatory training regarding abuse, on 02/19/2020 and 02/20/2020. Interview with Human Resources, on 02/21/2020 at 2:48 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and the DON to place SRNA #3 on suspension from the facility. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she was present on the conference call, on 02/12/2020 with the Administrator, and Human Resources to place SRNA #3 on suspension from the facility. Interview with the Administrator, on 02/21/2020 at 3:15 PM, revealed she was present on the conference call on 02/12/2020, with the DON and Human Resources to place SRNA #3 on suspension from the facility. Further, she called SRNA #3 on 02/18/2020 and informed her to return to the facility on [DATE] for mandatory training regarding Abuse with the SDED, on 02/19/2020 and 02/20/2020. 5. Review of the Abuse Prevention Audits, revealed audits began every shift starting 02/14/2020 and were completed daily by the SDED, DON, and Administrator. These audits included interviewing one (1) random staff member on all shifts daily and on the spot education was provided as required. Questions included: A) Can you name three (3) to four (4) types of abuse and give examples? B) What is the number first thing you do if you suspect abuse? C) Who do you report abuse to and when? Review of the Standards of Care (SOC) Meeting sign in sheet, dated 02/13/2020, revealed the Administrator, DON, SSD, SDED, and MDS Coordinator were in attendance and reviewed Abuse Prevention Audits between 02/13/2020 and 02/20/2020. No concerns were identified related to Abuse. Review of the QAPI minutes, dated 02/18/2020, revealed the Abuse Prevention audits were reviewed for the last two (2) weeks. No concerns were identified related to Abuse. Additional review revealed the Administrator was responsible for oversight of the audits. Further review revealed the audits would continue every shift, each day until IJ was abated. Interview with the SDED, on 02/21/ at 2:34 PM; and DON on 02/21/2020 at 2:57 PM; revealed Abuse Prevention Audits were conducted every shift daily to any staff member in the facility. Additionally, Audits were reviewed weekly in the SOC meeting and (TRUNCATED)

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to initiate an investigation in response to an alleged violation of abuse, allowing for further potential abuse for one (1) of six (6) sampled residents (Residents #1). Resident #1's daughter reported to the Director of Nursing (DON) on 01/22/ before 9:00 AM, she witnessed Licensed Practical Nurse (LPN) #1 yelling and jerking on Resident #1 while providing care earlier that morning, and also reported what she witnessed in detail to the DON and Administrator on 01/22/2020 at approximately 1:00 PM, upon returning from an appointment with Resident #1. However, there was no documented evidence an investigation was initiated as per Policy. In addition, State Registered Nurse Aide (SRNA) #3 alleged she witnessed LPN #1 jerk on Resident #1's left shoulder and hip, jerk on Resident #1's left hand/arm and place it across the resident's body and lean into the resident's body, and also yell at the resident while providing care on 01/22/2020 at approximately 8:15 AM prior to and after the resident's daughter entered the room. SRNA #3 did not report the allegation of abuse immediately after she witnessed the incident because she thought the resident's daughter, reported the incident. On 01/27/2020, five (5) days after the alleged incident, SRNA #3 reported the incident to the Social Services Director (SSD) and submitted a written statement. Statements and/or interviews were obtained from Resident #1's daughter on 01/22/2020 and from SRNA #3 and Resident #1 on 02/27/2020. However, there was no documented evidence further investigation was initiated until 02/13/2020, twenty-two (22) days after the alleged abuse, and after Surveyor intervention. LPN #1 was instructed to leave the building on 01/22/2020 and clocked out at 9:10 AM. However, LPN #1 was allowed to resume work on 01/23/2020 and continued to work her schedule until 02/12/2020 after 5:30 PM, allowing for the potential for further abuse. (Refer to F-600, F-607 and F-609) The facility's failure to ensure investigations were initiated related to alleged violations of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 02/12/2020, and was determined to exist on 01/22/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020, alleging removal of the Immediate Jeopardy on 02/19/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 02/19/2020, as alleged, prior to exit on 02/21/2020. The findings include: Review of the facility's Abuse Prevention Program Policy, dated December 2016, revealed all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will investigate the alleged incident. The individual conducting the investigation will review the completed documentation forms and review the resident's medical record to determine events leading up to the incident. Further review of the Policy, revealed the individual conducting the investigation will interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (medically as appropriate); consult the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; interview all staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; and interview other residents to whom the accused employee provides care or services. Continued review of the Policy, revealed the individual conducting the investigation will review all events leading up to alleged incident. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the investigation or until the results of the investigation have been reviewed by the Administrator. The results of the investigation will be recorded on approved documentation forms. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Initial Report, which was faxed to the Office of Inspector General (OIG) on 02/13/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020 involving Resident #1. Resident #1's Physician was notified of the alleged incident on 02/13/2020 at 7:30 PM; and Adult Protective Services (APS), and the Ombudsman were notified of the allegation on 02/13/2020 at 7:30 PM. This alleged incident occurred twenty-two (22) days prior to the Initial Report and notifications. Review of the facility's Investigation Report, dated 02/13/2020, which was signed by the Administrator, revealed an incident of physical and verbal abuse related to Resident #1 allegedly occurred on 01/22/2020 before 9:00 AM, which was reported on 01/22/2020 after 9:00 AM to the Director of Nursing (DON) and the Administrator. Resident #1's daughter reported to the DON that LPN #1 had a mean tone with the resident while helping him/her get ready for an appointment and she would talk to the DON about it when she returned from the appointment with the resident. LPN #1 clocked out of the facility at 9:10 AM, as a precaution and the nurse was informed she would be removed from Resident #1's direct care and would be scheduled off work for a few days. However, there was no documented evidence the DON informed LPN #1 she would be scheduled off a few days or would be removed from Resident #1's direct care after 01/22/2020. Additional review of the Investigation, revealed on 01/22/2020 from 1:15 PM until 1:38 PM, the DON and Administrator met with Resident #1's daughter; however, there was no allegation of abuse or mistreatment per the resident's daughter; only a concern that LPN #1 was loud and had a mean tone. Resident #1's daughter also voiced other staff complaining that LPN #1 was strict. Further review of the Investigation, revealed Resident #1's daughter verbalized agreement for the facility to address customer service skills with LPN #1 and agreed to this nurse no longer providing any direct care to Resident #1. On 01/22/2020, the DON completed a Skin Assessment for Resident #1 and no new impairments were identified. According to the Investigation, no other employee/person/resident verbalized any issues with LPN #1 on 01/22/2020; however, there was no documented evidence other employees/persons/residents had been interviewed related to the alleged abuse, until 01/27/2020. Further review of the Investigation, revealed on 01/27/2020, SRNA #3 and SRNA #6 approached the SSD inquiring why LPN #1 had not been fired and verbalized they had a concern related to this nurse. The SSD directed the SRNAs to report any issues related to abuse or threats. SRNA #3 and SRNA #6 immediately provided verbal and written Statements to the Administrator, including concerns that LPN #1 had a loud tone of voice. Per SRNA #6's Statement, Resident #1 referred to LPN #1 as a red headed [***] and SRNA #6 had reported LPN #1's tone and loudness before. Resident #1 was interviewed by the SSD, on 01/27/2020, and the resident stated one (1) staff member got smart with him/her and grabbed his/her arm, but did not hurt him/her and he/she wished the staff member would be kinder. Resident #1 described the staff member to have a lot of freckles and red hair, which was a description of LPN #1. Review of the facility Long Term Care Facility-Self Reported Incident Form/ Five (5) day/Follow up/Final Report, which was faxed to OIG on 02/18/2020, at 7:30 PM, revealed an alleged incident of physical and verbal abuse occurred on 01/22/2020 involving Resident #1. Review of the facility's Investigation Report, dated 02/18/2020, which was signed by the Administrator, revealed LPN #1, alleged perpetrator, was placed on suspension from the facility on 02/12/2020 at 4:14 PM, and on 02/13/2020 at 5:27 PM, via telephone conference call, LPN #1's employment was terminated. Further review revealed SRNA #3 was placed on suspension from the facility via a telephone conference call on 02/12/2020, pending further investigation and was to return to work on 02/19/2020 for education training regarding abuse. According to the Investigation Report, another interview with Resident #1 was conducted by the SSD on 02/18/2020 at 10:35 AM, and he/she denied abuse, mistreatment or any concerns with care at the facility. Resident #1's daughter was again interviewed on 02/18/2020 at 10:18 AM and denied any further issues. The facility determined that the alleged allegation was substantiated. Review of Resident #1's daughter's Statement, dated 01/22/2020 at 1:15 PM, revealed it was handwritten on a Post It Note by the Administrator. According to the Statement, LPN #1 yelled at Resident #1 when he/she wanted to hold onto the bed rail and the resident stated, Dammit, I'm trying. Further review revealed LPN #1 was not nice in her tone when she was talking to Resident #1 and SRNA #3. Additional review revealed staff told Resident #1's daughter that LPN #1 was mean and hateful to employees and she felt it was terrible how LPN #1 talked to the nurses. Interview with Resident #1's daughter, on 02/11/2020 at 12:00 PM, revealed on 01/22/2020 before 8:30 AM, she arrived at the facility to escort Resident #1 for an appointment. Per interview, the resident's door was open and when she entered the room, she heard LPN #1 yelling in a harsh raised voice at Resident #1 to Roll over and was Jerking around on Resident #1's right arm. Further interview revealed Resident #1 was yelling out, Dammit I'm trying and the nurse yelled back at the resident, Don't cuss me. She stated LPN #1 did not see her in the room at first because the nurse's back was to the door and when LPN #1 turned and saw her (Resident #1's daughter), the nurse immediately changed her tone and attitude. Further interview revealed she reported her concern of LPN #1 yelling and jerking on Resident #1 to the DON the morning of 01/22/2020, before leaving for the appointment and on that same day at 1:00 PM, she met with the Administrator and the DON and discussed what she had witnessed. Resident #1's daughter stated she was informed the incident sounded like Bad customer service. Review of Resident #1's Interview obtained by the facility, on 01/27/2020 at 2:45 PM, conducted by the SSD, revealed when the SDD questioned if anyone harmed him/her, the resident responded that one (1) staff member got smart with him/her and grabbed the resident's right forearm; however, had not hurt him/her. Further review revealed the resident informed the SSD he/she wished this staff member was kinder to him/her. Resident #1 described this staff member as having a lot of freckles and red hair, which was a description of LPN #1. Interview with Resident #1, on 02/11/2020 at 10:55 AM, revealed a few weeks ago a red haired older nurse (LPN #1) yelled at him/her and yanked his/her right arm; however, he/she could not recall the nurse's name. Per interview, SRNA #3 and the resident's daughter also witnessed the incident. Additionally, the nurse had a Bad attitude and if she mistreated me once, she would do it again and she had no right to treat anyone the way she treated me. Further interview revealed the resident's daughter reported the incident to the head nurse and the Social Worker had talked to him/her about the incident. Per interview, since the incident, the nurse still worked on the resident's hallway; however, was not allowed to provide care to him/her. Review of SRNA #3's Witness Statement, dated 01/27/2020, untimed, revealed the morning of 01/22/2020, Resident #1 wanted to change from his/her gown into clothes before going to the appointment. LPN #1 came with SRNA #3 to help get the resident ready as the resident was in the wheelchair and had to be assisted back to bed. After assisting the resident into bed, Resident #1 rolled towards SRNA #3 (towards the window) because it was easier for the resident to roll towards his/her left, and as the resident settled back in preparation to roll to the right he/she realized the bed rail was completely down and there was nothing to hold. Resident #1 asked LPN #1 to please raise the bed rail. LPN #1 told the resident No, and to hold on to her (LPN #1), then LPN #1 started pulling on the resident, trying to roll him/her towards the right. SRNA #3 informed LPN #1 at that time that Resident #1 needed the bed rail for safety and comfort and LPN #1 rolled her eyes, kept talking, and ignored her. Resident #1 pushed against LPN #1 and tried not to roll towards LPN #1 and asked again for the bed rail to be raised. Further review revealed LPN #1 was yelling and told Resident #1 the bed rail would be in her way, so she would not put it up and began pulling on the resident again. Additional review of the Statement, revealed Resident #1 was upset and said, No Dammit, and tried pushing against LPN #1 while reaching for the bed rail behind him/her. LPN #1 then grabbed Resident #1's hand and tucked it in front of the resident so he/she could not gain leverage. However, LPN #1 could not roll the resident and grabbed the bed rail and slammed it into place, then she yanked Resident #1 over. According to the Statement, SRNA #3 and LPN #1 noticed Resident #1's daughter was in the doorway and then LPN #1's demeanor flipped entirely and she was sweet, patient and caring. Resident #1's daughter questioned SRNA #3 as to who she could speak with and SRNA #3 wrote down the names. Interview with SRNA #3, on 02/11/2020 at 3:00 PM, revealed on the morning of 01/22/2020, at approximately 8:15 AM, she and LPN #1 were assisting Resident #1 to change clothes while the resident was in bed as the resident had an appointment that morning. Resident #1 realized the side rail was not up on the side of the in order for him/her to hold on to the side rail while being repositioned. However, SRNA #3 stated LPN #1 refused and SRNA #3 witnessed LPN #1 to place her hands on the resident's left hip and shoulder blade, and yank on the resident while trying to roll him/her. Per interview, then Resident #1's daughter entered the room and heard the resident scream, No Dammit it I'm not going to roll. SRNA #3 stated LPN #1 did not see the resident's daughter and yelled at Resident #1, Don't cuss at me. LPN #1 then grabbed/jerked the resident's left hand/arm and placed it across the resident's body and leaned into the resident in order to prevent him/her from grabbing the side rail behind him/her. Per interview, LPN #1 continued to attempt to roll the resident towards the right, but the resident was terrified of rolling out of the bed and resisted. SRNA #3 stated LPN #1 then slammed the side rail up and yelled, NOW roll over. Further interview with SRNA #3, revealed she did realize what she witnessed on 01/22/2020 was abuse as she had been provided education/training by the facility on abuse prior to the incident. However, she did not report the incident because she could not find the DON or Administrator immediately after the incident. Additional interview revealed she thought Resident #1's daughter had reported the incident because she had given the resident's daughter the Administrator and DON's name on a piece of paper after the incident per the daughter's request. She further stated she also saw LPN #1 leave the building shortly after the incident and thought the nurse had been sent home related to the incident. Further interview revealed SRNA #3 was scheduled off work for a few days following the 01/22/2020 incident, and noticed LPN #1 was working on 01/27/2020. Continued interview revealed on the morning of 01/27/2020, five (5) days after she witnessed the abuse, she (SRNA #3) reported that she had witnessed LPN #1 yelling and yanking at Resident #1 to the SSD and then gave a written and verbal statement to the Administrator, DON and SSD. Review of LPN #1's Witness Statement, dated 01/22/2020, untimed, revealed on 01/21/2020 at 8:05 AM, she was informed Resident #1 needed help getting his/her clothes changed before an appointment. At 8:15 AM, LPN #1 and SRNA #3 transferred Resident #1 via Hoyer lift (mechanical lift) from the wheelchair to the bed. Resident #1 rolled away from LPN #1, towards the window for SRNA #3 to put his/her pants on, then rolled on to his/her back. When LPN #1 asked the resident to roll towards her (towards the door), he/she stated, Dammit put up the rail, why is it not up? LPN #1 then explained the rail was placed down when transferring the resident to bed with the Hoyer lift; and LPN #1 raised the rail up and asked the resident to roll towards her and to not cuss her. However, the resident stated again the rail was not up and LPN #1 told the resident the rail was up. The resident reached for the rail and LPN #1 and SRNA #3 rolled the resident towards LPN #1. Further review revealed LPN #1 asked the resident to roll towards SRNA #3 so she could straighten the resident's clothing and he/she did with help. LPN #1 then moved the Hoyer lift back over to the edge of the bed to assist the resident back into the wheelchair. The Resident's daughter was in the room at that time, and LPN #1 asked her to step back some in order for staff to assist the resident into the wheelchair per the Hoyer lift. Additional review of the Statement, revealed LPN #1 asked the resident if he/she needed anything else once he/she was in the wheelchair and ready to go for the appointment and the resident stated, No. LPN #1 then informed Resident #1's daughter there was a folder at the desk that they needed to take to the appointment and the bus was at the facility for them, but the daughter did not respond. Per the Statement, Resident #1 left the floor with his/her daughter at 8:35 AM. Interview with the DON on 02/12/2020 at 4:50 PM, revealed LPN #1 provided her statement related to the incident when reporting to work on 01/23/2020 at 6:55 AM. Interview with LPN #1, on 02/11/2020 at 4:12 PM, revealed on 01/22/2020 at approximately 8:15 AM, she assisted SRNA #3 with getting Resident #1 changed before his/her appointment. She stated Resident #1 participated in care when turning in bed, and was pleasant and voiced no concerns. LPN #1 denied jerking/yanking on the resident's arms and denied yelling at the resident. She stated she did ask the resident not to cuss at her or SRNA #3 when the resident got upset and said, Dammit the rails not up. LPN #1 further stated she did raise the right side rail when the resident asked her to do so, during care while the resident was being assisted with turning and repositioning in bed. Per interview, Resident #1's daughter was present in the resident's room and was upset because she thought Resident #1 was upset when the resident stated, Dammit the rails not up. Additional interview revealed after Resident #1 left the floor at 8:35 AM with his/her daughter for an appointment, the DON asked her what happened with Resident #1. After giving her account of what happened that morning, the DON instructed her to clock out and leave the facility pending further investigation of the incident. Further, she returned to work on 01/23/2020 and was told by the DON and Administrator not to provide care for Resident #1 and was provided customer service training including a video, by the Staff Development/Educator Director. Per interview, starting 01/23/2020, she worked as scheduled at the facility. Interview with the SSD, on 02/12/2020 at 11:15 AM, revealed on 01/22/2020 between 1:00 PM and 1:30 PM she was informed by the Administrator and the DON that Resident #1's daughter had a customer service complaint and the daughter did not care for LPN #1's tone while she was providing care to Resident #1. The SSD stated since she was responsible for interviewing residents and staff as directed by the Administrator related to allegations of abuse in the facility, she asked the DON and Administrator if she needed to do anything. Per interview, both the DON and the Administrator told her they would address the customer service complaint. Additional interview revealed on 01/27/2020 while she was visiting residents around breakfast time SRNA #6 and SRNA #3 came up to her and voiced they thought LPN #1 had been fired from the facility because she had abused Resident #1. Further interview revealed SRNA #3 informed her she had witnessed abuse by LPN #1 toward Resident #1 on 01/22/2020. The SSD stated she then asked SRNA #3 and SRNA #6 follow her to her office to write their statements and then sent them to the DON's office to be interviewed related to their account of the alleged abuse. Per interview, she identified this as an allegation of abuse and immediately reported what she had been told by SRNA #3 to the Administrator. Interview with the DON, on 02/11/2020 at 4:50 PM, and on 02/12/2020 at 2:00 PM, and 6:00 PM, revealed when Resident #1's daughter reported on 01/22/2020 she had witnessed LPN #1 yelling at Resident #1 and also yanking on the resident this should have been identified as an allegation of abuse. However, she stated LPN #1 denied the allegation and both she (DON) and the Administrator decided an investigation was not necessary because they did not identify LPN #1's behavior towards Resident #1 as abuse, and thought the nurse's behavior would be considered bad customer service. Continued interview revealed SRNA #3 failed to immediately report the allegation on 01/22/2020 and reported the allegation on 01/27/2020. Per interview, the facility did obtain Statements/interviews from SRNA #3 and Resident #1 on 01/27/2020; however, the allegation was not identified as abuse. Per interview, further investigation was not initiated until Surveyor intervention on 02/13/2020, twenty- two (22) days after the alleged violation was witnessed. The DON confirmed LPN #1 did return to work on 01/23/2020, after the alleged abuse was witnessed and also continued to work as scheduled before she was suspended on 02/12/2020. Interview with the Administrator, on 02/12/2020 at 11:48 AM, and 6:30 PM, revealed Resident #1's daughter notified the DON and herself (the Administrator) of the allegation of abuse related to LPN #1 yelling at Resident #1 and also yanking on the resident, on 01/22/2020. Additionally, on 01/27/2020, SRNA #3 notified the SSD, DON, and the Administrator on 01/27/2020 of the allegation of abuse related to LPN #1 yelling at Resident #1 and yanking on his/her arm on 91/22/2020. Further interview revealed based on interviews from Resident #1's daughter on 01/22/2020, and interviews/Statements from Resident #1 and SRNA #3 on 01/27/2020, the facility failed to identify the allegation as abuse. Additional interview revealed as a result of the facility failing to identify the allegation as abuse and failing to immediately initiate an investigation on 01/22/2020, LPN #1 continued working her schedule on 01/23/2020 until 02/13/2020, allowing for further potential abuse. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/18/2020 that alleged removal of the Immediate Jeopardy (IJ) on 02/19/2020. Review of the AoC revealed the facility implemented the following. 1. On 01/27/2020, a Skin Assessment was completed for Resident #1, by the Director of Nursing (DON) and on 02/13/2020, a Skin Assessment was completed for Resident #1 by Licensed Practical Nurse (LPN) #3. 2. On 01/27/2020 and 02/13/2020, an interview was conducted by the Social Services Director (SSD) with Resident #1 related to abuse and mistreatment. 3. On 02/12/2020, the facility suspended LPN #1 from the facility pending further investigation, via conference call, with the Administrator, Human Resources Director, and DON. On 02/13/2020, the facility terminated LPN #1's employment with the facility, at 5:27 PM via conference call, with the Administrator, Human Resources Director, and Director of Nursing. 4. On 02/12/2020, the facility suspended State Registered Nursing Assistant (SRNA) #3, from the facility pending further investigation, via conference call with the Administrator, Human Resources Director, and DON. 5. Beginning 02/12/2020, Daily Abuse Prevention Audits will be completed per shift, until IJ is abated, by the Administrator, DON, or the Staff Development/Education Director (SDED). The Administrator is responsible for oversight of completion of audits, which will be reviewed weekly in Standards of Care (SOC) Meetings and during the next Quality Assurance Performance Improvement (QAPI) meeting. 6. On 02/13/2020, interviews were conducted by the SSD with all residents assessed as interviewable based on the Brief Interview for Mental Status (BIMS) scores of eight (8) and above. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. On 02/13/2020, interviews were conducted by the SSD with family representatives/Power of Attorneys for residents assessed as having a BIMS score of seven (7) or less. No concerns were reported which would indicate an allegation of abuse, neglect, or mistreatment. 7. On 02/13/2020, Skin Assessments were performed by the DON, Registered Nurse (RN)#1, RN #2 and LPN #3 for all facility residents. 8. On 02/13/2020, the facility initiated an investigation, upon being made aware by the Office of Inspector General (OIG) State Survey Agency (SSA) on 02/12/2020 of an allegation involving Resident #1, who was referenced in the Immediate Jeopardy (IJ) notification document. On 02/13/2020 at 7:30 PM, the facility initial investigation was completed and submitted electronically, to the OIG, the Ombudsman and the Power of Attorney (POA), by the Administrator. 9. On 02/14/2020 at 5:30 PM, the Administrator spoke with the Ombudsman, via telephone, about the Initial Investigation Report and alleged incident. 10. On 02/13/2020 at 6:10 PM, a phone conference call was completed between the facility's Board of Trustees Member, Administrator and DON to discuss: A) Immediate findings of four (4) IJs cited on 02/12/2020. B) The Board of Trustees Member stated she expected the facility's polices related to Abuse Investigations, Abuse Prevention, Abuse Reporting and Protecting Residents from Abuse to be followed by the Administrator and DON. C) The Administrator and Director of Nursing verbalized understanding. 11. On 02/14/2020 at 1:00 PM, the Board of Trustee member conducted education to Management Staff, related to abuse education and prevention. The training included types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of the resident from abuse, and facility policies related to abuse. Management staff included the Administrator, DON, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, Minimum Data Set Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, SSD, Director of Maintenance and Housekeeping, Registered Dietician, and Therapy Department Director. 12. By 02/17/2020 at 8:00 PM, Management Staff will complete Centers for Medicaid/Medicare Services (CMS) Hand in Hand Module #5, Preventing and Responding to Abuse, online training, including signature form, post-test, and associated worksheet with the training. Management staff on leave through or on 02/17/2020, will complete the above tasks upon return to work before any other task can be performed. The Administrator, DON or the Staff Development/Educator Director (SDED) will ensure management staff complete the training as assigned. 13. By 02/18/2020 at 8:00 PM, a mandatory, facility wide in-service and training session, for a minimum of eighty-five (85) employees will be completed to include types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse; including post-test with a passing score of ninety percent (90%). The SDED will be responsible as the first reviewer to ensure each staff member receives a passing score on the post-test, with the Administrator and DON providing oversight and monitoring. In-servicing will be completed by all staff that are not in the facility, immediately upon next day of employment and prior to completing any other task. In-servicing will be directed by the SDED or other managers who received Board of Trustee's training on 02/14/2020. The Administrator and/or DON will ensure employees receive training immediately upon return to work prior to performing any other task. 14. All newly hired employees will continue to receive training on types of abuse, abuse prevention, abuse investigation, abuse reporting, protection of residents from abuse and facility policies related to abuse, by the SSD or Life Enrichment Coordinator. 15. On 02/18/2020 at 1:00 PM, an informal QAPI meeting was held to focus on a review of Abuse Prevention Audits from the past two (2) weeks, and root cause of any issues. The Medical Director was notified of the meeting on 02/18/2020. Those in attendance included the Administrator, DON, SSD, Central Supply Manager, Finance Director, Director of Pastoral Care, Co-Directors of Pastoral Care, Mission Group Coordinator, Finance Director, Medical Records Director, Human Resources Director, Restorative Nursing Program Director, MDS Coordinator, Staff Development/Education Director, Life Enrichment/Activities Director, and SSD. 16. The Administrator will be responsible for monitoring and providing direct oversight/reviewing for the completion of all the trainings listed in the plan. The DON may assist the Administrator in this monitoring and oversight process, as needed. 17. The Administrator and the DON will be responsible for ensuring that each future case of suspected, potential, or actual abuse is investigated and handled by following all relevant policies. 18. The Administrator, DON, and Human Resources Director will be responsible for enforcing current employee policy related to immediate termination of employment for any employee that does not report any abuse allegation immediately per policy. The SSA validated the implementation of the facility's AoC as follows: 1. Record review revealed a Skin Assessment for Resident #1, dated 01/27/2020, was completed by the DON. Additional review revealed LPN #3 completed a Skin Assessment for Resident #1, dated 02/13/2020. Further review revealed no skin concerns were identified that were of a suspicious nature which could be indicative of abuse, neglect, or mistreatment. Interview with the DON, on 02/21/2020 at 2:57 PM, revealed she completed Resident #1's Skin Assessment on 01/27/2020 and reviewed Resident #1's Skin Assessment completed on 02/13/2020 by LPN #3. She stated she compared the skin assessments completed with the most recent previous skin assessment, looking for any discrepancies that could be indicative of abuse. She further stated she did not find any significant discrepancies. 2. Review of documented Interviews, revealed the SSD interviewed Resdient #1 on 01/27/2020 and 02/13/2020 related to abuse, to ensure no abuse or mistreatment had occurred. Interview with the SSD, on 02/21/2020 at 2:34 PM revealed she interviewed Resident #1 on 01/27/2020 and 02/13/2020. Per interview, Resident #1 had concerns related to LPN #1 getting smart with (TRUNCATED)

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to treat each resident with respect, dignity and care and in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one (1) of fourteen (14) sampled residents (Resident #6). Observation during initial tour of second floor on 12/03/19 revealed licensed staff member referring to Resident #6 as sweetheart and honey instead of his/her preferred name during wound care. The findings included: Review of the facility's policy, titled Resident Rights and Dignity, dated as revised on 04/2018, revealed the purpose of the policy was to provide general guidelines for resident rights and ensure each resident was cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. Further review of facility policy revealed staff would receive in-service training on resident rights, which included dignity and respect, prior to providing direct resident care. Continued policy review revealed staff would treat residents with dignity and respect at all times, and would speak respectfully to residents during all interactions. Additional review of the facility's policy revealed staff would address residents by his/her name of choice/preference while assisting each resident to maintain and enhance feelings of self-worth and self-esteem. Review of the clinical record revealed the facility admitted Resident #6 on 02/20/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further MDS review, revealed the facility assessed Resident #6 as requiring extensive physical assistance of two (2) for bed mobility, transfers, dressing, toilet use and personal hygiene. Continued MDS review revealed the facility assessed the resident as requiring total physical dependence of two (2) for locomotion on the unit and required extensive physical assistance of one (1) with eating. Additional review revealed the facility assessed Resident #6 as having functional limitation of range of motion to bilateral upper and bilateral lower extremities. The facility assessed Resident #6 as requiring a wheelchair and walker for mobility. Observations of the two-hundred (200)-East Hallway during initial tour, on 12/03/19 at 11:10 AM, revealed Resident #6 was sitting in his/her bedroom in a reclining chair with the bedroom door open. Continued observation revealed Resident #6 was yelling out at Licensed Practical Nurse (LPN) #1, who was positioned at the foot of the resident's reclining chair, in a squatting position. Further observations from resident's doorway revealed LPN #1 wearing gloves, and removing [MEDICATION NAME] dressing from resident's right foot and lower extremity with scissors obtained from a chair located just behind her. Continued observations revealed LPN #1 disposed of the soiled dressings in a plastic bag and placed the bag on a chair behind her next to the opened tube of Venelex cream, clean roll of [MEDICATION NAME] and scissors used to remove the soiled dressings. Further observations revealed LPN #1 obtained the open tube of Venelex cream from the chair, placed a small amount of cream on to her gloved hand and placed the cream on the resident's right foot wound. Additional observations revealed LPN #1, obtained [MEDICATION NAME] roll from the chair and, as Resident #6 continued to shout for LPN #1 to hurry up, LPN #1 wrapped the resident's right foot and lower extremity. LPN #1 then stated to the resident, Sweetheart, I'm sorry that it hurts but, I promise I will hurry and finish soon. Resident #6 did not respond. Further observations revealed LPN #1 removed her soiled gloves and washed her hands after placing the bag of soiled dressings in the resident's garbage. Continued observations revealed the resident continued to make requests of the nurse as she washed her hands. Additional observations revealed LPN #1 stated, I'm washing my hands honey, give me just a minute and I will get you something to drink. Interview with LPN #1, on 12/03/19 at 11:18 AM, revealed she worked the two-hundred (200) East-Hallway from eleven (11) AM to seven (7) PM since (MONTH) 2019 and routinely provided wound care for Resident #6. Further interview with LPN #1 revealed she had been a nurse for nearly thirty (30) years and had recently received education and training on Resident Rights and Dignity. Continued interview revealed she was unaware of calling Resident #6 honey or sweetheart and stated she should have referred to the resident by his/her preferred name to maintain the resident's dignity. Additional interview with LPN #1 revealed Resident #6 could potentially feel disrespected or humiliated if referred to by any name other than their preferred or given name and she would be sure to use the resident's preferred name in future encounters. Interview with Director of Nursing (DON), on 12/04/19 at 9:20 AM, revealed she was aware of LPN #1's failure to respect Resident #6 prior to the interview and was very disappointed. Further interview with the DON revealed nursing staff had recently received in-service training on Resident Rights and Dignity and the DON was embarrassed by the LPN #1's actions. Further interview with the DON revealed it was her expectation that all staff refer to the residents by their given name or name of preference. Continued interview with the DON revealed staff were never to refer to any of the residents as honey or sweetheart as this could be disrespectful, demeaning, degrading or humiliating. The DON advised she expected all residents to be treated with respect and dignity at all times. Interview with Licensed Nursing Home Administrator (LNHA), on 12/05/19 at 4:42 PM, revealed her expectation was for staff to follow Resident Rights Policy and refer to all residents by their name of choice. Further LNHA interview revealed she expected staff to refer to residents by the name the resident wishes to be referred to when providing the resident care. Continued interview with LNHA revealed she expected staff to always be respectful and polite towards the residents while adhering to facility policy regarding Resident Rights.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to provide personal privacy during medical treatment and personal care for one (1) of fourteen (14) sampled residents (Resident #6). Observation during initial tour of second floor, on 12/03/19, revealed licensed staff member performing wound care with a resident's bedroom door open, window shades not closed and the resident's lower extremities exposed to other residents, staff and visitors as they passed by the resident's room. The findings included: Review of the facility's policy, titled, Resident Rights: Confidentiality of Information and Personal Privacy, dated as revised on 04/2018, revealed the policy's purpose was to provide staff general guidelines for resident rights while providing direct resident care. Further review of the facility's policy revealed staff would receive in-service training on resident rights, including personal privacy and confidentiality, prior to providing direct resident care. Continued policy review revealed staff would close resident doors and provide for privacy, prior to performing any direct resident care. Additional review of the policy revealed the facility would protect and safeguard resident confidentiality and personal privacy regarding medical treatment, accommodations, and personal care at all times. Review of the clinical record revealed the facility admitted Resident #6 on 02/20/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further MDS review, revealed the facility assessed Resident #6 as requiring extensive physical assistance of two (2) for bed mobility, transfers, dressing, toilet use and personal hygiene. Continued MDS review revealed the facility assessed the resident as requiring total physical dependence of two (2) for locomotion on unit and required extensive physical assistance of one (1) with eating. Additional review revealed the facility assessed Resident #6 as having functional limitation of range of motion to bilateral upper and bilateral lower extremities. The facility assessed Resident #6 as requiring a wheelchair and walker for mobility. Observations of the two-hundred (200)-East Hallway during initial tour, on 12/03/19 at 11:10 AM, revealed Resident #6 in his/her room, with the door open. Continued observation revealed Resident #6 was shouting to Licensed Practical Nurse (LPN) #1 who was positioned at the foot of the resident's recliner chair, in a squatting position. Further observations from resident's doorway revealed LPN #1 removing [MEDICATION NAME] dressings from resident's right foot and lower extremity exposing resident's bare leg skin to hallway. Continued observations revealed resident's bedroom window blinds in the open position with the curtains present but not long enough to cover entire windowpane. Interview with LPN #1, on 12/03/19 at 11:18 AM, revealed she worked the two-hundred (200) East-Hallway since (MONTH) 2019 and routinely provided wound care for Resident #6. Further interview with LPN #1 revealed she had been a nurse for nearly thirty (30) years and had recently received education and training on Resident Rights regarding Privacy and Confidentiality. Continued interview revealed she should have provided privacy for Resident #6 while performing wound care and closed the resident's door and blinds. LPN #1 reported she usually closed the resident doors when providing medical treatments and had no explanation for not doing so. Additional interview with LPN #1 revealed Resident #6 could potentially feel his/her privacy and confidentiality was not protected when other residents, visitors and/or staff not providing care to the resident were aware of medical treatment (wound care) he/she required. LPN #1 added she was aware her actions were in violation of Resident #6's right to personal privacy and confidentiality, as staff were required to remove all residents from public view and prevent exposure of body parts during direct care, including wound care. Interview with Director of Nursing (DON), on 12/04/19 at 9:20 AM, revealed she was aware of the staff's failure to respect Resident #6's right to personal privacy and confidentiality prior to this interview and was very disappointed. Further interview with the DON revealed nursing staff recently received in-service training on Resident Rights and the DON was embarrassed by the violation. Further interview with the DON revealed it was her expectation that all staff close resident doors, privacy curtains (if in a shared room) and window blinds prior to performing any direct resident care. Continued interview with the DON revealed staff were expected to safeguard resident personal and medical information and should never provide direct care in public view or in a location where it could be possible for other residents, facility visitors or staff not assigned to resident could see or otherwise obtain knowledge of the resident's personal or medical care needs. Additional DON interview revealed all residents have the right to privacy and confidentiality for all aspects of care and her expectation was for staff to ensure the resident's rights were protected at all times. Interview with Licensed Nursing Home Administrator (LNHA), on 12/05/19 at 4:42 PM, revealed she expected all staff to follow the facility's Resident Rights Policy and close resident doors, privacy curtains (if in a shared room) and window blinds prior to performing any direct resident care, including wound care. Further interview with LNHA revealed she expected staff to safeguard resident personal and medical information and provide all direct care in a private, discreet location. Continued LNHA interview revealed staff were expected to adhere to facility policy regarding Resident Rights while protecting resident rights to privacy and confidentiality.

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of fourteen (14) sampled residents (Resident #6). Observations on 12/03/19 revealed staff failed to utilize proper hand hygiene and gloving technique during wound care. Additional observations during wound care revealed staff applied a potentially contaminated heel boot on the resident following wound care and failed to handle biohazardous waste in appropriate manner. The findings include: Review of the facility's Policy, titled Handwashing/Hand Hygiene, dated as revised on (MONTH) (YEAR), revealed the facility considered hand hygiene the primary means to prevent the spread of infection. Continued review revealed all personnel would be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of health-care associated infections. Further policy review revealed staff would follow handwashing/hygiene procedures to help prevent the spread of infections to residents, other staff members and visitors to facility. Additional policy review revealed staff were expected to wash hands before and after direct contact with residents, prior to performing any non-surgical invasive procedure, before gloves, before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, after handling used dressings, contaminated equipment, and after removing gloves. Continued review of facility policy revealed hand hygiene was the final step after removing and disposing of personal protective equipment. Review of the facility's Policy, titled Dry Dressings/Clean, dated as revised on (MONTH) 2013, revealed the purpose of the procedure was to provide guidelines for the application of clean, dry dressings. Further review revealed staff would establish a clean field of wound care supplies at the resident's bedside table, providing access to affected area, having a plastic bag either taped to the bedside table or utilizing a wastebasket below the table for soiled dressings. Continued policy review revealed staff would wash hands and apply clean gloves prior to the removal of the resident's soiled dressing. Further review revealed staff would remove soiled gloves, wash hands and apply clean gloves prior to the application of a clean dressing, utilizing clean technique. Additional review of the facility's Policy, revealed staff would wash their hands and remove biohazardous waste (soiled dressings) prior to exiting the resident room. Review of the facility's Policy, titled, Infection Control, dated as revised on (MONTH) (YEAR), revealed it was the facility's intention to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Further review revealed the facility's infection control policies and practices applied equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike in an effort to prevent, detect, investigate, and control infections in the facility. Review of the facility's Policy, titled Medical Waste, dated as revised on (MONTH) 2010, revealed the purpose of the policy was to provide definition of and guidelines for safe and appropriate handling of medical waste. Further review revealed medical waste included human blood and blood-soiled articles, contaminated items (ex: soiled dressings), items contaminated with feces from a person diagnosed as having a disease transmitted through feces, and disposable sharps (ex: needles/scalpels). Review of the clinical record revealed the facility admitted Resident #6 on 02/20/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the facility assessed Resident #6 as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further MDS review, revealed the facility assessed Resident #6 as requiring extensive physical assistance of two (2) for bed mobility, transfers, dressing, toilet use and personal hygiene. Continued MDS review revealed the facility assessed the resident as requiring total physical dependence of two (2) for locomotion on unit and required extensive physical assistance of one (1) with eating. Additional review revealed the facility assessed Resident #6 as having functional limitation of range of motion to bilateral upper and bilateral lower extremities. The facility assessed Resident #6 as requiring a wheelchair and walker for mobility. Review of the electronic clinical record revealed an active physician's orders [REDACTED]. Further review revealed an active order, with a start date of 11/06/19, for [MEDICATION NAME] Solution one (1) Gram to be administered intravenously one time every day for osteo[DIAGNOSES REDACTED] until 12/13/19. Continued clinical record review revealed an additional active order, with a start date of 11/12/19, for Venelex Cream/Ointment to the left heel deep tissue injury, right outer foot on fifth pinky toe (Stage I), and right inner foot by great toe on bunion (Stage I) every shift until healed. Additional review revealed an active order, dated 11/15/19, for [MEDICATION NAME] 100mg tablet, to administer one (1) tablet by mouth twice daily for osteo[DIAGNOSES REDACTED] until 12/13/19. Observations on 12/03/19 at 11:10 AM, revealed Resident #6 sitting in a recliner, in the bedroom with the door open with Licensed Practical Nurse (LPN) #1 positioned in the floor, at the foot of the resident's chair, in a squatting position. Further observations revealed LPN #1 wearing gloves, removing [MEDICATION NAME] dressing from the resident's right foot and lower extremity with scissors obtained from second chair that was located behind her. Continued observations revealed LPN #1 disposed of the soiled dressings in a clear plastic bag placing the bag on a chair behind her, sitting it next to an opened tube of Venelex cream, an opened roll of [MEDICATION NAME] wrap and scissors used to remove the resident's soiled dressings. Further observations revealed LPN #1 obtained the open tube of Venelex cream from chair, placed a small amount of cream on to her gloved hand and placed the cream on the resident's right heel wound. Additional observations revealed LPN #1, obtained the [MEDICATION NAME] wrap from the chair and wrapped the resident's right foot and lower extremity. LPN #1 picked up the heel lift boot from the floor beneath the foot of the recliner chair the resident was sitting in and placed it on Resident #6's right foot. Further observations revealed LPN #1 placed a bag of soiled dressings in to the resident's garbage receptacle located beneath the sink. Continued observations revealed LPN #1 removed her soiled gloves and washed her hands, leaving the plastic bag of soiled dressings in the resident garbage can. Additional observations revealed LPN #1 dried her hands and walked over to speak with Resident #6 as he/she requested a drink. Further observations revealed LPN #1 drying her hands over the resident's head as she spoke with the resident. Continued observations revealed LPN #1 assisted Resident #6 with a drink of juice from a spouted cup and the exited the room without washing or sanitizing hands or removing the biohazardous waste from the resident's garbage receptacle. Interview with LPN #1, on 12/03/19 at 11:18 AM, revealed she worked the two-hundred (200) East-Hallway, unit on which Resident #6 resided, since (MONTH) 2019, and routinely provided wound care for Resident #6. Further interview with LPN #1 revealed she had been a nurse for nearly thirty (30) years and was familiar with the facility's policy and practices regarding Infection Control and Standard Precautions. Continued interview revealed she should have set up a clean field of treatment supplies at the resident's bedside prior to providing wound care to ensure she performed a clean technique. LPN #1 advised she should have removed her gloves, washed her hands and applied clean gloves following removal of Resident #6 soiled dressing and prior to application of Venelex cream. LPN #1 advised she should have utilized a cotton-tipped swab for application of Venelex cream to the wound bed to prevent potential cross contamination from the gloves to the wound or from the resident's wound to her gloved hand. LPN #1 stated this was an infection control issue that she was aware of and stated, she had no explanation for her actions. Further interview revealed LPN #1 should have placed the resident's heel lift boot on his/her chair or in the resident's lap during wound care and never on the floor due to the potential for infection to the resident's wound by cross contamination from anything that could be living on the floor. Additional interview revealed LPN #1 should have removed the bag of soiled dressings from Resident #6 room and disposed of it in the biohazardous waste container located in the dirty utility room as per facility policy. LPN #1stated she did not recall drying her hands above the resident but reported this was an infection control concern due to the potential for cross contamination as well. Continued interview revealed LPN #1 should have washed her hands again prior to exiting Resident #6 room to prevent the potential spread of bacteria, germs, or other microorganisms to other staff members, residents, and visitors to facility. Interview with Staff Development Coordinator (SDC), on 12/05/19 at 2:53 PM, revealed she was responsible for providing educational material to licensed and certified staff members, which included training on Handwashing/Hand Hygiene, Infection Control and Wound Care. Further interview revealed the SDC was responsible for ensuring staff competency for providing care and services for residents. Continued interview with the SDC revealed LPN #1 had received education and training during orientation to the facility on Handwashing/Hand Hygiene, Infection Control and appropriate handling and disposal of Medical Waste. Additional interview revealed LPN #1 should have set up a clean field of wound care supplies, utilizing the resident's bedside table before providing wound care to ensure her supplies remained clean as she performed a clean technique. SDC advised LPN #1 should have washed her hands and applied clean gloves following removal of the resident's soiled dressing to prevent cross contamination of bacteria or other microorganisms from the resident's wound to her hands or from LPN #1's hands to the resident's wound. Further, the SDC interview revealed LPN #1 should have applied Venelex cream utilizing a clean cotton-tipped swab applicator to prevent the spread of germs/bacteria from her gloved hand to the resident's wound or from the resident's wound to her gloved hand. SDC advised LPN #1 should not take entire tube of cream to a resident's room and then place it back in to the treatment cart, as this was an infection control concern as well. SDC advised LPN #1 should have taken the amount of cream needed in a medication cup to the resident's room at the time of the treatment. SDC advised it was not appropriate to use gloved hands to apply cream to a staged wound bed. Continued interview with the SDC revealed LPN #1 should have removed her soiled gloves, washed her hands and applied clean gloves prior to placing Resident #6's heel lift boot to the right lower extremity. SDC stated it was not appropriate to place a heel lift boot on a resident after it had been on the floor as there was a potential for cross contamination from germs; bacteria and other microorganisms on the floor and could infect the open wound bed and cause severe infection. Further interview with SDC revealed LPN #1 should have elevated Resident #6's right lower extremity until she could retrieve a new heel lift boot. Additional SDC interview revealed LPN #1 should have removed the bag of soiled dressings (medical waste) from Resident #6's room and disposed of it in the biohazardous waste container located in the dirty utility room as per the facility's policy as this was an infection control concern and could potentially spread illness throughout the facility. SDC explained LPN #1 should have been aware of this information. Further interview revealed LPN #1 should have washed her hands prior to exiting Resident #6's room to prevent the potential spread of illness to other residents, staff and visitors to facility. Interview with Infection Control and Prevention Registered Nurse (ICP), on 12/05/19 at 3:38 PM, revealed she was responsible for ensuring staff received proper education and training regarding facility policies and practices regarding infection control and prevention. Further interview revealed LPN #1 should have set up a clean field at the resident's bedside prior to care on 12/03/19 to decrease the risk of potential cross contamination of bacteria and other microorganisms into Resident #6's wound. Continued interview revealed LPN #1 should have removed soiled gloves, washed hands and applied clean gloves prior to applying Venelex cream to the resident's wound. Additional ICP interview revealed LPN #1 should not apply cream to the wound bed with soiled gloves and should have used a cotton-tipped swab or other available treatment product such as a four (4) x (4) gauze pad to apply the cream. ICP advised utilizing proper procedure would assist to decrease the risk of potential cross contamination of bacteria and other germs to the wound or from the wound to LPN #1's gloved hand. Further ICP interview revealed following application of Venelex cream, LPN #1 should have removed the gloves, washed hands and applied clean gloves before application of [MEDICATION NAME] wrap and heel lift boot to right lower extremity. Continued interview with ICP revealed LPN #1 should not place a heel lift boot from the floor onto a resident as this was an infection control issue and could cause germs and other bacteria from the floor to enter the resident's wound. ICP revealed LPN #1 should have elevated Resident #6 right lower extremity and retrieved a new heel lift boot. Further interview revealed LPN #1 should have washed her hands prior to exiting Resident #6 room and disposed of the soiled dressing (medical waste) in the dirty utility room in a biohazardous waste container as per the facility's policy to decrease the risk of cross contamination and potential illness/infection of other residents, staff and/or visitors to facility. Interview with Director of Nursing (DON), on 12/04/19 at 4:38 PM, revealed LPN #1 should have washed hands, applied gloves and set up a clean field of treatment supplies at the resident's bedside, as per the facility's policy prior to wound care on 12/03/19. The DON advised it was not appropriate to utilize a resident's personal chair as a supply field during delivery of wound care. Further interview revealed LPN #1 was familiar with Resident #6's treatment to the lower extremity and should have obtained the amount of Venelex cream needed from the tube, placed it in medication cup and placed it within the field of treatment supplies. Continued DON interview revealed LPN #1 should have removed her soiled gloves, washed her hands and applied clean gloves prior to the application of Venelex cream to the wound bed. The DON reported LPN #1 should have applied Venelex cream to the wound bed utilizing a cotton-tipped swab, to prevent potential cross contamination of germs, bacteria or other microorganisms from her soiled gloves to the resident's wound or from the resident's wound to LPN #1's gloved hand. Additional interview revealed LPN #1 should have removed her gloves, washed her hands and applied clean gloves prior to the application of [MEDICATION NAME] wrap and repeated the process prior to the application of the heel lift boot to the resident's foot. Further DON interview revealed LPN #1 should have elevated Resident #6's right lower extremity and obtained new heel lift boot. The DON stated LPN #1 should not have placed a heel lift boot on the resident after it had been on the floor and this was an infection control concern as bacteria, microorganisms and other germs from urine, feces, blood and other body fluids could be on the floor and a potential for cross contamination into the resident's wound. Continued interview with the DON revealed LPN #1 should have removed gloves and washed hands prior to exiting the resident's room to prevent other residents, staff and visitors to facility from becoming ill due to the potential for cross contamination of germs or other microorganisms. Additionally, the DON revealed LPN #1 should have dried her hands completely prior to walking over to assist Resident #6. The DON stated drying hands above a resident could potentially cause cross contamination of germs and/or bacteria from LPN #1's hands to Resident #6 if the hands were not yet thoroughly dried, which could cause illness in resident. Further interview revealed LPN #1 should have removed the soiled dressing from the resident's room and disposed of it in the dirty utility room as this was biohazardous waste and should have been handled and disposed of properly and per the facility's policy. Interview with Licensed Nursing Home Administrator (LNHA), on 12/05/19 at 4:42 PM, revealed she expected staff to adhere to facility policies regarding Handwashing and Hand Hygiene, Clean/Dry Dressings and Infection Control during delivery of resident care. Further LNHA interview revealed she expected staff to wash hands prior to and following delivery of direct resident care to prevent the spread of germs/bacteria and potential illness and/or infection throughout the facility. Continued interview revealed LNHA would expect staff to remove soiled gloves, wash hands and apply clean gloves following removal of any wound dressing to prevent the spread of microorganisms, bacteria and other germs to the resident's wound or from the resident's wound to staff. Additional interview with LNHA revealed she expected staff would not place item obtained from the floor onto a resident's extremity as the item would most likely be contaminated and could potentially cause illness or infection in a resident. Further interview revealed LNHA expected staff would remove medical waste from a resident's room following the delivery of care and would dispose of the waste properly in a biohazardous waste container to decrease the likelihood of cross-contamination, which could cause illness or infection to other residents, staff, or visitors to her facility.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to protect one (1) out of four (4) sampled residents, Resident #4 from abuse. Review of the Facility Self Reported Incident dated 09/06/19 revealed State Registered Nursing Assistant (SRNA) #1 made statements of verbal abuse to Resident #4 in which SRNA #1 spoke harshly to the resident and cursed at him/her which was heard and witnessed by SRNA #2 and heard by SRNA #3. The findings include: Review of the facility policy, Abuse Investigating and Reporting, dated 2001 with a revision date of (MONTH) (YEAR), revealed all reports of resident abuse, neglect, exploitation, of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management with findings of abuse investigations reported. Continued review revealed witness reports will be obtained in writing and signed and dated. Record review on 10/07/19 revealed Resident #4 was admitted by the facility on 04/24/19 and discharged on [DATE] from the facility with the [DIAGNOSES REDACTED]. Per review the resident had a facility assessed Brief Interview for Mental status score of eight (8) on the 07/04/19 Quarterly Minimum Data Set (MDS) Assessment, indicating the resident to be moderately cognitively impaired for decision making. Review of the facility Self Reported Incident Form revealed, on 09/06/19 at approximately 2:30 PM SRNA #2 notified the Director of Nursing (DON) that she heard SRNA #1 in the third floor shower room. Per review, SRNA #2 stated she heard SRNA #1 speaking harshly and cursing at Resident #4. Continued review revealed, SRNA#3 heard the incident. Review of the facility investigation revealed SRNA #2's written witness statement revealed on 09/06/19, she heard SRNA #1 state to Resident #4 if I get you off that damn pot again, I'm not putting you back on. Per witness statement, SRNA #3 overheard SRNA #1 tell Resident #4, that he/she could just sit there on the toilet till whenever SRNA #1 would get to her after she pulled the light. Per SRNA #3's written statement, since Resident #1 had a chair alarm and was not supposed to be left alone in the bathroom, after hearing those comments SRNA #2 intervened and stated to SRNA #1 the resident should not be left the bathroom alone and SRNA #1 stated to her What do you expect me to do? I've already been in here this whole damn time and all the other aides do it and no body else follows that rule so what does it matter?. Per review of the witness statements, SRNA #2 said to SRNA #1, I can't help what other people do, I just wanted to make sure you were aware of how it goes. SRNA #2 stated at that point she was finished weighing her resident and had completed her task in the bathroom so she assisted her resident back to the room. After, assisting her resident, back to the room, SRNA #2 went back to the bathroom to check on Resident #4 and SRNA #1; however, they were no longer in the shower room. Review of SRNA #3 witness statement revealed at approximately 2:00 PM on 09/06/19 she overheard SRNA #1 yell I already put you on this [***] ing pot once and if I have to put you back on this damn pot again, I'm not getting you back off. Per the witness statement SRNA #3 stated she left the shower room at that point while SRNA #2 stayed in the room. Review of the facility's investigation on 10/07/19 revealed that after the incident was reported to the DON, she initiated an abuse investigation, suspended SRNA #1 from the facility pending the outcome of the investigation. Per review, although the staff stated the alleged perpetrator was questioned, there was no written statement from the alleged perpetrator. Continued review revealed the facility did question Resident #4 related to the incident and the resident denied harm by the SRNA #2. Interview with SRNA #1 on 10/07/19 at 3:24 PM revealed the facility did not ask her any questions related what happened with the Resident #4. Per interview she stated she told Resident #4 she didn't want to put the resident on the pot again, that she put the resident on this pot a few times already. She stated it was nothing serious, just joking around. Per interview it was not meant to harm anyone, just joking around. Per interview Resident #4 stated , I know Honey acknowledging the difficulty at night. Per interview she was called and told over the phone she could no longer work there because of the situation with Resident #4. Continued interview revealed she was upset about the results of the investigation and sorry it all had to work out that way. Interview with SRNA #2 revealed she had been employed by the facility since (MONTH) 2019. Per interview she reported an incident to the DON on 09/06/19 at approximately 2:00 PM, as soon as she overheard SRNA #1 talking with Resident #4 in the shower room. Per interview she was walking down the hall to get a weight on Resident #3 and was taking him/her into the shower room. Per interview Resident #4 said he/she had to sit back down and SRNA #1 told him/her, If you set back down one more time, I am not getting you up one more damn time. Per interview that was the time SRNA #2 walked in with Resident #3. Per interview at that point SRNA #1 was not in visual range of Resident #1 any longer and was hollering at the air, things like I don't know what you expect me to do . Per interview, SRNA #2 had explained after hearing the exchange that SRNA#1 was not allowed to leave the resident alone in the shower room. Per interview after completing the task of getting the weight on Resident #3, she went to find the Director of Nursing and report the incident as an allegation of verbal abuse. An Interview was attempted on 10/07/19 with SRNA #3 at 2:09 PM and 3:30 PM; however, was unable to be completed. Interview with Social Services Director on 10/07/19 at 2:17 PM revealed she interviewed Resident #4 after the incident on 09/06/19 at the request of the Administrator. Per interview Resident #4 was very hard of hearing and she used a dry erase board to make sure the resident understood the questioning. Per interview the Social Service Director had a picture of the alleged perpetrator (SRNA #1) and used this to question the resident and the resident denied any complaints related to the employee. Per interview the resident did have a [DIAGNOSES REDACTED]. Per interview the Social Service Director spoke several times to Resident #4 and the resident never had any complaints related to staff. Per interview as part of the abuse investigation, the Social Service Director did also pick a random sample of ten residents on the third floor to interview them related to issues with abuse. Interview with the Staff Development Coordinator on 10/07/19 at 3:10 PM revealed the staff received training on abuse at orientation and annually, and they used quizzes and inservices to provide the education. Per interview the Staff Development Coordinator stated it was important for everyone in the facility to receive training on abuse and how to recognize and report abuse. Per interview all allegations of abuse should be reported in a timely manner and investigated thoroughly for the safety of the residents. Interview with Director of Nursing (DON) on 10/07/19 at 3:49 PM, revealed she had been employed by the facility for six years. Per interview, SRNA #2 came to her office on 09/06/19 and made the allegations of abuse related to SRNA #1 and Resident #4. Per interview she initiate an abuse investigation with the Administrator, suspended the employee pending the results of the investigation and took statements from SRNA #2 and SRNA #3 regarding the event. Per interview, SRNA #1 was terminated from employment based on being found asleep on the job on the same day as this incident and not based on the allegations of this incident alone, as the employee was within their first ninety days of employment. Interview with the Administrator on 10/07/19 at 4:00 PM revealed she became aware of the situation by the DON and they started the abuse investigation on 09/06/19. Continued interview revealed SRNA #1 stated the incident did not happen when interviewed and SRNA #2 and SRNA #3 had slightly different stories so after SRNA #1 had been suspended and the investigation had been concluded it was decided to terminated the employee for the reason that she had been caught asleep on the same day as the other episode not because of the alleged abuse incident.

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services were provided by qualified persons in accordance with each resident's written Comprehensive Plan of Care for three (3) of fourteen thirty-two (32) sampled residents (Resident #13, #15, and #28). Resident #13, #15, and #28 were care planned for restorative nursing services; however, staff and resident interviews and review of three (3) months of restorative nursing data from (MONTH) (YEAR) through (MONTH) (YEAR), revealed the residents did not receive restorative therapy services as outlined in their care plans. The findings include: Review of the facility Using the Care Plan Policy, revised 08/2006, revealed the care plan was to be used in developing the resident's daily care routines and was available to all staff who had responsibility for providing resident care. The Policy further revealed nurse aides were responsible for reporting to the nurse supervisor any changes in resident condition or care plan goals and objectives that had not been met. Review of the facility Restorative Nursing Services Policy, revised 07/2017, revealed residents were to receive restorative nursing services to promote safety and independence, with goals and objectives outlined in the resident's plan of care. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 02/20/17 with [DIAGNOSES REDACTED]. Review of Resident #13's Comprehensive Care Plan, dated 05/24/17, revealed a focus area for potential for decline in mobility. The goal revealed the resident would demonstrate continued ROM by being able to complete bilateral lower extremity (BLE) active range of motion (AROM) exercise without difficulty or decline. The interventions included the following: ambulation with restorative nursing fifteen (15) minutes or more a day, and BLE AROM exercises fifteen (15) minutes or more a day. Review of Resident #13 Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review revealed the facility assessed the resident as having functional limitations in range of motion of both upper and lower extremities; as requiring extensive assist of one (1) person for transfers, and as requiring limited assist of one (1) person for ambulating in the corridor. Review of the Documentation Survey Report, dated (MONTH) (YEAR), revealed thirteen (13) days in which ambulation was not offered through restorative nursing, and twelve (12) days in which BLE exercises were not offered. Review of the Documentation Survey Report' dated (MONTH) (YEAR), revealed four (4) days in which ambulation was not offered through restorative nursing, and five (5) days in which BLE exercises were not offered. Review of the Documentation Survey Report dated (MONTH) (YEAR), revealed five (5) days in which ambulation was not offered through restorative nursing, and four (4) days in which BLE exercises were not offered. Interview with Resident #13, on 11/01/18 at 9:25 AM, revealed he/she had missed some days of exercise due to the Restorative Aide being busy. The resident stated sometimes he/she was not up for exercises. Resident #13 further stated he/she had spoken with the Restorative Aide, and felt the Restorative Aide would be providing exercises more consistently from here on out. Interview on 11/01/18 at 1:38 PM, with the Physical Therapist, revealed when Resident #13 was last discharged from physical therapy, he/she was ambulating ten (10) feet and the assessment conducted today, revealed he/she was able to walk twenty (20) feet. Further, Resident #13 used to require the assist of two (2) staff to transfer, but now was transferring with the assist of one (1) staff. Continued interview revealed there had been no decline in Resident #13's physical abilities, and she recommended Resident #13 continue with restorative therapy. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 12/07/15 with [DIAGNOSES REDACTED]. Review of Resident #15's Annual MDS Assessment, dated 08/09/18, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review revealed the facility assessed the resident as having functional limitations in range of motion of the upper and lower extremity on one (1) side; as ambulation not occurring; and as requiring extensive assist of two (2) staff for transfers. Review of Resident #15's Comprehensive Care Plan, revised 08/15/18, revealed a focus area regarding impaired mobility related to Stroke with left [MEDICAL CONDITION] and contracture to left knee. The goal revealed the resident would maintain the ability to ambulate fifty (50) to one hundred (100) feet with staff support. The interventions included: ambulate with restorative nursing fifteen (15) minutes or greater a day, and AROM therapy for both Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) fifteen (15) minutes or greater a day. Review of the Documentation Survey Report dated (MONTH) (YEAR), revealed twelve (12) days in which ambulation was not offered through restorative nursing, and thirteen (13) days in which AROM was not offered through restorative. Review of the Documentation Survey Report dated (MONTH) (YEAR), revealed seven (7) days in which ambulation was not offered through restorative nursing, and eleven (11) days in which AROM was not offered through restorative. Review of the Documentation Survey Report dated (MONTH) (YEAR), revealed ten (10) days in which ambulation was not offered through restorative nursing, and eight (8) days in which AROM was not offered through restorative. Interview with Resident #15, on 10/30/18 at 10:57 AM, revealed there wasn't enough staff to assist him/her with exercises. Per interview, whenever staff call off work, Restorative Aides were pulled to replace them. Further interview revealed staff were able to provide assistance with other needs such as showers, and answer call lights, although it may take a little longer when there wasn't as many staff. Interview on 11/01/18 at 12:53 PM, with SRNA #3, revealed sometimes Restorative Aides were pulled to work the floor due to staff calling in, and at one point they were pulled quite a bit due to call ins. She further stated sometimes Resident #15 complained about not being provided restorative nursing. Review of the Occupational Therapy Plan of Care Evaluation, dated 11/01/18, revealed there had been a slight improvement in the resident's toileting hygiene, from being dependent on the helper for assistance, to requiring substantial assistance from the helper with toileting hygiene. Review of the Physical Therapy Plan of Care Evaluation dated 11/01/18, revealed there had been no decline in the resident's physical functioning since previously seen by physical therapy. Interview on 11/01/18 at 1:38 PM, with the Physical Therapist, revealed Resident #15 had neither declined nor improved in functional ability, except for transfers, and had improved on transfers a little, based on the Evaluation today. The Physical Therapist recommended Resident #15 continue with restorative therapy. Interview on 11/01/18 at 1:38 PM, with the Occupational Therapist, revealed Resident #15 required the same amount of assistance with Activities of Daily Living (ADLS) now as back in (MONTH) (YEAR) when Physical Therapy started working with the resident. Further interview, revealed the Occupational Therapist recommended Resident #15 continue with restorative therapy. 3. Review of Resident #28's medical record revealed the facility admitted the resident on 01/20/17 with [DIAGNOSES REDACTED]. Review of Resident #28's Comprehensive Care Plan, revised 02/05/18, revealed a focus problem of being at risk for further decline in mobility. The goal revealed the resident would continue to ambulate with assist in facility; and would have no decline in ROM. The interventions included the following: ambulation with restorative nursing fifteen (15) minutes or more a day, and AROM exercises with Bilateral Lower Extremity (BLE) and Left Upper Extremity (LUE) fifteen (15) minutes or more a day. Review of Resident #28's Quarterly MDS Assessment, dated 08/30/18, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Continued review revealed the facility assessed the resident as having functional limitations in range of motion of the upper and lower extremity on one (1) side; as requiring limited assistance of one (1) person for ambulation; and as requiring extensive assist of one (1) staff for transfers. Review of the Documentation Survey Report dated (MONTH) (YEAR) revealed fifteen (15) days in which restorative ambulation was not offered. Continued review revealed sixteen (16) days in which AROM exercises were not offered. Review of the Documentation Survey Report, dated (MONTH) (YEAR), revealed eleven (11) days in which restorative ambulation was not offered, and eleven (11) days in which AROM exercises were not offered. Review of the Documentation Survey Report, dated (MONTH) (YEAR), revealed eleven (11) days in which restorative ambulation was not offered. Continued review revealed eleven (11) days in which AROM exercises were not offered. Interview with Resident #28, on 11/01/18 at 9:20 AM, revealed he/she did not always receive restorative exercises. Further interview revealed he/she may get exercise one (1) day a week, and some weeks he/she may not get them at all. Resident #28 further stated on occasion he/she had observed the Restorative Aide assisting another resident, and had been informed the Restorative Aide would get back with him/her, but it did not always happen. Review of the Occupational Therapy Plan of Care Evaluation 11/01/18, revealed no decline in the resident's ADL abilities since previously seen by occupational therapy. Review of the Physical Therapy Plan of Care Evaluation, dated 11/01/18, revealed no decline in the resident's physical functioning since previously seen by physical therapy. Interview on 11/01/18 1:38 PM, with the Physical Therapist, revealed Resident #28 had no decline, and was able to stand up from the chair, and ambulate one hundred fifty (150) feet easily with his/her quad cane. The Physical Therapist recommended Resident #28 continue with restorative therapy. Interview 10/31/18 at 8:55 AM, with State Registered Nurse Aide (SRNA) #1/Restorative Aide (RA), regarding the Documentation Survey Reports, revealed the majority of the time, if there was zero (0) time documented for restorative nursing, she was likely on the floor working as an SRNA and she wasn't available to provide restorative care. She further stated she was pulled to the floor a lot, sometimes three (3) days out of five (5) due to there not being enough help. Further interview revealed residents had complained to her when she wasn't available to provide restorative nursing. Per interview, she thought the facility was attempting to hire more staff, but the restorative program suffered when there was a call in. Interview on 11/01/18 at 1:23 PM with SRNA #4/RA, revealed sometimes she was unable to perform restorative nursing duties due to being pulled to the floor as a result of staffing concerns. She further stated Monday through Thursday, there were two (2) Restorative Aides, one (1) for each floor, but when there was only (one) Restorative Aide for both floors, they could not get all restorative care done, even when not pulled to the floor. Per interview, recently it had not been as bad, and now she was only been pulled to the floor an average of once a week. Interview with LPN #2 on 11/01/18 2:29 PM, revealed Resident #13, Resident #15, and Resident #28 had not informed her they were not getting their restorative nursing as care planned. She stated sometimes Restorative Aides were pulled to work the floor when there were staff calls in, and the Restorative Aides had mentioned to her in the past, they could not get the restorative care completed. Interview on 10/31/18 at 2:43 PM, with the Nursing Scheduler, revealed any SRNA could perform restorative nursing, and the facility was currently looking to hire more people. Further interview revealed staff often stayed over, or came in early to assist other shifts when staff called in to work. Interview on 11/01/18 at 2:43 PM, with the Restorative Nursing Coordinator, revealed she was responsible for developing and revising care plans regarding restorative nursing, based on physician's orders [REDACTED]. She stated Restorative Nurse Aides and SRNAs had access to care plan information including intervention for restorative nursing available on the Kardex. She further stated it was her expectation that restorative care was delivered as per the Comprehensive Care Plan in order to ensure residents maintained their level of function or improved. However, per interview, when there was a call in resident needs would have to be prioritized and the Restorative Aides would sometimes be pulled to the floor. Per interview, as a result restorative exercises were not always provided as care planned. Interview with the Director of Nursing (DON), on 11/01/18 10:25 AM, revealed it was her expectation for residents to be offered restorative therapy as per the Comprehensive Care Plan. Per interview, there was the potential for negative consequences such as a decline in ADL ability or further decrease in ROM if residents did not receive their restorative therapy. Further interview revealed the Care Plan was a guide in presenting the best opportunities for residents to improve in their daily living. She stated all staff were responsible for ensuring care plans were followed. Interview on 11/01/18 3:12 PM, with the Administrator, revealed it was her expectation care plans were followed related to restorative nursing. She stated there could be negative consequences for residents if the care plans were not followed.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure residents with limited range of motion and/or limited mobility, receive appropriate treatment and services to maintain or improve range of motion (ROM) and/or maintain or improve mobility, for three (3) of four (4) sampled residents reviewed for limited ROM and limited mobility, out of a total sample of thirty-two (32) residents (Resident #13, Resident #15, and Resident #28). Interview and record review revealed Resident #13, #15, and #28 did not receive restorative nursing as scheduled for the time period reviewed (MONTH) (YEAR) through (MONTH) (YEAR). The findings include: Review of the facility Restorative Nursing Services Policy, revised 07/2017, revealed residents were to receive restorative nursing services to promote safety and independence, with goals and objectives outlined in the resident's plan of care. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 02/20/17 with [DIAGNOSES REDACTED]. Review of Resident #13's Comprehensive Plan of Care, dated 05/24/17, revealed a focus area for potential for decline in mobility. The goal stated the resident would demonstrate continued ROM by being able to complete bilateral lower extremity (BLE) active range of motion (AROM) exercise without difficulty or decline. The interventions included: ambulation with restorative nursing fifteen (15) minutes or more a day, and BLE AROM exercises fifteen (15) minutes or more a day. The facility assessed Resident #13, in a Quarterly Minimum Data Set ((MDS) dated [DATE], as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review revealed the facility assessed the resident as having functional limitations in range of motion of both upper and lower extremities; as requiring extensive assist of one (1) person for transfers, and as requiring limited assist of one (1) person for ambulating in the corridor. Review of Resident #13's Documentation Survey Report, dated (MONTH) (YEAR), revealed thirteen (13) days in which ambulation was not offered through restorative nursing, and twelve (12) days in which BLE exercises were not offered. Review of Resident #13's Documentation Survey Report' dated (MONTH) (YEAR), revealed four (4) days in which ambulation was not offered through restorative nursing, and five (5) days in which BLE exercises were not offered. Review of Resident #13's Documentation Survey Report dated (MONTH) (YEAR), revealed five (5) days in which ambulation was not offered through restorative nursing, and four (4) days in which BLE exercises were not offered. Interview with Resident #13, on 11/01/18 at 9:25 AM, revealed he/she had missed some days with his/her exercises due to the Restorative Aide being busy. Further, the resident stated sometimes he/she was not up for exercises. Resident #13 stated he/she had spoken with the Restorative Aide, and felt the Restorative Aide would be providing exercises more consistently from here on out. Interview on 11/01/18 at 1:38 PM, with the Physical Therapist, revealed when Resident #13 was last discharged from physical therapy, he/she was ambulating ten (10) feet and the assessment conducted today, revealed the resident was able to walk twenty (20) feet. Per interview, Resident #13 used to require the assist of two (2) staff to transfer, but now was transferring with the assist of one (1) staff. Further interview revealed there had been no decline in Resident #13's physical abilities, and she recommended Resident #13 continue with restorative therapy. Interview with the Restorative Nursing Coordinator, on 11/01/18 at 2:43 PM, revealed Resident #13 was a fairly regimented person, who liked things when he/she liked them. She stated Resident #13 walked with restorative and performed BLE exercises with restorative when he/she desired. She stated staff worked to ensure Resident #13 felt safe when ambulating. 2. Review of Resident #15's medical record revealed the facility admitted the resident on 12/07/15 with [DIAGNOSES REDACTED]. The facility assessed Resident #15, in an Annual MDS Assessment, dated 08/09/18, as having a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review revealed the facility assessed the resident as having functional limitations in range of motion of the upper and lower extremity on one (1) side; as ambulation not occurring; and as requiring extensive assist of two (2) staff for transfers. Review of Resident #15's Comprehensive Plan of Care, revised 08/15/18, revealed a focus area for impaired mobility related to Stroke with left [MEDICAL CONDITION] and contracture to left knee. The goal stated the resident would maintain the ability to ambulate fifty (50) to one hundred (100) feet with staff support. The interventions included: ambulate with restorative nursing fifteen (15) minutes or greater a day, and AROM therapy for both Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) fifteen (15) minutes or greater a day. Review of Resident #15's Documentation Survey Report dated (MONTH) (YEAR), revealed twelve (12) days in which ambulation was not offered through restorative nursing, and thirteen (13) days in which AROM was not offered through restorative. Review of Resident #15's Documentation Survey Report dated (MONTH) (YEAR), revealed seven (7) days in which ambulation was not offered through restorative nursing, and eleven (11) days in which AROM was not offered through restorative. Review of Resident #15's Documentation Survey Report dated (MONTH) (YEAR), revealed ten (10) days in which ambulation was not offered through restorative nursing, and eight (8) days in which AROM was not offered through restorative. Interview with Resident #15, on 10/30/18 at 10:57 AM, revealed there wasn't enough staff to assist with his/her exercises. He/she stated whenever staff call off work, Restorative Aides were pulled to replace them. Continued interview revealed other than exercises, he/she wasn't aware of any other things that didn't get done. He/she stated staff were able to provide assistance with showers, and answer call lights, although it may take a little longer when staff were busy. Interview on 11/01/18 at 12:53 PM, with SRNA #3, revealed sometimes Restorative Aides were pulled to work the floor when staff called in, and at one point got pulled quite a bit due to call ins. She stated sometimes Resident #15 complained about not being provided restorative nursing. Review of the Occupational Therapy Plan of Care Evaluation, dated 11/01/18, revealed there had been a slight improvement in the resident's toileting hygiene, from being dependent on helper for assistance, to requiring substantial assistance from helper with toileting hygiene. Review of the Physical Therapy Plan of Care Evaluation dated 11/01/18, revealed there had been no decline in the resident's physical functioning since previously seen by physical therapy. Interview on 11/01/18 at 1:38 PM, with the Physical Therapist, revealed Resident #15 had neither declined nor improved, except for transfers, and has improved on transfers a little, based on the Evaluation this date. Per interview, the Physical Therapist recommended Resident #15 continue with restorative therapy. Interview on 11/01/18 at 1:38 PM, with the Occupational Therapist, revealed Resident #15 was requiring the same amount of assistance with Activities of Daily Living (ADLS) as back in (MONTH) (YEAR) when Physical Therapy started working with the resident. Per interview, the Occupational Therapist recommended Resident #15 continue with restorative therapy. Interview on 10/31/18 10:49 AM, with the Restorative Nursing Coordinator, revealed Resident #15 didn't always want to be ambulated, and she wasn't sure if this was being accurately documented as a refusal. She stated Resident #15 did receive care with transfers and ambulation from floor staff as well as Restorative Aides which may not be documented. 3. Review of Resident #28's medical record revealed the facility admitted the resident on 01/20/17 with [DIAGNOSES REDACTED]. Review of Resident #28's Comprehensive Plan of Care, revised 02/05/18, revealed a focus problem of being at risk for further decline in mobility. The goal stated the resident would continue to ambulate with assist in facility; and would have no decline in ROM. The interventions included ambulation with restorative nursing fifteen (15) minutes or more a day, and AROM exercises with Bilateral Lower Extremity (BLE) and Left Upper Extremity (LUE) fifteen (15) minutes or more a day. The facility assessed Resident #28, in a Quarterly MDS Assessment, dated 08/30/18, as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Further review revealed the facility assessed the resident as having functional limitations in range of motion of the upper and lower extremity on one (1) side; as requiring limited assistance of one (1) person for ambulation; and as requiring extensive assist of one (1) staff for transfers. Review of Resident #28's Documentation Survey Report dated (MONTH) (YEAR) revealed fifteen (15) days in which restorative ambulation was not offered. Continued review revealed sixteen (16) days in which AROM exercises were not offered. Review of Resident #28's Documentation Survey Report, dated (MONTH) (YEAR), revealed eleven (11) days in which restorative ambulation was not offered, and eleven (11) days in which AROM exercises were not offered. Review of Resident #28's Documentation Survey Report, dated (MONTH) (YEAR), revealed eleven (11) days in which restorative ambulation was not offered. Continued review revealed eleven (11) days in which AROM exercises were not offered. Interview with Resident #28, on 11/01/18 at 9:20 AM, revealed he/she didn't always receive restorative exercises. Per interview, he/she may get them one (1) day a week, and some weeks he/she may not get them at all. Resident #28 stated on occasion he/she had observed the Restorative Aide assisting another resident, and had been informed the Restorative Aide would get back with him/her, but it didn't always happen. The Resident expressed the need for exercises to maintain his/her mobility. Resident #28 stated he/she had not informed anyone that he/she was not getting restorative exercises. Review of the Occupational Therapy Plan of Care Evaluation 11/01/18, revealed there had been no decline in the resident's ADL abilities since previously seen by occupational therapy. Review of the Physical Therapy Plan of Care Evaluation, dated 11/01/18, revealed there had been no decline in the resident's physical functioning since previously seen by physical therapy. Interview on 11/01/18 1:38 PM, with the Physical Therapist, revealed Resident #28 had no decline, and was able to stand up from the chair, and ambulate one hundred fifty (150) feet easily with a quad cane. She recommended Resident #28 continue with restorative therapy. Interview on 11/01/18 at 2:43 PM, with the Restorative Nursing Coordinator, revealed she was aware Resident #28 worked better with one (1) of the Restorative Aides than with other staff, sometimes refusing restorative care from certain staff. She stated she was uncertain if everything was being correctly documented, and that some of the documentation indicating restorative wasn't offered might actually be refusals. Interview 10/31/18 at 8:55 AM, with State Registered Nurse Aide (SRNA) #1/Restorative Aide (RA), regarding the Documentation Survey Reports, revealed the majority of the time, if there was zero (0) time documented, she was likely on the floor working as an SRNA and she wasn't available to provide restorative care. She stated she was pulled to the floor a lot, sometimes three (3) days out of five (5) due to there not being enough help. Per interview, residents had complained to her when she wasn't available to provide restorative nursing. Continued interview revealed she thought the facility was attempting to hire more staff, but the restorative program suffered when there was a call in. Interview on 11/01/18 at 1:23 PM with SRNA #4/RA, revealed at times she was unable to perform restorative nursing duties due to being pulled to the floor as a result of staffing concerns. She stated Monday through Thursday, there were two (2) Restorative Aides, one (1) for each floor, but when there was only (one) Restorative Aide for both floors, they could not get all restorative care done, even when not pulled to the floor. She further stated recently it had not been as bad, and now she was only been pulled to the floor an average of once a week. Interview with SRNA #5 on 11/01/18 at 2:00 PM, revealed she would try to provide restorative nursing when the Restorative Aides were busy or got pulled to the floor due to staff calling in. Interview with Licensed Practical Nurse (LPN) #1 on 11/01/18 at 2:12 PM, revealed it used to be a frequent problem in months past with Restorative Aides being pulled to the floor, although in the past three (3) to four (4) months it had been less of a problem. She stated when Restorative Aides couldn't provide restorative services, nursing was alerted, and also the Restorative Aides reported this to the Restorative Nursing Coordinator. Per interview, SRNAs tried to assist the Restorative Aides on the floor when help was requested. Interview with LPN #2 on 11/01/18 2:29 PM, revealed Resident #13, Resident #15, and Resident #28 had not informed her they were not getting their restorative nursing as scheduled. She stated sometimes Restorative Aides were pulled to work the floor when there was staff calls in, and the Restorative Aides had mentioned to her in the past, they could not get the restorative care completed. However, she stated SRNAs would pitch in when they could to provide restorative therapy. Interview on 10/31/18 at 2:43 PM, with the Nursing Scheduler, revealed any SRNA could perform restorative nursing, and the facility was looking to hire more people. Continued interview revealed staff often stayed over, or came in early to assist other shifts when staff called in to work. Per interview, ninety percent (90%) of the time on day shift, one (1) of the two (2) Restorative Aides were present. Further interview on 11/01/18 at 2:43 PM, with the Restorative Nursing Coordinator, revealed when residents were discharged from therapy services, therapy would give nursing recommendations for the restorative nursing program. Per interview, it was her expectation that restorative care was delivered in order to ensure residents maintained their level of function or improved. However, per interview, when there was a call in resident needs would have to be prioritized and the Restorative Aides would be pulled to the floor to assist residents with meals, toileting, keeping people safe, and sometimes providing assistance to take residents to activities. Per interview, as a result restorative exercises were not always provided. Interview with the Director of Nursing (DON), on 11/01/18 10:25 AM, revealed it was her expectation for residents to be offered restorative therapy as scheduled. She stated the residents enjoyed the one-on-one (1:1) attention, and there was the potential for negative consequences such as a decline in ADL ability or further decrease in ROM if residents did not receive their restorative therapy as scheduled. Further interview revealed it should be clearly documented if restorative was offered and the resident refused due to not feeling up to it that day. Interview on 11/01/18 3:12 PM, with the Administrator, revealed there were twenty (20) residents on their restorative program, and she recognized some residents had developed rapport with Restorative Aides and didn't want other aides to perform restorative nursing as a result. She stated the facility would be educating residents as well as staff that other aides could provide restorative services. She further stated there were some instances in which staff were unable to provide restorative services; however, it was her expectation this would not happen often. Continued interview revealed she recognized the potential for negative outcomes if services were not received as recommended by therapy.

Based on observation, and interview, it was determined the facility failed to ensure the residents' environment remains as free from accident hazards as is possible. Observation of the second floor laundry room, on 10/25/17 and 10/26/17, revealed the laundry room door was unlocked and unattended by staff. Additionally, observation of the second floor, on 10/26/17, revealed housekeeping carts were left in the hall with cleaning chemicals on top of the carts unsecured and unattended by housekeeping staff. The findings include: Review of the facility's Hazardous Areas in the Facility Policy, revised May 2008, revealed all hazardous areas in the facility should be identified with appropriate precautionary signs. Continued review revealed hazardous areas such as power rooms, boiler rooms, oxygen and other flammable liquids storage rooms, etc., were to have no smoking signs. However, the Policy did not address ensuring doors to hazardous areas should be locked prior to staff exiting the areas. Interview with the Administrator, on 10/27/17 at 3:45 PM, revealed the facility's Hazardous Areas Policy did not address making sure doors to all potentially hazardous areas were locked and secured prior to staff leaving the area. Per interview, the laundry rooms and housekeeping carts on all floors were considered potentially hazardous areas because the laundry detergent and cleaning supplies that were stored in the laundry rooms and the cleaning supplies stored inside and on top of the housekeeping carts could be harmful to residents. Review of the List of Wandering Residents submitted by the facility during Survey, revealed there were eight (8) residents who were cognitively impaired and able to wander about the facility. 1. Observation on 10/25/17 at 12:30 PM, of the second floor laundry room, revealed the door was unlocked with an open container of Fresh and Clean Laundry Detergent sitting on top of the counter. There was also a container holding a liquid substance and a toilet brush on the floor in the laundry room. Continued observation revealed staff continued to enter and exit the room for ten (10) minutes without locking the door as they exited, leaving the room unattended and accessible to wandering residents. Review of the Fresh and Clean Laundry Detergent Safety Data Sheet (SDS), revealed it may be moderately irritating to eyes, skin, nose, throat, and respiratory tract. Continued review revealed it may be irritating to the mouth, throat, stomach, and may cause abdominal discomfort, nausea, vomiting, and diarrhea. Further review, revealed call poison control and get medical attention if ingested. Interview on 10/25/17 at 12:40 PM, with State Registered Nurse Aide (SRNA) #1, revealed the laundry detergent and other cleaners stored in the laundry room could be harmful to the residents. Interview on 10/25/17 at 2:25 PM, with Licensed Practical Nurse (LPN) #1, revealed all staff were responsible for making sure the laundry room door was locked when exiting the room. Continued interview revealed staff was to make sure the door was locked so residents did not have access to the cleaning solutions located in the room. Interview on 10/25/17 at 2:30 PM, with LPN #2, revealed the laundry room door should be locked when exiting the room. Continued interview revealed the cleaning supplies stored in the room could be harmful to the residents. Further interview revealed everyone who used the laundry room were responsible for making sure the door was locked when they exited the room. Additional observation on 10/25/17 at 2:35 PM, revealed the laundry room door on the second floor was unlocked, and accessible with no staff present. Re-Juv-Nal Disinfectant Cleaner in liquid form was found in a labeled opened container with a round pink toilet wand near the washing machine at wheel chair level. Review of the Re-Juv-Nal Disinfectant Cleaner SDS, revealed may cause skin corrosion or skin irritation, and may cause serious eye damage or eye irritation. Continued review revealed immediately call poison control and get medical attention. Observation again on 10/26/17 at 8:45 AM, of the second floor laundry room, revealed the door was unlocked with an open container of Fresh and Clean Laundry Detergent on top of the counter, and a container holding a liquid substance and a toilet brush on the floor in the laundry room. Continued observation revealed staff entering and exiting the room for twenty-one (21) minutes without locking the door when exiting the room, leaving the room accessible with no staff present. Interview on 10/26/17 at 9:10 AM, with SRNA #2, revealed the laundry room door should be locked because the room contained cleaning supplies that could be harmful to the residents. Continued interview revealed staff was to use the keypad to enter a code and turn the lock to enter and exit the room. Per interview, staff was to check the door after exiting the room to make sure it was locked. 2. Observation on 10/26/17 at 8:55 AM, of the second floor East Hall, revealed a housekeeping cart stationed outside room 203 with Re-Juv-Nal cleaning solution and Top Clean cleaning solution on top of the cart while Housekeeper #1 was cleaning the room with her back to the cart. Review of the Top Clean General Cleaner SDS, revealed instructions warning to ensure chemical did not get in eyes, on skin, or on clothing. Use only with adequate ventilation. Do not breathe spray mist (inhalation of the fog mist could cause irritation of the mucous membranes). In case of contact, immediately flush eyes or skin with plenty of water for at least fifteen (15) minutes. If skin irritation persists, get medical attention. Further review, revealed If swallowed, do not induce vomiting unless directed to do so by medical personnel. Interview on 10/26/17 at 9:00 AM, with Housekeeper #1, revealed the cleaners should not be on top of the cart and could be harmful to residents. Continued interview revealed the cleaners should have been stored in the cart and the cart should have been locked while the cart was unattended. Interview on 10/27/17 at 10:00 AM, with the Director of Nursing (DON), revealed the laundry room doors should be locked every time a staff member exited the room to prevent residents from entering because there was detergents and cleaners which could be harmful to the residents. Continued interview revealed during this survey she had recognized the keypad lock to the laundry room door did not function properly, and staff should have realized this and turned in a Work Order to Maintenance to have this repaired. She stated all staff was responsible for making sure the door was completely latched shut as they exited the room. Further interview revealed housekeeping staff should not leave the cleaning supplies on top of the carts, and cleaning supplies should be locked inside the cart whenever the carts were unattended by housekeeping. Ongoing interview revealed the facility had residents on both the second and third floor who were cognitively impaired and could self-propel themselves in wheelchairs, walk with a walker, or ambulate independently between floors. Per interview, if one of those resident was to ingest any of the cleaning solutions, it could make them sick. Interview on 10/27/17 at 2:45 PM, with the Maintenance/Housekeeping Technician, revealed staff should fill out a Work Order or call the maintenance department anytime something needed to be fixed, and a Work Order should have been completed to have the laundry room keypad lock repaired. Per interview, the laundry room doors should be locked at all times when staff was not in there. Continued interview revealed the housekeeping carts should not have cleaners stored on top of them and the cleaners should be locked inside the cart when the cart was not in view of the housekeeper. He stated any of the items stored in the laundry rooms or on the housekeeping carts could be harmful to the residents. Interview on 10/27/17 at 3:00 PM, with the Maintenance/Housekeeping Director, revealed anytime something was not functioning properly, staff was to fill out a Work Order or call maintenance directly. He stated the maintenance staff was on the nursing units four (4) to five (5) times a day and looked at all Work Orders and could fix any issue as soon as they were aware. Continued interview revealed it was important for the laundry room doors to latch securely shut for the safety of the residents. Further interview revealed he expected the housekeeping staff to secure all cleaners inside the locked compartment of the housekeeping cart when the cart was not within eyesight, or if the cart was left unattended by the housekeeping staff. Interview on 10/27/17 at 3:45 PM, with the Administrator, revealed any person exiting the laundry room should make sure the door appropriately locked because the chemicals stored inside could be harmful to confused residents. Per interview, it was her expectation the laundry room doors on all units have keypad locks that functioned properly, and if they did not, staff was to make maintenance aware as soon as possible. Continued interview revealed the housekeeping carts had a locked compartment located on each cart and all chemicals were to be kept in the locked compartment if the cart was not within direct view of the housekeeper in order to maintain resident safety.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation of the dressing supply cabinet, located on the second floor, on [DATE] revealed fifteen (15) MeSalt Sodium Chloride Dressings with an expiration date of [DATE], and eleven (11) Vaseline Gauze Strips with an expiration date of [DATE]. The findings include: Review of the facility's Storage of Medications Policy, revised [DATE], revealed the facility would store all drugs and biological's in a safe, secure, and orderly manner. Continued review revealed the facility would not use discontinued, outdated, or deteriorated drugs or biologicals. Observation on [DATE] at 2:20 PM, of the dressing supply cabinet located on the second floor, revealed fifteen (15) MeSalt Sodium Chloride Dressings with an expiration date of [DATE], and eleven (11) Vaseline Gauze Strips with an expiration date of [DATE]. Interview on [DATE] at 2:25 PM, with Licensed Practical Nurse (LPN) #1, revealed the Central Supply Clerk was responsible for stocking the supply cabinets on the nursing units once a week, and should be checking the supplies to make sure they were not expired. Continued interview revealed nurses should check to make sure supplies were not expired before they use them because the dressing might not be as effective and the resident might not get the desired effect if the dressing was expired. Interview on [DATE] at 2:30 PM, with LPN #2, revealed supplies should be routinely checked by the Central Supply Clerk to make sure expired dressings and other expired items were removed and inaccessible for use. Per interview, the nurses should check dressing supplies prior to use for expiration date. Interview on [DATE] at 3:15 PM, with the Central Supply Clerk, revealed usually the nurses would let her know when supplies were expired. Continued interview revealed she only checked the expiration dates for the supplies in the supply closet on the ground floor before new items were sent up to the units. Further interview revealed it was important to make sure items were not expired because if they were, they might lose their effectiveness. Interview on [DATE] at 10:00 AM, with the Director of Nursing (DON), revealed both the Central Supply Clerk and the nurses were responsible for making sure dressing supplies were not expired. Per interview, supplies should be routinely inspected and expired supplies should be removed from stock because residents might not receive the full benefits of an expired item. Continued interview revealed it was the DON's expectation that all dressing supplies be checked by the nurse prior to use to ensure they were not expired. She further stated she expected staff to follow the facility's Storage of Medications Policy. Interview on [DATE] at 3:45 PM, with the Administrator, revealed she expected both the nurses and the Central Supply Clerk to check dressing supplies at least weekly and prior to use, to make sure they were not expired. Per interview, expired items lose their effectiveness over time and the quality of the material could be compromised if it were expired.

Based on observation, interview, review of the kitchen cleaning schedules and review of the facility's policy, it was determined the facility failed to prepare, store and serve food under sanitary conditions. Initial tour of the kitchen revealed the cook stove and drip pan was dirty, scoops and spoons were stored improperly, and four (4) dented cans were stored on the rack accessible for use. The findings include: 1. Review of the facility's General Sanitation of Kitchen Policy, dated 2010, revealed staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. Per Policy, cleaning and sanitation tasks would be recorded, a cleaning schedule would be posted and employees would initial and date tasks when completed. Observation of the kitchen on initial tour, on 01/05/16 at 11:50 AM, revealed the stove burners had a build up of grease and burnt food items on the burners and in the burner drip pans. Further observation, revealed the stoves pull out drip pan was dirty with what appeared to be burned on grease and food items. 2. Review of the facility's Handling Clean Equipment and Utensils Policy, dated 2010, revealed clean utensils would be handled to prevent contamination. Per Policy, when handling clean and sanitized utensils staff would avoid touching the parts that would come in contact with the food, and clean utensils would be stored in a clean dry location in a way that protected them from contamination. Further review, revealed stored utensils should be inverted and handled by the hand piece, and should be stored accordingly. Observation of the kitchen on initial tour, on 01/05/16 at 11:55 AM, revealed eight (8) scoops stored in a drawer with handles turned in all directions. In a second drawer eleven (11) dippers and serving spoons were also stored improperly with handles in different directions. 3. Review of the Food Safety and Sanitation Policy, dated 2010, revealed bulging cans, or cans with dents on the seams were not to be used. Observation during the initial tour of the kitchen, on 01/05/16 at 12:00 PM, revealed four (4) dented cans on the shelf for use which were identified as two (2) cans of cranberry sauce and two (2) cans of Mexican chili beans. Interview with the Dietary Manager (DM), on 01/06/16 at 11:00 AM, revealed the daily and weekly cleaning task was kept in a binder in her office. Per interview there was no cleaning schedule posted as per the facility's policy. Review of the daily cleaning schedules for December 2015 and January 2016 with the DM, revealed staff had not initialed the tasks completed except for six (6) of the task on two (2) days, and five (5) of the tasks on one (1) day. The DM revealed the staff would get busy and forget to initial the book. She further stated, she checked the kitchen areas to ensure the cleaning had been done. However, she stated the stove was dirty and it had been a while since she had checked the cleanliness of the stove. Further interview, revealed the stock person was to check all cans for dents when the stock was put away, I guess she missed these. The DM stated the dented cans should not be on the rack accessible for use, but should have been on a separate table where they kept the dented cans. She further stated, she agreed the scoops, dippers, and spoons were stored wrong, and the handles should all lay the same way and should be inverted. Interview, with the Administrator on 01/07/16 at 5:35 PM, revealed she expected the dietary staff to follow the facilities policies, keep the kitchen very clean, keep dented cans on the correct shelves, and store utensils properly.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection for three (3) of twelve (12) sampled residents (Residents #2, #4 and #7). Observation of a skin assessment for Resident #7 and revealed staff failed to use proper hand hygiene and glove usage during skin assessments. Observation of perineal care for Resident #2, and #4, revealed improper infection control technique. The findings include: Review of the facility's Infection Control Policy and Procedure, revised 08/2009, revealed, under prevention of infections, an important facet of prevention of infections was to educate staff and ensuring that they adhered to proper techniques and procedures. Review of the facility's policy titled Handwashing/Hand Hygiene revised 04/2010, revealed staff must wash their hands before and after direct resident contact, before and after assisting residents with personal care, before and after changing a dressing, and after removing gloves. Review of the facility's policy titled Perineal Care, revised 10/2010, revealed after performing perineal care staff should remove gloves and discard into container and wash and dry hands thoroughly. Then reposition the bed covers and make the resident comfortable. 1. Observation of a skin assessment on 01/06/16 at 9:10 AM for Resident #7, revealed Licensed Practical Nurse (LPN) #1 began assessing the resident's skin starting with Resident #7's ears and proceeding in a downward manner toward his/her toes without the application of gloves. When Resident #7 was positioned on his/her left side, with the assistance of the State Registered Nursing Assistant (SRNA), LPN #1 assessed the resident's back and buttocks. As the nurse proceeded to assess the resident's coccyx area, the duoderm dressing was noted to be loose from the wound area and LPN #1 applied gloves to remove the duoderm completely from the wound. LPN #1 then removed the gloves and washed her hands, but did not re-apply gloves before proceeding with the skin assessment. LPN #1 proceeded to assess Resident #7's perineal area, placing hands on the groin area to assess for redness, but did this procedure without gloves. Additionally, LPN #1 completed the skin assessment, and replaced the dressing to the coccyx, without wearing gloves. Upon completion of applying the duoderm to Resident #7's coccyx area, LPN #1 proceeded to wash her hands as she ended care of this resident. Interview with LPN #1, on 01/06/16 at 9:22 AM, revealed she usually practiced proper handwashing and glove usage when providing care to her residents and proper handwashing technique and glove use was discussed during her orientation as a new hire, four (4) weeks ago. LPN #1 stated, she should have washed her hands and applied gloves prior to assessing Resident #7's skin, before and after the application of gloves, and before and after the dressing change. LPN #1 revealed, handwashing was important for the prevention of infection. Additionally, LPN #1 revealed, she became nervous during the skin assessment with surveyors observing her care of Resident #7. 2. Record review for Resident #2 revealed the facility admitted the resident on 07/12/14 with [DIAGNOSES REDACTED]. During an observation of perineal care for Resident #2, on 01/06/16 at 4:10 PM, SRNA #1 was observed to remove the resident's brief soiled with urine with her gloved hands and with her soiled gloves, cleanse the resident's perineal area with cleansing wipes. SRNA #1 then re-applied the resident's clean brief with the same soiled gloves, and without washing her hands or changing gloves, proceeded to reposition the resident in bed touching the sheets with the soiled gloves. The SRNA then washed her hands and went to the closet to get a topical cream for the nurse. The SRNA then reapplied clean gloves. Continued observation, revealed Licensed Practical Nurse (LPN) #8 washed her hands, donned gloves, and then proceeded to apply the topical cream to the resident's perineal area. The LPN removed her gloves but did not wash her hands and proceeded to pick up the resident's clothes from the back of the wheel chair and put resident's slacks on. The LPN reapplied gloves, but did not wash or sanitize her hands before putting on clean gloves. LPN #8 then put the bra and blouse on the resident and assisted the resident to the chair with the help of the SRNA. Interview with SRNA #1, on 01/06/16 at 4:40 PM, revealed she realized she had messed up because she was nervous. The SRNA stated she was trained related to washing her hands and glove usage and knew to wash her hands after removing the gloves. She revealed it was important to wash hands to make certain the hands were clean under the gloves. Interview with LPN #8, on 01/06/16 at 4:45 PM, revealed she was uncertain what the facility's policy was on washing hands or sanitizing hands between glove changes. She stated she did not wash her hands after changing gloves because it was on the same resident. LPN #8 commented she guessed she should have washed her hands or sanitized her hands between glove changes. 3. Observation, on 01/06/16 at 11:00 AM, revealed SRNA #3 washed her hands and donned gloves, then performed perineal care and Foley Catheter care for Resident #4. SRNA #3 then proceeded to assist Resident #4 with clothing and transferred the resident from a lying position to a sitting position with the same soiled gloves. She then changed her gloves and donned clean gloves; however, failed to wash her hands prior to emptying the resident's urinary drainage bag. Interview with SRNA #3, on 01/06/16 at 11:45 AM revealed she should have washed her hands as well as changed her gloves after providing perineal care and Foley Catheter care for the resident and before assisting the resident with clothing and transferring. Further interview revealed she should have washed her hands before changing gloves to empty the urinary drainage bag. Interview, on 01/06/16 at 2:00 PM, with the Director of Nursing (DON) revealed staff should wash their hands before and after a procedure such as Foley Catheter care and perineal care. She further stated after contact with a dirty area of the body, staff should wash their hands and use new gloves. Interview with the Infection Control Nurse, on 01/07/16 at 12:00 PM, revealed staff should change gloves, perform hand hygiene when moving from dirty to clean. She further stated the facility realized they needed to work on that, and would be doing training. Interview with the Administrator, on 01/07/16 at 5:35 PM, revealed the expectation was for all residents' care to be done within the Infection Control guidelines and the facility's policies and procedures. Further, she stated hands should be washed and gloves changed anytime they are soiled or going from dirty to clean.