Every finding on record at Signature Healthcare at Jefferson Place Rehab & We

Based on observation, interview, and review of the facility policy, it was determined the facility failed to serve food under sanitary conditions. Dietary Aide (DA)2 failed to perform hand hygiene after touching various items, and prior to serving food. In addition, DA2 failed to wear a finger cot over a wound to prevent possible contamination while handling food. The findings include: Review of the facility policy Food Preparation dated 09/2017, revealed all staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Observation on 06/17/2025 at 11:15 AM, revealed DA2 was obtaining temperatures (temping) of several items on the food line. DA2 who had a band-aid on one finger, was not wearing gloves. He then stepped away from the food line and walked over to a bucket and, using his bare hands, pulled out a wet cloth from the bucket. DA2 then walked back to the food line, and wiped down the shelf above the food he was temping. He then went back to the bucket, dropped the soiled cloth in the bucket, and returned to the food temping area. DA2 failed to perform hand hygiene after cleaning the area and touching the soiled rag with his bare hands. He then reached for the lid of one of the food items on the food line. After intervention by the survey team, the Dietary Manager instructed DA2 to wash his hands prior to handling the food. In interview on 06/17/2025 at 12:45 PM, the Dietary Manager stated staff need to follow guidelines and policy. She stated when staff steps away from the food and does other tasks, they should always wash their hands prior to returning to the food line. She further stated DA2 should have worn a finger cot on his finger when there was an injury, such as a cut, on the finger to ensure safe handling of the food. Interview with the District Manager of Food Services at 06/18/2025 at 10:52 AM revealed a finger cot should be used when there is an injury, such as a cut. She stated DA2 should have worn gloves when wiping down the shelf and should have washed his hands before he returned to the food line. She stated hand washing is important because cross contamination can occur. In interview on 06/18/2025 at 1:47 PM, DA2 confirmed he did not wash his hands when going back to the table, stating that he had a lot on his mind and was distracted. He further stated he should have worn gloves to wipe down the shelf. Interview with DA1 at 06/18/2025 at 10:54 AM revealed hand washing needed to be done whenever you leave the food service area. She stated this was important because of the potential for cross contamination. In interview on 06/18/2025 at 2:51 PM, the Administrator stated education for all staff was done yearly and as needed, regarding infection control. She stated she has high expectations for the dietary staff, and it is important to wash hands properly when preparing food to prevent illness and ensure the safety of each resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed opened and undated containers of salad dressing in the walk-in refrigerator. The findings include: Review of the facility's policy, Labeling and Dating Policy, dated 2017, revealed proper labeling and dating ensured all foods were stored, rotated, and utilized in a first in, first out manner. This helped minimize waste and ensured items past their due date were discarded. Tour of the kitchen with the Dietary Manager, on [DATE] at 10:00 AM, revealed two (2) salad dressing containers that were opened, but were not dated in the walk-in refrigerator. Interview with the Dietary Manager (DM), on [DATE] at 10:00 AM, revealed food and drinks needed to be labeled so that staff would know when they were first opened. She stated food and drinks should be labeled and dated with the date opened and when it expired. She stated if food or drinks were opened and not dated that it could make residents sick if those food items were used. Interview with the Director of Nursing (DON), on [DATE] at 3:24 PM, revealed she would have to refer to the facility's policy about labeling and dating of food items. She stated if residents received food that was undated it could be expired and could cause nausea, vomiting, upset stomach, or nothing could happen. Interview with the Senior Administrator, on [DATE] at 4:36 PM, revealed her expectation for storage of food was that it should be labeled and dated with the opened date and the date it expired. She stated this practice occurred to prevent staff from serving expired food.

Based on observation, interview, record and policy review, it was determined the facility failed to maintain an infection prevention and control program that ensured a safe, sanitary, and comfortable environment for the prevention of communicable diseases and infections. Observations during the survey revealed direct care staff, housekeeping staff, compassionate care staff, and one (1) resident did not consistently utilize masks and/or eye protection, as currently required when working in, or traveling through resident care areas. The findings include: Review of the facility's policy titled Infection Control, revised October 2018, revealed the facility's infection control policies and practices applied equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public. Review of the facility's policy titled, Novel Corona Virus (COVID-19), last revised 09/13/2021, revealed under subheading General Prevention Measures, during the pandemic, the facility required all direct care stakeholders to wear a surgical facemask while in the facility, in coordination with the Centers for Disease Control (CDC), State and Federal guidelines. Under the same subheading, eye protection (face shield or goggles) would be worn by stakeholders (in addition to masks) during an outbreak, until the facility went fourteen (14) days without a new resident or stakeholder positive case; and when county/community spread was Moderate to High (meaning positivity rates were greater than or equal to 5%.) Review of the facility's policy titled Novel Coronavirus (COVID-19), last revised 05/17/2021, under subheading Facility Education and Visitation, revealed the facility's residents and families/visitors were expected to adhere to a list of seven (7) core principles labeled by alpha letters (a through g.) Principle (c) revealed a face covering or mask should cover the mouth and the nose, and social distancing of at least six (6) feet between persons should be maintained, in accordance with CDC guidance. Principle (d) revealed the facility should have instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices. Review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, revealed hands should be sanitized with an alcohol-based hand rub containing at least 62% alcohol; or, alternatively washed with soap and water before and after entering isolation precaution settings. Review of Droplet Isolation Signage, at a resident's doorway, revealed everyone must clean hands when entering and leaving the room, wear a mask, and doctors and staff must wear a gown, gloves, and an eye cover if contact with secretions was likely. Review of Contact Isolation Signage at a resident's doorway, revealed to clean hands when entering and leaving the room. Doctors and Staff must put on a gown and gloves at the door. Both, aforementioned signs also indicated families and visitors must follow instructions from the information sheets. Record review revealed the Administrator provided documentation the facility had one (1) dietary staff person that tested positive for COVID-19 on 09/09/2021. Interview, on 09/15/2021 at 10:57 AM, with the Director of Nursing (DON)/Infection Preventionist (IP), revealed a dietary staff person tested positive for COVID-19 on 09/09/2021, and the staff person last worked on 09/08/2021. The DON/IP provided a copy of the staff member's Polymerase Chain Reaction (PCR) positive lab test dated 09/09/2021, which confirmed the individual was positive for COVID-19 on 09/09/2021. The IP said the county/community spread designation was currently classified as High. Observation, on 09/12/2021 at 12:13 PM, revealed Certified Nursing Assistant (CNA) #14 entered the room of Resident #82 to give the resident their breakfast tray. The resident was in droplet precautions and the CNA entered the room with only a mask and goggles - no gown or gloves. Additionally, continued observation revealed the CNA performed no hand hygiene. Observation on the Green Unit, 300 Hallway, on 09/14/2021 at 3:50 PM, revealed Resident #312, who resided in room [ROOM NUMBER], was sitting in his/her bed talking with a visitor. Signage at the resident's door indicated the resident was under droplet isolation precautions. Resident #312's visitor identified herself as the Hospice Social Worker. The Hospice Social worker was wearing a mask, but she was not wearing eye protection (no goggles or faceshield). Review of Resident #312's clinical record revealed the facility originally admitted the resident on 05/12/2021 for a brief respite care stay. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated hospice staff visited Resident #312 during his/her brief stays at the facility. Interview, on 09/20/2021 at 8:50 AM with the Hospice Social Worker, revealed the facility's staff had not instructed her to wear eye protection while in resident care areas. She said she was aware the facility had a recent COVID-19 positive case because the admissions' staff person told her. She said she did not observe any signage at the front entry directing her to wear eye protection. The Social Worker said she had goggles with her on 09/14/2021 when she visited Resident #312, but she had taken them off because it was hot in the resident's room. Observation, on 09/17/2021 at 8:15 AM, revealed Certified Nursing Assistant (CNA) #15 entered resident room [ROOM NUMBER] after putting on gloves, but no gown. Signage at the doorway to the resident's room revealed the resident was in droplet precautions and staff must wear mask, gown, gloves and eye protection. Interview with CNA #15, at the time of the observation, revealed she just did not think to put on a gown. Additionally, CNA #15 stated by not wearing the appropriate protection she could become sick or she could relay an infection to a resident, causing their illness or death. Observation, on 09/18/2021 at 1:45 PM, revealed a Hospice Registered Nurse (RN), completed the electronic COVID-19 screening process at the lobby before proceeding to the Green Unit to visit a resident. The Hospice RN was wearing a mask, but she did not put on eye protection before walking down the hallway toward the Green Unit nurses' station. Interview, on 09/18/2021 at 1:45 PM with the Hospice RN, revealed no one instructed her that she had to wear eye protection while in the facility. She stated she visited many long-term care facilities in the city, and each one seemed to have different PPE use rules. She said she had not noticed any signs directing her to put on eye protection. The RN said she had goggles in her backpack; she put her goggles on. Observation, on 09/18/2021 at 1:53 PM of the front lobby and staff/visitor screening area, revealed there were no instructions directing staff and visitors to use eye protection when in the facility. Observation, on 09/17/2021 at 6:36 AM on the Maroon Unit, revealed Certified Nursing Assistant (CNA) #8 walked from the 700 hallway toward the nurse's station. The CNA was wearing a facemask, but she was not wearing eye protection. The CNA then walked into the nurse's station. Interview, on 09/18/2021 at 10:59 AM with Registered Nurse (RN) #1, revealed all facility staff and visitors were required to wear a mask and eye protection regardless of where they were in the facility. She said the protective measures prevented possible spread of COVID-19. RN #1 said if a resident was under isolation precautions, then staff and visitors were required to wear a disposable gown, gloves, a mask, and eye protection in the resident's room. Once again, the nurse stated wearing the PPE in the resident isolation rooms, as directed by the sign at the resident's door, assisted with preventing the spread of the infection(s). She said the guidance applied to compassionate care personnel (hospice staff), too. Observation, on 09/18/2021 at 1:00 PM on the Maroon Unit, revealed the Medical Records Staff/Registered Nurse (RN) was sitting at the nurses' station. The Medical Records Staff/RN was wearing a surgical mask, but her nose was fully exposed. In addition, she not wearing a face shield or goggles. While talking with the Medical Records Staff/RN, she pushed her mask back up on her face several times because it kept slipping down below her nose. Interview with the Medical Records/RN, revealed she did not think she had to wear eye protection when sitting at the nurses' station, but added she thought they (meaning facility leaders) wanted staff to wear the goggles or a faceshield everywhere. The Medical Records RN also stated, I guess I should go get a mask that fits me better. Observation, on 09/18/2021 at 1:55 PM on the Maroon Unit, revealed CNA #8 wheeled Resident #79 to a space in the common area of the unit near the Turf Room (dining area). Resident #79 was not wearing a mask. The CNA walked over to some cabinets in the dining room, and returned in about two (2) minutes. She then went back to be with the resident, but did not bring a mask to place on the resident's face. Interview, on 09/18/2021 at 1:59 PM with CNA #8, revealed Resident #79 was supposed to wear a surgical mask when not in his/her room, and said, Oh my God, I forgot to get a mask for the resident. I will get one for (him/her) immediately. The CNA also stated that when not in their rooms residents were supposed to wear a surgical mask to prevent the spread of germs. Record review revealed the facility admitted Resident #79 on 10/27/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #79's Quarterly Minimum Data Set (MDS) assessment, dated 07/09/2021, revealed the resident was non-verbal and not interviewable. Interview, on 09/18/2021 at 11:38 AM with Licensed Practical Nurse (LPN) #6, who worked on the Maroon Unit, revealed staff and visitors who were allowed in the facility, such as hospice staff, were to wear a mask and goggles or a face shield to prevent the possible spread of COVID-19. LPN #6 stated staff and visitors entering a droplet isolation area were to put on a disposable gown and gloves in addition to the mask and goggles they should already be wearing. LPN #6 stated before exiting an isolation area or room, individuals were to remove the PPE, dispose of it in the resident's room, and wash/sanitize their hands. Further interview revealed even if just delivering a meal tray, staff should put on a gown and gloves at the doorway, and discard the PPE and wash or sanitize their hands before exiting the room. She stated staff should sanitize their hands after delivering each meal tray. LPN #6 stated this was necessary to prevent the spread of contagious infections. She stated staff received infection control training by completing modules in the facility's computerized training program. Interview, on 09/18/2021 at 2:27 PM with the Director of Nursing/Infection Preventionist (DON/IP), revealed she monitored staff and visitors for compliance with PPE use during frequent walking rounds through all nursing units and other areas of the facility. The DON/IP said she, the Administrator, and the Staff Development Coordinator (SDC) ensured they reviewed the most current guidance on the prevention of COVID-19. The DON/IP revealed eye protection and surgical masks were required PPE for all staff and visitors while they were in resident care areas. The DON/IP said the only areas not considered resident care areas were closed-in storage rooms and the staff break room. The DON/IP said the nurses' stations and facility hallways were designated as resident care areas, and staff working in or moving through those areas must wear their masks and eye protection. The DON/IP said in order to wear the surgical mask properly, it must fully cover the resident's or staff member's mouth and nose. Additionally, the DON/IP stated eye protection could include goggles, a face shield, or eye wings added to personal eyewear. The DON/IP said housekeepers must also wear masks and eye protection whenever they were working in resident care areas. She said this was the facility's current practice as recommended by the Centers for Disease Control (CDC). She stated COVID-19 was an airborne infection. Continued interview with the DON/IP, on 09/18/2021 at 2:27 PM, revealed use of a disposable gown and gloves was not always necessary for staff when in a droplet isolation room, unless the staff person had to provide direct care, for example, taking the resident to the restroom. The DON/IP said she clarified that with the Corporate Infection Control Nurse. Regarding delivery of meal trays to resident rooms, the DON/IP, said the facility's policy directed staff to sanitize their hands before leaving each resident's room. She stated, however, after delivering the third meal tray, the staff must then wash their hands with soap and water. The DON/IP stated she was confident she had previously educated the hospice nurse on the use of a mask and eye protection while at the facility, but was she not sure she had provided the education to the Hospice Social Worker. Interview with the Administrator, on 09/18/2021 at 4:36 PM, revealed she was unaware of any issues regarding staff use of personal protective equipment in the facility. The Administrator stated the use of personal protective equipment prevented the spread of infection to those in the facility.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure reasonable accommodations for one (1) of seventy-four (74) sampled residents (Resident) #79, on two (2) occasions. Observations of Resident #79 during survey revealed the call light button out of reach of the resident. The findings include: The facility did not provide a policy for accommodation of residents' needs. Review of Resident #79's medical records revealed the facility admitted the resident on 10/27/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #79's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident as absent of the spoken word and somewhat had the ability to understand others. A Brief Interview for Mental Status (BIMS) examination was not completed at this time; no BIMS was present in Resident #79's medical record. Continued review of the MDS revealed the facility determined the resident had poor decision-making skills, required cues and supervision from staff. Continued review of Resident #79's MDS dated [DATE], revealed the facility determined the resident was an extensive assist for bed mobility, to transfer, to dress, to toilet and for personal hygiene. This MDS also revealed the facility identified the resident as set up only to eat. Review of Resident #79's Comprehensive Care Plan, last revised on 09/15/2021, revealed the facility determined the resident at risk for falls and the call bell should be placed within easy reach of resident. This approach was initiated 11/06/2020 and was last edited on 02/13/2021. The care plan further revealed the resident was at high risk for impaired vision related to inability to participate in vision test, edited on 09/15/2021. The intervention listed to keep call light in reach at all times as an approach for this resident, initiated on 11/06/2020. Observation, on 09/12/2021 at 11:16 AM, revealed Resident #79 pointed to the closet and motioned for a drink. When the resident was asked to push the call light, he/she looked around to find the call light button and could not locate it. Continued observations revealed the call light button was attached to the top of resident's pillow, closest to the mattress side. Resident #79 attempted to reach the call light, but was unable as the call light button was out of reach. Observation, on 09/16/2021 at 1:12 PM, revealed Resident #79 in the bed, with the head of the bed in the up position as the resident ate lunch. Continued observation revealed the call light was attached to the bottom part of the mattress, out of the resident's reach. When asked where the call light button was located the resident made a motion with his/her hands as to imply I do not know. On 09/18/2021 at 4:25 PM, interview with Certified Nurse Aide (CNA) #8 revealed she worked at the facility for one (1) year and one (1) month and she provided care for Resident #79. She revealed Resident #79 used a regular call light. She stated it was important for this resident to be able to reach the call light as the resident had a [CONDITION(S)] bag and the resident requested staff when he/she needed assistance. CNA #8 further stated the resident only used gestures to communicate and it was important to observe the resident since that was his/her communication style. She further stated the purpose of the call light was to notify staff when the resident needed something. Interview, on 09/18/2021 at 4:45 PM, with Licensed Practical Nurse (LPN) # 6 revealed it was important for the resident to have the call light button within reach, in case the resident needed anything. LPN #6 stated Resident #79 could only communicate through hand gestures and was nonverbal. She further revealed if the call button was out of reach from the resident, staff might not respond quickly to meet the resident's needs. On 09/18/2021 at 4:45 PM, interview with the Director of Nursing (DON) revealed the call button should have been within reach of the resident. She reported it was important to have the call button within reach, so residents had immediate access to it. On 09/18/2021 at 4:30 PM, interview with the Administrator revealed the expectation for the call light buttons was they would be located on the bed or if the resident was in a wheelchair it would be close to the wheelchair. The Administrator stated the purpose of the call light button was to inform staff if the resident needed something.

Based on observation, interview, and record review it was determined the facility failed to maintain and implement an effective infection prevention and control program to provide a safe, sanitary environment and help prevent the transmission of communicable diseases and infections, including the COVID-19 virus. Observations during survey revealed staff not wearing masks in the reception area of the facility. The findings include: Review of facility policy Novel Coronavirus (COVID-19), revised 08/18/2020, revealed the policy provided clarification of the steps the facility took to insure the health and safety of the facility's residents. In addition, review of the policy revealed for the duration of the state of emergency/COVID-19 pandemic, all direct care stakeholders wore a surgical facemask and face shield or goggles in the facility. Non-direct care workers utilized a microbe safety mask when working in non-resident care areas. Observation, on 09/08/2020 at 8:10 AM, upon entering the facility, revealed staff at a screening table and a receptionist behind a half wall and neither person was wearing a mask. Interview with the Receptionist, on 09/08/2020 at 9:30 AM, revealed it was her understanding she did not have to wear a mask when at her desk, not in a resident care area. Continued observation and interview with the Receptionist revealed without a mask she walked out from behind the half wall and directed the State Survey Agency staff down the hallway. The Receptionist stated it was important to wear masks to prevent transmission of disease between people. Interview with the Director of Nursing (DON), on 09/08/2020 at 2:00 PM, revealed everyone in the facility was to wear a mask even in the front area of the building. Additionally, the DON stated the receptionist should wear a mask as that position is in contact with multiple persons. The DON stated it was important to wear masks to prevent the spread of COVID-19. Interview with the Administrator, on 09/08/2020 at 2:00 PM, revealed his understanding of the mask policy was that staff did not have to wear a mask when not providing direct resident care.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of seven (7) sampled residents (Resident #4). The facility admitted Resident #4 on 03/21/19 and Occupational Therapy assessed the resident on 03/22/19 to require maximum assist (at least assist of two (2) staff) for transfers and total assist for toileting. In addition, on 03/24/19, Physical Therapy assessed the resident as requiring maximum assistance for transfers. However, according to Certified Nursing Aide (CNA) #2's documented interview obtained on 03/27/19, and the facility Investigation, undated, on 03/27/19, CNA #2 independently assisted the resident on to the commode and helped wash up the resident, then the resident got up using the grab bars and was standing up for three to four (3-4) minutes. When CNA #2 bent over to pull up Resident #4's undergarments, the resident sustained [REDACTED].#4 was transferred to the Hospital emergency roiagnom on [DATE], and admitted with a [DIAGNOSES REDACTED]. (Refer to F-656) The findings include: Review of the facility's Falls Policy, revised 07/16/19, revealed the intent of the facility is to provide residents with assistance and supervision in an effort to minimize falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change in condition. A Comprehensive Care Plan will be implemented based on the fall risk evaluation score with an individual goal and interventions specific to each resident. Review of Resident #4's closed clinical record revealed the facility admitted the resident on 03/21/19 with [DIAGNOSES REDACTED]. Review of Resident #4's Fall Risk Assessment, dated 03/03/19, revealed the resident scored a sixteen (16) indicating the resident was at risk for falls. According to the assessment, Resident #4's risk factors included: requires assistance with elimination; confined to chair; uses bed rails; not able to attempt balance without physical help; health condition; and medications. Further review of the assessment, revealed a resident who scores a ten (10) or higher is at risk for falls and fall interventions should be put into place. Review of Resident #4's Physician order [REDACTED]. There was no Minimum Data Set (MDS) Assessment to review after the resident's admission on 03/21/19. Review of Resident #4's Comprehensive Care Plan, initiated 03/21/19, revealed the resident was at risk for falls related to weakness, and history of dizziness. The Goal stated the resident would not sustain injury related to falls over the next thirty (30) days. The interventions included complete [NAME]'s Hopkins Fall Risk screening tool on admission; cue for safety awareness; keep environment safe; place call bell within reach; and assist times two (2) for toileting and transfers as needed. Review of Resident #4's Occupational Therapy (OT) Notes, dated 03/22/19, revealed the resident was assessed as requiring maximum assistance for transfers. Further review revealed Resident #4 required total dependence upon staff to toilet. Review of Resident #4's Physical Therapy (PT) Notes, dated 03/24/19, revealed the resident was assessed as requiring maximum assistance for transfers. Review of the facility's Long Term Care Facility-Self Reported Incident Form/Initial Report, dated 03/27/19, signed by the former Administrator in Training, revealed CNA #2 assisted Resident #4 to the restroom. While Resident #4 was standing in the restroom, Resident #4's right knee buckled. CNA #2 assisted the resident to the floor, in a controlled manner using a gait belt. X-ray findings revealed a Right Ankle Fracture. Review of the facility documented interview with CNA #2, dated 03/27/19, revealed on 03/27/19, CNA #2 had her gait belt on and took the resident to the bathroom in the wheelchair. She assisted the resident on to the commode and helped wash up the resident. The resident got up using the grab bars and was standing up for three to four (3-4) minutes. CNA #2 bent over to pull up the resident's undergarments, and it appeared the resident's right knee buckled and she helped to lower the resident to the ground. CNA #2 notified the nurse. According to the documented interview, Resident #4 required one (1) person assist on the previous admission, and CNA #2 was unaware the resident required two (2) persons to assist. Review of the Event Report, dated, 03/27/19, created at 9:27 AM, signed by Licensed Practical Nurse (LPN) #5, revealed Resident #4 exhibited or complained of pain in his/her right foot related to the fall, and the pain was rated a seven (7) out of ten (10) indicating horrible or intense pain. Range of Motion (ROM) was painful or limited in right lower extremity. Positioning of extremities revealed rotation/deformity/shortening of the right lower extremity. The Report further stated the fall occurred in the bathroom with CNA #2 present. Review of the Evaluation Section of the Report, revealed Resident #4 was standing while his/her peri area was washed and his/her legs gave out. The CNA helped lower the resident to the floor. The resident did not hit head or lose consciousness. Once back in bed, the resident complained of right ankle pain. The Physician and family were notified, and an X-Ray was ordered. After the X-Ray was ordered, the Physician gave orders to send the resident to the emergency room and Emergency Medical Services transported the resident to the hospital. Review of the facility's Fall Investigation, undated, signed by the previous Director of Nursing (DON), revealed the event occurred on 03/27/19 (time not specified). Per the investigation, while Resident #4 was standing in the bathroom holding onto the rail, his/her right knee buckled and CNA #2 lowered the resident to the floor. The Investigation revealed Resident #4 was Care Planned to require two (2) person assist with transfers, and the CNA did not review the Care Plan prior to assisting the resident. The root cause was determined to be the CNA did not follow the Care Plan, and the CNA was immediately suspended. According to the Investigation, CNA #2 received the appropriate education and counseling, and education with staff to be conducted related to CNA Care Plans. Review of the Radiology Report, dated 03/27/19 at 9:41 AM, revealed a Fracture involving the Distal Tibia and Fibula with no displacement. Per the Report, the joint alignment was maintained, and there was no soft tissue swelling. Review of Resident #4's Hospital Discharge Summary, dated 04/05/19, revealed the resident was admitted to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED]. Per the Summary, Resident #4 underwent Open Reduction Internal Fixation (ORIF) of the right ankle and subsequent medical management while an inpatient. According to the Summary, the resident was to be strict non-weight bearing to the operative extremity, and an order was placed for a wheelchair. Phone interview with CNA #2, on 09/26/19 at 2:25 PM, revealed she did not remember Resident #4, nor did she remember the resident sustaining a fall on 03/27/19. Per interview, she also did not recall giving a statement or being interviewed by administrative staff regarding a fall for Resident #4. She stated in regards to transferring residents, she would always refer to the Nurse Aide Care Plan as this was the reference used by CNAs in providing care to residents. She further stated she always carried the Nurse Aide Care Plan in her pocket as these were available at the nurse's station to pick up at the beginning of the shift. Continued interview revealed she always used the gait belt and used the method of transfer technique listed on the Nurse Aide Care Plan for all transfers. She stated it was important to follow the Care Plan regarding transfer assistance because if not, the resident or staff could be harmed during transfer. Interview with Licensed Practical Nurse (LPN) #5, on 09/27/19 at 3:32 PM, who was the nurse assigned to Resident #4 on 03/27/19, revealed she could not remember the event in which Resident #4 sustained a fall, nor did she remember assessing the resident after a fall. However, she stated she did create and complete the event report dated 03/27/19. She stated the CNAs carried a Nurse Aide Care Plan they used as a reference for providing care including the transfer technique to be used and the number of staff required for transfers. She stated these Care Plans were available for the CNAs at the nurse's station to ensure appropriate care was provided for resident safety. Interview with the Occupational Therapy Supervisor, on 09/27/19 at 8:38 AM, revealed she was the Therapist who initially evaluated Resident #4 on 03/22/19, but she did not remember the resident. She stated if the Occupational Therapy Note, dated 03/22/19, stated the resident was totally dependent on staff for toileting, this meant the resident required at least two (2) staff to assist with toileting. Further, if the Note stated the resident required maximum assistance for transfers, this meant the resident required at least two (2) staff to assist with transfers. Additional interview with the Occupational Therapy Supervisor, revealed there was a Therapy Book utilized by PT and OT which listed the residents' required assistance level. Per interview, on Tuesdays this book was reviewed by Therapy staff and any required changes were made and then the book was given to the Director of Nursing (DON) to take to the morning meeting. Per interview, the residents' Care Plans were updated related to any changes in the required assistance level during the morning meeting. She stated it was important for staff to know what transfer and toileting assistance a resident required for the safety of the residents and staff. Interview with the Physical Therapist (PT), on 09/27/19 at 9:00 AM, revealed he did not evaluate Resident #4 and the PT who treated the resident was no longer at the facility. However, after reviewing the Physical Therapy Notes, dated 03/24/19, he stated the resident was assessed as requiring maximum assistance for transfers. He further stated maximum assist required at least two (2) staff. Interview with the Advanced Practitioner Registered Nurse (APRN), on 09/27/19 at 10:57 AM, revealed if therapy assessed a resident to require two (2) persons to assist for transfers or to require total dependence for toileting, the resident required that assistance and it was important the resident received the assistance therapy recommended. She stated it was important to follow therapy recommendations related to transfers and toileting in order to prevent falls and injuries. Interview with the Assistant Director of Nursing (ADON), on 09/27/19 at 3:45 PM, revealed the Interdisciplinary Team updated Care Plans related to transfer/toileting assistance daily as needed throughout the week in morning meetings. She stated therapy would communicate with her about any updates in transfer/toileting assistance and then she would update the Nurse Aide Care Plans. She stated the Nurse Aide Care Plans were kept in a binder at the nurse's station for nurses and CNAs to utilize, but were not kept as part of the permanent record. She stated a resident who required two (2) staff for transfers or toileting should never be transferred or toileted with just one (1) staff member. Interview with the Director of Nursing (DON), on 09/27/19 at 6:18 PM, revealed she started as DON at the facility only a few months ago and therefore was not at the facility at the time Resident #4 sustained the fall. She stated Therapy staff assessed residents on admission and communicated the transfer technique to be used to the Interdisciplinary Team (IDT). Per interview, IDT reviewed resident transfer assistance every morning during the morning meeting and ensured Comprehensive Care Plans and Nurse Aide Care Plans were up to date and accurate. She further stated staff performed 'huddles' between shift changes to ensure information was passed along to staff from shift to shift to ensure staff were aware of any changes related to resident care. Further, it was her expectation the CNAs review the Nurse Aide Care Plans prior to providing care for each resident, especially related to transfers and toileting. Per interview, these Nurse Aide Care Plans were shredded daily and new ones printed daily, and therefore were not a part of the permanent record. Continued interview revealed in order to prevent falls and injuries, staff should never independently assist a resident who required two (2) staff for transfers. The DON stated Resident #4 should have been transferred with two (2) staff on 03/27/19, as per Therapy recommendation and as care planned. Interview with the facility's Administrator on 09/27/19 at 7:16 PM, revealed he had been at the facility about a month, and therefore was not at the facility on 03/27/19 when Resident #4 sustained the fall with injury. Further interview revealed the facility had a process in place in which Therapy assessed residents for transfer technique to be used for transfers and toileting and this information was passed on to the Interdisciplinary Team to be care planned. Further interview revealed Resident #4's Therapy recommendations and Care Plan should have been followed on 03/27/19 for the resident's safety and well-being. The State Agency Representative attempted a phone interview with the former DON on 09/27/19 at 8:32 AM and 8:35 AM. A message was left, with no return phone call. The State Agency Representative attempted a phone interview with the former Administrator, who worked at the facility at the time of Resident #4's fall on 09/27/19 at 8:35 AM. A message was left, with no return phone call.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure the comprehensive person-centered care plan was implemented in order to meet each resident's medical and nursing needs for one (1) of seven (7) sampled residents (Resident #4). According to Resident #4's Comprehensive Care Plan, dated 03/21/19, the resident was to be transferred with two (2) staff for toileting and transfers as needed. However, on 03/27/19, Certified Nursing Aide (CNA) #2 independently assisted the resident on to the commode and helped wash up the resident, then the resident stood up using the grab bars and was standing up for three to four (3-4) minutes. CNA #2 bent over to pull up Resident #4's undergarments, and the resident sustained [REDACTED].#4 was transferred to the Hospital emergency roiagnom on [DATE], and was admitted with a [DIAGNOSES REDACTED]. (Refer to F-689) The findings include: Review of the facility's Comprehensive Care Plans Policy, revised 07/19/19 revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Review of the facility's Falls Policy, revised 07/16/19, revealed the intent of the facility is to provide residents with assistance and supervision in an effort to minimize falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change in condition. A Comprehensive Care Plan will be implemented based on the fall risk evaluation score with an individual goal and interventions specific to each resident. 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. Review of Resident #4's closed medical record revealed the facility admitted the resident on 03/21/19 with [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) Assessment to review after the resident's admission on 03/21/19, due to the resident being newly admitted . Review of Resident #4's Comprehensive Care Plan, dated 03/21/19, revealed the resident was at risk for falls related to weakness, and history of dizziness. The goal revealed the resident would not sustain injury related to falls over the next thirty (30) days. The interventions included complete Fall Risk screening tool on admission; cue for safety awareness; keep environment safe; place call bell within reach; and assist times two (2) for toileting and transfers as needed. Review of the facility's Long Term Care Facility-Self Reported Incident Form/Initial Report, dated 03/27/19, signed by the former Administrator in Training, revealed CNA #2 assisted Resident #4 to the restroom, and while Resident #4 was standing in the restroom, Resident #4's right knee buckled. CNA #2 then assisted the resident to the floor, in a controlled manner using a gait belt. The X-ray findings revealed a Right Ankle Fracture. Review of CNA #2's documented interview obtained by the facility, dated 03/27/19, revealed on 03/27/19, CNA #2 had her gait belt on and took the resident to the bathroom in the wheelchair. She then assisted the resident on to the commode and helped wash up the resident. Resident #4 got up using the grab bars and was standing up for three to four (3-4) minutes. CNA #2 then bent over to pull up the resident's undergarments, and it appeared the resident's right knee buckled and she helped to lower the resident to the ground. The nurse was notified by CNA #2. According to the documented interview, the resident required one (1) person assist on the previous admission, and CNA #2 was unaware Resident #4 required two (2) persons to assist. Review of the Event Report, dated, 03/27/19, created at 9:27 AM, by Licensed Practical Nurse (LPN) #5, revealed Resident #4 sustained a fall that occurred in the bathroom with CNA #2 present. Review of the Evaluation Section of the Report, revealed Resident #4 was standing while his/her peri area was washed, his/her legs gave out, and the CNA helped lower the resident to the floor. Once back in bed, the resident complained of right ankle pain, and the Physician and family were notified. After the X-Ray was ordered, orders were received to send the resident to the emergency room and Emergency Medical Services transported the resident to the hospital. Review of the facility's Fall Investigation, undated, signed by the previous Director of Nursing (DON), revealed the fall event occurred on 03/27/19 (time not specified). According to the Investigation, while Resident #4 was standing in the bathroom holding onto the rail, his/her right knee buckled and CNA #2 lowered the resident to the floor. Per the Investigation, Resident #4 was Care Planned to require two (2) person assist with transfers, and the CNA did not review the Care Plan prior to assisting the resident. Further review of the Investigation revealed the root cause was determined to be the CNA did not follow the Care Plan. Review of Resident #4's Radiology Report, dated 03/27/19 at 9:41 AM, revealed a Fracture involving the Distal Tibia and Fibula with no displacement. Review of the Hospital Discharge Summary, dated 04/05/19, revealed Resident #4 was admitted to the hospital on [DATE] with an admitting [DIAGNOSES REDACTED]. Further review of the Discharge Summary, revealed Resident #4 underwent Open Reduction Internal Fixation (ORIF) of the right ankle and subsequent medical management while an inpatient. Phone interview with CNA #2, on 09/26/19 at 2:25 PM, revealed she did not recall Resident #4, nor did she remember the resident sustaining a fall on 03/27/19. Per interview, she also did not recall giving a statement or being interviewed by administrative staff related to a fall for Resident #4. Per interview, she always used the gait belt and used the method of transfer technique listed on the Nurse Aide Care Plan for transferring and toileting residents. She stated it was important to follow the Care Plan related to transfer assistance because if not, the resident or staff could be harmed during transfer. Interview with Licensed Practical Nurse (LPN) #5, on 09/27/19 at 3:32 PM, who was the nurse assigned to Resident #4 on 03/27/19, revealed she could not recall the event in which Resident #4 sustained a fall, nor did she remember assessing the resident after a fall. However, she stated she did create and complete the event report dated 03/27/19 for Resident #4. Per interview, the CNAs carried a Nurse Aide Care Plan they used as a reference for providing care which included the transfer technique to be used and the number of staff required for transfers. Further, these Care Plans were available for the CNAs at the nurse's station to ensure appropriate care was provided for resident safety. Interview with the Assistant Director of Nursing (ADON), on 09/27/19 at 3:45 PM, revealed the Interdisciplinary Team (IDT) updated Care Plans related to transfer/toileting assistance daily as needed throughout the week in the morning meetings. She stated Occupational Therapy and Physical Therapy would communicate with her about any updates in transfer/toileting assistance and then she would update the Nurse Aide Care Plans. Further, the Nurse Aide Care Plans were kept in a binder at the nurse's station for nurses and CNAs to utilize, but were not kept as part of the permanent record and were shredded and new ones were printed daily. The ADON stated a resident who required two (2) staff for transfers or toileting should never be transferred or toileted with just one (1) staff member. Interview with the Director of Nursing (DON), on 09/27/19 at 6:18 PM, revealed she was fairly new and was not the DON at the facility at the time Resident #4 sustained the fall. She stated the Interdisciplinary Team (IDT) reviewed resident transfer assistance every morning during the morning meeting and ensured the Comprehensive Care Plans and Nurse Aide Care Plans were up to date and accurate. Further, staff performed 'huddles' between shift changes to ensure information was passed along to staff from shift to shift to ensure staff were aware of any changes related to resident care. The DON stated it was her expectation the CNAs review the Nurse Aide Care Plans prior to providing care for each resident, especially related to transfers and toileting. Additional interview revealed Resident #4 should have been transferred with two (2) staff on 03/27/19, as per the Comprehensive Care Plan. Interview with the facility's Administrator on 09/27/19 at 7:16 PM, revealed he had been at the facility about a month, and therefore was not at the facility on 03/27/19 when Resident #4 sustained the injury related to a fall. Further interview revealed it was his expectation staff implement the interventions on the Care Plan for resident safety and to provide the best care. Additional interview revealed Resident #4's Care Plan should have been implemented related to a two (2) person transfer on 03/27/19, for the resident's safety and well-being.

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (1) of seven (7) sampled residents (Resident #3). Resident #3 was prescribed an antibiotic ([MEDICATION NAME]) upon admission to the facility on [DATE], for an infection of his right foot and ankle. However, the medication was unavailable and could not be obtained by the facility Pharmacy. Resident #3 did not receive the prescribed antibiotic on 07/01/19, 07/02/19, or 07/03/19, and was subsequently transferred to the hospital on [DATE] in order to receive the medication. The findings include: Review of the facility's Ordering and Receiving Non-Controlled Medications Policy, dated 09/2010, revealed it is the policy of the facility that medications and related products are received from the provider pharmacy on a timely basis. Further review revealed timely delivery of new orders is required so that medication administration is not delayed. Review of the facility's Medication Administration Policy, dated 09/2018, revealed it is the facility's policy that medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. Further review revealed medications are administered in accordance with written orders of the prescriber. Continued review revealed medications are administered within sixty (60) minutes of the scheduled time. Review of the facility's Antibiotic Stewardship Policy, revised 11/07/18, revealed the inventory of antibiotics available after hours in the emergency kit will be reviewed with the pharmacy consultant and a representative of the antibiotic stewardship program to ensure availability is not a barrier for the use of preferred agents. Review of the facility's Pharmacy Contract, signed 04/28/15, revealed the Pharmacy will select and prepare [MEDICATION NAME] products, as appropriate, and provide and maintain IV (intravenous) administration products as necessary for IV drug therapy. Review of Resident #3's medical record revealed the facility admitted the resident on 07/01/19 with [DIAGNOSES REDACTED]. Review of Resident #3's Hospital Discharge Summary, dated 07/01/19, revealed a discharge medication list that included [MEDICATION NAME] 3 Grams IV every six (6) hours. Review of Resident #3's Admission physician's orders [REDACTED]. Review of Resident #3's Prescription Order, dated 07/01/19, revealed a prescription for [MEDICATION NAME] 3 Gram every eight (8) hours was transmitted to the Pharmacy on 07/01/19 at 9:31 PM, by Licensed Practical Nurse (LPN) #1. Review of Resident #3's Progress Notes, dated 07/02/19 at 12:29 PM, revealed Licensed Practical Nurse (LPN) #2 called the Pharmacy regarding Resident #3's [MEDICATION NAME] not being delivered. Per the Note, the Pharmacist informed her the [MEDICATION NAME] antibiotic was on backorder. Further review revealed the Advanced Practice Registered Nurse (APRN) was notified as well as Resident #3's Infectious Disease Physician. Per the Note, Resident #3 was also informed the [MEDICATION NAME] was unavailable. Review of Resident #3's subsequent Progress Notes, dated 07/02/19 at 4:20 PM, written by LPN #2, revealed she had not received a call back from Resident #3's Infectious Disease Physician. Per the Note, she attempted to reach the Infectious Disease Physician again. Review of Resident #3's subsequent Progress Notes, dated 07/02/19 at 7:36 PM, written by LPN #2, revealed she had not received a call back from Resident #3's Infectious Disease Physician. Per the Note, the nurse for the next day (07/03/19) would attempt to contact Resident #3's Infectious Disease Physician. Review of Resident #3's Progress Notes, dated 07/03/19 at 3:43 PM, written by LPN #3, revealed Resident #3 and his/her family member was requesting that Resident #3 be sent to the emergency room (ER). Further review revealed Resident #3's family member transported the resident to the ER. Review of Resident #3's Nursing Home to Hospital Transfer Form, dated 07/03/19, revealed Resident #3 was transferred to the hospital per his/her family's request. Review of Resident #3's Medication Administration Record [REDACTED]. Interview on 09/27/19 at 9:15 AM, with LPN #1, revealed she was the nurse that admitted Resident #3 on 07/01/19. She stated upon Resident #3's admission his/her medications were ordered STAT (urgent) in order for the facility to receive the medications in a timely manner. She stated it could take up to six (6) hours to receive a medication once the order was sent to the pharmacy. She further stated if medications were ordered STAT, it generally took from two (2) to six (6) hours for the medications to be delivered. Further interview revealed she did not receive Resident #3's [MEDICATION NAME] antibiotic before she left for her shift on 07/01/19, but the first dose want not due until midnight which was after her shift ended. Interview on 09/26/19 at 2:27 PM, with LPN #2, revealed she was assigned to Resident #3 on 07/02/19. She stated in her experience, there have been some issues in the past with Pharmacy providing IV antibiotics. She stated the Pharmacy did call her on 07/02/19 and reported Resident #3's IV antibiotic was on backorder. She further stated she then informed both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) that the IV antibiotic was on backorder. Further, she attempted to contact Resident #3's Infectious Disease Physician multiple times as directed by the APRN. However, further interview revealed she did not receive a return call from the Infectious Disease Physician. She stated she informed the oncoming shift that the Infectious Disease Physician needed to be notified of the antibiotic being on backorder. Interview on 09/26/19 at 2:31 PM, with LPN #3, revealed she was the nurse assigned to Resident #3, on 07/03/19. She stated she did speak with Resident #3's Infectious Disease Physician on 07/03/19 about changing the antibiotic for Resident #3 until the [MEDICATION NAME] was back in stock. She further stated Resident #3's Infectious Disease Physician did not want to change the antibiotic. Per interview, she then informed the DON the antibiotic was on backorder and that the Infectious Disease Physician did not want to change the antibiotic. Further, she then informed Resident #3 and his/her family member, and they requested the resident be sent to the Hospital emergency room for further evaluation. Interview with the ARNP, on 09/27/19 at 10:57 AM, revealed she was notified the medication was not available for administration for Resident #3 and she did not want to give a substitute antibiotic and therefore told staff to call the Infectious Disease Physician for further instructions. Further interview revealed if she had been notified the nurses could not reach the Infectious Disease Physician timely, she may have given orders to send the resident to the Hospital emergency room to receive the antibiotics. Phone interview on 09/26/19 at 11:05 AM, with Resident #3's Infectious Disease Physician, revealed he remembered being contacted when Resident #3 was admitted to the facility and informed that the [MEDICATION NAME] was not available from the Pharmacy. He stated he told the nurse if the facility could not get the medication for the resident, they should send the resident to the ER in order to receive the medication. He stated he did not hear anything else about the antibiotic until Resident #3 was seen in the ER two (2) to three (3) days later. Further interview revealed missing the antibiotics for those days did not directly result in the need for any further or more drastic treatment of [REDACTED]. Interview on 09/27/19 at 12:27 PM, with Pharmacist #2, revealed it was Pharmacy process to attempt to obtain a medication from a backup pharmacy if a medication was unavailable. Further, if the backup pharmacy did not have the medication, the Pharmacist would attempt to call the facility and explain that the medication was not available. He further stated the Pharmacist would also suggest medications that could be used as a substitute. Continued interview revealed Resident #3's medication was on backorder, but the Pharmacy suggested two (2) medications that could be used as a substitute. Pharmacist #2 stated they did not hear back from the facility after the substitute medications were suggested. Interview on 09/27/19 at 3:47 PM, with the ADON, revealed she was aware of one (1) or two (2) instances when Pharmacy has been unable to provide a prescribed IV antibiotic. However, she stated she was not aware that Resident #3 did not receive his/her antibiotic after admission to the facility on [DATE]. Interview on 09/27/19 at 6:16 PM, with the Director of Nursing (DON), revealed it was her expectation medications be administered as per physician's orders [REDACTED].#3's medication was on backorder and unavailable for administration. Further interview revealed when the nurses notified the ARNP on 07/02/19 that the medication was on backorder, the nurse should have also notified the Provider of the estimated time that the medication would be received by the facility in order to find out if the ARNP wanted the resident sent to the Hospital emergency room to receive the medication. The DON acknowledged the facility did not provide pharmaceutical services to meet the needs of Resident #3. Interview on 09/27/19 at 6:38 PM, with the Administrator, revealed if an antibiotic medication was unavailable for administration, the DON should be notified and there should be follow through to ensure the resident received a substitution antibiotic at the Physician's discretion or the resident was transferred to the ER for the medications also at the Physician's discretion. Further interview revealed the Administrator acknowledged the facility did not provide pharmaceutical services to meet the needs of Resident #3.

Based on observation, record review, review of the facility's Policies, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure services provided or arranged by the facility meet professional standards of quality for one (1) of seven (7) sampled residents (Resident #1). Upon admission to the facility on [DATE], Resident #1 was prescribed Nuplazid (a medication to treat [MEDICAL CONDITION] induced hallucinations and delusions); and due to the medication being above the cost limit, pharmacy required the approval of the Director of Nursing (DON) or the Administrator prior to dispensing the medication. However, there was no documented evidence the DON or the Administrator reviewed the request and/or approved or denied the request until 09/19/19. Further, there was no documented evidence the Provider was notified the medication was not dispensed to the facility until 09/19/19. Resident #1 did not receive the first dose of Nuplazid medication until 09/20/19, revealing the resident missed sixteen (16) consecutive doses of the medication. The findings include: Review of the facility's Ordering and Receiving Non-controlled Medications Policy, reviewed 09/2010, revealed it is the policy of the facility that medications and related products be received from the Provider Pharmacy on a timely basis. Review of the facility's Pharmacy Contract, signed 04/28/15, revealed the Pharmacy will provide and deliver to the Customer prescription and non-prescription medication in accordance with the orders of the Resident's Attending Physician. Review of the KBN, AOS #14, revised (MONTH) (YEAR), Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes (KRS) 314.021 (2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). This includes preparing and administering medications in the prescribed dosage, route, and frequency. Review of Resident #1's medical record revealed the facility admitted the resident on 09/04/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission physician's orders [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 09/11/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15) indicating severe cognitive impairment. Further, per the MDS Assessment, the facility assessed the resident as having a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, 09/04/19, revealed a focus of Activities of Daily Living (ADL) Self Care Deficit related to [MEDICAL CONDITION]. The goal stated the resident would have reduced risk regarding complications related to decreased mobility and would be appropriately dressed and groomed. There were several interventions including assist with transfers and toileting and provide ADL care to ensure daily needs are met. Review of Resident #1's Progress Notes, dated 09/19/19, written by Licensed Practical Nurse (LPN) #2, revealed the resident had not received Nuplazid medication since his/her admission on 09/04/19. Further review of the Note, revealed the Advanced Practice Registered Nurse (APRN) was notified and was not comfortable changing the medication. Per the Note, Resident #1's representative was notified by the Director of Nursing (DON) the medication was not available. There was no documented evidence the Providers were notified the resident's medication was not available for administration until the Progress Note written on 09/19/19, which was fifteen (15) days after the medication was prescribed. Review of Resident #1's Medication Administration Record (MAR), dated (MONTH) 2019, revealed the resident did not receive Nuplazid 09/04/19 through 09/19/19. Further review revealed the facility staff responsible for administering the medication documented on the MAR, the medication was not administered due to the medication not being available. Per the MAR, the resident received the first dose of the medication on 09/20/19 between 7:00 AM and 11:00 AM. (The facility did not list specific times for medication administration, but instead listed range of times for the medication to be administered). The MAR revealed the resident missed sixteen (16) consecutive doses of the medication. Review of the Pharmacy Notes, submitted to the State Agency Representative for review, revealed on 09/04/19, Resident #1 was added to the pharmacy database as a new resident of the facility. Further review revealed on 09/06/19, a Pharmacy Representative called the facility and left a voicemail for the DON stating Nuplazid was over the facility cost limit and a three (3) day supply had been sent: however, a fourteen (14) day supply would need approval from the DON or Administrator. Additional review of the Pharmacy Notes, revealed on 09/09/19, a Pharmacy Representative spoke with the facility Administrator regarding the cost of a fourteen (14) day supply of Nuplazid being over the cost limit. The Pharmacy Representative documented the Administrator would call the Pharmacy regarding approval of the medication. Continued review revealed on 09/09/19, the Pharmacy canceled the prescription until the facility either approved or denied the medication. Further review of the the Pharmacy Notes, revealed on 09/19/19, the Pharmacy once again called the facility to obtain approval for the medication. The Pharmacy Representative documented speaking with the DON and receiving approval for a seven (7) day supply of the medication. Per the Notes, on 09/26/19, the DON approved a fourteen (14) day supply to be dispensed by the pharmacy. Interview with Licensed Practical Nurse (LPN) #2, on 09/26/19 at 2:27 PM, revealed she did identify the prescribed Nuplazid medication was not in the Medication Cart on the days she was assigned to administer medication to Resident #1 on 09/06/19, 09/10/19, and 09/19/19. Per interview, Pharmacy was sometimes very slow to deliver medication, so she did not think about calling Pharmacy. Further interview revealed she thought the Physician had already been informed the medication was unavailable, and therefore she did not inform the ARNP the medication was unavailable until 09/19/19. Interview with LPN #3, on 09/26/19 at 2:31 PM, revealed Resident #1's Nuplazid medication was unavailable on 09/05/19, when she was scheduled to administer medication to the resident. Per interview, she documented on the MAR that the medication was unavailable on that date. She stated she had been told the medication had not been delivered from pharmacy, but was not informed the Physician had not been notified the medication was unavailable. Interview on 09/27/19 at 10:57 AM, with the APRN, revealed it was her expectation medications be administered as prescribed, as medications were prescribed for a reason. Further interview revealed she would expect to be notified if a medication was not unavailable for administration. The ARNP stated she was not made aware the resident did not receive the medication until 09/19/19. She further stated she didn't feel comfortable changing the medication when she was notified, because the medication was for [MEDICAL CONDITION] induced hallucinations and she did not prescribe the medication. Per interview, staff should have contacted the resident's Neurologist when staff identified the medication was not available for administration. Interview on 09/27/19 at 3:33 PM, with Resident #1's Attending Physician, revealed it was his expectation that ordered medications be administered as prescribed. He stated if a medication was prescribed, then the resident needed the medication. He further stated if a medication was unavailable the facility should contact either himself or the APRN for further instructions. Continued interview revealed he was unaware the resident had not received the prescribed Nuplazid until this interview. Further interview revealed adverse consequences of not receiving Nuplazid would be the potential for hallucinations. Interview on 09/27/19 at 2:17 PM, with Pharmacist #3, revealed Pharmacy received the order for Resident #1 to receive Nuplazid on 09/04/19. She stated the medication was over the cost limit set by the facility and needed approval to be dispensed. She further stated it was the Pharmacies process to contact the facility as soon as possible if a medication needed approval. Further, Pharmacy made several attempts to contact the facility regarding Resident #1's Nuplazid. She stated on 09/19/19, the DON gave approval for a seven (7) day supply only, which was dispensed on 09/19/19. She further stated, on 09/26/19, the DON gave approval for a fourteen (14) day supply, which was dispensed on 09/26/19. Interview on 09/27/19 at 6:19 PM. with the Director of Nursing (DON), revealed the Corporation that owned the facility had a limit set on the amount of money they would pay for medications without approval. She stated if a medication was over the cost limit the Pharmacy would notify the facility to obtain approval from either the DON or Administrator for the cost of the medication. Continued interview revealed she was not present at the facility when the Pharmacy initially called for approval of Resident #1's Nuplazid medication. The DON stated she was made aware of the medication being over the cost limit and gave approval to the pharmacy to send a seven (7) day supply, but she could not recall the date she gave this approval. Additional interview with the DON, revealed per her job description, it was her responsibility to manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations. Further, per her job description it was her responsibility to monitor the pharmacy consultant reports and take appropriate actions. She further stated, according to her job description, it was her responsibility to monitor stock level of medication, medical supplies, and equipment to verify they are maintained on premises at all times to adequately meet the needs of the resident. Additional interview revealed the facility's failure to take action on the pharmacy request for approval for Resident #1's medication and the fact that the resident went sixteen (16) days without a prescribed medication was not in accordance with professional standards of quality or professional nursing standards. The DON stated it was her expectation medications be administered per physician's orders [REDACTED]. Interview on 09/27/19 at 6:38 PM, with the Administrator, revealed if a medication was above the cost limit the Pharmacy would call the facility to get approval regarding the cost of the medication. He stated Pharmacy did call and speak to him, about Resident #1's medication requiring approval, and he gave approval for the medication and told the Pharmacy to send the medicine. He further stated he was unsure why the medication was not sent after this phone call with Pharmacy, and he could not recall the date of the phone call. Further interview revealed he did not follow up to ensure the medication was delivered. Continued interview with the Administrator, revealed it was his expectation Pharmacy requests for high cost medication be reviewed timely. He stated Resident #1's Nuplazid medication was not approved in a timely manner and as a result the resident missed sixteen (16) days of the medication. He further stated it was his expectation the Physician be notified if a medication was unavailable. Additional interview revealed it was not in accordance with professional standards of quality for a resident not to receive medication as prescribed.

Based on observation, record review, and review of facility's Policies it was determined the facility failed to immediately consult with the resident's Physician when a medication was unavailable for administration for one (1) of seven (7) sampled residents (Resident #1). The facility admitted Resident #1 on 09/04/19, and Nuplazid (a medication to treat [MEDICAL CONDITION] induced hallucinations and delusions) was prescribed to start on that date. However, the medication was above the cost limit and pharmacy required facility approval prior to dispensing the medication. Due to the facility's failure to approve the medication timely, the resident did not receive the first dose of medication until 09/20/19, revealing the resident missed sixteen (16) doses of the medication. There was no documented evidence the Provider was notified the medication was unavailable to administer until 09/19/19, fifteen (15) days after the medication was prescribed. The findings include: Review of the facility's Change of Condition Policy, revised 07/2018, revealed the facility will relay information to the Physician if there is a need to alter treatment. Review of Resident #1's clinical record revealed the facility admitted the resident on 09/04/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission physician's orders [REDACTED]. Review of the Progress Notes, dated 09/19/19, written by LPN #2, revealed Resident #1 had not received Nuplazid medication since his/her admission on 09/04/19. Additional review of the Note, revealed the Advanced Practice Registered Nurse (APRN) was notified and was not comfortable changing the medication. There was no documented evidence the Providers were notified the resident's medication was not available for administration until the Progress Note written on 09/19/19, fifteen (15) days after the medication was prescribed. Review of the Medication Administration Record (MAR), dated (MONTH) 2019, revealed the resident did not receive Nuplazid 09/04/19 through 09/19/19. Continued review revealed the facility staff responsible for administering the medication documented on the MAR, the medication was not administered due to the medication was not available. According to the MAR, the resident received the first dose of the medication on 09/20/19 between 7:00 AM and 11:00 AM. (This facility did not list specific times for medication administration, but instead listed range of times for the medication to be administered). The MAR further revealed the resident missed sixteen (16) consecutive doses of the medication. Interview with Licensed Practical Nurse (LPN) #2, on 09/26/19 at 2:27 PM, revealed the medication was not available for administration on the days she was scheduled to administer medication to Resident #1 after his/her admission. However, she stated she did not notify the Physician of this because she thought the Physician was already aware. Continued interview revealed she did not inform the ARNP the medication was unavailable until 09/19/19. Interview with LPN #3, on 09/26/19 at 2:31 PM, revealed Resident #1's Nuplazid medication was unavailable on the days she was scheduled to administer medication to the resident the first weeks after the resident's admission. She stated she was told the medication had not been delivered from pharmacy, but was not informed the Physician had not been notified the medication was unavailable. Interview on 09/27/19 at 10:57 AM, with the APRN, revealed it was her expectation to be notified if a medication was not unavailable for administration. Further interview revealed she was not made aware Resident #1 did not receive the Nuplazid medication until 09/19/19. She stated staff should have contacted her or the resident's Neurologist who prescribed the medication when staff first identified the medication was not available for administration. Interview on 09/27/19 at 3:33 PM, with Resident #1's Attending Physician, revealed medications were to be administered as prescribed. Further interview revealed if a medication was unavailable the facility should contact either himself or the APRN for further instructions. The Attending Physician stated he was unaware the resident had not received the prescribed Nuplazid until this interview. Interview on 09/27/19 at 2:17 PM, with Pharmacist #3, revealed Pharmacy received the order for Resident #1 to receive Nuplazid on 09/04/19; however, the medication was over the cost limit set by the facility and needed approval to be dispensed. Further interview revealed Pharmacy made several attempts to contact the facility regarding Resident #1's Nuplazid; however, the facility did not give approval for the first supply of the medication until 09/19/19, and the medication was dispensed on that date. Interview on 09/27/19 at 6:19 PM. with the Director of Nursing (DON), revealed Resident #1's Nuplazid medication was over the cost limit and therefore the Pharmacy required approval from either the DON or Administrator for the cost of the medication. Continued interview revealed the facility failed to review the requests for approval for the medication in a timely manner, and therefore the medication was not delivered until 09/19/19. Further interview revealed it was her expectation the nurses notify the Physician or ARNP in a timely manner when a medication was not available to administer as prescribed. Per interview, the Provider may want to alter treatment if a medication was not available, and the Provider needed to be informed if a resident did not receive medications as ordered. Interview on 09/27/19 at 6:38 PM, with the Administrator, revealed Resident #1's Nuplazid medication was not approved by the facility in a timely manner and as a result the resident missed sixteen (16) days of the medication. He further stated it was his expectation the Physician be notified if a medication was unavailable, or if a medication was not administered as prescribed.

Based on observation, interviews, and policy review, it was determined the facility failed to ensure food was heated and held on the steamtable at safe temperature levels, which created the risk for foodborne illness. Observation of food temperatures revealed the ground beef temperature was 130 degrees F. In addition, during food temperature testing, the Dietary Manager failed to wash her hands prior to the testing process. The findings include: Review of the facility's policy, Food Temperatures, revised 01/04/19, revealed foods should be served at proper temperatures to insure food safety and palatability. Acceptable serving temperatures for meat was => 140 degrees F; however, the preferable temperature range was 140-165 degree F. Further review revealed the Food and Drug Administration Food Code allowed 135 degrees as the minimum hot holding temperature. The policy stipulated reheating food for hot holding had to reach 165 degrees F and had to hold this temperature for 15 seconds. Reheating of food by dietary staff was done within a two (2) hour period. Review of the facility's policy, Handwashing/Hand Hygiene, revised (MONTH) (YEAR), revealed all facility personnel was trained and regularly in-serviced on the importance of hand hygiene to prevent the transmission of healthcare-associated infections and followed the handwashing/hand hygiene procedures to help prevention and spread of infections to other personnel, residents and visitors. The policy stated the use of gloves did not replace handwashing/hand hygiene. The facility recognized the integration of glove use along with routine hand hygiene as the best practice for preventing healthcare-associated infections. Observation of the main dining room steamtable, on 03/05/19 at 12:10 PM, revealed the Dietary Manager conducted food temperature testing without performing hand hygiene prior to testing. The ground beef temperature was 123 degrees F and the Manager took the ground beef to the kitchen to reheat. She returned at 12:20 PM with the reheated container of ground beef and retested the temperature, which resulted 130 degrees F, which was below the safe holding temperature for meat. After completion of this task, she stood at the door and briefly chatted with the Nurse Consultant. While doing so, she pulled her pants up and touched her stomach, and proceeded to grab resident meal tickets and organized them, and put them on the top of the steam table where the Dietary Assistant picked them up. Interview, on 03/08/19 at 8:05 AM, with the Dietary Manager revealed the ground beef holding temperature should have been 140 degrees F to keep residents from getting sick, because they were more vulnerable. She stated handwashing was important because germs could possibly transfer through anything she touched and could potentially affect a resident's wellbeing. She stated she thought she washed her hands prior to taking food temperatures and did not realize she had touched her body. The Dietary Manager further stated she had been trained handwashing was the most important thing to do. Interview, on 03/08/19 at 9:17 PM, with the Administrator revealed staff was to follow infection control practices for handwashing and other associated issues with infection control. He stated he was not aware of any issues with infection control prior to today and was not aware of infection control practices during the survey.

Based on interview, record review and facility policy review it was determined the facility failed to maintain an accurate clinical record related to medication administration for four (4) of nineteen (19) sampled residents, Residents #9, #30, #33, and #36. The findings include: Review of the facility's policy, Medication Administration, dated (MONTH) (YEAR), revealed the individual who administered the medication dose should record the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication. When as needed (PRN) medications were administered, the following documentation should be provided: the date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted; and signature or initials of the person recording administration and signature or initials of the person recording the effects. The resident should be observed for medication actions/reactions and recorded in the nurse's notes as appropriate. Any noted adverse consequence should be reported to the prescriber and/or attending physician. 1. Review of the clinical record for Resident #30 revealed a Physician Order, dated 01/10/19, for [MEDICATION NAME] 1 milligram (mg) via gastrostomy tube ([DEVICE]) or by mouth twice a day as needed (PRN) for anxiety. Review of the Resident #30's Controlled Drug Records for [MEDICATION NAME] 1 mg revealed fifteen (15) doses were signed out in (MONTH) 2019. Further review revealed thirty-two (32) doses of [MEDICATION NAME] were signed out in (MONTH) 2019. Review of Resident #30's MAR, dated (MONTH) 2019, revealed eight (8) of the fifteen (15) doses of PRN [MEDICATION NAME] signed out in (MONTH) were administered; however, there was no documentation for the remaining seven (7) doses that were signed out. Review of the MAR, dated (MONTH) 2019, revealed ten (10) of the thirty-one (31) doses signed out were administered; however, there was no documentation of administration for the remaining twenty-two (22) doses that were signed out. 2. Review the MAR for Resident #9, for (MONTH) and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Record revealed staff signed out the [MEDICATION NAME] on 01/31/19, 02/02/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. Further review of the MAR for Resident #9 for (MONTH) and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Record revealed staff signed out the [MEDICATION NAME] on 01/11/19, 01/14/19, 01/20/19, 01/21/19, 01/25/19, 01/31/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. 3. Review of the MAR for Resident #33, for (MONTH) and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Records revealed staff signed out the [MEDICATION NAME] on 01/14/19, 01/17/19, 01/20/19, 01/25/19, 01/27/19, 02/02/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. 4. Review of the MAR for Resident #36, for (MONTH) and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Records revealed staff signed out the [MEDICATION NAME] on 01/11/19, 01/14/19, 01/17/19, 01/20/19, 01/25/19, 01/27/19, 01/28/19, 01/31/19, 02/02/19, 02/03/19, 02/14/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. Interview, on 03/07/19 at 5:15 PM, with Licensed Practical Nurse (LPN) #3 via telephone revealed staff was to sign out controlled medication in the Controlled Drug Record and the sign them as administered on the MAR. However, documenting administration of the medication in the computer on the MAR was not her first priority, and she did not chart the medications 100% of the time on the MAR. Further interview revealed LPN #3 had access to the computer and was able to chart on the MAR, except for times when the computer system went down for updates. Interview with LPN #2, on 03/08/19 at 3:22 PM, revealed PRN medication should be documented on the Controlled Drug Record and on the MAR; however she did not always document on the MAR. According to LPN #2, there was potential for a medication error if an administration was not documented on the MAR. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed administration of PRN medication should be documented on the MAR, including follow up for effectiveness; however, she did not always document. The LPN further revealed she signed out controlled medications after she administered them, but should probably sign them out as soon as the narcotic was removed from the pack to prevent potential discrepancies in the count. She stated there was a risk of a medication error if an administration was not documented on the MAR. Interview with the Assistant Director of Nursing (ADON), on 03/08/19 at 4:13 PM, revealed she audited random MARs and was not aware of any issues. She stated it was important to document administration and follow up of PRN medications to ensure the medication was effective. She further revealed there was a potential for diversion of controlled medication if the medication was not signed out on both the MAR and Controlled Drug Record. Interview with the Consultant Pharmacist, on 03/08/19 at 4:46 PM, revealed he spot checked random MARs and Controlled Drug Records monthly and was not aware of any issues related to discrepancies in documentation. According to the Pharmacist, there could be potential diversion of controlled medication if narcotics were signed out on the Controlled Drug Record and not documented on the MAR. Interview, on 03/08/19 at 8:28 PM and 8:51 PM, with the Administrator revealed leadership had identified documentation issues. He was concerned about the gaps in documentation and expected nurses to document according to the policy.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to safeguard, control, and account for controlled medications for three (3) of nineteen (19) sampled residents, Resident #9, #33 and #36. Review of Controlled Drug Records and Medication Administration Records (MAR) revealed the residents' controlled medications were not maintained and accurately reconciled to ensure the residents received their medications. The findings include: Review of the facility's policy, Controlled Medication and Drug Diversion, reviewed [DATE], revealed medication included in the Drug Enforcement Administration (DEA) classified as controlled substances were subject to special handling, storage, disposal, and recordkeeping with the facility in accordance with federal, state and other applicable laws and regulations. A controlled medication accountability record was prepared when receiving or checking in a Schedule II, III, IV, or V medication and the following information was part of the report: name of resident; prescriber number; name, strength, and dosage form of medication; date received; quantity received; and name of the person receiving the medication supply. At shift change, or when keys were rendered, a physical inventory of all controlled medications was conducted by two (2) staff, either a licensed nurse, Certified Medication Technician, or per state regulation, and documented on the controlled substances accountability record. The facility kept a current controlled medication accountability record in the narcotic book and when it was completed, the record/s was submitted to the Director of Nursing (DON) and maintained on file at the facility. Review of the facility's policy, Medication Discrepancies, reviewed [DATE], revealed discrepancies were documented and reported to the resident's attending physician, DON, responsible party and the Performance Improvement Committee. In the event of a medication discrepancy, the facility took immediate action, as necessary, to protect the resident's safety and welfare and a medication discrepancy/error/incident report was completed and was included in the shift change report. Review of the facility's policy, Medication Administration General Guidelines, dated (MONTH) (YEAR), revealed the individual who administered the medications dose, recorded the administration on the resident's MAR immediately following the medication being given The resident's MAR/Treatment Administration Record (TAR) was initialed by the person administering the medications in the space provided under the date, and on the line for that specific medication dose administration and times. Review of the facility's policy, Provider Pharmacy Requirements, dated (MONTH) (YEAR), revealed the pharmacy assisted the facility, as necessary, in determining the appropriate acquisition, receipt, dispensing, and administration of all medications and biologicals to meet the medications needs of the residents and the facility. 1. Observation of Licensed Practical Nurse (LPN) #4, on [DATE] at 10:41 AM, revealed she was about to sign off on the Controlled Substance Accountability Count Record for the 500 Hall medication cart in the presence of the Surveyor. However, the nurse did not attempt to count the controlled medication in the double locked narcotic box prior to signing. Interview with LPN #4, on [DATE] at 10:42 AM, revealed she and another nurse had counted the controlled medication in the locked box earlier but she forgot to sign the Controlled Substance Accountability Count Record. She stated since she signed the Record later than when she counted the medication, the count could have been off, as a medication could have been taken out since the count was conducted. Interview with Registered Nurse (RN) #1, on [DATE] at 1:51 PM, revealed when she started her shift she counted controlled medications with the off going nurse and they signed the Controlled Substance Accountability Count sheet. She stated sometimes the previous nurse would forget to sign the Controlled Substance Accountability Count sheet, which happened occasionally. Interview with the DON, on [DATE] at 12:06 PM, revealed nurses signed off on the Controlled Substance Accountability Sheet Record when shift change occurred, or if a nurse split the shift with another nurse. 2. Review of Resident #9's MARs, dated (MONTH) 2019 and (MONTH) 2019, revealed an order for [REDACTED]. Review of Resident #9's Controlled Drug Record revealed the [MEDICATION NAME] was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, further review of the MAR revealed the no evidence the medication was administered to the resident on those dates. Continued review of Resident #9's MAR revealed an order for [REDACTED]. Review of the Controlled Drug Records revealed [MEDICATION NAME] was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, the MARs revealed no evidence the medication was administered to the resident on those dates. In addition, according to the MAR, LPN #3 administered [MEDICATION NAME] on [DATE]; however, did not sign out the [MEDICATION NAME] on the Controlled Drug Record. 3. Review of Resident #33's MARs, dated (MONTH) 2019 and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Records, revealed [MEDICATION NAME] was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, review of the MARs revealed no evidence the medication was administered to the resident on those dates. 4. Review of Resident #36's MARs, dated (MONTH) 2019 and (MONTH) 2019, revealed an order for [REDACTED]. Review of the Controlled Drug Records revealed [MEDICATION NAME] was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, review of the MARs revealed none of the doses was administered to the resident. Interview with LPN #3, on [DATE] at 5:15 PM via telephone, revealed she was to sign medications out on the Controlled Drug Record and chart in the computer (MAR). However, the nurse stated she did not chart the medication 100% of the time in the computer. She revealed she had signed out controlled medications; however, she had not signed them as administered on the MAR. According to the LPN, Resident #9, #33, and #36 got their pills every night. She could not recall if she had been educated on the policy for medication administration and she had not received training on medication administration. The LPN further stated she had never seen anyone audit the medication cart and Assistant Director of Nursing (ADON) #1 had sometimes waited for over a month to remove discontinued controlled medications from the cart. Interview with LPN #1, on [DATE] at 11:25 AM, revealed she was trained on administering as needed medications and stated she should probably document the controlled substances were administered when she gave them to a resident, but she had a bad habit about not doing so. However, she stated it was good practice to document the right time of giving the medication because she could be pulled away and forget to sign the MAR. Interview with ADON #1, on [DATE] at 10:16 AM, revealed controlled medications were to be signed out on the Controlled Drug Record when they were pulled from the bubble pack, then after they were administered, the MAR was signed. She stated she had audited controlled medications and done so by looking at the Controlled Drug Records and the medication left in the bubble packs, and she removed narcotics from the mediation cart when a resident expired. However, she had no specific audit tool she used. Interview with RN #1, on [DATE] at 1:51 PM, revealed she reordered controlled medication when there were only about two (2) to three (3) days left in a bubble pack. However, when she called the pharmacy to reorder Resident #9's [MEDICATION NAME], the pharmacist said the resident's [MEDICATION NAME] should last at least another three (3) days and could not be refilled. She checked the order for the frequency and it was correct and when she checked the Controlled Drug Record and MAR, she realized there were missing signatures on the MAR, she notified ADON #1, and an investigation began. However, the RN stated she had not seen any supervisor audit the medication carts for accuracy. RN #1 stated she had been trained on counting controlled substances in orientation. Continued interview with LPN #1, on [DATE] at 11:45 AM, revealed she probably had not documented all the time at night when she administered controlled medication. She stated because she was too busy might be why there were omissions on the MAR. She was not aware if medication carts or controlled medications were monitored by the ADON or the DON. Interview with the Pharmacy Consultant, on [DATE] at 4:25 PM via telephone, revealed he was not aware Resident #9 needed an early refill for controlled medications. He stated he performed routine monthly audits at the facility and had not noticed any discrepancies. He stated he audited controlled medication by comparing the Controlled Drug Record with the MAR and he had not found any discrepancies. He would pick one random medication on a couple of medication carts and after completed his audit, he compiled a report. According to the Pharmacy Consultant, the signature on the Controlled Drug Record just meant the medication was taken out of the bubble pack and did not verify it had been administered. If a controlled medication was signed out on the Controlled Drug Record, but not on the MAR, there was a possibility of diversion and he would make sure nursing staff checked the Controlled Drug Record and the MAR on a daily basis and recommended frequent, in-depth auditing. Interview with the DON, on [DATE] at 10:22 AM and [DATE] at 6:42 PM, revealed RN #1 informed her the pharmacy was not able to refill Resident #9's [MEDICATION NAME] because there should have been several doses left. However, when the RN inspected the bubble pack it contained only three (3) doses of the eight (8) to nine (9) doses expected to be in the bubble pack. The DON started an investigation, reported to all state and local authorities, and suspended LPN #3, who was suspected of drug diversion. ADON #1 interviewed Resident #9, #33 and #36 and other residents, and no one voiced any concerns related to pain or anxiety during the interviews. During the audit, she noticed a trend of discrepancies in documentation on the Controlled Drug Records and the MARs. She discussed the findings with the Administrator and the resident's medications were replaced at facility cost. The DON stated ADON #1 and #2 and herself was responsible to ensure residents received the medications as ordered. Interview with the Administrator, on [DATE] at 8:28 PM, revealed the facility determined LPN #3 had signed out medications she had not documented on the MAR and he terminated the nurse for not following basic nursing standards.

Based on observation, interview, and record review, it was determined the facility failed to provide showers and grooming to one (1) of nineteen (19) sampled residents, Resident #221. The findings include: The facility did not provide a policy for resident showers. Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for personal hygiene and physical assistance of one (1) staff for bathing. The facility assessed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15). Review of the Resident #221's Care Plan, dated 02/28/19, revealed the resident had a Self-Care Deficit with interventions for staff to provide all activities of daily living care to ensure the resident's needs were met. Observation, on 03/7/19 at 12:31 PM, revealed Resident #221 was unshaven, with visible facial hair. Interview, on 03/07/19 at 12:32 PM, with Resident #221 revealed he/she preferred to be clean-shaven and staff had not assisted him/her to shave for several days. In addition, the resident stated staff had not provided showers as scheduled and staff did not always assist him/her with washing up in the mornings. Review of the Green Unit Assignment Sheet, dated 03/08/19, revealed Resident #221 was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays on second shift. Review of Resident #221's Bathing Report revealed the facility provided a shower for the resident on 02/23/19 (Saturday) and the activity did not occur again until seven (7) days later on 03/02/19 (Saturday). Review of Resident #221's Progress Notes, dated 02/22/19 through 03/02/19, revealed no entries related to staff not providing showers to the resident due to the resident refusing the showers. Interview with and observation of Resident #221, on 03/08/19 at 8:20 AM, revealed the resident remained unshaven. The resident stated staff assisted him/her with a shower the previous evening; however, had not assisted with shaving and he/she agreed to have shaving delayed until today (03/08/19). Interview, on 03/08/19 at 8:25 AM, with Certified Nursing Assistant (CNA) #4 revealed staff had not told her in morning report that she needed to shave Resident #221. She stated her assignment included assisting Resident #221, but since it was not his/her shower day, and she had not received information about shaving him/her in report, she would have not known to offer assistance with shaving the resident. According to the CNA, shaving was part of the showering process and should have been included when staff gave the resident a shower, as it was part of personal hygiene. The CNA stated she made sure she completed resident showers assigned to her unless a resident refused. In addition, she would not know to pick up resident showers from a previous shift unless she was told in report because she was unable to look back at records to see if there were any missed showers. Interview, on 03/08/19 at 8:55 AM, with Licensed Practical Nurse (LPN) #7 revealed residents should receive showers three (3) days a week unless a resident refused. She stated if staff could not provide a scheduled shower to a resident, she asked the CNA to pass it on to the next shift in report. In addition, she stated shaving was part of the showering process and when a CNA provided a shower, the CNA should offer shaving as well. LPN #7 observed Resident #221 and stated the resident had several days beard growth. Interview, on 03/08/19 at 11:41 AM, with Assistant Director of Nursing (ADON) #2 revealed she saw Resident #221 earlier in the morning and noted the resident had up to a week's beard growth. She stated she expected staff to offer shaving to residents when they provided showers and should not delay the shaving to the next shift if the resident wanted to be shaved. The ADON reviewed the Bathing Report for Resident #221 and stated the record showed a gap in showers given. She stated staff should have provided Resident #221 a shower on 02/26/19 (Tuesday) and 02/28/19 (Thursday). She further stated staff should have noted the reason the resident missed the two (2) showers on the shower sheet. According to the ADON, if a resident had not received a scheduled shower, it should have been passed on to next shift or staff should have re-approached the resident later if he/she had refused. She stated she was not aware of a way for the nurses to look back to see if showers had been given. The ADON stated if staff did not provide residents their showers, it posed a risk of skin breakdown, or if the resident's skin was already compromised, the condition could become worse. She stated she was not aware of the facility doing any audits of resident showers. Interview, on 03/08/19 at 3:32 PM, with the Director of Nursing (DON) revealed the facility scheduled showers for residents three (3) times a week and staff was to assist residents with washing their face and peri-care daily and as needed. She stated if a resident refused a shower, the CNA should have documented the refusal and reported it to the nurse. In addition, any showers that the CNAs could not give should have been passed on to the next shift. She stated the risk for residents not having a shower for a week was compromised skin integrity. In addition, CNAs were to offer shaving when providing showers. She stated a resident that wanted to be clean-shaven and was not could result in altered self-image, as the resident might not like the way they looked. Interview, on 03/08/19 at 4:07 PM, with the Administrator revealed staff was to meet residents' needs, which included showers and shaving.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was implemented related to behavior management for one (1) of three (3) sampled residents, Resident #30. Staff did not implement behavioral interventions prior to administration of a [MEDICAL CONDITION] medication ([MEDICATION NAME]). The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/09/18, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident. The policy stated care plan interventions would address the underlying source(s) of the problem area(s) and reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Observation, on 03/06/19 at 11:31 AM, revealed Resident #30 sitting up in bed with his/her eyes closed. Review of the clinical record revealed the facility admitted Resident #30 on 06/04/18, with [DIAGNOSES REDACTED]. Review of the resident's Care Plan for Alteration in Mood State revealed the goal was to reduce or eliminate verbalization of negative thoughts and reduce yelling out episodes. Interventions included offering chaplain services, 1:1 visits for socialization, and encouraging out of room interactions. Review Resident #30's Physician Order, dated 01/10/19, revealed [MEDICATION NAME] 1 milligram (mg) via gastrostomy tube ([DEVICE]) or by mouth twice a day as needed (PRN) for anxiety. Review of the Resident #30's Controlled Drug Records, for [MEDICATION NAME] 1 mg, revealed fifteen (15) doses were signed out in (MONTH) 2019, and thirty-two (32) doses were signed out in (MONTH) 2019. Review of the Progress Notes for Resident #30 revealed there was no clinical rationale for twelve (12) of the [MEDICATION NAME] doses signed out in January, or for thirty-one (31) of the doses in February. In addition, there was no documentation of non-pharmacological interventions attempted, per the care plan, prior to administration of the PRN [MEDICATION NAME]. Interview, on 03/08/19 at 9:45 AM, with Licensed Practical Nurse (LPN) #2 revealed staff was responsible for implementing interventions to manage behaviors, including repositioning the resident, toileting, and offering food or music. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed PRN [MEDICATION NAME] was not a primary intervention to manage a behavior(s) and stated non-pharmacological interventions should be attempted first, such as repositioning and reassuring the resident. Interview with the Director of Nursing (DON), on 03/08/19 at 6:42 PM, revealed Resident #30's care plan interventions were not implemented to ensure management of behaviors. Interview with the Administrator, on 03/08/19 at 8:27 PM, revealed he was not aware of any issues related to implementation of care plans.

Based on observation, interview, and record review, it was determined the facility failed to accommodate residents' needs for one (1) of nineteen (19) sampled residents, Resident #221. Observation revealed the resident's urinal was not within reach of the resident while he/she was in bed. The findings include: Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for toileting. The resident was frequently incontinent of bowel and bladder. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Review of Resident #221's Care Plan, dated 02/28/19, revealed the resident had a self-care deficit with a goal for the resident to maintain Activities of Daily Living self-performance levels. In addition, the resident had an actual or potential for complications associated with urinary incontinence with an intervention for staff to encourage self-performance. Review of the Green Unit Assignment Sheet, dated 03/8/19, revealed Resident #221 required two (2) staff and a mechanical lift for transfers, and the resident's right leg was amputated below the knee. The document noted the resident was on a bowel and bladder training program and staff checked the resident for incontinence and changed briefs as needed every two (2) hours. The Assignment Sheet did not contain information regarding use of a urinal to facilitate independence and increase urinary continence. Observations, on 03/06/19 at 8:45 AM, 03/07/19 at 10:08 AM and 12:32 PM, and 03/08/19 at 8:20 AM, of Resident #221's room revealed a urinal in a plastic bag, which was tied to the resident's bedside table drawer and out of reach of the resident. Interview with Resident #221, on 03/07/19 at 12:33 PM, revealed staff placed the urinal out of reach in a bag tied to the handle of the drawer on the bedside table. The resident stated when in bed, he/she had to use the call light to get staff to hand him/her the urinal, and by the time staff arrived in the room to assist, the resident was not able to wait and urinated on himself/herself. Observation, on 03/08/19 at 8:22 AM, revealed Certified Nursing Assistant (CNA) #4 entered Resident #221's room, assisted the resident with his/her cell phone, and exited the resident's room without moving the resident's urinal within reach of the resident who was in the bed. Interview, on 03/08/19 at 8:25 AM, with CNA #4 revealed staff should have placed the urinal in reach of the resident while he/she was in bed, by hanging the urinal on the side of a trashcan beside the resident's bed. The CNA stated the Assignment Sheet did not have any instructions related to the resident's urinal, but noted the resident was incontinent. The CNA stated if a resident's urinal was out of reach, it could cause the resident to be incontinent. In addition, the CNA stated she did not know staff had left the resident's urinal out of reach. Interview, on 03/08/19 at 8:55 AM, with Licensed Practical Nurse (LPN) #7 revealed staff should have kept the resident's urinal at the bedside within reach of the resident positioned in bed. The LPN observed Resident #221's room and bathroom and stated there was a urinal in a bag in the resident's bathroom and another in a bag tied to the bedside table. She stated urinals should be kept accessible for residents to use, and staff should encourage residents to use the urinal and then press the call light as soon as they were done using the urinal. According to the LPN, when a urinal was out of a resident's reach it put the resident at risk for a fall if the resident attempted to get to the urinal, and being out of reach could cause the resident to have an incontinent episode unnecessarily. Per interview, CNAs and nurses were responsible for ensuring urinals were in reach of the residents. Interview, on 03/08/19 at 11:20 AM, with Assistant Director of Nursing (ADON) #2, revealed she had managed the unit since 01/21/19 and had not addressed expectations for staff related to resident urinals. However, she stated urinals should be clean, in a bag, and stored in reach of the resident, as the resident preferred. She stated the purpose of urinal use was to allow the resident to empty his/her bladder independently. The ADON further stated the best practice was for staff to ensure the resident's urinal was in reach when the resident was in bed. She revealed waiting for help to access the urinal after using a call light increased the resident's risk of incontinence. Interview, on 03/08/19 at 3:51 PM, with the Director of Nursing (DON) revealed staff should keep Resident #221's urinal where he/she could access it at all times in case he/she could not wait for someone to respond to the call light. She further stated CNAs were trained to keep items such as urinals in reach of the residents. Interview, on 03/08/19 at 4:17 PM, with the Administrator revealed staff should keep urinals in reach of resident's who were able to use the urinal independently.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents, Resident #30, was free from unnecessary [MEDICAL CONDITION] medication. Nursing staff did not monitor behaviors or implement non-pharmacological interventions prior to administration of a [MEDICAL CONDITION] medication ([MEDICATION NAME]). The findings include: Review of the facility's Behavior Management Program Overview, not dated, revealed the purpose of the program was to identify and assess for disruptive behaviors in residents in order to develop interventions as appropriate. The policy revealed nursing staff should document each episode of the resident's behavior, precipitating factors, interventions, and outcomes of the interventions with noted side effects of psychoactive medications using the flow record in the Medication Administration Record (MAR). Further review revealed the Clinical Nurse Manager was responsible to ensure the licensed nurses completed the Behavior/Intervention Monthly Flow record correctly in the MAR. Observation, on 03/06/19 at 9:54 AM, revealed Resident #30 was in bed with his/her eyes closed. Review of the clinical record revealed the facility admitted Resident #30 on 06/04/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) and determined he/she was not interviewable. Review of a Physician Order, dated 01/10/19, revealed [MEDICATION NAME] 1 milligram (mg) via gastrostomy tube ([DEVICE]) or by mouth twice a day as needed (PRN), for sixty (60) days for anxiety. Review of Resident #30's Controlled Drug Records, revealed fifteen (15) doses of [MEDICATION NAME] 1 mg PRN were signed out in (MONTH) 2019. Further review revealed thirty-two (32) doses of [MEDICATION NAME] were signed out in (MONTH) 2019. Review of Resident #30's MARs, dated (MONTH) 2019 and (MONTH) 2019, and the Progress Notes for Resident #30, revealed there was no clinical rationale for twelve (12) of the doses of [MEDICATION NAME] signed out in (MONTH) or thirty-one (31) of the doses signed out in February. In addition, there was no documentation indicating non-pharmacological interventions were attempted prior to administration of the PRN [MEDICATION NAME]. Interview, on 03/08/19 at 9:45 AM, with Licensed Practical Nurse (LPN) #2 revealed the nurse was responsible for documenting the behaviors exhibited, non-pharmacological interventions attempted, and the effectiveness of the medication when a psychoactive medication was administered. She stated non-pharmacological interventions would include repositioning the resident, toileting, and offering food or music. LPN #2 stated it was important to document the behaviors, interventions, and effectiveness to effectively manage future behaviors. She further revealed it was important to follow-up with the resident after the medication was given to ensure it was effective and monitor for potential side effects. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed PRN [MEDICATION NAME] was not a primary intervention to manage a behavior(s) and stated non-pharmacological interventions should be attempted first, such as repositioning and reassuring the resident. LPN #1 stated administration of PRN medication should be documented on the MAR, including follow up for effectiveness; however, she did not always document. She further revealed she did not always document the non-pharmacological interventions because she got busy. According to the LPN, a resident could potentially be prescribed a medication they did not need. Interview with the Social Services Director (SSD), on 03/08/19 at 7:57 PM, revealed the interdisciplinary team (IDT) monitored resident behaviors by reviewing progress notes during the morning meeting. He stated behavior monitoring would not be effective if behaviors and interventions were not documented in the clinical record. Interview with the Assistant Director of Nursing (ADON), on 03/08/19 at 4:13 PM, revealed she randomly audited clinical records and was not aware of any issues related to behavior monitoring or PRN psychoactive medication. According to the ADON, behaviors and interventions should be documented in the record to ensure a psychoactive medication was necessary. Interview with the Director of Nursing (DON), on 03/08/19 at 6:42 PM, revealed behavior monitoring would not be effective if all components were not included in the record. She further revealed the psychoactive performance improvement team reviewed clinical records for psychoactive medications and behavior monitoring; however, the team had not met since (MONTH) (YEAR). Interview with the Consultant Pharmacist, on 03/08/19 at 4:46 PM, revealed resident specific behaviors should be documented in the clinical record in order to monitor for effectiveness of a psychoactive medication. The Pharmacist stated he audited MARs and psychoactive medication usage monthly and was not aware of any issues. Interview with the Administrator, on 03/08/19 at 8:27 PM, revealed he was not aware of any issues related to psychoactive medications or behavior monitoring. He stated the IDT reviewed clinical records to identify resident behaviors and implement appropriate interventions; however, it did not appear to be an effective system. According to the Administrator, the facility should have an understanding of the potential impact of medications on residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of nineteen (19) sampled residents, Resident #62. Observation of medication pass revealed Licensed Practical Nurse (LPN) #4 dropped a pill on the medication cart, used her bare fingers to pick up the pill, and put the pill into the medication cup, and administered the medication to Resident #62. In addition, the nurse failed to perform hand hygiene during medication administration. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised (MONTH) (YEAR), revealed all facility personnel was trained and regularly in-serviced on the importance of hand hygiene to prevent the transmission of healthcare-associated infections and followed the handwashing/hand hygiene procedures to help prevention and spread of infections to other personnel, residents, and visitors. The policy stated hand washing was required before and after handling medications, before and after direct contact with residents, and after contact with a resident's intact skin. The policy further stated the use of gloves did not replace hand washing/hand hygiene. The facility recognized the integration of glove use along with routine hand hygiene as the best practice for preventing healthcare-associated infections. Observation of medication pass, on 03/06/19 at 8:48 AM, revealed LPN #4 pushed Resident #62's Potassium pill from the bubble pack and it landed on the medication cart. The nurse used her bare fingers and put the Potassium pill in the medication cup, with the resident's other medications. She entered the resident's room, washed her hands in the resident's bathroom and grabbed a pair of gloves, touched the bathroom door handle, laid the gloves on the bed, and obtained the resident's blood pressure. She administered the oral medications, put on the gloves without performing hand hygiene after touching the door handle, used an alcohol pad to clean an area on the left side of the resident's stomach, and administered an injection of [MEDICATION NAME]. She removed her gloves and left the room without performing hand hygiene. Interview with LPN #4, on 03/06/19 at 9:07 AM, revealed she probably should not have put the Potassium pill into the resident's medication cup because the medication could have been contaminated from germs on the medication cart, and her fingers. She further stated she was educated on how to handle a dropped medication and she was supposed to waste the pill and pop out another pill from the bubble pack. LPN #4 stated she should have washed her hands again after she touched the handle of the resident's bathroom because anything could be on the handle, like germs. She further stated she should have washed her hands again because she gave an injection ([MEDICATION NAME]) and broke the resident's skin, which could cause infections. Interview with the Director of Nursing (DON), on 03/08/19 at 8:16 PM, revealed the medication cart was dirty and there was a potential for cross contamination when the pill landed on the cart and was put in the medication cup with bare hands. The DON stated nurses were to follow the infection control policy related to hand hygiene. Interview with the Administrator, on 03/08/19 at 9:17 PM, revealed staff should follow infection control for handwashing and he was not aware of any issues with infection control prior to today.

Based on interview, record review, and review of the facility's policy, investigations, and Complaint/Grievance Reports, it was determined the facility failed to have an effective system to ensure residents were free from abuse and neglect for four (4) of ten (10) sampled residents, Residents #1, #2, #4, and #5. Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed an allegation of abuse was defined as a report, complaint, grievance, or statement that a reasonable person would understand that abuse was occurring, had occurred, or plausibly might have occurred. Interview with Resident #4's Granddaughter (GD) revealed on 10/12/18 at approximately 10:30 PM, her grandparent called and reported to her State Registered Nurse Aide (SRNA) #3 took off his/her back brace and slung it across the room, told the resident to get himself/herself off the toilet and to bed by himself/herself, and refused to assist the resident with incontinent care by telling the resident he/she was clean enough, then left the room. In addition, Resident #4 told her the night before the same SRNA gave him/her a shower in hot water and when the resident told SRNA #3 the water was too hot, the SRNA continued to give him/her the shower. Resident #4's GD stated she immediately phoned the facility because she felt SRNA #3 was abusive to Resident #4 and reported the incidents to the night shift House Supervisor, Licensed Practical Nurse (LPN) #4, and also completed grievances with the facility the next day. Interview with LPN #4 revealed she received the report from Resident #4's GD but did not report the incident to the Administrator or the Director of Nursing (DON), per the facility's policy and procedures, because she thought Resident #4 might have been confused and considered the resident's concern as a grievance. Review of the facility's Complaint Grievance Report, completed 08/31/18, revealed under Investigation Findings, Resident #5 stated he/she needed assistance with a brief change and an unknown staff member responded to Resident #5's call light. The staff member advised the resident an extra-large brief was the only size and he/she would have to use it. The resident stated he/she requested a smaller size and the staff member told him/her that was the only size. Resident #5 stated the staff member told him/her in fact just do it yourself and left the room. Resident #5 fell while trying to put the brief on without assistance and sustained a skin tear. Resident #5 reported the incident to LPN #5; however, LPN #5 treated the information as a grievance and did not report the allegation that an employee failed to provide services to the DON or the Administrator, per the facility's policy and procedure. Review of a facility Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use his/her urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice and then left the room. Interview with LPN #3 revealed Resident #2 reported to her on 07/20/18, that SRNA #2 cursed him/her, was rude, and had a bad attitude. LPN #3 stated she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of verbal abuse. The facility's failure to ensure residents were free from abuse/neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/16/18, which alleged removal of the Immediate Jeopardy on 11/13/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/13/18, prior to exit on 11/21/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed it was the facility's policy to prevent the occurrence of abuse and neglect and to ensure all alleged occurrences of abuse and neglect were immediately reported and investigated. In addition, the policy stated an allegation of abuse was defined as a report, complaint, grievance, or statement that a reasonable person would understand that abuse was occurring, had occurred, or plausibly might have occurred. The policy stated all staff members would report any allegation of abuse to the charge nurse on duty. Continued review of the facility's policy revealed if the suspected perpetrator was a staff member, the charge nurse would immediately remove the staff person from resident care areas and suspend him/her while the matter was investigated. Directly after assuring that residents involved were safe and secure, and the alleged perpetrator had been removed from the resident care area, the charge nurse would inform the Facility Administrator and the Director of Nursing of the allegation of abuse. Review of the facility's policy, Investigate Complaint/Grievances, last revised 07/19/18, revealed resident-centered healthcare was the priority and mission of the facility. In addition, residents had the right to present a concern or complaint about his/her care and treatment, staff, other residents, and any other concern regarding their facility stay. Further review of the facility's policy revealed all reports of abuse, neglect, misappropriation of resident property, harassment or mistreatment, including injuries of unknown source, must be reported to the Administrator immediately and to the State Agencies as required. Interview with Assistant Director of Nursing (ADON) #1, on 10/17/18 at 3:37 PM and 11/07/18 at 11:08 AM, revealed all allegations of abuse or neglect came through the grievance process. The ADON stated the facility determined through clinical judgement if an allegation was abuse or a resident complaint/grievance. Further interview with ADON #1 revealed he was responsible for investigating grievances regarding nursing care. ADON #1 stated he generated a grievance/complaint report each morning, Monday thru Friday. 1. Record review revealed the facility admitted Resident #4 on 10/08/18, with [DIAGNOSES REDACTED]. Review of a Physician Order, dated 10/08/18, revealed Resident #4 was to wear a Thoracolumbosacral Orthosis (TLSO) brace at all times when out of bed or above a thirty (30) degree angle. Review of the Admission Minimum Data Set (MDS), dated [DATE], for Resident #4, revealed the facility assessed Resident #4's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15). In addition, the assessment revealed Resident #1 required the assistance of one (1) staff member for toileting, transferring, and walking. Interview with Resident #4, on 10/15/18 at 5:30 PM, revealed SRNA #3 had given him a shower in water that was too hot. Resident #4 stated he/she told the SRNA the water was too hot; however, the SRNA continued with the shower. Continued interview with Resident #4 revealed the SRNA used a wash cloth to wash him/her and started with his/her feet and legs. Resident #4 stated the SRNA used the same wash cloth up his/her body to his/her face. Resident #4 stated He was going to use that same wash cloth on my face until I stopped him! Continued interview with Resident #4 revealed the next night the same SRNA, SRNA #3, assisted him/her to the toilet. Resident #4 stated the SRNA took off his/her brace and slung it across the room. Resident #4 stated the SRNA told him/her to get cleaned up by himself/herself and to get himself/herself back to bed. Resident #4 stated I have a broken back and I am not supposed to be up without the brace. Resident #4 stated he/she was fearful of this SRNA and immediately after that happened the resident called his/her granddaughter and told her what happened. Review of a facility Investigation Summary revealed on 10/11/18, SRNA #3 gave Resident #4 a shower and sprayed Resident #4 with water. Resident #4 reported to SRNA #3 that the water was too hot; however, SRNA #3 continued to give Resident #4 the shower. In addition, SRNA #3 washed Resident #4 without soap beginning with his/her lower body and continued up the resident's body. When Resident #4 questioned SRNA #3 about the use of the same rag, SRNA #3 responded to Resident #4 by saying, You're clean enough. In addition, on 10/12/18, while Resident #4 was on the toilet, SRNA #3 removed the resident's physician ordered TLSO brace and tossed the brace in front of the closet. Resident #4 asked SRNA #3 to stay and ensure he/she was clean; however, was told by SRNA #3, You are clean enough and the SRNA left the room for Resident #4 to put himself/herself to bed without the brace. Interview with Resident #4's Granddaughter (GD), on 10/16/18 at 4:10 PM, revealed on 10/12/18 at approximately 10:30 PM, her grandparent called her at home to report staff at the facility was being mean to him/her. Resident #4's GD stated Resident #4 told her he/she was in the bathroom when SRNA #3 took of his/her brace and slung it across the room. Continued interview with Resident #4's GD revealed Resident #4 told her SRNA #3 then told Resident #4 to get himself/herself off the toilet and to bed by himself/herself. In addition, Resident #4 asked SRNA #3 to stay and help him/her get cleaned up and was told by SRNA #3 he/she was clean enough. Resident #4 told her, the night before the same SRNA gave him/her a shower in hot water. Resident #4 told SRNA #3 that the water was too hot; however, SRNA #3 continued to give him/her the shower. Resident #4 also stated SRNA #3 began washing his/her feet and legs and proceed up his/her body to his/her neck with the same washcloth. Resident #4's GD stated she immediately phoned the facility and spoke with the night shift House Supervisor, LPN #4, and reported the incident to her because she believed SRNA #3's behavior was abusive. In addition, Resident #4's GD stated she came in the following morning, which was a Saturday, and completed grievances with the facility. Interview with House Supervisor/LPN #4, on 10/17/18 at 4:53 PM, revealed she received the report from Resident #4's GD on 10/12/18 at approximately 10:55 PM. She stated the GD reported the resident was very upset with the care SRNA #3 provided. The GD stated the aide removed the resident's brace and threw it across the room. In addition, the aide would not help with toileting or assisting the resident to the bed as requested. LPN #4 stated SRNA #3 had already gone home for the evening. Continued interview with LPN #4 revealed she thought Resident #4 might have been confused and considered the resident's concern as a grievance. Interview with SRNA #2, on 10/17/18 at 5:36 PM and 11/07/18 at 6:35 AM, revealed she came in to work on 10/12/18 at 10:30 PM and SRNA #3 had already left for the evening. SRNA #2 stated Resident #4's call light was on and she went into the resident's room to check on him/her and the resident was standing in his/her room by the bathroom door, shaking, without his/her brace, and appeared upset. SRNA #2 stated Resident #4 reported to her SRNA #3 told him/her to toilet self and put himself/herself to bed. SRNA #2 stated Resident #4 reported to her SRNA #3 had showered him/her with hot water. SRNA #2 stated she calmed Resident #4 down and assisted him/her to bed, and then she reported the allegation to LPN #4 who was already aware. Further interview with LPN #4, on 10/17/18 at 4:53 PM, revealed she did not report the incident to the Administrator or the DON per the facility's policy and procedures. LPN #4 stated the report could have been considered an allegation of abuse, but she believed it was just a grievance. Interview with SRNA #3, on 10/18/18 at 9:55 AM, revealed SRNA #3 stated, That is a false allegation, why do they investigate me? Who am I to have to fight? Interview, on 10/17/18 at 3:37 PM and 11/07/18 at 11:08 AM, with ADON #1 revealed he received Resident #4's grievance report on 10/15/18, regarding the incident that happened on 10/12/18. He stated at that time it was considered a potential allegation of abuse. Interview with the DON, on 10/17/18 at 3:00 PM and 11/07/18 at 12:55 PM, revealed she did not identify concerns with the investigation. The DON stated, We don't want to jump to conclusions. Further interview with the DON revealed the facility unsubstantiated the allegation of abuse related to Resident #4. 2. Record review revealed the facility admitted Resident #5 on 05/15/18 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS, dated [DATE], revealed the facility assessed Resident #5's cognition as intact with a BIMS score of fourteen (14) indicating Resident #5 was interviewable. Continued review of the MDS revealed Resident #5 required extensive assistance of one (1) staff member for transferring and toileting. Interview with Resident #5, on 10/15/18 at 5:45 PM, revealed on an unknown date a staff person that he/she had never seen before came into his/her room to help him/her into the bathroom. Resident #5 stated he/she told the staff person he/she needed to use a smaller brief and the unknown staff person threw the brief at him/her and said for him/her to put it on himself/herself. Resident #5 stated the unknown staff person left the bathroom and he/she fell while trying to put on the brief without assistance. Review of a facility Complaint/Grievance Report, dated 08/26/18, revealed on 08/25/18, an unknown staff member entered Resident #5's room to change his/her brief. The unknown staff member attempted to put a size extra-large brief on Resident #5. Resident #5 requested a smaller size and the unknown staff member stated to Resident #5 he/she could wear the size extra-large and told Resident #5 that he/she could just do it himself/herself. The unknown staff member then left the room without assisting the resident. Resident #5 fell while trying to put the brief on without assistance and sustained a skin tear. Interview with LPN #5, on 10/16/18 at 4:39 PM, revealed Resident #5 reported the incident to her on 08/26/18, and Resident #5 told her the incident happened the day before. LPN #5 stated she completed a Complaint/Grievance Report to address the resident's concern. She stated she did not report the allegation to the Administrator or the DON because she did not think it was an allegation of abuse or neglect, just that an unknown employee was rude. LPN #5 stated she should have reported the allegation of verbal abuse and neglect to the Administrator as she had been trained. Interview with ADON #1, on 10/17/18 at 3:37 PM and 11/07/18 at 11:08 AM, revealed he received the grievance on 08/27/18 regarding Resident #5. ADON #1 stated he did not feel the grievance was a potential allegation of abuse or neglect and therefore did not investigate it as an allegation of abuse/neglect, but as a grievance that needed a resolution to the resident's concern. Interview with the DON, on 10/17/18 at 3:15 PM and 11/07/18 at 12:55 PM, revealed she did not feel the allegation was abuse or neglect and the facility did not investigate the allegation to identify the alleged perpetrator. Interview with the Social Worker, on 11/07/18 at 9:49 AM, revealed an instance of staff refusing to provide assistance to a resident, who required staff assistance with Activities of Daily Living, that resulted in a resident fall, would be considered abuse. Interview with the Administrator, on 11/07/18 at 3:33 PM, revealed We felt it was more of a customer service based issue, rather than an allegation of abuse or neglect. 3. Closed record review revealed the facility admitted Resident #1 on 07/10/18, with [DIAGNOSES REDACTED]. Continued record review revealed Resident #1 was discharged home from the facility on 07/31/18 due to no longer needing services. Review of an Admission MDS, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a BIMS score of fourteen (14). In addition, the facility assessed Resident #1 required extensive assistance of one (1) staff member for bed mobility and toileting. Review of a facility Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so that he/she could use his/her urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice. Interview with SRNA #2, on 10/17/18 at 5:21 PM, revealed she overheard a confrontation between Resident #1 and SRNA #1. SRNA #2 stated she could not hear exactly what was being said, but described the confrontation as being loud. In addition, SRNA #2 stated soon after the confrontation, SRNA #1 approached her with angry body language and stated, You are going to have to take care of Resident #1 for the rest of the evening. In addition, SRNA #2 stated she overheard SRNA #1 saying with an attitude that she was frustrated with answering the call lights that same evening. SRNA #2 stated she did not report this to the nurse because the nurse already knew about SRNA #1's attitude. Interview with LPN #1, on 10/17/18 at 3:25 PM, revealed he entered Resident #1's room immediately after the incident and Resident #1 told him he/she would like to know why SRNA #1 was so angry with him/her and stated SRNA #1 sure had a bad attitude tonight. Continued interview with LPN #1 revealed he treated the potential allegation of verbal abuse as a complaint/grievance and did not identify what Resident #1 had reported to him as potential abuse. LPN #1 stated he should have identified what Resident #1 had reported to him as abuse, sent SRNA #1 home, and reported the allegation to the DON. Interview with LPN #2, on 10/17/18 at 6:00 PM, revealed she worked the evening of 07/22/18, and during her shift she heard SRNA #1 swear and curse every time the call lights went off. LPN #2 stated on one occasion during the evening she overheard SRNA #1 tell a resident to stop putting on his/her call light because she was only going to do rounds every two (2) hours and would change the resident at that time and not in between. Further interview with LPN #2 revealed she did not take any immediate action and stated, I should have intervened. LPN #2 stated she did not know why she did not, and stated, I just took care of the residents. Attempted interviews with SRNA #1, on 11/06/18 at 5:10 PM and 11/07/18 at 10:00 AM, via telephone were unsuccessful. Interview with the Administrator and the DON, on 10/16/18 at 1:52 PM, revealed they did not substantiate abuse had occurred by SRNA #1; however, based on the interviews with staff, they did not feel SRNA #1 was a good fit for the facility and her employment was terminated. 4. Record review revealed the facility admitted Resident #2 on 07/20/18, with [DIAGNOSES REDACTED]. Review of an Admission MDS, dated [DATE], revealed the facility assessed Resident #2's cognition as intact with a BIMS score of fifteen (15). In addition, the facility assessed Resident #2 required supervision and physical assistance of one (1) staff for toileting. Review of a facility Investigation Summary, not dated, revealed on 07/20/18 at approximately 10:30 PM, Resident #2 rang the call light in the bathroom for assistance. SRNA #2 entered Resident #2's bathroom and stated to Resident #2, What do you want? Are you ready? How did you get in here? In addition, when Resident #2 got back to bed, he/she became mad and proceeded to the hallway to let the nurse know he/she did not want SRNA #2 back in his/her room. Resident #2 reported to the nurse he/she felt SRNA #2 was rude and had a bad attitude. Interview with Resident #2, on 11/07/18 at 3:08 PM, revealed he/she was admitted to the facility on [DATE], and later that evening a severe storm came through the area and caused the power to go out in the facility. Resident #2 stated he/she needed to use the restroom so he/she used the light from his/her Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine (used for patients with obstructive sleep apnea to assist with breathing) to light the way to the restroom. Resident #2 stated when he/she got into the bathroom, the light on the [MEDICAL CONDITION] went off and he/she rang his/her call light in the bathroom. Resident #2 stated SRNA #2 came in his/her bathroom and said, What do you want? The resident stated he/she felt SRNA #2 was rude and had an attitude. Resident #2 stated he/she was upset regarding SRNA #2's attitude and he/she stepped out in the hallway and reported to the nurse he/she did not want SRNA #2 back in his/her room. Interview with LPN #3, on 10/15/18 at 6:09 PM, revealed she was standing at the nurses' station outside Resident #2's room and observed Resident #2 come into the hallway and say he/she did not want SRNA #2 back in his/her room. LPN #3 stated she talked with Resident #2 and stated the resident reported SRNA #2 cursed at him/her, was rude, and had a bad attitude. LPN #3 stated she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as a potential allegation of verbal abuse and did not take actions per the facility's abuse policy. Interview with SRNA #2, on 11/07/18 at 6:56 AM, revealed when she spoke with Resident #2, she was concerned because he/she was a new resident and was insistent on transferring independently. SRNA #2 stated she was trying to make Resident #2 understand it was dangerous for him/her to transfer independently. SRNA #2 stated after she assisted Resident #2 to bed, the resident got out of bed, came out of his/her room and into the hallway yelling, and stated he/she did not want her back in his/her room. Interview with the House Supervisor, LPN #4, on 10/15/18 at 6:57 PM, revealed she witnessed Resident #2 come out of his/her room and stated the resident was cursing, was very angry, and hostile. LPN #4 stated Resident #2 reported he/she did not want SRNA #2 back in his/her room again because she was rude. THE LPN stated she talked with SRNA #2 and told her not go back into Resident #2's room and allowed SRNA #2 to continue to provide care to other residents, just not to Resident #2. LPN #4 stated she did not immediately report the allegation of verbal abuse to the Administrator or the DON per the facility's policy and because she viewed it as a grievance. Interview with the DON, on 11/07/18 at 12:55 PM, revealed she did not identify a concern regarding staff not immediately reporting the allegation of abuse. The DON stated an allegation that staff was rude might not necessarily be an allegation of abuse. Per interview, she expected staff to treat all residents with dignity and respect. Interview with the Administrator, on 10/18/18 at 5:01 PM, revealed he expected all staff to follow the facility's policy and procedures regarding abuse and neglect. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #4 were discharged from the facility. The Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints with care or staff. 2. The Staff Development Coordinator and Administrator in Training educated staff on 11/07/18 on abuse and neglect, investigating abuse, timely reporting, and rendering care based on the care plan. A posttest was administered and staff not scoring 100% was reeducated. Certified letters were mailed on 11/10/18 to staff not educated informing them they would not be allowed to work until education was completed. 3. The charge nurses completed skin assessments on residents with Brief Interview for Mental Status (BIMS) scores of less than eight (8) on 11/07/18 and 11/08/18 to validate no changes in skin integrity and to observe for signs of distress or fearfulness. No new skin issues or signs of distress or fearfulness were noted. 4. Department leaders (Social Services Director and Assistant, Dietary Manager, Plant Operations, Minimum Data Set (MDS) Nurse, Assistant Director of Nursing (ADON), Business Office Manager, and Quality of Life Director) interviewed residents with BIMS scores greater than eight (8) on 11/08/18 to validate no potential grievance and/or allegation of abuse. The interview resulted in one (1) resident with a reportable incident. 5. Risk Management and Consultants audited grievances on 11/08/18 to determine if resolutions were completed, and validate if any reportable was identified it was reported timely to the appropriate State Agencies. Staff involved with any alleged reportable would be suspended immediately pending investigation. The audit revealed three (3) grievances that required reporting to State Agencies. Grievances would be reviewed daily. 6. The Director of Nursing (DON) and Staff Development from a sister facility, and the MDS Nurse audited care plans and Certified Nursing Assistant (CNA) care plans of all residents by 11/08/18, to ensure they were current and reflected resident status. Care plans would be reviewed Monday through Friday to validate interventions were followed by staff and findings would be reported in the QA committee weekly. 7. The Regional Vice President educated the Chief Executive Officer (CEO) on 11/08/18 regarding administration of a skilled facility, resident rights, quality of care, and professional standards. 8. Corporate oversight would be completed by the Consultant, Regional Vice President, and/or Corporate Risk Management daily until removal of the immediacy, beginning 11/08/18. Subsequent visits would continue two (2) times weekly for four (4) week, then one (1) time per week for twelve (12) weeks. 9. Department leaders and regional staff would round and focus on care provided to the residents every shift. The rounds were initiated on 11/08/18 and included observations of overall Activities of Daily Living (ADL) care as well as random interviews to validate residents' comfort and safety in the facility. The rounds would continue until the immediacy was removed and results of the rounds were reviewed in Quality Assurance Performance Improvement (QAPI). 10. An ad-hoc QAPI meeting was held on 11/08/18 to discuss cited deficiencies and plans to correct. Weekly QAPI meetings would be held until the immediacy was removed, then weekly for four (4) weeks, then monthly. Rounding tools would be reviewed to validate resident care provisions were met. The State Survey Agency validated the facility implemented the following actions: 1. Review of the facility's census revealed Resident #1 and Resident #4 no longer resided at the facility. Record review revealed the Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints regarding care or staff. 2. Interviews, on 11/21/18 at 9:26 AM with Certified Nursing Assistant (CNA) #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with Licensed Practical Nurse (LPN) #3, 10:12 AM with Registered Nurse (RN) #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. Nursing staff revealed they were educated on care plans, to be updated and followed. Interview, on 11/21/18 at 10:34 AM, with the Dietary Manager revealed all staff was educated on the abuse/grievance process. She stated she was educated by leadership, and then helped train other staff. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed she had been trained on abuse, neglect, reporting, and care plans and then she trained staff. Record review revealed staff education with posttests occurred 11/07/18 through 11/12/18. Record review revealed certified letters were sent to staff regarding required education. 3. Record review revealed skin assessments were conducted on 11/07/18 and 11/08/18 with no new issues noted. 4. Record review revealed department leaders interviewed residents on 11/08/18 to identify grievances/abuse and none were noted except for one (1) resident who had a complaint that was reported to the state survey agency and investigated by the facility. 5. Interview with the Administrator, on 11/20/18 at 2:00 PM, revealed grievances were reviewed daily in the morning meeting and assigned to members of leadership for follow-up. Record review revealed the Consultant conducted an audit of grievances on 11/08/18. Three (3) reportable incidents were discovered and reported to the State Survey Agency. The Regional Vice President and Clinical Care Consultant reviewed Accident and Incident reports and Grievances daily. 6. Interview with MDS Nurse #1, on 11/21/18 at 10:54 AM, revealed she reviewed and updated care plans and CNA care plans and the plans were reviewed daily in the clinical meeting. Interview with the Administrator, on 11/21/18 at 2:00 PM, revealed each resident's care plan was reviewed and updated in daily clinical meetings as needed. Record review revealed care plans and CNA care plans were audited on 11/08/18. Updates to the plans were made. 7. Record review revealed the Regional Vice President educated the Administrator on job description and expectations, QAPI, abuse policy and reporting guideline, and investigating complaints and grievances. 8. Record review revealed an Oversight Audit Tool was developed and implemented by the facility. The audit began on 11/8/18 through 11/20/18. The audit tool encompassed an aggregation of a clinical summary report, daily nursing notes, social services notes, accident and incidents, twenty-four (24) hour report, care plan, and CNA care plan. Corporate rounding was conducted 11/08/18 through 11/20/18. 9. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed the leadership team rounded every shift and educated staff with scenarios on how to protect residents from abuse and immediately report to their supervisor. Interviews, on 11/21/18 at 9:26 AM with CNA #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with LPN #3, 10:12 AM with RN #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. They confirmed different members of the Management Staff had been walking around and randomly asking questions about abuse and care plans to various staff. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he did care monitoring observations, which included ADL care, catheter care, and medication pass. If issues were found, staff education occurred immediately. Record review revealed abuse follow-up interviews with staff were conducted 11/08/18 to 11/21/18. Record review revealed resident interviews were conducted 11/08/18 through 11/11/18 Record review revealed care observations were conducted 11/08/18 through 11/19/18. 10. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he attended QAPI meetings and the care audits were discussed. Interview with the DON, on 11/21/18 at 2:10 PM, revealed QAPI meeting were conducted weekly and reviewed audits. Record review

Based on interview, record review, facility investigation review, review of the facility's policies, and review of the Administrator's Job Description, it was determined the facility failed to have an effective system to ensure the facility was administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being for four (4) of ten (10) sampled residents, Resident #1, #2, #4, and #5. Per interview and record review, Resident #1, #2, #4, and #5 made allegations of abuse and/or neglect by staff. The alleged perpetrators were not immediately removed from resident care to prevent further abuse and neglect, and the allegations were not immediately reported to Administration. The initial resident reports regarding care and service issues were viewed by the facility as complaints or grievances. (Refer to F600, F609, and F610) The facility's failure to have an effective system in place to ensure the facility was administered in a manner to keep residents free from abuse/neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/16/18, which alleged removal of the Immediate Jeopardy on 11/13/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/13/18, prior to exit on 11/21/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the Administrator's job description, updated (MONTH) 2011, revealed the Administrator was responsible to lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents. Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, not dated, revealed it was the facility's policy to prevent the occurrence of abuse and neglect and to ensure all alleged occurrences of abuse and neglect were immediately reported and investigated. In addition, the policy stated an allegation of abuse was defined as a report, complaint, grievance, or statement that a reasonable person would understand that abuse was occurring, had occurred, or plausibly might have occurred. The policy stated all staff members would report any allegation of abuse to the charge nurse on duty. Further review revealed if the suspected perpetrator was a staff member, the charge nurse would immediately remove the staff person from resident care areas and suspend him/her while the matter was investigated. Directly after assuring residents involved were safe and secure and the alleged perpetrator had been removed from the resident care areas, the charge nurse would inform the Facility Administrator and the Director of Nursing of the allegation of abuse. Review of the facility's policy, Investigate Complaint/Grievances, last revised 07/19/18, revealed resident-centered healthcare was the priority and mission of the facility. In addition, residents had the right to present a concern or complaint about his/her care and treatment, staff, other residents, and any other concern regarding their facility stay. Further review of the facility's policy revealed all reports of abuse, neglect, misappropriation of resident property, harassment or mistreatment, including injuries of unknown source, must be reported to the Administrator immediately and to the state agencies as required. 1. Interview and record review revealed on 10/11/18, State Registered Nurse Aide (SRNA) #3 gave Resident #4 a shower and sprayed Resident #4 with water, which Resident #4 reported to SRNA #3 was too hot; however, the SRNA continued to give the resident the shower. In addition, SRNA #3 washed Resident #4 without soap beginning with his/her lower body and continued up the resident's body and when Resident #4 questioned SRNA #3 about the use of the same washcloth, SRNA #3 responded to Resident #4 by saying he/she was clean enough. In addition, on 10/12/18, while Resident #4 was on the toilet, SRNA #3 removed the resident's physician ordered back brace and tossed the brace in front of the closet. Resident #4 asked SRNA #3 to stay and ensure he/she was clean; however, SRNA #3 told the resident he/she was clean enough. SRNA #3 left the room and Resident #4 had to put himself/herself to bed without the brace. Resident #4 called his/her granddaughter and reported the allegation and she notified Licensed Practical Nurse (LPN) #4; however, LPN #4 treated the allegation of abuse as a grievance and failed to notify the Director of Nursing (DON) or the Administrator per the facility's policy and procedure. Interview with Resident #4 during the survey revealed the resident remained fearful of SRNA #3. Interview with Administrator, on 11/07/18 at 3:33 PM, revealed the facility did not identify the information Resident #4's granddaughter shared with LPN #4 was abuse at the time. He stated staff should have called him to discuss. 2. Interview and record review revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance and SRNA #1 entered the room and asked the resident what he/she wanted. Resident #1 asked for his/her bed to be adjusted so he/she could use his/her urinal. SRNA #1 told the resident in a loud and angry tone of voice she was not messing with him/her, and to solve it himself/herself. The resident reported the allegation to LPN #1; however, the LPN did not report the allegation of verbal abuse to the DON or the Administrator per the facility's policy and procedure. In addition, on 07/22/18, LPN #2 heard SRNA #1 swear and curse when the call lights went off and heard SRNA #1 tell a resident to stop putting on his/her call light because she was going to do rounds every two (2) hours and would change the resident at that time and not in between. LPN #2 did not take any immediate action to protect the residents and did not immediately report the allegation to the Administrator or the DON. Interview with the Administrator, on 10/16/18 at 1:52 PM, revealed the facility did not substantiate abuse had occurred to Resident #1 by SRNA #1; however, based on the interviews with staff, they did not feel SRNA #1 was a good fit for the facility and her employment was terminated. 3. Interview and record review revealed Resident #2 reported to LPN #3 on 07/20/18, that SRNA #2 cursed him/her, was rude, and had a bad attitude. LPN #3 stated she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of verbal abuse; therefore, no immediate action was taken to protect residents from potential further abuse. Interview with the Administrator, on 10/18/18 at 5:01 PM, revealed if staff had a reason for concern related to Resident #2's care, then follow-up regarding the concern should happen. He stated he expected all staff to follow the facility's policy and procedure regarding abuse and neglect. 4. Interview and record review revealed on 08/24/18, an unknown staff member entered Resident #5's room to change his/her brief. The unknown staff attempted to put a size extra-large brief on Resident #5 and the resident requested a smaller size and the unknown staff told the resident he/she could wear the extra-large and left the room without assisting the resident. Resident #5 fell while trying to put the brief on without assistance and sustained a skin tear. Resident #5 reported the allegation to LPN #5; however, LPN #5 treated the allegation of neglect as a grievance and did not report the allegation to the DON or to the Administrator per the facility's policy and procedure. Interview with the Administrator, on 11/07/18 at 3:33 PM, revealed he regarded Resident #5's report as a customer service based issue, rather than an allegation of abuse or neglect. Continued interview with the Administrator, on 11/07/18 at 3:33 PM, revealed he expected all staff to follow the facility's policy and procedures. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #4 were discharged from the facility. The Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints with care or staff. 2. The Staff Development Coordinator and Administrator in Training educated staff on 11/07/18 on abuse and neglect, investigating abuse, timely reporting, and rendering care based on the care plan. A posttest was administered and staff not scoring 100% was reeducated. Certified letters were mailed on 11/10/18 to staff not educated informing them they would not be allowed to work until education was completed. 3. The charge nurses completed skin assessments on residents with Brief Interview for Mental Status (BIMS) scores of less than eight (8) on 11/07/18 and 11/08/18 to validate no changes in skin integrity and to observe for signs of distress or fearfulness. No new skin issues or signs of distress or fearfulness were noted. 4. Department leaders (Social Services Director and Assistant, Dietary Manager, Plant Operations, Minimum Data Set (MDS) Nurse, Assistant Director of Nursing (ADON), Business Office Manager, and Quality of Life Director) interviewed residents with BIMS scores greater than eight (8) on 11/08/18 to validate no potential grievance and/or allegation of abuse. The interview resulted in one (1) resident with a reportable incident. 5. Risk Management and Consultants audited grievances on 11/08/18 to determine if resolutions were completed, and validate if any reportable was identified it was reported timely to the appropriate State Agencies. Staff involved with any alleged reportable would be suspended immediately pending investigation. The audit revealed three (3) grievances that required reporting to State Agencies. Grievances would be reviewed daily. 6. The Director of Nursing (DON) and Staff Development from a sister facility, and the MDS Nurse audited care plans and Certified Nursing Assistant (CNA) care plans of all residents by 11/08/18, to ensure they were current and reflected resident status. Care plans would be reviewed Monday through Friday to validate interventions were followed by staff and findings would be reported in the QA committee weekly. 7. The Regional Vice President educated the Chief Executive Officer (CEO) on 11/08/18 regarding administration of a skilled facility, resident rights, quality of care, and professional standards. 8. Corporate oversight would be completed by the Consultant, Regional Vice President, and/or Corporate Risk Management daily until removal of the immediacy, beginning 11/08/18. Subsequent visits would continue two (2) times weekly for four (4) week, then one (1) time per week for twelve (12) weeks. 9. Department leaders and regional staff would round and focus on care provided to the residents every shift. The rounds were initiated on 11/08/18 and included observations of overall Activities of Daily Living (ADL) care as well as random interviews to validate residents' comfort and safety in the facility. The rounds would continue until the immediacy was removed and results of the rounds were reviewed in Quality Assurance Performance Improvement (QAPI). 10. An ad-hoc QAPI meeting was held on 11/08/18 to discuss cited deficiencies and plans to correct. Weekly QAPI meetings would be held until the immediacy was removed, then weekly for four (4) weeks, then monthly. Rounding tools would be reviewed to validate resident care provisions were met. The State Survey Agency validated the facility implemented the following actions: 1. Review of the facility's census revealed Resident #1 and Resident #4 no longer resided at the facility. Record review revealed the Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints regarding care or staff. 2. Interviews, on 11/21/18 at 9:26 AM with Certified Nursing Assistant (CNA) #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with Licensed Practical Nurse (LPN) #3, 10:12 AM with Registered Nurse (RN) #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. Nursing staff revealed they were educated on care plans, to be updated and followed. Interview, on 11/21/18 at 10:34 AM, with the Dietary Manager revealed all staff was educated on the abuse/grievance process. She stated she was educated by leadership, and then helped train other staff. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed she had been trained on abuse, neglect, reporting, and care plans and then she trained staff. Record review revealed staff education with posttests occurred 11/07/18 through 11/12/18. Record review revealed certified letters were sent to staff regarding required education. 3. Record review revealed skin assessments were conducted on 11/07/18 and 11/08/18 with no new issues noted. 4. Record review revealed department leaders interviewed residents on 11/08/18 to identify grievances/abuse and none were noted except for one (1) resident who had a complaint that was reported to the state survey agency and investigated by the facility. 5. Interview with the Administrator, on 11/20/18 at 2:00 PM, revealed grievances were reviewed daily in the morning meeting and assigned to members of leadership for follow-up. Record review revealed the Consultant conducted an audit of grievances on 11/08/18. Three (3) reportable incidents were discovered and reported to the State Survey Agency. The Regional Vice President and Clinical Care Consultant reviewed Accident and Incident reports and Grievances daily. 6. Interview with MDS Nurse #1, on 11/21/18 at 10:54 AM, revealed she reviewed and updated care plans and CNA care plans and the plans were reviewed daily in the clinical meeting. Interview with the Administrator, on 11/21/18 at 2:00 PM, revealed each resident's care plan was reviewed and updated in daily clinical meetings as needed. Record review revealed care plans and CNA care plans were audited on 11/08/18. Updates to the plans were made. 7. Record review revealed the Regional Vice President educated the Administrator on job description and expectations, QAPI, abuse policy and reporting guideline, and investigating complaints and grievances. 8. Record review revealed an Oversight Audit Tool was developed and implemented by the facility. The audit began on 11/8/18 through 11/20/18. The audit tool encompassed an aggregation of a clinical summary report, daily nursing notes, social services notes, accident and incidents, twenty-four (24) hour report, care plan, and CNA care plan. Corporate rounding was conducted 11/08/18 through 11/20/18. 9. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed the leadership team rounded every shift and educated staff with scenarios on how to protect residents from abuse and immediately report to their supervisor. Interviews, on 11/21/18 at 9:26 AM with CNA #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with LPN #3, 10:12 AM with RN #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. They confirmed different members of the Management Staff had been walking around and randomly asking questions about abuse and care plans to various staff. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he did care monitoring observations, which included ADL care, catheter care, and medication pass. If issues were found, staff education occurred immediately. Record review revealed abuse follow-up interviews with staff were conducted 11/08/18 to 11/21/18. Record review revealed resident interviews were conducted 11/08/18 through 11/11/18 Record review revealed care observations were conducted 11/08/18 through 11/19/18. 10. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he attended QAPI meetings and the care audits were discussed. Interview with the DON, on 11/21/18 at 2:10 PM, revealed QAPI meeting were conducted weekly and reviewed audits. Record review revealed QAPI meetings were held on 11/08/18, 11/12/18, and 11/19/18. The next QAPI meeting was scheduled for 11/26/18.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system to ensure allegations of abuse and neglect were reported to the authorities no later than twenty-four (24) hours for four (4) of ten (10) sampled residents, Resident #1, #2, #4, and #5. (Refer to F600) Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed it was the facility's policy to prevent the occurrence of abuse and neglect and to ensure all alleged occurrences of abuse and neglect were immediately reported. Interview with Resident #4's Granddaughter (GD) revealed on 10/12/18 at approximately 10:30 PM, her grandparent called her at home and reported to her staff at the facility was being mean to him/her. Resident #4's GD stated she immediately phoned the facility and spoke with the night shift House Supervisor/Licensed Practical Nurse (LPN) #4 and reported the incident to her because she believed State Registered Nurse Aide (SRNA) #3's behavior was abusive. Interview with LPN #4 revealed she received the report from the Resident #4's GD on 10/12/18 at approximately 10:55 PM. LPN #4 revealed she did not report the incident to the Administrator or the Director Of Nursing (DON) per the facility's policy and procedures because she believed the resident was confused. Review of Verification of Investigation, not dated, revealed the incident was not reported to the authorities until three (3) days later, on 10/15/18. Review of the facility's Complaint/Grievance Report, dated 08/26/18, revealed on 08/25/18, an unknown staff member entered Resident #5's room to change his/her brief. The unknown staff member attempted to put a size extra-large brief on Resident #5. Resident #5 requested a smaller size and the unknown staff member told Resident #5 he/she could wear the size extra-large and could just do it himself/herself. The unknown staff member left the room without assisting the resident. Resident #5 reported the allegation to LPN #5; however, LPN #5 treated the allegation of neglect as a grievance and did not report the allegation to the DON or to the Administrator per the facility's policy and procedure. Further review of the Complaint/Grievance Report revealed the incident was not reportable to the State Agency. On 10/15/18, Resident #2 informed LPN #3 he/she did not want SRNA #2 back in his/her room. LPN #3 stated the resident reported SRNA #2 was rude, cussed him/her, and had a bad attitude. However, LPN #3 felt the resident's report was a grievance, told SRNA #2 not to go back into Resident #2's room for the rest of the evening, and did not notify the DON or Administrator. Review of the facility's Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use the urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice. Interview with LPN #2 revealed she heard SRNA #1 swear and curse every time the call lights went off during her shift on 07/22/18. LPN #2 stated on one occasion during the evening she overheard SRNA #1 tell a resident to stop putting on his/her call light because she was only going to do rounds every two (2) hours and would change the resident at that time and not in between. Further interview with LPN #2 revealed she did not report what she heard or observed to the Administrator or the DON until several days later during the investigation. The facility's failure to report allegations of abuse timely has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/16/18, which alleged removal of the Immediate Jeopardy on 11/13/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/13/18, prior to exit on 11/21/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed it was the facility's policy to prevent the occurrence of abuse and neglect and to ensure all alleged occurrences of abuse and neglect were immediately reported and investigated. The policy stated all staff members would report any allegation of abuse to the charge nurse on duty and the charge nurse would inform the Facility Administrator and the Director of Nursing of the allegation of abuse. Continued review revealed any abuse allegation would be reported to the State within two (2) hours of the time the allegation was received. Review of the facility's policy, Investigate Complaint/Grievances, last revised 07/19/18, revealed all reports of abuse, neglect, misappropriation of resident property, harassment or mistreatment, including injuries of unknown source, must be reported to the Administrator immediately and to the State Agencies as required. 1. Review of the facility's Verification of Investigation report, not dated, revealed on 10/11/18, SRNA #3 gave Resident #4 a shower and sprayed Resident #4 with water. Resident #4 reported to SRNA #3 the water was too hot; however, SRNA #3 continued to give Resident #4 the shower. In addition, SRNA #3 washed Resident #4 without soap beginning with his/her lower body and continued up the resident's body. When Resident #4 questioned SRNA #3 about the use of the same rag, SRNA #3 responded to Resident #4 by saying you're clean enough. Further Review of Verification of Investigation, revealed the incident was not reported to the authorities until three (3) days later, on 10/15/18. In addition, on 10/12/18, while Resident #4 was on the toilet, SRNA #3 removed the resident's physician ordered TLSO brace and tossed the brace in front of the closet. Resident #4 asked SRNA #3 to stay and ensure he/she was clean; however, was told by SRNA #3 he/she was clean enough and the SRNA left the room for the Resident #4 to put himself/herself to bed without the brace on or with staff assistance. On 10/17/18 at 5:36 PM and 11/07/18 at 6:35 AM, interview with SRNA #2 revealed Resident #4 reported to her what had happened with SRNA #3. SRNA #2 stated she reported the allegation to LPN #4 who was already aware. Interview with Resident #4's GD, on 10/16/18 at 4:10 PM, revealed on 10/12/18 at approximately 10:30 PM, her grandparent called her at home and reported to her staff at the facility was being mean to him/her. Resident #4's GD stated she immediately phoned the facility and spoke with the night shift House Supervisor, LPN #4, and reported the incident to her. In addition, Resident #4's GD stated she came in the following morning, which was a Saturday morning, and completed grievances with the facility. Interview with LPN #4, on 10/17/18 at 4:53 PM, revealed she received the report from Resident #4's GD on 10/12/18 at approximately 10:55 PM. Continued interview with LPN #4 revealed she did not report the incident to the Administrator or the DON per the facility's policy and procedure because she spoke to the nurse working with Resident #4, RN #1, who told her he saw SRNA #3 helping Resident #4 to bed that evening. LPN #4 stated she thought Resident #4 might have been confused and considered the resident's concern as a grievance and not a reportable allegation. Interview with the DON, on 10/17/18 at 3:00 PM and 11/07/18 at 12:55 PM, revealed she expected staff to treat all residents with dignity and respect. The DON stated the facility did not identify potential abuse was going on when the report was received. In addition, since the resident did not state he/she was abused, the facility did not think abuse had occurred. The DON stated she did not identify concerns with staff reporting allegations timely. Also she did not have concerns with the way the facility handled the investigation and stated, We don't want to jump to conclusions when a resident made a report. Further interview with the DON revealed the facility unsubstantiated the allegation of abuse. 2. Review of a facility Complaint/Grievance Report dated 08/26/18, revealed on 08/25/18, an unknown staff member entered Resident #5's room to change his/her brief. The unknown staff member attempted to put a size extra-large brief on Resident #5. Resident #5 requested a smaller size and the unknown staff member told Resident #5 he/she could wear the size extra-large and could just do it himself/herself. The unknown staff member then left the room without assisting the resident. Resident #5 fell while trying to put the brief on without assistance and sustained a skin tear. Interview with LPN #5, on 10/16/18 at 4:39 PM, revealed Resident #5 reported the incident to her on 08/26/18 and she completed a Complaint/Grievance Report to address the resident's concern. LPN #5 stated she did not report the allegation to the Administrator or the DON because she did not think it was an allegation of abuse or neglect, just the unknown employee was rude. LPN #5 stated she should have reported the allegation of verbal abuse and neglect to the Administrator as she had been trained. Interview, on 10/17/18 at 3:37 PM and 11/07/18 at 11:08 AM, with Assistant Director of Nursing (ADON) #1 revealed he received the grievance on 08/27/18 regarding Resident #5. ADON #1 stated he did not feel the grievance was an allegation of abuse or neglect. Interview with the DON, on 10/17/18 at 3:15 PM and 11/07/18 at 12:55 PM, revealed she did not feel the allegation was abuse or neglect so the facility did not report the allegation to the State Agency per the facility's policy and procedure. Interview with the Administrator, on 11/07/18 at 3:33 PM, revealed they thought this issue was more of a customer service based issue, rather than an allegation of abuse or neglect. 3. Review of the facility's Investigation Summary, not dated, revealed on 07/20/18 at approximately 10:30 PM, Resident #2 rang the call light in the bathroom for assistance. SRNA #2 entered Resident #2's bathroom and stated to Resident #2, What do you want? Are you ready? How did you get in here? In addition, when Resident #2 got back to bed, he/she became mad and proceeded to the hallway to let the nurse know he/she did not want SRNA #2 back in his/her room. Resident #2 reported to the nurse he/she felt SRNA #2 was rude and had a bad attitude. Continued review revealed the allegation was reportable to the State; however, the allegation was not reported until three (3) days later, on 07/23/18, and was not reported to the State Agency within twenty-four (24) hours, as required. Interview with LPN #3, on 10/15/18 at 6:09 PM, revealed she talked with Resident #2 and the resident reported SRNA #2 was rude, cussed him/her, and had a bad attitude. LPN #3 stated she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of abuse and did not report the allegation to the DON as required. Interview, on 10/15/18 at 6:57 PM, with the House Supervisor, LPN #4, revealed Resident #2 reported he/she did not want the rude SRNA back in his/her room again. The LPN #4 stated she talked with SRNA #2 and told her not go back into Resident #2's room. LPN #4 stated she did not immediately report the allegation of potential verbal abuse to the Administrator or the DON per the facility's policy and stated she viewed it as a grievance. Interview with the DON, on 10/16/18 at 2:30 PM and 11/07/18 at 12:55 PM, revealed the facility received a grievance on 07/23/18 from Resident #2 regarding the behavior of SRNA #2. She stated an investigation was started; however, during the investigation she did not identify a concern regarding staff not immediately reporting the allegation of abuse. She stated, We don't jump to conclusions when a resident says that staff are rude. 4. Review of a facility Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use the urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice. Interview, on 10/17/18 at 5:21 PM, with SRNA #2 revealed she overheard a confrontation between Resident #1 and SRNA #1 but she did not report this to the nurse because the nurse already knew about SRNA #1's attitude. Interview with LPN #1, on 10/17/18 at 3:25 PM, revealed he entered Resident #1's room immediately after the incident and Resident #1 stated to him he/she would like to know why SRNA #1 was so angry with him/her and stated SRNA #1 sure had a bad attitude tonight. Continued interview with LPN #1 revealed he treated the potential allegation of verbal abuse as a complaint/grievance and did not identify what Resident #1 had reported to him as potential abuse. LPN #1 stated he should have identified what Resident #1 had reported to him as abuse. The LPN stated he did not report the allegation to the DON. Interview, on 10/17/18 at 6:00 PM, with LPN #2 revealed she heard SRNA #1 swear and curse every time the call lights would go off during her shift on 07/22/18, and also overheard SRNA #1 tell a resident to stop putting on his/her call light because she was only going to do rounds every two (2) hours and would change the resident at that time and not in between. Further interview, with LPN #2 revealed she did not report what she heard or observed to the Administrator or the DON until several days later, when the DON interviewed her about the incident with Resident #1. LPN #2 stated, I should have intervened. LPN #2 stated she did not know why she did not, and stated, I just took care of the residents. Interview with the Administrator and the DON, on 10/16/18 at 1:52 PM, revealed staff did not report Resident #1's comments because they believed the report was a grievance and the resident did not say he/she was abused. They stated the facility did not substantiate abuse had occurred by SRNA #1; however, based on the interviews with staff, they did not feel SRNA #1 was a good fit for the facility and her employment was terminated. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #4 were discharged from the facility. The Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints with care or staff. 2. The Staff Development Coordinator and Administrator in Training educated staff on 11/07/18 on abuse and neglect, investigating abuse, timely reporting, and rendering care based on the care plan. A posttest was administered and staff not scoring 100% was reeducated. Certified letters were mailed on 11/10/18 to staff not educated informing them they would not be allowed to work until education was completed. 3. The charge nurses completed skin assessments on residents with Brief Interview for Mental Status (BIMS) scores of less than eight (8) on 11/07/18 and 11/08/18 to validate no changes in skin integrity and to observe for signs of distress or fearfulness. No new skin issues or signs of distress or fearfulness were noted. 4. Department leaders (Social Services Director and Assistant, Dietary Manager, Plant Operations, Minimum Data Set (MDS) Nurse, Assistant Director of Nursing (ADON), Business Office Manager, and Quality of Life Director) interviewed residents with BIMS scores greater than eight (8) on 11/08/18 to validate no potential grievance and/or allegation of abuse. The interview resulted in one (1) resident with a reportable incident. 5. Risk Management and Consultants audited grievances on 11/08/18 to determine if resolutions were completed, and validate if any reportable was identified it was reported timely to the appropriate State Agencies. Staff involved with any alleged reportable would be suspended immediately pending investigation. The audit revealed three (3) grievances that required reporting to State Agencies. Grievances would be reviewed daily. 6. The Director of Nursing (DON) and Staff Development from a sister facility, and the MDS Nurse audited care plans and Certified Nursing Assistant (CNA) care plans of all residents by 11/08/18, to ensure they were current and reflected resident status. Care plans would be reviewed Monday through Friday to validate interventions were followed by staff and findings would be reported in the QA committee weekly. 7. The Regional Vice President educated the Chief Executive Officer (CEO) on 11/08/18 regarding administration of a skilled facility, resident rights, quality of care, and professional standards. 8. Corporate oversight would be completed by the Consultant, Regional Vice President, and/or Corporate Risk Management daily until removal of the immediacy, beginning 11/08/18. Subsequent visits would continue two (2) times weekly for four (4) week, then one (1) time per week for twelve (12) weeks. 9. Department leaders and regional staff would round and focus on care provided to the residents every shift. The rounds were initiated on 11/08/18 and included observations of overall Activities of Daily Living (ADL) care as well as random interviews to validate residents' comfort and safety in the facility. The rounds would continue until the immediacy was removed and results of the rounds were reviewed in Quality Assurance Performance Improvement (QAPI). 10. An ad-hoc QAPI meeting was held on 11/08/18 to discuss cited deficiencies and plans to correct. Weekly QAPI meetings would be held until the immediacy was removed, then weekly for four (4) weeks, then monthly. Rounding tools would be reviewed to validate resident care provisions were met. The State Survey Agency validated the facility implemented the following actions: 1. Review of the facility's census revealed Resident #1 and Resident #4 no longer resided at the facility. Record review revealed the Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints regarding care or staff. 2. Interviews, on 11/21/18 at 9:26 AM with Certified Nursing Assistant (CNA) #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with Licensed Practical Nurse (LPN) #3, 10:12 AM with Registered Nurse (RN) #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. Nursing staff revealed they were educated on care plans, to be updated and followed. Interview, on 11/21/18 at 10:34 AM, with the Dietary Manager revealed all staff was educated on the abuse/grievance process. She stated she was educated by leadership, and then helped train other staff. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed she had been trained on abuse, neglect, reporting, and care plans and then she trained staff. Record review revealed staff education with posttests occurred 11/07/18 through 11/12/18. Record review revealed certified letters were sent to staff regarding required education. 3. Record review revealed skin assessments were conducted on 11/07/18 and 11/08/18 with no new issues noted. 4. Record review revealed department leaders interviewed residents on 11/08/18 to identify grievances/abuse and none were noted except for one (1) resident who had a complaint that was reported to the state survey agency and investigated by the facility. 5. Interview with the Administrator, on 11/20/18 at 2:00 PM, revealed grievances were reviewed daily in the morning meeting and assigned to members of leadership for follow-up. Record review revealed the Consultant conducted an audit of grievances on 11/08/18. Three (3) reportable incidents were discovered and reported to the State Survey Agency. The Regional Vice President and Clinical Care Consultant reviewed Accident and Incident reports and Grievances daily. 6. Interview with MDS Nurse #1, on 11/21/18 at 10:54 AM, revealed she reviewed and updated care plans and CNA care plans and the plans were reviewed daily in the clinical meeting. Interview with the Administrator, on 11/21/18 at 2:00 PM, revealed each resident's care plan was reviewed and updated in daily clinical meetings as needed. Record review revealed care plans and CNA care plans were audited on 11/08/18. Updates to the plans were made. 7. Record review revealed the Regional Vice President educated the Administrator on job description and expectations, QAPI, abuse policy and reporting guideline, and investigating complaints and grievances. 8. Record review revealed an Oversight Audit Tool was developed and implemented by the facility. The audit began on 11/8/18 through 11/20/18. The audit tool encompassed an aggregation of a clinical summary report, daily nursing notes, social services notes, accident and incidents, twenty-four (24) hour report, care plan, and CNA care plan. Corporate rounding was conducted 11/08/18 through 11/20/18. 9. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed the leadership team rounded every shift and educated staff with scenarios on how to protect residents from abuse and immediately report to their supervisor. Interviews, on 11/21/18 at 9:26 AM with CNA #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with LPN #3, 10:12 AM with RN #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. They confirmed different members of the Management Staff had been walking around and randomly asking questions about abuse and care plans to various staff. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he did care monitoring observations, which included ADL care, catheter care, and medication pass. If issues were found, staff education occurred immediately. Record review revealed abuse follow-up interviews with staff were conducted 11/08/18 to 11/21/18. Record review revealed resident interviews were conducted 11/08/18 through 11/11/18 Record review revealed care observations were conducted 11/08/18 through 11/19/18. 10. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he attended QAPI meetings and the care audits were discussed. Interview with the DON, on 11/21/18 at 2:10 PM, revealed QAPI meeting were conducted weekly and reviewed audits. Record review revealed QAPI meetings were held on 11/08/18, 11/12/18, and 11/19/18. The next QAPI meeting was scheduled for 11/26/18.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to implement the plan of care for three (3) of ten (10) sampled residents, Resident #1, #4, and #5. Record review revealed Resident #4 was admitted to the facility with a T-7 Compression Fracture ([MEDICAL CONDITION]). Review of an Interim Admission Care Plan dated 10/08/18 revealed staff was to provide Activities of Daily Living (ADL) care to ensure daily needs were met and assist the resident with toileting and transfers as needed. Interview with the physician revealed the resident was required to wear the brace to stabilize balance and to prevent re-injury. On 10/12/18, while Resident #4 was on the toilet, State Registered Nurse Aide (SRNA) #3 removed the resident's back brace and tossed the brace in front of the closet. Resident #4 asked SRNA #3 to stay and help with toileting and transferring back to the bed; however, SRNA #3 left the room and did not provided the requested assistance, as per the care plan. Record review revealed the facility assessed Resident #5 required extensive assistance of one (1) staff to transfer and for toileting. Review of the resident's Care Plan revealed the resident was at risk for falls and staff was to assist Resident #5 with transfers and ambulation as needed. In addition, Resident #5 required staff to provide all ADL care to ensure his/her daily needs were met and provide Resident #5 with the amount of assistance needed for toileting. On 08/24/18, an unknown staff member entered Resident #5's room to change his/her brief and attempted to put a size extra-large brief on the resident. Resident #5 requested a smaller size and the unknown staff told the resident he/she could wear the extra-large, could do it himself/herself, and left the room without assisting the resident. Resident #5 fell while trying to put the brief on without assistance, per the care plan, and sustained a skin tear. Resident #1 was admitted to the facility on [DATE], and the Interim Admission Care Plan revealed staff was to provide ADL care to ensure daily needs were met and assist Resident #1 with toileting and transfers as needed. The facility assessed Resident #1 required extensive assistance of one (1) staff for bed mobility and toileting. On 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance and SRNA #1 entered the room and asked what the resident wanted. Resident #1 told the SRNA he/she needed his/her bed adjusted so he/she could use his/her urinal. SRNA #1 told the resident she was not messing with him/her and to solve it himself/herself. The SRNA did not assist the resident, as per the care plan. The facility's failure to implement the residents' plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/16/18, which alleged removal of the Immediate Jeopardy on 11/13/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/13/18, prior to exit on 11/21/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Comprehensive Care Plans, not dated, revealed the facility would develop a person-centered Comprehensive Care Plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. Further review revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes and would reflect the action, treatment, or procedure to meet the objectives toward achieving the resident goals. 1. Review of Resident #4's clinical record revealed the facility admitted the resident on 10/08/18, with [DIAGNOSES REDACTED]. Review of a Physician Order, dated 10/08/18, revealed Resident #4 was to wear a Thoracolumbosacral Orthosis (TLSO) brace at all times when out of bed or above a thirty (30) degree angle. Review of an Interim Admission Care Plan, dated 10/08/18, revealed staff was to provide ADL care to ensure daily needs were met. In addition, staff was to assist Resident #4 with toileting and transfers as needed. Interview with Resident #4, on 10/15/18 at 5:30 PM, revealed SRNA #3 assisted him/her to the toilet and took off his/her brace and slung it across the room. Resident #4 stated the SRNA told him/her to get cleaned up by himself/herself and to get himself/herself back to bed. Resident #4 stated he/she had a broken back and was not supposed to be up without the brace on. Review of a facility Investigation Summary revealed on 10/12/18, while Resident #4 was on the toilet, SRNA #3 removed the resident's TLSO brace and tossed the brace in front of the closet. Resident #4 asked SRNA #3 to stay and ensure he/she was clean; however, the SRNA #3 told him/her he/she was clean enough and the SRNA left the room and did not assist Resident #4 to bed or assist to put the brace on. Interview with SRNA #2, on 10/17/18 at 5:36 PM and 11/07/18 at 6:35 AM, revealed she worked on 10/12/18 at 10:30 PM and SRNA #3 had just left for the evening. SRNA #2 stated Resident #4's call light was on and she went into the resident's room to check on him/her and the resident was standing in his/her room by the bathroom door without his/her brace on and appeared upset. SRNA #2 stated Resident #4 reported to her what had happened with SRNA #3 and she calmed the resident down and assisted him/her to bed. Continued interview with SRNA #2 revealed SRNAs were responsible to ensure the interventions on the care plan were followed and at the beginning of each shift, they got an assignment sheet and report from the nurses. Interview with LPN #6, on 11/06/18 at 4:21 PM, revealed she worked on 10/12/18 and observed Resident #4 was upset; however, stated the resident did not report anything to him/her. LPN #6 stated all staff was responsible for carrying out interventions on the resident's care plan and there was a care plan binder at the nurses' station. She stated staff was to get report and review the care plans at the beginning of each shift and the SRNAs got report at the beginning of each shift and got a copy of each resident's interventions on their assignment sheets. Further interview with LPN #6 revealed the nurses were responsible for ensuring the care plans were followed for each resident, which was done through rounding and observing care. 2. Review of Resident #5's clinical record revealed the facility admitted the resident on 05/15/18, with [DIAGNOSES REDACTED]. Review of a Quarterly MDS, dated [DATE], revealed the facility assessed Resident #5 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15) and determined the resident was interviewable. Per the MDS, Resident #5 required extensive assistance of one (1) staff for transferring and toileting. Review of the Care Plan, dated 07/30/18, revealed Resident #5 was at risk for falls and staff was to assist the resident with transfers and ambulation as needed. In addition, staff was to provide all ADL care to ensure his/her daily needs were met, and provide the resident with the amount of assistance needed for toileting. Interview with Resident #5, on 10/15/18 at 5:45 PM, revealed on an unknown date a staff person he/she had never seen before came into his/her room to help him/her into the bathroom. Resident #5 stated he/she told the staff he/she needed to use a smaller brief and the unknown staff threw the brief at him/her and said for him/her to put it on himself/herself. Resident #5 stated the unknown staff left the bathroom and he/she fell trying to put on the brief without assistance. Review of a facility Complaint/Grievance Report, dated 08/26/18, revealed on 08/25/18, an unknown staff member entered Resident #5's room to change his/her brief and attempted to put a size extra-large brief on the resident. Resident #5 requested a smaller size and the unknown staff told the resident he/she could wear the size extra-large and do it himself/herself. The unknown staff then left the room without assisting the resident and the resident fell while trying to put the brief on without assistance and sustained a skin tear. Interview with LPN #3, on 11/07/18 at 11:47 AM, revealed all staff was responsible for carrying out interventions on the resident care plans and staff was to get report and review the care plans at the beginning of each shift. 3. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/10/18, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fourteen (14) of fifteen (15) and determined the resident interviewable. In addition, the facility assessed Resident #1 required extensive assistance of one (1) staff for bed mobility and toileting. Review of a facility Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance and SRNA #1 entered Resident #1's room and asked the resident what he/she wanted. Resident #1 stated he/she needed his/her bed adjusted so he/she could use his/her urinal and SRNA #1 told the resident she was not messing with him/her and to solve it himself/herself. Interview with SRNA #2, on 10/17/18 at 5:21 PM and 11/07/18 at 6:35 AM, revealed she overheard a confrontation between Resident #1 and SRNA #1, but could not hear exactly what was being said; however, described the confrontation as being loud. In addition, SRNA #2 stated soon after the confrontation, SRNA #1 approached her and said SRNA #2 was going to have to take care of Resident #1 for the rest of the evening. Continued interview with SRNA #2 revealed SRNAs were responsible to ensure the interventions on the care plans were followed. SRNA #2 stated at the beginning of each shift, they got an assignment sheet and report from the nurses. Attempted interviews with SRNA #1, on 11/06/18 at 5:10 PM and 11/07/18 at 10:00 AM, via telephone were unsuccessful. Interview with Assistant Director of Nursing (ADON) #1, on 11/07/18 at 11:08 AM, revealed all staff was responsible for following resident care plans. ADON #1 stated a care plan binder was located at each nurses' station and the nurses were responsible to review the care plans for each resident at the beginning of each shift. Continued interview with ADON #1 revealed SRNAs got an assignment sheet, which listed each resident's interventions. ADON #1 stated management conducted random audits, observed care, and interviewed residents to ensure care plan interventions were being followed. Interview with the Director of Nursing (DON), on 11/07/18 at 1:45 PM, revealed she expected all staff to follow resident care plans and had not identified any concerns with staff not following resident care plans. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #4 were discharged from the facility. The Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints with care or staff. 2. The Staff Development Coordinator and Administrator in Training educated staff on 11/07/18 on abuse and neglect, investigating abuse, timely reporting, and rendering care based on the care plan. A posttest was administered and staff not scoring 100% was reeducated. Certified letters were mailed on 11/10/18 to staff not educated informing them they would not be allowed to work until education was completed. 3. The charge nurses completed skin assessments on residents with Brief Interview for Mental Status (BIMS) scores of less than eight (8) on 11/07/18 and 11/08/18 to validate no changes in skin integrity and to observe for signs of distress or fearfulness. No new skin issues or signs of distress or fearfulness were noted. 4. Department leaders (Social Services Director and Assistant, Dietary Manager, Plant Operations, Minimum Data Set (MDS) Nurse, Assistant Director of Nursing (ADON), Business Office Manager, and Quality of Life Director) interviewed residents with BIMS scores greater than eight (8) on 11/08/18 to validate no potential grievance and/or allegation of abuse. The interview resulted in one (1) resident with a reportable incident. 5. Risk Management and Consultants audited grievances on 11/08/18 to determine if resolutions were completed, and validate if any reportable was identified it was reported timely to the appropriate State Agencies. Staff involved with any alleged reportable would be suspended immediately pending investigation. The audit revealed three (3) grievances that required reporting to State Agencies. Grievances would be reviewed daily. 6. The Director of Nursing (DON) and Staff Development from a sister facility, and the MDS Nurse audited care plans and Certified Nursing Assistant (CNA) care plans of all residents by 11/08/18, to ensure they were current and reflected resident status. Care plans would be reviewed Monday through Friday to validate interventions were followed by staff and findings would be reported in the QA committee weekly. 7. The Regional Vice President educated the Chief Executive Officer (CEO) on 11/08/18 regarding administration of a skilled facility, resident rights, quality of care, and professional standards. 8. Corporate oversight would be completed by the Consultant, Regional Vice President, and/or Corporate Risk Management daily until removal of the immediacy, beginning 11/08/18. Subsequent visits would continue two (2) times weekly for four (4) week, then one (1) time per week for twelve (12) weeks. 9. Department leaders and regional staff would round and focus on care provided to the residents every shift. The rounds were initiated on 11/08/18 and included observations of overall Activities of Daily Living (ADL) care as well as random interviews to validate residents' comfort and safety in the facility. The rounds would continue until the immediacy was removed and results of the rounds were reviewed in Quality Assurance Performance Improvement (QAPI). 10. An ad-hoc QAPI meeting was held on 11/08/18 to discuss cited deficiencies and plans to correct. Weekly QAPI meetings would be held until the immediacy was removed, then weekly for four (4) weeks, then monthly. Rounding tools would be reviewed to validate resident care provisions were met. The State Survey Agency validated the facility implemented the following actions: 1. Review of the facility's census revealed Resident #1 and Resident #4 no longer resided at the facility. Record review revealed the Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints regarding care or staff. 2. Interviews, on 11/21/18 at 9:26 AM with Certified Nursing Assistant (CNA) #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with Licensed Practical Nurse (LPN) #3, 10:12 AM with Registered Nurse (RN) #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. Nursing staff revealed they were educated on care plans, to be updated and followed. Interview, on 11/21/18 at 10:34 AM, with the Dietary Manager revealed all staff was educated on the abuse/grievance process. She stated she was educated by leadership, and then helped train other staff. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed she had been trained on abuse, neglect, reporting, and care plans and then she trained staff. Record review revealed staff education with posttests occurred 11/07/18 through 11/12/18. Record review revealed certified letters were sent to staff regarding required education. 3. Record review revealed skin assessments were conducted on 11/07/18 and 11/08/18 with no new issues noted. 4. Record review revealed department leaders interviewed residents on 11/08/18 to identify grievances/abuse and none were noted except for one (1) resident who had a complaint that was reported to the state survey agency and investigated by the facility. 5. Interview with the Administrator, on 11/20/18 at 2:00 PM, revealed grievances were reviewed daily in the morning meeting and assigned to members of leadership for follow-up. Record review revealed the Consultant conducted an audit of grievances on 11/08/18. Three (3) reportable incidents were discovered and reported to the State Survey Agency. The Regional Vice President and Clinical Care Consultant reviewed Accident and Incident reports and Grievances daily. 6. Interview with MDS Nurse #1, on 11/21/18 at 10:54 AM, revealed she reviewed and updated care plans and CNA care plans and the plans were reviewed daily in the clinical meeting. Interview with the Administrator, on 11/21/18 at 2:00 PM, revealed each resident's care plan was reviewed and updated in daily clinical meetings as needed. Record review revealed care plans and CNA care plans were audited on 11/08/18. Updates to the plans were made. 7. Record review revealed the Regional Vice President educated the Administrator on job description and expectations, QAPI, abuse policy and reporting guideline, and investigating complaints and grievances. 8. Record review revealed an Oversight Audit Tool was developed and implemented by the facility. The audit began on 11/8/18 through 11/20/18. The audit tool encompassed an aggregation of a clinical summary report, daily nursing notes, social services notes, accident and incidents, twenty-four (24) hour report, care plan, and CNA care plan. Corporate rounding was conducted 11/08/18 through 11/20/18. 9. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed the leadership team rounded every shift and educated staff with scenarios on how to protect residents from abuse and immediately report to their supervisor. Interviews, on 11/21/18 at 9:26 AM with CNA #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with LPN #3, 10:12 AM with RN #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. They confirmed different members of the Management Staff had been walking around and randomly asking questions about abuse and care plans to various staff. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he did care monitoring observations, which included ADL care, catheter care, and medication pass. If issues were found, staff education occurred immediately. Record review revealed abuse follow-up interviews with staff were conducted 11/08/18 to 11/21/18. Record review revealed resident interviews were conducted 11/08/18 through 11/11/18 Record review revealed care observations were conducted 11/08/18 through 11/19/18. 10. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he attended QAPI meetings and the care audits were discussed. Interview with the DON, on 11/21/18 at 2:10 PM, revealed QAPI meeting were conducted weekly and reviewed audits. Record review revealed QAPI meetings were held on 11/08/18, 11/12/18, and 11/19/18. The next QAPI meeting was scheduled for 11/26/18.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure residents were protected from further alleged abuse after an allegation was made for three (3) of ten (10) sampled residents, Resident #1, #2 and #4. (Refer to F600) Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed if the suspected perpetrator of abuse was a staff member, the charge nurse would immediately remove the staff person from resident care areas and suspend him/her while the matter was investigated. Interview with Resident #4's Granddaughter, on 10/16/18 at 4:10 PM, revealed on 10/12/18 at approximately 10:30 PM, her grandparent called her at home and reported to her staff at the facility was being mean to him/her. Resident #4's Granddaughter stated she immediately phoned the facility and spoke with the night shift House Supervisor, Licensed Practical Nurse (LPN) #4, and reported the incident to her because she believed State Registered Nurse Aide (SRNA) #3's behavior was abusive. In addition, Resident #4's Granddaughter stated she came in the following morning, which was a Saturday morning, and completed grievances with the facility. Interview with Assistant Director of Nursing (ADON) #1 revealed he received Resident #4's grievance on 10/15/18, regarding the incident that occurred on 10/12/18, and at that time SRNA #3 was suspended from resident care, three (3) days after the alleged abuse occurred. Interview with LPN #3, on 10/15/18 at 6:09 PM, revealed she had been standing at the nurses' station outside Resident #2's room when she observed Resident #2 come into the hallway and say he/she did not want SRNA #2 back in his/her room. LPN #3 stated she talked with Resident #2 and the resident reported SRNA #2 was rude to him/her, cussed him/her, and had a bad attitude. LPN #3 stated she felt the resident's report was a grievance and did not investigate the allegation or interview other residents or staff. LPN #3 stated she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of abuse, but should have. SRNA #2 continued to provide resident care after the allegation of potential abuse and the incident was not investigated. Review of the facility's Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use his/her urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice. Interview with LPN #2, on 10/17/18 at 6:00 PM, revealed she heard SRNA #1 swear and curse every time the call lights went off and on one occasion during the evening on 07/22/18, she overheard SRNA #1 tell a resident to stop putting on his/her call light because she was only going to do rounds every two (2) hours and would change the resident at that time and not in between. LPN #2 stated she did not take any immediate action to protect the residents. The facility's failure to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/16/18, which alleged removal of the Immediate Jeopardy on 11/13/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/13/18, prior to exit on 11/21/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, not dated, revealed it was the facility's policy to prevent the occurrence of abuse and neglect and to ensure all alleged occurrences of abuse and neglect were immediately reported and investigated. Continued review of the facility's policy revealed if the suspected perpetrator was a staff member, the charge nurse would immediately remove the staff person from resident care areas and suspend him/her while the matter was investigated. Directly after assuring the residents involved were safe and secure, and the alleged perpetrator had been removed from the resident care area, the charge nurse would inform the Facility Administrator and the Director of Nursing of the allegation of abuse. 1. Review of the facility's Verification of Investigation report, not dated, revealed Resident #4 was fearful of SRNA #3 and contacted family on 10/12/18 to report SRNA #3's behavior. Resident #4 reported to his/her family that SRNA #3 was giving him/her a shower and sprayed him/her with hot water and the resident had to adjust the water himself/herself to cool it. In addition, the resident reported another incident occurred while on the toilet with the same SRNA. Resident #4 stated SRNA #3 removed the resident's back brace and tossed it in front of the closet. Resident #4 asked SRNA #3 to stay and ensure he/she was clean; however, the SRNA #3 told him/her that he/she was clean enough and left the room and did not assist Resident #4 to bed or assist to put the brace on. The family member called the facility to express their concerns regarding the SRNA's care and services. The family member requested for SRNA #3 not to provide care to Resident #4 anymore. The investigation documentation revealed SRNA #3 was not suspended after the reporting of SRNA #3's behavior, but three (3) days later, on 10/15/18, when the ADON interviewed the resident regarding the filed grievance. Interview with SRNA #2, on 10/17/18 at 5:36 PM and 11/07/18 at 6:35 AM, revealed she arrived to work on 10/12/18 at 10:30 PM and she went into the Resident #4's room to check on him/her and the resident reported to her what had happened with SRNA #3. SRNA #2 stated she calmed the resident down and assisted him/her to bed and reported the allegation to LPN #4, who was already aware. Interview with the House Supervisor/LPN #4, on 10/17/18 at 4:53 PM, revealed Resident #4's Granddaughter called her around 10:30 PM on 10/12/18 and reported Resident #4 was very upset with the facility's care and services. The House Supervisor stated the Granddaughter told her SRNA #3 took the resident's brace off, and would not assist the resident with toileting or back to bed. She stated the report could have been considered an allegation of neglect or abuse, but she did not consider it at the time. She stated SRNA #3 was allowed to finish out his shift. The House Supervisor stated she was aware of the abuse policy and procedure requirements for protecting residents from further abuse. Interview with ADON #1, on 10/17/18 at 3:37 PM and 11/07/18 at 11:08 AM, revealed all allegations of abuse or neglect came through the grievance process. The ADON revealed it was determined through clinical judgement if a resident complaint or grievance was an allegation of abuse/neglect. Further interview with ADON #1 revealed he was responsible for investigating grievances regarding nursing care. ADON #1 stated he generated a grievance/complaint report each morning, Monday through Friday. ADON #1 stated he received Resident #4's grievance on 10/15/18, regarding the incident that occurred on 10/12/18, and at that time the facility investigation started and SRNA #3 was suspended from resident care. Interview, on 10/17/18 at 3:00 PM and 11/07/18 at 12:55 PM, with the Director of Nursing (DON), revealed SRNA #3 was out of the building from 10/12/18 to 10/15/18, but not suspended. In addition, she did not identify concerns with how the investigation was handled, though she acknowledged the potential for further abuse if an employee was not suspended after an allegation was made. Further interview with the DON revealed the facility unsubstantiated the allegation of abuse. Interview with Administrator, on 11/07/18 at 3:33 PM, revealed the facility did not identify the information Resident #4's Granddaughter shared with the House Supervisor was abuse at the time. He stated staff should have called him to discuss. 2. Review of the facility's Investigation Summary, not dated, revealed on 07/20/18 at approximately 10:30 PM, Resident #2 rang the call light in the bathroom for assistance. Further review revealed SRNA #2 entered Resident #2's bathroom and stated to Resident #2, What do you want? and How did you get in here? In addition, when Resident #2 got back to bed, he/she became mad and proceeded to the hallway to let the nurse know he/she did not want SRNA #2 back in his/her room. Resident #2 reported to the nurse he/she felt SRNA #2 was rude and had a bad attitude. Interview, on 11/07/18 at 3:08 PM, with Resident #2 revealed he/she felt SRNA #2 was rude and had an attitude. Resident #2 stated he/she was upset regarding SRNA #2's attitude and he/she stepped out in the hallway and reported to the nurse he/she did not want SRNA #2 back in his/her room. Interview with SRNA #2, on 11/07/18 at 6:56 AM, revealed she did not go back into the resident's room the rest of the evening and was not removed from resident care until 07/23/18, three (3) days later. Interview with LPN #3, on 10/15/18 at 6:09 PM, revealed Resident #2 stated he/she did not want SRNA #2 back in his/her room. LPN #3 talked with Resident #2 and the resident reported to her SRNA #2 was rude to him/her, cussed him/her, and had a bad attitude. However, LPN #3 stated she felt the resident's report was a grievance and did not investigate the allegation or interview other residents or staff. Per interview, she told SRNA #2 not to go back into Resident #2's room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of abuse, but should have. Interview with the House Supervisor, LPN #4, on 10/15/18 at 6:57 PM, revealed Resident #2 told her SRNA #2 scolded him/her and was rude and the resident did not want the rude SRNA back in his/her room again. She stated if a resident reported a staff member was rude it could be an allegation of verbal abuse. However, she viewed the resident's comments as a grievance and not potential verbal abuse. LPN #4 stated SRNA #2 continued to provide care to other residents, just not to Resident #2. Interview with the DON, on 11/07/18 at 12:55 PM, revealed she did not identify a concern regarding employees not being immediately removed from resident care after an allegation of abuse. Interview with the Administrator, on 10/18/18 at 5:01 PM, revealed if staff had a reason for concern related to resident care, then follow-up regarding the concern should happen. He stated he expected all staff to follow the policy and procedure regarding abuse and neglect. 3. Review of the facility's Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1's room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use his/her urinal. SRNA #1 stated to Resident #1, I'm not messing with you, solve it yourself in a loud and angry tone of voice. Interview with SRNA #2, on 10/17/18 at 5:21 PM, revealed she overheard a confrontation between Resident #1 and SRNA #1. SRNA #2 stated she could not hear exactly what was being said, but described the confrontation as being loud. In addition, SRNA #2 stated soon after the confrontation, SRNA #1 approached her with angry body language and stated, You are going to have to take care of Resident #1 for the rest of the evening. In addition, SRNA #2 stated she overheard SRNA #1 saying with an attitude that she was frustrated with answering the call lights that same evening. SRNA #2 stated she did not report this to the nurse because the nurse already knew about SRNA #1's attitude. Interview, on 10/17/18 at 3:25 PM, with LPN #1 revealed Resident #1 stated to him he/she would like to know why SRNA #1 was so angry with him/her and stated SRNA #1 sure had a bad attitude tonight. LPN #1 stated he treated the potential allegation of verbal abuse as a complaint/grievance and did not identify it as potential abuse. LPN #1 stated he should have identified the incident as potential abuse, sent SRNA #1 home, and reported the allegation to the DON. Interview with LPN #2, on 10/17/18 at 6:00 PM, revealed she heard SRNA #1 swear and curse every time the call lights went off and on one occasion during the evening of 07/22/18, she overheard SRNA #1 tell a resident to stop putting on his/her call light because she was only going to do rounds every two (2) hours and would change the resident at that time and not in between. Further interview with LPN #2 revealed she did not take any immediate action to protect the residents and did not report the allegation to the Administrator or the DON until several days later, when the DON interviewed her about the incident with Resident #1. LPN #2 stated, I should have intervened. LPN #2 stated she did not know why she did not, and stated, I just took care of the residents. Interview with the Administrator and the DON, on 10/16/18 at 1:52 PM, revealed they did not substantiate abuse occurred by SRNA #1; however, based on the interviews with staff, they did not feel SRNA #1 was a good fit for the facility and her employment was terminated. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 and Resident #4 were discharged from the facility. The Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints with care or staff. 2. The Staff Development Coordinator and Administrator in Training educated staff on 11/07/18 on abuse and neglect, investigating abuse, timely reporting, and rendering care based on the care plan. A posttest was administered and staff not scoring 100% was reeducated. Certified letters were mailed on 11/10/18 to staff not educated informing them they would not be allowed to work until education was completed. 3. The charge nurses completed skin assessments on residents with Brief Interview for Mental Status (BIMS) scores of less than eight (8) on 11/07/18 and 11/08/18 to validate no changes in skin integrity and to observe for signs of distress or fearfulness. No new skin issues or signs of distress or fearfulness were noted. 4. Department leaders (Social Services Director and Assistant, Dietary Manager, Plant Operations, Minimum Data Set (MDS) Nurse, Assistant Director of Nursing (ADON), Business Office Manager, and Quality of Life Director) interviewed residents with BIMS scores greater than eight (8) on 11/08/18 to validate no potential grievance and/or allegation of abuse. The interview resulted in one (1) resident with a reportable incident. 5. Risk Management and Consultants audited grievances on 11/08/18 to determine if resolutions were completed, and validate if any reportable was identified it was reported timely to the appropriate State Agencies. Staff involved with any alleged reportable would be suspended immediately pending investigation. The audit revealed three (3) grievances that required reporting to State Agencies. Grievances would be reviewed daily. 6. The Director of Nursing (DON) and Staff Development from a sister facility, and the MDS Nurse audited care plans and Certified Nursing Assistant (CNA) care plans of all residents by 11/08/18, to ensure they were current and reflected resident status. Care plans would be reviewed Monday through Friday to validate interventions were followed by staff and findings would be reported in the QA committee weekly. 7. The Regional Vice President educated the Chief Executive Officer (CEO) on 11/08/18 regarding administration of a skilled facility, resident rights, quality of care, and professional standards. 8. Corporate oversight would be completed by the Consultant, Regional Vice President, and/or Corporate Risk Management daily until removal of the immediacy, beginning 11/08/18. Subsequent visits would continue two (2) times weekly for four (4) week, then one (1) time per week for twelve (12) weeks. 9. Department leaders and regional staff would round and focus on care provided to the residents every shift. The rounds were initiated on 11/08/18 and included observations of overall Activities of Daily Living (ADL) care as well as random interviews to validate residents' comfort and safety in the facility. The rounds would continue until the immediacy was removed and results of the rounds were reviewed in Quality Assurance Performance Improvement (QAPI). 10. An ad-hoc QAPI meeting was held on 11/08/18 to discuss cited deficiencies and plans to correct. Weekly QAPI meetings would be held until the immediacy was removed, then weekly for four (4) weeks, then monthly. Rounding tools would be reviewed to validate resident care provisions were met. The State Survey Agency validated the facility implemented the following actions: 1. Review of the facility's census revealed Resident #1 and Resident #4 no longer resided at the facility. Record review revealed the Social Services Director interviewed Resident #5 on 11/08/18 and the resident had no complaints regarding care or staff. 2. Interviews, on 11/21/18 at 9:26 AM with Certified Nursing Assistant (CNA) #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with Licensed Practical Nurse (LPN) #3, 10:12 AM with Registered Nurse (RN) #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. Nursing staff revealed they were educated on care plans, to be updated and followed. Interview, on 11/21/18 at 10:34 AM, with the Dietary Manager revealed all staff was educated on the abuse/grievance process. She stated she was educated by leadership, and then helped train other staff. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed she had been trained on abuse, neglect, reporting, and care plans and then she trained staff. Record review revealed staff education with posttests occurred 11/07/18 through 11/12/18. Record review revealed certified letters were sent to staff regarding required education. 3. Record review revealed skin assessments were conducted on 11/07/18 and 11/08/18 with no new issues noted. 4. Record review revealed department leaders interviewed residents on 11/08/18 to identify grievances/abuse and none were noted except for one (1) resident who had a complaint that was reported to the state survey agency and investigated by the facility. 5. Interview with the Administrator, on 11/20/18 at 2:00 PM, revealed grievances were reviewed daily in the morning meeting and assigned to members of leadership for follow-up. Record review revealed the Consultant conducted an audit of grievances on 11/08/18. Three (3) reportable incidents were discovered and reported to the State Survey Agency. The Regional Vice President and Clinical Care Consultant reviewed Accident and Incident reports and Grievances daily. 6. Interview with MDS Nurse #1, on 11/21/18 at 10:54 AM, revealed she reviewed and updated care plans and CNA care plans and the plans were reviewed daily in the clinical meeting. Interview with the Administrator, on 11/21/18 at 2:00 PM, revealed each resident's care plan was reviewed and updated in daily clinical meetings as needed. Record review revealed care plans and CNA care plans were audited on 11/08/18. Updates to the plans were made. 7. Record review revealed the Regional Vice President educated the Administrator on job description and expectations, QAPI, abuse policy and reporting guideline, and investigating complaints and grievances. 8. Record review revealed an Oversight Audit Tool was developed and implemented by the facility. The audit began on 11/8/18 through 11/20/18. The audit tool encompassed an aggregation of a clinical summary report, daily nursing notes, social services notes, accident and incidents, twenty-four (24) hour report, care plan, and CNA care plan. Corporate rounding was conducted 11/08/18 through 11/20/18. 9. Interview, on 11/21/18 at 10:54 AM, with MDS Nurse #1 revealed the leadership team rounded every shift and educated staff with scenarios on how to protect residents from abuse and immediately report to their supervisor. Interviews, on 11/21/18 at 9:26 AM with CNA #3, 9:34 AM with CNA #4, 9:38 AM with CNA #5, 9:48 AM with CNA #6, 10:02 AM with LPN #3, 10:12 AM with RN #1, 10:21 AM with LPN #4, and at 10:46 AM with Dietary Assistant #1, revealed staff had recently completed training on abuse and neglect. They confirmed different members of the Management Staff had been walking around and randomly asking questions about abuse and care plans to various staff. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he did care monitoring observations, which included ADL care, catheter care, and medication pass. If issues were found, staff education occurred immediately. Record review revealed abuse follow-up interviews with staff were conducted 11/08/18 to 11/21/18. Record review revealed resident interviews were conducted 11/08/18 through 11/11/18 Record review revealed care observations were conducted 11/08/18 through 11/19/18. 10. Interview with ADON #1, on 11/21/18 at 11:10 AM, revealed he attended QAPI meetings and the care audits were discussed. Interview with the DON, on 11/21/18 at 2:10 PM, revealed QAPI meeting were conducted weekly and reviewed audits. Record review revealed QAPI meetings were held on 11/08/18, 11/12/18, and 11/19/18. The next QAPI meeting was scheduled for 11/26/18.